Upper airway Upper airway obstruction:obstruction:

Croup and its differentialCroup and its differentialPeter LouiePeter Louie

January 2004January 2004

Case: 12 month old male, with 1 day Case: 12 month old male, with 1 day history of coryza, barky cough, and fever. history of coryza, barky cough, and fever.

Presents with 2 hour Hx. Stridor & Presents with 2 hour Hx. Stridor & difficulty breathing difficulty breathing

ObjectivesObjectivesDifferential diagnosis of upper airway obstructionDifferential diagnosis of upper airway obstruction

CroupCroup► Def’n, ethilogy, epidemiology, Def’n, ethilogy, epidemiology,

pathophysiologypathophysiology► History and physical findingsHistory and physical findings► TreatmentTreatment

EpiglottitisEpiglottitisForeign bodyForeign body

DDX upper airway DDX upper airway obstructionobstruction

Airway swellingAirway swellingInfectious: Infectious: viral croupviral croup

Bacterial Bacterial tracheitistracheitis

epiglottisepiglottis diphteriadiphteria

Non-infectious: anaphylaxisNon-infectious: anaphylaxis

Space occupying lesion or Space occupying lesion or structural abnormalitystructural abnormality

Congenital Congenital (choanal atresia, larynogomalacia, (choanal atresia, larynogomalacia, subglottic stenosis, laryngeal subglottic stenosis, laryngeal

web)web)

AcquiredAcquired► Foreign bodyForeign body► Human papilloma virusHuman papilloma virus► Retropharyngeal abscessRetropharyngeal abscess► TumorTumor► HematomaHematoma

Croup: DefinitionCroup: DefinitionClinical syndrome characterized by triad of Clinical syndrome characterized by triad of 1.1. inspiratory stridorinspiratory stridor

2.2. Barking coughBarking cough

3.3. HoarsenessHoarseness

…………and varying degrees of respiratory distress and varying degrees of respiratory distress

Types of CroupTypes of Croup

Viral croup (laryngotracheobronchitis)Viral croup (laryngotracheobronchitis)

Pseudomembranous croup Pseudomembranous croup (bacterial tracheitis) (bacterial tracheitis)

Spasmodic croupSpasmodic croup

Viral Croup: etiologyViral Croup: etiologyParainfluenza 1 (most common), 2, 3Parainfluenza 1 (most common), 2, 3Respiratory syncytial virus (RSV)Respiratory syncytial virus (RSV)AdenovirusAdenovirusInfluenza A, BInfluenza A, Benterovirusesenteroviruses

Viral Croup: pathophysiologyViral Croup: pathophysiology

Viral Croup - PathogenesisViral Croup - Pathogenesis► Subglottic trachea at cricoid Subglottic trachea at cricoid

cartilage is the narrowest part cartilage is the narrowest part of a child’s airway. of a child’s airway.

► This area is surrounded by firm This area is surrounded by firm cartilage. cartilage.

► Any swelling in this area can Any swelling in this area can encroach on the airway.encroach on the airway.

Viral Croup: pathophysiologyViral Croup: pathophysiologyRespiratory droplets Respiratory droplets

Host immune response activatedHost immune response activated

mucous secretionmucous secretion edema & erythema of edema & erythema of vocal vocal cords (hoarseness) cords (hoarseness)

subglottic region (stridor)subglottic region (stridor)

Upper airway obstruction Upper airway obstruction

Steeple SignSteeple Sign

Viral Croup: EpidemiologyViral Croup: Epidemiology►First 3 years of life (6 – 36 First 3 years of life (6 – 36

months)months)

►Peak incidence 2 yrs: 4.7/100Peak incidence 2 yrs: 4.7/100

►Male:female (3:2)Male:female (3:2)

Clinical presentation: historyClinical presentation: history►Onset and duration Onset and duration ►FeverFever►choking choking ►dysphagia, droolingdysphagia, drooling►Trauma, previous airway manipulationTrauma, previous airway manipulation►AllergiesAllergies► immunization immunization

Clinical presentationClinical presentation►onset of fever, barky cough, coryzaonset of fever, barky cough, coryza►Stridor follows 1-2 days afterwardsStridor follows 1-2 days afterwards►Stridor and respiratory distress Stridor and respiratory distress

worsens worsens at night and when child at night and when child

agitatedagitated

Clinical presentation: Clinical presentation: physicalphysical

►A: A: inspect, listeninspect, listen

►B: B: sats, RR, A/Esats, RR, A/E

►C: C: color, pulse, BPcolor, pulse, BP

►D: D: LOCLOC

Nasal flaring

RetractionsInability to lie down

•Appearance: quiet, tired, no drooling•Airway: inspiratory stridor •Breathing: RR 24, SaO2 96%, harsh breath sounds

•Circulation: HR 170, cool extremities, cap refill 3 sec•Disability: awake, tired•Exposure: Wt 9 kg

Viral croup: Investigations?Viral croup: Investigations?► Not necessary, clinical diagnosisNot necessary, clinical diagnosis► Uncertainty of diagnosisUncertainty of diagnosis CBC: ?bacterial infectionCBC: ?bacterial infection

Xrays: Xrays: Anterior posterior: viral croup(steeple sign)Anterior posterior: viral croup(steeple sign) lateral neck: epiglottitis (thumb sign)lateral neck: epiglottitis (thumb sign)

retropharyngeal abscessretropharyngeal abscess Radio-opaque foreign bodyRadio-opaque foreign body

Viral croup: treatmentViral croup: treatment► Do not agitate child: Do not agitate child: crying increases oxygen demand and crying increases oxygen demand and

worsens laryngeal obstructionworsens laryngeal obstruction

► Ensure adequate fluid intakeEnsure adequate fluid intake

► Analgesia : paracetemolAnalgesia : paracetemol

► Illness self limited: 3-5 daysIllness self limited: 3-5 days

Viral croup: treatmentViral croup: treatment►Cool MistCool Mist

►SteroidsSteroids

►EpinephrineEpinephrine

Cool MistCool Mist Previous beliefs that:Previous beliefs that:

► mist moistens airway secretions & soothes inflammed mucosa.mist moistens airway secretions & soothes inflammed mucosa.► Mist can activate mechanoreceptors in larynx and lead to reflex slowing of respiratory Mist can activate mechanoreceptors in larynx and lead to reflex slowing of respiratory

rate.rate.

No evidence supports the effectiveness of mist therapy. No evidence supports the effectiveness of mist therapy. Klassen T, Klassen T, Pediatr Clin North Am, Pediatr Clin North Am, 1999; 46(6).1999; 46(6).

SteroidsSteroids reduced length of time spent in ER and reduced length of time spent in ER and

admissionsadmissions

decrease laryngeal mucosa edemadecrease laryngeal mucosa edema

Clinical improvement, but not immediateClinical improvement, but not immediate►Single dose IM/oral dexamethasone (0.6mg/kg) Single dose IM/oral dexamethasone (0.6mg/kg)

effective in 6 hours. effective in 6 hours. ►Single dose Inhaled budesonide as effective Single dose Inhaled budesonide as effective

(effective in 2-4 hours).(effective in 2-4 hours).

SteroidsSteroids Dexamethasone 0.15 mg/kg/dose as effective Dexamethasone 0.15 mg/kg/dose as effective

as 0.6 mg/kg/dose; oral and IM as effective as 0.6 mg/kg/dose; oral and IM as effective Geelhoed & Macdonald. Pediatr Pulmonol. 20. 1995Geelhoed & Macdonald. Pediatr Pulmonol. 20. 1995

Poor evidence supporting combined Poor evidence supporting combined budenoside and dexamethasone Rx.budenoside and dexamethasone Rx.

Klassen et al. Pediatrics 97 (4). 1996Klassen et al. Pediatrics 97 (4). 1996 Dexamethasone preferred over budenoside Dexamethasone preferred over budenoside

because of ease of administration, lower cost, because of ease of administration, lower cost, and more widespread availabilityand more widespread availability. . Klassen et al. JAMA 279 (20). 1998Klassen et al. JAMA 279 (20). 1998

Epinephrine/adrenalineEpinephrine/adrenaline►Potent alpha and beta adrenergic stimulatorPotent alpha and beta adrenergic stimulator►Alpha adrenergic mediated vasocontriction of Alpha adrenergic mediated vasocontriction of

edematous laryngeal mucosaedematous laryngeal mucosa► Indications: respiratory distress, stridor at restIndications: respiratory distress, stridor at rest►Onset of action: 30-60 min, duration: 2 hrs Onset of action: 30-60 min, duration: 2 hrs ►Rebound effect: does not alter course of illnessRebound effect: does not alter course of illness►Monitor for signs of worsening respiratory Monitor for signs of worsening respiratory

distress and impending respiratory failure distress and impending respiratory failure

Bacterial tracheitis Bacterial tracheitis ►Potentially life threatening infection of Potentially life threatening infection of

the tracheal mucosathe tracheal mucosa► Important complication of measlesImportant complication of measles►Proceeding viral infectionProceeding viral infection►Organisms:Organisms:

Staphylococcus aureus(most common)Staphylococcus aureus(most common)Streptococcus pneumoniaStreptococcus pneumoniaHemophilus influenza BHemophilus influenza BTBTB

Bacterial tracheitisBacterial tracheitisInfectionInfection

purulent secretions and mucosal necrosispurulent secretions and mucosal necrosis (sloughing mucosa)(sloughing mucosa)

Airway obstructionAirway obstruction

Bacterial tracheitis Bacterial tracheitis ►Acute: over 8-10 hoursAcute: over 8-10 hours►Toxic appearanceToxic appearance

high feverhigh feverlethargylethargymarked signs of respiratory marked signs of respiratory

obstructionobstruction►Absence of droolingAbsence of drooling

Bacterial tracheitisBacterial tracheitis►Monitor airway closelyMonitor airway closely

►Prepare for emergent intubationPrepare for emergent intubation

►Abx: Cefuroxime or CephalexinAbx: Cefuroxime or Cephalexin chloramphenicol and penicillinchloramphenicol and penicillin

►Complication: tracheal stenosisComplication: tracheal stenosis

Spasmodic CroupSpasmodic Croup►Sudden onset of dyspnea, inspiratory Sudden onset of dyspnea, inspiratory

stridor, croupy cough w/out fever or stridor, croupy cough w/out fever or URTI prodrome; often wakes child from URTI prodrome; often wakes child from sleepsleep

►Sxs a result of non-inflammatory Sxs a result of non-inflammatory subglottic edema (pale, boggy)subglottic edema (pale, boggy)

►Associated with atopic disease Associated with atopic disease (asthma, eczema, hay fever)(asthma, eczema, hay fever)►Treatment: moist-air and reassuranceTreatment: moist-air and reassurance

EpiglottitisEpiglottitisDefinitionDefinition► Life threatening Life threatening

bacterial infectionbacterial infection► Cellulitis and edema Cellulitis and edema

of epiglottis, of epiglottis, aryepiglottic folds, aryepiglottic folds, arytenoids, and arytenoids, and hypopharynx hypopharynx narrowed glottic narrowed glottic openingopening

EpiglottitisEpiglottitisEtiologic agentsEtiologic agents►Hemophilus influenza B (>90% cases)Hemophilus influenza B (>90% cases)►Staphylococcus aureusStaphylococcus aureus►Streptococcus pneumoniaStreptococcus pneumonia►Streptococcus pyogenesStreptococcus pyogenes►Candida (immunocompromised)Candida (immunocompromised)

Epiglottitis: clinical Epiglottitis: clinical presentationpresentation

►Age of onset: 2-7 yrs, peak 2-3 yearsAge of onset: 2-7 yrs, peak 2-3 years►Abrupt onset, minimal or no prodromeAbrupt onset, minimal or no prodrome►Stridor is softStridor is soft►High fever(39-40 ), tripod positionHigh fever(39-40 ), tripod position►DDysphagia, ysphagia, DDrooling, rooling, DDysarthyriaysarthyria►Rapid onset of respiratory distress and Rapid onset of respiratory distress and

obstructionobstruction

Epiglottitis: managementEpiglottitis: managementDo NotDo Not► Examine throatExamine throat► lie child supinelie child supine► Xray neckXray neck► Perform invasive Perform invasive

proceduresprocedures► Nasopharyngeal tube Nasopharyngeal tube

for oxygenfor oxygen

DoDo► Calm childCalm child► Attach pulse oximeterAttach pulse oximeter► Arrange for controlled Arrange for controlled

intubation under intubation under general anaesthetic general anaesthetic

► IV, blood and throat IV, blood and throat culturescultures

► Abx: Abx: 1.1. Cefuroxime, cefotaxime, Cefuroxime, cefotaxime,

or ceftriaxone or ceftriaxone2.2. Chloramphenical and Chloramphenical and

penicillinpenicillin

Croup Vs. EpiglottitisCroup Vs. EpiglottitisCroup Croup epiglottitisepiglottitis

Age Age 6 months-3 6 months-3 yearsyears

2-7 years2-7 years

onsetonset daysdays HoursHoursPreceeding Preceeding coryzacoryza

yesyes nono

coughcough Severe, barkySevere, barky Absent or mildAbsent or mildAppearance Appearance unwellunwell toxictoxicfeverfever <38.5<38.5 >38.5>38.5Dysphagia,drooliDysphagia,droolingng

nono yesyes

voicevoice hoarsehoarse softsoftintubationintubation 1%1% 80%80%

Inhaled foreign BodyInhaled foreign Body►Sudden onset cough, stridorSudden onset cough, stridor►Previously wellPreviously well►Asymmetrical breath soundsAsymmetrical breath sounds►X-raysX-rays

Lateral neckLateral neckinspiratory and expiratory filmsinspiratory and expiratory films

(air trapping)(air trapping)80% objects non radiopaque80% objects non radiopaque

DDX upper airway DDX upper airway obstructionobstruction

Airway swellingAirway swellingInfectious: Infectious: viral croupviral croup

Bacterial Bacterial tracheitistracheitis

epiglottisepiglottisdiphteriadiphteria

Non-infectious: anaphylaxisNon-infectious: anaphylaxis adenoid adenoid

hypertrophyhypertrophy

Space occupying lesion Space occupying lesion or structural or structural abnormalityabnormality

Congenital (choanal atresia, Congenital (choanal atresia, larynogomalacia, subglottic larynogomalacia, subglottic stenosis, laryngeal web)stenosis, laryngeal web)

AcquiredAcquired► Foreign bodyForeign body► Human papilloma virusHuman papilloma virus► Retropharyngeal abscessRetropharyngeal abscess► TumorTumor► HematomaHematoma

Take home messageTake home messagePatient with stridor/upper airway obstructionPatient with stridor/upper airway obstruction►Newborn: congenital anatomical anomalyNewborn: congenital anatomical anomaly►6 months-3 yrs nontoxic6 months-3 yrs nontoxic viral croup viral croup

toxic toxic bacterial tracheitis bacterial tracheitis epiglottitisepiglottitis

►Older child, persistent stridor Older child, persistent stridor Human Human papillomapapilloma virusvirus