Croup

croup disease in children with the classification , diagnosis and treatment.

1. C r oup Present ed by: Jeevan kishore Group: 16

2. C r ou p Croup is a respiratory illness characterized by inspiratory stridor, cough, and hoarseness. These symptoms result from inflammation in the larynx and subglottic airway A barking cough is the hallmark of croup among infants and young children, whereas hoarseness predominates in older children and adults. Although croup usually is a mild and self-limited illness, significant upper airway obstruction, respiratory distress , and rarely death , can occur.

3. The term croup has been used to describe a variety of upper respiratory conditions in children including : L aryngitis L aryngotracheitis L aryngotracheobronchitis bacterial tracheitis or spasmodic croup

4. Laryngitis: refers to inflammation limited to the larynx and manifests itself as hoarseness . It usually occurs in older children and adults Laryngotracheitis : refers to inflammation of the larynx and trachea .Although lower airway signs are absent, the typical barking cough will be present.

5. Laryngotracheobronchitis (LTB): occurs when inflammation extends into the bronchi, resulting in lower airway signs Further extension of inflammation into the lower airways results in laryngotracheobronchopneumonitis , which sometimes can be complicated by bacterial superinfection. Bacterial superinfection can be manifest as pneumonia, bronchopneumonia, or bacterial tracheitis

6. Bacterial tracheitis: Bacterial tracheitis (also called bacterial croup) describes bacterial infection of the subglottic trachea, resulting in a thick, purulent exudate , which causes symptoms of upper airway obstruction Bacterial tracheitis may occur as a complication of viral respiratory infections (usually those which manifest themselves as LTB or (laryngotracheobronchopneumonitis) or as a primary bacterial infection.

7. Spasmodic croup: Spasmodic croup is characterized by the sudden onset of inspiratory stridor at night , short duration (several hours), and sudden cessation. This is often in the setting of a mild upper respiratory infection, but without fever or inflammation . A striking feature of spasmodic croup is its recurrent nature, hence the alternate descriptive term, "frequently recurrent croup". Because of some clinical overlap with atopic diseases, it is sometimes referred to as "allergic croup".

8. ETIOLOGY

9. Croup is usually caused by viruses . Bacterial infection may occur secondarily. para influenza virus type 1,2 & 3 Respiratory syncytial virus (RSV) and adenoviruses Human coronavirus NL63 (HCoV-NL63) Measles Influenza virus Rhinoviruses, enteroviruses ( especially Coxsackie types A9, B4,and B5, and echovirus types 4, 11, and 21 ), Herpes simplex virus Metapneumo viruses

10. Croup also may be caused by bacteria. The most common secondary bacterial pathogens include Staphylococcus aureus Streptococcus pyogenes Streptococcus Pneumoniae secondary bacterial infection may occur in children with laryngotracheitis, laryngotracheobronchitis, or laryngotracheobronchopneumonitis . Bacterial infection :

11. E PID O M I O L OGY Croup affects about 15% of children most commonly occurs in children 6 to 36 months of age. It is more common in boys, with a male: female ratio of about 4:1 Most cases occur in the fall or early winter Family history of croup is a risk factor for croup and recurrent croup

12. pathophysiology

13. The viral pathogen is inhaled and infects the cells of the respiratory epithelium. Consequently leading to localized inflammatory response including Inflammation of the subglottic area Mucosal edema Increased mucous production Swelling of the involved airway particularly involving the lateral walls of the trachea just below the vocal cords The combination of swelling, edema and excess mucous production leads to narrowing of the internal airway lumen- this is aggravated by inspiration where further inflammation can results from walls of the subglottic space are drawn in during inspiration

14. Clinical presentation

15. Clinical presentation

16. Over the next 12 to 48 hours, a progressively worsening "barky" cough, hoarseness and inspiratory stridor are noted, secondary to some degree of upper airway obstruction and laryngeal inflammation. Croup symptoms appear to subside during the day (possibly because of positioning), only to recur the following night. The onset is often rapid and typically in the early morning hours (e.g., 2:00 am). Thus, a child with significant stridor presenting during daylight, may be more seriously affected.

17. Most children with mild symptoms have no more than a croupy cough and hoarse cry and some may have stridor only upon activity or agitation. Children with more severe cases have: inspiratory and expiratory stridor at rest. visible suprasternal, intercostal, subcostal retractions. Air entry may be poor. lethargy and agitation hypoxemia and increasing hypercarbia respiratory arrest may occur suddenly during an episode of severe coughing

18. W a rning signs: tachypnea, tachycardia out of proportion to fever. hypotonia. unable to maintain adequate oral intake. cyanosis.

19. Diagnosis Laboratory studies add little to the diagnosis of croup if bacterial infection is not suspected. White blood cell counts may be elevated above 10,000 with a predominance of polymorphonuclear cells. White blood cell counts greater than 20,000 may suggest bacterial superinfection

20. I maging : Lateral neck radiographs are often obtained, not as much to confirm the diagnosis of croup, but to rule out other causes of stridor such as soft tissue densities in the trachea, a retropharyngeal abscess and epiglottitis. Chest radiographs may show subglottic narrowing (in 50% of children with croup), but this can also be seen in normal patients.

21. Pulse oximetry To determine the percentage of oxyhemoglobin in blood pulsating through a network of capillaries. A low reading of oxygen saturation on pulse oximetry indicates significant respiratory impairment.

22. Direct or indirect laryngoscopy is not usually required and is indicated if there is a concern for an anatomical malformation of the upper airway, possible aspiration of a foreign object, or should the child rapidly deteriorate or not respond to routine therapy in the anticipated manner. Laryngoscopy

23. Severity as s ess m en t: Total score 0-17 Westley score

24. Westley croup score of <3. occasional barking cough, no stridor at rest, and mild or absent suprasternal or subcostal retractions. Is defined by a Westley croup score of 3 to 6. includes frequent cough, audible stridor at rest, and visible retractions, but little distress or agitation. Is defined by a Westley croup score of ≥8. consists of frequent cough, prominent inspiratory (and, occasionally, expiratory) stridor, conspicuous retractions, decreased air entry on auscultation, and significant distress and agitation. Lethargy, cyanosis, and decreasing retractions are harbingers of impending respiratory failure. Mild croup Medium croup Severe croup

25. DIFFERENTIAL DIAGNOSIS Acute epiglottitis Peritonsillar and retropharyngeal abscesses Foreign body aspiration or Ingestion Allergic reaction Acute angioneurotic Edema Upper airway injury Congenital anomalies of the upper airway Laryngeal diphtheria

26. Treatment Keep child calm Cool mist or night air Steam(vaporizer of from shower) Antipyretics Encouragement of fluid intake Humidified air Single dose of oral dexamethasone(0.6 mg/kg) MILD CROUP

27. MODERATE TO SEVERE CROUP Supportive care Humidified air or humidified oxygen Monitoring Fluid s Intubation

28. Pharmacotherapy Corticosteroids provide benefit for children with viral croup by reducing the severity and shortening the course of the symptoms Dexamethasone is the most commonly used, with the dose being 0.6 mg/kg (maximum 10 mg) by mouth or intramuscularly Clinical improvement from corticosteroids is usually not apparent until 6 hours after treatment.

29. Nebulized epinephrine Is thought to stimulate alpha-adrenergic receptors with subsequent constriction of arterioles and decreased laryngeal edema. Nebulized epinephrine may have marked effect to decrease inspiratory stridor and the work of breathing. The effects of this medication last less than two hours and children need to be monitored serially for the return of symptoms.

30. Racemic epinephrine L-epinephrine Is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution. It is given via nebulizer over 15 minutes. Racemic epinephrine and L-epinephrine appear to be equally effective. Is administered as 0.05 mL/kg per dose (maximum of 0.5 mL)of a 2.25 percent solution diluted to 3 mL total volume with normal saline. It is given via nebulizer over 15 minutes .

31. Antibiotics should be used only to treat specific bacterial complications of croup. Hospitalization if : Progressive stridor Stridor at rest Respiratory distress Cyanosis Depressed mental status

32. Viral croup is usually a self-limited disease The prognosis for croup is excellent, and recovery is almost always complete. Symptoms usually improve within three days, but may last for up to seven days Less than 5 percent of children with croup require hospital admission, and among those, 1 to 6 percent require intubation Mortality is rare, occurring in <0.5 percent of intubated children Prognosis

33. Complications hypoxemia (oxygen saturation <92 percent in room air) and respiratory failure. pulmonary edema pneumothorax, and pneumomediastinum c omplications in croup are rare . Lymphadenitis otitis media Secondary bacterial infections Bacterial tracheitis bronchopneumonia, and pneumonia cardiac arrest and death

34. References: Nelson textbook of pediatrics 19 th edition http://www.uptodate.com http://www. medescape.co m http://www.hawaii.edu/medicine/pediatric s https://www.slideshare.net/najah_abbas/croup-laryngotracheobronchitis-2015?qid=8e93eeb1-531b-4638-93de-e00cf0f49367&v=&b=&from_search=6 https://www.slideshare.net/mrmodaq/croup-55390752 https://www.webmd.com/children/understanding-croup-basic-information http://www.mayoclinic.org/diseases-conditions/croup/symptoms-causes/syc-20350348