Presentation on theme: "CROUP Dr.S. Alyasin Associated professor Pediatric Department"— Presentation transcript:
1 CROUP Dr.S. Alyasin Associated professor Pediatric Department Shiraz University of Medical Science
2 CroupAirway resistance is inversely proportional to 4th power of radius : minor reduction: increase in air flow resistance.Larynx: 4 major cartilage: epiglottic – arytenoid – thyroid – cricoid & the soft tissue souround itCricoid is just below vocal cord & narrowest in children < 10 yr -0
3 Supraglottic Infraglottic Epiglotitis – peritonsilar abcess- retropharyngeal abcessDrooling - hot potato voice – positional preferenceInfraglotticLaryngitis – lanyngotracheitis, laryngotracheobronchitisCroup: Heterogenous group of acute and infectious processBark like cough , may hoarsness, stridor ,distress(affect larynx,trachea ,bronchus)Stridor:Harsh ,high pitched usually inspiratory or biphasic ,turbulant flow
6 Croup ;Epidemiology Age: 3 mo – 5yr, peak: 2nd yr of life Boy Late fall & winter (but can throughout the year)Recurrents : 3-6 yr of age, decrease with growthFamily hx of croup in 15%
7 Croup (Laryngotracheobronchitis) Some clinicians use the term laryngotracheitis for the most common & most typical form of croup andlaryngotrachobronchitis for more sever form with bacterial super-infection (in 5-7 days course)URI in familyURI rhinorrhea- pharyngitis- cough- low grade fever 1-3 days then barking coughLow grade to c or afebrile
8 Croup : Clinical manifestation Worse at nightImprove in a weekAgitation aggravate symptomPrefer sit upOlder children are not ill.
9 Croup : Clinical manifestation PE- hoarse voiceCoryzamild to mod infla. PharynxRR↑variable respiratory distress (RR- nasal flaring – retraction)- Stridor
10 Croup :DxAlveolar gas exchange is nl so hypoxia only in complete airway obstruction (occasionally difficult to differentiate from epiglottitis)X-ray may be helpful in distinguishing between sever LTB & epiglottitis but after airway stabilization.
11 Diagnosis Croup is a clinical diagnosis and not require X ray. X Ray AP: steeple sign(false +ve & -ve & not correlate with severity) distinghish between epiglotitis & LTB after stabilization of airway“steeple sign” of subglottic narrowing. (b) Laternal neck radiographshowing subglottic narrowing consistent with acute laryngotracheitis
12 Spasmodic croup 1-3 yr No URI hx in family member & patient No fever Cause?: viral- allergic – psychologicAn allergic reaction to viral antigen.
13 Acute infectious laryngitis Virus – DiphteriaURI -sore throat – cough- hoarseness- loss of voice: mildIn infant : RDSubglottic inflammation
14 Croup: Treatment Admission: -progressive stridor severe stridor at rest- RD- hypoxia- cyanosis- depressed mental status– poor oral intake– need for observation.
15 Croup: TreatmentL epinephrinin (5 ml: 1/1000) is as potent as racemic epinephrin (tachycardia – HTN), every 20 minutes.Indication:-stridor at restneed for intubation- RD- hypoxia(caution: tachycardia- TOF- venticular outlet obstruction)
16 Croup: treatment: corticosteroid anti inflammatory action: laryngeal edemaOral CS even in mild croup:↓ admission↓ duration of admission- ↓need for E –Oral dexametason 0.6 to 0.15 mg/kg single dose= im dexametson or budesonideSingle dose of prednisolon is less potent1 week CS: candidal infection*No during varicella infection
17 Croup: treatment No Antibiotic – No cough medication in children <4y-0Heliox
18 Croup Discharge: after 2-3 hr observation: - no stridor at rest - normal air entry- nl pulse oximetry– nl level of consciousness- received steroid
23 PrognosisIs related to Length of admission and extension o f infection( except in epiglotitis)Death in croup:- laryngeal obstruction– complication of tracheotomyPx is excellentAdmitted patient: increased bronchial reactivity
24 Croup : Df Dx Foreign body 6mo-3 yrs, sudden , No prodrom Retropharngeal abscess (CT)Peritonsilar abscessExtrinsic compression (web- vascular ring)Intraluminal (papiloma- hemangioma)AngioedemaPost extubationHypocalcaemia tetaniI.MonoTraumaTumorMalformationVery hot liquid : epiglottis like drooling – dysphagia – stridor
28 Epiglotitis: Etiology Hl type B ↓80-90% in vaccinated area for epiglottis:st. pyogen- st. pneumonia- st. aureusAge 2-4 (although range of 1 to 7 y-0)
29 Epiglotitis Potentially lethal High fever- sore throat- dyspnea- resp obstruction within few hours: toxicdifficult swallowingDrooling- neck extentionTripod positionAir hunger, restless: cyanosis & comaStridor after complete airway obstructionNo barking cough – No illness in family
31 Epiglotitis Dx lanygoscopy: cherry red epiglottis when dx is certain or probable, lanyngoscopy should be done in OR or in ICUPhlebotomy, IV line, supine or direct inspection of oral cavity after airway is secureIf dx is not certain :lat X ray neck “ thumb sign”direct visualization.
33 Epiglotittis Anxiety provoked intervention (phlebotomy- supine –IV-direct inspection of oral cavity) should be avoided.Most patients have bacteremia: occasionally pneumonia- cervical LAP- OM, rarely: meningitis – arthritis- Occasionally aryepiglottic fold is more involved than epiglottis
34 Treatment: Epiglotitis Epiglotitis is medical emergency: Artificial airway in OR or ICU : improved immediatelyculture (B- epi_ sometimes CSF) after airway stabilizedAll should recieve O2Ceftriaxone – Cefotoxime- meropenem daysCS or E are not effective
35 Treatment: Epiglotitis Indication for rifampin for household members if:- any centact < 48 mo of age incompletevaccinated- Any contact < 12 mo of age not received the 10vaccine series- Immuno-compromised child
37 Bacterial tracheitisStap au.* - morexella cat.- Non typable HI- anerobicAge: 5-7 y-o2nd to LT & viral infection is more common than 10 infectionBrassy cough- high fever- toxic – RD-not drool- can lie- no dysphageaNeed intubation in % (younger children)Major pathology: mucosal swelling in cricoid cartilagepurulent secretionpseudomembrane
38 Bacterial tracheitis : diognosiS : Fever- purulent discharge- absence of epiglottitisfindingX-Ray is not needed but show classic findingDuring ET intubation : pus below cordTx: Artificial airway is strongly suspectedVancomycin + nafcillinO2suction
39 Lateral neck radiograph showing intraluminal membranes and tracheal wall irregularity (arrows) consistent with bacterial tracheitis.
41 Tracheotomy; Endotracheal Intubation Epiglotitis mortality rate of 6% dropped to zero-In OR or in ICU-Tube mm smaller than estimationT, ET for most patient of bacterial tracheitis (50-60%)T, ET in LTB in outbreak of influenza A & measlseExtubation :few daysT. complication: Mediastinal emphysema / pneumothoraxDL in epiglottitis: after 42 hr inflammation ↓, (2-3 days after antibiotic)