Croup/ Laryngotracheobronchitis/ laryngotracheitis Definition: Effects between 6months- 6 years with 2 years being the mean age of diagnosis. It is a common syndrome involving inflammation of the subglottic area, presenting with fever, barking cough, and stridor. Patients rarely appear toxic as in epiglottitis Pathophysiology: The inflammation causes narrowing or the larynx just below the vocal cords called the subglottic airway. The cartilage in this part of the airway forms a complete ring which restricts the airways ability to expand when inflamed. Inflammation in this area causes the distinctive barky cough and stridor (hallmark of the disease) Risk factors: Causative organisms: -​ Parainfluenza -​ Influenza A and B -​ Adenovirus -​ RSV -​ Metapneumovirs History: Typically a 1 to 4 day history of: -​ non-specific cough, rhinorrhoea and fever -​ progressing to a barking cough {due to tracheal edema and collapse} -​ hoarseness {due to inflammation of the vocal cords} and -​ stridor {high pitched sound on inspiration indicating obstruction} -Symptoms often starting and being worse at night -Other family members may have a mild respiratory illness -Red flag symptoms for respiratory failure- drowsiness and lethargy MAIN Q’s to ASK: Onset and progression of illness? Recent oral intake? Dysphagia or drooling? ( to R/O epiglottits) Choking episode? Underlying airway abnormalities? Previous intubation? Respiratory conditions? Recent Hx of viral URTI? Examination: General assessment: -​ Vital signs normal? -​ Comfortable? -​ Working hard to breathe? -​ Awake? Or sleepy? -​ dehydrated? Resp exam: -​ Abnormal sounds- stridor and barky cough 1)Stridor 2)Chest sounds may be normal, but there is a severe airflow limitation these sounds can be decreases 3)Respiratory distress: tachypnea, intercostal recession 4)Red flags for respiratory failure: cyanosis, lethargic/decreased level of consciousness, laboured breathing, tachycardia, hypoxia, cyanosis, stridor at rest Investigation: -​ Croup is a clinical diagnosis. Radiographs are not routinely recommended. In Neck XR the characteristic “steeple” sign (subglottic narrowing) is only present in 50% of cases with croup. The “steeple sign” can also be present in children without croup depending on their phase of respiration at the time of radiograph Diagnosis/Differentials: 1)​ Epiglottits 2)​ Inhaled foreign body 3)​ Bacterial tracheitis (rare) 4)​ Retropharyngeal abscess Graded based on the Westley score: Clinical feature Score SaO2 <92% 0 = None 4 = When agitated 5 = At rest Stridor 0 = None 1 = When agitated 2 = At rest Retractions 0 = None 1 = Mild 2 = Moderate 3 = Severe Air entry 0 = Normal 1 = Reduced 2 = Markedly reduced Consciousness 0 = Normal 5 = Reduced 1)Mild (score 0-2) 2)Moderate (score 3-5) 3)Severe (score 6-11) 4)Impending respiratory failure (score 12-17) Management: a. Mild (no stridor at rest): Treat with minimal disturbance In clinic: -single dose of oral dexamethasone (0.6mg/kd) → discharge At home: -Antipyretic (acetaminophen) -oral hydration b. Moderate to severe (1) The efficacy of mist therapy is not established (2) Racemic epinephrine (2.25%), 0.05 mL/kg/dose (maximum dose, 0.5 mL) in 3 mL normal saline (NS) over 15 min every 1 to 2 hr, or nebulized epinephrine, 0.5 mL/kg of 1:1000 (1 mg/mL) in 3 mL NS (max dose, 2.5 mL for <4 years old, 5 mL for >4 years old). Observe for a minimum of 2 to 4 hr after administering nebulized epinephrine due to potential for rebound obstruction. Hospitalize if more than one nebulization is required (3) Dexamethasone, 0.3 to 0.6 mg/kg IV, IM, or PO once. Effect lasts 2–3 days. Alternatively, nebulized budesonide (2 mg) may be used, though little data exist to support its use and some studies find it to be inferior to dexamethasone (4) A helium-oxygen mixture may decrease resistance to turbulent gas flow through a narrowed airway c. If a child fails to respond as expected to therapy, consider other etiologies (e.g. retropharyngeal abscess, bacterial tracheitis, subglottic stenosis, epiglottitis, or foreign body). Obtain airway radiography, computed tomography (CT), and evaluation by otolaryngology or anesthesiology Pharmacology Review: 1)Dexamethasone (decadron/Baycadron/Ciprodex) Class: Glucocorticoid (corticosteroid) MOA: reduce the inflammatory edema and to prevent obstruction of the ciliated epithelium. Dosage: 0.6mg/kg/dose IV/PO for two doses given 24-26hrs apart. Max:16mg/dose S/E: -oral use- hiccups, hyperglycaemia, Contraindications Indications for admission: Previous history of severe airway obstruction < 6 months of age Immunocompromised Have had inadequate fluid intake Have had a poor response to initial treatment The diagnosis is uncertain There is significant parental anxiety  Complications: 1)​ Bronchopneumonia 2)​ Cervical lymphadenitis 3)​ Otitis media 4)​ Meiningitis 5)​ Septic arthritis 6)​ Tracheonronchitis 7)​ Pneumothorax

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