2. CROUP
Term croup describes both laryngotracheobronchitis and laryngotracheitis.
Laryngotracheobronchitis refers to “ inflammation of larynx , trachea and bronchi
mostly of viral pathology.
Present with : low grade fever, cough , cold followed by barking type of cough ,
stridor and chest indrawing.
Symptoms are characteristically worse at night and resolve within a week
Croup is a disease of upper airway and alveolar gas exchange is normal
Rarely upper airway obstruction progresses and is accompanied by increasing
respiratory rate ,nasal flaring supra/infra/intercostal retractions and continuous
stridor .
.
3. c) Severe croup – stridor at rest
severe chest indrawing
poor air entry on bilateral lung fields
may be hypoxic , significant agitation and cyanosis .
Divided into
a) mild cases – occasional barking cough
no stridor at rest
no indrawing
b)moderate cases – frequent barking cough with stridor at
rest
retractions +
good air entry on bilateral lung fields .
4. Age of presentation 6 moths to 6 years old ,peak incidence in children 12months to 2 years
WESTLEY croup score : objective measure to identify severity of
croup
Mild score – 0 to 2
Moderate score – 3 to 5
Severe score – 6 to 11
Impending respiratory failure – 12 to 17
ETIOLOGY :
Viral – parainfluenza virus – 1,2,3
influenza A, B
RSV
Measles
Mycoplasma
5. Chest wall retraction None 0
Mild +1
Moderate +2
severe +3
stridor none 0
With agitation +1
At rest +2
cyanosis none 0
With agitation +4
At rest +5
Level of consciousness normal o
disoriented +5
Air entry normal 0
Decreased +1
Markedly decreased +2
6. Management
1) lab – in some cases x-ray neck may reveal subglottic narrowing as
classical “steeple sign “
This Photo by Unknown Author is licensed under CC
BY-SA
7. Treatment
1)Airway management - most imp step in cases of stridor in order to avoid hypoxic
respiratory failure, initially maintain airway , clear secretions and providing humidified oxygen
to maintain sPo2
> 95%
2) Epinephrine nebulization – reduces mucosal edema
L –epinephrine injection 0.5 ml/kg ,maximum 5 ml
added to 2 to 3 ml NS in nebulizing chamber and Nebulization is given along with
oxygen .
stridor is significantly reduced within 30 minutes of nebulization, risk of rebound
increase in symptoms present , so observe the patient for at least 2 hours
8. Corticosteroids :
oral , intramuscular or intravenous dose of dexamethasone is effective in reducing upper airway
edema .
onset of action is within 1 hour and peak effect noted in 6 to 12 hours .
single dose of dexamethasone 0.6 mg/kg is effective .
No significant difference between oral dexamethasone and prednisolone in reducing croup
symptoms
“Corticosteroids reduce the need for epinephrine nebulization , intubation and frequency of
readmission”
Inhaled corticosteroid as budesonide nebulization 2 to 4 mg can also be given
Heli ox : helium oxygen mixture 60:40 or 70: 30 promotes laminar gas flow in obstructed
airways ,
used for severe croup ( not easily available )
Antitussives and decongestants have no role in croup .analgesics provide comfort by
reducing pain and fever.
9. ACUTE EPIGLOTTITIS
Etiology
bacterial
Hemophilus influenza type –B
Age of presentation – 2 to 6 years
Clinical features – acute onset of fever
irritability
throat pain ( severe dysphagia )
drooling of saliva
patient assumes tripod position with hot potato voice and soft
stridor
Progression to respiratory failure occurs very quickly
Incidence of acute epiglottitis has reduced dramatically due to universal
immunization against Hemophilus influenza
10. Management
1) Diagnosis is done by direct visualization of swollen red epiglottis and
culture swab taken from surface.
2) Neutrophilic leukocytosis may be present.
3) X-ray of neck in anterior-posterior and lateral view with head in slight
extension in deep inspiration.
“thumb sign – swollen epiglottis”
If intubation required , 0.5mm smaller ET tube for
age inserted
Iv antibiotics like ceftriaxone / Cefotaxime are
administered and airways kept secured for at least
48 to 72 hours till edema subsides
This Photo by Unknown Author is
licensed under CC BY-SA-NC
11. Epiglottitis is medical emergency and warrants immediate airway placement
Racemic epinephrine and corticosteroids are ineffective
Indication for Rifampin prophylaxis 20mg/kg orally once a day for 4 days for all
household members include a child within the home who is younger than 4 years
and incompletely immunized, younger than 12 months age and not completed
primary vaccination series or immunocompromised
Complications : pneumonia , otitis media , cervical lymphadenitis or rarely
meningitis or septic arthritis can occur
12. APPROACH TO CHILD WITH RESPIRATORY DISTRESS
Definition : any unusual pattern of breathing , causing subjective feeling of
discomfort , in previously well child is termed as Respiratory distress .It includes fast or
slow breathing ,shallow or labored efforts ,noisy breathing .
Cut offs for RR marking significant lower chest disease (WHO)
Age group Respiratory rate cut off
Young infant ( < 2 months ) > 60/min
Infants ( 2 months – 1 year ) >50/min
Children ( 1 -5 years ) >40/min
School children (>5 years ) >30/min
13. Causes of respiratory distress in children
Upper respiratory tract involvement
croup , acute epiglottitis
retropharyngeal abscess
foreign body aspiration
diphtheria
laryngospasm
lower respiratory tract involvement
pneumonia
bronchiolitis
asthma
pneumothorax
atelectasis
pleural effusion or empyema and hemothorax
14. Non pulmonary causes
- congestive heart failure due to heart disease or severe anemia
CNS infections , cerebral edema ,tumor ( raised Ict , GBS, spinal cord injury )
- metabolic acidosis
renal failure
renal tubular acidosis
diabetic acidosis
psychogenic hyperventilation , anxiety and panic attacks
15. Clinical pearls
symptoms of impending respiratory failure
- cyanosis
- silent chest
- poor respiratory efforts
- fatigue/ exhaustion
- agitation or reduced level of consciousness
preterminal signs :
bradycardia, desaturation and altered sensorium
16. Clinical features diagnosis
Fever , cough and rapid breathing Lower respiratory tract infections like
pneumonia , bronchiolitis
Exercise induced dyspnea Asthma , congestive heart failure ,severe
anemia
Nocturnal cough, orthopnea and
dyspnea
Congestive heart failure
Fever , sore throat, stridor Acute epiglottitis
Severe chest pain with rapid ,shallow
breathing ,decreased air entry
Pneumonia , pneumothorax , pulmonary
embolism
Fast breathing , altered sensorium ,
polyuria ,dehydration
Diabetic acidosis
Acute respiratory distress after
choking ,hyperinflated chest
Foreign body inhalation
Clinical feature based diagnostic clues
19. *H/o recurrent wheeze
*family hist of
asthma/atopy
*good response to
bronchodilator
*B/L hyperinflation of
chest
*Age <2yrs
*h/o viral prodrome
*poor response to
bronchodilator
*B/L hyperinflation of
chest
*h/o chocking
*U/L wheeze
*X ray s/o air
trapping
*h/o fever ,cough
*Fast breathing
*chest indrawing
*consolidation
,infiltrates in cxr
asthm
a
bronchiolitis
Foreign
body
pneumoni
a
WHEEZE/CREPTS
Bronchodilato
r
steroid
O2 IV
fluids
Bronchoscopic
removal
IV
antibiotics
20. Decreased air
entry
h/o fever, cough, fast
breathing trauma
Hyper resonance
on percussion
pneumothorax
ICD
Dullness on
percussion
Pleural
effusion
ICD/antibiotic
s
22. DIARRHEA
Is one of the major contributors to under five age mortality in india
It is responsible for 10% infant deaths and 14% of 0 to 4 year children deaths in our country
Definition :
Acute diarrhea –passage of loose /watery stool more than three episodes ( in 24hrs)
with/with out vomiting .
stool consistency is more important than frequency .
further divided into a) acute watery diarrhea – secretory nature (
producing large quantities of watery stools).
b) acute bloody diarrhea – invasive nature ,mucosal invasion leading to
blood in stool and cramping.
23. Prolonged diarrhea – last more than 7 days and requires a different
approach for management than acute diarrhea
persistent diarrhea – lasts more than 14 days and can lead to malnutrition
and non intestinal infections apart from dehydration .
24. Etiology
Infections
viruses- rotavirus, adenovirus , calcivirus
bacteria – E.coli , V.cholera, C.jejuni, salmonella ,shigella
protozoal – E. histolytica , G lamblia , cryptosporidium
Non infective
drug induced – antibiotics
inflammatory bowel disease
celiac disease
hyperthyroidism
25. Clinical features
following points must be noted on history
1) Onset and duration of diarrhea
2) Frequency ,color and consistency of stool
3) Presence of blood in stool
4) Presence of fever , vomiting ,cough or other accompanying symptoms ( convulsion ,recent me
5) Recent travel if any
6) Presence of any comorbidities and drug history
7) Immunization history
8) Pre illness feeding practices ( raw/undercooked food , bottle feeding )
9) Type and amount of fluids (including breast milk )
26. features Small bowel diarrhea Large bowel diarrhea
Volume of stools large small
frequency Not very frequent
Odour of stools offensive odourless
Nature of stools Bulky, watery,
steatorrhea, frothy
Loose stools with blood
and mucus or jelly like
tenesmus absent present
dehydration present Usually absent
complications dehydration HUS, toxemia
27. features Osmotic diarrhea Secretory diarrhea
stools Large volume ,semisolid Large volume ,watery
flatulence ++ -
Stool consistency Soupy-lactose watery
Evidence of
malabsorption
present absent
Perianal excoriation present absent
Stool pH <5 >6
Stools for reducing
substances
positive negative
appearence Not ill look Ill loking
28. - For severity
decreased urine frequency /concentrated appearance of urine (signifies
dehydration)
Activity and alertness of child
- Cholera typically presents with profuse watery diarrhea with characteristic fishy
odor.
- Dysentery is bacterial origin and Presents with blood and mucus in stool ,
abdominal cramping and fever
- Intussusception and appendicitis sometimes require imaging
- Urinary tract infections can initially present as fever with diarrhea and require urine
tests for differentiation .
- Complications a) dehydration
- b)AKI
- c)seizures ( dur to dyselectrolytemia / hypoglycemia )
- d)encephalopathy
- e)circulatory shock
29. Assessment Severe dehydration
General condition Lethargic , unconsciousness
eyes Sunken
Skin pinch Goes back very slowly
thirst Drinks poorly
Heart rate Marked tachycardia /bradycardia
Capillary refill Markedly de;ay
Periphehries Cold /cyanotic
Urine output Markedly decreased
Fluid deficit as% of body >10%
Mucosal membranes Dried out
Fluid deficit in ml/kg body weiht >100 mlkg
30. Laboratory investigations
-complete blood count
-Electrolytes
-Blood gas
-Renal function tests
-Glucose level
Elevated BUN has been shown have some correlation with degree of dehydration
Serum bicarbonate less than 17 mEq/l has been demonstrated to have 94
%sensitivity for more than 10% dehydration
Inflammatory markers such as C-reactive protein and ESR cannot reliably
differentiate between viral and bacterial etiologies
Blood culture is limited utility except to detect salmonella
31. - Urine specific gravity is an indicator of degree of dehydration
- Urinalysis can help to differentiate from urinary tract infection
- Stool routine microscopy can reveal presence of blood, mucus ,and
leucocytes (dysentery) and in rare cases protozoal cysts/trophozoites
- Few exception when identification of etiological agent is important
- cholera
- suspected hemolytic uremic syndrome
- hospital acquired diarrhea (after 3 days of admission )
- suspected clostridium difficile infection
- prolonged diarrhea more than 2 weeks –to decide on antibiotic
administration
Abdominal imaging (ultrasound /CT) is indicated only in cases with severe
abdominal pain and tenderness or strong clinical suspicion of underlying
pathology( appendicitis)
Endoscopy is reserved only for cases of protracted diarrhea with unclear
etiology
32. Clinical evaluation of dehydration
a) Mild dehydration - <5% in infant , < 3% in older child
normal or increased pulse
decreased urine output ; thirsty
b)Moderate dehydration – ( 5 to 10 % in infant , 3 to 6 % in old child )
tachycardia , little or no urine output
irritable /lethargic , dry mucous membranes
delayed capillary refill ( >1.5 sec)
sunken eyes and fontanelle , delay in skin elasticity
c)Severe dehydration – ( > 10% I infant , > 6% in older child )
peripheral pulses either rapid , weak or absent
no urine output
poor skin turgor
delayed capillary refill ( >3sed)
very sunken eyes and fontanelle
decreased blood pressure
33. Treatment of severe dehydration
Mainstay of treatment is rehydration i.e “restoration of water and electrolyte deficit
simultaneously along with maintenance fluid therapy and replacement of ongoing
losses”
Require iv fluid therapy .generally ringer lactate(RL) or normal saline (NS) is used for iv
dehydration
Use of large amounts of NS leads to hyperchloremic metabolic acidosis
For infants , 30 ml/kg iv RL is given in 1 hour followed by 70 ml/kg over next 5 hours
Correction in older children is done faster
-initial 30ml/kg over 30 minutes followed by 70ml/kg in next 2 half
hour
The patient should be continuously reassessed ; if radial pulses are weak , fluid should
be administered at faster rate
A patient with signs of shock should be managed with fluid boluses and if required
ionotropic support similar to septic shock guidelines
34. In acute diarrhea , dyselectrolytemias are commonly seen and include
hyponatremia hypernatremia and hypokalemia.
- Extreme high or low sodium leads to adverse effects including seizures,
cerebral edema ,.
- Oral rehydration therapy wherever feasible is helpful and safer than
intravenous therapy as will not lead to sudden swing in sodium.
- Potassium losses during diarrhea ,if not replaced will lead to hypokalemia
,especially in children with malnutrition , which has deleterious effects
including muscle weakness ,paralytic ileus and arrythmias .
35. Zinc supplementation : has an important role in metallo-enzymes and cell
membrane ,and function .
Zinc supplementation reduces both duration and severity of diarrhea in children less
than 5years of age .
It is recommended to give zinc to all children more than 3 months at dose of 20mg
elemental zinc /day during and for up to 7 days after diarrhea
Vitamin A supplementation is also useful
Role of antimicrobial therapy : no role for routine use of antimicrobial agents in acute
diarrhea
few select conditions
a)cholera – profuse voluminous watery diarrhea with potential for severe
dehydration and shock
single dose of doxycycline in an older child or 3 day course of
erythromycin/azithromycin in a child less than 12 years is effective in aborting the
illness
36. b) Acute dysentery /bloody diarrhea (shigella) : Nalidixic acid /ciprofloxacin or 3rd
generation cephalosporin for 3 to 5 days should be given .
c) Salmonella (typhoid): prolonged antibiotic therapy for 10 to 14 days with ceftriaxone
/cefixime is required .
d) Clostridium difficile diarrhea is very rare and seen in population like
immunocompromised children on prolonged antibiotics , treatment with oral
metronidazole or vancomycin is recommended.
Role of probiotics : preliminary data from west indicate that probiotics have a beneficial
role In acute gastroenteritis in children .
Antiemetics : vomiting commonly accompany acute diarrhea ,but is usually self limited
and resolves in 48 hours of rehydration .
in severe recurrent vomiting domperidone /ondansetron can be used , the
concern with ondansetron is cause cardiac arrythmias ,especially in presence of underlying
long QT syndrome .
37. Diet : age appropriate feeding should be continued and not stopped in cases with
mild – moderate dehydration .
In severe dehydration or when there is excessive vomiting ,feeding should be
started as quickly as possible once rehydration and supportive care has been
provided.
Enteral nutrition is important for regeneration of enterocytes in GIT damaged by
infection .
Breastfeeding should be continued and ORS offered in between feeds In young
infants .
Antimotility agents ( loperamide ) adsorbents ( charcoal) bismuth or
cholestyramine should NOT be used in treatment of acute childhood diarrhea
38. COVID 19 UPDATES
- Total cases recorded in world over 24 hors 2,54, 122
- India has recorded over 50,000 cases in past 24 hours for consecutive last 7 days
- Now
- total cases in india – 19,06,613
- total deaths - 39,820
- Fatality rate 2.10%
TELANGANA –total cases confirmed 68,946
recovered 49,675
total deaths 563
39. ICMR – human trials of indigenously developed Covid vaccines move to phase
2
At present ,there are three vaccines that are in different phases of clinical testing
in india
First one – inactivated virus vaccine developed b Bharat biotech , completed
phase 1 study and started is phase 2 study
Simialrly Zydus cadila DNA vaccine completed phase 1 and started phase 2
Recombinant oxford vaccine manufactured by serum institute of india given
approval for phase 2 and 3 clinical trials ,which would start within a week