CROUP
Dr.S. Alyasin
Associated professor
Pediatric Department
Shiraz University of Medical Science
Croup
• Airway resistance is inversely proportional to 4th
power of radius : minor reduction: increase in
air flow resistance.
• Larynx: 4 major cartilage: epiglottic – arytenoid
– thyroid – cricoid & the soft tissue souround it
• Cricoid is just below vocal cord & narrowest in
children < 10 yr -0
Supraglottic
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Epiglotitis – peritonsilar abcess- retropharyngeal abcess
Drooling - hot potato voice – positional preference
Infraglottic
Laryngitis – lanyngotracheitis, laryngotracheobronchitis
• Croup: Heterogenous group of acute and infectious
process
Bark like cough , may hoarsness, stridor ,distress
- (affect larynx,trachea ,bronchus)
- Stridor:Harsh ,high pitched usually inspiratory or
biphasic ,turbulant flow
Croup
• Croup typically affects larynx, tarcheabronchi (acute infection
• - bark cough
• - hoarsness
• - stridor)
Croup :Etiolology
Viral :Para -influenza 1,2,3
75%
Influenza A-B, Adenovirus, RSV, measlse,
Inf A: Severe LTB
Bacterial: diphtheria- bacterial thracheitisepiglotitis – mycoplasma (mild)
Croup ;Epidemiology
• Age: 3 mo – 5yr, peak: 2nd yr of life
• Boy
• Late fall & winter (but can throughout the
year)
• Recurrents : 3-6 yr of age, decrease with
growth
• Family hx of croup in 15%
Croup (Laryngotracheobronchitis)
• Some clinicians use the term laryngotracheitis
for the most common & most typical form of
croup and
laryngotrachobronchitis for more sever form with
bacterial super-infection (in 5-7 days course)
• URI in family
• URI rhinorrhea- pharyngitis- cough- low grade
fever 1-3 days then barking cough
• Low grade to 39- 40 0c or afebrile
Croup : Clinical manifestation
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Worse at night
Improve in a week
Agitation aggravate symptom
Prefer sit up
Older children are not ill.
Croup : Clinical manifestation
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PE
- hoarse voice
- Coryza
- mild to mod infla. Pharynx
- RR↑
- variable respiratory distress (RR- nasal flaring –
retraction)
- Stridor
Croup :Dx
• Alveolar gas exchange is nl so hypoxia only in
complete airway obstruction (occasionally difficult
to differentiate from epiglottitis)
• X-ray may be helpful in distinguishing between
sever LTB & epiglottitis but after airway
stabilization.
Diagnosis
Croup is a clinical diagnosis and not require X
ray.
X Ray AP: steeple sign
(false +ve & -ve & not correlate with severity)
distinghish between epiglotitis & LTB after
stabilization of airway
“steeple sign” of subglottic narrowing. (b) Laternal neck radiograph
showing subglottic narrowing consistent with acute laryngotracheitis
Spasmodic croup
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1-3 yr
No URI hx in family member & patient
No fever
Cause?: viral- allergic – psychologic
An allergic reaction to viral antigen.
Acute infectious laryngitis
• Virus – Diphteria
• URI -sore throat – cough- hoarseness- loss of
voice: mild
• In infant : RD
• Subglottic inflammation
Croup: Treatment
• Admission:
-progressive stridor
- severe stridor at rest
- - RD
- - hypoxia
- - cyanosis
- - depressed mental status
- – poor oral intake
- – need for observation.
Croup: Treatment
• L epinephrinin (5 ml: 1/1000) is as potent as
racemic epinephrin (tachycardia – HTN)
, every 20 minutes.
• Indication:
-stridor at rest
- need for intubation
- - RD
- - hypoxia
(caution: tachycardia- TOF- venticular outlet
obstruction)
Croup: treatment: corticosteroid
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anti inflammatory action: laryngeal edema
Oral CS even in mild croup:
↓ admission
↓ duration of admission
- ↓need for E –
Oral dexametason 0.6 to 0.15 mg/kg single dose
= im dexametson or budesonide
• Single dose of prednisolon is less potent
• 1 week CS: candidal infection
*No during varicella infection
Croup: treatment
• No Antibiotic –
• No cough medication in children <4y-0
• Heliox
Croup
• Discharge: after 2-3 hr observation:
- no stridor at rest
- normal air entry
- nl pulse oximetry
– nl level of consciousness
- received steroid
Treatment:
acute laryngeal swelling on an allergic basis
• Epinephrine 1/1000 – 0.01 ml/kg im or
Racemic E Q .5 ml / with 3 ml nl/s
• CS 2-4 mg/kg/24 : prednison
Post-extubation croup
- Racemic E
- - dexametason 0.5 mg/kg/dose every 6 hrs
Croup: complication
• 15% Om
• bronchial , lung parenchyma
• Bacterial tracheitis (with toxic shock syndrome)
Prognosis
• Is related to Length of admission and extension o f
infection( except in epiglotitis)
• Death in croup:
- laryngeal obstruction
– complication of tracheotomy
• Px is excellent
• Admitted patient: increased bronchial reactivity
Croup : Df Dx
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Foreign body
6mo-3 yrs, sudden , No prodrom
Retropharngeal abscess (CT)
Peritonsilar abscess
Extrinsic compression (web- vascular ring)
Intraluminal (papiloma- hemangioma)
Angioedema
Post extubation
Hypocalcaemia tetani
I.Mono
Trauma
Tumor
Malformation
Very hot liquid : epiglottis like drooling – dysphagia – stridor
• Foreign Body
• Lateral neck radiograph demonstrating widening of
the retropharyngeal space and reversal of the normal
cervical spine curvature. The epiglottis and subglottic
area are normal.
Epiglotitis: Etiology
• Hl type B ↓80-90% in vaccinated area for
epiglottis:
st. pyogen- st. pneumonia- st. aureus
• Age 2-4 (although range of 1 to 7 y-0)
Epiglotitis
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Potentially lethal
High fever- sore throat- dyspnearesp obstruction within few hours: toxic
difficult swallowing
Drooling- neck extention
Tripod position
Air hunger, restless: cyanosis & coma
Stridor after complete airway obstruction
No barking cough – No illness in family
Epiglotitis
Dx
lanygoscopy: cherry red epiglottis
when dx is certain or probable, lanyngoscopy
should be done in OR or in ICU
Phlebotomy, IV line, supine or direct inspection
of oral cavity after airway is secure
If dx is not certain :
lat X ray neck “ thumb sign”
direct visualization.
Epiglotittis
• Anxiety provoked intervention
(phlebotomy- supine –IV-direct inspection of oral
cavity) should be avoided.
- Most patients have bacteremia: occasionally
pneumonia- cervical LAP- OM, rarely: meningitis –
arthritis
• - Occasionally aryepiglottic fold is more involved
than epiglottis
Treatment: Epiglotitis
• Epiglotitis is medical emergency: Artificial airway
in OR or ICU : improved immediately
• culture (B- epi_ sometimes CSF) after airway
stabilized
• All should recieve O2
• Ceftriaxone – Cefotoxime- meropenem 7-10 days
• CS or E are not effective
Treatment: Epiglotitis
• Indication for rifampin for household members if:
- any centact < 48 mo of age incomplete
vaccinated
- Any contact < 12 mo of age not received the 10
vaccine series
- Immuno-compromised child
Bacterial tracheitis
• Stap au.* - morexella cat.- Non typable HI- anerobic
• Age: 5-7 y-o
• 2nd to LT & viral infection is more common than 10
infection
- Brassy cough- high fever- toxic – RD- not drool- can lie- no dysphagea
• Need intubation in 50-60 % (younger children)
- Major pathology: mucosal swelling in cricoid cartilage
purulent secretion
pseudomembrane
Bacterial tracheitis
• : diognosiS :
Fever- purulent discharge- absence of epiglottitis
finding
• X-Ray is not needed but show classic finding
• During ET intubation : pus below cord
• Tx: Artificial airway is strongly suspected
• Vancomycin + nafcillin
• O2
suction
Lateral neck radiograph showing intraluminal
membranes and tracheal wall irregularity (arrows)
consistent with bacterial tracheitis.
Tracheotomy;
Endotracheal Intubation
• Epiglotitis mortality rate of 6% dropped to zero
-In OR or in ICU
-Tube 0.5-1 mm smaller than estimation
- T, ET for most patient of bacterial tracheitis (5060%)
- T, ET in LTB in outbreak of influenza A & measlse
- Extubation :few days
- T. complication: Mediastinal emphysema /
pneumothorax
- DL in epiglottitis: after 42 hr inflammation ↓, (2-3
days after antibiotic)