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Viral croup and epiglottitis are two major inflammatory causes of airway obstruction in children. Two conditions, spasmodic croup and membranous laryngotracheobronchitis, are also frequent causes of obstruction on an inflammatory basis. Rapid diagnosis and effective management are required to ensure an uncomplicated outcome. The pharmacologic treatment, role and timing of endoscopy, and airway management principles are discussed.

Common causes of acute laryngotracheobronchitis (LTB) are viral infections. More rarely, bacterial germs, unspecific irritants, foreign bodies, rachitic laryngospasm, mild malformation, tumours, C1 esterase inhibitor deficiency, bilateral vocal cord paralysis, and psychogenic laryngospasm may be responsible for croup. Symptoms similar to epiglottitis may occur in pharyngitis based on common bacterial tonsillitis or infectious mononucleosis and peritonsillar abscess. It is decisively important to establish a precise diagnosis to provide for an appropriate therapy. Viral croup of mild degree is often sufficiently treated by cold and moistened air and--if necessary--prednisolone. In serious disease, oxygen insufflation and adrenaline (epinephrine) are useful. Recurrent croup is due to an unspecific hyperreactivity of tracheobronchial mucosa. It often leads to asthma. Consequently, preventive measures have to be considered similar to patients with bronchial hyperreactivity. Vaccination with haemophilus influenzae type b vaccine has proved effective and safe. The disease has therefore become impressively less frequent.

Viral croup is the most common form of upper airway obstruction in children 6 months to 6 years of age. It typically presents in the late fall or early winter, is often preceded by an upper respiratory infection, and is characterized by a low-grade fever, barking cough, and inspiratory stridor. Diagnosis is made on clinical grounds with no specific confirmatory test. The differential diagnosis of croup, including epiglottitis and retropharyngeal abscess, must always be considered in evaluating children with inspiratory stridor. Three therapeutic modalities are available for the treatment of croup: humidified air, racemic epinephrine, and adrenal corticosteroids. Maintaining at least 50% relative humidity in the child's room is recommended. If there is evidence of hypoxemia, a mist tent with supplemental oxygen may be helpful. Racemic epinephrine administered by nebulizer can quickly reverse airway obstruction in children with croup. The patient needs to be monitored for rebound airway obstruction for at least 2 hours after administration. The mainstay of treatment for severe croup is dexamethasone, administered 0.6 mg/kg, intramuscularly (IM). Dexamethasone is effective at decreasing the obstructive symptoms of croup, but its onset of action is approximately 6 hours after administration. Therefore, administration of racemic epinephrine is often helpful until the steroids begin to take effect. The correct dosage of dexamethasone is important, as lower steroid dosages have proven to be ineffective in treating croup. Dexamethasone IM, or an equivalent dose of oral prednisone, may be considered in children with moderately severe croup who do not require hospitalization.

Children with bacterial tracheitis present with the symptoms of viral laryngotracheobronchitis or epiglottitis, but do not respond to appropriate therapy for these diseases and frequently develop acute respiratory decompensation. Since the treatment and outcome of bacterial tracheitis differ so much from those of viral laryngotracheobronchitis and epiglottitis, prompt and accurate diagnosis is essential. The aim of this study was to evaluate the significance of different diagnostic characteristics in a group of eleven patients and to compare the results to those recently reported in the pediatric and otorhinolaryngologic literature. The present study suggests that reliable predictive factors do not exist for bacterial tracheitis. No single clinical, radiological or laboratory feature was a reliable diagnostic predictor for bacterial tracheitis, nor was it any combination of these features. The only diagnostic procedure to distinguish bacterial tracheitis accurately and promptly from other forms of acute obstructive upper airway diseases was direct laryngo-tracheo-bronchoscopy. Following endoscopic removal of all tracheal secretions and pulmonary toilet, nasotracheal intubation provides sufficient airway maintenance and obviates the need for tracheostomy. Endoscopy is thus diagnostic and therapeutic at the same time. If bacterial tracheitis is suspected a direct laryngoscopy and rigid tracheobronchoscopy should be performed under general anesthesia, as prompt diagnosis and adequate treatment are essential to survival. The cultures of the purulent tracheal secretions frequently revealed Staphylococcus aureus in combination with various pathogens, particularly the involvement of Pseudomonas aeruginosa was noted in two patients. Our data imply a susceptibility of children with Down's syndrome or immunodeficiency to bacterial tracheitis.

Background: Croup normally is characterized by acute onset and a self limited course of only few days. In 1990 and 1991 at the University Children's Hospital Freiburg an unexpected high number of patients were hospitalized for prolonged Croup syndrome. Expanded microbiological investigations were used to uncover etiologic factors., Methods: Of a total of 138 inpatients with Croup 60 (17 in their first year of life, 21 in the second year of life and 22 infants older than 2 years) had bacteriological (37 nasopharyngeal-, 4 tracheal-aspirates or 19 throat swabs), and virological (antigen detection in nasopharyngeal aspirates, n = 28) tests. Of these patients 48% were hospitalized longer than 3 days (mean 4,7; range 1-18 days)., Results: Bacteria found: B. catarrhalis 24/11 (total/pure-culture), S. pneumoniae 15/6, H. influenzae 10/3, S. group A 5/4 and S. aureus 4/1. Sixteen specimen yielded more than one pathogen, one specimen was sterile. Nasopharyngeal secretions had the most reliable results: Pure cultures (72%) and associations of two pathogens (87%) were found in these aspirates, and only 26% of the unspecific mixed findings (p < 0.005; chi 2-Test). Of the patients hospitalized longer than 3 days 27.6% had positive cultures for H. influenzae, whereas only 6.5% of those hospitalized shorter (p < 0.05; chi 2-Test). The only microorganism with an age-bound distribution was B. catarrhalis found predominantly (54.2%) in the 2nd year of life, with 62% of patients positive (p < 0.05; chi 2-Test). Virus found: RSV (n = 3), Parainfluenza 2 (1) and Parainfluenza 3 (1)., Conclusions: Nasopharyngeal aspirate is the most reliable specimen for a bacteriologic diagnosis in Croup. In the second year of life B. catarrhalis is present in most Croup cases, and H. influenzae was associated with a prolonged course of the disease. An appropriate antibiotic therapy therefore must cover these two pathogens.

Viral croup as the most frequent of laryngeal obstructions in childhood appears in the form of spasmodic croup and acute laryngotracheitis. The evaluation of the severity of laryngeal obstruction can be made by using score systems. In more severe forms of viral croup the inhalation of 0.25 ml/kg 2.25% epinehrine and a single dose dexamethasone 0.6 mg/kg i.m. is recommended.

The objective of this study was to audit the management of acute laryngo-tracheo-bronchitis in a paediatric unit. This was achieved by retrospective case note audit and a review of the investigations and management of all admitted patients in light of the current literature. There was inappropriate use of radiography and outmoded therapies. There has been an increasing use of adrenaline and steroids in the past 4 years. Prescribing of adrenaline was lax and was associated with potential danger to the patient. For a common condition such as croup, an agreed protocol taking into account current published recommendations is warranted and has been introduced into this unit following this audit.

Croup is a common childhood disease that has no specific diagnostic test. It must be differentiated from life-threatening diseases, such as epiglottitis, that demand specific interventions. A high degree of toxicity, the presence of dysphagia and the absence of cough help distinguish epiglottitis from croup. The usefulness and safety of visualization of the epiglottis in patients with croup are controversial. Clinical recognition of respiratory distress and failure is vital. Hypoxia is common. Pulse oximetry is helpful in the assessment of hypoxia, but readings do not correlate with clinical status or respiratory failure. Although studies have not proved that mist therapy is beneficial, the efficacy of racemic epinephrine is well documented. High dose corticosteroids have proved effective in the treatment of croup. Outpatient use of racemic epinephrine and steroids remains controversial.

The management of croup relies upon the traditional clinical skills of observation and examination. Parental involvement is essential and the appropriate reassurance of the patient is important. Endotracheal intubation is required only in a small percentage of children whose airway is compromised to such a degree as to produce fatigue and/or near occlusion.

A retrospective analysis was completed of the charts of the 1,727 patients with the diagnosis of croup seen during two years (1985 and 1986) in the Emergency Department of The Hospital for Sick Children in Toronto. Cough (91.4%) was the most common presenting symptom. Other presenting signs and symptoms included stridor (57.5%), chest wall retraction (38%), coryza and wheezing (18.5%) and tracheal tug (15%). The majority of patients were treated on an ambulatory basis while 377 (21.7%) were admitted for further management. Inpatient treatment included racemic epinephrine (120 patients) and parenteral steroids (17). Twelve (12) patients required airway support (endotracheal intubation). No tracheotomy for tracheitis was performed during this two year period. No deaths occurred in this patient population.

This is a retrospective study of 500 cases of hospitalized patients with the diagnosis of croup (laryngotrachitis), admitted between January 1986 and August 1988, at the Montreal Children's Hospital. The patient's age, sex, clinical history, physical examination, number of admissions, season of admission, method of diagnosis, treatment and management were reviewed. Two per cent of these patients were diagnosed as bacterial croup. All of them required intubation and endoscopic evaluation in their management. Of all the viral croup patients, less than one-third were severe enough to require an intensive care setting for their management. In these patients, 6% required endotracheal intubation, and on endoscopy, a significant number of these patients had an endoscopic airway abnormality in addition to croup (subglottic edema). According to our findings, we suggest diagnostic micro-laryngoscopy and bronchoscopy be performed on certain groups of croup patients because of their higher yield of airway abnormality on endoscopy.

Although viral croup is usually a self-limiting disease, its signs and symptoms are distressing enough to make parents seek immediate medical advice. This is fortunate because a much more serious disorder may be present. Indeed, morbidity requiring hospitalization may occur, as may a true emergency. Drs Thomsen and Edmonds discuss the epidemiology and current management of croup and related conditions.

Serious bacterial infections occurred in ten children (1.4%) of 710 patients with croup admitted to the Soroka Medical Center during the years 1983-1989. Sixty-four patients (9% of all croup patients) were admitted to the pediatric intensive care unit (PICU), and 13 of them (20%) required intubation. Bacterial infections were noted in nine of the 13 intubated patients, in none of the other 51 PICU patients who did not require intubation and in one of the 646 patients (0.2%) who were not admitted to the PICU (p less than 0.0001). There was no difference in age, ethnic origin, or body temperature on arrival between the two PICU groups. Causative microorganisms were isolated from blood samples (three cases) and tracheal pus (eight cases). All intubated PICU patients were seriously ill: eight had bacterial tracheitis and one supraglottitis. Patients with bacterial tracheitis required frequent suctioning of the trachea for copious purulent secretions. The single patient with bacterial infection who was not admitted to the PICU had transient bacteremia. We conclude that the need for intubation in croup patients was an indicator for the presence of a serious bacterial infection.

The exact diagnosis of pharyngitis remains a problem despite the advent of rapid streptococcal screening. An apparent resurgence of rheumatic fever outbreaks makes it more important to attempt to accurately diagnose pharyngitis. Positive identification of streptococci should be followed by treatment with penicillin, or erythromycin in the patient with penicillin allergy. The patient without positive identification of streptococci will need either observation or further evaluation depending on the degree of illness. Classic croup or laryngotracheobronchitis is a clinical entity that can be diagnosed with reasonable confidence. The few patients that require hospitalization can be treated with humidity, racemic epinephrine, corticosteroids, parental and child support, or any combination of these with good results. Continued observation of all patients with croup is necessary to recognize the uncommon complication of bacterial tracheitis when it occurs. Epiglottitis has a varied clinical appearance and management according to age groups. Infants show a mixed clinical picture similar to croup, but with more obstruction. The classic epiglottitis with acute airway obstruction is seen in the 3-8-year-old age group. Adults have a less fulminant form of supraglottitis. Infants and children will need artificial airway management in most cases, whereas many adults can be treated simply with observation.

From January 1980 to December 1987, seven patients with acute inflammatory swelling of the subglottic space were treated. Their ages ranged from 25 to 73 years. Medical history and symptomatology are similar to those characteristic of laryngotracheobronchitis (croup) in the pediatric age groups (i.e., an antecedent common cold followed by a barking cough and varying symptoms of upper airway obstruction). Physical findings before and after treatment were confirmed and documented by anteroposterior radiographs of the neck. Three patients required airway intervention but there were no deaths. To our knowledge there are no previous reports in the English literature describing this entity in adults. The purpose of this presentation was to introduce physicians, in general, and otolaryngologists, in particular, to this potentially serious infection. Our limited experience suggests that the pathogenesis and management of croup in adults are very similar to those in children.

Between January 1983 and July 1988, 2623 patients with croup were admitted to the Royal Children's Hospital, Melbourne. A total of 416 patients (16%) were admitted to the Intensive Care Unit and 176 of these patients required intubation. Of these patients 117 patients were successfully extubated at the first attempt and 59 needed reintubation. Of the patients who were reintubated 35 were given steroids prior to subsequent extubation attempts. Only one patient who had received steroids failed extubation. Of those who did not receive steroids 59% required reintubation. In patients with croup who fail the first extubation the results of this study suggest that steroids significantly increase the success of subsequent extubations.

We retrospectively review 893 cases of children, occurred in epidemic bout in September-October 1987, in order to study the usual management of his pathology in our hospital. In most cases (82.3%) diagnose was laryngitis or acute laryngitis without specification acute laryngotracheitis or spasmodic group. Epiglottitis was no detected in any case. Complementary tests were performed only in 5% of the patients, but they were of little help for the diagnose. Treatment applied was ambiental hummidiffication (95.5%), followed by water and alcohol impregned neck collar (87.2%), rectal magnesium-sulfate + papaverine (67.5%), epinephrine nebulization (63%), antibiotics (44.3%), steroids (9%), bronchodilatadors (4.8%). This therapeutic approach is discussed.

In the 6-year period 1980-1985 162 children required tracheostomy during treatment of laryngotracheobronchitis at Red Cross War Memorial Children's Hospital, Cape Town. This represents 4.6% of 3,500 children with this disorder and 28% of those requiring airway intervention. Fifty-eight percent of the children were decannulated within 4 weeks and 75% within 10 weeks. Fifty-four per cent of the children required one or more further procedures before decannulation, including 7 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 24 children and suprastomal collapse was a cause of decannulation failure in 29 children. Use of an expiratory valve as an aid to decannulation is discussed. Three children died of tracheostomy airway complications and 6 of a medical disorder. Another complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration.

Results of a recently published study over a test period of 18 years showed no relationship between croup incidence of hospitalized children and SO2 levels measured in the city of Bochum. In the following study 642 hospitalized children with stenosing laryngotracheitis were examined for a possible time-dependent relationship between croup incidence and NO2, NO- and dust immission levels measured in the city of Bochum (approx. 1000 000 readings). Evaluation of a 6-year period yielded a decrease of croup patients for the lower NO2 concentration range and a statistical increase of croup cases during days with higher NO2 concentrations. However no cause-effect relationship between both variables can be established because other determinants like infections, temperature, weather change influences, in door pollution etc., could not be excluded. Evaluation of NO levels over 3 years and dust levels over a test period of 1 year showed no statistical relationship with corresponding croup incidence.

The reliability of "leak" as a criterion for elective extubation of children with croup treated with nasotracheal intubation was studied during the three month "croup epidemic" in Ontario of September 1, 1983 to November 30, 1983. Twenty-eight patients experienced 36 extubations; 31 planned and five accidental. Three of 23 (13 per cent) planned extubations with "leak" required reintubation whereas three of eight (38 per cent) children electively extubated after seven days of intubation without "leak" required reintubation. "Leak" is a helpful but not absolute prognostic indicator of a successful extubation.

The domiciliary management of a four-year-old with suspected croup is difficult. The differential diagnosis ranges from relatively benign viral illnesses to acute epiglottitis and even diphtheria. Complete obstruction can occur with little warning, and the social situation may further complicate arrangements. As it is not possible to admit every patient with such symptoms, clinical judgement is vitally important.

Over a four year period of 2,567 croup admissions, 65 required secondary airway support, 45 were intubated, and 30 underwent tracheotomy. The median duration of nasotracheal intubation was six days and of tracheotomy 11 days. The overall morbidity was less for nasotracheal intubation but tubal obstruction resulted in the death of one patient in this group.

Twelve heartworm-free mongrel dogs (10 males, 2 females) mean weight 22.2 kg (range 17.7--28.2 kg) were sedated and placed in a supine position with the neck extended. A double tracheotomy was performed under sterile conditions. The first tracheotomy tube was inserted 2 cm above the sternum in the direction of the carina using a shortened Silastic American tracheotomy tube (id 10 mm); the second was inserted two cartilage rings proximal to the first and approximately 5 cm distal to the larynx. All animals were kept deeply anesthesized by repeated iv injections of 3--6 mg/kg pentobarbitone sodium so that all reflexes (in particular laryngeal and palatal) were abolished. After control translaryngeal pressure measurements were obtained, the vocal cords were visualized, and steam was introduced onto the through the cords for a mean of 10 sec from above. For 2 hr after this, repeat pressure measurements, as described above, were made. After an overnight stabilizing period, two to three of five randomly chosen air environments were passed over the larynx at 10 liters/min via the proximal tracheotomy, and four half-hourly pressure measurements taken with control periods of at least 2 hr, as described above, separating each experiment. Environments utilized were as follows: i) "cold dry" air, i.e., air at a mean temperature of 9 degrees, obtained by passing compressed air through a coil placed in a solution of alcohol/Dry Ice; ii) "cold moist" air, i.e., air as above, subsequently passed over cold water at a mean temperature of 11 degrees; iii) "warm dry" air, i.e., air at a mean temperature of 36.5 degrees, obtained by passing compressed air through a copper coil, immersed in hot water; iv) "warm moist" air at a mean temperature of 36 degrees, obtained by passing compressed air through a heated Puritan humidifier; v) "ultrasonically produced mist" at room temperature (24 degrees), produced by a De Vilbiss ultrasonic nebulizer 900, set at maximum output. Six 2-hr experimental periods were utilized for each regimen of treatment (i--v). The mean of the combined experimental resistance calculations for each environment were compared statistically with those of its similarly acquired control data, expressed as a positive or negative percentage change, and displayed as a histogram. In addition, the data from each experimental environment were compared with the others, and mean percentage changes from control against time were calculated. Results indicate no statistically significant change in resistance from control for ultrasonic mist or warm moist treatment regimens. Warm dry, cold dry, and cold moist treatments, however, all produced significant reductions in translaryngeal resistance (74%, 60%, and 54%, respectively), there being no difference between cold dry and cold moist and warm dry and cold dry. Significant differences between warm dry and cold moist treatments were obtained, the former decreasing translaryngeal resistance the greatest amount...

The case histories of 50 children who required tracheal intubation for epiglottitis or croup in two English regions have been reviewed. The incidence of severe croup was different in the two regions. The presentation of epiglottitis was variable, and the correct diagnosis was frequently made only at laryngoscopy. Unexpected and rapid deterioration occurred in both diseases, and cyanosis was commonly present on hospital admission and at laryngoscopy. Two children required planned tracheostomy and there were two deaths. The principles of safe management are discussed.

Laryngotracheobronchitis (LTB) continues to occur in epidemics necessitating many hospital admissions. A short barking cough, stridor with a crowing sound on inspiration, and retractions of the intercostal respiratory muscles are hallmarks of the disease. LTB is most frequently a viral disease causing acute inflammation of the subglottic area, the trachea, and the segmental bronchus. Increasing subglottic edema and generalized fatigue of patients with this disease can cause progression of airway obstruction. Respiratory and cardiac arrest follow unless an immediate airway is established. The management of LTB is primarily medical and consists of moist air, sedation, close observation, and occasionally antibiotics. Patients with respiratory difficulties severe enough to require intubation should undergo direct laryngoscopy and bronchoscopy to rule out other causes of airway obstruction.

Croup is a syndrome of inspiratory stridor, cough, and hoarseness, due to varying degrees of laryngeal obstruction. It is a viral disease and must be differentiated from epiglottitis. In addition to a careful clinical assessment, neck films are the most valuable diagnostic tool in differentiating these two. The principle modes of therapy for croup include provision of adequate hydration, ensuring maximum available humidification, sedation, and administration of intermittent positive pressure breathing (IPPB) with nebulized racemic epinephrine. The latter mode of therapy will provide symptomatic relief and may eliminate the need for hospitalization and tracheostomy. Steroids offer little benefit in treating this disease, and antibiotics offer none.

Croup and epiglottitis continue to be potentially life-threatening diseases in children. Early distinction is imperative as definitive treatment differs significantly. To determine the correlation of various clinical features, x-rays, and laboratory tests with diagnosis and management planning, a retrospective chart analysis of 194 children with croup (N = 169) and epiglottitis (N = 25) was performed. The clinical history and physical findings were most important in differential diagnosis. Patient age, lateral neck x-ray, and white blood count (WBC) strongly correlated with diagnosis. Counter immunoelectrophoresis (CIE) results did not alter therapy. No blood cultures were positive unless the patient had: WBC over 15,000 with more than 10 stabs, WBC over 20,000, or WBC with more than 20 stabs. Ampicillin resistant H. influenzae occurred in 21% of positive blood cultures. Capillary blood gases did not correlate with clinical need for intubation. It is suggested that a selective evaluation of patients with epiglottitis and croup can be performed in a more cost-effective manner without sacrifice in patient care.

A systematic and expeditious approach to the emergency in the pediatric patient requires strict attention to prioritization of activities, assessment, and treatment. Only then can the clinician approach the patient with competency while maintaining sensitivity toward the unique needs of children.

We have reviewed 43 cases of severe croup admitted from 1977 to 1981 at North Carolina Memorial Hospital. All patients were treated with mist, 23 (54%) of 43 were treated with racemic epinephrine, but only 7 (16%) of 43 were treated with steroids. None of the 5 patients who required intubation received steroids. Nine (36%) of 25 patients available for at least 6 months of follow-up had subsequent clinical diagnoses of asthma. We have concluded that: 1. males with subglottic narrowing on x-ray, high leukocyte counts, and no steroid treatment appear to have increased need for airway support; 2. while humidification and racemic epinephrine are accepted forms of treatment, steroids are still rarely used even in severe croup; 3. severe croup may be a signal for the later development of asthma. Because it is difficult to predict which patients with severe croup will need later airway management, we strongly recommend that all patients with croup requiring racemic epinephrine be treated with at least a single dose of 1.0 to 1.5 mg/kg of dexamethasone.

Toxic patterns of diphtheria of the fauces in adults are characterized by laryngeal lesions which considerably deteriorate the disease prognosis. The clinical manifestations of diphtheric croup may be unpronounced in such cases and be masked by other severe disease symptoms. If patients with toxic diphtheria develop croup, the necessity of surgical treatment arises at earlier times as compared with cases of isolated croup.