Croup

CroupAbbas Wael Abbas1

croup refers to a heterogeneous group of mainly acute and infectious processes that are characterized by a bark- like or brassy cough and may be associated with hoarseness, inspiratory stridor, and respiratory distressspasmodic or laryngotracheobronchitis 2

Croup typically afects the larynx, trachea, and bronchi. When the involvement of the larynx is sufcient to produce symptoms, they dominate the clinical picture over the tracheal and bronchial signs

Stridor sign of upper airway obstruction is a harsh, high-pitched respiratory sound, which is usually inspiratory but can be biphasic and is produced by turbulent airfow;

EtiologyMost common cause of upper airway acute infection is virus , except ? parainfuenza viruses (types 1, 2, and 3) 75% of casesInfuenza A is associated with severe laryngotracheobronchitisadenovirus, RSV , and measlesM.pneumoniae rare cause, mild

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Except diphtheria, bacterial trechitis , epiglotitis

Most patient between 3 mo and 5 yr, with the peak in the 2nd yr of lifemore common in boys most commonly in the late fall and winter15% of patients have a strong family history of croup

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Clinical manifestation Croup is a clinical diagnosismost common form of acute upper respiratory obstructionlow-grade fever 1-3 days before the signs and symptoms of upper airway obstruction become apparentrhinorrhea, pharyngitis, mild coughbarking cough, hoarseness, and inspiratory stridor

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Te low- grade fever can persist, occasionally reach 39-40C some children are afebrile

child may prefer to sit up in bed or be held upright

Symptoms are characteristically worse at nightAnd aggravated by agitation and crying

resolve completely within a week

Other family members might have mild respiratory illnesses with laryngitis.

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Physical examination hoarse voicecoryzanormal to moderately inflamed pharynx slightly increased respiratory rateRarely respiratory distress alveolar gas exchange ? severe laryngotracheobronchitis is difficult to differentiate from epiglottitis7

Coryza inflammation of the mucus membrane lining the nasal cavity ( runny nose, nasal conjestion, loss of smell)alveolar gas exchange normal b/c croup upper airway disease The child who is hypoxic, cyanotic, pale, or obtunded needs immediate airway management

Spasmodic Croupchildren 1-3 yr of agecause is allergic, psychologic. Viral in some cases similar to acute laryngotracheobronchitis, except? most commonly in the evening or nighttime, begins suddenly Child awake with a barking, metallic cough, noisy inspiration, and respiratory distress symptoms generally diminishes within several hours8

except that the history of a viral prodrome and fever in the patient and family are ofen absent.

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1-33m-5y 10

Complication 15% of patient middle ear, terminal bronchioles, or pulmonary parenchyma infection . Bacterial tracheitis11

Bacterial trechitis associated with S. aureus or S. pyogenes, toxic shock syndrome can develop

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Treatment The mainstay of treatment for children with croup is airway management and treatment of hypoxiaMost children with either acute spasmodic croup or infectious croup can be managed safely at homeobservation showed cold night air is benefcial, a Cochrane review has found no evidence supporting

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Oral coticosteroid Beneficial in mild, moderate, sever if given in the first 3 days single dose of 0.6 mg/ kg. a dose as low as 0.15 mg/kg may be just as effectiveoral dose of dexamethasone as effective as intramuscular. Nebulized budesonide oral prednisolone is less effectiveadverse effect candida albican laryngotracheitis in patient who received dexamethasone, 1 mg/ kg/24 hr, for 8 days.

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Should be given orally, by tablet IM if not tolerated orally

Nebulized racemic epinephrine is an accepted treatment for moderate or severe croupdecrease the laryngeal mucosal edemadose of 0.25-0.5 mL of 2.25% racemic epineph- rine in 3 mL of normal saline. can be used as often as every 20 minThere is evidence that l-epinephrine (5 mL of 1:1,000 solution) is equally effective as racemic epinephrine16

Indication of racemic epinephrinmoderate to severe stridor at restpossible need for intubationrespiratory distresshypoxia.

Duration of activity < 2hobserve 2-3 h then discharge

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Discharge if no stridor at rest; have normal air entry, normal pulse oximetry, and normal level of consciousness; and have received steroids

Antibiotics are not indicated in croup. Nonprescription cough and cold medications should not be used in children < 4 yrA helium-oxygen mixture (heliox) may be considered in children with severe croup for whom intubation is being considered although the evidence is inconclusive18

Hospitalizationprogressive stridorsevere stridor at rest respiratory distresshypoxiacyanosisdepressed mental status poor oral intakethe need for reliable observation19

Severe forms of laryngotracheobronchitis that require intubation in a high proportion of patients have been reported during severe measles and infuenza A virus epidemics

Imaging Does not require a radiograph of the neck Steeple sign (PA)Not specific Does not correlate with disease activity Considered after airway stabilization in atypical presentation 20

Thank you 21