Good Morning!

Semantic QualifiersSymptoms

Acute /subacute Chronic

Localized Diffuse

Single Multiple

Static Progressive

Constant Intermittent

Single Episode Recurrent

Abrupt Gradual

Severe Mild

Painful Nonpainful

Bilious Nonbilious

Sharp/Stabbing Dull/Vague

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem Systemic problem

Acquired Congenital

New problem Recurrence of old problem

Stridor• Harsh, high-pitched

resp sound• Usually inspiratory– But can be biphasic

• Cause by turbulent flow• Sign of upper airway

obstruction• NOT a diagnosis

Site of Pathology

Respiratory Rate

Retractions Audible Sounds

Extrathoracic airway

Stridor

Intrathoracic extra-pulmonary

Wheezing

Intrathoracic intrapulmonary

Wheezing

Alveolar interstitial

Grunting

Stridor

• Viral croup

• Noninfectious croup

• Epiglottitis

• Bacterial tracheitis

• Extraluminal compression

• Intraluminal obstruction from masses

• Foreign body

• Retropharyngeal abscess

• Peritonsillar abscess

• Angioedema

• Caustic ingestion

• Vocal cord dysfunction

“Croup”• Group of conditions – Acute and infectious causes of upper airway

inflammation • Upper airway of children

Laryngotracheitis

• = most common “Croup” illness– Laryngotracheitis vs.

Laryngotracheobronchitis/pneumonitis

• Predisposing Factors – Between age 3 months and 5 yrs– Peak in 2nd year of life– M > F– Can occur anytime of year but peaks in late fall and

winter– Preceding URI illness

Laryngotracheitis

• Pathophysiology– Inflammation involving the vocal cords and

structures inferior to the cords

Laryngotracheitis

• Pathophysiology– Viral etiology is most common• Parainfluenza viruses (type 1, 2, and 3) ~ 75% of cases• Influenza A

– Associated with SEVERE disease

• Influenza B• Adenovirus• RSV• Measles

– Mycoplama pneumoniae rarely isolated

Laryngotracheitis

• Clinical Presentation**– URI symptoms for 1-3 days prior to signs of upper

airway obstruction • Rhinorrhea, pharyngitis, mild cough, low-grade fever

– Characteristic “barking” cough, “seal-like”– Hoarseness– Inspiratory stridor– +/- fever

Laryngotracheitis

• Clinical Presentation** – Symptoms characteristically worse at night – Agitation and crying aggravate symptoms– Varying degrees of respiratory distress on exam– Should not be hypoxic – this is a sign that

complete airway obstruction is imminent

Laryngotracheitis

• Diagnosis – Clinical – Xrays• “Steeple sign” in

AP view• Do not correlate

with disease severity• Can help distinguish

from other causes

Laryngotracheitis

• Treatment**– Most patients managed

as outpatients

– Cool mist??• Not proven in literature, but used since the 1900’s• If bronchospasm present, can worsen with cool mist

– Antibiotics not indicated in viral croup

Laryngotracheitis

• Treatment**– Corticosteroids• Action: decrease laryngeal mucosal edema• Effective in reducing hospitalization rates, shorter

hospital stays, reduced need for subsequent interventions• Dose: 0.6mg/kg single dose DEXAMETHASONE (max

16mg)– PO/IM Decadron both effective – Clincal improvement 6 hours after dose – Prednisolone less effective than Dexamethasone

Laryngotracheitis

• Treatment**– Nebulized racemic epinephrine (Vaponeb)

• For moderate to severe croup• Action: decrease laryngeal mucosal edema• Dose: 0.25ml-0.5ml of 2.25% racemic epi in 3ml of NS nebulized

– Onset of relief 10-30min– Duration of activity <2-3 hours– Can repeat q20 min– Monitor for symptoms once

the Vaponeb activity duration is over (rebound?), generally 3-4 hrs after a treatment

• Use caustiously in patients with tachycardia, and heart conditions such as TOF or ventricular outlet obstruction

Laryngotracheitis

• Indications for hospitalization with croup– Progressive stridor– Severe stridor at rest– Respiratory distress– Hypoxia/cyanosis– Depressed mental status– Poor oral intake– Need for reliable observation

Laryngotracheobronchitis/pneumonitis

• More severe form of croup• Considered an extension of laryngotracheitis

associated with bacterial superinfection– Occurs 5-7 days into the clinical course– New onset fever– Worsening clinical symptoms, toxic– Increased work of breathing• Signs of both upper and lower airway obstruction

• Requires empiric antibiotics

FeatureAcute

LaryngotracheitisSpasmodic

Croup EpiglottitisBacterial Tracheitis

Prodrome URI

Mean Age 3 mo - 5 yr

Onset gradual

Fever variable

Hoarseness, barking cough Yes

Inspiratory stridorYes:

minimal to severe

Dysphagia No

Toxic appearance No

Etiology Viral

X-ray findings Steeple sign

Treatment

cool mist, racemic epi neb, dexamethasone

Noninfectious Croup

• “Spasmodic” croup**– Most often children 1 to 3 yrs– Pathogenesis unknown – possible allergic etiology– Clinically similar to croup but without the viral

prodrome or fever– Most common in the evening– Sudden onset, preceded by mild cough or hoarseness– Episode of characteristic coughing, stridor and

respiratory distress, anxious– Severity improves over hours and can have repeat

episodes x1-2 more nights

FeatureAcute

LaryngotracheitisSpasmodic

Croup EpiglottitisBacterial Tracheitis

Prodrome URInone or minimal

coryza

Mean Age 3 mo - 5 yr 1 to 3 yr

Onset gradual sudden

Fever variable no

Hoarseness, barking cough Yes Yes

Inspiratory stridorYes:

minimal to severeYes: usually moderate

Dysphagia No No

Toxic appearance No No

Etiology Viral Noninfectious

X-ray findings Steeple sign ---

Treatment

cool mist, racemic epi neb, dexamethasone cool mist

Epiglottitis

• Predisposing Factors– Typical age of patients 2 to 4 yrs– Unimmunized

Epiglottitis

• Pathophysiology– Prevaccine, most common cause:• Haemophilus influenzae type B

– Now, larger number of cases in vaccinated patients due to:• Streptococcus pyogenes• Streptococcus pneumoniae• Staphylococcus aureus

Epiglottitis

• Pathophysiology– Inflammation of

epiglottis– Degree of

inflammation leads to degree of obstruction of airway

Epiglottitis

• Clinical Presentation– Acute– High fever– Sore throat– Dyspnea– Rapidly progressing respiratory obstruction• Can be within hours – become toxic, difficulty

swallowing, labored breathing

Epiglottitis

• Clinical Presentation– Drooling – Holding neck in hyperextended position– Tripod position– Stridor is a late finding!– Not usually associated with a cough

Epiglottitis

• Diagnosis– Visualization via laryngoscopy • In controlled environment

Epiglottitis

• Diagnosis– Xrays• “Thumb sign” in lateral view

Epiglottitis

• Treatment**– Careful on exam**• Avoid anxiety-provoking procedures (labs/IV), avoid

placing patient supine or direct inspection of oral cavity• To prevent acute airway obstruction

– Medical emergency – Placement of artificial airway in controlled setting• Mortality ~6% without airway vs. <1% with airway

– Oxygen via mask until artificial airway • As long as mask doesn’t cause agitation

Epiglottitis

• Treatment**– Antibiotics**• Ceftriaxone• Cefotaxime• Meropenem• Obtain cultures from blood, epiglottic surface, and if

needed from CSF (after obtain airway)• Treat with at least 7-10 antibiotics, but usually patient

improves after 2-3 days

Epiglottitis

• Rifampin prophylaxis indicated for:– Any household contacts <48 months old and

incompletely immunized– Any household contacts <12 months old and has

not received primary vaccination series– Any immunocompromised child in the household

FeatureAcute

LaryngotracheitisSpasmodic

Croup EpiglottitisBacterial Tracheitis

Prodrome URInone or minimal

coryza none or mild URI

Mean Age 3 mo - 5 yr 1 to 3 yr 2 to 4 yr (range 1 to 8 yr)

Onset gradual sudden rapid

Fever variable no High

Hoarseness, barking cough Yes Yes No

Inspiratory stridorYes:

minimal to severeYes: usually moderate

Yes: moderate to severe

Dysphagia No No Yes

Toxic appearance No No Yes

Etiology Viral NoninfectiousBacterial: Hib, Strep,

S. aureus

X-ray findings Steeple sign --- Thumb sign

Treatment

cool mist, racemic epi neb, dexamethasone cool mist

Intubation, Ceftriaxone, or Cefotaxime,

or Meropenem

Bacterial Tracheitis

• Predisposing Factors– Mean age 5 to 7 yrs– M=F– Preceding viral respiratory

infection • Bacterial complication of

croup

– More common than epiglottitis in vaccinated patients

Bacterial Tracheitis

• Pathophysiology– Mucosal swelling at the

level of the of the cricoid cartilage

– Complicated by copius, thick, purulent secretions, sometimes pseudomembranes

– Most common pathogen: S. aureus• Other organisms: Moraxella catarrhalis, nontype H.

influenzae, and anaerobic organisms

Bacterial Tracheitis

• Clinical Presentation**– Preceding croup illness with cough– Then develops high fever and toxic-appearance– Differs from epiglottitis• Patient can lie down, does not drool, no dysphagia

– Differs from croup• More toxic, does not respond to racemic epi

Bacterial Tracheitis

• Diagnosis– Clinical picture• Toxic + absence

of classic epiglottitis

– Xrays• Not necessary• Findings of irregular

lining of the tracheadue to pseudomembranes• Can have “steeple sign”

Bacterial Tracheitis

• Treatment**– Artificial airway required in ~50-60% of patients– More likely to require intubation if younger

– Antibiotics• Including appropriate Staph coverage• Vanc + 3rd gen Cephalosporin = empiric coverage

FeatureAcute

LaryngotracheitisSpasmodic

Croup EpiglottitisBacterial Tracheitis

Prodrome URInone or minimal

coryza none or mild URI URI/croup

Mean Age 3 mo - 5 yr 1 to 3 yr 2 to 4 yr (range 1 to 8 yr) 5 yr to 7 yr

Onset gradual sudden rapid acute after prodrome

Fever variable no High High

Hoarseness, barking cough Yes Yes No

Variable, with prodrome

Inspiratory stridorYes:

minimal to severeYes: usually moderate

Yes: moderate to severe

Yes:Variable

Dysphagia No No Yes No

Toxic appearance No No Yes Yes

Etiology Viral NoninfectiousBacterial: Hib, Strep,

S. aureus Bacterial: S. aureus

X-ray findings Steeple sign --- Thumb sign Irregular tracheal lining

Treatment

cool mist, racemic epi neb, dexamethasone cool mist

Intubation,Ceftriaxone, or Cefotaxime,

or Meropenem

Often intubation required,

Vancomycin and 3rd gen Cephalosporin

Noon Conference!