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  1. 1. Croup Present by: Dr: Sahar Eljaili Mohammed
  2. 2. • This is a 20 month old male who presents to the emergency department with a chief complaint of cough. • Two days ago he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh "barky," cough. Today he developed a "whistling" sound when he breathes, so his parents brought him to the emergency department. • His past medical history is unremarkable. His 6 year old brother also has cold symptoms.
  3. 3. • Exam: • VS T 37.5, P 140, R 36, BP 90/64, oxygen saturation 96% in room air. He is alert, with good eye contact, in mild respiratory distress. He has a dry barking cough and a hoarse cry. • He has some clear mucus rhinorrhea but no nasal flaring. His pharynx is slightly injected, but there is no enlargement or asymmetry.His heart is regular without murmurs. • His lung exam shows good aeration and slight inspiratory stridor at rest. He has very slight subcostal retractions. No wheeze or rhonchi are noted. His abdomen is flat, soft, and non-tender. His extremities are warm and pink with good perfusion.
  4. 4. • He is treated with nebulized racemic epinephrine and his cough subsided and his stridor resolved. • A lateral neck X-ray revealed no prevertebral soft tissue widening or evidence of epiglottitis. The subglottic region is mildly narrowed. • He is treated with oral dexamethasone. He is discharged home after 3 hour of monitoring and his parents were instructed to treat him with humidified mist therapy.
  5. 5. Introduction
  6. 6. Crou p  Croup is a respiratory illness characterized by inspiratory stridor, cough, and hoarseness.  These symptoms result from inflammation in the larynx and subglottic airway
  7. 7. Cont . A barking cough is the hallmark of croup among infants and young children, whereas hoarseness predominates in older children and adults. Although croup usually is a mild and self-limited illness, significant upper airway obstruction, respiratory distress, and rarely, death, can occur.
  9. 9. The term croup has been used to describe a variety of upper respiratory conditions in children including :  laryngitis  laryngotracheitis laryngotracheobronchitis  bacterial tracheitis  or spasmodic croup
  10. 10. Laryngitis: refers to inflammation limited to the larynx and manifests itself as hoarseness . It usually occurs in older children and adults Laryngotracheitis (croup) refers to inflammation of the larynx and trachea .Although lower airway signs are absent, the typical barking cough will be present.
  11. 11. Laryngotracheobronchitis (LTB): occurs when inflammation extends into the bronchi, resulting in lower airway signs (eg, wheezing, crackles, air trapping, increased tachypnea) Further extension of inflammation into the lower airways results in laryngotracheobronchopneumonitis, which sometimes can be complicated by bacterial superinfection. Bacterial superinfection can be manifest as pneumonia, bronchopneumonia, or bacterial tracheitis
  12. 12. Bacterial tracheitis: Bacterial tracheitis (also called bacterial croup) describes bacterial infection of the subglottic trachea, resulting in a thick, purulent exudate, which causes symptoms of upper airway obstruction Bacterial tracheitis may occur as a complication of viral respiratory infections (usually those which manifest themselves as LTB or (laryngotracheobronchopneumonitis) or as a primary bacterial infection.
  13. 13. Spasmodic croup: Spasmodic croup is characterized by the sudden onset of inspiratory stridor at night, short duration (several hours), and sudden cessation This is often in the setting of a mild upper respiratory infection, but without fever or inflammation. A striking feature of spasmodic croup is its recurrent nature, hence the alternate descriptive term, "frequently recurrent croup". Because of some clinical overlap with atopic diseases, it is sometimes referred to as "allergic croup".
  14. 14. ETIOLOGY
  15. 15. ETIOLO GY Croup is usually caused by viruses. Bacterial infection may occur secondarily.  parainfluenza virus: • Parainfluenza type 1 • Parainfluenza type 2 • Parainfluenza type 3
  16. 16. Other viral causes include: Respiratory syncytial virus (RSV) and adenoviruses Human coronavirus NL63 (HCoV-NL63) Measles Influenza virus Rhinoviruses, enteroviruses (especially Coxsackie types A9, B4, and B5, and echovirus types 4, 11, and 21), and herpes simplex virus Metapneumoviruses
  17. 17. Bacterial infection: Croup also may be caused by bacteria. Mycoplasma pneumoniae has been associated with mild cases of croup. secondary bacterial infection may occur in children with laryngotracheitis, laryngotracheobronchitis, or laryngotracheobronchopneumonitis. The most common secondary bacterial pathogens include Staphylococcus aureus, Streptococcus pyogenes, and S. pneumoniae
  18. 18. pathophysiology
  19. 19. pathophysiology • Like most respiratory infections, the initial site of infection is thought to be the nasopharynx with subsequent spread to the larynx and trachea. • The respiratory epithelium becomes diffusely inflamed and edematous, resulting in airway narrowing and stridor. • Reduced mobility of the vocal cords results in a hoarse voice or cry.
  21. 21. EPIDOMIOL OGY Croup affects about 15% of children most commonly occurs in children 6 to 36 months of age. It is more common in boys, with a male: female ratio of about 1.4:1 Most cases occur in the fall or early winter
  22. 22. CONT . family history of croup is a risk factor for croup and recurent croup ED visits for croup are most freguent B/W 10:00 PM and 4:00 AM hospital admission for croup have declined steadily since the late of 1970
  24. 24. CLINICAL PRESENTATION: • Croup generally starts with several days of : rhinorrhea pharyngitis  low-grade fevers  mild cough
  25. 25. CONT . •Over the next 12 to 48 hours, a progressively worsening "barky" cough, hoarseness and inspiratory stridor are noted, secondary to some degree of upper airway obstruction and laryngeal inflammation. •The speed of progression and degree of airway obstruction can vary widely.
  26. 26. CONT . The onset is often rapid and typically in the early morning hours (e.g., 2:00 am). Croup symptoms appear to subside during the day (possibly because of positioning), only to recur the following night. Thus, a child with significant stridor presenting during daylight, may be more seriously affected.
  27. 27. On examination • the physical presentation of croup has wide variation the child with croup typically does not appear toxic •Most children with mild symptoms have no more than a"croupy" cough and hoarse cry and some may have stridor only upon activity or agitation.
  28. 28. Children with more severe cases have: inspiratory and expiratory stridor at rest. visible suprasternal,intercostal,subcostal retractions. Air entry may be poor. lethergy and agitation hypoxemia and increasing hypercarbia respiratory arrest may occur suddenly during an episode of severe coughing
  29. 29. Warning signs: tachypnea,tachycardia out of proportion to fever. hypotonia. unable to maintain adequate oral intake. cyanosis.
  30. 30. Severity assessment: Westley croup score Normal, including sleep = 0 None = 0 None = 0 Normal = 0 None = 0 Level of consciousness Cyanosis Stridor Air entry Retractions Total score 0- 17 Depressed = 5 with agitation = 4 at rest = 5 with agitation = 1 at rest = 2 decreased = 1 markedly decreased = 2 mild = 1 moderate = 2 sevre=3
  31. 31. Mild croup: Is defined by a Westley croup score of <3 consists of occasional barking cough, no stridor at rest, and mild or absent suprasternal or subcostal retractions.
  32. 32. Moderate croup:  Is defined by a Westley croup score of 3 to 6.  includes frequent cough, audible stridor at rest, and visible retractions, but little distress or agitation.
  33. 33. Severe croup:  Is defined by a Westley croup score of ≥8.  consists of frequent cough, prominent inspiratory (and, occasionally, expiratory) stridor, conspicuous retractions, decreased air entry on auscultation, and significant distress and agitation. Lethargy, cyanosis, and decreasing retractions are harbingers of impending respiratory failure.
  34. 34. Diagnosis
  35. 35. Laboratory studies Laboratory studies add little to the diagnosis of croup if bacterial infection is not suspected. White blood cell counts may be elevated above 10,000 with a predominance of polymorphonuclear cells. White blood cell counts greater than 20,000 may suggest bacterial superinfection.
  36. 36. Imaging : Chest radiographs may show subglottic narrowing (in 50% of children with croup), but this can also be seen in normal patients. Lateral neck radiographs are often obtained, not as much to confirm the diagnosis of croup, but to rule out other causes of stridor such as soft tissue densities in the trachea, a retropharyngeal abscess and epiglottitis.
  37. 37. Croup: Anteroposterior radiograph with "steeple sign"
  38. 38. The lateral view :demonstrate overdistention of the hypopharynx during inspiration and subglottic haziness
  39. 39. Epiglottitis: thumb sign
  40. 40. Bacterial tractitis
  42. 42. DIFFERENTIAL DIAGNOSIS Acute epiglottitis Peritonsillar and retropharyngeal abscesses Foreign body aspiration or ingestion Allergic reaction Acute angioneurotic edema Upper airway injury Congenital anomalies of the upper airway Laryngeal diphtheria
  43. 43. Epiglottitis vs Croup Feature Epiglottitis Croup Organism H. influenzae parainfluenza virus Age 2-6 years 6m-3y Onset rapid gradual Site supraglottic subglottic Temperature high fever low grade fever Dysphagia severe absent (mild) Dyspnoea +++ variable Drooling present not present
  44. 44. Epiglottitis vs Croup (cont.) Feature Epiglottitis Croup Stridor inspiratory or expiratory mainly inspiratory Lymph nodes +++ + Cough not common barking cough Voice muffled hoarse Posture sitting forward lying down Behaviour quiet; terrified struggling Appereance toxic not toxic X-ray thumb sign steeple sign
  45. 45. Treatment
  46. 46. MILD CROUP Home treatment:  Keep child calm  Cool mist or night air  Steam(vaporizer of from shower  Antipyretics  Encouragement of fluid Oinutat kpea.tient treatment: Humidified air Single dose of oral dexamethasone(0.6 mg/kg)
  47. 47. MODERATE TO SEVERE CROUP Supportive care Humidified air or humidified oxygen Monitoring Fluids Intubation
  48. 48. Pharmacotherapy Corticosteroids Corticosteroids provide benefit for children with viral croup by reducing the severity and shortening the course of the symptoms Dexamethasone is the most commonly used, with the dose being 0.6 mg/kg (maximum 10 mg) by mouth or intramuscularly
  49. 49. Co nt. Clinical improvement from corticosteroids is usually not apparent until 6 hours after treatment. More recent studies have shown high dose nebulized budesonide to be as effective as dexamethasone, with more rapid onset of effect.
  50. 50. Nebulized epinephrine is thought to stimulate alpha-adrenergic receptors with subsequent constriction of arterioles and decreased laryngeal edema. Nebulized epinephrine may have marked effect to decrease inspiratory stridor and the work of breathing. The effects of this medication last less than two hours and children need to be monitored serially for the return of symptoms.
  51. 51. Racemic epinephrine Is administered as 0.05 mL/kg per dose (maximum of 0.5 mL)of a 2.25 percent solution diluted to 3 mL total volume with normal saline. It is given via nebulizer over 15 minutes. L-epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution. It is given via nebulizer over 15 minutes. Racemic epinephrine and L-epinephrine appear to be equally effective.
  52. 52. Antibiotic As n:tibiotics should be used only to treat specific bacterial complications of croup. Antitussives and decongestants : Antitussives and decongestants are of unproven benefit in the management of croup.
  53. 53. Co nt. Hospitalization if : • Progressive stridor • Stridor at rest • Respiratory distress • Cyanosis • Depressed mental status
  54. 54. Discharge criteria:  No stridor at rest  Normal pulse oximetry  Good air exchange  Normal color  Normal level of consciousness  Demonstrated ability to tolerate fluids by mouth
  55. 55. prognosis
  56. 56. Prognosis: Viral croup is usually a self-limited disease The prognosis for croup is excellent, and recovery is almost always complete. Symptoms usually improve within tree days, but may last for up to seven days Less than 5 percent of children with croup require hospital admission, and among those, 1 to 6 percent rMeoqrutairleit yin itsu braarteio, no ccurring in <0.5 percent of intubated children
  57. 57. Complications
  58. 58. Complications Complications in croup are rare.  Lymphadenitis  hypoxemia (oxygen saturation <92 percent in room air) and respiratory failure.  pulmonary edema  pneumothorax, and pneumomediastinum  otitis media  Secondary bacterial infections  Bacterial tracheitis  bronchopneumonia, and pneumonia  cardiac arrest and death
  59. 59. Questions
  60. 60. 1. Which of the following viruses are most commonly associated with viral croup? a. Adenovirus. b. Human papilloma virus c. Varicella virus d. Parainfluenza viruses e. RSV
  61. 61. 2. Which of the following is/are true? a. There is good evidence from randomized controlled trials that mist therapy is effective for the treatment of croup. b. Antibiotics are indicated in the treatment of croup. c. Dexamethasone has been shown to be effective in the treatment of croup.
  62. 62. 3. Which of the following is/are true? a. Croup affects more girls than boys. b. Croup shows no seasonal prevalence. c. Most cases occur in teenagers. d. It is a common respiratory infection in children.
  63. 63. 4- True/False: Once a child with croup has been given corticosteroid treatment and racemic epinephrine, they may safely be discharged home after 20-30 minutes of monitoring?
  64. 64. References: s