Croup Flashcards
(50 cards)
1
Q
At what ages does Croup typically occur? (TOP)
A
- 6 months to 3 years
2
Q
What season does Croup predominantly occur? (TOP)
A
- Autumn
3
Q
Does croup affect boys or girls more? (CMAJ)
A
- Boys
- M:F 1.4:1
4
Q
What is Croup usually caused by? (TOP)
A
- Parainfluenza virus
5
Q
How can Croup be further classified? (TOP)
A
- Acute laryngotracheobronchitis (included viral prodrome)
- Spasmodic croup (no viral prodrome, can have recurrent episodes)
6
Q
What symptoms commonly precede symptoms of croup? (TOP)
A
- Viral Prodrome (24 – 72 hours prior)
- Non-specific cough
- Rhinorrhea
- Fever
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
8
Q
When does stridor typically occur for Croup? (TOP)
A
- Inspiration (can be biphasic – with expiration – with more severe distress)
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
10
Q
When do symptoms in children typically resolve by? (TOP/CMAJ)
A
- 48 hours in 60%
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%
12
Q
What are resolving Croup symptoms usually followed by? (TOP)
A
- Typical URTI-like symptoms
- Occasionally a secondary bacterial-induced otitis media
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
14
Q
What is the most common and second most common alternative diagnosis to croup? (TOP)
A
- Bacterial tracheitis
- Epiglotitis
15
Q
What is the most frequently isolated bacterial pathogen in bacterial tracheitis? (CMAJ)
A
- Staphylococcus aureus
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
17
Q
How is bacterial tracheitis typically treated? (TOP)
A
- Broad-spectrum IV antibioitics
- Close monitoring
- Intubation and respiratory support frequently required
18
Q
What is epiglottitis primarily caused by? (TOP)
A
- Haemophilus influenza (HIB vaccine)
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
20
Q
What is the most crucial aspect of management for epiglottitis? (TOP)
A
- Intubation (securing the airway)
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
**If epiglottitis or bacterial tracheitis is suspected, what test is contraindicated and why? (TOP)**
* Lateral and AP soft tissue neck film à manipulation of the neck or agitation to the child may precipitate increased airway obstruction
26
**For children with moderate to severe croup, what should be monitored during assessment? (TOP)**
* Pulse oximetry
27
**When should oxygen be administered to children with croup? (TOP)**
* Hypoxia (O2 sat \< 92%)
* Significant respiratory distress
28
**What are the levels of severity for children with croup? (TOP)**
29
**For patients with croup in respiratory distress, what type of oxygen is recommended? (TOP)**
* Blow-by humidified oxygen (administration of oxygen through a plastic hose with the end opening held near the child’s nose and mouth)
30
**Is there any benefit to mist therapy or humidifiers for children with croup? (TOP)**
* No
31
**What is the evidence for mist therapy for croup? (TOP)**
* 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
**Why are mist tents in particular not recommended? (TOP)**
* 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
**What is the evidence for antitussives and decongestants for children with croup? (TOP)**
* No evidence, should NOT be recommended
34
**Is there a benefit for beta-2 agonists for treating croup? (TOP)**
* No (Croup upper airway disease, no physiological basis)
35
**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)**
* 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
**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)**
* 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
**Do patients with croup treated with epinephrine develop a ‘rebound effect’ after 2 hours? (TOP)**
* No
38
**For patients that receive nebulized epinephrine for croup, do they require admission to hospital? (TOP)**
* No – but should NOT be discharged home before 2 hours after treatment
39
**Should repeat doses of epinephrine be used in patients with croup? Why or why not? (TOP)**
* No (one paper reported on a child receiving 3 nebulizations within one hour developed ventricular tachycardia and had a myocardial infarction)
40
**What should all children diagnosed with croup be administered as treatment? (TOP)**
* Dexamethasone (Oral preferred to IM except in very severe croup)
41
**What is the dose of dexamethasone to treat croup? (TOP)**
* 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
**When does clinical improvement begin for croup after treatment with dexamethasone? (TFP)**
* Improvement within 1 to 3 hours
43
**What is the NNT for benefit with dexamethasone for croup symptoms? (TFP)**
* Significant improvement in croup symptoms at 6 hours (NNT = 5)
* Fewer return visits to emergency and/or (re)admissions (NNT = 17)
44
**How long do patients with croup that are treated with dexamethasone have improved symptoms? (TOP)**
* 24 to 48 hours
45
**How long should children with croup receiving corticosteroids be observed before the decision is made whether to admit to hospital? (CMAJ)**
* 4 hours
46
**What are 2 relative contraindications to dexamethasone treatment in patients with croup? (TOP)**
* Known immune deficiency
* Recent exposure to varicella
47
**What % of patients with croup receiving oral dexamethasone vomit? (TOP)**
* \< 5%
48
**When would nebulized budesonide be given for croup? (TOP)**
* Persistent vomiting
* Severe respiratory distress
* Mixed with epinephrine and administered simultaneously (2 mg budenoside nebulized with epinephrine)
49
**Why is budesonide not routinely used to treat croup? (TOP)**
* No more effective than dexamethasone
* More traumatic to administer
* Substantially more expensive
50
**Name 1 indication for admission for croup and 3 relative indications for admission. (TOP)**
* 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
