ENT

Croup / Epiglottitis

    A 2 year old girl presents to the emergency room with fever, cough, runny nose, stridor and difficulty breathing. Temperature is 101, RR 30, there is audible stridor and a barky cough (click on barky cough). The chest is clear and the child does not look toxic.

Croup steeple sign.jpg
The steeple sign as seen on an AP neck X-ray of a child with croup
https://en.wikipedia.org/wiki/Croup
 

What other history is important?

  1. Nature of the onset , was it sudden or gradual? Very acute onset of stridor may be suggestive of a foreign body aspiration. What was the child doing when the symptoms started?
  2. Has the child had a URI?
  3. What is the immunization history? Most cases of epiglottitis are caused by H. flu.
  4. Is there a past history of croup? Some children have recurrent bouts of croup (spasmodic croup). 
  5. Is there a history of prior intubation? If the child had been intubated they may have residual changes including subglottic stenosis.

Epiglottitis

  1. Acute onset of symptoms, the child appears toxic and often leaning forward. (tripod position) Rapid course of airway obstruction
  2. Most common etiology is Hemophilus influenza type b The incidence is very low since the introduction of the Hib vaccine although there have been reports of cases in immunized children.  There are other bacteria including S.pneumo, S.aureus, and S.pyogenes.
  3. Usually febrile and often no preceding URI symptoms. No coughing.
  4. Drooling, and voice sounds muffled or "hot potato". Three D's-drooling, dysphagia, and distress.
  5. If you suspect epiglottitis, child needs to be prepared for intubation with ENT and anesthesiologist available. Diagnosis by visualization of an enlarged, very red epiglottis. If you send the patient to radiology for an endolateral view of the airway, the patient must be accompanied by medical staff prepared to bag the child or intubate immediately.
  6. Treatment
    1. Nasotracheal intubation by anesthesia
    2. Antibiotics to cover H. influenza. About 50% of direct cultures of the epiglottis are positive and large percentage of cases organisms are recovered from a blood culture.

Bacterial tracheitis

  1. "Classic" presentation:
     ·      “Viral” prodrome (1-3 days): rhinorrhea, low-grade fever,        cough, and sore throat
    ·      Rapid evolution to toxic-appearing child with high fever, cough (50-100%), and acutely-worsening stridor (65-95%)
    ·      Adherent, pseudomembranous tracheal exudates (commonly seen)
    ·      Increased work of breathing
    ·      Preference to lie flat
  2. Treatment
    1. nasotracheal intubation
    2. Antibiotics to cover Staph, Strep, and H. flu.
    3. Fluid resuscitation

Croup (laryngotracheobronchitis)        

  1. Inspiratory stridor and barky cough (click on links). Stridor is accentuated by crying and being excited. Try to evaluate the patient when they are quiet and relaxed to best judge difficulty of breathing. 
  2. Often preceded by URI and symptoms may improve after emesis. 
  3. Common viral etiologies are parainfluenza, influenza, and RSV.
  4. Treatment
    1. In mild case increasing humidity may help
    2. Cold night air may relieve the symptoms. Parents should dress the child and take them outside and see if there is improvement.
    3. If the child is hypoxic or cyanotic, supplemental oxygen should be administered. 
    4. Croup tents often make it difficult to observe patients and separate patients from caregivers. Not recommended
    5. Moderate to severe symptoms of stridor may require racemic epinephrine 0.05 ml/kg by mask.  
    6. Recent studies have demonstrated the effectiveness of a single dose of IM or oral dexamethasone(Decadron), 0.6mg./dose in alleviating symptoms.
    7.  Children who have received nebulized epinephrine and dexamethasone may be discharged home if symptoms have improved after observation for 2-3 hours. 
    8. Prior to the introduction of glucocorticoids, 2% of patients required intubation and ventilatory support. 
  5. Indication for hospitalization
    1. Cyanosis
    2. Not improving or getting worse
    3. Decreased alertness
    4. Family anxious about the child's condition
    5. No guarantee of follow-up

 

References

  1. Ramboud-Cousson, Annie Bacterial Tracheitis among Children Hospitalized for Severe Dyspnea Pediatric Infectious Disease Vol. 9, No. 4 April 1990
  2. Ruddy, Richard M. Croup- Has Management Changed? Contemporary Pediatrics Vol 10 December 1993
  3. Custer,Joseph R. Pediatrics in Review Vol 14 No 1 January 1993
  4. Johnson, David, Jacobson, Sheila, Edney, Peter, Mundy, Marianne, Schuh, Suzanne. A comparison of Nebulized Budesonide, Intramuscular Dexamthasone, and Placebo for Moderately Severe Croup. NEJM. August 20, 1998.
  5. The Treatment of Croup with Glucocorticoids. Editorial. NEJM August 20, 1998
  6. Malholtra and Krilov Viral Croup Pediatric in Review  January 2001
  7. Rosenkrans Julia.  Viral Croup: Curren Diagnosis and Treatment Mayo Clinic Proceedings Vol 73(11) November 1998
  8. Bjornson C.L. A Randomized Trial of a Single Dose of Dexamethasone for Mild Croup.  NEJM Sept 23, 2004
  9. Klass. Croup- The Bark is Worse than the Bite NEJM Sept 23, 2004
  10. Cherry J. Croup.  NEJM Jan 24, 2008