​Kembara Xtra - Medicine - Croup

​Kembara Xtra - Medicine - Croup 
Introduction 
Croup is an upper respiratory illness that is self-limiting and causes inflammation of the larynx and the subglottic airway. Croup is characterized by a barking cough and inspiratory stridor in its sufferers.
Croup is a respiratory illness that, despite its typically minor symptoms, can result in substantial respiratory difficulty and even death.

Croup is also known as viral laryngotracheitis (LT) or laryngotracheobronchitis (LTB). Both of these terms refer to the same condition. It is a common viral disease that manifests itself with symptoms that are not particular to the upper respiratory tract.
 Croup is characterized by an inflamed and obstructed upper airway, which results in the pathognomonic barking cough and inspiratory stridor; symptoms begin suddenly and are at their worst in the evening and overnight.

Epidemiology (Incidence and Prevalence) The disease most frequently affects children between the ages of 6 months and 3 years old, with the average age of a patient affected being somewhere around 2.5 years old.
Croup can afflict children as young as 3 months old and as elderly as 7 years old, despite the fact that it is quite uncommon.
● Predominant sex: male > female (1.5:1)
Although it is most common in the late fall and the beginning of winter, it can occur at any time of the year.
Incidence

 Is responsible for 1.3% of cases seen in emergency departments
 Although the vast majority of cases are categorized as being mild, between 3 and 7% of cases necessitate hospitalization.
3% of patients require laryngoscopic or airway treatments. 4.4% of patients under the age of 18 were readmitted to the emergency room during the first 48 hours.
Prevalence
Sixty percent of cases of barking cough were cleared within 48 hours, and just two percent of patients had symptoms that persisted for more than five nights.

Pathophysiology
Infection of the larynx and the subglottic region, which results in a constriction of the airway as a result of inflammation and swelling.
Small children have airways that are more narrow, which makes it easier for them to collect edema. The condition known as inspiratory stridor is caused by the drawing in of the airway walls during negative-pressure inspiration.
Typically caused by viruses that initially infect the oropharyngeal mucosa and migrate inferiorly, with the most prevalent culprit being the parainfluenza virus (types 1 to 4), which is responsible for more than 80 percent of cases.
The most typical kind of diabetes is type 1.
Bronchiolitis and pneumonia are two conditions that are associated with type 3 in young infants and toddlers.
Type 4, which is further subdivided into subtypes 4A and 4B, is not well understood but is linked to a less severe sickness than the other types.
Other viruses include respiratory syncytial virus (RSV), paramyxovirus, influenza virus types A or B, adenovirus, rhinovirus, enteroviruses (coxsackie and echo), reovirus, measles virus in areas where immunization is not frequent, and metapneumovirus.
There have been reports of Mycoplasma pneumoniae and Corynebacterium diphtheriae, but these are extremely uncommon.
Genetics
Croup that comes back on its own is one of the symptoms that can be caused by congenital subglottic stenosis, which is a narrowing of the lumen of the cricoid region.

factors of danger 
Prior intubations, premature birth, and age less than three years all raise the risk of recurrent croup, which is defined as more than two episodes in a given year (2).
GENERAL PREVENTION
The croup is contagious and spreads through droplets. Children should be considered contagious up to three days from the onset of their sickness and/or until they have reached the point when they are no longer feverish. There is no vaccine designed specifically to prevent croup; however, vaccination against seasonal influenza may contribute to a reduced risk.

Conditions That Often Occur Together 

There is some evidence to show that being hospitalized for croup may be related with an increased risk of developing asthma in the future.
Host factors or allergic factors should be considered if the condition recurs (has more than two episodes in a year) or occurs within the first 90 days of life.
Underlying anatomic anomaly (for example, subglottic stenosis or paradoxical vocal cord dysfunction) Consider gastroesophageal reflux disease as a diagnostic possibility for patients who experience repeated symptoms of croup.

Croup is a clinical diagnostic; most children present with acute onset of typical "seal-like" barking cough, inspiratory stridor, hoarseness, and chest wall indrawing. The diagnosis is made by clinical observation.
The severity of croup is established by clinical inspection for symptoms of respiratory distress, including nasal flaring, retractions, tripoding, sniffing position, abdominal breathing, and tachypnea. However, the lack of fever should not lessen the suspicion of croup.
Late signs of severity include hypoxia, cyanosis, and weariness; however, these symptoms are infrequent.
It is recommended that SARS-CoV-2 testing be undertaken for patients who exhibit more severe symptoms or who do not show signs of improvement as quickly as was anticipated.

● The Westley Croup Severity Score is the scoring method that is most widely utilized. It considers the following five clinical characteristics, and the scores are as follows: 2 indicates a mild condition; 3–7 indicates a moderate condition; 8–11 indicates severe; and 12 indicates approaching respiratory failure.
- Normal level of consciousness, including sleep, equals 0; level of disorientation, equals 5
– Cyanosis: none equals 0; with agitation equals 4; at rest equals 5 – Stridor: none equals 0; with agitation equals 1; at rest equals 2 – Air entry: normal equals 0; decreased equals 1; considerably decreased equals 2 – Retractions: none equals 0; mild equals 1; moderate equals 2; severe equals 3 HISTORY
Croup is primarily diagnosed through clinical observation and can be recognized by its sudden onset of a barking cough, inspiratory stridor, and hoarseness.

Clinical Exam 

 Tachypnea and tachycardia may be exhibited on the patient's vital signs.
Pulse oximetry readings are typically within normal range when there is no disruption to the normal alveolar gas exchange; but, in more severe situations, oxygen saturation levels may drop.
The patient's breathing sounds and voice are essential to the diagnosis; in most cases, the patient will exhibit hoarseness, stridor, and/or inspiratory wheezing during auscultation. – Wheezing, ronchi, and rales that are significant enough should prompt a search for an alternate diagnosis.
Decreased breath sounds and respiratory effort may be an indication that the child is deteriorating towards respiratory failure and is becoming less able to make an effort to transfer air.


Differential Diagnosis 

 Infection of the Upper Respiratory Tract
A high index of suspicion is required for the diagnosis of foreign body aspiration.
bacterial tracheitis is characterized by a high temperature, a hacking cough, difficulty breathing, and a rapid decline in health.
Dysphonia can be caused by a retropharyngeal or peritonsillar abscess, both of which have a similar septic look.

 An allergic reaction, also known as acute angioneurotic edema, can cause spasmodic croup, which is characterized by typical nighttime worsening.
Epiglottitis: sudden onset, high fever, dysphonia, drooling, and the characteristic posture of leaning forward with the chin extended. The widespread vaccination against Haemophilus influenzae has been replaced by vaccination against strep and staph organisms, which has resulted in a significant decrease in the incidence of epiglottitis. Others: subglottic stenosis, thermal injury/smoke inhalation, hemangioma, airway anomalies (such as tracheo-/laryngomalacia), and other anatomic obstructions including subglottic
The SARS-CoV-2 virus causes symptoms that are more severe, and the body's response to treatment is not as quick as was anticipated.


Results From the Laboratory 

The diagnosis of LTB is made on the basis of clinical symptoms and does not require any additional tests.
It is not necessary to perform blood tests, but if it is, the white blood cell count can be slightly raised with a lymphocyte majority.
– The presence of a leftward shift in the white blood cell count, also known as bandemia, is suggestive of a bacterial etiology (such as epiglottitis, bacterial tracheitis, peritonsillar, and/or retropharyngeal abscess).
Patients for whom the initial treatment is ineffective are the only ones who should be considered for rapid antigen or viral culture testing.
If imaging were to be performed, posteroanterior and lateral neck films would show a funnel-shaped subglottic region with normal epiglottis. This is referred to as the "steeple" or "pencil point" sign, and it is seen in 40–60% of children who have LTB.
– Patients may present with a steeple sign even if they do not have croup, which would justify alternative considerations.
– During imaging, each patient should be observed because there is a possibility of sudden airway obstruction.
● The following observations can be taken into consideration when an alternate diagnosis is being considered:
– Retropharyngeal abscess: a protrusion of the posterior pharyngeal wall – Epiglottitis: a thickened epiglottis, sometimes known as the thumb sign
When the SARS-CoV-2 virus is thought to be the root cause of croup, a polymerase chain reaction test is performed on the mucosa obtained from the nasopharynx.
Initial Tests (lab, imaging)
Radiographic imaging is not typically recommended in this situation. Patients who have a suspected abscess, tumor, or foreign body aspiration may benefit from having a CT of the neck performed (2).
Diagnostic Methods and Other Procedures
Laryngoscopy is an examination that should only be performed in unusual cases or when another diagnosis is thought to be possible (2). To be more specific, patients who are hospitalized but are not being intubated, as well as those who have a history of being intubated but are younger than 36 months old.

The management consists of supportive treatment; depending on the severity of the sickness, additional measurements may be required. The limited experience with COVID-19 croup implies that instances can present with severe pathology and may not resolve as swiftly as with conventional croup. Patients in a recent case study needed more than one dosage of glucocorticosteroids before there was any noticeable change in their clinical condition.


The Standard Procedure 
Treatment that focuses on the symptoms
It is important to keep the child as calm as possible during laboratory tests, imaging scans, and other procedures. Anxiety makes tachypnea worse and may be more harmful than simply accepting a clinical diagnosis.
In cases of hypoxemia or severe respiratory distress, pulse oximetry and oxygen should be administered. Frequent clinical checks may be more sensitive in identifying worsening disease. Heliox is a mixture of helium and oxygen that is used to treat respiratory conditions; it appears to improve airflow resistance by decreasing gas density. However, there is a lack of evidence about its benefits.


First and foremost, medication
Epinephrine in nebulized form with corticosteroid inhalation Corticosteroids: Oral corticosteroids are the treatment of choice for patients with any severity. They provide speedier resolution and reduce the need for hospital admission by reducing the amount of edema that occurs in the laryngeal mucosa.
– Because it only requires a single dose and may be administered in three different ways (intramuscularly, orally, and intravenously), dexamethasone is the corticosteroid of choice. Additionally, it is the steroid with the lowest cost. It is not known what the optimal dosage should be, however 0.60 mg/kg is the range that is most frequently used. – Beneficial effects can be achieved with additional steroids such as betamethasone, budesonide, and prednisolone. In randomized clinical tests that compare prednisolone and dexamethasone, the latter is more typically utilized in the emergency department; however, there is no difference in the two medications' levels of efficacy when administered in the community.
Racemic or L-epinephrine (both have the same levels of efficacy and negative effects). It is only given to patients with moderate to severe instances who have stridor when they are at rest.
– When nebulizing racemic epinephrine in normal saline to a total volume of 3 mL, the recommended dosage is 0.05 mL/kg of a 2.25% solution (maximum of 0.5 mL). Nebulized L-epinephrine is administered at a rate of 0.5 milliliters per kilogram, with a maximum dose of 5 milliliters. The beginning of the effect occurs between 1 and 5 minutes after administration, and it lasts for around 2 hours. Repeat as often as required for as long as the unwanted effects may be endured. After the effects of the epinephrine have worn off, the kid should be monitored for a period of two hours.
Due to the fact that this illness is caused by a virus, antibiotic treatment is not necessary.
● Oxygen as needed
There is no evidence that breathing in humidified air helps patients with mild to severe croup.


Intubation is only required very seldom during surgical procedures; the tube must be between 0.5 and 1.0 millimeters narrower than normal. Intubation may be necessary in cases of exhaustion caused by the effort of breathing or obstruction.

Admission Outpatient care for patients with less severe conditions
After receiving medical treatment, most patients only require observation in the emergency department before being discharged.
Poor response to medication or recurring stridor at repose once epinephrine wears off are admission criteria. Additional reasons for admission include increasing oxygen need, pneumonia, or other serious diseases.

 Criteria for discharge: at least two hours have passed since the patient's most recent dosage of epinephrine; patient has been given a dose of steroids
- Normal air entry, color, and consciousness - No stridor when the patient is at rest and no trouble breathing

Continued Patient Observation and Monitoring
The majority of people who have croup do not need any additional follow-up.
● Cool, watery diet is better tolerated.

 Numerous, infrequent, yet smaller feedings
Croup is a self-limiting and minor condition in most cases; nevertheless, some people will require more intensive hospital care than others.
Refrain from becoming agitated because this can make symptoms worse; dress lightly and use antipyretics as directed. Stay hydrated by drinking drinks, eating ice pops, and the like.
Call an ambulance immediately for cyanosis, lethargy, difficulty breathing, excessive drooling, and an inability to swallow.
Since the early stages of croup infection are communicable, practicing proper hand hygiene is essential during this time.

It's possible that the cough will linger for a few of weeks. The parents of patients diagnosed with croup caused by COVID-19 should be counseled on quarantine protocols.

Prognosis ● Prognosis is good. The comprehensive care of respiratory symptoms is effective for the few cases that are severe. Recurrence is uncommon in diseases that are caused by viruses. If you have chronic croup, you should investigate possible anatomic, allergy, or obstructive causes.


Complications include subglottic stenosis in patients who are intubated; bacterial tracheitis; cardiopulmonary arrest; pneumonia; and subglottic obstruction.