Croup and Epiglottitis.pptx. by dr shahzaib r paracha

presentation about croup and epiglotits
clinical signs and symptoms
diagnosis and treatment

1. Croup & Epiglottitis By Dr . Shahzaib Rasool House Officer GTTH

2. Learning Objectives What is croup/ Epiglottitis Pathophysiology Clinical features Investigation D/D Management Complications Q/A

3. A 2 year old boy presents with noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils and hoarseness. Cough is worsening at night. He has a mild URTI for 3 days. On examination he has fever of 100f, R/R 55 per min, and H/R 140 per min. What is D/D? What is provisional diagnosis?

4. What is croup ?

5. Croup (laryngotracheobronchitis) Croup is a term used for a respiratory distress with inspiratory stridor, cough (barklike or brassy) and hoarseness resulting from obstruction in the region of the larynx,trachea or bronchi. Most patients are between the age of 3 months and 5 years, with peak in the 2 nd year of life. M o r e c o mm o n i n b o ys a n d i n w i n te r m o n t h s . Approximately 8-15% of children with croup require hospitalization and among those , less than 1%require intubation. M o r t a li t y i s r ar e , o c cu rr in g i n < . 5 % o f in t ub a te d children.

6. An a t o m y of Neck

7. E t iolo g y P a r a - i n f l u e n z a v ir u s e s (ty p e 1,2,3) -75% Influenza A and B viruses Adenovirus RSV Measles virus Bacteria

8. Pathophysiology

9. C lini c a l f e a t u r e s Viral croup usually has a gradual onset and course Symptoms are often worse at night Initially child gets a cold with cough, coryza and low grade fever Gradually (in 12-48 hrs) cough becomes “croupy” ( barky with inspiratory stridor) causing varying degrees of respiratory distress with retractions and even cyanosis The duration of symptoms is usually 3-7 days Other family members might have mild respiratory illness with laryngitis

10. Severity criteria for croup

11. D i ag n o s is Diagnosis is usually apparent from clinical features and examination O/E = hoarse voice, coryza, a normal or minimal inflamed larynx and an increased respiratory rate with prolonged inspiratory phase and stridor Xray = subglottic narrowing White cell count = normal

12. X ray AP view shows glottic narrowing (steeple sign)

13. Differential Diagnosis Acute epiglottitis Retropharyngeal abscess Peritonsillar abscess Foreign body aspiration

14. Indications for hospitalization Cyanosis Decreased level of consciousness Progressive stridor Toxic appearance

15. M a n a g e m e n t Main treatment includes : airway management treatment of hypoxia Mist therapy > it is given by hot steam by a vaporizer or cold steam from a nebulizer. Respiratory distress may improves within minutes but humidification should be continued until the cough subsides Oxygen should be provided Nebulized racemic epinephrine > ( 0.25-0.5ml of 2.25% racemic epinephrine in 3ml of normal saline can be used as often as every 20 min) Dexamethasone > (0.6mg/kg once oral or I/M) Anti biotics > only when suspicious of secondary bacterial infection

16. Discharge criteria No stridor at rest Normal pulse oximetry at room air Normal color Normal level of consciousness Good air exchange Demonstrated ability to tolerate fluids by mouth

17. C o m pl i c a t i o n s of c r o u p Secondary bacterial infection Hypoxia with respiratory fatigue Pulmonary edema Pneumothorax Pneumomediastinum

18. S p a s m o d ic C r o u p Characterized by sudden onset of inspiratory stridor at night,short duration and sudden cessation. This is often in the setting of a mild upper respiratory infection but without fever and inflammation. Clinical course usually benign, symptoms are almost always relieved by comforting the anxious child and administering humidified air. Rarely children may benefit from treatment with corticosteroids and /or nebulized epinephrine.

19. (439) Sounds of Croup (Laryngotracheitis) - Lung Sounds - M E D Z C OO L - Y o u T ub e

20. An 11 months old girl presents with fever, cough, difficulty in breathing and palpitations.On examination she is tachpneic , has stridor and subcostal and intercostal recessions. She is not toxic looking. What is most likely diagnosis? What is the commonest etiological agent? Give steps of management.

21. Acute Epiglottitis

22. Acute Epiglotitis Refers to infection of epiglottis, the aryepiglottic folds and arytenoid soft tissues The condition occurs mostly in the winter months, affecting males often. Rarely occurs before age of 2 years and the peak incidence is between 2-5 years. It is a bacterial infection , the commonest organism being H.Influenza type b. The incident of epiglotitis may be markedly decreased due to use of vaccine, therefore other agents such as strep.pyogenes,step.pneumonia, staph.aureus and non type b. •

23. Pathophysiology Acute epiglottitis may be due to direct invasion of the mucosal layer by microorganisms. Infectious microorganisms may lead to acute inflammation of the epiglottitis from direct invasion or spread via bacteraemia. Typically, bacteria (most common cause) reside in the nasopharynx and infiltrate the epiglottis mucosa through defects (i.e. microtrauma). Defects in the mucosa may occur due to a preceding viral illness or direct trauma from swallowing food. Inflammation and swelling occur and rapidly lead to infection of the entire supraglottic airway leading to potentially life-threatening airway obstruction.

24. C lini c a l f e a t u r e s Abrupt onset of high grade fever 39-40c M o d e r a t e t o s e v e r e r e s p i r a to r y d is t r e s s Stridor Drooling Irr i t a bili t y a n d r e s t l e ss n e s s Often a choking sensation and the child sits, leaning forward Complete obstruction of the airway is seen and death ensue unless adequate treatment is provided A large cherry red ,swollen epiglottis is visualized by laryngoscopy under controlled circumstances (ICU)

25. D i ag n o s is Leukocytosis = more than 10,000/mm3 Direct visualization = swollen, erythematous Xray of soft tissue of neck

26. Xray shows the presence of thumb- printing sign , a common radiographic marker for epiglottitis

27. M a n a g e m e n t This is generally an emergency Secure the airway O x y g e n i s gi ve n b y m a s k Best treatment is nasotracheal intubation. The patient should be given ventilatory support until edema subsides Fluid and electrolyte support I / V anti b i ot ics i s gi ve n f o r 7 - 1 d a y s Initial agents are ceftriaxone 100mg/kg/day cefotaxime 3 - m e r o p e n e m 4 - c h l o r a m p h e n ic o l 5 - 75 m g / k g / d a y Acute laryngeal swelling due to allergic reaction is best treated with : 1- Epinephrine (1:1000 dilution in dosage of 0.01ml/kg to a maximum of 0.5ml/dose) I/M 2- Racemic epinephrine ( dose of 0.5ml of 2.25% racemic epinephrine in 3ml of N/S) 3- corticosteroids are often needed (1-2mg/kg/24 hrs of prednisone fir 3-5 days)

28. Prognosis After insertion of the artificial airway, patient improves immediately and respiratory distress and cyanosis disappear. Epiglottitis resolves after a few days of antibiotic treatment and the patient may be extubated but antibiotics are given for 10 days.

29. A 6 years old boy presents in ER with the 3 hrs history of high grade fever and sore throat. Child appears alert but anxious and toxic. On examination there is mild inspiratory stridor, drooling and R/R 30. What is most likely diagnosis? What investigation you will order? How will you manage the patient?