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Paediatrics > Croup > Flashcards

Croup Flashcards

1
Q

At what ages does Croup typically occur? (TOP)

A
  • 6 months to 3 years
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2
Q

What season does Croup predominantly occur? (TOP)

A
  • Autumn
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3
Q

Does croup affect boys or girls more? (CMAJ)

A
  • Boys
  • M:F 1.4:1
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4
Q

What is Croup usually caused by? (TOP)

A
  • Parainfluenza virus
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5
Q

How can Croup be further classified? (TOP)

A
  • Acute laryngotracheobronchitis (included viral prodrome)
  • Spasmodic croup (no viral prodrome, can have recurrent episodes)
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6
Q

What symptoms commonly precede symptoms of croup? (TOP)

A
  • Viral Prodrome (24 – 72 hours prior)
    • Non-specific cough
    • Rhinorrhea
    • Fever
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7
Q

Name 8 symptoms of Croup. (TOP)

A
  • Seal-like barky cough
  • Hoarseness
  • None to moderately high fever (up to 40 degrees C)
  • Irritability
  • Stridor
  • Chest wall indrawing of varying severity
  • Absence of drooling
  • Non-toxic appearance
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8
Q

When does stridor typically occur for Croup? (TOP)

A
  • Inspiration (can be biphasic – with expiration – with more severe distress)
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9
Q

When do symptoms of Croup typically appear during the day? (TOP)

A
  • Late evening/night and abrupt onset
  • Usually improve during the day and often recur again the following night
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10
Q

When do symptoms in children typically resolve by? (TOP/CMAJ)

A
  • 48 hours in 60%
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11
Q

How long can children remain symptomatic with croup in a small percentage of cases? (TOP/CMAJ)

A
  • 5-6 days in less than 2%
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12
Q

What are resolving Croup symptoms usually followed by? (TOP)

A
  • Typical URTI-like symptoms
  • Occasionally a secondary bacterial-induced otitis media
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13
Q

Name 5 other potential causes of stridor in children other than Croup. (TOP)

A
  • Bacterial tracheitis
  • Epiglottitis
  • Foreign body lodged in upper esophagus
  • Retropharyngeal or Peritonsillar abscess
  • Hereditary angioedema
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14
Q

What is the most common and second most common alternative diagnosis to croup? (TOP)

A
  1. Bacterial tracheitis
  2. Epiglotitis
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15
Q

What is the most frequently isolated bacterial pathogen in bacterial tracheitis? (CMAJ)

A
  • Staphylococcus aureus
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16
Q

How does bacterial tracheitis typically present? (TOP)

A
  • Sudden worsening of symptoms following a mild-to-moderate episode of croup
  • Acute onset of high fever
  • Toxic appearance
  • Poor response to epinephrine
  • *Thick tracheal secretions have the potential to cause airway occlusion
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17
Q

How is bacterial tracheitis typically treated? (TOP)

A
  • Broad-spectrum IV antibioitics
  • Close monitoring
  • Intubation and respiratory support frequently required
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18
Q

What is epiglottitis primarily caused by? (TOP)

A
  • Haemophilus influenza (HIB vaccine)
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19
Q

How does epiglottitis typically present? (TOP)

A
  • Sudden onset of high fever
  • Dysphagia
  • Drooling
  • Toxic appearance
  • Anxious
  • Sitting forward in a “sniffing position”
  • Absence of a barky cough
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20
Q

What is the most crucial aspect of management for epiglottitis? (TOP)

A
  • Intubation (securing the airway)
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21
Q

What are 5 signs of impending respiratory failure in children? (TOP)

A
  • Change in mental status such as fatigue and listlessness
  • Pallor or cyanosis
  • Dusky appearance
  • Decreased retractions or asynchronous chest wall and abdominal movement
  • Decreased breath sounds with decreasing stridor
22
Q

Are laboratory and radiological assessment necessary to diagnose croup? (TOP)

A
  • No
23
Q

What imaging studies could be ordered to help clarify the diagnosis in children with atypical croup-like symptoms? Describe 4 findings on x-ray suggesting of Croup or other diagnoses. (TOP)

A
  • Lateral and AP soft tissue neck film
    • Croup à “Steeple Sign” (cone-shaped narrowing) on AP
    • Bacterial Tracheitis à ragged edge or a membrane spanning the trachea
    • Epiglottitis à thickening of epiglottis and aryepiglottic folds
    • Retropharyngeal abscess à bulging posterior pharynx soft tissues
24
Q

If ordering radiography in a child with possible croup, what needs to be done? (TOP)

A
  • Child must be monitored closely be personnel with skills and experience in the management of difficult airways
25
Q

If epiglottitis or bacterial tracheitis is suspected, what test is contraindicated and why? (TOP)

A
  • Lateral and AP soft tissue neck film à manipulation of the neck or agitation to the child may precipitate increased airway obstruction
26
Q

For children with moderate to severe croup, what should be monitored during assessment? (TOP)

A
  • Pulse oximetry
27
Q

When should oxygen be administered to children with croup? (TOP)

A
  • Hypoxia (O2 sat < 92%)
  • Significant respiratory distress
28
Q

What are the levels of severity for children with croup? (TOP)

A
29
Q

For patients with croup in respiratory distress, what type of oxygen is recommended? (TOP)

A
  • Blow-by humidified oxygen (administration of oxygen through a plastic hose with the end opening held near the child’s nose and mouth)
30
Q

Is there any benefit to mist therapy or humidifiers for children with croup? (TOP)

A
  • No
31
Q

What is the evidence for mist therapy for croup? (TOP)

A
  • Systematic review found no significant difference in croup score following humidified air
  • RCT published in JAMA 2006
    • Randomized 140 children with moderate to severe croup in an ED
    • Humidified ‘blow-by’ oxygen (placebo – ambient humidity equal to room air) vs 40% humidified oxygen vs 100% humidified oxygen
    • No significant benefit to humidity (croup score, admission to hospital, need for additional medical care, treatment with epinephrine or dexamethasone
32
Q

Why are mist tents in particular not recommended? (TOP)

A
  • Uncomfortable wet, cold, “caged” environment
  • Separate the child from their parents which results in agitating the child
  • If improperly cleaned between use may disperse contaminants into the child’s room
33
Q

What is the evidence for antitussives and decongestants for children with croup? (TOP)

A
  • No evidence, should NOT be recommended
34
Q

Is there a benefit for beta-2 agonists for treating croup? (TOP)

A
  • No (Croup upper airway disease, no physiological basis)
35
Q

For patients with croup and severe respiratory distress (i.e. marked sternal wall indrawing and agitation), what can be given for the temporary relief of symptoms of airway obstruction? (TOP)

A
  • Epinephrine (L-epinephrine = racemic epinephrine)
    • Racemic epinephrine 2.25% (0.5 mL in 2.5 mL saline)
      • No longer available in North America
    • L-epinephrine 1:1000 (5 mL)
36
Q

How long does it take to see a benefit with epinephrine for croup, how long does the improvement typically las, and how long until the effects dissipate? (TOP)

A
  • Within 10 minutes can see benefit (improvement in croup score on systematic review 30 minutes following administration)
  • Lasts for more than an hour
  • Dissipates within 2 hours
37
Q

Do patients with croup treated with epinephrine develop a ‘rebound effect’ after 2 hours? (TOP)

A
  • No
38
Q

For patients that receive nebulized epinephrine for croup, do they require admission to hospital? (TOP)

A
  • No – but should NOT be discharged home before 2 hours after treatment
39
Q

Should repeat doses of epinephrine be used in patients with croup? Why or why not? (TOP)

A
  • No (one paper reported on a child receiving 3 nebulizations within one hour developed ventricular tachycardia and had a myocardial infarction)
40
Q

What should all children diagnosed with croup be administered as treatment? (TOP)

A
  • Dexamethasone (Oral preferred to IM except in very severe croup)
41
Q

What is the dose of dexamethasone to treat croup? (TOP)

A
  • Dexamethasone 0.6 mg/kg PO/IM once
    • Can consider lower dose of 0.15 mg/kg PO/IM (TFP)
  • May repeat in 6 to 24 hours
42
Q

When does clinical improvement begin for croup after treatment with dexamethasone? (TFP)

A
  • Improvement within 1 to 3 hours
43
Q

What is the NNT for benefit with dexamethasone for croup symptoms? (TFP)

A
  • Significant improvement in croup symptoms at 6 hours (NNT = 5)
  • Fewer return visits to emergency and/or (re)admissions (NNT = 17)
44
Q

How long do patients with croup that are treated with dexamethasone have improved symptoms? (TOP)

A
  • 24 to 48 hours
45
Q

How long should children with croup receiving corticosteroids be observed before the decision is made whether to admit to hospital? (CMAJ)

A
  • 4 hours
46
Q

What are 2 relative contraindications to dexamethasone treatment in patients with croup? (TOP)

A
  • Known immune deficiency
  • Recent exposure to varicella
47
Q

What % of patients with croup receiving oral dexamethasone vomit? (TOP)

A
  • < 5%
48
Q

When would nebulized budesonide be given for croup? (TOP)

A
  • Persistent vomiting
  • Severe respiratory distress
    • Mixed with epinephrine and administered simultaneously (2 mg budenoside nebulized with epinephrine)
49
Q

Why is budesonide not routinely used to treat croup? (TOP)

A
  • No more effective than dexamethasone
  • More traumatic to administer
  • Substantially more expensive
50
Q

Name 1 indication for admission for croup and 3 relative indications for admission. (TOP)

A
  • Significant respiratory distress persisting for 4 or more hours after treatment with corticosteroids
    • Sternal wall indrawing
    • Easily audible stridor at rest
  • *Lack of timely access to care, risk of no observation and follow-up
  • *Significant parental anxiety
  • *Multiple ED visits within 24 hours

Paediatrics (2 decks)

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