Cardio Resp - Week 9 (Croup, Bronchiolitis, Epiglottitis)

What is croup?

Inflammation of the upper airway, larynx and trachea, often worse at night. Characterised by a barking cough and inspiratory stridor. Caused by parainfluenza and is often only mild.

In what age group is croup most common?

6 months to 3 years

What is the prodrome for croup?

- Fever

- Runny nose

- Sore throat

What is the disease process for croup?

- Airway inflammation

- Cascade of inflammatory reactions

- Infiltration of white blood cells

- Oedema of the upper airway

- Partial airway obstruction

- Increase WOB

- Turbulent noisy airflow

What is the difference between croup and bronchiolitis?

Croup is a subglottic infection whereas bronchiolitis is much lower down in the bronchioles

What are some general principles for croup management?

- Don't upset the child with your examination

- BP and pulse-ox can be omitted if it will distress child

- No need to examine the throat

- Keep the child with their parent/carer and involve them in the examination

What are some risk factors for severe croup?

- History of previous croup

- Pre-existing upper airway narrowing

- Co-exisitng medical conditions affecting airway tone

- young age

Signs/Symptoms of croup

- Barking cough

- Inspiratory stridor

- Hoarse voice

- Associated widespread wheeze

- Increased WOB

- Fever

Mild Croup:

- Cough

- Husky voice

- No stridor

Moderate croup:

- Cough and husky voice

- Hard to speak and/or breathe

- Have a stridor (not at rest)

Severe croup:

- Cough and husky voice

- Hard to speak / breathe

- Inspiratory stridor even at rest

- Significant WOB

- Anxious and scared

- Irritable and uncomfortable

Supportive management for croup

- positioning: being held my parent

- Oxygen not usually required

- Analgesics typically unnecessary

- Rest, hydration, nutrition

Mild croup medication:

Low dose dexamethasone = 150 mcg / kg orally

Moderate croup medication:

Low dose dexamethasone = 150 mcg / kg orally

Severe croup medication:

- 5 mg nebulised adrenaline

- high dose dexamethasone = 600 mcg / kg orally

What are some differentials for croup?

- Foreign body airway obstruction

- Anaphylaxis

- Epiglottitis

What is bronchiolitis?

A lower respiratory tract infection causes by the RSV virus affecting children aged <12 months

Risk factors for bronchiolitis?

- Chronic lung disease

- Congenital heart disease

- Chronic neurological conditions

- Tobacco smoke exposure

- Slow weight gain

- Lower SES

- Immunodeficiency

Pathophysiology of bronchiolitis

Viral infection of bronchiolar epithelium --> causes cell death --> inflammation of small airways --> increased mucous production --> mucous plugging --> airway narrowing and obstruction --> increased WOB

History questions to ask for bronchiolitis

- Cough?

- Fever?

- Difficulty feeding?

- Difficulty sleeping?

- Periods of apnoea?

- Unsettled?

- Restless?

Signs/symptoms of mild bronchiolitis

- Normal behaviour

- Possibly mild tachypnoea

- Unlikely to be accessory muscle use

- O2 >92% room air

- No periods of apnoea

- Normal feeding

Signs/symptoms of moderate bronchiolitis

- Some Irritable behaviour

- Increased respiratory rate

- Some use of accessory muscles (chest wall retraction, nasal flare)

- O2 90-92% room air

- Brief apnoea

- Difficulty feeding

Signs/symptoms of severe bronchiolitis

- Irritable, lethargic, fatigued

- Increased resp rate

- Increased accessory muscle use

- O2 <90 on room air

- Frequent apnoea

- Reluctant / unable to feed

Management for bronchiolitis?

- Supportive management (rest, hydration, nutrition)

What is epiglottitis?

Acute life-threatening bacterial or viral infection that results in swelling and inflammation of the epiglottis

This causes breathing problems, including stridor, that can progressively worsen and may lead to complete obstruction of the airway.

Risk factors for epiglottitis?

- Children who haven't had the Hib vaccine

- Immunocompromised children (due to medications or diseases)

Pathophysiology of epiglottitis

Bacterial infection of supraglottic structures --> rapid inflammation and oedema of epiglottis and surrounding tissues --> narrow airway becomes obstructed --> stridor, drooling --> complete obstruction and respiratory arrest

Signs/symptoms of epiglottitis

- Drooling

- Difficulty breathing

- Unable to talk

- Leaning forward / tripod

- open mouth

Differentials for epiglottitis

- Acute tonsillitis

- Pharyngitis

- Peritonsillar abscess (quincy)

- Deep neck space infection

Management for epiglottitis

- Suspected epiglottitis is an airway emergency

- No action should be taken to stimulate or irritate them → do not inspect airway or take child from parent

- Manage in an upright position

- Transport with notification to closest facility (with paediatric ENT)