Med Note [1]: Croup

Chapter 1 – Croup

v History

o Usu’ starts w/ Øspecific respirat’ sympt’: rhinorrhea, sore throat, cough. General’ fever is low grade (38-39^OC), can > 40^OC. W/in 1-2 days, (oft’ sudden’) (+) characteris’ hoarseness, barking cough, & inspirat’ stridor, along w/ variab’ degree of respirat’ distress. Perception: sympt’ worsen at night. Sympt’ typic’ resolve w/in 3-7 days, but can last for 2 weeks.

o Spasmod’ (recurr’) croup typic’ presents @ night w/ sudden onset of barking cough & stridor. Child ~’ve had mild upper resiprat’ complaints prior to this, but more oft’ has presented well prior to sympt’ onset. Allergic factors ~ cause recurr’ croup due to respirat’ epithel’ changes from viral infec’.

o Recurr’ croup child’ report’ sympt’ relief when treated for gastroesophag’ reflux (GER).

v Physic’ Exam’

o Wide varia’ of physic’ present’. Most child’ only (+) barki’ cough & hoarse cry. Some ~ (+) stridor only @ activi’ or agitation, others’ve audib’ stridor at rest & clinical’ evident respirat’ distress. +++ly affected child’ ~ (+) quiet stridor due to bigger degree of airway obstruction. @ Child’, typic’ Ø appear toxic.

o Child’s sympt can range from minim’ inspirat’ stridor to +++ respirat’ fail’ due to airway obstruction. If mild, resti’ respirat’ sound is normal; mild expirat’ wheezi’ ~ heard. If more +++, (+) inspirat’ & expirat’ stridor at rest w/ visib’ suprastern’, inter- & sub-cost’ retract’. Air entry ~ poor. Lethargy & agitat’ due to marked respirat’ diffcul’ à hypoxem’ & ↑ed hypercarbia. During episode of +++ cough, ~ (+) sudden respirat’ arrest.

o Other respirat’ distress’s warni’ signs: tachypn’, tachy♥, out of proportion to fever, & hypotonia. If child’ w/o adequate oral intake, (+) dehydration. Cyanosis, late, ominous sign.

o Scori’ syst’

· Westley Score (wide use @ research & Tx protocol’s evaluati’, its clinic’ value Ø yet extensive’ studied): Inspirat’ stridor: (-) – 0, at agitat’ – 1, at rest – 2; Retracti’: (-) – 0, mild – 1, moderate – 2, +++ - 3; Air entry: normal – 0, mild ↓ - 1, heavy ↓ - 2; Cyanosis: (-) – 0, at agitat’ – 4, at rest – 5, Conscious’: normal, includi’ sleep – 0, depressed – 5.

< 3: mild ill’. 3-6: moderate ill’. > 6: +++ ill’.

· Mild: (+) occasional barki’ cough, no stridor at rest, mild or no suprastern’ or subcost’ retracti’. Moderate: frequent cough, audib’ stridor at rest, visib’ retracti, little distress or agitat’. +++: frequent cough, +++ inspirat’ (occasional’ + expirat’) stridor, conspicu’ retracti’, ↓ed air entry on auscult’, +++ distress & agitat’. Lethargy, cyanos’, & ↓ing retracti’ presage respirat’ fail’.

· Alberta Clinical Practice Guideline Working Group classifi’:

o Mild: occasion’ barki’ cough, no audib’ stridor at rest, & no or mild suprastern’ & or intercost’ retracti’.

o Moderate: frequent barki’ cough, easi’ audib’ stridor at rest, suprastern’ & stern’ wall retracti’ at rest, & no or minim’ agitat’.

o +++: frequent barki’ cough, +++ inspirat’ (occasion’ + expirat’) stridor, +++ stern’ wall retracti’, & +++ agitat’ & distress.

o Impendi’ respirat’ fail’: barki’ cough (oft’ Ø +++), audib’ stridor @ rest, stern’ wall retracti’ ~ Ø +++, lethargy & ↓ed conscious’, & oft’ dusky appear’ w/o supplemental O₂ support.

· Tx based on algorithm based on Px’s initial symptoms’s severity.

v DDx

o Spasmodic croup (recurrent croup)

o Retropharyngeal abscess

o Subglottic stenosis

o Angioedema

o Allergic reaction

o Tracheomalacia

o Laryngeal web

o Laryngeal papillomatosis

o Laryngeal hemangioma

o Subglottic hemangioma

o Vocal cord paralysis

o Uvulitis

o Innominate artery compression

o Right aortic arch vascular ring

o Double aortic arch

o Aberrant subclavian artery

o Pulmonary artery sling

o Rarer etiologies in the pediatric population - Laryngeal tuberculosis, neoplasm (compressing trachea), sarcoidosis, Wegener granulomatosis

o Gastroesophageal reflux (diagnostic consideration for recurrent croup)

o Bacterial Tracheitis

o Inhalation Injury

o Laryngeal Fractures

o Laryngomalacia

o Measles

o Pediatric Airway Foreign Body

o Pediatric Diphtheria

o Pediatric Epiglottitis

o Pediatric Mononucleosis and Epstein-Barr Virus Infection

o Pediatric Peritonsillar Abscess

v Workup

o Prmari’ a clinic’ Dx. CBC usu’ Øspecific, WBC ~ suggest viral etio’ w/ lymphocytosis. Specific viral etio’ identification (eg: parainfluenza virus serotype, respiratory syncytial virus (RSV)) via nasal washi’ ~ for determini’ isolation needs in hospital setting, or (in influenza A) antiviral Tx initiati’.

o Pulse O₂metry, most’ normal, used to monitor need for supplement’ O₂ support or worsen’ respirat’ comprom’ as evident w/ tachypn’ & poor mainten’ of O₂ saturation. ABG is standard’ unnecessary & Ø reveal hypoO₂ or hypercarbia unless respirat’ fatig’ ensues.

o If Px presentat’ w/ fever, tachypn’, & history of ↓ed fluid intake à evaluate Px’s hydration status! Compromised oral intake & inabili’ to mainta’ needed fluid volume ~ need IV fluid support to sustain Px’s fluid needs.

o Laryngoscopy: indicated only in unusu’ setting (eg: atypic’ course of ill’, child (+) sympt’ suggesti’ underly’ congeni’ or anatomi’ disord’, child (+) bacterial tracheit’ (to get culture to guide antibiot’ Tx)); if throat (+) tongue depression, no epiglottit’ (which (+) erythem’ enlarg’ epiglottis (cherry red epiglott’). Thought that vigor’ exam’ of child’s throat cause laryngospasm & respirat’, but never has been documented.

o ~ be indicated: direct laryngoscopy if child Ø at acute distress; fiberoptic laryngoscopy; bronchoscopy (for recurr’ croup to rule out airway ill’).

o (+) High risk of moderate to +++ find’ in laryngo & bronchoscopy & need of further surgic’ interventi’ @ child w/: (1) w/o history of intubati’ but (+) inPx consulta’, or (2) w/ history of intubati’ & age < 36 months.

o Radiography

§ Plain film can verify presump’ Dx or exclude other stridor-causing ill’. Lateral neck radiog’ can help detect clinical Dx s.as aspirated or esophage’ foreign bodi’, congeni’ subglott’ stenos’, epiglottit’, retropharyng’ absce’, or bacterial tracheit’ (thicken’ trach’). Ø needed @ uncomplica’.

§ ~ (-) at 50% cases @ child.

Anteroposterior (AP) radiog’ of neck’s soft tissues classic’ (+) steeple sign (pencil-point sign), signifies subglott’ narrowi’; lateral neck view ~ (+) distended hypopharynx (ballooni’) at inspirati’.

§ Steeple sign ~ also (+) w/o croup @ epiglottit’, therm’ injury, angioedema, or bacterial tracheit’. Monitor during imaging because progress’ of airway obstruction ~ rapid.

(Figure right below) Croup at child. Steeple sign at proximal trachea evident. AP view.