1 CROUP Diagnostico y ManejoCoordinador: Dr Ramirez Figueroa Ponente: Dr Nelson Baez R4PM ROTACION NEUMOLOGIA PEDIATRICA CENTRO MEDICO NACIONAL SXXI
2 Definiciones Croup Croup ( laringotraqueobronquitis)Obstrucción de la vía aérea subglótica Viral o bacteriana Número 1. Virus Parainfluenza tipo 1 y 2 Otros: VSR, adenovirus, influenza, rinovirus, difteria, metaneumovirus Incidencia/prevalencia Niños de 6 meses a 5 años incidencia 3% niños menores de 6 años otoño- invierno Sexo masculino 1.4x Periodo de incubación 3-6 días
3 Croup Condiciones asociadas Historia de presentaciónFaringitis Parainfluenza tipo 3. bronquiolitis Historia de presentación Pródromos de 2 a 5 días. Fiebre, rinorrea, ronquera Empeora por la noche De duración de 4-7 días Estado general: fiebre, taquicardia, taquipnea, estridor, tos perruna
4 Croup A la auscultación: Diagnósticos diferenciales SibilanciasEstridor inspiratorio Inspiración prolongada Retracción supraesternal y tiros intercostales en los caso severos Diagnósticos diferenciales Epiglotitis aguda. Urgencia pediatrica Traqueitis bacteriana Aspiración de cuerpo extraño Obstrucción nasal en niños menores de 3 meses Otras infecciones: difteria, angina de ludwig, abceso retrofaringeo, hemorragia, ingestión cáusticos, trauma, lesión penetrante de vía aérea, disrupción laringotraqueal
5 Croup Puntos PrácticosFiebre alta, apariencia tóxica, y pobre respuesta a epinefrina sugiere Traqueitis bacteriana Instalación súbita de sintomatología con fiebre alta, ausencia de tos perruna, disfagia, salivación abundante, apariencia ansiosa y posición de olfateo Epiglotitis Otras causas potenciales de estridor. Cuerpo extraño localizado en parte superior de esófago, absceso retrofaríngeo, o angioedema hereditario
6 Croup Puntos PrácticosFalla respiratoria inminente: Cambio en el estado mental Palidez Disminución retracción Disminución de los sonidos respiratorios con disminución del estridor
7 Clasificación Croup Niveles de severidad Condiciones especiales:Leve. Tos ocasional, no estridor audible al descanso, sin retracción supraesternal o tiraje intercostal Moderado. Tos frecuente, estridor fácilmente audible al descanso. TIC y RSE presentes. Sin agitación o diestres Severo. Tos frecuente, estridor inspiratorio marcado – ocasionalmente – estridor espiratorio. Con retracción supraesternal y TIC mayor. Con diestres y agitación Condiciones especiales: tos frecuente, estridor audible al resposo. Retracción de pared esternal, letargo o disminución en el estado de alerta, apariencia – dusky – sin O2
8 Escala Wesley
9 Croup Score 1 2 3 Stridor None Only with agitation Mild at restCroup Severitya Croup Score Croup Score 1 2 3 Stridor None Only with agitation Mild at rest Severe at rest Retraction Mild Moderate Severe Air entry Normal Mild decrease Moderate decrease Marked decrease Color Not applicable Cyanotic Level of consciousness Restless when disturbed Restless when undisturbed Lethargic
10 Croup Severity Score Degree Management 4 Mild Outpatient—mist therapy5–6 Mild to moderate Outpatient if child improves in emergency department after mist, is older than 6 mo, and has a reliable family 7–8 Moderate Admitted—racemic epinephrine ≥9 Severe Admitted—racemic epinephrine, oxygen, intensive care unit aAny one category with score of 3 leads to classification as severe disease. Modified from Taussig LM, et al. Treatment of laryngotracheobronchitis (croup): use of intermittent positive pressure breathing and racemic epinephrine. Am J Dis Child 1975;129:790.
11 Epiglottitis Croup Anatomy Supraglottic Subglottic Etiology Bacterial (formerly H. influenzae) Viral: parainfluenza Age range 3–7 yr, adults 0.5–3 y Onset 6–24 h 24–72 h Toxicity Marked Mild to moderate Drooling Frequent Absent Cough Unusual Hoarseness White blood cell count Leukocytosis Normal
12 Alg. Croup LEVE MODERADO SEVERO MINIMA INTERVENCIÓN DEXAMETASONA VO 0.6 M,G EDUCACIÓN DE LOS FAMILIARES DEXAMETASONA VO 0.6 M,G EDUCACIÓN DE LOS FAMILIARES MEJORIA No DR, o estridor Eduación familiares alta a domicilio Ninguno o mínimos cambios por 4 horas considerar la hospitalización
13 Pronóstico Croup Duración alrededor de 4-7 días< 2% requiere hospitalización 1-2 % de aquellos admitidos requerirá de intubación
14 Croup Consideraciones de HospitalizaciónRecibió esteroide hace más de 4 horas Continua con diestres respiratorio moderado sin agitación o letargo Estridor en reposo Disminución de los movimientos respiratorios
15 Fisiopatologia CROUP Mandell, Bennett, & Dolin: Principles and Practice of Infectious Diseases, 6th ed.
16 NORMALIDAD RADIOGRAFIAFigure Normal anteroposterior radiographic view of the soft tissues of the neck demonstrating the normal shouldering contours of the proximal trachea (white arrows). Many children will show slight angulation of the trachea, which is a normal variant (black arrow). Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
17 Figure Normal lateral soft-tissue radiography of the airway with normal epiglottis (large open arrow) and well-defined vallecula (small open arrow). The black arrow shows the laryngeal ventricle. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
18 Figure 195-3 Narrowed subglottis in viral croup (arrows) in the anteroposterior radiographic view.Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
19 Figure 195-4 Hazy subglottis in the lateral radiographic view (arrows) seen in viral croup.Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
20 Figure Normal child larynx with crisp vocal folds and widely patent subglottis visualized by a rigid rod telescope. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
21 Figure Viral croup with severe vocal fold and subglottic edema as seen with a rigid rod telescope. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
22 Figure Histologic section of a larynx (postmortem) in supraglottitis showing posterior curling of the epiglottic cartilage (arrowheads) and severe inflammatory edema of the lingual surface of the epiglottis (arrows). Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
23 Figure Supraglottitis seen on lateral soft-tissue radiograph with a rounded epiglottis (arrow), thickened aryepiglottic folds (arrowheads), and distention of the hypopharynx. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
24 Figure 195-9 Supraglottitis just after intubation, visualized by a rigid rod telescope.Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
25 Traqueitis BacterianaFigure Bacterial tracheitis in a lateral soft-tissue radiograph with obscured tracheal airway caused by sloughed mucosa (arrows). The epiglottis (arrowhead) is normal. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
26 Figure Bacterial tracheitis with severe glottic and subglottic edema with sloughed mucosa in the lumen. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
27 Figure Retropharyngeal cellulitis and abscess seen on a lateral radiographic view with widened soft tissue in the retropharynx compared with the adjacent vertebral bodies. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
28 Figure Retropharyngeal abscess in a lateral view with gas production within the soft tissues of the retropharynx. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed
29 Figure 30-4 A, Lateral neck radiograph of a 22-month-old boy with bacterial tracheitis caused by Staphylococcus aureus showing subglottic haziness (similar to laryngotracheobronchitis, or croup). B, Endoscopic view of trachea shows mucosal denudation, intraluminal debris, and purulent laryngotracheal secretions.
30 Figure 31.3 Anteroposterior (A) and lateral (B) neck roentgenograms of a 2-year-old child with croupy cough, inspiratory stridor, and fever. The anteroposterior view shows subglottic narrowing in the steeple pattern (arrow) characteristic of laryngotracheobronchitis caused by parainfluenza virus. Lateral view shows ballooning of hypopharynx resulting from laryngeal obstruction.
31 Figure 9-5 Croup. In a child with a “barking” cough, a lateral soft tissue view of the neck (A) demonstrates a markedly ballooned pharynx (Ph). (B) An anteroposterior (AP) view of the neck shows a steeple-shaped trachea (T) (arrows) caused by subglottic edema.
32 A, Thick adherent membranous secretions.Figure Thick tracheal membranes seen on rigid bronchoscopy. The supraglottis was normal. A, Thick adherent membranous secretions. B, The distal tracheobronchial tree is unremarkable. In contrast to croup, tenacious secretions are seen throughout the trachea, and in contrast to bronchitis, the bronchi are not affected. Otolaryngol Head Neck Surg 2004;131:871–876.
33 Fig. 2. Acute epiglottitis with views of the cherry red epiglottis on direct laryngoscopy
34 Figure 9-4 Epiglottitis. A lateral soft tissue view of the neck shows a ballooned pharynx (Ph) with a swollen epiglottis (E) in the shape of a large thumbprint (arrows).
35 FIGURE A 3-year-old girl with epiglottitis has an anxious appearance, assumes the “sniffing” position (B), and prefers to remain sitting (A).
36 FIGURE Appearance of the lateral neck region in a normal child (A and B) and a child with epiglottitis (C and D).
37 Barkin RM, Rosen P: Emergency pediatrics, St Louis, 1999, Mosby