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Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003

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Presentation on theme: "Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003"— Presentation transcript:

1 Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003
CROUP Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003

2 Introduction Croup or LTB laryngo tracheo bronchitis is a clinical syndrome Hoarse voice Barking cough Inspiratory stridor COMMON cause of upper airway obstruction usually mild & self limiting BUT is also the commonest cause of potentially life threatening airway obstruction in childhood

3 Anatomically Viral infection of upper airway
Inflammation of larynx, trachea & bronchi Compromises airflow through proximal airway

4 Causes & Differential Commonest cause is viral (parainfluenza, RSV)
Very rarely  diphtherial croup (non immunized)

5 Causes & Differential Foreign Body Inhalation Structural Sudden onset
May have unilateral signs Exp wheeze > insp stridor Structural Children < 3/12 Combination insp & exp stridor (eg. Subglotic stenosis, laryngomalacia, laryngeal cysts, webs, thermal, chemical injury)

6 Causes & Differential Toxic Exclude bacterial tracheitis Epigloltitis
Retropharyngeal abscess

7 Assessment of Severity
Remember it is the severity of the airway obstruction NOT the stridor that is assessed Worsening obstruction may lead to softer stridor !!! Repeated clinical assessment is the key

8 Airway Obstruction Mild Moderate Moderate progressing to severe Severe

9 Danger Signs General: agitated, tiring,  LOC  observe closely
Resp distress: stridor at rest, tracheal tug, retractions pulsus Paradoxus  will need RX Cyanosis / extreme pallor  RX immediately Oxymetry is a late sign Do not wait for desaturation to commence RX

10 Mild Airway Obstruction
Happy child, playful, tolerating fluids Mild chest wall retractions, tachycardia NO stridor at rest MX Reassure parents Counsel parents re: warning signs No medication required

11 Moderate Airway Obstruction
Characterised by Stridor at rest Accessory muscle use, chest wall retractions  HR,  RR Child is interactive & can be placated MX Will require corticosteriods Observation for a minimum of 4 hours Further RX if child progresses to severe obstruction

12 Progression from Moderate to Severe Airway Obstruction
Child will need admission Child becomes preoccupied, tired, sleepy Close monitoring Regular review every mins MX Corticosteriods Nebulized Adrenaline

13 Severe Airway Obstruction
Characterised by Tiredness, exhaustion, tachycardia Restless, agitated  LOC Hypotonic, pale & cyanosed MX Do not disturb unnecessarily O2 via face mask Nebulized Adrenaline Intubation (under anaesthetic) & ventilation Systemic steroids when airway secure } Late signs indicating imminent airway obstruction

14 What Evidence is there for Current Rx Options
Non pharmacologic Steam 2 large RCT’s looked at steam Rx in croup No evidence that it is beneficial Oxygen Initial treatment of choice for children with moderate to severe viral croup

15 What Evidence is there for Current Rx Options
Drugs Steroids Precise mechanism in croup unclear ? Ante-inflammatry ? Vasoconstricts upper airway Oral preferred route Dexamethazone 0.3 mg/kg Prednisore 1 mg/kg Steriods have led to  intubation  Duration of ventilation nebulized budesonide vs oral dexamethazone

16 Drugs (continued) Nebulized Adrenaline
Moderate to severe croup (i.e stridor at rest) needs nebulized adrenaline Dose 0.5 mg/kg 1:1000 (max 5 mls) Administered neat via neb Effect  Bronchial & tracheal epithelial vascular permeability  Airway oedema Onset is rapid  30 minutes Duration is approx 2 hrs Severe croup may need repeated doses

17 Drugs (continued) Ongoing requirements for Nebulized Adrenaline
Consider intubation and/or transfer to Paediatric ICU Other factors to consider for transfer Age of child Severity of illness Underlying anatomic problems Level of exposure at hospital

18 Questions

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