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CROUP Dr Jonny Taitz Sydney Childrens Hospital, Randwick April 2003.

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Presentation on theme: "CROUP Dr Jonny Taitz Sydney Childrens Hospital, Randwick April 2003."— Presentation transcript:

1 CROUP Dr Jonny Taitz Sydney Childrens Hospital, Randwick April 2003

2 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 3 Anatomically Viral infection of upper airway Inflammation of larynx, trachea & bronchi Compromises airflow through proximal airway

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

5 5 Causes & Differential Foreign Body Inhalation –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 6 Causes & Differential Toxic –Exclude bacterial tracheitis –Epigloltitis –Retropharyngeal abscess

7 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 8 Airway Obstruction Mild Moderate Moderate progressing to severe Severe

9 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 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 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 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 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 14 What Evidence is there for Current Rx Options Non pharmacologic –Steam 2 large RCTs 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 15 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 What Evidence is there for Current Rx Options

16 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 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 18 Questions

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