Upper airway
obstruction:
Croup and its differential
Peter Louie
January 2004
Case: 12 month old male, with 1 day
history of coryza, barky cough, and fever.
Presents with 2 hour Hx. Stridor &
difficulty breathing
Objectives
Differential diagnosis of upper airway obstruction
Croup
Defn, ethilogy, epidemiology, pathophysiology
History and physical findings
Treatment
Epiglottitis
Foreign body
DDX upper airway
obstruction
Airway swelling
Infectious: viral croup
Bacterial
tracheitis
epiglottis
diphteria
Non-infectious: anaphylaxis
Space occupying lesion or
structural abnormality
Congenital
(choanal atresia, larynogomalacia,
subglottic stenosis, laryngeal web)
Acquired
Foreign body
Human papilloma virus
Retropharyngeal abscess
Tumor
Hematoma
Croup: Definition
Clinical syndrome characterized by triad of
1. inspiratory stridor
2.
Barking cough
3.
Hoarseness
and varying degrees of respiratory distress
Types of Croup
Viral croup (laryngotracheobronchitis)
Pseudomembranous croup
(bacterial tracheitis)
Spasmodic croup
Viral Croup: etiology
Parainfluenza 1 (most common), 2, 3
Respiratory syncytial virus (RSV)
Adenovirus
Influenza A, B
enteroviruses
Viral Croup: pathophysiology
Viral Croup - Pathogenesis
Subglottic
trachea at cricoid
cartilage is the narrowest part
of a childs airway.
This
area is surrounded by firm
cartilage.
Any
swelling in this area can
encroach on the airway.
Viral Croup: pathophysiology
Respiratory droplets
Host immune response activated
mucous secretion edema & erythema of
vocal
cords (hoarseness)
subglottic region (stridor)
Upper airway obstruction
Steeple Sign
Viral Croup: Epidemiology
First
3 years of life (6 36 months)
Peak
incidence 2 yrs:
Male:female
(3:2)
4.7/100
Clinical presentation: history
Onset
and duration
Fever
choking
dysphagia,
drooling
Trauma, previous airway manipulation
Allergies
immunization
Clinical presentation
onset
of fever, barky cough, coryza
Stridor follows 1-2 days afterwards
Stridor and respiratory distress
worsens
at night and when child
agitated
Clinical presentation:
physical
A:
inspect, listen
B:
sats, RR, A/E
C:
color, pulse, BP
D:
LOC
Appearance: quiet, tired, no drooling
Airway: inspiratory stridor
Breathing: RR 24, SaO2 96%, harsh breath sounds
Nasal flaring
Retractions
Inability to lie down
Circulation: HR 170, cool extremities, cap refill 3 sec
Disability: awake, tired
Exposure: Wt 9 kg
Viral croup: Investigations?
Not
necessary, clinical diagnosis
Uncertainty of diagnosis
CBC: ?bacterial infection
Xrays:
Anterior posterior: viral croup(steeple sign)
lateral neck: epiglottitis (thumb sign)
retropharyngeal abscess
Radio-opaque foreign body
Viral croup: treatment
Do
not agitate child:
crying increases oxygen demand and
worsens laryngeal obstruction
Ensure
adequate fluid intake
Analgesia
Illness
: paracetemol
self limited: 3-5 days
Viral croup: treatment
Cool Mist
Steroids
Epinephrine
Cool Mist
Previous beliefs that:
mist moistens airway secretions & soothes inflammed mucosa.
Mist can activate mechanoreceptors in larynx and lead to reflex slowing of respiratory
rate.
No evidence supports the effectiveness of mist therapy.
1999; 46(6).
Klassen T, Pediatr Clin North Am,
Steroids
reduced length of time spent in ER and
admissions
decrease laryngeal mucosa edema
Clinical improvement, but not immediate
Single dose IM/oral dexamethasone (0.6mg/kg)
effective in 6 hours.
Single dose Inhaled budesonide as effective
(effective in 2-4 hours).
Steroids
Dexamethasone 0.15 mg/kg/dose as effective
as 0.6 mg/kg/dose; oral and IM as effective
Geelhoed & Macdonald. Pediatr Pulmonol. 20. 1995
Poor evidence supporting combined budenoside
and dexamethasone Rx.
Klassen et al. Pediatrics 97 (4). 1996
Dexamethasone preferred over budenoside
because of ease of administration, lower cost,
and more widespread availability.
Klassen et al. JAMA 279 (20). 1998
Epinephrine/adrenaline
Potent
alpha and beta adrenergic stimulator
Alpha adrenergic mediated vasocontriction of
edematous laryngeal mucosa
Indications: respiratory distress, stridor at rest
Onset of action: 30-60 min, duration: 2 hrs
Rebound effect: does not alter course of illness
Monitor for signs of worsening respiratory
distress and impending respiratory failure
Bacterial tracheitis
Potentially
life threatening infection of
the tracheal mucosa
Important complication of measles
Proceeding viral infection
Organisms:
Staphylococcus aureus(most common)
Streptococcus pneumonia
Hemophilus influenza B
TB
Bacterial tracheitis
Infection
purulent secretions and mucosal necrosis
(sloughing mucosa)
Airway obstruction
Bacterial tracheitis
Acute:
over 8-10 hours
Toxic appearance
high fever
lethargy
marked signs of respiratory
obstruction
Absence of drooling
Bacterial tracheitis
Monitor
airway closely
Prepare
for emergent intubation
Abx:
Cefuroxime or Cephalexin
chloramphenicol and penicillin
Complication:
tracheal stenosis
Spasmodic Croup
Sudden
onset of dyspnea, inspiratory
stridor, croupy cough w/out fever or
URTI prodrome; often wakes child from
sleep
Sxs a result of non-inflammatory
subglottic edema (pale, boggy)
Associated with atopic disease
(asthma, eczema, hay fever)
Treatment: moist-air and reassurance
Epiglottitis
Definition
Life
threatening
bacterial infection
Cellulitis and edema
of epiglottis,
aryepiglottic folds,
arytenoids, and
hypopharynx
narrowed glottic
opening
Epiglottitis
Etiologic agents
Hemophilus influenza B (>90% cases)
Staphylococcus aureus
Streptococcus pneumonia
Streptococcus pyogenes
Candida (immunocompromised)
Epiglottitis: clinical
presentation
Age
of onset: 2-7 yrs, peak 2-3 years
Abrupt onset, minimal or no prodrome
Stridor is soft
High fever(39-40 ), tripod position
Dysphagia, Drooling, Dysarthyria
Rapid onset of respiratory distress and
obstruction
Epiglottitis: management
Do Not
Examine throat
lie child supine
Xray neck
Perform invasive
procedures
Nasopharyngeal tube
for oxygen
Do
1.
2.
Calm child
Attach pulse oximeter
Arrange for controlled
intubation under
general anaesthetic
IV, blood and throat
cultures
Abx:
Cefuroxime, cefotaxime,
or ceftriaxone
Chloramphenical and
penicillin
Croup Vs. Epiglottitis
Age
onset
Preceeding
coryza
cough
Appearance
fever
Croup
epiglottitis
6 months-3
years
days
2-7 years
yes
Hours
no
Severe, barky
unwell
Absent or mild
toxic
<38.5
Dysphagia,drooli no
ng
voice
hoarse
>38.5
yes
soft
Inhaled foreign Body
Sudden
onset cough, stridor
Previously well
Asymmetrical breath sounds
X-rays
Lateral neck
inspiratory and expiratory films
(air trapping)
80% objects non radiopaque
DDX upper airway
obstruction
Bacterial
Space occupying lesion
or structural
abnormality
epiglottis
diphteria
Congenital (choanal atresia,
larynogomalacia, subglottic
stenosis, laryngeal web)
Airway swelling
Infectious:
tracheitis
viral croup
Non-infectious: anaphylaxis
adenoid
hypertrophy
Acquired
Foreign body
Human papilloma virus
Retropharyngeal abscess
Tumor
Hematoma
Take home message
Patient with stridor/upper airway obstruction
Newborn: congenital anatomical anomaly
6 months-3 yrs nontoxic viral croup
toxic bacterial tracheitis
epiglottitis
Older child, persistent stridor Human
papilloma
virus
