Croup and Epiglottitis by DR.PREMRAJ

PRATHIMA INSTITUTE OF MEDICAL COLLEGE
2nd YEAR MD.PEDIATRICS

1. Croup and epiglottitis Dr n prem raj MENTOR: DR.G.V. HARISH PROFESSOR DEPT.OF PEDIATRICS PIMS.

2. CROUP Term croup describes both laryngotracheobronchitis and laryngotracheitis. Laryngotracheobronchitis refers to “ inflammation of larynx , trachea and bronchi mostly of viral pathology. Present with : low grade fever, cough , cold followed by barking type of cough , stridor and chest indrawing. Symptoms are characteristically worse at night and resolve within a week Croup is a disease of upper airway and alveolar gas exchange is normal Rarely upper airway obstruction progresses and is accompanied by increasing respiratory rate ,nasal flaring supra/infra/intercostal retractions and continuous stridor . .

3. c) Severe croup – stridor at rest severe chest indrawing poor air entry on bilateral lung fields may be hypoxic , significant agitation and cyanosis . Divided into a) mild cases – occasional barking cough no stridor at rest no indrawing b)moderate cases – frequent barking cough with stridor at rest retractions + good air entry on bilateral lung fields .

4. Age of presentation 6 moths to 6 years old ,peak incidence in children 12months to 2 years WESTLEY croup score : objective measure to identify severity of croup Mild score – 0 to 2 Moderate score – 3 to 5 Severe score – 6 to 11 Impending respiratory failure – 12 to 17 ETIOLOGY : Viral – parainfluenza virus – 1,2,3 influenza A, B RSV Measles Mycoplasma

5. Chest wall retraction None Mild +1 Moderate +2 severe +3 stridor none With agitation +1 At rest +2 cyanosis none With agitation +4 At rest +5 Level of consciousness normal o disoriented +5 Air entry normal Decreased +1 Markedly decreased +2

6. Management 1) lab – in some cases x-ray neck may reveal subglottic narrowing as classical “steeple sign “ This Photo by Unknown Author is licensed under CC BY-SA

7. Treatment 1) Airway management - most imp step in cases of stridor in order to avoid hypoxic respiratory failure, initially maintain airway , clear secretions and providing humidified oxygen to maintain sPo2 > 95% 2) Epinephrine nebulization – reduces mucosal edema L –epinephrine injection 0.5 ml/kg ,maximum 5 ml added to 2 to 3 ml NS in nebulizing chamber and Nebulization is given along with oxygen . stridor is significantly reduced within 30 minutes of nebulization, risk of rebound increase in symptoms present , so observe the patient for at least 2 hours

8. Corticosteroids : oral , intramuscular or intravenous dose of dexamethasone is effective in reducing upper airway edema . onset of action is within 1 hour and peak effect noted in 6 to 12 hours . single dose of dexamethasone 0.6 mg/kg is effective . No significant difference between oral dexamethasone and prednisolone in reducing croup symptoms “Corticosteroids reduce the need for epinephrine nebulization , intubation and frequency of readmission” Inhaled corticosteroid as budesonide nebulization 2 to 4 mg can also be given Heli ox : helium oxygen mixture 60:40 or 70: 30 promotes laminar gas flow in obstructed airways , used for severe croup ( not easily available ) Antitussives and decongestants have no role in croup .analgesics provide comfort by reducing pain and fever .

9. ACUTE EPIGLOTTITIS Etiology bacterial Hemophilus influenza type –B Age of presentation – 2 to 6 years Clinical features – acute onset of fever irritability throat pain ( severe dysphagia ) drooling of saliva patient assumes tripod position with hot potato voice and soft stridor Progression to respiratory failure occurs very quickly Incidence of acute epiglottitis has reduced dramatically due to universal immunization against Hemophilus influenza

10. Management Diagnosis is done by direct visualization of swollen red epiglottis and culture swab taken from surface. Neutrophilic leukocytosis may be present. X-ray of neck in anterior-posterior and lateral view with head in slight extension in deep inspiration. “ thumb sign – swollen epiglottis” If intubation required , 0.5mm smaller ET tube for age inserted Iv antibiotics like ceftriaxone / Cefotaxime are administered and airways kept secured for at least 48 to 72 hours till edema subsides This Photo by Unknown Author is licensed under CC BY-SA-NC

11. Epiglottitis is medical emergency and warrants immediate airway placement Racemic epinephrine and corticosteroids are ineffective Indication for Rifampin prophylaxis 20mg/kg orally once a day for 4 days for all household members include a child within the home who is younger than 4 years and incompletely immunized, younger than 12 months age and not completed primary vaccination series or immunocompromised Complications : pneumonia , otitis media , cervical lymphadenitis or rarely meningitis or septic arthritis can occur

12. APPROACH TO CHILD WITH RESPIRATORY DISTRESS Definition : any unusual pattern of breathing , causing subjective feeling of discomfort , in previously well child is termed as Respiratory distress .It includes fast or slow breathing ,shallow or labored efforts ,noisy breathing . Cut offs for RR marking significant lower chest disease (WHO) Age group Respiratory rate cut off Young infant ( < 2 months ) > 60/min Infants ( 2 months – 1 year ) >50/min Children ( 1 -5 years ) >40/min School children (>5 years ) >30/min

13. Causes of respiratory distress in children Upper respiratory tract involvement croup , acute epiglottitis retropharyngeal abscess foreign body aspiration diphtheria laryngospasm lower respiratory tract involvement pneumonia bronchiolitis asthma pneumothorax atelectasis pleural effusion or empyema and hemothorax

14. Non pulmonary causes - congestive heart failure due to heart disease or severe anemia CNS infections , cerebral edema ,tumor ( raised Ict , GBS, spinal cord injury ) - metabolic acidosis renal failure renal tubular acidosis diabetic acidosis psychogenic hyperventilation , anxiety and panic attacks

15. Clinical pearls symptoms of impending respiratory failure - cyanosis - silent chest - poor respiratory efforts - fatigue/ exhaustion - agitation or reduced level of consciousness preterminal signs : bradycardia, desaturation and altered sensorium

16. Clinical features diagnosis Fever , cough and rapid breathing Lower respiratory tract infections like pneumonia , bronchiolitis Exercise induced dyspnea Asthma , congestive heart failure ,severe anemia Nocturnal cough, orthopnea and dyspnea Congestive heart failure Fever , sore throat, stridor Acute epiglottitis Severe chest pain with rapid ,shallow breathing ,decreased air entry Pneumonia , pneumothorax , pulmonary embolism Fast breathing , altered sensorium , polyuria ,dehydration Diabetic acidosis Acute respiratory distress after sudden choking ,hyperinflated chest Foreign body inhalation Clinical feature based diagnostic clues

17. investigtion Suggested diagnosis Complete blood count with peripheral smear Leukocytosis /leucopenia, toxic granules , anemia / polycythemia, eosinophilia pneumonia, sepsis CRP, ESR Raised- pneumonia , bronchiolitis Blood culture Sepsis with pneumonia Kidney function tests Acute /chronic kidney disease Arterial blood gas Hypoxemia ,hypercarbia ,acidosis (metabolic/respiratory) pneumothorax AKI Chest x-ray , x-ray soft tissue neck Pneumonia ,pneumothorax, effusion, acute epiglottitis, CHF echocardiography Cardiac disease Lumbar puncture / cranial CT scan Pleocytosis raised protein and decreased sugar meningoencephalitis/raised ict 24 hour pH monitoring GERD investigation

18. *H/o choking *Recurrent lobar consolidation *U/L hyperinflation Poor response to medical treatment *H/o fever *no DPT vaccination *cervical lymphadenopathy *membrane of throat *H/o fever *hoarse voice *barking cough *CXR-Steeple sign *H/o fever *dysphagia *post pharyngeal wall swelling STRIDOR Diphtheria Croup Retropharyngeal abscess Foreign body aspiration Bronchoscopic removal *Throat swab *antibiotic * Antidiphtheric serum *antibiotics *steroid *adrenaline nebulization *aspiration/I &D *ATT

19. *H/o recurrent wheeze *family hist of asthma/atopy *good response to bronchodilator *B/L hyperinflation of chest *Age <2yrs *h/o viral prodrome *poor response to bronchodilator *B/L hyperinflation of chest *h/o chocking *U/L wheeze *X ray s/o air trapping *h/o fever ,cough *Fast breathing *chest indrawing *consolidation ,infiltrates in cxr asthma bronchiolitis Foreign body pneumonia WHEEZE/CREPTS Bronchodilator steroid O2 IV fluids Bronchoscopic removal IV antibiotics

20. Decreased air entry h/o fever, cough, fast breathing trauma Hyper resonance on percussion pneumothorax ICD Dullness on percussion Pleural effusion ICD/antibiotics

21. HYPERVENTILATION WITH CHEST CLEAR ( with out chest retractions ) h/o recurrent infections , poor growth Neuroimaging/fundus exam h/o poor growth , decreased U/O DKA h/o anxiety/psychiatric complaints O/E; edema ,hematuria ,deranged KFTs O/E: dehydration, raised blood sugar , urinary sugar &ketones+ VBG s/o met acidosis PshychSomatic illness h/o fever/headache/vomiting irritability/convulsions Raised ICT IV FLUIDS/insulin Renal failure Fluid restriction /dialysis Psychiatry opinion Antibiotics /decongestive measures, steroids, shunt placement

22. DIARRHEA Is one of the major contributors to under five age mortality in india It is responsible for 10% infant deaths and 14% of 0 to 4 year children deaths in our country Definition : Acute diarrhea – passage of loose /watery stool more than three episodes ( in 24hrs) with/with out vomiting . stool consistency is more important than frequency . further divided into a) acute watery diarrhea – secretory nature ( producing large quantities of watery stools). b) acute bloody diarrhea – invasive nature ,mucosal invasion leading to blood in stool and cramping.

23. Prolonged diarrhea – last more than 7 days and requires a different approach for management than acute diarrhea persistent diarrhea – lasts more than 14 days and can lead to malnutrition and non intestinal infections apart from dehydration .

24. Etiology Infections viruses- rotavirus, adenovirus , calcivirus bacteria – E.coli , V.cholera, C.jejuni , salmonella ,shigella protozoal – E. histolytica , G lamblia , cryptosporidium Non infective drug induced – antibiotics inflammatory bowel disease celiac disease hyperthyroidism

25. Clinical features following points must be noted on history Onset and duration of diarrhea Frequency ,color and consistency of stool Presence of blood in stool Presence of fever , vomiting ,cough or other accompanying symptoms ( convulsion ,recent measles) Recent travel if any Presence of any comorbidities and drug history Immunization history Pre illness feeding practices ( raw/undercooked food , bottle feeding ) Type and amount of fluids (including breast milk )

26. features Small bowel diarrhea Large bowel diarrhea Volume of stools large small frequency Not very frequent Odour of stools offensive odourless Nature of stools Bulky, watery, steatorrhea, frothy stools Loose stools with blood and mucus or jelly like tenesmus absent present dehydration present Usually absent complications dehydration HUS, toxemia

27. features Osmotic diarrhea Secretory diarrhea stools Large volume ,semisolid Large volume ,watery flatulence ++ - Stool consistency Soupy-lactose intolernce watery Evidence of malabsorption present absent Perianal excoriation present absent Stool pH <5 >6 Stools for reducing substances positive negative appearence Not ill look Ill loking

28. For severity decreased urine frequency /concentrated appearance of urine (signifies dehydration) Activity and alertness of child Cholera typically presents with profuse watery diarrhea with characteristic fishy odor. Dysentery is bacterial origin and Presents with blood and mucus in stool , abdominal cramping and fever - Intussusception and appendicitis sometimes require imaging Urinary tract infections can initially present as fever with diarrhea and require urine tests for differentiation . Complications a) dehydration b)AKI c)seizures ( dur to dyselectrolytemia / hypoglycemia ) d)encephalopathy e)circulatory shock

29. Assessment Severe dehydration General condition Lethargic , unconsciousness eyes Sunken Skin pinch Goes back very slowly thirst Drinks poorly Heart rate Marked tachycardia /bradycardia Capillary refill Markedly de;ay Periphehries Cold /cyanotic Urine output Markedly decreased Fluid deficit as% of body >10% Mucosal membranes Dried out Fluid deficit in ml/kg body weiht >100 mlkg

30. Laboratory investigations - complete blood count -Electrolytes -Blood gas -Renal function tests -Glucose level Elevated BUN has been shown have some correlation with degree of dehydration Serum bicarbonate less than 17 mEq /l has been demonstrated to have 94 %sensitivity for more than 10% dehydration Inflammatory markers such as C-reactive protein and ESR cannot reliably differentiate between viral and bacterial etiologies Blood culture is limited utility except to detect salmonella

31. Urine specific gravity is an indicator of degree of dehydration Urinalysis can help to differentiate from urinary tract infection Stool routine microscopy can reveal presence of blood, mucus ,and leucocytes (dysentery) and in rare cases protozoal cysts/trophozoites - Few exception when identification of etiological agent is important cholera suspected hemolytic uremic syndrome hospital acquired diarrhea (after 3 days of admission ) suspected clostridium difficile infection prolonged diarrhea more than 2 weeks –to decide on antibiotic administration Abdominal imaging (ultrasound /CT) is indicated only in cases with severe abdominal pain and tenderness or strong clinical suspicion of underlying pathology( appendicitis) Endoscopy is reserved only for cases of protracted diarrhea with unclear etiology

32. Clinical evaluation of dehydration Mild dehydration - <5% in infant , < 3% in older child normal or increased pulse decreased urine output ; thirsty b) Moderate dehydration – ( 5 to 10 % in infant , 3 to 6 % in old child ) tachycardia , little or no urine output irritable /lethargic , dry mucous membranes delayed capillary refill ( >1.5 sec) sunken eyes and fontanelle , delay in skin elasticity c) Severe dehydration – ( > 10% I infant , > 6% in older child ) peripheral pulses either rapid , weak or absent no urine output poor skin turgor delayed capillary refill ( >3sed) very sunken eyes and fontanelle decreased blood pressure

33. Treatment of severe dehydration Mainstay of treatment is rehydration i.e “restoration of water and electrolyte deficit simultaneously along with maintenance fluid therapy and replacement of ongoing losses” Require iv fluid therapy .generally ringer lactate(RL) or normal saline (NS) is used for iv dehydration Use of large amounts of NS leads to hyperchloremic metabolic acidosis For infants , 30 ml/kg iv RL is given in 1 hour followed by 70 ml/kg over next 5 hours Correction in older children is done faster -initial 30ml/kg over 30 minutes followed by 70ml/kg in next 2 half hour The patient should be continuously reassessed ; if radial pulses are weak , fluid should be administered at faster rate A patient with signs of shock should be managed with fluid boluses and if required ionotropic support similar to septic shock guidelines

34. In acute diarrhea , dyselectrolytemias are commonly seen and include hyponatremia hypernatremia and hypokalemia. Extreme high or low sodium leads to adverse effects including seizures, cerebral edema ,. Oral rehydration therapy wherever feasible is helpful and safer than intravenous therapy as will not lead to sudden swing in sodium. Potassium losses during diarrhea ,if not replaced will lead to hypokalemia ,especially in children with malnutrition , which has deleterious effects including muscle weakness ,paralytic ileus and arrythmias .

35. Zinc supplementation : has an important role in metallo -enzymes and cell membrane ,and function . Zinc supplementation reduces both duration and severity of diarrhea in children less than 5years of age . It is recommended to give zinc to all children more than 3 months at dose of 20mg elemental zinc /day during and for up to 7 days after diarrhea Vitamin A supplementation is also useful Role of antimicrobial therapy : no role for routine use of antimicrobial agents in acute diarrhea few select conditions a) cholera – profuse voluminous watery diarrhea with potential for severe dehydration and shock single dose of doxycycline in an older child or 3 day course of erythromycin/azithromycin in a child less than 12 years is effective in aborting the illness

36. b) Acute dysentery /bloody diarrhea (shigella ) : Nalidixic acid /ciprofloxacin or 3 rd generation cephalosporin for 3 to 5 days should be given . c) Salmonella (typhoid): prolonged antibiotic therapy for 10 to 14 days with ceftriaxone /cefixime is required . d) Clostridium difficile diarrhea is very rare and seen in population like immunocompromised children on prolonged antibiotics , treatment with oral metronidazole or vancomycin is recommended. Role of probiotics : preliminary data from west indicate that probiotics have a beneficial role In acute gastroenteritis in children . Antiemetics : vomiting commonly accompany acute diarrhea ,but is usually self limited and resolves in 48 hours of rehydration . in severe recurrent vomiting domperidone /ondansetron can be used , the concern with ondansetron is cause cardiac arrythmias ,especially in presence of underlying long QT syndrome .

37. Diet : age appropriate feeding should be continued and not stopped in cases with mild – moderate dehydration . In severe dehydration or when there is excessive vomiting ,feeding should be started as quickly as possible once rehydration and supportive care has been provided. Enteral nutrition is important for regeneration of enterocytes in GIT damaged by infection . Breastfeeding should be continued and ORS offered in between feeds In young infants . Antimotility agents ( loperamide ) adsorbents ( charcoal) bismuth or cholestyramine should NOT be used in treatment of acute childhood diarrhea

38. COVID 19 UPDATES Total cases recorded in world over 24 hors 2,54, 122 India has recorded over 50,000 cases in past 24 hours for consecutive last 7 days Now total cases in india – 19,06,613 total deaths - 39,820 Fatality rate 2.10% TELANGANA – total cases confirmed 68,946 recovered 49,675 total deaths 563

39. ICMR – human trials of indigenously developed Covid vaccines move to phase 2 At present ,there are three vaccines that are in different phases of clinical testing in india First one – inactivated virus vaccine developed b Bharat biotech , completed phase 1 study and started is phase 2 study Simialrly Zydus cadila DNA vaccine completed phase 1 and started phase 2 Recombinant oxford vaccine manufactured by serum institute of india given approval for phase 2 and 3 clinical trials ,which would start within a week

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