1. By Duangruethai Tunprom, MD. 3 rd years emergency medical resident, PMK hospital

7. Comparison of adult and pediatric airways

8. Comparison of adult and pediatric airways

11. Cause of stridor Feature Supraglottic Glottic Subglottic trachea Sound Sonorous Biphasic stridor High pitched stridor Gurgling Inspiratory stridor Coarse Expiratory stridor Structures Nose Larynx Subglottic trachea Pharynx Vocal cord Epiglottis

12. Cause of stridor Feature Supraglottic Glottic Subglottic trachea Congenital Micrognathia Laryngomalacia Subglottic stenosis Pierre Robin syndrome Vacal cord paralysis Tracheomalacia Treacher Collins syndrome Laryngeal web Tracheal stenosis Macroglossia Laryngocele Vascular ring Down syndrome Hemangioma cyst Storage disease Choanal atresia Lingual thyroid Thyroglossal cyst Acquired Adenopathy Papillomas Croup Tonsillar hypertrophy Foreign body Bacterial tracheitis Foreign body Subglottic stenosis Pharyngeal abscess Foreign body Epiglottitis

17. Comparison of infectious upper airway emergencies Average age Common etiology medication Croup 6 mo-6 yrs Parainfluenzae Dexa ±racemic epinephrine Bacterial tracheitis 4-6 yrs S.aueus Antibiotic IV Retropharyngeal abscess 3 yrs GABHS, S.aueus,anaerobe Antibiotic IV Peritonsillar abscess Adolescence GABHS Antibiotic PO & IV Epiglottitis 2-8 yrs H.influenzae, Staphylococi, Streptococus species Antibiotic IV

18. Comparison of Croup,Epiglottitis & Bacterial Tracheitis Croup Epiglotitis Bacterial trachea Peak age 6 mo-3 years 3-7 years 3-5 years Pathogen Subglottic inflammation Inflammation & edema epiglottis, aryepiglottic folds Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea Organism Parainflueazae, RSV,adenovirus Haemophilus influenzae, Strep sp, Staphylococcus aureus Staphyloccus aureus or mixed flora Clinical Feature Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor Rapid progression of high fever, toxicity, drooling, stridor Several-day prodome of crouplike illness progressing to toxicity, inspiratory/expiratory stridor, marked distress Lab & film Steeple sign on film neck PA veiw or normal Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds,loss of air in varecula Normal upper airway structures, shaggy tracheal air column Management Steriod uncommon Aerosolized epinephrine Intubation, abtibiotics Intubation (70 %) antibiotics rare

25. Film lateral neck : show retropharyngeal abscess

26. Retropharyngeal abscess ( cont. )

29. Normal epiglottis contrasted with thickness epiglottis Thumbprint sign

36. Croup score

39. CPG croup ชมรมโรคระบบหายใจและเวชบำบัดวิกฤตในเด็กแห่งประเทศไทย ราชวิทยากุมารแพทย์แห่งประเทศไทย

40. Rebound phenomenon of epinephrine 1- 2 hours

43. CXR AP : showing Croup

52. Croup Epiglotitis Bacterial trachea Peak age 6 mo-3 years 3-7 years 3-5 years Pathogen Subglottic inflammation Inflammation & edema epiglottis, aryepiglottic folds Bacterial superinfection with inflammation of tracheal mucosa, copious mucopurulent secretion obstructing the trachea Organism Parainflueazae , RSV,adenovirus Haemophilus influenzae, Strep sp , Staphylococcus aureus Staphyloccus aureus or mixed flora Clinical Feature Onset follow URI prodrome consisting of croupy cough, hoarse voice, low grade fever, inspiratory stridor Rapid progression of high fever, toxicity , drooling , stridor Several-day prodome of crouplike illness progressing to toxicity , inspiratory/expiratory stridor, marked distress Lab & film Steeple sign on film neck PA veiw or normal Thumbprint sign on lateral aspect of neck, thickened aryepiglottic folds , loss of air in varecula Normal upper airway structures , shaggy tracheal air column Management Steriod uncommon Aerosolized epinephrine Intubation, abtibiotics Intubation (70 %) antibiotics rare

53. Pedriatric Dosing For Antibiotics In Upper Airway Infections Dose from children’ hospital of Philadelphia formulary (Pharmacy handbook formulary, Lexi-Comp) PO Dose Amoxicillin/clavulanic acid 90 mg/kg/d divided BID (max 875 mg/dose) Clindamycin 25 mg/kg/d divided BID(max450 mg/dose) IV Dose Amoxicillin/clavulanic acid 100 mg/kg/d divided Q 6 hrs (max 8 g/d) Clindamycin 40 mg/kg/d divided Q 8 hrs (max 2.7 g/d) Cefotaxime 120 mg/kg/d divided Q 8 hrs (max 2g Q 8 hrs) Ceftriaxone 50 mg/kg/d Q 24 hrs (max 2 g/d) Vancomycin 10 mg/kg Q 6 hrs (max 2 g/d) Oxacillin 150 mg/kg/d divided Q 6 hrs (max 8 g/d)