Transcript Croup: Not all that barks is viral! Craig Dobson, MD CPT, MC, USAR NCC Pediatrics.

Croup:
Not all that barks is
viral!
Craig Dobson, MD
CPT, MC, USAR
NCC Pediatrics
Definitions
Croup- term used to describe the
clinical picture of laryngotracheitis.
Hoarse voice
 Barking cough
 Inspiratory stridor
 Possible respiratory distress
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Epidemiology
Peak fall & winter.
Range primarily 1-6 years
Incidence 5/100 of children between
age 1-2 years
Males > females
Etiologies
Parainfluenza, types 1,2,3
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Contribute 65% of cases.
Influenza A & B
Adenovirus
RSV
Rarely mycoplasma.
Pathogenesis
Subglottic narrowing due to
inflammation.
Cricoid ring allows fixed area for
obstruction.
1mm swelling causes 65% obstruction
in infant.
Pathogenesis
Atelectasis/mucus plugging
Ventilation/perfusion mismatch
Negative intrapleural pressure may lead
to varying degrees of pulmonary
edema.
Hypoxia/hypercarbia
Air hunger
 Anxiety/Lethargy/Obtundation.
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Clinical history
Parents usually report viral URI
symptoms 12-48hrs prior to cough.
Fever, “Barking cough,”Stridor
Typical course 3-5 days.
Worry if
Drooling
 Dyphagia
 Toxic appearance
 Stridor without cough or without fever
 Incomplete immunizations
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Badness mimicking
croup
Epiglottis
Dysphagia
 Odynophagia
 Drooling
 Tripoding/sword-swallowing
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Pt resists lying on back
 Prefers leaning forward
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Stat to OR for evaluation/intubation
Badness Mimicking
Croup, cont.
Bacterial tracheitis
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More common in order children to teens
Staph aureus/Diphtheria
Fever/ resp distress/Dysphagia/Odynophagia
Worsening over hours
Difficult to distinguish from epiglottis
Doesn’t matter, management is same:
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OR intubation
Abx, worry more about Staph coverage if child is older.
Badness Mimicking
Croup, cont.
Bacterial superinfection of Croup
Symptoms 5-7 days
 Worsening quickly over hours
 Increasingly high fevers
 Toxic appearance
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Badness Mimicking
Croup, cont.
Retropharyngeal/peritonsilar abscess
Fever
 Odynophagia
 Prodrome of sore throat
 Often swollen, tender ant. cerv. Nodes.
 Resistence to neck movement
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Badness Mimicking
Croup, cont.
Neoplasm
Foreign body
Afebrile
 Toddlers most at risk
 Often no history of aspiration
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Trauma
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History/physical exam.
Badness Mimicking
Croup, cont.
Angioneurotic edema
Recurrent
 Lip swelling
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Spasmotic croup (well, not really
badness)
Recurrent
 Nighttime
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Laboratory tests
No value….. ‘nough said.
Agitation for sticking child for ABG will
worsen child’s symptoms.
You still need IV access, though, sorry.
Radiographic findings
Steeple sign
Lateral neck films if unsure of ruling out
retropharyngeal abscess
Fluouroscopy if still unsure
Still this is a clinical diagnosis
If any airway worries, no radiographs
Example radiograph…
Management of Croup
Do I need an artificial airway!!!!
Cool mist
No literature to support efficacy
 Multiple studies demonstrating that it may
worsen situation
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Bronchospasm
 Hypothermia in young infants
 Tent obscures close observation of pt.
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Epinephrine
Mechanism- constricts arterioles to airway
thus reducing further edema.
Waiisman, et al. Prospective RCT comparing
L-epi and RE in treatment of
laryngotracheitis. Pediatrics. 1992.
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Demonstrated reduced croup score by 30min,
lasts usually 2hrs.
Dose 0.5cc of 2.25% racemic solution
No difference found L- epi using 5cc of 1:1000
conc.
Epi, cont.
Rebound phenomenon
Bunk… It just wears off in 2hours usually.
 Multiple studies demonstrating safe to d/c
pt from ER if:
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Steroids were given, too.
 No resting stridor 2-4 hrs after tx.
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Corticosteroids
‘Roid controversy…. getting clearer.
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Ausejo, M. Glucocorticoids for croup. Cochrane
Database of Systemic Reviews Jan 2000.
Repeated with identical results by Moyer in
Pediatrics, March 2000.
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Metanalysis (N=2221 patients)
Improved Croup score at 6 and 12 hrs, not 24 after
dexamethasone or budesonide neb.
Decr. need for epi nebs by 9%.
Decr. Emergency Room stay (-11hrs).
Decr. Hospital stay (-16hrs).
Corticosteroids, cont.
Kairys, et al. Steroid treatment of
laryngotracheitis. Pediatrics. 1989.
First meta-analysis of randomized trials.
 Demonstrated reduction in intubation from
1.27% (no steroids) to 0.17% steroids.
 No difference in inhaled budesonide versus
IM dex.
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Corticosteroids, cont
Ritticher and Ledwith. Outpatient
treatment of moderate croup with
dexamethasone: Intramuscular versus
oral dosing. Pediatrics. 2000
ER patients sent home.
 No statistical difference in later
interventions.
 Power to detect at least 10% difference.
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Corticosteroids, cont.
Klassen, et al. Nebulized budesonide
and oral dexamethasone treatment for
croup. JAMA. 1998
Oral dexamethasone/Inhaled budesonide
 Both treatments
 No difference in groups
 Budesonide much more expensive.
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Corticosteroids
A moment on dosage:
Most studies 0.6mg/kg (IM or PO)
 Malhotra and Krilov. Viral Croup. PIR, 2001
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Lower doses of 0.15mg/kg and 0.3mg/kg
shown to be equally effective.
Heliox
Weber, JE. A randomized comparison of
Heliox and racemic epinephrine for the
treatment of moderate to severe croup.
Pediatrics. 2001
N=29
 Similar improvement in both groups.
 No significant difference in croup score,
oxygen sat, respiratory rate or heart rate.
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Where to now?
Still unanswered questions:
Should you re-dose dexamethasone since
the duration is pharmacologically is 48hrs,
but benefit was only demonstrated though
12hrs?
 What about heliox and epi together?
 Should any patient with croup symptoms
be given steroids?
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