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Croup Not all that barks is viral (PowerPoint)

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Croup Not all that barks is viral (PowerPoint) Powered By Docstoc
					             Croup


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

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




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




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



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




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             Pathogenesis
• 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
• REMEMBER – CROUP IS A CLINICAL
  DIAGNOSIS!!!

• Steeple sign on PA Film

• Lateral neck films if unsure of ruling out
  retropharyngeal abscess

• Fluouroscopy if still unsure
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             Anatomy




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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?




               Epiglottis
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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
    croup)
     • Bronchospasm
     • Hypothermia in young infants
     • Tent obscures close observation of pt.

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                 Epinephrine
• 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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               Corticosteroids
• 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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             Corticosteroids
• 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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                    Heliox
• 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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posted:7/31/2011
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