2. EPIGLOTTITIS and CROUP

3. Basic Science l Venturi effect l Bernoulli principle turbulence  stridor

4. Bernoulli's Principle l as the speed of moving air increases, the pressure within the air decreases. When airflow is forced through a narrowed tube, a local area of low pressure creates a vacuum effect distal to the narrowing. The focal area of low pressure distal to a narrowed airway causes the airway walls to collapse and vibrate, generating the squeak characteristic of stridor

5. Basic Science l glottis l supraglottic l subglottic l intrathoracic trachea

6. Basic Science l pedi airway narrowest at subglottis cross-section of airway proportional to square of radius (  r 2 )

7. Supraglottitis- Epiglottitis l “angina epiglottidea anterior” l bacterial cellulitis of supraglottis l 2 to 7 years old l Haemophilus influenzae type B most common l incidence greatly decreased since vaccine

8. Supraglottitis l odynophagia l fever l irritability l stridor l rapidly progressive

9. Supraglottitis l if suspected, diagnose by direct laryngoscopy in OR l lateral neck film - “thumb sign” l 1nasotracheal intubation l IV antibiotics l extubate when air leak noted - usually within 48 hours

10. Laryngotracheobronchitis l croup - Scottish for barking cough l 6 months to 3 years old l Parainfluenza viruses types 1 and 2 most common

11. Laryngotracheobronchitis l URI symptoms l barking cough l hoarseness l inspiratory stridor l low-grade fever

12. Laryngotracheobronchitis l laryngoscopy for those with respiratory distress l AP neck - “steeple sign” l supraglottis normal

13. Laryngotracheobronchitis l usually self-limited l humidified air l racemic epinephrine l steroids l heliox l intubation for severe, refractory cases

14. Spasmodic Croup l presentation similar to LTB l sudden onset stridor l afebrile l recurrent episodes that resolve spontaneously l unknown cause

15. Case Study 1 l1l14 month old male lblbreathing difficulties l2l2-3 days of URI symptoms ltlthis morning, cough and loud breathing sound

16. l afebrile, respirations 26/min, pulse 124 beats/min l reclining in mother’s lap, NAD l soft, biphasic stridor l lungs clear to auscultation

17. Case Study 1 l laryngotracheobronchitis l differential: epiglottitis, bacterial tracheitis, foreign body, subglottic stenosis

18. Case Study 1 l lateral airway film - neck extended, inspiratory l racemic epinephrine l oral dexamethasone

19. Case Study 1 l observe for 3 hours l vastly improved at 4 hours post- treatment l consider direct laryngoscopy and bronchoscopy in 3-4 weeks

20. Case Study 2 l6l6 year old lrlrhinorrhea, cough, low grade fever lalacute onset high fever and stridor

21. ltlto OR for endoscopy leledematous larynx lululceration and sloughing of tracheal mucosa lplpurulent secretions in right lower lobe

22. lnlnasotracheal intubation lIlIV Cefuroxime lSlS. aureus lClCXR with right lower lobe pneumonia lelextubated 4 th day post intubation

23. Controversies and Future l drastic decrease in supraglottitis as a result of vaccine l nasotracheal intubation for supraglottitis l disposition of children treated for LTB with epinephrine l steroids in LTB

24. Conclusion l cause of much morbidity in pediatric population l potentially life-threatening l prompt diagnosis l assure adequate airway