Transcript Croup and Bronchiolitis

Croup and Bronchiolitis
Karen D. Sawitz, MD
St. Barnabas Hospital
Department of Pediatrics
The Pediatric Airway
Croup - Epidemiology
•
•
•
•
•
•
15% of respiratory visits in children
Most common cause of stridor in children
Primarily 1 to 6 years, mean 18 months
Boys > girls (1.5 to 1)
Peak incidence in US 5 per 100 in 2nd yr
Predominates during fall and winter
Croup - Etiology
•
•
•
•
•
•
Viral-mediated inflammatory condition
AKA laryngotracheitis, laryngotracheobronchitis
Affects vocal cords and subglottic airway
65% due to parainfluenza types 1, 2, 3
Most hospitalized cases are type 1
Others: adenovirus, RSV, varicella, measles,
HSV, enteroviruses, Mycoplasma pneumoniae,
and influenza A and B
• Transmitted by inhalation via nasopharynx
Croup – Clinical Presentation
• Prodrome: rhinorrhea, pharyngitis, low-grade
fever, +/- cough over 12-48 hours
• Gradual development of barking cough,
hoarseness, varying inspiratory stridor +/- fever
• May develop more severe obstruction with
inspiratory stridor at rest, increased HR/RR,
nasal flaring, retractions, progressive hypoxia
and cyanosis
• Symptoms may worsen at night/with crying
• Mild course 3-7 days, more severe 7-14 days
Westley Croup Score
Inspiratory Stridor
• None (0 points)
• When agitated (1 points)
• On/off at rest (2 points)
• Continuous at rest (3 points)
Retractions
• None (0 points)
• Mild (1 points)
• Moderate (2 points)
• Severe (3 points)
Air Movement/Entry
• Normal (0 points)
• Decreased (1 points)
• Moderately decreased (2 points)
• Severely decreased (3 points)
Cyanosis (Color)
• None (0 points)
• Dusky (1 point)
• Cyanotic on room air (2 points)
• Cyanotic with supplemental
oxygen (3 points)
Level of Alertness (Mentation)
• Alert (0 points)
• Restless or anxious (1 points)
• Lethargic/Obtunded (2 points)
<4 Mild
5-6 Mild-Moderate
7-8 Moderate
9-10 Severe
©2008 UpToDate®
Croup – Differential Diagnosis
• Infectious
– Acute epiglottitis
– Bacterial Tracheitis
– Retropharyngeal or peritonsillar abscess
• Noninfectious
– Angioneurotic edema
– Foreign body aspiration
Pediatrics in Review January 2001
Croup - Treatment
• Home Management
– Cool mist or night air
– Steam (vaporizer or from shower)
– Keep child calm
• Primary Care/ER Setting
– Cool mist (may precipitate bronchospasm)
– Steroids: oral or IM dexamethasone 0.6 mg/kg single dose
(half-life 36-52 hours)
– Racemic epinephrine in severe cases: 0.25-0.5 ml in 2.5
ml saline by nebulizer
Croup - Treatment
• Criteria for discharge after Racemic Epi
– Observation for 3-4 hours
– No stridor at rest
– Normal air entry
– Normal color
– Normal level of consciousness
– Have received a dose of dexamethasone
Croup – Indications for Admission
•
•
•
•
•
•
•
Suspected or actual epiglottitis
Cyanosis/hypoxemia/pallor
Stridor at rest or progressive stridor
Respiratory distress
Depressed sensorium
Restlessness
Toxic appearance
Nelson Textbook of Pediatrics 16th Edition 2000
Bronchiolitis - Epidemiology
• Most common lower respiratory tract infection in infants
• Most common etiology is RSV, most cases between December and
March (75% of cases under 2)
• More common in crowded living conditions and smoke exposure
• Breastfeeding appears to confer a protective advantage
• Most severe symptoms in those under 2
• >50% affected by age 1, 80-90% by age 2, 40% have LRTI
• No permanent RSV immunity, reinfections common
• 1-2% require hospitalization
• 90,000 hospitalizations annually (80% under 1 year)
• Deaths 4500 (1985)  510 (1997)  390 (1999)
• Cost of hospitalization infants under 1 year: $700 mil/yr
• More likely to have respiratory problems when older
RSV Spread
•
•
•
•
Humans only source of infection
Direct or close contact with secretions
Large-particle droplets <3 ft or fomites
May persist hours on surfaces or 30
minutes on hands
• Viral shedding 3-8 days or longer
• Incubation period 2-8 days (4-6)
Bronchiolitis – Clinical Features
• Pathophysiology
– Marked inflammation, edema, necrosis of smaller
airway epithelial cells
– Increased mucus production
– Bronchospasm
• Clinical Features
–
–
–
–
–
–
Rhinitis, tachypnea, wheezing, cough, crackles
Accessory muscle use and nasal flaring
Apnea, grunting, cyanosis
Poor feeding, difficulty sleeping, fussiness
Tachycardia and dehydration may occur
Natural course 7-10 days, peak on day 4
Bronchiolitis – Diagnosis & Testing
• Clinical diagnosis on basis of H & P
• Laboratory and radiologic studies should
not routinely be ordered per AAP
• NP swab for RSV ELISA may be used eg
for cohorting
• CXR to exclude other Dx, or if not
improving as expected
• Concurrent SBI is rare, may need to be
ruled out in febrile young infants (UTI)
Bronchiolitis – Risk Factors for
Severe Disease
• Age under 6-12 weeks
• History of prematurity esp < 28 weeks GA
• Underlying cardiopulmonary disease
– Chronic lung disease (BPD, CF)
– Complex congenital heart disease
– Congenital airway abnormalities
• Immunodeficiency
• Severe neuromuscular disease
Bronchiolitis - Management
• Mainstay: supportive care (hydration, oxygenation, nasal
suction, respiratory support if needed)
• No routine bronchodilator use – may improve symptoms
short-term but no effect on length of illness or LOS;
potential for harm (SE, cost)
• No routine corticosteroid use – no benefit in RR, O2 sat,
LOS though given to 60% of inpatients
• No routine use of ribavirin – variable results, may be
appropriate for severely ill infants
• Antibiotics only if indication of concurrent bacterial
infection
Bronchiolitis – Criteria for Admission
•
•
•
•
•
•
Persistent hypoxia
Respiratory distress
Inability to tolerate fluids
Inability to ensure close follow-up
Infants under 2 months of age - consider
Premature infants - consider
RSV Bronchiolitis - Prevention
• Palivizumab (Synagis®) prophylaxis for
selected infants under 24 months
– 15 mg/kg IM monthly November-March
• Hand washing
• Avoiding passive smoke exposure
• Promotion of breastfeeding
Criteria for Passive Immunization
• ≤24 mos old with
– CLD on therapy in 6 mos before start of RSV season
– Hemodynamically significant congenital heart disease
• ≤32 weeks GA even without CLD
– <28 wks GA during first season/≤12 mos at start
– 29-32 wks GA up to 6 mos of age at start of season
• 32-35 wks GA up to 3 mos with ≥1 risk factor:
– Day care attendance or
– Sibling under 5 years of age
• <34 wks GA with airway abn or neuromuscular dz
Source: AAP Red Book 2009
Source: AAP Red Book 2009
Source: AAP Red Book 2009