presentation about croup and epiglotits clinical signs and symptoms diagnosis and treatment

1. Croup & Epiglottitis
By Dr. Shahzaib Rasool
House Officer GTTH

2. Learning Objectives
• What is croup/ Epiglottitis
• Pathophysiology
• Clinical features
• Investigation
• D/D
• Management
• Complications
• Q/A

3. A 2 year old boy presents with noisy breathing on
inspiration, marked retractions of the chest wall,
flaring of the nostrils and hoarseness. Cough is
worsening at night. He has a mild URTI for 3 days.
On examination he has fever of 100f, R/R 55 per
min, and H/R 140 per min.
• What is D/D?
• What is provisional diagnosis?

4. What is croup ?

5. Croup
(laryngotracheobronchitis)
• Croup is a term used for a respiratory distress with
inspiratory stridor, cough (barklike or brassy) and
hoarseness resulting from obstruction in the region of
the larynx,trachea or bronchi.
• Most patients are between the age of 3 months and 5
years, with peak in the 2nd year of life.
• More common in boys and in winter months.
• Approximately 8-15% of children with croup require
hospitalization and among those , less than 1%require
intubation.
• Mortality is rare, occurring in <0.5% of intubated
children.

6. Anatomy
of Neck

7. Etiology
• Para-influenza viruses (type
1,2,3) -75%
• Influenza A and B viruses
• Adenovirus
• RSV
• Measles virus
• Bacteria

8. Pathophysiology

9. Clinical features
• Viral croup usually has a gradual onset and course
• Symptoms are often worse at night
• Initially child gets a cold with cough, coryza and low grade fever
• Gradually (in 12-48 hrs) cough becomes “croupy” ( barky with inspiratory
stridor) causing varying degrees of respiratory distress with retractions and
even cyanosis
• The duration of symptoms is usually 3-7 days
• Other family members might have mild respiratory illness with laryngitis

10. Severity criteria for croup

11. Diagnosis
• Diagnosis is usually apparent from clinical features and examination
• O/E = hoarse voice, coryza, a normal or minimal inflamed larynx and an
increased respiratory rate with prolonged inspiratory phase and stridor
• Xray = subglottic narrowing
• White cell count = normal

12. X ray AP view
shows glottic
narrowing
(steeple sign)

13. Differential Diagnosis
• Acute epiglottitis
• Retropharyngeal abscess
• Peritonsillar abscess
• Foreign body aspiration

14. Indications for hospitalization
• Cyanosis
• Decreased level of consciousness
• Progressive stridor
• Toxic appearance

15. Management
• Main treatment includes :
1 airway management
2 treatment of hypoxia
Mist therapy > it is given by hot steam by a vaporizer or cold steam from a
nebulizer. Respiratory distress may improves within minutes but humidification
should be continued until the cough subsides
Oxygen should be provided
Nebulized racemic epinephrine > ( 0.25-0.5ml of 2.25% racemic epinephrine in 3ml
of normal saline can be used as often as every 20 min)
Dexamethasone > (0.6mg/kg once oral or I/M)
Anti biotics > only when suspicious of secondary bacterial infection

17. Discharge criteria
• No stridor at rest
• Normal pulse oximetry at room air
• Normal color
• Normal level of consciousness
• Good air exchange
• Demonstrated ability to tolerate fluids by mouth

19. Complications of croup
• Secondary bacterial infection
• Hypoxia with respiratory fatigue
• Pulmonary edema
• Pneumothorax
• Pneumomediastinum

20. Spasmodic Croup
• Characterized by sudden onset of inspiratory stridor at night,short duration
and sudden cessation.
• This is often in the setting of a mild upper respiratory infection but without
fever and inflammation.
• Clinical course usually benign, symptoms are almost always relieved by
comforting the anxious child and administering humidified air. Rarely children
may benefit from treatment with corticosteroids and /or nebulized
epinephrine.

21. (439) Sounds of Croup (Laryngotracheitis) - Lung Sounds -
MEDZCOOL - YouTube

22. An 11 months old girl presents with fever,
cough, difficulty in breathing and
palpitations.On examination she is tachpneic ,
has stridor and subcostal and intercostal
recessions. She is not toxic looking.
• What is most likely diagnosis?
• What is the commonest etiological agent?
• Give steps of management.

23. Acute Epiglottitis

24. Acute Epiglotitis
• Refers to infection of epiglottis, the aryepiglottic folds and arytenoid soft
tissues
• The condition occurs mostly in the winter months, affecting males often.
• Rarely occurs before age of 2 years and the peak incidence is between 2-5
years.
• It is a bacterial infection , the commonest organism being H.Influenza type b.
• The incident of epiglotitis may be markedly decreased due to use of vaccine,
therefore other agents such as strep.pyogenes,step.pneumonia, staph.aureus
and non type b.
•

25. Pathophysiology
• Acute epiglottitis may be due to direct invasion of the mucosal layer by
microorganisms.
• Infectious microorganisms may lead to acute inflammation of the epiglottitis from
direct invasion or spread via bacteraemia. Typically, bacteria (most common cause)
reside in the nasopharynx and infiltrate the epiglottis mucosa through defects (i.e.
microtrauma).
• Defects in the mucosa may occur due to a preceding viral illness or direct trauma from
swallowing food. Inflammation and swelling occur and rapidly lead to infection of the
entire supraglotticairway leading to potentially life-threatening airway obstruction.

26. Clinical features
• Abrupt onset of high grade fever 39-40c
• Moderate to severe respiratory distress
• Stridor
• Drooling
• Irritability and restlessness
• Often a choking sensation and the child sits, leaning forward
• Complete obstruction of the airway is seen and death ensue unless adequate
treatment is provided
• A large cherry red ,swollen epiglottis is visualized by laryngoscopy under controlled
circumstances (ICU)

29. Diagnosis
• Leukocytosis = more than 10,000/mm3
• Direct visualization = swollen, erythematous
• Xray of soft tissue of neck

30. Xray shows the
presence of
thumb- printing
sign , a common
radiographic
marker for
epiglottitis

31. Management
• This is generally an emergency
• Secure the airway
• Oxygenis given by mask
• Best treatment is nasotracheal intubation.The patient should be given ventilatory support until edema subsides
• Fluid and electrolyte support
• I/V antibioticsis given for 7-10 days
• Initial agents are
1 ceftriaxone 100mg/kg/day
2cefotaxime
3-meropenem
4- chloramphenicol 50-75mg/kg/day
Acute laryngealswelling due to allergic reaction is best treated with :
1- Epinephrine (1:1000 dilution in dosage of 0.01ml/kg to a maximum of 0.5ml/dose) I/M
2- Racemic epinephrine ( dose of 0.5ml of 2.25% racemic epinephrine in 3ml of N/S)
3- corticosteroids are often needed (1-2mg/kg/24 hrs of prednisone fir 3-5 days)

33. Prognosis
• After insertion of the artificial airway, patient improves immediately and
respiratory distress and cyanosis disappear.
• Epiglottitis resolves after a few days of antibiotic treatment and the patient
may be extubated but antibiotics are given for 10 days.

35. A 6 years old boy presents in ER with the 3 hrs
history of high grade fever and sore throat.
Child appears alert but anxious and toxic. On
examination there is mild inspiratory stridor,
drooling and R/R 30.
• What is most likely diagnosis?
• What investigation you will order?
• How will you manage the patient?