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CROUP. Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003. Introduction. Croup or LTB laryngo tracheo bronchitis is a clinical syndrome Hoarse voice Barking cough Inspiratory stridor COMMON cause of upper airway obstruction usually mild & self limiting

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croup

CROUP

Dr Jonny Taitz

Sydney Children’s Hospital, Randwick

April 2003

introduction
Introduction
  • Croup or LTB laryngo tracheo bronchitis is a clinical syndrome
  • Hoarse voice
  • Barking cough
  • Inspiratory stridor
  • COMMON cause of upper airway obstruction usually mild & self limiting
  • BUT is also the commonest cause of potentially life threatening airway obstruction in childhood
anatomically
Anatomically
  • Viral infection of upper airway
  • Inflammation of larynx, trachea & bronchi
  • Compromises airflow through proximal airway
causes differential
Causes & Differential
  • Commonest cause is viral (parainfluenza, RSV)
  • Very rarely  diphtherial croup (non immunized)
causes differential5
Causes & Differential
  • Foreign Body Inhalation
    • Sudden onset
    • May have unilateral signs
    • Exp wheeze > insp stridor
  • Structural
    • Children < 3/12
    • Combination insp & exp stridor
    • (eg. Subglotic stenosis, laryngomalacia, laryngeal cysts, webs, thermal, chemical injury)
causes differential6
Causes & Differential
  • Toxic
    • Exclude bacterial tracheitis
    • Epigloltitis
    • Retropharyngeal abscess
assessment of severity
Assessment of Severity
  • Remember it is the severity of the airway obstruction NOT the stridor that is assessed
  • Worsening obstruction may lead to softer stridor !!!
  • Repeated clinical assessment is the key
airway obstruction
Airway Obstruction
  • Mild
  • Moderate
  • Moderate progressing to severe
  • Severe
danger signs
Danger Signs
  • General: agitated, tiring,  LOC  observe closely
  • Resp distress: stridor at rest, tracheal tug, retractions pulsus Paradoxus  will need RX
  • Cyanosis / extreme pallor  RX immediately
  • Oxymetry is a late sign
  • Do not wait for desaturation to commence RX
mild airway obstruction
Mild Airway Obstruction
  • Happy child, playful, tolerating fluids
  • Mild chest wall retractions, tachycardia
  • NO stridor at rest
  • MX
    • Reassure parents
    • Counsel parents re: warning signs
    • No medication required
moderate airway obstruction
Moderate Airway Obstruction
  • Characterised by
    • Stridor at rest
    • Accessory muscle use, chest wall retractions
    •  HR,  RR
    • Child is interactive & can be placated
  • MX
    • Will require corticosteriods
    • Observation for a minimum of 4 hours
    • Further RX if child progresses to severe obstruction
progression from moderate to severe airway obstruction
Progression from Moderate to Severe Airway Obstruction
  • Child will need admission
  • Child becomes preoccupied, tired, sleepy
  • Close monitoring
  • Regular review every 30-60 mins
  • MX
    • Corticosteriods
    • Nebulized Adrenaline
severe airway obstruction
Severe Airway Obstruction
  • Characterised by
    • Tiredness, exhaustion, tachycardia
    • Restless, agitated
    •  LOC
    • Hypotonic, pale & cyanosed
  • MX
    • Do not disturb unnecessarily
    • O2 via face mask
    • Nebulized Adrenaline
    • Intubation (under anaesthetic) & ventilation
    • Systemic steroids when airway secure

}

Late signs indicating imminent airway obstruction

what evidence is there for current rx options
What Evidence is there for Current Rx Options
  • Non pharmacologic
    • Steam
      • 2 large RCT’s looked at steam Rx in croup
      • No evidence that it is beneficial
    • Oxygen
      • Initial treatment of choice for children with moderate to severe viral croup
what evidence is there for current rx options15
What Evidence is there for Current Rx Options
  • Drugs
    • Steroids
      • Precise mechanism in croup unclear
      • ? Ante-inflammatry
      • ? Vasoconstricts upper airway
      • Oral preferred route
        • Dexamethazone 0.3 mg/kg
        • Prednisore 1 mg/kg
      • Steriods have led to
        •  intubation
        •  Duration of ventilation
      • nebulized budesonide vs oral dexamethazone
drugs continued
Drugs (continued)
  • Nebulized Adrenaline
    • Moderate to severe croup (i.e stridor at rest) needs nebulized adrenaline
    • Dose 0.5 mg/kg 1:1000 (max 5 mls)
    • Administered neat via neb
    • Effect
      •  Bronchial & tracheal epithelial vascular permeability
      •  Airway oedema
    • Onset is rapid  30 minutes
    • Duration is approx 2 hrs
    • Severe croup may need repeated doses
drugs continued17
Drugs (continued)
  • Ongoing requirements for Nebulized Adrenaline
    • Consider intubation and/or transfer to Paediatric ICU
    • Other factors to consider for transfer
      • Age of child
      • Severity of illness
      • Underlying anatomic problems
      • Level of exposure at hospital