Dr.

AMANULLAH,
Department of pediatrics
 CROUP is a hetrogenous group of Acute and
infectious processes in children (between the
age group of 6 months & 6 Years) that
manifest most commonly with characteristic
INSPIRATORY STRIDOR, BARKING COUGH,
HOARSE VOICE, & VARYING DEGREES OF
RESPIRATORY DISTRESS.
 STRIDOR is a loud ,harsh, medium pitched,
musical sound produced by turbulent airflow
through a partially obstructed airway. It is a
SYPMTOM & not a diagnosis or a disease.

 STRIDOR is primarily Inspiratory but can be

Biphasic
The word CROUP is
derived from Anglo –
Saxon word KROPAN
which means CRYING
ALOUD.
 The Diseaseas included are-

 Acute laryngotracheobronchitis, ie, viral

croup

 Spasmodic croup

 Acute infectious laryngitis

 Acute epiglottitis, ie, acute supraglottitis

 also known as viral croup, or simply -croup.

 the most common cause of upper airway

obstruction seen in pediatric practice.

 Viral croup is usually seen in patients ages 3

months to 5 years. Peak incidence is seen at
the age of 12- 24 months.

 Mostly seen in winter and autumn season.

It is caused by respiratory viruses mainly
parainfluenza type 1 , parainfluenza Type 2,
parainfluenza type 3, account for 75% 0f
cases.
 Other viruses includes, - Influenza A and B
Rhino viruses,
 Adenovirus,
 Respiratory syncytial virus,
 Measles virus
 rarely Mycoplasma.
 The illness usually starts like a common cold
with symptoms of Rhinorrhea, Cough,
SoreThroat, & Fever.

 Features of UPPER AIRWAY OBSTRUCTION ie,

INSPIRATORY STRIDOR, HOARSENESS &
BARKING COUGH develop over next 2 to
3days. Symptoms are Worse at Night.

In Most cases Symptoms usually resolve within

a week.
 Few children will develop symptoms of Severe Airway
Obstruction characterised by Intercoastal
Recession , Tacypnoea, Irritability, Lethargy &
Cyanosis & need hospitalization.

 These symptoms usually occur due to

Inflammation of Larynx, Trachea & Bronchus hence
term –LARNGOTRACHEOBRONCHITIS.

 It is specifically the SUBGOTTIC INFLAMMATION &

resultant swelling that compromises the airway &
results in STRIDOR & DIFFICULTY in Breathing.
 Mild Moderate severe
General Happy , Irritable Restless, altered
appearance interested sensorium
stridor On cough, not at At rest , At rest ,
rest increased on increased on
agitation agitation

Respiratory No distress Tachypnea and Marked and

distress retactions severe retraction
Cyanosis Absent Absent May be present

Oxygen >92% >92% <92%

saturation in
room air
 The diagnosis is based on history and physical
examination.

 CROUP is a clinical diagnosis & does not require any

investigations.

 Neck x-rays can have a characteristic appearance.

 The Neck X-Ray may show the typical SUBGLOTTIC

NARROWING in P A view.

 This is also known as the steeple sign because it

resembles a church spire.
 The complete blood count or CBC is generally
unremarkable except for a lymphocytosis.

 Patchy infiltrate in X-RAY can be seen in

laryngotracheal- bronchitis or pneumonitis.

 Pulse oximetry or arterial blood gas analysis

can be used.
 Treatment is dependent upon severity of the disease.

 Mild cases can be managed on ambulatory basis with

symptomatic treatment for fever & encouraging the child to take
liqiuds orally. Humidified Air can be used in mild cases

 Parents should be explained about the progression of the

disease & bring back the child in case of worsening of
symptoms. NO ROLE FOR ANTIBIOTICS.
 MODERATELY SEVERE - Patient may need
hospitalization.
 Nebulisation with RACEMIC EPINEPHRINE
diluted with water for immediate relief of
symptoms.
 A single I.M. dose of DEXAMETHASONE (0.3 –
0.6 mg /kg) reduces overall severity during
first 24 hours.
 Inhalation of BUDESONIDE in 1mg twice a day
for 2 days have shown good results.
 SEVERE CROUP may need treatment
preferably in Pediatric Intensive Care unit
with Oxygen inhalation, & steroids –( similar
to Moderate severity).
 Worsening distress may need short term
Ventilation.
 Antibiotics have no role unless some bacterial
infection is suspected
 Most often seen in Children in the age group
between 1-3years.

 It is Clinically similar to Acute

Laryngotracheobronchitis, except that the
history of Viral prodrome & fever is usually
absent.
 Viral in most instances

Allergic factors

 Psychological factors appear to play an

important role in some children.

 SPASMODIC CROUP may represent more of

an ALLERGIC reaction to Viral Antigen.
 The child wakes up suddenly in the night
time Or early hours of the morning with
brassy cough & noisy breathing. Symptoms
improves within few hours.
 Similar attacks but less severe may occur
for another one or two nights.
 Such episodes recurs several times.
 pharynx reveals only minimal edema.

 Acute spasm of the vocal cord adductors may

be the cause, possibly triggered by allergy,
viral infection, or gastroesophageal reflux.
 Humid fiction at home by exposure to steam.


 Racemic epinephrine will break the attack if
needed.

 Parents need accurate information and

reassurance before discharging the patient
home including written instructions such as
those for viral croup.
 Epiglottitis, also termed supraglottitis .

 It is an inflammation of structures above the

insertion of the glottis and is most often
caused by bacterial infection.
 Haemophilus influenzae B.

 Streptococcus.

 Pneumococcus.

 Stayphlococcus.
 Epiglottitis is characterized by the abrupt
onset of severe symptoms.

 Without airway control and medical

management, symptoms may rapidly
progress to respiratory obstruction and death
in a matter of hours.
 Fever is usually the first symptom, and
temperatures often reach 40°C.
 This is rapidly followed by stridor and labored
breathing.
 Child will have Dysphagia,Drooling of saliva
& not able to phonate.
 Child looks Toxic.
 Child may assume the TRIPOD POSITION ie,
Sitting upright and leaning forward with chin
up & mouth open while bracing the arms.
 The clinical triad of drooling, dysphagia, and
distress is the classic presentation.
 Fever is with associated respiratory distress
or air hunger in most patients.
 Accessory respiratory muscles will be
activated.
 As the child becomes fatigued, stridor
diminishes.
 An erythematous and classic swollen, cherry
red epiglottis can often be seen during
careful examination of the oropharynx,
although this examination should not be
attempted, it may compromise respiratory
effort.
 Securing an airway is the over riding priority.

 An expert should always perform an

endotracheal intubation on any child with
suspected epiglottitis before radiography or
blood work is performed.
 Laryngoscopy is the best way to confirm the
diagnosis, but it is not advised to attempt any
procedures without securing the airway.

 Can cause sudden reflex spasm of larynx.

 Laboratory evaluation is nonspecific in
patients with epiglottitis and should be
performed once the airway is secured.

 The white blood cell (WBC) count may be

elevated from 15,000-45,000 cells/
 Blood cultures and culture of the epiglottis
should be performed only after the airway is
secured.

 Blood cultures may show Haemophilus

influenzae type b (Hib).

 Cultures of the surface of the epiglottis

obtained during endotracheal intubation are
positive in 50-75% of cases
 Lateral neck radiography

 Never obtain a lateral neck radiograph before

achieving definitive airway control.

 In classic epiglottitis, a lateral soft-tissue

radiograph of the neck reveals a swollen
epiglottis protruding from the anterior wall of the
hypopharynx (ie, thumbprint sign), thickened
aryepiglottic folds, obliteration of the vallecula,
and dilation of the hypopharynx.
 Needs hospitalization.

 Airway, Breathing, and Circulation maintain.

 Supplemental oxygen (humidified)

administration.

 Sedatives should be avoided.

 Fluids should be given.

 Once supplemental oxygen is provided,
 the next step is to mobilize a team to
establish an appropriate airway via
endotracheal intubation.
 Mortality rates for children who receive
endotracheal intubation are less than 1%.
 Children who do not receive intubation have
mortality rates as high as 10%.
 Antibiotic therapy is necessary in the
management of epiglottitis .

 Ceftriaxone or cefotaxime at 100mg/kg/day.

 Acetaminophen is the drug of choice (DOC) for

treating pain.


 Haemophilus b conjugate vaccine (ActHIB,
Hiberix, PedvaxHIB)

 This vaccine is used for routine immunization

of children against invasive diseases caused
by H influenzae type b by decreasing
nasopharyngeal colonization
These 4 syndromes must be differntiated
from one another & from variety of other
entities that can present as upper air way
obstruction.
The important ones are,1) DIPTHERITIC CROUP
2) MEASLES CROUP 3) FOREIGN BODY
ASPIRATION 4) ANGIONEUROTIC EDEMA
5) RETROPHARYNGEAL OR PERITONSILLAR
ABCESS 6)EXTRINSIC AIRWAY COMPRESSION
7) INTRALUMINAL OBSTRUCTION
 1) _________ is the most common cause of
upper airway obstruction in children between
6months & 6 years.
 A)- Foreign Body
 B) Viral Croup
 C) Epiglottis
 D) Congenital laryngeal cyst.
 2)__________ has no role in management of
Viral Croup.
 A) Dexamethasone
 B) Inhaled Steroids
 C) Anti microbials
 3) TRIPOD POSITION is Charecteristic of
 A) Viral Croup
 B) Spasmodic Croup
 C) Bronchiolitis
 D) Epiglottitis
 4) All except _______ are Differntial
Diagnosis for Croup Syndrome
 A) Diptheritic Croup
 B) Angioneurotic Edema
 C) Bronchial Asthma
 D) Foreign Body.
 5)Steeple Sign refers to
 A) Steele like narrow subglottic area on plain
X-Ray seen in Viral croup.
 B) refers to X-Ray finding in Epiglottitis.
 C) Chest X-Ray finding in Bronchiolitis.
 1. Which of the four entities of the croup
syndromes is the most common?
 4.

 What organism commonly causes viral croup?

 6. What is the primary treatment for croup?
 Discuss the clinical features and
Management of Viral Croup.
Discuss the Etiology, clinical features of Acute
Epiglottitis.
 Prevention of Acute epiglottitis
 Role of inhaled steroids in management of
Viral Croup