1. Croup
& ACUTE EPIGLOTTITIS
Baha D .alosy

2. Objectives - Goals
1. Diagnosis and Management of Croup
1. Review natural history of viral croup
2. Distinguish between and review evidence
of various treatment options
2. Determining need for outpatient vs
inpatient treatment
1. Develop a differential diagnosis
2. Review indications for hospitalization

3. Definition
 “A generic term”
 A heterogenous group of illnesses
affecting the larynx, trachea, and
bronchi
 Viral origin
 Characteristic cough, inspiratory
stridor, hoarseness

4. Epidemiology
 Annual incidence: 6 cases per 100
children younger than 6yoa
 Affects children 6mos-12yoa, peak
incidence at 2yoa
 Boys:Girls 1.5:1
 Fall and winter predominance

5. Cost
 Leading cause of hospitalization in
children younger than 4yoa
 $56 million annually

6. The Usual Suspects
 Viral: Parainfluenza, Influenza A &
B, Adenovirus, RSV, rhinovirus,
enteroviruses, measles
 Spasmodic: viral associated, possibly
allergic reaction to antigens

7. Clinical Course
 Symptoms
 12-72hr prodrome of
fever/ coryza
 Hoarseness
 “Croupy”/barking
cough
 Stridor
 Dyspnea/wheeze
 Signs
 Hx consistent w/
croup
 Normal pulse ox
 Low-grade fever

8. Differential Dx
 Epiglottitis
 Bacterial tracheitis
 Foreign body
 Subglottic stenosis
 Peritonisillar
abscess
 Retropharyngeal
abscess
 Diptheria
 Laryngomalacia
 Vocal cord
paralysis
 Smoke inhalation
 Burns/Thermal
injury
 Neoplasm
 Laryngeal fracture

9. Studies?
 Plain neck XR: “Steeple sign”
 CT: supected other causes
 Larynogoscopy

10. Management
 Serial observation
 Mist therapy
 Steroids
 Epinephrine

11. Indications to Hospitalize
 Actual/expected epiglottitis
 Cyanosis
 Depressed sensorium
 Hypoxemia
 Pallor
 Progressive stridor
 Resp distress
 Restlessness
 Toxic-appearing

12. ACUTE EPIGLOTTITIS
 First described in 1878 by Michel and labeled “angina
epiglottidea anterior”, epiglottitis, or more correctly
supraglottitis, represents a true airway emergency. It
is a bacterial cellulitis of the supraglottic structures,
most notably the lingual surface of the epiglottis, but
also affecting the aryepiglottic folds. As the
supraglottic edema increases, the epiglottis is forced
posteriorly causing progressive airway obstruction.
Supraglottitis tends to occur in patients aged 2 to 7
years old, but cases in patients under 1 year have
been reported

13.  Haemophilus influenzae type B
(HIB) is the most commonly
implicated organism, but
group A, β-hemolytic
streptococcus, staphylococcus,
pneumococcus, klebsiella,
pseudomonas, candida and
viruses have been isolated as
well..

14. Supraglottitis
 odynophagia
 fever
 irritability
 stridor
 rapidly progressive

15. Supraglottitis
 if suspected, diagnose by direct
laryngoscopy in OR
 lateral neck film - “thumb sign”
 1nasotracheal intubation
 IV antibiotics
 extubate when air leak noted -
usually within 48 hours

16. Epiglottitis Croup
Age Can occur in infants, older
children, or adults
Six months to six years
Onset Sudden Gradual
Location Supraglottic Subglottic
Temp High fever Low-grade fever
Dysphagia Severe Mild or absent
Dyspnea Present Present
Drooling Present Present
Cough Uncommon Characteristics cough
Position Sitting forward with mouth open Comfortable in different
positions
Radiology Positive thumb sign* Positive steeple sign
.
Comparison of the Features of Epiglottitis and Croup

17. Management: Steroids 1
 1970 – the debate begins!
 “With the battle won, what remains
are largely minor skirmishes
 Nebulized vs oral vs IM
 Inpatient vs outpatient
 Dose

18. Management: Steroids 2
 BMJ 1999, meta-analysis: Steroids
improve sx within 6hrs for up to 12hrs
 Nebulized vs Oral: 1999 & 2004 RCTs,
equivalent; 2002 oral significantly better.
 Oral vs IM: 2000 Randomized,
uncontrolled, equivalent
 Dose: equivalent outcomes with 0.15/kg,
0.3/kg and 0.6/kg dexamethasone

19. Management: Steroids 3
 Nebulized vs oral vs IM
 For children with increased WOB
 Might consider oral or IM over nebulized
 Inpatient vs Outpatient
 Either – depends on VS/PE
 Dose
 PO: 0.15mg/kg – lowest known effective
dose of dexamethasone
 IM: 0.15-0.6mg/kg IM

20. Management: Epinephrine
 For moderate to severe distress
 5ml 1:1000 Nebulized racemic
epinephrine
 Decreased stridor/retractions in
30min
 Duration 2 hrs
 Rebound phenomenon
 Observe 3-4hrs after administration
 Side effects: tachycardia, HTN

21. Case #1
 T.T. is a 16mos baby who comes in
w/ his very worried mother.
 Runny nose started 2 days ago
 Temp 100.3 yesterday
 Barking cough started this AM
 Now making a horrible noise when he
takes a deep breath in
 Refuses to lie down

22. Case # 1 Continued
 VS: 99.8F 120 22 O2 sat 96% when quiet
 Gen: alert, sitting in mother’s lap quietly when
you enter, sees you and starts to cry  you note
inspiratory stridor
 Ears: nl TMs
 Nose: rhinnorhea
 Mouth: no exudate, tonsils normal
 Neck: cervical LAD
 Chest: expiratory wheeze, inspiratory sounds
obscured, subcostal retractions worsened w/
crying
 CV: RRR no murmur
 Ext: 2+ cap refill, wwp

23. Case #1 – Follow-up
 You decide to give T.T. a dose of
dexamethasone in the clinic at
0.3mg/kg
 Advise mother to check in on him
during the night and gave warning
signs
 Suggest taking him out into the air or
running a hot shower might help

24. Case #1a
 T.T. returns to your clinic in 2 days.
His mother says that the cough is
tapering and he is sleeping better
through the night. However, he has
been tugging at his ear all day long
and complaining of pain.
 PE: notable for a erythematous TM on
left w/ decreased mobility and
obscured landmarks

25. Complications
 Otitis media
 Bronchiolitis
 Pneumonia (rare)
 Bacterial tracheitis (rare)

26. Summary
 Croup is a common viral illness in
children
 Treatment options include
 Steroids – good evidence to support
 Epinephrine – years of experience and
trials support its use
 Mist – years of use/no data to support
 Evidence supports outpatient
treatment in mild to moderate croup

27. Case #1a Follow-up
ANTIBIOTICS?
I THINK NOT!