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croup

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CROUP

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croup

  1. 1. Magdalena Sidhartani 1
  2. 2.  “Croup syndrome” : a group of diseases • Laryngotracheitis • Spasmodic croup, • Bacterial tracheitis, • Laryngotracheobronchitis, and • Laryngotracheobronchopneumonitis.  Manifestation : Hoarse voice ; dry, barking cough; inspiratory stridor; and respiratory distress ,develops over a brief period of time  Infection: Common and typical 2
  3. 3. 1. Acute viral infection : acute laryngotracheitis  obstruction of the upper airway, larynx, infraglottic tissues, trachea 2. Bacterial and atypical agents 3. Noninfectious : foreign body aspiration, trauma (Intubation), and allergic reaction ( acute angioneurotic edema) 3
  4. 4.  15 % of respiratory tract disease  Aged 1-6 years of age ( mean:18 mo)  Peak incidence, 5 cases / 100 during second year of life,  Boys > Girls 4
  5. 5. 1. Parainfluenza viruses ( tipes 1,2 and 3) : 65 % 2. Adenovirus, RSV, Measles 3. Mycoplasma pneumoniae 5
  6. 6.  Laryngotracheobronchitis and laryngotracheobronchopneumonitis : • Streptococcus pyogenes, • S pneumoniae, •Staphylococcus aureus, •Haemophilus influenzae •Moraxella catarrhalis 6
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  8. 8.  Nasopharynx  respiratory ephitelium on larynx and trachea  bronchus  Diffuse inflammation, erythema and edema develop in tracheal walls  impaired mobility of vocal cord  Subglotic trachea swelling cause encroaches on the airway and airflow restriction inspiratory stridor and hoarse voice. 8
  9. 9.  Tracheal lumen obstructed by fibrinous exudate and pseudomembranes.  Histologic : marked edema, cellular infiltration of histiocytes, lymphocytes, plasma cell and PMN leucocytes 9
  10. 10.  Rhinorrhea, pharyngitis, low grade fever of few days duration, and mild cough  After 12-48 hours upper airway obstructive sign and symtomss are noted “barking” cough, hoarseness, and inspiratory stridor, fever +/- 10
  11. 11.  Hoarse voice, coryza, a normal or inflamed pharynx and slightly increased RR  Most cases only the hoarseness and barky cough, no evidence or airway obstruction  Gradualy normalize whithin 3-7 days. 11
  12. 12.  Increasing severity of obstruction and accompanied by: • Increasing HR and RR • Flaring of alar nasi • Cyanosis with supra and infraclavicular and sternal retraction • Restless and anxious with the development of progressive hypoxia • Duration of illness 7-14 days 12
  13. 13.  Elevated WBC above 10x109 /L ( 10.000/cu mm ), PMN predominant  Anterior CXR : subglottitis narrowing 13
  14. 14.  14
  15. 15.  Extensions of acute laryngotracheitis.  Sign and symptoms of laryngotracheitis suddenly progresses to severe desease caused by : • Bacterial superinfection ,sudden worsening of clinical sign and symtoms, high grade fever, Increasing work of breathing (RR, Rales, Wheezing, Air trapping ) • CXR : pulmonary infiltrates  May requires intubation or a tracheostomy. 15
  16. 16.  Occur at night, children 3 months – 3 years  Awakens at night with sudden dyspnea, croupy cough, and inspiratory stridor (sudden subglottic edema), no fever  Endoscopic : pale and boggy laryngeal mucosa 16
  17. 17.  Epiglottitis : • Lack of croupy cough, drooling, toxic appearance, growing anxiety and apprehension • A sitting posture, chin pushed forward, refuse to lie down • Inspection : cherry-red epiglottis 17
  18. 18. • Laringotracheitis :“ The Steeple Sign” • Epiglottitis : “ Thumb Sign” 18
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  21. 21.  DD : • Foreign body aspiration and angioneurotic edema • Laryngeal diphtheria • Retropharyngeal or peritonsilar abscess • Subglottic stenosis • Infectious mononucleosis • Bacterial tracheitis • Paraquat poisoning • Importance information : immunization history, clinical evidence of pharyngeal involvement, greater degree of hoarseness and relative slowness of disease progression 21
  22. 22.  Primarily : Clinical  CXR : Plain film of the neck • Steeple sign • Overdistended hypo pharynx( lateral)  Pulse Oxymetri : maybe normal  Need : serial observation and frequent physical exam 22
  23. 23. SISTEM SKORING
  24. 24. Epiglottitis Croup Age Infants, older children, 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 Chracteristic cough Position Sitting forward with mouth open Comfortable in positions Radiology Positive thumb sign* Positive steeple sign Adapted with permission from DeSoto H. Epiglottitis and croup in airway obstruction in children. Anesthesiol Clin North Am 1998;16:85 Comparison of the Features of Epiglottitis and Croup 24
  25. 25.  Serial observation  Mist therapy  Epinephrine  Steroids 25
  26. 26.  Cool mist is as effective as hot steam  Cool mist moistens airway secretions  Humidity ↓ the viscosity of mucus secretions 26
  27. 27.  Stimulate α-adrenergic receptor  For moderate to severe distress  Decreased stridor/retractions (<2hrs) • Rebound phenomenon • Observe 3-4hrs after administration  Side effects: tachycardia, hypertension 27
  28. 28.  Dose : 0,25 - 0,75 ml of 2,25 % racemic epinephrine solution in 2,5 ml NaCL, every 20 mnt  If not available, 5 ml mixture of l-isomer epinephrine and saline ( 1:100)  Caution : tachycardia, ToF, Ventricular outlet obstruction 28
  29. 29.  Single parenteral dose; • 0,6 mg/kgBW dexamethason( max 10 mg) • 0,15 mg /kgBW dexamethason is as effective as 0,3 or 0,6 mg /kgBW in relieving symptom •Clinical improvement not apparent until 6 hrs of initiation of treatment •Nebulized budesonide (dose 2 - 4 mg), rapid effect (2-4 hour) 29
  30. 30.  Endotracheal intubation • Severe croup, with hypercarbia and probable respiratory failure • Only for brief period  Helium-oxigen mixture  Antibiotics  Evidence for bacterial infection  Aim for S aureus, S pyogenes, S pneumoniae and H influenzae  Initial treatment second generation of cephalosporin or combination therapy with semisyntethic penicillin and third-generation cephalosporin 30
  31. 31.  Croup is a common viral illness in children, generally benign  Treatment options : • Mist – years of use • Epinephrine – years of experience and trials support its use • Steroids – good evidence to support • Not preventable • Vaccine could reduce the incidence of croup due to influenza A and B 31
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