Croup and epiglottitis: Clinical sciences

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Introduction0:00–0:49

Croup and epiglottitis are causes of acute upper airway obstruction in Children. Croup, also known as laryngotracheitis is a common viral infection mostly caused by the parainfluenza virus or other respiratory viruses that results in subglottic inflammation and narrowing.
On the other hand, epiglottitis is typically a bacterial infection most often caused by haemophilus influenzae or streptococcus pneumoniae that can cause rapid and lifethreatening, swelling of the epiglottis and supraglottic structures.
Signs and symptoms on a focused history and physical examination can help distinguish croup from epiglottitis when a patient presents with a chief concern suggesting croup or epiglottitis first, perform an ABCD E assessment to determine if your patient is unstable or stable, if unstable, stabilize their airway breathing and circulation.

Unstable patient0:49–2:48

In some cases, you might need to intubate your patient. Next.
Obtain IV access. Put your patient on continuous vital sign monitoring, including pulse, oximetry, respiratory rate and cardiac monitoring.
And don't forget to provide supplemental oxygen if needed. Here's a clinical pearl to keep in mind whenever possible.
Ensure the child's airway is secured before doing any anxiety producing procedures like obtaining IV access. That's because discomfort and agitation can exacerbate symptoms, increasing, narrowing of the airway and ultimately cause an acute airway obstruction.
Once you stabilize the patient, obtain a focused history and physical exam. If your patient's caregiver reports a rapid onset of high fever, as well as difficulty breathing and swallowing with drooling.
In the absence of a cough, you should immediately think of epiglottitis. Physical exam will usually reveal an anxious appearing child sitting upright with her neck extended in a tripod position with the chin pushed forward.
Additionally, your patient may have a muffled voice, an audible stridor with labored breathing. If you're able to visualize the pharynx without worsening your patient's distress, you may even see a cherry red epiglottis.
These signs and symptoms are highly suggestive of epiglottitis, which is a true emergency. So don't waste any more time and secure the airway emergently.
Now, here's a clinical pearl. If your patient has a stable airway or their signs and symptoms do not clearly point to epiglottitis, you can order a lateral neck X ray.
If it reveals the thumb sign as well as swelling of the air epiglottic folds, you can confirm the diagnosis of epiglottitis.

Treatment2:48–3:52

Once you've diagnosed epiglottitis, you should promptly proceed with treatment first, perform emergent endotracheal intubation in a controlled setting such as the operating room.
Additionally, you should consult the surgical team in advance for consideration of tracheotomy. If an endotracheal tube cannot be placed.
Medical management involves empiric IV antibiotics which commonly consists of a third generation cephalosporin as well as additional coverage of methicillin resistant Staphylococcus Arius before starting the antibiotics, make sure you obtain cultures of blood and airway secretions.
If possible culture results may identify the cause of bacteria. In which case you can tailor antibiotics.
Now, here's a high yield fact. The most common causes of epiglottitis include respiratory pathogens such as haemophilus influenzae type B and streptococcus pneumoniae.
Since these bacterial infections are vaccine preventable, you should have a high index of suspicion for epiglottitis in patients who are unvaccinated.
Now, let's return to the ABCD E assessment and take a look at stable patients. In this case, start by performing a focused history and physical exam.

Stable patient3:52–5:37

A child presenting with symptoms, suggesting croup is typically between six months and three years old with a low grade fever and upper respiratory infection symptoms such as nasal congestion or rhinorrhea.
In addition, your patient's caregiver may describe hoarseness as well as the rapid onset of a cough that's barking or seal like and may worsen at night.
A physical exam typically reveals a child with labor breathing tachypnea and normal oxygen, saturation. Inspiratory stridor is a common finding and suprasternal intercostal and subcostal retractions may also be present if your patient presents with these signs and symptoms, you can clinically diagnose croup.
Here's a clinical pearl to keep in mind. Although croup can usually be diagnosed clinically based on classic history and physical exam findings in some circumstances.
The presentation might not be so clear cut if this is the case, you can order a lateral neck X ray to evaluate the subglottic structures and consider a viral PCR to identify respiratory viral pathogens.
If the neck X ray demonstrates the steeple sign with subglottic narrowing. Or if PCR results are positive for parainfluenza virus, R SV influenza virus or adenovirus, you can confirm the diagnosis of croup.
Also keep in mind that certain auscultatory findings such as crackles and wheezing do not suggest croup. So consider other diagnoses if you hear these now that you've diagnosed croup, your next step is to assess the underlying cause.

Viral croup5:37–6:11

First, let's discuss the infectious causes of croup fever and symptoms of an upper respiratory infection together with a barking cough and stridor that occur during both day and night with worsening at night are highly suggestive of viral croup.
Once you diagnose viral croup, before deciding on management, you should first assess your patient's disease severity to do this.
Use a validated scoring system like the Wesley croup severity score. Let's start with mild croup.

Mild croup6:11–6:44

These patients typically have a barking cough but no stridor at rest. Keep in mind that they may demonstrate inspiratory stridor only when agitated while tachypnea and retractions are absent.
Patients with mild croup can be treated with oral dexamethasone and then continue symptomatic care at home for symptom relief.
Instruct caretakers to keep the child calm and provide cool mistreatments. Ok.
Moving on to moderate croup. These patients have a frequent barking cough, stridor at rest and mild to moderate retractions with normal air entry treatment should begin at the hospital with oral or intramuscular dexamethasone and consider administering nebulized racemic epinephrine to reduce airway edema.

Moderate croup6:44–7:36

Keep in mind that rebound edema can occur in 2 to 3 hours once you give RMIC epinephrine. So always observe your patient for at least three hours before discharge.
If rebound symptoms occur, admit your patient to the hospital and consider humidified oxygen Again, for symptomatic care, keep the child calm and provide cool missed treatments.
Lastly, we have severe croup. These patients demonstrate a frequent barking cough and appear agitated.

Severe croup7:36–8:33

In addition, you may observe nasal flaring with severe retractions and moderate to severe stridor at rest. Auscultation of the lungs may reveal poor air entry.
These Children require hospital admission and should receive intramuscular or even IV dexamethasone as well as frequent nebulized racemic epinephrine.
Additionally, you can consider heliox to facilitate air entry again for symptomatic care, implement measures to keep the child as calm as possible and provide cool missed treatments.
Lastly, intubation is considered when the patient exhibits signs of impending airway compromise and respiratory failure.
These signs include a depressed level of consciousness, stridor at rest, severe retractions and cyanosis. All right.

Spasmodic croup8:33–9:19

Now that we've discussed viral croup, let's go back and consider another type of croup. You should suspect a noninfectious cause if your patient presents with a sudden onset of stridor and barking cough that only occurs during the night fever is usually absent and the child's caretaker may report frequent episodes of croup in the past.
In this case, you can diagnose spasmodic croup. Although the cause is usually unknown.
Spasmodic croup is often associated with atopic disease or gastroesophageal reflux. So, make sure to treat the underlying cause if you suspect one and again, symptomatic care includes keeping the child calm and cool, missed and most patients can be managed at home.
All right, as a quick recap. If you suspect croup or epiglottitis, perform an ABCD E assessment.

Review9:19–10:30

If your patient is unstable with high fever, labored breathing, drooling and an absent cough, suspect epiglottitis. In this case, immediately secure the airway and begin treatment with IV antibiotics.
On the other hand, if your patient is stable and presents with a barking cough and inspiratory stridor suspect croup and assess for the underlying cause.
Patients with low grade fever and U ri symptoms have viral croup and should be treated based on their severity. Mild croup can be treated with dexamethasone calming methods and cool mist, moderate croup should also be treated with dexamethasone and patients could benefit from nebulized racemic epinephrine.
Finally, patients with severe symptoms require hospital admission, dexamethasone, nebulized racemic epinephrine and sometimes heliox or even intubation on the flip side, Children with spasmodic croup should receive symptomatic care and treatment of the underlying cause if identified
Croup and epiglottitis: Video, Causes, Symptoms | Osmosis