CROUP, EPIGLOTITTIS, BRONCHIOLITIS

• CROUP (LARYNGOTRACHEOBRONCHITIS OR LTB)


  Inflammation of larynx and trachea (subglottic area); 6 mos. to 6 y.o.
• CROUP


  • Viral in origin: Parainfluenza virus, RSV, Influenza virus, Adenovirus
  • Bacterial superinfections: Staphylococcus aureus, Streptococcus pyogenes Group A, Haemophilus influenzae Type B
• Clinical Manifestations of Croup

  • Nasal congestion, fever and coughing
  • Inspiratory and expiratory stridor (crowing) with a noisy, dry, barking cough
  • Dyspnea, suprasternal retractions, cyanosis, exhaustion and agitation occurs as the disease progresses
• Neck X-ray


  • Characteristic narrowing of the trachea called the "steeple" or "pencil" sign
• Treatment for Croup


  1. Cool aerosol mist (croupette/ O2 tent)

  2. Nebulization with racemic epinephrine or dexamethasone; budesonide for mild-moderate cases

  3. O2 therapy

  4. Cough supressant (antitussives)

  5. Antibiotic if indicated

  6. Intubation/ tracheostomy/ mechanical ventilation (in severe cases)

  7. Use of heliox for severe cases
• EPIGLOTTITIS


  Acute inflammation of supraglottic area; may cause potential upper AW obstruction (life threatening)
• EPIGLOTTITIS


  • Bacterial in origin: Haemophilus influenzae Type B (Pfeiffer's bacillus)
  • Other bacteria: group A S. pneumoniae, Staphylococcus aureus, K. pneumoniae, H. parainfluenzae
  • Normally occurs in older children (2-8 y.o.)
• Clinical Manifestations in Epiglottitis

  • Inspiratory stridor, sore throat, noisy labored breathing, fever, drooling and difficulty in swallowing
  • Patient does not have a croupy bark but instead exhibits a muffled voice
  • Increased WBC count (>10,000/ cu. mm.)
  • Lateral neck x-ray: markedly thickened and flattened (the "thumb sign")
• Neck x-ray of Patient with Epiglottitis

  • Edema in the pharyngeal region and epiglottitis are visible. A thumbprint sign can be seen.
  • The edema has disappeared. An examination using a flexible fiberscope can also show signs of edema.
• Treatment for Epiglottitis


  1. Artificial airways (tracheostomy/ ETT) in severe cases)

  2. Mechanical ventilation (PSV with CPAP)

  3. Antibiotic therapy

  4. Symptomatic treatment for fever

  5. Cool aerosol mist (CAM) therapy; O2 therapy

  6. IVF administration
• Prevention: HiB vaccine for children <5 years
• Bronchiolitis


  Inflammation of bronchioles (ages: 6 mos. to 3 y.o.)

  
• Patients most susceptible to bronchiolitis

  • Immunodeficiency, with co-morbidities (BPD, congenital heart disease, CF or childhood asthma)

  
• Clinical manifestations of bronchiolitis

  • Slight fever, intermittent cough. Dyspnea and tachypnea develops. Inspiratory and expiratory wheezing.
• CXR findings in bronchiolitis

  • Hyperinflation, with areas of consolidation

  
• CXR findings in bronchiolitis

  • Mildly hyperaerated lungs
  • Diffuse increase in linear markings in the parahilar areas - peribronchial cuffing or thickening
  • Fluid or mucus build up in small airways with atelectasis

  
• Clinical Management for Bronchiolitis

  1. Prophylaxis: high risk infants <2 years old. Palivizumab (Synagis) – passive immunity

  2. Oxygen therapy with increased humidification

  3. Increased fluid intake

  4. Mechanical ventilation with heliox for severe cases; low RR or prolonged expiratory time settings to prevent air trapping

  5. Vigorous bronchial hygiene and suctioning

  6. Antibiotic therapy if secondary bacterial infection is present

  
• Aerosol therapy with ribavirin (Virazole)


  1. Using small particle aerosol generator (SPAG) – for continuous therapy of 12 – 18 hrs.

  2. Ribavirin used with caution; mutagenic and teratogenic

  3. Other side-effects: Bronchospasm, Anemia, Rash, Headache, Conjunctivitis