Pediatric Examination and Board Review by Robert Daum, Jason Canel Page A
Authors: Robert Daum, Jason Canel
Ads: Link
treatment is largely symptomatic. Marked improvement in the duration of airway obstruction has been seen with the use of corticosteroids. Parenteral dexamethasone in a dose not exceeding 0.3 mg/kg has been recommended for severe airway obstruction. A single dose of 0.6 mg/kg may be given intramuscularly as an adjunctive therapy in severe croup. Oral dexamethasone in doses of 0.15-0.6 mg/kg lessens the severity, duration of symptoms, and need for hospitalization in patients with less severe croup. Although for many years cold mist has been recommended to treat croup, there is little evidence that this intervention is beneficial.
12. (A) Most cases of presumed viral croup can be managed as outpatients. Hospitalization is reserved for those few that are severely ill.
13. (A) Once a child has received racemic epinephrine, it is important to observe for a period of no less than 6 hours because there may be a rebound increase in airway obstruction and progressive symptoms during this time period.
14. (C) Should symptoms of croup progress to airway obstruction, there will usually be a classic series of signs demonstrated by the patient. Initially, patients with upper airway disease (extrathoracic symptoms) present with inspiratory stridor. As the extrathoracic airway obstruction progresses, both inspiratory and expiratory stridor develop. Finally as the airway narrows critically, stridor becomes quite muffled until there is little air movement at all and no sound. When patients develop biphasic stridor, respiratory failure can be anticipated and the patient should be placed in a monitored setting and aggressively treated, perhaps even intubated.
Physiologically, the airway is divided into 2 portions: an extrathoracic and an intrathoracic portion. Symptoms of airway disease depend on the location of the pathology in the airway. Epiglottitis and croup represent diseases of the extrathoracic airway. Under these conditions, airway symptoms begin on inspiration because the extrathoracic airway narrows on inhalation, whereas the intrathoracic airway will expand with the negative intrathoracic pressure generated with inhalation. Intrathoracic airway pathology, such as a vascular ring or a mediastinal tumor, presents with symptoms on exhalation. That sound heard on exhalation as a result of airway disease is frequently misconstrued as wheezing and treated as asthma when, in fact, the clinician is dealing with expiratory stridor.
Disease that compromises the intrathoracic airway causes expiratory stridor first because the intrathoracic airway is reduced in caliber during exhalation. As airway caliber is reduced to a critical level, regardless of the location, stridor will be present on inspiration and expiration (biphasic stridor) and heralds impending respiratory failure.
S UGGESTED R EADING
Cohen LF. Stridor and upper airway obstruction in children. Pediatr Rev. 2000;21:4-5.
Gallagher PG, Myer CM III. An approach to the diagnosis and treatment of membranous laryngotracheo-bronchitis in infants and children. Pediatr Emerg Med. 1991;7(6):337-334.
Jenkins IA, Saunders M. Infections of the airway. Paediatr Anaesth 2009;19(suppl 1):118-130.
Leipzig B, Oski FA, Cummings CW, et al. A prospective randomized study to determine the efficacy of steroids in treatment of croup. J Pediatr. 1979;94(2):194-196.
Malhotra A, Krilov LR. Viral croup. Pediatr Rev. 2001;22:5-12.
CASE 9: A 6-YEAR-OLD BOY FOUND AT THE BOTTOM OF THE NEIGHBOR’S POOL
A 6-year-old boy is brought to the emergency department by emergency medical services (EMS). He was found at the bottom of his neighbor’s swimming pool and rescued. At the scene, he was without vital signs initially. After 5 minutes of basic life support efforts, he had a cardiac rhythm and a pulse, but he was making no respiratory effort. The child was intubated and placed in a cervical collar.
On physical examination the child is unresponsive. His vital signs are blood pressure 110/56, pulse
12. (A) Most cases of presumed viral croup can be managed as outpatients. Hospitalization is reserved for those few that are severely ill.
13. (A) Once a child has received racemic epinephrine, it is important to observe for a period of no less than 6 hours because there may be a rebound increase in airway obstruction and progressive symptoms during this time period.
14. (C) Should symptoms of croup progress to airway obstruction, there will usually be a classic series of signs demonstrated by the patient. Initially, patients with upper airway disease (extrathoracic symptoms) present with inspiratory stridor. As the extrathoracic airway obstruction progresses, both inspiratory and expiratory stridor develop. Finally as the airway narrows critically, stridor becomes quite muffled until there is little air movement at all and no sound. When patients develop biphasic stridor, respiratory failure can be anticipated and the patient should be placed in a monitored setting and aggressively treated, perhaps even intubated.
Physiologically, the airway is divided into 2 portions: an extrathoracic and an intrathoracic portion. Symptoms of airway disease depend on the location of the pathology in the airway. Epiglottitis and croup represent diseases of the extrathoracic airway. Under these conditions, airway symptoms begin on inspiration because the extrathoracic airway narrows on inhalation, whereas the intrathoracic airway will expand with the negative intrathoracic pressure generated with inhalation. Intrathoracic airway pathology, such as a vascular ring or a mediastinal tumor, presents with symptoms on exhalation. That sound heard on exhalation as a result of airway disease is frequently misconstrued as wheezing and treated as asthma when, in fact, the clinician is dealing with expiratory stridor.
Disease that compromises the intrathoracic airway causes expiratory stridor first because the intrathoracic airway is reduced in caliber during exhalation. As airway caliber is reduced to a critical level, regardless of the location, stridor will be present on inspiration and expiration (biphasic stridor) and heralds impending respiratory failure.
S UGGESTED R EADING
Cohen LF. Stridor and upper airway obstruction in children. Pediatr Rev. 2000;21:4-5.
Gallagher PG, Myer CM III. An approach to the diagnosis and treatment of membranous laryngotracheo-bronchitis in infants and children. Pediatr Emerg Med. 1991;7(6):337-334.
Jenkins IA, Saunders M. Infections of the airway. Paediatr Anaesth 2009;19(suppl 1):118-130.
Leipzig B, Oski FA, Cummings CW, et al. A prospective randomized study to determine the efficacy of steroids in treatment of croup. J Pediatr. 1979;94(2):194-196.
Malhotra A, Krilov LR. Viral croup. Pediatr Rev. 2001;22:5-12.
CASE 9: A 6-YEAR-OLD BOY FOUND AT THE BOTTOM OF THE NEIGHBOR’S POOL
A 6-year-old boy is brought to the emergency department by emergency medical services (EMS). He was found at the bottom of his neighbor’s swimming pool and rescued. At the scene, he was without vital signs initially. After 5 minutes of basic life support efforts, he had a cardiac rhythm and a pulse, but he was making no respiratory effort. The child was intubated and placed in a cervical collar.
On physical examination the child is unresponsive. His vital signs are blood pressure 110/56, pulse
Similar Books
