Croup

Laryngotracheobronchitis (yes, that's a long one!) is an overly complex medical term that simply means "a respiratory infection" which in young children is commonly called "Croup." No matter what you like to call it, croup affects children between 1 and 3 years of age. Although it can affect any region of the respiratory tract, it normally presents as inspiratory stridor that is suggestive of an upper airway occlusion caused by swelling. A patient with croup also experiences wheezes and is more than likely suffering from an infection that has spread to the lower airway.  A characteristic cough and various degrees of respiratory distress can be expected in these patients. Croup manifests with a runny nose, a low-grade fever, a barking cough, and hoarseness. Croup's upper respiratory infection may be mild, moderate, or severe. It tends to be worse at night and is most commonly identified by the classic “seal-bark cough”. Many of these children have recently had the flu and/or have experienced croup previously. Nasal flaring, intercostal retractions, and cyanosis are late signs of respiratory insufficiency. Children with severe croup are at risk of serious airway compromise from the narrowed diameter of the trachea.

EMS Croup Management

Good prehospital management of croup includes airway maintenance with the administration of humidified air/oxygen and rapid transport in the position of comfort to an appropriate medical facility. Symptoms may improve dramatically in patients with croup after the child is treated with oxygen.

If your patient is severely hypoxic, racemic Epinephrine may be indicated. Check your local protocol and medical control for direction.

Epiglottitis 

Epiglottitis although rare, is inflammation of the epiglottis due to a bacterial infection. The epiglottis is located in the upper airway. It's that little flap that covers the trachea during swallowing. If this "flap" becomes inflamed, it swells and this swelling could cause a partial or even complete airway occlusion, thus compromising ventilation and if intubation is needed. The inflammation may involve other structures such as the arytenoid, false cords, and posterior tongue. Epiglottitis traditionally affected children 2-5 years of age; however, routine vaccination against the common causative organism or epiglottitis has virtually eradicated this disease.

Epiglottic inflammation occurs quickly and can be deadly if not recognized and dealt with rapidly. A serious fever above 104F (40C) often accompanies this illness along with signs of severe respiratory distress. 

These children will often be found sitting on the edge of their chair, leaning forward and using accessory muscles in an attempt to help move air in and out of their lungs more effectively. Many children with epiglottitis will complain of a severe sore throat especially when they swallow. It is common to witness excessive salivation in children experiencing a sore throat and/or difficulty swallowing (dysphagia). A cough is not usually seen with epiglottitis, mainly due to the upper airway component of the illness. Epiglottitis is a true medical emergency that requires prompt, expert airway management!

These kids sound sick, look sick, and may get even sicker; be prepared!

As always, aggressive airway management, including intubation, may be indicated if the child appears to be experiencing impending respiratory failure.
Signs include:

• Severe hypoxia
• Bradycardia
• Decreasing respiratory effort

History:

If the patient doesn't present with imminent signs and symptoms like the ones mentioned above, it is important to obtain a good medical history from a parent (when possible):

• Does the patient have any known drug allergies?
• Has the child had an upper respiratory infection in the past?
• If they have; did the illness present like this episode?
• It is important to know: was the onset acute or gradual?
  (Epiglottitis generally presents with an acute onset)
• Has the child been sick lately; perhaps with the flu or common cold?
• Is your patient up to date with pediatric vaccinations?
  (Most cases of epiglottitis are caused by Hemophilus influenza for which there is a very effective vaccine)
• Has the child ever been intubated for any reason?
  (This helps identify whether you will need to be aggressive)

Epiglottitis Treatment

Children with acute epiglottitis are in danger of full airway obstruction and respiratory arrest that comes on rapidly and may be caused by minor irritation of the throat. For this reason; gentle handling of a child suspected of having epiglottitis is essential. The following guidelines should be observed when dealing with the potentially fatal illness:

• DO NOT try to lay the patient flat or dictate their position of comfort
• DO NOT visualize the airway if the airway of the child is still adequately ventilating
• Advise the receiving facility of your suspicion of epiglottitis
• Administer 100% humidified oxygen by mask, if tolerated
• DO NOT attempt vascular access (the added stress can be detrimental to the airway)
• Have the proper advanced airway adjuncts ready and at hand
• Intercostal retractions with decreasing stridor are an ominous sign of impending respiratory failure
• Transport the child in a position of comfort with parents nearby
• Decreasing mental status means decreasing respiratory drive; TREAT AGGRESSIVELY!
• If respiratory arrest occurs before arrival at the ED, intubation should be attempted once, rapidly
• If respiratory arrest occurs, then IV/IO access is appropriate after airway control is initiated

Epiglottitis Intubation Tips

The EMS professional should be prepared for a difficult intubation if epiglottitis is suspected because the vocal cords will more than likely be hidden by swollen tissues. The important thing in this situation is to depend on your skills and training to defeat a bad situation. Remember; adapt and overcome! You have what it takes to win the battle!

The following tips may help you conquer a difficult airway:

• Choose an uncuffed ET tube that is 1-2 sizes smaller than the tube you would have normally used for this patient
• Locate the laryngeal opening to the larynx by looking for mucus "bubbles' in the cleft between the edematous folds and the swollen epiglottis
  (chest compressions during glottic visualization may produce bubbles at the tracheal opening)
• Sometimes a patient may be ventilated effectively with a BVM and a tight facial seal. This method requires two skilled rescuers to deliver ventilations
• If the patient can not be intubated, medical control may order a needle cricothyroidotomy
• Don't forget to check out 6 Pack for Success: Intubation Tips and Respiratory Emergencies from JEMS