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Croup

Sonny Wijanarko 08/264946/KU/12622 Fakultas Kedokteran-Universitas Gadjah Mada

Definition
Croup, or laryngotracheobronchitis, is a common childhood upper airway disorder caused by a viral infection resulting in inflammation to the upper airway Croup is characterised by the abrupt onset, most commonly at night, of a barking cough, inspiratory stridor, hoarseness, and respiratory distress due to upper airway obstruction

Epidemiology
Croup is a common illness responsible for up to 15 percent of emergency department visits due to respiratory disease in children in the United States annual incidence of 3%, and accounts for 5% of emergency admissions to hospital in children aged under 6 years in North America

croup occurred most commonly in children aged between 6 months and 3 years, but can also occur in children as young as 3 months and as old as 1215 years. Case-report data suggest that it is extremely rare in adults.

Etiology
Viral: Parainfluenza (75%)
Remaining cases: syncytial virus, metapneumovirus, influenza A and B, adenovirus, coronavirus, and mycoplasma

Pathophysiology
Viral invasion -> inflammation, hyperaemia, and oedema. -> narrowing of the subglottic region. Narrowing-> Compensated (Tachypnea + retraction) -> Decompensated: Turbulence (Stridor), decreased chest wall compliance -> paradoxical breathing -> fatigue -. Hypoxic + hypercapneic -. Failure, arrest, death.

Clinical Manifestation
Croup symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress.

Differential Diagnosis
The most important diagnoses to differentiate from croup include bacterial tracheitis, epiglottitis, and the inhalation of a foreign body. Recurrent croup is similar to viral croup in presentation, except that it recurs and lacks symptoms of respiratory tract infection

Condition Angioedema

History Physical examination Detailed questioning to Swelling of face and identify the offending neck antigen

Bacterial tracheitis Mild to moderate presentation, then rapid decomposition in three to seven days

Epiglottitis

High-grade fever, toxic appearance, copious secretions, productive cough, retractions; no drooling or odynophagia Rapid onset of High-grade fever, symptoms, sore throat, toxic appearance, muffled voice, drooling child sitting or leaning forward

Foreign body Sudden onset, history of Stridor aspiration choking Laryngotracheitis Barking cough, coryza Low-grade fever, nasal flaring, (viral croup) respiratory retractions, stridor

Workup Epicutaneous skin testing or radioallergosorbent testing may be performed later Lateral neck radiography may be helpful, bacterial culture of tracheal secretions after intubation, WBC count (elevated) Lateral neck radiography if clinical diagnosis unclear, WBC count (elevated) CT, bronchoscopy Generally not indicated

Common etiologies Allergic reaction

Staphylococcus aureus,Haemophilus influenzae, group A streptococci

H. influenzae, group A -hemolytic streptococcus

Foreign body Parainfluenza virus types 1 to 3, influenza, respiratory syncytial virus

Peritonsillar abscess

Dysphagia, throat pain that is more severe on affected side

Retropharyngeal abscess

Lateral neck Gram-positive radiography organisms (including (widening of the -lactamase retropharyngeal soft producing), gramtissues); CT with negative organisms, intravenous contrast anaerobes media is helpful Spasmodic croup Usually recurrent, short Afebrile, less Generally not Same as viral croup, with possible allergic (recurrent croup) duration, barking cough retractions and nasal indicated, but bronchoscopy component or flaring (especially in children gastroesophageal younger than three reflux years) and endoscopy may be considered

Fever, odynophagia, dysphagia, neck pain

Inferior and medial displacement of the tonsil, contralateral deviation of the uvula, erythema and exudates on the tonsil Drooling, stridor, neck mass, nuchal rigidity

CT with intravenous Gram-positive organisms (including contrast media -lactamase producing), gramnegative organisms, anaerobes

Diagnosis
Abrupt onset of barking cough, hoarseness, and inspiratory stridor . Px: low-grade fever absence of wheezing respiratory status and rate, retractions, stridor, heart rate, use of accessory muscles, and mental status. The most reliable findings to assess severity are the presence of stridor and the severity of retractions. Pulse oximetry can also be used to assess the severity of disease. Lab and imaging is only to rule out other illnesses.

Assessment of degree of airway obstruction (treat with the most severe symptoms) Mild Normal mental state No stridor or only when distressed Moderate Anxious, tired Stridor at rest Severe Life threatening

Agitated, exhausted Confused, drowsiness Stridor at rest Stridor at rest

No accessory muscle Minor accessory use, tracheal tug, or muscle use, chest wall retraction tracheal tug, chest wall retraction
Able to talk/feed Increased heart rate Some limitation to talking/feeding

Marked accessory muscle use, tracheal tug, and chest retraction


Markedly increased heart rate

Maximal accessory muscle use, tracheal tug, chestwall retraction


Markedly increased heart rate or falling heart rate

Increased Poor respiratory respiratory rate, too effort, silent chest breathless to talk/feed Pallor, low muscle tone Cyanosis

Initial Treatment Send to hospital by ambulance Give oxygen Nebulised adrenaline (4.0 mL) 1:1000 do not dilute drive with oxygen where possible Consider oral prednisolone 1.0 mg/kg Oral prednisolone 1.0 mg/kg Oral prednisolone 1.0 mg/kg or IM dexamethasone 0.6 mg/kg

Allow child to adopt the position that they find most comfortable; provide parent information

Send home if stable or reassess after 1 hour if stable Response to treatment

Observe if facilities available in surgery and reassess after 1 hour

Good response send home if child has no symptoms or signs of moderate or severe airway obstruction consider further doses of prednisolone 12 hourly for next 24 hours provide parent information including when to return Poor response send to hospital via ambulance

Complication
Uncommon complications of croup include pneumonia, pulmonary oedema, and bacterial tracheitis

Prognosis
Croup symptoms resolve in most children within 48 hours a small percentage of children with croup have symptoms that persist for up to a week less than 5% of all children with croup are admitted to hospital Of those admitted to hospital, only 1%3% are intubated less than 0.5% of intubated children died

Prevention
Immunization against Haemophilus influenzae type b has contributed to the decreased incidence of epiglottitis

References
http://www.ncbi.nlm.nih.gov/pmc/articles/P MC2907784/pdf/2009-0321.pdf http://www.aafp.org/afp/2011/0501/p1067.p df http://www.racgp.org.au/download/documen ts/AFP/2010/May/201005starr.pdf

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