1.Croup in children Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah, UAE saadsalani@aol.com

2. A child with croup ,stridor and barking cough 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 2 3. Croupy cough 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 3 4. Croup Croup is a common primarily pediatric viral respiratory tract illness Its alternative names, laryngotracheitis and laryngotracheobronchitis 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 4 5. It is the most common etiology for hoarseness, cough, and onset of acute stridor in febrile children Croup (cont.) The vast majority of children with croup recover without consequences or sequelae Symptoms of coryza may be absent, mild, or marked 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 5 6. Croup manifests as : Hoarseness Seal-like barking cough Inspiratory stridor Variable degree of respiratory distress Croup (cont.) 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 6 7. Severe croup 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 7 8. Croupy child 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 8 9. Morbidity is secondary to narrowing of the larynx and trachea below the level of the glottis (subglottic region), causing the characteristic audible inspiratory stridor CroupCroup (cont.) 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 9 10. Steeple or pencil sign of the proximal trachea evident on this anteroposterior film. Child with croup Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 10 11. Etiology Viruses causing acute infectious croup are spread through either: 1. Direct inhalation from a cough and/or sneeze 2. By contamination of hands from contact with fomites 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 11 12. Causes Parainfluenza viruses (types 1, 2, 3) are responsible for as many as 80% of croup cases Type 3 parainfluenza virus causes bronchiolitis and pneumonia in young infants and children Parainfluenza types 1 and 2, accounting for nearly 66% of cases. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 12 13. Other infectious causes of croup Adenovirus Respiratory syncytial virus (RSV) Enterovirus Metapneumovirus Reovirus Influenza A and B Human bocavirus Coronavirus Rhinovirus Echovirus Rarer causes - Measles virus, herpes simplex virus, varicella 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 13 14. Epidemiology Gender Male-to-female ratio for is approximately 1.4:1. Age Primarily a disease of infants and toddlers, croup has a peak incidence from age 6-36 months (3 y). 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 14 15. Prognosis The prognosis for croup is excellent, and recovery is almost always complete. Hospitalization rates vary widely among communities, ranging from 1.5-30% and typically averaging 2-5% The majority of patients can be managed successfully as outpatients, without the need for inpatient hospital care. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 15 16. Complications Complications in croup are rare Death occurred in approximately 0.5% of intubated patients. Less than 5% of children who were diagnosed with croup required hospitalization . Less than 2% of those who were hospitalized were intubated. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 16 17. A secondary bacterial infection may result in pneumonia or bacterial tracheitis Complications (cont.) Key bacterial pathogens Staphylococcus aureus group A streptococcus Moraxella catarrhalis Streptococcus pneumoniae Haemophilus influenzae anaerobes 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 17 18. Clinical presentation Croup usually begins with nonspecific respiratory symptoms (i.e., rhinorrhea, sore throat, cough). Within 1-2 days, the characteristic signs of hoarseness, barking cough, and inspiratory stridor develop, often suddenly, along with a variable degree of respiratory distress. Fever is generally low grade (38-39C) but can exceed 40C. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 18 19. Clinical presentation (cont.) Symptoms are perceived as worsening at night, with most ED visits occurring between 10 pm and 4 am. Symptoms typically resolve within 3-7 days but can last as long as 2 weeks. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 19 20. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 20 21. Physical Examination The physical presentation of croup has wide variation. Others have audible stridor at rest and clinical evidence of respiratory distress. Some may have stridor only upon activity or agitation Most children have no more than a "croupy" cough and hoarse cry. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 21 22. Scoring systems The Westley score evaluates the severity of croup by assessing the following 5 factors, with a score range of 0 to 17 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 22 23. Westley score Factor 0 1 2 3 4 5 1 Stridor None Upon agitation At rest 2 Retractions None Mild Moderate Severe 3 Air entry Normal Mild decrease Marked decrease 4 Cyanosis None Upon agitation At rest 5 Level of consciousness Normal, including sleep Depressed 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 23 24. Alberta Clinical Practice Guideline Working Group Degree of severity Clinical presentation Mild severity Occasional barking cough, no audible stridor at rest, and either no or mild suprasternal and/or intercostal retractions Moderate severity Frequent barking cough, easily audible stridor at rest, and suprasternal and sternal wall retractions at rest, with no or minimal agitation Severe severity Frequent barking cough, prominent inspiratory (and occasionally expiratory) stridor, marked sternal wall retractions, significant agitation and distress Impending respiratory failure Barking cough (often not prominent), audible stridor at rest, sternal wall retractions may not be marked, lethargy or decreased consciousness, and often dusky appearance without supplemental oxygen support 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 24 25. Croup Differential Diagnoses Airway Foreign Body Bacterial Tracheitis Diphtheria Epiglottitis Inhalation Injury Laryngeal Fractures Laryngomalacia Measles Mononucleosis and Epstein-Barr Virus Infection Peritonsillar Abscess 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 25 26. Diagnosis Croup is primarily a clinical diagnosis, with the diagnostic clues based on presenting history and physical examination findings. Laboratory test results rarely contribute to confirming this diagnosis. The complete blood cell (CBC) count is usually nonspecific 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 26 27. Diagnosis (cont.) Pulse oximetry is helpful to assess for the need for supplemental oxygen support and to monitor for worsening respiratory. Arterial blood gas (ABG) measurements are unnecessary and do not reveal hypoxia or hypercarbia unless respiratory fatigue ensues 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 27 28. Radiography Plain films can verify a presumptive diagnosis or exclude other disorders causing stridor and hence mimic croup. A lateral neck radiograph can help detect clinical diagnoses such as: 1. Aspirated foreign body 2. Esophageal foreign body 3. Congenital subglottic stenosis 4. Epiglottitis 5. Retropharyngeal abscess or bacterial tracheitis (thickened trachea) 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 28 29. The steeple or pencil sign of the proximal trachea evident on this anteroposterior film. A Child with croup Courtesy of Dr. Kelly Marshall, CHOA at Scottish Rite. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 29 30. Steeple sign on radiograph Steeple sign 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 30 31. Croup Treatment & Management Urgent care or emergency department treatment of croup depends on the degree of respiratory distress Keep young children as comfortable as possible 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 31 32. Careful monitoring of ; - Heart rate - Respiratory rate -Respiratory mechanics - Pulse oximetry Cont. ? Efficacy of cool mist or humidification therapy 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 32 33. Those with severe respiratory distress or compromise may require 100% oxygenation with ventilation support, initially with a bag- valve-mask device Cont. Steroids have proven beneficial in severe, moderate, and even mild croup Cornerstones of treatment in the urgent care clinics or emergency departments are corticosteroids and nebulized epinephrine 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 33 34. In the straightforward cases of croup, antibiotics are not prescribed, as the primary cause is viral. Cont. Typically, these patients initially would have had moderate-to-severe croup scores, requiring inpatient care and observation. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 34 35. A single dose of dexamethasone is effective in reducing the overall severity of croup, if administered within the first 4-24 hours after the onset of illness. The long half-life of dexamethasone (36-54 h) often allows for a single injection or dose to cover the usual symptom duration Cont. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 35 36. Patients given a single oral dose of prednisolone (1 mg/kg) were found to have made more return visits than did those who received a single oral dose of dexamethasone (0.15 mg/kg). Cont. Nebulized racemic epinephrine is typically reserved for patients in the hospital setting with moderate-to-severe respiratory distress. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 36 37. Heliox is a gas containing a mixture of helium and oxygen (with not less than 20% oxygen). Delivery to the patient is via nasal cannula, face mask, or hood Cont. ? Beneficial effect of heliox in pediatric croup management Equally effective in moderate to severe croup when compared with racemic epinephrine 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 37 38. Discharge criteria Patients can be discharged home only if they demonstrate: -Healthy color -Good air entry -Baseline consciousness -No stridor at rest -Have received a dose of corticosteroids. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 38 39. Medication Summary Current cornerstones in the treatment of croup are corticosteroids and nebulized epinephrine Nebulized racemic epinephrine is typically reserved for patients in moderate to severe distress. Steroids have proven beneficial in severe, moderate, and even mild croup 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 39 40. References Benson BE, Baredes S, Schwartz RA. Stridor. Medscape Reference by WebMD [serial online]. January 26, 2010;Accessed October 5, 2011. Available at http://emedicine.medscape.com/article/995267-overview. Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. Feb 16 2011;CD006619. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. Jul 2006;91(7):580-3. Geelhoed GC. Budesonide offers no advantage when added to oral dexamethasone in the treatment of croup. Pediatr Emerg Care. Jun 2005;21(6):359-62. Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011;(1):CD001955 Zoorob R, Sidani M, Murray J. Croup: an overview. Am Fam Physician. May 1 2011;83(9):1067-73. Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. Feb 16 2011;CD006619 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 40 41. 6/16/2014 Croup in children Prof.Dr.Saad S Al Ani 41