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1. Good Morning!

2. Semantic Qualifiers

3. Stridor • Harsh, high-pitched resp sound • Usually inspiratory • But can be biphasic • Cause by turbulent flow • Sign of upper airway obstruction • NOT a diagnosis

4. Stridor • Viral croup • Noninfectious croup • Epiglottitis • Bacterial tracheitis • Extraluminal compression • Intraluminal obstruction from masses • Foreign body • Retropharyngeal abscess • Peritonsillar abscess • Angioedema • Caustic ingestion • Vocal cord dysfunction

5. “Croup” • Group of conditions • Acute and infectious causes of upper airway inflammation • Upper airway of children

6. Laryngotracheitis • = most common “Croup” illness • Laryngotracheitisvs. Laryngotracheobronchitis/pneumonitis • Predisposing Factors • Between age 3 months and 5 yrs • Peak in 2nd year of life • M > F • Can occur anytime of year but peaks in late fall and winter • Preceding URI illness

7. Laryngotracheitis • Pathophysiology • Inflammation involving the vocal cords and structures inferior to the cords

8. Laryngotracheitis • Pathophysiology • Viral etiology is most common • Parainfluenza viruses (type 1, 2, and 3) ~ 75% of cases • Influenza A • Associated with SEVERE disease • Influenza B • Adenovirus • RSV • Measles • Mycoplamapneumoniaerarely isolated

9. Laryngotracheitis • Clinical Presentation** • URI symptoms for 1-3 days prior to signs of upper airway obstruction • Rhinorrhea, pharyngitis, mild cough, low-grade fever • Characteristic “barking” cough, “seal-like” • Hoarseness • Inspiratorystridor • +/- fever

10. Laryngotracheitis • Clinical Presentation** • Symptoms characteristically worse at night • Agitation and crying aggravate symptoms • Varying degrees of respiratory distress on exam • Should not be hypoxic – this is a sign that complete airway obstruction is imminent

11. Laryngotracheitis • Diagnosis • Clinical • Xrays • “Steeple sign” in AP view • Do not correlate with disease severity • Can help distinguish from other causes

12. Laryngotracheitis • Treatment** • Most patients managed as outpatients • Cool mist?? • Not proven in literature, but used since the 1900’s • If bronchospasm present, can worsen with cool mist • Antibiotics not indicated in viral croup

13. Laryngotracheitis • Treatment** • Corticosteroids • Action: decrease laryngeal mucosal edema • Effective in reducing hospitalization rates, shorter hospital stays, reduced need for subsequent interventions • Dose: 0.6mg/kg single dose DEXAMETHASONE (max 16mg) • PO/IM Decadron both effective • Clincal improvement 6 hours after dose • Prednisolone less effective than Dexamethasone

14. Laryngotracheitis • Treatment** • Nebulizedracemic epinephrine (Vaponeb) • For moderate to severe croup • Action: decrease laryngeal mucosal edema • Dose: 0.25ml-0.5ml of 2.25% racemicepi in 3ml of NS nebulized • Onset of relief 10-30min • Duration of activity <2-3 hours • Can repeat q20 min • Monitor for symptoms once the Vaponeb activity duration is over (rebound?), generally 3-4 hrs after a treatment • Use caustiously in patients with tachycardia, and heart conditions such as TOF or ventricular outlet obstruction

15. Laryngotracheitis • Indications for hospitalization with croup • Progressive stridor • Severe stridor at rest • Respiratory distress • Hypoxia/cyanosis • Depressed mental status • Poor oral intake • Need for reliable observation

16. Laryngotracheobronchitis/pneumonitis • More severe form of croup • Considered an extension of laryngotracheitis associated with bacterial superinfection • Occurs 5-7 days into the clinical course • New onset fever • Worsening clinical symptoms, toxic • Increased work of breathing • Signs of both upper and lower airway obstruction • Requires empiric antibiotics

18. Noninfectious Croup • “Spasmodic” croup** • Most often children 1 to 3 yrs • Pathogenesis unknown – possible allergic etiology • Clinically similar to croup but without the viral prodrome or fever • Most common in the evening • Sudden onset, preceded by mild cough or hoarseness • Episode of characteristic coughing, stridor and respiratory distress, anxious • Severity improves over hours and can have repeat episodes x1-2 more nights

20. Epiglottitis • Predisposing Factors • Typical age of patients 2 to 4 yrs • Unimmunized

21. Epiglottitis • Pathophysiology • Prevaccine, most common cause: • Haemophilusinfluenzaetype B • Now, larger number of cases in vaccinated patients due to: • Streptococcus pyogenes • Streptococcus pneumoniae • Staphylococcus aureus

22. Epiglottitis • Pathophysiology • Inflammation of epiglottis • Degree of inflammation leads to degree of obstruction of airway

23. Epiglottitis • Clinical Presentation • Acute • High fever • Sore throat • Dyspnea • Rapidly progressing respiratory obstruction • Can be within hours – become toxic, difficulty swallowing, labored breathing

24. Epiglottitis • Clinical Presentation • Drooling • Holding neck in hyperextended position • Tripod position • Stridor is a late finding! • Not usually associated with a cough

25. Epiglottitis • Diagnosis • Visualization via laryngoscopy • In controlled environment

26. Epiglottitis • Diagnosis • Xrays • “Thumb sign” in lateral view

27. Epiglottitis • Treatment** • Careful on exam** • Avoid anxiety-provoking procedures (labs/IV), avoid placing patient supine or direct inspection of oral cavity • To prevent acute airway obstruction • Medical emergency • Placement of artificial airway in controlled setting • Mortality ~6% without airway vs. <1% with airway • Oxygen via mask until artificial airway • As long as mask doesn’t cause agitation

28. Epiglottitis • Treatment** • Antibiotics** • Ceftriaxone • Cefotaxime • Meropenem • Obtain cultures from blood, epiglottic surface, and if needed from CSF (after obtain airway) • Treat with at least 7-10 antibiotics, but usually patient improves after 2-3 days

29. Epiglottitis • Rifampin prophylaxis indicated for: • Any household contacts <48 months old and incompletely immunized • Any household contacts <12 months old and has not received primary vaccination series • Any immunocompromised child in the household

31. Bacterial Tracheitis • Predisposing Factors • Mean age 5 to 7 yrs • M=F • Preceding viral respiratory infection • Bacterial complication of croup • More common than epiglottitis in vaccinated patients

32. Bacterial Tracheitis • Pathophysiology • Mucosal swelling at the level of the of the cricoid cartilage • Complicated by copius, thick, purulent secretions, sometimes pseudomembranes • Most common pathogen: S. aureus • Other organisms: Moraxellacatarrhalis, nontypeH. influenzae, and anaerobic organisms

33. Bacterial Tracheitis • Clinical Presentation** • Preceding croup illness with cough • Then develops high fever and toxic-appearance • Differs from epiglottitis • Patient can lie down, does not drool, no dysphagia • Differs from croup • More toxic, does not respond to racemicepi

34. Bacterial Tracheitis • Diagnosis • Clinical picture • Toxic + absence of classic epiglottitis • Xrays • Not necessary • Findings of irregular lining of the trachea due to pseudomembranes • Can have “steeple sign”

35. Bacterial Tracheitis • Treatment** • Artificial airway required in ~50-60% of patients • More likely to require intubation if younger • Antibiotics • Including appropriate Staph coverage • Vanc + 3rd gen Cephalosporin = empiric coverage

37. Noon Conference!