Respiratory/ ENT Flashcards
Epidemiology of Croup
- Commonly affects children who are aged 6 months – 3 years, but can affect those who are as young as 3 months
- Peak incidence is at 2 years of age
- Affects 3% of kids a year, often in winter/ autumn
- M:F 1.4:1
Symptoms of croup
- Aka laryngotracheobronchitis
- Sudden onset of a seal-like barking cough
- Stridor. Chest sounds can be normal but if severe expect reduced air entry
- Voice hoarseness
- Respiratory distress inc. cyanosis etc in more severe cases
- Intercostal breathing
- Prodromal non-specific URTI symptoms e.g coryza, cough up to 48 hours beforehand is common
- Often starts/ is worse at night
- Low grade fever
How do you categorise croup?
Mild – seal-like barking cough but no stridor or sternal/intercostal recession at rest.
Moderate – seal-like barking cough with stridor and sternal recession at rest; no agitation or lethargy.
Severe – seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy.
Impending respiratory failure – increasing upper airway obstruction, sternal/intercostal recession, asynchronous chest wall and abdominal movement, fatigue, pallor or cyanosis, decreased level of consciousness. The degree of chest wall recession may diminish with the onset of respiratory failure as the child tires. Respiratory rate of over 70 breaths/minute.
Admit all children with moderate or higher croup
What are the most common organisms associated with croup?
– Parainfluenza Virus (types I,II, II & IV). Most common culprit 80%
– Respiratory Syncytial virus
– Adenovirus
– Rhinovirus
– Enteroviruses
– Measles
– Meta Pneumovirus
– Influenza A and B
Investigations in ? croup
-Consider epiglottis (more likely to have higher temp, drooling, not speaking or feeding) and inhaled foreign body
- FBC, U&Es, CRP
- Chest Xray if ?foreign body inhalation
Advice for mild croup
- Can be managed at home with a single dose of PO dexa given immediately.
- Symptoms usually resolve within 48 hours but may last for up to a week.
- Croup is a viral illness and antibiotics are not needed.
- Paracetamol or ibuprofen can be used to control pain and fever.
- Ensure that the child has an adequate fluid intake.
- To seek urgent medical advice if symptoms worsen
Treatment for moderate or above croup depending on clinical need:
- Give oxygen if low sats/ signs of respiratory distress
- For all children with croup give a single dose of oral dexamethasone. If too unwell give inhaled budesonide or IM dexa.
- Nebulised adrenaline can be given to provide temporary relief of symptoms
- Ensure the child is kept as calm as possible as continuing crying increases oxygen demand & causes respiratory muscle fatigue
- Contact ENT and an anaesthetist if there is need for airway support
Reasons for admission in mild croup:
- Chronic lung disease
- Congenital heart disease
- Neuromuscular disorders
- Immunodeficiency
- Age under three months
- Inadequate fluid intake
Croup Scoring Criteria:
Westley Scoring Criteria
What is dexamethasone’s MoA?
As a glucocorticoid, dexamethasone is an agonist of the glucocorticoid receptor
What is the aetiology of asthma? (2)
Asthma is characterised by paroxysmal and reversible obstruction of the airways. It is increasingly understood as an inflammatory condition combined with bronchial hyper-responsiveness. Acute asthma involves:
- Bronchospasm (smooth muscle spasm narrowing airways).
- Excessive production of secretions (plugging airways).
Name some asthma triggers:
- Cold symptoms - upper respiratory tract infection (URTI) - frequently trigger exacerbations.
- Cold air
- Exercise - symptoms may occur during exercise but more classically after exercise. Running tends to be worse than cycling.
- Pollution - especially cigarette smoke.
- Allergens - exacerbations may occur seasonally around pollen exposure or following exposure to animals such as cats, dogs or horses.
- Time of day - there is a natural dip in peak flow overnight and in a vulnerable person this may precipitate or aggravate symptoms. It may cause nocturnal waking or simply being rather short of breath or wheezy in the morning.
Protective factors against asthma:
- Breast-feeding
- Vaginal birth - observational studies suggest that caesarean delivery might be associated with a greater risk of asthma
- Increasing sibship.
- Farming environment
Symptoms of asthma:
More than one of the following symptoms:
-wheeze, breathlessness, chest tightness and cough,
Particularly if:
- Symptoms are worse at night and in the early morning.
- Symptoms are present in response to exercise, allergen exposure and cold air.
- Symptoms are present after taking aspirin or beta-blockers.
- History or family history of atopic childhood eczema/hay fever.
- Otherwise unexplained low forced expiratory volume in one second (FEV1) or peak expiratory flow (historical or serial readings).
Differentials in a child with asthma symptoms:
- Bronchiolitis - be aware of the dangers of making a definitive diagnosis of asthma in a very young child.
- Especially if the problem appears to have been present since birth, consider cystic fibrosis. It may also cause severe infections and a persistent cough.
- Other congenital problems may present from birth or early in infancy - eg, laryngeal or tracheal structural abnormalities, congenital heart disease.
- Vomiting and aspiration in babies suggests gastro-oesophageal reflux which can cause a cough on lying down.
- Inhalation of a foreign body can occur at all ages. Things tend to go down the right main bronchus and cause considerable inflammation, and obstruct the right lower lobe.
- Postnasal drip causes a cough, which is worse at night.
- Inspiratory stridor and wheeze suggest a laryngeal disorder including croup
Investigation in ?asthma:
- Measurement of peak expiratory flow rate (PEFR) is the simplest and most basic test. A peak flow meter can be sent home with the child with a diary to take a reading both morning and night for a few weeks. This is good to determine lung function between wheezy episodes.
- Spirometry is now preferred over peak flow measurement for initial confirmation of obstruction of airways in the diagnosis of asthma, as it is felt to offer clearer identification of airway obstruction, to be less effort-dependent and more repeatable. Spirometry measures the whole volume that may be expelled in one breath (vital capacity). It also permits calculation of the percentage exhaled in the first second - the FEV1. However, as with peak flow, some (particularly young children) may not be able to undertake it reliably, so it’s better for older kids.
Lung function tests, whether peak flow or spirometry, are unreliable below the age of 5 years.
Things to ask in an asthma history:
- History of recurrent episodes (attacks) of symptoms, ideally corroborated by variable peak flow when symptomatic and asymptomatic.
- Symptoms of wheeze, cough, breathlessness and chest tightness that vary over time.
- Recorded observation of wheeze heard by a healthcare professional.
- Personal/family history of other atopic conditions (particularly atopic eczema/dermatitis, allergic rhinitis).
- No symptoms/signs to suggest alternative diagnoses.
Differentials in a child with asthma symptoms:
Structural abnormalities eg vascular ring. laryngeal abnormality congenital heart disease bronchopulmonary dysplasia cystic fibrosis ciliary dyskinesia gastro-oesophageal reflux disease (GORD) foreign body Bronchiectasis recurrent aspiration immunodeficiency developmental anomaly post-infection TB
- Bronchiolitis - be aware of the dangers of making a definitive diagnosis of asthma in a very young child.
- Especially if the problem appears to have been present since birth, consider cystic fibrosis. It may also cause severe infections and a persistent cough.
- Other congenital problems may present from birth or early in infancy - eg, laryngeal or tracheal structural abnormalities, congenital heart disease.
- Vomiting and aspiration in babies suggests gastro-oesophageal reflux which can cause a cough on lying down.
- Inhalation of a foreign body can occur at all ages. Things tend to go down the right main bronchus and cause considerable inflammation, and obstruct the right lower lobe.
- Postnasal drip causes a cough, which is worse at night.
- Inspiratory stridor and wheeze suggest a laryngeal disorder including croup
