Croup, Epiglottis, & Bronchiolitis

Epiglottitis (x_ray signs)

"Thumb sign" showing enlarged and swollen epiglottis

Respiratory Syncital Virus (Tx)

Admin of ribavarin given in very severe cases. The Ribavarin is given by small particle generator (SPAG), 12 to 18 hours a day for 3 to 7 days.

Epiglottitis (when to extubate?)

After a period of 12 hours of no fever

Epiglottitis (Etiology)

B Haemophilus influenzae; less commonly, staphylococcus aureus or streptococcus pneumoniae.

Epiglottitis

Bacterial infection of the epiclottis and other supraglottic structures in children 2-6 y.o. (sometimes in 8 or 9 y.o.)

Croup (Tx)

Cool mist with O2 PRN and Racemic epinephrine via medication nebulizer, 0.5 ml is given in 3-4 ml of NS, 1-2 hours. Keep child calm. Corticosteroids(0.3 - 0.6 mg/kg of dexamethasone) also reduce the severity and duration of croup, especially in patients where cool mist and epi don't work. Budesonide(aerosolized intranasally) reduces the severity of symptoms

Epiglottitis (Tx)

Don't examine mouth or throat if eppiglottits is suspected. Don't treat with aerosols including racemic epi. O2 is needed, hopsitalize patient, administer ampicillin(200-400 mg/kg/day or chloramphenicol 100 mg/kg/day).

Acute infectious bronchiolitis (Pathophysiology)

Edema and inflammation of the bronchiole walls, the submucosa and the adventitial tissue. Necrosis of the epithelium of the small airways leads to sloughing of the necrotic tissue into the airway. WOB inc, airway becomes occluded -> air trapping & hyperinflation & atelactasis-> V/Q abnormalities & hypoxemia

Acute infectious bronchiolitis (clinical manifestations)

Frequently starts with an upper airway infection and rhinorrhea, pharyngitis and low-grade fever. Hyperressonant chest w/ rhonci&wheezing, prolonged expiratory time, tachycardia, barely heard breath sounds

Respiratory Syncital Virus (Dx)

Identification of virus is by sputum sample. Sputum may be obtained by nasal lavage or nasotracheal suctioning.

Croup (X-ray findings)

Inc density (haziness) in the subglottic area/ narrowing of trachea/ aka "steeple sign"

Croup (Pathophysiology)

Inflammation & swelling of subglottic structures due to infection. Inc. mucus production & edema due to uneven lymphatic capillary distribution(leading to rapid fluid spreading). V/Q abnormalities can develop leading to hypoxemia.

Acute infectious bronchiolitis

Inflammation of the bronchioles, most often occurring in infants and children under the age of 3 years.

Epiglottitis (Pathophysiology)

Inflammation of the epiglottis, aryepiglottic folds, and arytenoids; the epiglottis turns a bright cherry red. Pt has difficulty swallowing, and airway narrowing which is pronounced in during inspiration.

Croup (Tx of severe causes)

Intubation & mechanical ventilation

Acute infectious bronchiolitis (Tx)

Mainly supportive: high humidity w oxygen, fluids, brochodilators if significant bronchospasm & wheezing present or asthma not ruled out. Antibiotics occasionally administered.

Acute infectious bronchiolitis (Etiology)

Most commonly viral. 43% caused by RSV. Parainfluenza and Adenovirus are other common causative agents.

Croup (Etiology)

Parainfluenza virus 1(also 2 and 3); less frequently, influenza A and B, respiratory syncital virus, and adenovirus.

Croup (clinical manifestations)

Slow onset: 1-2 days of low-grade fever, nasal congestion and coughing. The onset of croup is announced by sever brassy, barking cough, & hoarseness. Usually worsens at night. Stridor can also develop as the extrathoracic airways narrow on inspiration. inspiratory retractions seen below the clavicles and in the intercostal spaces.

Epiglottitis (Clinical Manifestations)

Symptoms appear abruptly (2-4 hours) & patients appear more acutely ill than with croup. Symptoms are fever, sore throat, and difficulty swallowing which leads to drooling (the most apparent sign of epiglottitis) Stridor and ins retractions are often present. WBC(neutrophils) inc.

What determines the severity of croup

The degree of tachycardia and tachypnea.

Respiratory Syncital Virus (Hx)

Usually follow exposure to older sibling,parent, another child in daycare/school who has cold like symptoms. Incubation period may be from 2 to 8 days, average of 4 days, preceded by signs of upper airway infection

Croup

Viral infection of the larynx, trachea, and bronchi, primarily affecting infants and small children, 6 months to 6 years.

Respiratory Syncital Virus (risk factors that inc severity)

children < 3 months, congenital heart disease, prematurity, bronchoplasia, cystic fibrosis

Acute infectious bronchiolitis (ABGs)

dec PaO2 & PaCO2. Inc PaCO2 shows inc. deadspace ventilation, fatigue or both. if sev hypoxemia, met acidosis may occur

Acute infectious bronchiolitis (X- ray findings)

hyperradiolucency flattened diaphragms increased AP diameter with increased retrosternal airspace (lateral x-ray) possible linear atelectasis, infiltrates

RSV patients are kept in _____________

isolation

Respiratory Syncital Virus

most common resp pathogen for infants & children. Causes 43% of broncholitis & 25% of pneumonias. By age 2 100% of children are exposed to the virus. Infection is more sever in younger