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Good Morning!
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Problem Characteristics Recurrence of old problem
Semantic Qualifiers Symptoms Acute /subacute Chronic Localized Diffuse Single Multiple Static Progressive Constant Intermittent Single Episode Recurrent Abrupt Gradual Severe Mild Painful Nonpainful Bilious Nonbilious Sharp/Stabbing Dull/Vague Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problem Systemic problem Acquired Congenital New problem Recurrence of old problem
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Stridor Harsh, high-pitched resp sound Usually inspiratory
But can be biphasic Cause by turbulent flow Sign of upper airway obstruction NOT a diagnosis Site of Pathology Respiratory Rate Retractions Audible Sounds Extrathoracic airway Stridor Intrathoracic extra-pulmonary Wheezing Intrathoracic intrapulmonary Alveolar interstitial Grunting
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Stridor Viral croup Noninfectious croup Epiglottitis
Bacterial tracheitis Extraluminal compression Intraluminal obstruction from masses Foreign body Retropharyngeal abscess Peritonsillar abscess Angioedema Caustic ingestion Vocal cord dysfunction
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“Croup” Group of conditions Upper airway of children
Acute and infectious causes of upper airway inflammation Upper airway of children
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Laryngotracheitis = most common “Croup” illness Predisposing Factors
Laryngotracheitis vs. Laryngotracheobronchitis/pneumonitis Predisposing Factors Between age 3 months and 5 yrs Peak in 2nd year of life M > F Can occur anytime of year but peaks in late fall and winter Preceding URI illness
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Laryngotracheitis Pathophysiology
Inflammation involving the vocal cords and structures inferior to the cords
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Laryngotracheitis Pathophysiology Viral etiology is most common
Parainfluenza viruses (type 1, 2, and 3) ~ 75% of cases Influenza A Associated with SEVERE disease Influenza B Adenovirus RSV Measles Mycoplama pneumoniae rarely isolated
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Laryngotracheitis Clinical Presentation**
URI symptoms for 1-3 days prior to signs of upper airway obstruction Rhinorrhea, pharyngitis, mild cough, low-grade fever Characteristic “barking” cough, “seal-like” Hoarseness Inspiratory stridor +/- fever
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Laryngotracheitis Clinical Presentation**
Symptoms characteristically worse at night Agitation and crying aggravate symptoms Varying degrees of respiratory distress on exam Should not be hypoxic – this is a sign that complete airway obstruction is imminent
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Laryngotracheitis Diagnosis Clinical Xrays “Steeple sign” in AP view
Do not correlate with disease severity Can help distinguish from other causes
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Laryngotracheitis Treatment** Most patients managed as outpatients
Cool mist?? Not proven in literature, but used since the 1900’s If bronchospasm present, can worsen with cool mist Antibiotics not indicated in viral croup
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Laryngotracheitis Treatment** Corticosteroids
Action: decrease laryngeal mucosal edema Effective in reducing hospitalization rates, shorter hospital stays, reduced need for subsequent interventions Dose: 0.6mg/kg single dose DEXAMETHASONE (max 16mg) PO/IM Decadron both effective Clincal improvement 6 hours after dose Prednisolone less effective than Dexamethasone
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Laryngotracheitis Treatment** Nebulized racemic epinephrine (Vaponeb)
For moderate to severe croup Action: decrease laryngeal mucosal edema Dose: 0.25ml-0.5ml of 2.25% racemic epi in 3ml of NS nebulized Onset of relief 10-30min Duration of activity <2-3 hours Can repeat q20 min Monitor for symptoms once the Vaponeb activity duration is over (rebound?), generally 3-4 hrs after a treatment Use caustiously in patients with tachycardia, and heart conditions such as TOF or ventricular outlet obstruction
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Laryngotracheitis Indications for hospitalization with croup
Progressive stridor Severe stridor at rest Respiratory distress Hypoxia/cyanosis Depressed mental status Poor oral intake Need for reliable observation
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Laryngotracheobronchitis/pneumonitis
More severe form of croup Considered an extension of laryngotracheitis associated with bacterial superinfection Occurs 5-7 days into the clinical course New onset fever Worsening clinical symptoms, toxic Increased work of breathing Signs of both upper and lower airway obstruction Requires empiric antibiotics
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Hoarseness, barking cough
Feature Acute Laryngotracheitis Spasmodic Croup Epiglottitis Bacterial Tracheitis Prodrome URI Mean Age 3 mo - 5 yr Onset gradual Fever variable Hoarseness, barking cough Yes Inspiratory stridor Yes: minimal to severe Dysphagia No Toxic appearance Etiology Viral X-ray findings Steeple sign Treatment cool mist, racemic epi neb, dexamethasone
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Noninfectious Croup “Spasmodic” croup** Most often children 1 to 3 yrs
Pathogenesis unknown – possible allergic etiology Clinically similar to croup but without the viral prodrome or fever Most common in the evening Sudden onset, preceded by mild cough or hoarseness Episode of characteristic coughing, stridor and respiratory distress, anxious Severity improves over hours and can have repeat episodes x1-2 more nights
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Hoarseness, barking cough
Feature Acute Laryngotracheitis Spasmodic Croup Epiglottitis Bacterial Tracheitis Prodrome URI none or minimal coryza Mean Age 3 mo - 5 yr 1 to 3 yr Onset gradual sudden Fever variable no Hoarseness, barking cough Yes Inspiratory stridor Yes: minimal to severe Yes: usually moderate Dysphagia No Toxic appearance Etiology Viral Noninfectious X-ray findings Steeple sign --- Treatment cool mist, racemic epi neb, dexamethasone cool mist
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Epiglottitis Predisposing Factors Typical age of patients 2 to 4 yrs
Unimmunized
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Epiglottitis Pathophysiology Prevaccine, most common cause:
Haemophilus influenzae type B Now, larger number of cases in vaccinated patients due to: Streptococcus pyogenes Streptococcus pneumoniae Staphylococcus aureus
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Epiglottitis Pathophysiology Inflammation of epiglottis Degree of
inflammation leads to degree of obstruction of airway
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Epiglottitis Clinical Presentation Acute High fever Sore throat
Dyspnea Rapidly progressing respiratory obstruction Can be within hours – become toxic, difficulty swallowing, labored breathing
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Epiglottitis Clinical Presentation Drooling
Holding neck in hyperextended position Tripod position Stridor is a late finding! Not usually associated with a cough
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Epiglottitis Diagnosis Visualization via laryngoscopy
In controlled environment
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Epiglottitis Diagnosis Xrays “Thumb sign” in lateral view
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Epiglottitis Treatment** Careful on exam** Medical emergency
Avoid anxiety-provoking procedures (labs/IV), avoid placing patient supine or direct inspection of oral cavity To prevent acute airway obstruction Medical emergency Placement of artificial airway in controlled setting Mortality ~6% without airway vs. <1% with airway Oxygen via mask until artificial airway As long as mask doesn’t cause agitation
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Epiglottitis Treatment** Antibiotics** Ceftriaxone Cefotaxime
Meropenem Obtain cultures from blood, epiglottic surface, and if needed from CSF (after obtain airway) Treat with at least 7-10 antibiotics, but usually patient improves after 2-3 days
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Epiglottitis Rifampin prophylaxis indicated for:
Any household contacts <48 months old and incompletely immunized Any household contacts <12 months old and has not received primary vaccination series Any immunocompromised child in the household
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Hoarseness, barking cough
Feature Acute Laryngotracheitis Spasmodic Croup Epiglottitis Bacterial Tracheitis Prodrome URI none or minimal coryza none or mild URI Mean Age 3 mo - 5 yr 1 to 3 yr 2 to 4 yr (range 1 to 8 yr) Onset gradual sudden rapid Fever variable no High Hoarseness, barking cough Yes No Inspiratory stridor Yes: minimal to severe Yes: usually moderate moderate to severe Dysphagia Toxic appearance Etiology Viral Noninfectious Bacterial: Hib, Strep, S. aureus X-ray findings Steeple sign --- Thumb sign Treatment cool mist, racemic epi neb, dexamethasone cool mist Intubation, Ceftriaxone, or Cefotaxime, or Meropenem
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Bacterial Tracheitis Predisposing Factors Mean age 5 to 7 yrs M=F
Preceding viral respiratory infection Bacterial complication of croup More common than epiglottitis in vaccinated patients
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Bacterial Tracheitis Pathophysiology Mucosal swelling at the
level of the of the cricoid cartilage Complicated by copius, thick, purulent secretions, sometimes pseudomembranes Most common pathogen: S. aureus Other organisms: Moraxella catarrhalis, nontype H. influenzae, and anaerobic organisms
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Bacterial Tracheitis Clinical Presentation**
Preceding croup illness with cough Then develops high fever and toxic-appearance Differs from epiglottitis Patient can lie down, does not drool, no dysphagia Differs from croup More toxic, does not respond to racemic epi
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Bacterial Tracheitis Diagnosis Clinical picture Xrays Toxic + absence
of classic epiglottitis Xrays Not necessary Findings of irregular lining of the trachea due to pseudomembranes Can have “steeple sign”
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Bacterial Tracheitis Treatment**
Artificial airway required in ~50-60% of patients More likely to require intubation if younger Antibiotics Including appropriate Staph coverage Vanc + 3rd gen Cephalosporin = empiric coverage
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Hoarseness, barking cough
Feature Acute Laryngotracheitis Spasmodic Croup Epiglottitis Bacterial Tracheitis Prodrome URI none or minimal coryza none or mild URI URI/croup Mean Age 3 mo - 5 yr 1 to 3 yr 2 to 4 yr (range 1 to 8 yr) 5 yr to 7 yr Onset gradual sudden rapid acute after prodrome Fever variable no High Hoarseness, barking cough Yes No Variable, with prodrome Inspiratory stridor Yes: minimal to severe Yes: usually moderate moderate to severe Variable Dysphagia Toxic appearance Etiology Viral Noninfectious Bacterial: Hib, Strep, S. aureus Bacterial: S. aureus X-ray findings Steeple sign --- Thumb sign Irregular tracheal lining Treatment cool mist, racemic epi neb, dexamethasone cool mist Intubation, Ceftriaxone, or Cefotaxime, or Meropenem Often intubation required, Vancomycin and 3rd gen Cephalosporin
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