The chair of pediatrics with children’s surgery, course of children infectious diseases
Methodological Instructions to lesson for 6th year students No 2
(practical classes - 7 hours)
Theme: Differential diagnostic of air droplet infection which have Croup syndrome.
Aim: to know diagnostic criterions of croup syndrome in children, how to examine a
patient with this disease, and prove the diagnosis, differentiate, give the individual
treatment and prevention.
Professional motivation:
Air-droplet infections are the most wide-spread group of infectious diseases in children,
among them acute respiratory viral infections occupy the first place. Well-timed
investigation and treatment of these diseases in children prevents the development of
severe complications, as croup syndrome. Among air-droplet infections not less important
is diphtheria of the respiratory ways, which has especially severe duration in children with
manifestations of the croup syndrome. The physicians must know how to diagnose these
diseases and give the professional help to ill child.
Basic level
1. To know how to ask complaints, history of the disease and life in children
[propedeutic pediatrics].
2. To perform clinical examination of the child [propedeutic pediatrics].
3. To know microbiology, pathophysiology, pathomorphology and clinical features of
Influenza, upper respiratory viral infections, diphtheria, whooping cough, measles,
chickenpox [Microbiology, pathophysiology, and pathomorphology, Children
infectious diseases].
4. To diagnose croup syndrome after clinical, laboratory and instrumental examination
of sick person [infection diseases, propedeutic pediatrics, microbiology, and
pathophysiology].
5. To give etiological, pathogenetical and symptomatical treatment of croup syndrome
[pharmacology].
6. To prevent diseases that may be complicated by croup syndrome.
Students’ independent study program.
1. Objectives for students' independent studies.
You should prepare for the practical class using the existing textbook and lectures. Special
attention should be paid to the following:
Acute viral upper respiratory tract infections –– is a large group of infectious
diseases, which are caused by viruses, transmitted by droplet way, characterized by
intoxication and catarrhal syndrome with predominant changes in mucous membranes of
the upper respiratory tract.
Clinical classification of Upper Respiratory Tract Viral Infections
Etiology
Clinical forms
Severity
Duration
1
Adenoviruses
Pharyngoconjunctival fever, catarrh of the
Upper Respiratory Tract,
keratoconjunctivitis, tonzyllopharyngitis,
diarrhea (intestinal syndrome),
mesadenitis, hepatosplenomegaly
1. Without
complications.
Mild
Paramyxoviruses
Croup syndrome, catarrh of the Upper
Respiratory Tract, tonzyllopharyngitis,
RS-viruses
Acute bronchitis, bronchiolitis, Croup
syndrome
Rhinoviruses
Rhinitis, rhinopharyngitis, catarrh of the
Upper Respiratory Tract, interstitial
pneumonia, Croup syndrome (seldom)
2. With
complications
Moderate
Severe
Differential Diagnosis between Viral Respiratory Infections
Signs
and Influenza
symptoms
Tracheitis
Respiratory
tract
Parainfluenza
Laryngitis
Intoxication
Catarrhal s-m
Temperature
Severe
Mild
High
Moderate
Moderate
Moderate
Eye pain
Myalgias,
Arthralgia
Hemorrhages
Present
Expressed
Absent
Absent
May
present
Moderate
Dry
be Absent
Rhinitis
Cough
Conjunctivitis
Pharyngeal
hyperemia
lymphadenopat
hy
Liver
Spleen
Diarrhea
Adenoviral
RS-infection
infection
Pharyngotonsilli Bronchitis,
tis
bronchiolitis,
pneumonia
Moderate
Moderate
Expressed
Expressed
High, for long Moderate
period
Absent
Rarely
Moderate
Rarely
Rhinoviral
infection
Rhinitis
Absent
Absent
Absent
Moderate
Often repeated,
with obstructive
component
Absent
Moderate
Expressed
Rarely
Moderate
Expressed
dry, hoarseness, Rarely
“barking”
Absent
Expressed
Absent
Moderate
Absent
Absent
Normal
Normal
Absent
Normal
Normal
Absent
Often
Expressed,
tonsillitis
Polyadenopathy
rarely:
neck,
submandibular
Often enlarged
May be enlarged
May be enlarged Normal
May be present Absent
Mild
Expressed
Subfebril
Absent
Absent
Absent
Moderate
Absent
Normal
Normal
Absent
Croup Syndrome
2
Symptoms
І st. (compensated)
acute beginning,
more often at
night with URTI
previous
signs
(high temperature,
catarrhal
syndrome,
pharyingitis:
hyperemia of the
pharynx and soft
palate, catarrhal
conjunctivitis,
scleritis may be
present);
Typical triad:
Barking
cough;
Hoarseness;
Typical triad, but
Stridor appears only
when
child
is
irritable,
during
physical exercises.
Laboratory signs of
breath failure are
absent (lips are pink,
blood gases are
normal), metabolic
acidosis may be
present.
Croup stages
ІІ st.
ІІІ st. (decompensated)
(subcompensated)
Moderate
breath Severe
breath
failure
failure (skin pallor, (stable cyanosis of lips,
perioral
cyanosis, acrocyanosis,
pallor);
tachycardia);
Expressed
irritability,
irritability;
anxiety;
Stridor
with
Stridor
with moderate involvement of
moderate
all respiratory muscles with
involvement of all depression of lower part of
respiratory muscles;
sternum;
tachycardia,
Barking cough;
deficit of pulse during
Hoarseness;
inspiration; dullness of
рО2 is decreased or cardiac tones, myocardial
on the lower normal dilatation may be present,
grade;
cardiao-pulmonary
insufficiency;
рО2
is
decreased
(50-70
mm
Hg.);
рСО2 is normal;
рСО2 is increased (48-50
mm Hg.)
IV st. (asphyxia)
skin is pallor-gray,
cyanotic,
cold
extremities;
breathing
is
superficial, gasping,
or apneic;
progressive
bradycardia;
subnormal
temperature;
unconsciousness,
seizures;
no
controlled
urination
and
defecation;
p О2 decreases to
50-40 mm Hg.;
р СО2 increases to
70-100 mm Hg.;
Stridor.
Stenotic laryngotracheitis, or false croup, exists in case of ARVI (influenza, parainfluenza,
аdenoviral infection), measles, Chickenpox. Diphtheria of the respiratory ways has clinic
of true croup, which necessary to differentiate with false croup..
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death.
Differential Diagnosis of the Respiratory Tract Diphtheria
Signs
Beginning
Parainfluenza
acute
Diphtheria
gradual
Chicken pox
acute
Measles
Main signs
Catarrhal
symptoms from
the upper
respiratory tract,
laryngitis
Laryngitis, slowly
development of
airways obstruction,
low intoxication
rashes
Catarrhal symptoms
from the upper
respiratory tract,
conjunctivitis,
rashes
Catarrhal
symptoms (cough,
corryza)
Expressed,
moderate
absent
mild
expressed
Character of the
cough
dry, rough,
barking
“ barking”, then
soundless
is rare
dry, or moist
Voice
Oropharyngeal
changes
Hoarse
Moderate
hyperemia
Is not changed
absent
May be hoarse
Enanthem, light
hyperemia
Lymphadenitis
absent
Hoarse, then soundless
Absent or may be
combined with
oropharyngeal
diphtheria
regional
absent
May be plural
Pathomorphology
Edema of the
larynx
Obstruction by
fibrinoid membranes
Edema of the larynx
Edema of the larynx
acute
TREATMENT: Management of croup depends on the severity of disease.
Prehospital care:
 Prehospital care includes fever control and attempts to alleviate respiratory
symptoms and patient anxiety.
 Respiratory symptoms commonly improve with benign measures such as calming,
and exposing the child to the cool night air.
 Antipyretics may assist with fever control.
Hospital care
Ethiothrope therapy (for true diftherial croup)
Clinical form
First dose
Thousand IU
Repeated dose
Thousand IU
Total dose
Thousand IU
Diphtheria of the larynx
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Localized croup
Spread croup
30-40
40-50
-20-30
30-40
60-80
Basic therapy: for all patients:
– Warm alkalic drinks, hot milk with soda;
– alkalic mist inhalations 4-6 times per day, antiedematous inhalations;
– mucolithics;
– distractive measures (ozokerit boots);
– suction of mucus from the upper air ways.
Intensification
1. in case of II st. – treatment in mist oxygen tent, with:
– bronchodilators (Euphyllin, solutan);
– corticosteroids (hydrocortisone);
– mucosolvents (tripsyn, chemotripsyn);
– prednisolon parenterally 1-3 mg/kg.
2. in case of III st. patient must be treated in emergency care department, all
manipulation are doing in mist oxygen tent, number of inhalations increases to 6 times
per day;
– IM or IV prednizone 2-5 mg/kg;
– In case of anxiety – Na oxybutirati 50-100 mg/kg or droperidoli 0,25% 0,05-0,1
ml/kg;
– Cardiac medicine – strophantin 0,05%, corglycon 0,06%, rhiboxin 2%,
cocarboxylasa;
– antienzymes (contrical) 1000 UD/kg;
– anticoagulants (heparin) 200-500 UD/kg.
3. in case of IV st. – nasotracheal intibation.
Desintoxication therapy
– for all patients – increased peroral hydration;
– in case of III-IV st. IV: crioplasma, 20% albumin 5-15 ml/kg, rheopolyglucin 10-20
ml/kg, 10% glucose 40-50 ml/kg.
Accompanying therapy
1. hypoallergic diet, antihystamines (diasolin 1-3 mg/kg, and other)
2. in case of croup, caused by Influenza viruses:
– to 2-year – 1.5 ml, 2-7 years – 3 ml, older then 7 years – 4,5ml. Amantadine or
Remantadine 4 to 6 mg/kg/daily for 5 days. Children older than 10 year can take a 100
mg tablet twice a day.
3. in case of III-IV st. of croup – antibiotics of broad spectrum (penicillines,
cephalosporines, macrolydes).
Prevention
Prevention of influenza
1. Special prevention by immunization .Only in activated influenza vaccines are
licensed for use [whole virus vaccines and split-product]. Influenza vaccine is specially
recommended for children 6 months of age and older. First time vaccinees less then 9 year
of age need to receive two doses of vaccine separated by a 1-month interval.
2. Amantadine 25mg/day during 10-14 days can be a useful adjunct for prevention of
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influenza A.
Prevention of diphtheria
- Specific by DTP vaccine from 3 months age 3 times in 30 days interval (3, 4, 5 months),
revaccination in 18 months (DTP), 6, 11, 14, 18 years (DT), later – every 10 years.
- Close contacts who were previously immunized longer then 5 years before should
receive booster dose of diphtherial toxicoid.
- Revealing sanation of healthy infected persons, looking after contacts for 10 days,
disinfection of epidemic focus.
Prevention of whooping cough
- Isolation of the ill person on 30 days from the beginning of the disease.
- Isolation of the contact persons younger 7 years old on 14 days.
Specific vaccination by DTP vaccine from 3 months of old 3 times with 30 days interval.
Tests and assignments for self-assessment
Choose the correct answer / statement:
1. The child, 1 year old, is treated in infectious department with diagnosis Parainfluenza.
On the 2nd day of the disease his condition became worse. The child is excited, inspiratory
dyspnea, tachypnea, tachycardia, cyanosis of the lips, tip of the nose and fingers, cool
perspiration has appeared. Intercostal spaces involvement is noted at breathing. What
degree of larynx stenosis is present?
А. I
В. II
С. III
D. IV
E. V
2. The child, 2 years old, is treated from influenza. His condition suddenly became worse:
the body temperature has increased to 39.8 ºС, has appeared rough barking cough,
hoarseness of the voice, expressed inspiratory dyspnea. Objectively: involvement of the
auxiliary musculature in breathing, skin pallor, tachycardia. What complication of
influenza has developed?
А. Pneumonia
В. Bronchiolitis
С. Croup syndrome
D. Obstructive bronchitis
E. Pharyngitis
3. The child is 7 years old. He has influenza for 5 days. The condition of the child sharply
worsened. Once again has increased the body temperature, has appeared: moist cough with
separation of mucous-purulent phlegm, dyspnea. Breathing - 30 in 1 min.; cyanosis of
perioral triangle; in lower parts of the lungs, more in the right, dullness of the lung sound,
moist small wheezes. Pulse - 120 in 1 min., heart tones are weakened. What complication
of influenza is possible?
А. Croup syndrome
В. Pneumonia
С. Meningitis
D. Myocarditis
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E. Obstructive bronchitis
4. During cough paroxysm, which disturbs the child during last three weeks, child’s face
has reddened, became cyanotic, tearing has appeared, tongue was brought forth outward.
The paroxysm has ended by cough with transparent phlegm and vomiting. Name the
diagnosis:
А. Bronchiolitis;
В. Obstructive bronchitis;
С. Whooping cough;
D. Croup syndrome;
E. Bronchial asthma.
5. The child, 3 years old, is ill for 3 days. The disease has begun with subfebril
temperature, hoarseness of the voice, barking cough. Yesterday cough and voice became
soundless. Today, because of dyspnea, has addressed to family pediatrician. During
examination are revealed slight pharyngeal hyperemia, perioral cyanosis, and tachypnea
above 30 per minute, retraction of additional muscles during inspiration. Heart tones are
weak, pulse is 130 per minute. What is the probable diagnosis?
А. Parainfluenza, croup syndrome.
В. Diphtheria of the larynx, stenotic stage
С. Measles, croup syndrome.
D. Chickenpox, croup syndrome.
E. Respiratory-syncitial infection, obstructive bronchitis
Answers for the self-control :
Tests: 1-A. 2-C. 3-B. 4-C.5-B.
Aids and material tools: Charts “Influenza”, “Upper respiratory viral infections”,
“Diphtheria”, “Measles”, “Chickenpox”, “Whooping cough”.
Student’s practical activities:
I. To perform the diagnosis:
1. Ask complaints, anamnesis and life history.
2. Examine the patients, find clinical features of disease
3. Make diagnose due to clinical and laboratory dates.
II Provide the treatment of croup syndrome and prevention of diseases that may be
complicated by croup syndrome.
Students must know :
1. Etiology, epidemiology and pathogenesis of croup syndrome.
2. Clinical diagnostic features of croup syndrome.
3. Laboratory data in patient with croup syndrome.
4. Differential diagnosis of croup syndrome in children.
5. Main treatment of croup syndrome.
6. Prevention of diseases that may be complicated by croup syndrome.
Student should be able to
1. Separate anamnesis data, which told us about risk factors of croup syndrome.
2. Find diagnostic clinical criterions of croup syndrome during examination of patients.
3. To perform differential diagnosis among diseases which have the same clinical
features.
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4. To learn main tendentions of the croup syndrome treatment.
5. To perform prevention of diseases that may be complicated by croup syndrome.
References:
Main:
1. Ambulatory pediatric care / edited by Robert A. Derchewitz;-2- nd ed. LippincotRaven, 1992.-p. 58-59; 151-153, 315-319, 602-605, 611-615, 618-623, 753-755,
742-748.
2. Current therapy in pediatric infections disease-2/ edited by D.Nelson, M.D.B.C.Decker Inc. Toronto. Philadelphia, 1988-p. 38-40, 44-51, 247-251.
Additional:
1. Textbook of Pediatric Nursing. Dorothy R. Marlow; R. N., Ed. D. –London, 1989.661p.
2. Pediatrics ( 2nd edition, editor – Paul H.Dworkin, M.D.) – 1992. – 550 pp.
Prepared by I.L.Goryshna
Adopted at the chair sitting 26.02.04
Minutes No 7
Revised at the chair sitting
Minutes No 1 August 29, 2006.
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