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  1. CROUP Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003

  2. 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

  3. Anatomically • Viral infection of upper airway • Inflammation of larynx, trachea & bronchi • Compromises airflow through proximal airway

  4. Causes & Differential • Commonest cause is viral (parainfluenza, RSV) • Very rarely  diphtherial croup (non immunized)

  5. 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)

  6. Causes & Differential • Toxic • Exclude bacterial tracheitis • Epigloltitis • Retropharyngeal abscess

  7. 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

  8. Airway Obstruction • Mild • Moderate • Moderate progressing to severe • Severe

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. Questions