Croup Not all that barks is viral

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Croup Not all that barks is viral Powered By Docstoc

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• Clarify the definition and epidemiology of
• List the potential etiologic agents
• Know the signs and symptoms
• Differentiate croup from other causes of
  inspiratory stridor and upper respiratory
• Understand the management of croup

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• Croup- term used to describe the clinical
  picture of laryngotracheitis.
   – Hoarse voice
   – Barking cough
   – Inspiratory stridor
   – Possible respiratory distress

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• Peak fall & winter.
• Range primarily 1-6 years
• Incidence 5/100 of children between age
  1-2 years
• Males > females

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• Parainfluenza, types 1,2,3
    – Contribute 65%-80% of cases.
•   Influenza A & B
•   Adenovirus
•   RSV
•   Rarely mycoplasma.

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• Subglottic narrowing due to inflammation.
• Cricoid ring allows fixed area for
• 1mm swelling causes 65% obstruction in

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• Atelectasis/mucus plugging
• Ventilation/perfusion mismatch
• Negative intrapleural pressure may lead to
  varying degrees of pulmonary edema.
• Hypoxia/hypercarbia
   – Air hunger
   – Anxiety/Lethargy/Obtundation.

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               Clinical history
• Parents usually report viral URI symptoms
  12-48hrs prior to cough.
• Fever, “Barking cough,”Stridor
• Typical course 3-5 days.

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                    Worry if

   – Drooling
   – Dyphagia
   – Toxic appearance
   – Stridor without cough or without fever
   – Incomplete immunizations

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      Badness mimicking croup
• Epiglottis
   – Dysphagia
   – Odynophagia
   – Drooling
   – Tripoding/sword-swallowing
      • Pt resists lying on back
      • Prefers leaning forward
   – Stat to OR for evaluation/intubation

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Badness Mimicking Croup, cont.
• Bacterial tracheitis
   –   More common in order children to teens
   –   Staph aureus/Diphtheria
   –   Fever/ resp distress/Dysphagia/Odynophagia
   –   Worsening over hours
   –   Difficult to distinguish from epiglottis
   –   Doesn’t matter, management is same:
        • OR intubation
        • Abx, worry more about Staph coverage if child is older.

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Badness Mimicking Croup, cont.
• Bacterial superinfection of Croup
   – Symptoms 5-7 days
   – Worsening quickly over hours
   – Increasingly high fevers
   – Toxic appearance

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Badness Mimicking Croup, cont.
• Retropharyngeal/peritonsilar abscess
   – Fever
   – Odynophagia
   – Prodrome of sore throat
   – Often swollen, tender ant. cerv. Nodes.
   – Resistence to neck movement

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Badness Mimicking Croup, cont.
• Neoplasm
• Foreign body
   – Afebrile
   – Toddlers most at risk
   – Often no history of aspiration
• Trauma
   – History/physical exam.

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Badness Mimicking Croup, cont.
• Angioneurotic edema
   – Recurrent
   – Lip swelling
• Spasmotic croup (well, not really badness)
   – Recurrent
   – Nighttime

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              Laboratory tests
• Little to no value…...

• ABG to assess for respiratory acidosis –
  could worsen child’s symptoms by
  stressing them

• May need IV access if in moderate to
  severe distress
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         Radiographic findings

• Steeple sign on PA Film

• Lateral neck films if unsure of ruling out
  retropharyngeal abscess

• Fluouroscopy if still unsure
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            Anatomy on X-ray

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       Red -dilated hypopharynx
       White - dilatation of the laryngeal ventricle
       Blue - narrowing of the sub-glottic trachea

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                    Steeple Sign

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                    What is this?

             Retropharyngeal Abscess!

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                    What is this?

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        Management of Croup
• Do I need an artificial airway!!!!
• Cool mist
   – No literature to support efficacy
   – Multiple studies demonstrating that it may
     worsen situation (in moderate to severe
      • Bronchospasm
      • Hypothermia in young infants
      • Tent obscures close observation of pt.

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• Mechanism- constricts arterioles to airway thus
  reducing further edema.
• Waiisman, et al. Prospective RCT comparing L-
  epi and RE in treatment of laryngotracheitis.
  Pediatrics. 1992.
   – Demonstrated reduced croup score by 30min, lasts
     usually 2hrs.
   – Dose 0.5cc of 2.25% racemic solution
   – No difference found L- epi using 5cc of 1:1000 conc.

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                     Epi, cont.
• Rebound phenomenon
   – Bunk… It just wears off in 2hours usually.
   – Multiple studies demonstrating safe to d/c pt
     from ER if:
      • Steroids were given, too.
      • No resting stridor 2-4 hrs after tx.

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• Steroid controversy…. getting clearer.
   – Ausejo, M. Glucocorticoids for croup. Cochrane
     Database of Systemic Reviews Jan 2000.
   – Repeated with identical results by Moyer in
     Pediatrics, March 2000.
      • Metanalysis (N=2221 patients)
      • Improved Croup score at 6 and 12 hrs, not 24 after
        dexamethasone or budesonide neb.
      • Decr. need for epi nebs by 9%.
      • Decr. Emergency Room stay (-11hrs).
      • Decr. Hospital stay (-16hrs).

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          Corticosteroids, cont.
• Kairys, et al. Steroid treatment of
  laryngotracheitis. Pediatrics. 1989.
   – First meta-analysis of randomized trials.
   – Demonstrated reduction in intubation from
     1.27% (no steroids) to 0.17% steroids.
   – No difference in inhaled budesonide versus
     IM dex.

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          Corticosteroids, cont
• Ritticher and Ledwith. Outpatient
  treatment of moderate croup with
  dexamethasone: Intramuscular versus
  oral dosing. Pediatrics. 2000
   – ER patients sent home.
   – No statistical difference in later interventions.
   – Power to detect at least 10% difference.

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          Corticosteroids, cont.
• Klassen, et al. Nebulized budesonide and
  oral dexamethasone treatment for croup.
  JAMA. 1998
   – Oral dexamethasone/Inhaled budesonide
   – Both treatments
   – No difference in groups
   – Budesonide much more expensive.

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• A moment on dosage:
   – Most studies 0.6mg/kg (IM or PO)
   – Malhotra and Krilov. Viral Croup. PIR, 2001
      • Lower doses of 0.15mg/kg and 0.3mg/kg shown to
        be equally effective.

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• Weber, JE. A randomized comparison of
  Heliox and racemic epinephrine for the
  treatment of moderate to severe croup.
  Pediatrics. 2001
   – N=29
   – Similar improvement in both groups.
   – No significant difference in croup score,
     oxygen sat, respiratory rate or heart rate.

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               Where to now?
• Still unanswered questions:
   – Should you re-dose dexamethasone since the
     duration is pharmacologically is 48hrs, but
     benefit was only demonstrated though 12hrs?
   – What about heliox and epi together?
   – Should any patient with croup symptoms be
     given steroids?

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