What is croup ,features ,diagnosis ,differential diagnoses,management ,videos on croupy children

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
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Croup in children
Prof.Dr.Saad S Al Ani
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3. Croupy cough
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Croup in children
Prof.Dr.Saad S Al Ani
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4. Croup
Croup is a common primarily pediatric viral
respiratory tract illness
Its alternative names, laryngotracheitis and
laryngotracheobronchitis
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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6. Croup manifests as :
•Hoarseness
•Seal-like barking cough
•Inspiratory stridor
•Variable degree of respiratory
distress
Croup (cont.)
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Croup in children
Prof.Dr.Saad S Al Ani
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7. Severe croup
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Croup in children
Prof.Dr.Saad S Al Ani
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8. Croupy child
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Croup in children
Prof.Dr.Saad S Al Ani
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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.)
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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).
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Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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 (38-39°C) but can
exceed 40°C.
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Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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20. 6/16/2014
Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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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)
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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30. Steeple sign on radiograph
Steeple sign
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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.
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Croup in children
Prof.Dr.Saad S Al Ani
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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
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Prof.Dr.Saad S Al Ani
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