Magdalena Sidhartani

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“Croup syndrome” : a group of diseases• Laryngotracheitis• Spasmodic croup, • Bacterial tracheitis, • Laryngotracheobronchitis, and• Laryngotracheobronchopneumonitis.

Manifestation : Hoarse voice ; dry, barking cough; inspiratory stridor; and respiratory distress ,develops over a brief period of time

Infection: Common and typical

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1. Acute viral infection : acute laryngotracheitis obstruction of the upper airway, larynx, infraglottic tissues, trachea

2. Bacterial and atypical agents

3. Noninfectious : foreign body aspiration, trauma (Intubation), and allergic reaction ( acute angioneurotic edema)

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15 % of respiratory tract disease Aged 1-6 years of age ( mean:18 mo) Peak incidence, 5 cases / 100 during

second year of life, Boys > Girls

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1. Parainfluenza viruses ( tipes 1,2 and 3) : 65 %

2. Adenovirus, RSV, Measles3. Mycoplasma pneumoniae

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Laryngotracheobronchitis and laryngotracheobronchopneumonitis :• Streptococcus pyogenes,• S pneumoniae,• Staphylococcus aureus, • Haemophilus influenzae• Moraxella catarrhalis

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Nasopharynx respiratory ephitelium on larynx and trachea bronchus

Diffuse inflammation, erythema and edema develop in tracheal walls impaired mobility of vocal cord

Subglotic trachea swelling cause encroaches on the airway and airflow restriction inspiratory stridor and hoarse voice.

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Tracheal lumen obstructed by fibrinous exudate and pseudomembranes.

Histologic : marked edema, cellular infiltration of histiocytes, lymphocytes, plasma cell and PMN leucocytes

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Rhinorrhea, pharyngitis, low grade fever of few days duration, and mild cough

After 12-48 hours upper airway obstructive sign and symtomss are noted “barking” cough, hoarseness, and inspiratory stridor, fever +/-

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Hoarse voice, coryza, a normal or inflamed pharynx and slightly increased RR

Most cases only the hoarseness and barky cough, no evidence or airway obstruction

Gradualy normalize whithin 3-7 days.

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Increasing severity of obstruction and accompanied by:• Increasing HR and RR• Flaring of alar nasi• Cyanosis with supra and infraclavicular and sternal

retraction• Restless and anxious with the development of

progressive hypoxia• Duration of illness 7-14 days

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Elevated WBC above 10x109 /L ( 10.000/cu mm ), PMN predominant

Anterior CXR : subglottitis narrowing

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Extensions of acute laryngotracheitis. Sign and symptoms of laryngotracheitis

suddenly progresses to severe desease caused by :• Bacterial superinfection ,sudden worsening of clinical

sign and symtoms, high grade fever, Increasing work of breathing (RR, Rales, Wheezing, Air trapping )

• CXR : pulmonary infiltrates May requires intubation or a tracheostomy.

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Occur at night, children 3 months – 3 years

Awakens at night with sudden dyspnea, croupy cough, and inspiratory stridor (sudden subglottic edema), no fever

Endoscopic : pale and boggy laryngeal mucosa

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Epiglottitis :• Lack of croupy cough, drooling, toxic appearance,

growing anxiety and apprehension• A sitting posture, chin pushed forward, refuse to lie

down• Inspection : cherry-red epiglottis

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• Laringotracheitis :“ The Steeple Sign”

• Epiglottitis : “ Thumb Sign”

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DD :• Foreign body aspiration and angioneurotic edema• Laryngeal diphtheria• Retropharyngeal or peritonsilar abscess• Subglottic stenosis• Infectious mononucleosis• Bacterial tracheitis• Paraquat poisoning• Importance information : immunization history,

clinical evidence of pharyngeal involvement, greater degree of hoarseness and relative slowness of disease progression

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Primarily : Clinical CXR : Plain film of the neck

• Steeple sign• Overdistended hypo pharynx( lateral)

Pulse Oxymetri : maybe normal Need : serial observation and frequent

physical exam

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SISTEM SKORING

Epiglottitis Croup

Age Infants, older children, adults Six months to six years

Onset Sudden Gradual

Location Supraglottic Subglottic

Temp High fever Low-grade fever

Dysphagia Severe Mild or absent

Dyspnea Present Present

Drooling Present Present

Cough Uncommon Chracteristic cough

Position Sitting forward with mouth open Comfortable in positions

Radiology Positive thumb sign* Positive steeple sign

Adapted with permission from DeSoto H. Epiglottitis and croup in airway obstruction in children. Anesthesiol Clin North Am 1998;16:855.

Comparison of the Features of Epiglottitis and Croup

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Serial observation Mist therapy Epinephrine Steroids

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Cool mist is as effective as hot steam Cool mist moistens airway secretions Humidity the viscosity of mucus

secretions

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Stimulate -adrenergic receptor For moderate to severe distress Decreased stridor/retractions (<2hrs)

• Rebound phenomenon• Observe 3-4hrs after administration

Side effects: tachycardia, hypertension

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Dose : 0,25 - 0,75 ml of 2,25 % racemic epinephrine solution in 2,5 ml NaCL, every 20 mnt

If not available, 5 ml mixture of l-isomer epinephrine and saline ( 1:100)

Caution : tachycardia, ToF, Ventricular outlet obstruction

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Single parenteral dose; • 0,6 mg/kgBW dexamethason( max 10 mg)• 0,15 mg /kgBW dexamethason is as effective as 0,3 or

0,6 mg /kgBW in relieving symptom• Clinical improvement not apparent until 6

hrs of initiation of treatment• Nebulized budesonide (dose 2 - 4 mg), rapid

effect (2-4 hour)

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Endotracheal intubation• Severe croup, with hypercarbia and probable respiratory

failure• Only for brief period Helium-oxigen mixture Antibiotics Evidence for bacterial infection Aim for S aureus, S pyogenes, S pneumoniae and H

influenzae Initial treatment second generation of cephalosporin or

combination therapy with semisyntethic penicillin and third-generation cephalosporin

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Croup is a common viral illness in children, generally benign

Treatment options :• Mist – years of use• Epinephrine – years of experience and trials support its

use• Steroids – good evidence to support• Not preventable• Vaccine could reduce the incidence of croup

due to influenza A and B

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