Good
Morning!
Semantic Qualifiers
Symptoms
Acute /subacute
Chronic
Localized
Diffuse
Single
Multiple
Static
Progressive
Constant
Intermittent
Single Episode
Recurrent
Abrupt
Gradual
Severe
Mild
Painful
Nonpainful
Bilious
Nonbilious
Sharp/Stabbing
Dull/Vague
Problem Characteristics
Ill-appearing/
Toxic
Well-appearing/
Non-toxic
Localized problem
Systemic problem
Acquired
Congenital
New problem
Recurrence of old
problem
• Harsh, high-pitched
resp sound
• Usually inspiratory
Stridor
– But can be biphasic
Site of
Pathology
Respiratory
Rate
• Cause by turbulent flow
• Sign of upper airway
obstruction
• NOT a diagnosis
Retractions
Audible Sounds
Extrathoracic
airway
Stridor
Intrathoracic
extrapulmonary
Wheezing
Intrathoracic
intrapulmonary
Wheezing
Alveolar
interstitial
Grunting
Stridor
• Viral croup
• Foreign body
• Noninfectious croup
• Retropharyngeal abscess
• Epiglottitis
• Peritonsillar abscess
• Bacterial tracheitis
• Angioedema
• Extraluminal compression
• Caustic ingestion
• Intraluminal obstruction
from masses
• Vocal cord dysfunction
“Croup”
• Group of conditions
– Acute and infectious causes of upper airway
inflammation
• Upper airway of children
Laryngotracheitis
• = most common “Croup” illness
– Laryngotracheitis vs.
Laryngotracheobronchitis/pneumonitis
• Predisposing Factors
–
–
–
–
Between age 3 months and 5 yrs
Peak in 2nd year of life
M>F
Can occur anytime of year but peaks in late fall and
winter
– Preceding URI illness
Laryngotracheitis
• Pathophysiology
– Inflammation involving the vocal cords and
structures inferior to the cords
Laryngotracheitis
• Pathophysiology
– Viral etiology is most common
• Parainfluenza viruses (type 1, 2, and 3) ~ 75% of cases
• Influenza A
– Associated with SEVERE disease
•
•
•
•
Influenza B
Adenovirus
RSV
Measles
– Mycoplama pneumoniae rarely isolated
Laryngotracheitis
• Clinical Presentation**
– URI symptoms for 1-3 days prior to signs of upper
airway obstruction
• Rhinorrhea, pharyngitis, mild cough, low-grade fever
– Characteristic “barking” cough, “seal-like”
– Hoarseness
– Inspiratory stridor
– +/- fever
Laryngotracheitis
• Clinical Presentation**
– Symptoms characteristically worse at night
– Agitation and crying aggravate symptoms
– Varying degrees of respiratory distress on exam
– Should not be hypoxic – this is a sign that
complete airway obstruction is imminent
Laryngotracheitis
• Diagnosis
– Clinical
– Xrays
• “Steeple sign” in
AP view
• Do not correlate
with disease severity
• Can help distinguish
from other causes
Laryngotracheitis
• Treatment**
– Most patients managed
as outpatients
– Cool mist??
• Not proven in literature, but used since the 1900’s
• If bronchospasm present, can worsen with cool mist
– Antibiotics not indicated in viral croup
Laryngotracheitis
• Treatment**
– Corticosteroids
• Action: decrease laryngeal mucosal edema
• Effective in reducing hospitalization rates, shorter
hospital stays, reduced need for subsequent
interventions
• Dose: 0.6mg/kg single dose DEXAMETHASONE (max
16mg)
– PO/IM Decadron both effective
– Clincal improvement 6 hours after dose
– Prednisolone less effective than Dexamethasone
Laryngotracheitis
• Treatment**
– Nebulized racemic epinephrine (Vaponeb)
• For moderate to severe croup
• Action: decrease laryngeal mucosal edema
• Dose: 0.25ml-0.5ml of 2.25% racemic epi in 3ml of NS
nebulized
–
–
–
–
Onset of relief 10-30min
Duration of activity <2-3 hours
Can repeat q20 min
Monitor for symptoms once
the Vaponeb activity duration
is over (rebound?), generally
3-4 hrs after a treatment
• Use caustiously in patients with tachycardia, and heart
conditions such as TOF or ventricular outlet obstruction
Laryngotracheitis
• Indications for hospitalization with croup
– Progressive stridor
– Severe stridor at rest
– Respiratory distress
– Hypoxia/cyanosis
– Depressed mental status
– Poor oral intake
– Need for reliable observation
Laryngotracheobronchitis/pneumonitis
• More severe form of croup
• Considered an extension of laryngotracheitis
associated with bacterial superinfection
– Occurs 5-7 days into the clinical course
– New onset fever
– Worsening clinical symptoms, toxic
– Increased work of breathing
• Signs of both upper and lower airway obstruction
• Requires empiric antibiotics
Feature
Acute
Spasmodic
Laryngotracheitis
Croup
Prodrome
URI
Mean Age
3 mo - 5 yr
Onset
gradual
Fever
variable
Hoarseness,
barking cough
Inspiratory stridor
Yes
Yes:
minimal to severe
Dysphagia
No
Toxic appearance
No
Etiology
Viral
X-ray findings
Steeple sign
Treatment
cool mist,
racemic epi neb,
dexamethasone
Epiglottitis
Bacterial
Tracheitis
Noninfectious Croup
• “Spasmodic” croup**
– Most often children 1 to 3 yrs
– Pathogenesis unknown – possible allergic etiology
– Clinically similar to croup but without the viral
prodrome or fever
– Most common in the evening
– Sudden onset, preceded by mild cough or hoarseness
– Episode of characteristic coughing, stridor and
respiratory distress, anxious
– Severity improves over hours and can have repeat
episodes x1-2 more nights
Feature
Acute
Spasmodic
Laryngotracheitis
Croup
Prodrome
URI
none or minimal
coryza
Mean Age
3 mo - 5 yr
1 to 3 yr
Onset
gradual
sudden
Fever
variable
no
Inspiratory stridor
Yes
Yes:
minimal to severe
Yes
Yes: usually
moderate
Dysphagia
No
No
Toxic appearance
No
No
Etiology
Viral
Noninfectious
X-ray findings
Steeple sign
---
Treatment
cool mist,
racemic epi neb,
dexamethasone
cool mist
Hoarseness,
barking cough
Epiglottitis
Bacterial
Tracheitis
Epiglottitis
• Predisposing Factors
– Typical age of patients 2 to 4 yrs
– Unimmunized
Epiglottitis
• Pathophysiology
– Prevaccine, most common cause:
• Haemophilus influenzae type B
– Now, larger number of cases in vaccinated
patients due to:
• Streptococcus pyogenes
• Streptococcus pneumoniae
• Staphylococcus aureus
Epiglottitis
• Pathophysiology
– Inflammation of
epiglottis
– Degree of
inflammation leads to
degree of obstruction
of airway
Epiglottitis
• Clinical Presentation
– Acute
– High fever
– Sore throat
– Dyspnea
– Rapidly progressing respiratory obstruction
• Can be within hours – become toxic, difficulty
swallowing, labored breathing
Epiglottitis
• Clinical Presentation
– Drooling
– Holding neck in hyperextended position
– Tripod position
– Stridor is a late finding!
– Not usually associated with a cough
Epiglottitis
• Diagnosis
– Visualization via laryngoscopy
• In controlled environment
Epiglottitis
• Diagnosis
– Xrays
• “Thumb sign” in
lateral view
Epiglottitis
• Treatment**
– Careful on exam**
• Avoid anxiety-provoking procedures (labs/IV), avoid
placing patient supine or direct inspection of oral cavity
• To prevent acute airway obstruction
– Medical emergency
– Placement of artificial airway in controlled setting
• Mortality ~6% without airway vs. <1% with airway
– Oxygen via mask until artificial airway
• As long as mask doesn’t cause agitation
Epiglottitis
• Treatment**
– Antibiotics**
•
•
•
•
Ceftriaxone
Cefotaxime
Meropenem
Obtain cultures from blood, epiglottic surface, and if
needed from CSF (after obtain airway)
• Treat with at least 7-10 antibiotics, but usually patient
improves after 2-3 days
Epiglottitis
• Rifampin prophylaxis indicated for:
– Any household contacts <48 months old and
incompletely immunized
– Any household contacts <12 months old and has
not received primary vaccination series
– Any immunocompromised child in the household
Feature
Acute
Spasmodic
Laryngotracheitis
Croup
Epiglottitis
Prodrome
URI
none or minimal
coryza
Mean Age
3 mo - 5 yr
1 to 3 yr
2 to 4 yr (range 1 to 8 yr)
Onset
gradual
sudden
rapid
Fever
variable
no
High
Inspiratory stridor
Yes
Yes:
minimal to severe
Yes
Yes: usually
moderate
No
Yes:
moderate to severe
Dysphagia
No
No
Yes
Toxic appearance
No
No
Yes
Hoarseness,
barking cough
none or mild URI
Etiology
Viral
Noninfectious
Bacterial: Hib, Strep,
S. aureus
X-ray findings
Steeple sign
---
Thumb sign
Treatment
cool mist,
racemic epi neb,
dexamethasone
cool mist
Intubation,
Ceftriaxone, or Cefotaxime,
or Meropenem
Bacterial
Tracheitis
Bacterial Tracheitis
• Predisposing Factors
– Mean age 5 to 7 yrs
– M=F
– Preceding viral respiratory
infection
• Bacterial complication of
croup
– More common than epiglottitis
in vaccinated patients
Bacterial Tracheitis
• Pathophysiology
– Mucosal swelling at the
level of the of the cricoid
cartilage
– Complicated by copius, thick, purulent secretions,
sometimes pseudomembranes
– Most common pathogen: S. aureus
• Other organisms: Moraxella catarrhalis, nontype H.
influenzae, and anaerobic organisms
Bacterial Tracheitis
• Clinical Presentation**
– Preceding croup illness with cough
– Then develops high fever and toxic-appearance
– Differs from epiglottitis
• Patient can lie down, does not drool, no dysphagia
– Differs from croup
• More toxic, does not respond to racemic epi
Bacterial Tracheitis
• Diagnosis
– Clinical picture
• Toxic + absence
of classic epiglottitis
– Xrays
• Not necessary
• Findings of irregular
lining of the trachea
due to pseudomembranes
• Can have “steeple sign”
Bacterial Tracheitis
• Treatment**
– Artificial airway required in ~50-60% of patients
– More likely to require intubation if younger
– Antibiotics
• Including appropriate Staph coverage
• Vanc + 3rd gen Cephalosporin = empiric coverage
Feature
Acute
Spasmodic
Laryngotracheitis
Croup
Epiglottitis
Bacterial
Tracheitis
none or mild URI
URI/croup
Prodrome
URI
none or minimal
coryza
Mean Age
3 mo - 5 yr
1 to 3 yr
2 to 4 yr (range 1 to 8 yr)
5 yr to 7 yr
Onset
gradual
sudden
rapid
acute after prodrome
Fever
variable
no
High
High
Hoarseness,
barking cough
Inspiratory stridor
Yes
Yes:
minimal to severe
Yes
Yes: usually
moderate
No
Yes:
moderate to severe
Variable, with
prodrome
Yes:
Variable
Dysphagia
No
No
Yes
No
Toxic appearance
No
No
Yes
Yes
Bacterial: S. aureus
Etiology
Viral
Noninfectious
Bacterial: Hib, Strep,
S. aureus
X-ray findings
Steeple sign
---
Thumb sign
Irregular tracheal lining
Intubation,
Ceftriaxone, or Cefotaxime,
or Meropenem
Often intubation
required,
Vancomycin and 3rd
gen Cephalosporin
Treatment
cool mist,
racemic epi neb,
dexamethasone
cool mist
Noon
Conference!