Pediatric Croup and Bronchiolitis

Question 1

Pediatric vs adult airway

Answer 1

Larynx more anterior and more rostral

Larger tongue

Epiglottis larger and less cartilaginous…difficult to ID

Narrowest part is the criocoid cartilage (vs. vocal cords)

these things make it more difficult to see

Adult is a nice straight column down…the pediatric is more like a funnel that narrows to the pediatric cricoid cart

Question 2

Ramifications of pediatricsvs. adults

Answer 2

MOre prone to obstruction (tongue blocks)

INfants are obligate nasal breathers

Smaller larynx means less space

Epiglottis borader in adults…pediatric epiglottis omega

Infant larynx around C2-3…adult around C4-5

Pedaitric resembles adult around 10 y/o

Question 3

Edema in airway*****

Answer 3

Halving radius increases resistance times 16…so pediatric is far more susceptible to compromise

Question 4

Grunting Drooling

Answer 4

Can’t keep open their lower airway

Drooling can be upper problem

Question 5

Inhalation vs. exhalation vs. diphasic sounds `

Answer 5

In - above level of vocal cords

Ex - below (intrathoracic)

Biphasic - involve coval cord issue

Question 6

Tx modalities

Answer 6

CSs - anti inflam…reduce mucosal edema…but its delayed

Vasoconstrictive - epinephrine…reduces swelling…temporary so could have rebound swelling

Heliox - He less dense than N…can reduce turbulent flow across narrowed airway…less viscous

Adjuncts - oral, nasipharyngeal, LMA, endotracheal intubation

Question 7

Croup

Answer 7

Viral laryngotracheobronchitis

Vrial resp infection

Most common parainfluenza

Any virus that causes bronchiolitis

Consider bacterial tracheitis as differential

Viral inflammatioj leads to swelling in supraglottic and laryngotracheal area

Increased mucus production

Turbulent flow across narrowed area (stridor)

Question 8

Croup sx

Answer 8

Cough (barking seal)

Should be inspiratory Stridor

Bacterial tracheitis - toxic appearing and high fever

Epiglottitis, must maintain certain position and cannot change with ease…won’t be croup

They SHOULD be able to change positions easily

Question 9

Epiglottitis vs. croup radio

Answer 9

Croup - epiglottis will be normal…can see the airway narrow on an AP

Epiglottitis - inflamed thumbprint sign

Question 10

Croup tx

Answer 10

Supportive care is most important…supplemental oxygen or hydration

Steroids - can reduce inflammation
ENT eval???

Question 11

Airway forreign body

Answer 11

Lack of viral prodrome

Sudden onset

Biphasic stridor suggests obstruction at level of cords

One volume may be hyperinflated

Air trapping on one side from FB obstructive effect

Question 12

Acute bact epiglottitis

Answer 12

Raditional cause is Haemophilus type B

Also with S pnumo, GAS, S auerus

Tx with steroids and Abs

Question 13

If kid stops breathing

Answer 13

Allow them to assume position of comfort

Control the airway

Surgical backup for tracheotomoy

Question 14

DDx of actue bacterial epiglottitis

Answer 14

Bacterial trachitis - usually not associated with impending airway compromise

Retropharyngeal abscess

Periotonsilar abscess (can be visualized)

Diptheria - psuedomembrane rare in US

Question 15

Pierre Robin sequence

Answer 15

Mandibular hypoplasia, micrognathia, cleft palate

Resp and feeding difficulty

Question 16

Cystic teratoma

Answer 16

Obvious airway obstruction

Question 17

Choaanl atresis

Answer 17

Nasal obstruction in newborn

Uni or bilateral

Bilateral is emergency

Pass tube into nostril

Death by ashphyxia

Question 18

The flow

Answer 18

Generated by pressure gradient bt alveolus and mouth

Flow in conducting zone is bulk flow

Resp is diffusion based

Airway resistance from IM sized bronchioels

Question 19

Causes of hypoxia

Answer 19

V/Q mismatch - children

Shunt

Hypoventilation

High elevation (low Patm and low PO2)

Diffusion abnormaitly

Question 20

Bronchiolitis

Answer 20

Viral lower airwya infection

RSV most common

Under 2 y/o most severe

Older kids/Adults nasty cold/URI

Smaller children develop mucous plugging of small and medium sized airways…leads to increased airway resistance

Dvelop air trapping and obstructive lung dz wirth exp wheezing

Question 21

Risk factors

Answer 21

Pretaurity

HEart dz

Infansts under 2 y/o

Any other dz really***

Question 22

Dx

Answer 22

Seasonal peak (nov through march)

In warmer climates throughout year

Nasal congestion

Wheezing

Resp distress

Apnea (neonates)

Nasopharyngeal wwashings for rapid antigen detection

Question 23

Bronchiolitis most common pop

Answer 23

Most younger than 1 year…over half under 6 mos

Mean hospital stay 3 days

More in boys

Question 24

Patho of bronchilitis

Answer 24

Viruses enter and cause damage and inflammation

Patho within 24 hours

Bronchiolar cell necrosis, ciliary disruption, peribronchial lymphcytic infiltration

Edema, excessive mucous, sloughed epithelium, lead to airway obstruction and atelectasis

Question 25

Course

Answer 25

Begin with URI sx

4-6 day is peak

2-4 weeks, sx abate with residual cough

Most is self limited

Bacterial pneumonia or UTI can occur comorbd

Question 26

Ddx of bronchiolitis

Answer 26

No astham in infants

Bacterial pneumonia - will see focal finding…not much secretion

FB aspiration

GE reflux or dysphagia

HEart dz

Question 27

Bronchiolitis tx

Answer 27

Supportive care

B2 agonist (maybe)

Steroids - limited but maybe better if chronic lung dz

Ribivirin - not beneficial and associated with significant toxcity

Question 28

Association with asthma

Answer 28

RSV bronchiolitis at risk for asthma later in life

Question 29

Prevention

Answer 29

Avoid cigarette smoke

Good hand washing

Avoiding contact

Influenza vaccine for children over 6

Palivizumab - monoclonal AB against RSV…covered if premature, congenital heart dz, NM disease

Question 30

Asthma differencews

Answer 30

Recurrent epsidoes of wheezing

Hx, age over 2, PFTs, ID triggers