WEEK 3

Question 1

What is the first priority in epiglottitis patients?

Answer 1

Establishment of an artificial airway in the safest place possible (ex: OR)

Question 2

What is the definition of epiglottitis?

Answer 2

(supraglottis)
an acute, severe, life-threatening disease of upper airway.

Question 3

What is the definition of Croup?

Answer 3

An acute viral infection is characterized by barking cough, hoarseness, inspiratory stridor, and varying degrees of respiratory distress. Most common cause of upper airway obstruction in children.

Question 4

What is the definition of RSV?

Answer 4

Viral respiratory tract infection resulting in small airway obstruction symptoms.

Question 5

What is the causative organism for acute bronchiolitis?

Answer 5

RSV

Question 6

What is the etiology of epiglottitis?

Answer 6

-Most common organism causing this is Haemophilus influenzae type B.

-Other pathogens causing this includes: (Group 1, B and C streptococcus, streptococcus pneumoniae, Klebsiella pneumoniae, Candida albicans, Staphylococcus aureus, Haemophilus parainfluenza, Neisseria meningitidis, varicella zoster.

-Direct trauma, and thermal injury can also cause inflammation of the epiglottis.

Question 7

What is the most common organism causing epiglottitis?

Answer 7

Haemophilus influenzae type B

Question 8

What is the most frequent age for epiglottitis patient?

Answer 8

2-7 years old

Question 9

What is the etiology of croup?

Answer 9

-Primarly involves larynx and extend into trachea and bronchi.

-Sex: male to female ratio 2:1

-Age: 6 mo to 3 y.o.
Mean age: 18 months.
-Decrease in incidence after 6 years old (if diagnosis in >6y.o; may suspect anatomic abnormality)

Question 10

What is the most frequent age for CROUP patients?

Answer 10

6 months to 3 years old

Question 11

What is the etiology of RSV?

Answer 11

-Highly contagious in infants 2-6 months old.

-Faily common with avg. population with little to no symptoms present.

Question 12

What is the pathophysiology of EPIGLOTTITIS?

Answer 12

-Invasive H influenzae disease is secondary to a bacteremia.

• Children ingesting hot liquids could also develop symptoms.

-Group A beta-hemolytic streptococcus (GABHS) has been seen increasing (sample size too small for definite change noticed)

Question 13

Where will the bacteremia causing inflammation and edematous from epiglottitis reach?

Answer 13

epiglottis
aryepiglottic folds
false vocal cords
supraglottic structures which will cause narrowing of airway & resp. compromise.
(Insp. airway occlusion happens before total occlusion from supraglottic edema.)

Question 14

What is the pathophysiology of Croup?

Answer 14

-Walls of the larynx and trachea become erythematous and edematous.

-Fibrinous exudate partially occludes the lumen of the trachea.

-Hypoxemia can occur secondary to luminal narrowing and impaired alveolar ventilation and ventilation-perfusion mismatch.

-Hoarseness (barklike cough)

Question 15

What will edema due to CROUP do in young children/ infants cause? What about edema of the vocal cords?

Answer 15

-lead to significant airway compromise such narrowing airway diameter (esp. around cricoid cartilage)
-edema of vocal chores and subglottic larynx = stridor

Question 16

What are the causes of EPIGLOTTITIS?

Answer 16

-Caustic ingestions
-Foreign bodies
-Inhalation injuries
-Angioneurotic edema
-Sidestream exposure to crack cocaine
-Burns from crack cocaine pipe screen filter.

Question 17

What are the causes of CROUP?

Answer 17

-60% cases due to Parainfluenza virus type I.
-Parainfluenza type II, III, and IV.
-Influenza A and B
-Adenovirus
-RSV
-Coxsackivirus A & B
-Echovirus

-Influenza A: found in pt with severe respiratory compromise.

Question 18

What is the most common cause of stridor in febrile child?

Answer 18

CROUP

Question 19

What is the frequency in epiglottitis?

Answer 19

Prevalence has shown a dramatic decline since the HIB vaccine.

From 3.47 cases per 100 000 people (1980)
To 0.63 cases per 100 000 (1990)

Question 20

What is the frequency in croup?

Answer 20

In USA annual peak incidence: 50 per 1000 children new cases at 2 years old.
-Recurrence rate is 5%

Question 21

What time of the year does croup typically take place?

Answer 21

Late fall, early winter

Question 22

What is the mortality/morbidity in epiglottitis?

Answer 22

Mortality: approaching 0
Morbidity: <4%
Diagnosis delay mortality: 9-18%
Management without intubation: 6% mortality rate

Question 23

What is the mortality/morbidity in CROUP?

Answer 23

Mortality: rare
Morbidity: Small
No significant respiratory compromise

Question 24

What are the signs/symptoms for EPIGLOTTITIS?

Answer 24

Classic presentation: fever, sore through, child refuse to eat, over a matter of hours child is unable to tolerate own secretion and drools.

-signs of upper airway obstruction with stridor and varying degree of respiratory compromise. Air hunger, cyanosis.

-older child pptx: prolonged prodome, more subtle findings, neck extended in sniffing / tripod posture

Physical presentation:
-febrile, toxic, anxious

Cough is rare.

Question 25

What are the signs/symptoms for CROUP?

Answer 25

Symptoms: can range from mild to severe with respiratory failure secondary to airway obstruction.

-Prodome, mild upper respiratory infection with coryza, nasal congestion, sore throat, and cough.

-Onset of fever without toxicity.

-Hoarse voice, harsh, brassy, barklike cough follow.

-Resp. stridor typically develops at night.

Physical presentation:
-minimal distress to severe failure due to airway obstruction
-mild wheezing can occur
-more severe: primarily inspiratory stridor at rest with nasal flaring, suprasternal and intercostal retractions. poor air entry. lethargy or agitation due to hypoxemia.

Question 26

What are the signs/symptoms for RSV?

Answer 26

Peak of symptoms takes place: 48-72 hrs.

-Rapid deterioration due to increase need for oxygenation, ventilation and perfusion support.

-Increased WOB
-Cough
-Runny nose
-Fever (100.4+)
-Respiratory distress
-Wheezing
-Head bobbing
-Lethargy
-Difficulty feeding
-Auscultation: diffuse coarse ‘sticky’ rales (Velcro rales) may be accompanied by wheezing.

Question 27

What is a common symptom in young infants with bronchiolitis due to RSV?

Answer 27

Severe apnea

Question 28

What is the diagnosis for EPIGLOTTITIS?

Answer 28

*refer to table 26-1
- Blood culture (>80% are positive caused by H. influenzae) & Epiglottis culture (50% are positive for H. influenzae.) (but only after airway is secured)

• Leukocytosis with left shift is common

Question 29

What is the diagnosis for CROUP?

Answer 29

Viral and bacterial cultures.

-WBC: within range but
lymphocytosis or leukopenia can take place.

-Hypoxemia is observed in severe disease.

-Suspected bacterial superinfection will enable laryngoscope.

Question 30

What is the diagnosis for RSV?

Answer 30

Virus sample such as nasopharyngeal aspirate or nasal lavage.

-Other diagnosis mentionned: clinical diagnosis comes RSV confirmation, clinical HX also considered preceding respiratory symptoms as well.

Question 31

What is the radiology findings in EPIGLOTTITIS?

Answer 31

‘Thumbprint’ (enlarged epiglottis) are classic findings.

-Uncertain cases may include: soft tissue lateral neck on CXR.

(For unstable pt, do not put child in supine position. Supination has reported to lead to respiratory arrest.)

Question 32

What is the radiology findings in CROUP?

Answer 32

Typically unnecessary except if diagnosis is in question.

-When performed findings include:
- subglottic narrowing from soft tissue edema in severe disease.
-Normal cxr in most cases with visible overdistention of hypopharynx during inspiration.
-Anteroposterior view of neck: narrowing of laryngeal air colum 5-10mm below vocal chords (steeple sign) in 50-60% of cases.

Question 33

What is the treatment for EPIGLOTTITIS?

Answer 33

-Establishment of airway is the first priority in tx.
(required for 12-48 hrs. to allow inflamed tissue to shrink in response to therapy.

-TX course is relatively short:
2-day course of ceftriaxone or
5-day course of chloramphenicol.

Question 34

What is the treatment for CROUP?

Answer 34

-Humidification, vasoconstrictors and glucocorticoids.

-Heliox (60-80% helium) mix in order to prevent intubation. Decreases the the force needed to move gas to airways and mechanical work of respiratory muscles.

-Severe respiratory distress or compromise require 100% O2 with ventilation support using bag-valve-mask device.

Most croup has no stridor.

-Cool mist can activate mechanoreceptors in larynx which produce reflex indicating respiratory flow rate.

Methods used for high humidity deliverance:
Croup tents, croupettes, masks, blow-by O2.

Question 35

What is the treatment for RSV?