CROUP SYNDROMES

• Acute inflammatory disease of

the .

• Early winter.

• Mostly viral cause.

• Symptoms persist 4-7 days.

• VIRAL • Viral croup generally affects young children 6 months to 5 years of age in the fall and early winter and is most often caused by Parainfluenza virus serotypes. • However, many other viral organisms as well as M.pneumoniae can cause croup.

• in the subglottic space accounts for the predominant signs of upper airway obstruction although inflammation of the entire airway is often present.

SYMPTOMS AND SIGNS

• Usually, a prodrome of upper symptoms is followed by a barking cough and stridor.

• Fever is usually absent; patients with mild disease may have stridor when agitated.

• As obstruction worsens, stridor occurs at rest, accompanied in severe cases by retractions, air hunger( severe breathlessness) and cyanosis.

CLINICAL FINDINGS • On examination, the presence of cough and the absence of drooling favor the diagnosis of viral

croup over .

• Imaging are not routinely indicated for patients with classic presentation of croup. For atypical presentation, X-ray shows subglottic narrowing (the ) without the irregularities seen

in and a normal . TREATMENT • Treatment of viral croup is based on the symptoms.

• Mild croup, signified by a barking cough and no stridor at rest, requires supportive therapy with oral hydration and minimal handling.

• Mist therapy has historically been used but clinical studies do not demonstrate effectiveness.

1. Patients with stridor at rest require active intervention.

2. Oxygen should be administered to patients with oxygen desaturation.

3. Nebulized racemic epinephrine (0.05 ml/kg, maximum 1.5ml ) of 2.25% solution diluted in sterile saline, is commonly used because it has a rapid onset of action within 10-30 minutes, it is effective in alleviating symptoms and decreasing the need for intubation. • Dexamethasone, 0.6mg/kg intramuscularly as one dose, improves symptoms, reduces the duration of hospitalizations and frequency of intubations, and permits earlier discharge from the emergency department.

• Oral dexamethasone (0.15 mg/kg) may be equally effective for mild to moderate croup

• Inhaled budesonide (2-4 mg) also improves symptoms and decreases hospital stay and may be as effective as dexamethasone.

• Dexamethasone has also been shown to be more effective than prednisolone in equivalent doses. • The use of heliox, a mixture of helium and oxygen, improves turbulent airflow, but is not superior to nebulized medication. Its use is limited in hypoxic children because of its low fractional concentration of inspired oxygen. • If symptoms resolve within 3-4 hours of glucocorticoids and nebulized epinephrine, patients can safely be discharged without fear of a sudden rebound in symptoms. • If, however, recurrent nebulized epinephrine treatments are required or if respiratory distress persists, patients require hospitalization for close observation, supportive care, and nebulization treatment as needed.

• In patients with impending , an airway must be established. Intubation with an endotracheal tube of slightly smaller diameter than would ordinarily be used is reasonably safe. Extubation should be accomplished within 2-3 days to minimize the risk of laryngeal injury. Other underlying causes should be considered in hospitalized patients with persistent symptoms over 3-4 days despite treatment.

PROGNOSIS

• Most children with viral croup have an uneventful course and improve within a few days.

• Some evidence suggests that patients with a history of croup associated with wheezing may have airway hyper activity. It is not always clear if the hyper reactivity was present prior to the

croup episode or if the viral infection causing croup altered airway function.

BACTERIAL TRACHEITIS

• Bacterial tracheitis (pseudomembranous croup) is a severe life-threatening form of laryngotracheobronchitis.

• Tracheitis is a common cause of pediatric airway emergency requiring admission to the pediatric intensive care unit. This diagnosis must be high in the differential when a patients present with sever upper airway obstruction and fever. • The organism most often isolated is Staphylococcus aureus, but organisms such as H , group A Streptococcus pyogenes, Neisseria species, Moraxella catarrhalis, and other have been reported.

• A viral prodrome is common.

• The disease probably represents localized mucosal invasion of bacterial in patients with primary

viral croup, resulting in inflammatory edema, purulent secretions, and pseudo membranes.

• Although cultures of the tracheal secretions are frequently positive, blood

cultures are almost always negative.

SYMPTOMS AND SIGNS • The early clinical picture is similar to that of viral croup. However, instead of gradual improvement, patients develop higher fever, toxicity, and progressive or intermittent severe

upper airway obstruction that is unresponsive to standard croup therapy. • The incidence of sudden respiratory arrest or progressive respiratory failure is high, requiring airway intervention. Finding of toxic shock and the acute respiratory distress syndrome may be

also being seen. Aggressive medical treatment and debridement is indicated.

LAB FINDINGS AND IMAGING • The white cell count is usually elevated with a left shift. Cultures of tracheal secretions usually

demonstrate one of the causative organisms.

• Bronchoscopy showing a normal epiglottis and the presence of copious purulent tracheal

secretions and membranes confirms the diagnosis.

TREATMENT • Patients with suspected bacterial tracheitis will require direct visualization of the airway in a controlled environment and debridement of the airway. Most patients will be intubated because the incidence of respiratory arrest or progressive respiratory failure is high.

• Patients may also require debridement, humidification, frequent suctioning, and intensive care

monitoring to prevent endotracheal tube obstruction by purulent tracheal secretion.

• Intravenous antibiotics to cover S.aureus, H influenza, and the other organisms are indicated.

Epiglottitis

With the introduction of the Haemophilus influenzae conjugate vaccine, the incidence of epiglottitis is rare in countries with immunization programs. If disease occurs, it is likely to be associated with H influenzae in unimmunized children, or another organism such as nontypeable H influenzae, Neisseria meningitides, or Streptococcus species in immunized populations.

Signs and symptoms

 The classic presentation is a sudden onset of high fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis, and soft stridor. Patients often sit in the so-called sniffing dog position, with the hyperextended and the chin stretched forward, which gives them the best airway possible under the circumstances. Progression to total airway obstruction may occur and result in respiratory arrest.

The definitive diagnosis is made by direct inspection of the epiglottis, a procedure that should be done by an experienced airway specialist under controlled conditions (typically in the operating room during intubation). The typical findings are a cherry-red and swollen epiglottis and swollen arytenoids. Imaging - Lateral neck radiographs may be helpful in demonstrating a classic “thumbprint” sign caused by the swollen epiglottis. Obtaining radiographs, however, may delay important airway intervention. Treatment Once the diagnosis of epiglottitis is made, endotracheal intubation must be performed immediately in children but not necessarily in adults. After an airway is established, cultures of the blood and epiglottis should be obtained and the patient should be started on appropriate intravenous antibiotics to cover H influenzae and Streptococcus species. Extubation can usually be accomplished in 24–48 hours, when direct inspection shows a significant reduction in the size of the epiglottis. Intravenous antibiotics should be continued for 2–3 days, followed by oral antibiotics to complete a 10-day course.

References: 1- Hay, W., 2009. Current Pediatric Diagnosis & Treatment. 24th ed. New York: McGraw-Hill Medical. 2- Marcdante, K. and Kliegman, R., n.d. Nelson Essentials Of Pediatrics. 8th ed. Philadelphia: W.B. Saunders Co.