1. Croup Viral or bacterial infection of the upper airway that causes swelling and inflammation (airway narrowing) The type of croup ( there are four) is named according to the anatomical area most severely involved In all forms of croup mucosal inflammation and edema causes airway narrowing

2. Croup The narrowing of the airway is critical in infants and children as their airway is smaller in diameter ( susceptible to spasm)

3. Types of croup or triad of croup Acute spasmodic laryngitis ( spasmodic croup) Acute laryngotracheobronchitis Acute epiglottitis Acute tracheititis

4. Etiology and incidence Para influenza virus causes most of viral croup Cause of acute spasmodic croup is unknown Laryngotracheobronchitis is the most common form of croup, usually affect infants and toddlers, common cause of airway obstruction in children ages 6 months to 6 years Incidence of croup is higher among the boys than the girls

5. Etiology cont.. Most common during winter months

6. Comparison of types of croup Acute spasmodic croup Usually occurs in 1 – 3 year olds Swelling and inflammation is bellow vocal codes Caused by viral infection Sudden onset, usually at night, children awakened at night with harsh cough, inspiratory stridor, dyspnea and hoarseness. Usually no fever Treatment: humidity, fluids and can be treated at home

7. Comparison cont.… Acute laryngotracheobronchitis Age 3 months to 3 years Swelling and inflammation below the vocal codes, including bronchi Cause is usually viral, but can be bacterial also Gradual onset, usually at night, harsh cough, and inspiratory stridor Treatment: humidity, racemic epinephrine, iv fluids, and hospitalization may be necessary * Epinephrine can cause the heart rate to go up

8. Comparison cont.. Acute epiglottitis Age is usually 3 – 7 years Swelling and inflammation is above the vocal codes ( supraglottic) Cause is bacterial Onset is sudden, may rapidly progress to complete air way obstruction and death Symptoms: sore throat, dyspnea, high fever Treatments: antibiotics iv, artificial airway, iv fluids and emergency hospitalization

9. Comparison cont.. Acute tracheitis Age is usually 1 month to 6 years Location of swelling is mucosa of upper trachea Symptoms: fever, stridor, croupy cough, purulent secretion Treatment : oxygen, humidified oxygen, antipyretic, IV antibiotics, and may require intubation

10. Common manifestation Fever 104 Sudden onset of barky, harsh, metallic cough Use of accessory muscles to breathe Frightened appearance Agitation Cyanotic

11. Diagnostic evaluation Diagnosis mainly from observation of clinical symptoms Croup score is used to describe the severity

12. Therapeutic management Goal of treatment is to maintain patent airway Calm approach- crying can cause spasms Taking child out to cool moist air may relieve mucosal swelling Children who develop stridor, severe agitation, moderate to severe retraction, and unable to take oral fluids should be taken to the ER Racemic epinephrine with oxygen ( only in hospital setting) administration May treat with oral Dexamethasone Sedation is contraindicated If moderate to severe hypoxia develops child is intubated Child with respiratory distress should never be left alone If epiglottitis is suspected, physician should be contacted, throat should not be inspected because this may cause laryngospasm Emergency equipment should be closely available

13. Therapeutic management Child should be kept as quiet as possible to prevent laryngospasm Maintain fluid balance( tachypnea or increased resp rate) causes insensible fluid loss Iv fluid may be administered, oral fluids are contraindicated in severe respiratory distress Inform family that once a child has had croup,it tends to recur Humidified environment is desired Cold and cough suppressants are avoided as they tend to thicken or dry secretions

14. Signs and symptoms of recovery Vital signs back to normal limits Moist mucous membrane Decreased agitation

15. Epiglottitis ( supraglottitis) Bacterial form of croup Acute inflammation and swelling of the epiglottis and the surrounding tissues May cause complete airway obstruction Medical emergency/ life threatening

16. Etiology and incidence Almost always caused by H. Influenza Viral epiglottitis is rare Occurs most often in children 3 – 7 years Incidence equal in boys and girls Incidence has decreased with use of Hib vaccine

17. Manifestations Abrupt onset and rapid progression Often complains that the child awakened with a severe sore throat and difficulty swelling and drooling High fever 102- 104 Appears very ill Child appears anxious and frightened Irritable or lethargic Child insists on sitting upright Nasal flaring, intercostal retraction, cyanosis and tachycardia Epiglottis appears cherry red

18. diagnosis Cherry red, edematous epiglottis Examination of epiglottis is contraindicated until emergency equipment and qualified people are available

19. Cardinal symptoms of epiglottitis Drooling Dysphasia( difficulty swallowing) Dysphonia ( difficulty talking) Distress inspiratory effort

20. Therapeutic management Patent airway as soon as possible Emergency equipment, intubation box at bedside Mechanical ventilation Child should be kept calm No taking oral temperature Never force the child to lie down Humidified oxygen in high concentration While intubated child should be restrained to prevent self extubation. Re intubation may be difficult due to spasm Encourage to get H. Influenza vaccine

21. RSV ( respiratory syncytial virus) Virus that causes respiratory infection Major cause of lower respiratory tract infection and hospital visit during infancy and childhood In temperate climates there is an annual epidemic during winter months In tropical climates infection is prevalent during rainy season Easily communicable, hand washing is very important In the U.S 60 % of the infants are infected during their first RSV season and nearly all children will have been infected with the virus by 2 – 3 years of age Infants can be infected multiple times during the same season Incidence of severity decreases with age

22. Manifestations Tachypnea – resp rate > 60 breathes per min Tachycardia – HR > 140 Wheezes, crackles and rhonchi Intercostal and subcostal retractions Cyanosis Body temperature varies – hypothermic to 105.8 F

23. Diagnosis Clinical presentation and the age of the child suggest the diagnosis Cultures- nasal and nasopharyngeal washing Therapeutic management Can be treated at home Fluids, humidification and rest Supplemental oxygen Iv fluids HOB AT 30-40 degrees Antibiotics are not given unless secondary bacterial infections Hand washing and prevention is most important IM administration of Pavilizumab ( synagis), administered monthly throughout the RSV season significantly decreases the hospitalization of premature infants Isolate infants with RSV – CONTACT ISOLATION Nurses caring for these infants should not be taking care of immunocompromised patients.