Croup and epiglottitis

Surgical approach (if required)

• Not primary surgical diseases; surgery is airway rescue and source control if deterioration/obstruction.
• Epiglottitis: ENT may perform airway intervention in theatre (preferred) or ED if crashing.
  • Direct laryngoscopy/bronchoscopy to assess supraglottis; secure airway with small cuffed ETT.
  • Prepare for immediate surgical airway: needle cricothyroidotomy (temporising) and/or tracheostomy (definitive).
  • Drainage of supraglottic abscess if present; cultures; ICU admission.
• Croup: rarely requires operative intervention.
  • If impending respiratory failure: intubation (often in ED/ICU/theatre) with smaller ETT; no routine surgical procedure.

Anaesthetic management (when airway intervention required)

• Type of anaesthesia: usually GA with maintenance of spontaneous ventilation until airway secured (especially epiglottitis).
• Airway device: cuffed ETT preferred; choose smaller size than age-predicted (oedema). Avoid SGA as definitive airway in epiglottitis.
  • Have multiple ETT sizes ready; consider microcuff; check leak/pressures.
• Technique: inhalational induction (sevoflurane) commonly; IV induction only if stable and expert team ready. Avoid paralysis until ability to ventilate confirmed (case-dependent).
  • Topicalisation generally avoided in distressed child; gentle handling; keep child with parent if possible.
• Duration: airway intervention typically short (15–45 min) but expect ICU ventilation 24–72 h depending on severity.
• Analgesia: low–moderate procedural pain; main issue is airway oedema/obstruction rather than pain. Use paracetamol ± small opioid doses if intubated/ventilated.
• Key principle: do not upset the child; avoid repeated airway examinations; prioritise oxygenation and a controlled environment with ENT + senior anaesthetist + ICU.

Definitions and epidemiology

• Croup (viral laryngotracheobronchitis): subglottic inflammation causing inspiratory stridor and barking cough; typically 6 months–3 years; often parainfluenza.
• Epiglottitis (supraglottitis): inflammation of epiglottis and adjacent supraglottic structures causing rapidly progressive airway obstruction; historically Hib, now also Streptococcus (incl. GAS), Staph aureus; can occur in vaccinated children and adults.

Anatomy and pathophysiology (exam-relevant)

• Croup: oedema in the subglottis (narrowest part of paediatric airway is functionally the cricoid/subglottic region). Small reductions in radius markedly increase resistance (Poiseuille).
  • Turbulent flow dominates in upper airway obstruction → work of breathing rises; stridor indicates critical narrowing.
• Epiglottitis: supraglottic oedema; airway obstruction can be sudden and complete; manipulation may precipitate laryngospasm/complete obstruction.
• Paediatric physiology: higher O2 consumption, lower FRC → rapid desaturation during apnoea; obstruction worsens with agitation/crying.

Clinical features and differentiation

• Croup: barking cough, hoarse voice, inspiratory stridor, coryzal prodrome, low-grade fever; symptoms often worse at night.
• Epiglottitis: high fever, severe sore throat, toxic appearance, drooling, dysphagia, muffled “hot potato” voice, tripod position; cough usually absent/minimal; stridor is late and ominous.
• Key discriminator: ability to swallow/secretions.
  • Drooling and refusal to lie flat strongly suggest epiglottitis.
• Consider differentials: foreign body, anaphylaxis/angioedema, bacterial tracheitis, retropharyngeal abscess, peritonsillar abscess, inhalational injury.

Assessment and investigations (what to do / what to avoid)

• Initial approach: ABC with minimal distress; keep child with parent; avoid unnecessary separation; senior help early.
• Croup severity (practical): mild (no stridor at rest), moderate (stridor at rest, recession), severe (marked recession, agitation/lethargy), impending failure (silent chest, cyanosis, reduced consciousness).
• Epiglottitis: do NOT attempt throat examination with tongue depressor in ED; avoid upsetting; secure airway in controlled setting if any concern.
• Imaging: not required for croup; epiglottitis diagnosis is clinical—lateral neck X-ray (“thumb sign”) only if stable and does not delay airway management.
• Blood gases: may be misleading; rising CO2 is a late sign; do not delay treatment to obtain ABG/VBG in a distressed child.

Initial management (ED/ward/ICU) — croup

• General: keep calm, minimal handling, oxygen only if tolerated; treat fever; hydration.
• Steroids: dexamethasone 0.15–0.6 mg/kg PO/IM/IV (local policy) reduces admission and intubation; onset within hours.
• Nebulised adrenaline (epinephrine): for moderate–severe croup; rapid onset, short duration; observe for rebound (typically 2–3 h).
  • If repeated doses required or persistent stridor at rest → senior review, consider ICU.
• Antibiotics: not routine (viral) unless bacterial tracheitis suspected.
• Escalation: exhaustion, hypoxia, hypercapnia, reduced consciousness, poor air entry/silent chest → prepare for intubation and ICU.

Initial management — epiglottitis

• Call for help early: senior anaesthetist, ENT, paeds/ICU; move to theatre/ICU with full difficult airway setup if not crashing.
• Position of comfort; high-flow oxygen if tolerated; keep parent present; avoid cannulation if it causes distress (case-by-case).
• Antibiotics: IV ceftriaxone/cefotaxime (local policy) ± anti-staphylococcal cover if severe/complicated; take cultures once airway secured.
• Steroids: commonly given (e.g., dexamethasone) though evidence variable; may reduce oedema; do not delay airway decisions.
• Do not attempt to visualise epiglottis in ED unless in a controlled environment with immediate ability to secure airway.

Airway strategy and intubation — key FRCA points

• Shared principles: plan A/B/C; full difficult airway trolley; ENT scrubbed with tracheostomy set open; pre-brief roles; prepare for rapid desaturation.
• Maintain spontaneous ventilation until airway secured (especially epiglottitis). Avoid agitation; avoid repeated attempts.
• Induction: sevoflurane in oxygen (± air) titrated; consider gentle CPAP; avoid high flows that distress child; secure IV once deep if not already.
• Laryngoscopy: gentle; use appropriate blade; have videolaryngoscope available but do not persist if view poor; consider rigid bronchoscopy by ENT if needed.
• Tube choice: smaller than age-predicted; cuffed tube acceptable; confirm position with capnography; secure well; consider NG/OG if ventilated.
• If cannot intubate but can ventilate: wake if possible (rare in epiglottitis) or proceed to ENT rigid bronchoscopy/intubation; avoid repeated trauma.
• If cannot ventilate/cannot intubate: immediate front-of-neck access (FONA). In small children, needle cricothyroidotomy is temporising; definitive tracheostomy by ENT.
  • Know local paediatric CICO pathway and equipment (cannula size, oxygenation method, jet ventilation risks).

Post-intubation/ICU care

• Ventilation: lung-protective; humidification; suction carefully; sedation/analgesia to prevent tube displacement.
• Extubation planning: only when leak present around tube and clinical improvement; consider airway endoscopy if concern; extubate in controlled environment with reintubation plan.
• Complications: post-extubation stridor, subglottic stenosis (trauma/oversized tube), VAP, accidental extubation, negative pressure pulmonary oedema.

Adult epiglottitis (often asked as contrast)

• Adults may present less dramatically but can deteriorate; symptoms: severe sore throat, odynophagia, muffled voice, drooling; stridor is late.
• Airway approach: awake fibreoptic intubation may be appropriate in cooperative adult with topicalisation and ENT backup; avoid heavy sedation.
• CT neck may help if stable and diagnosis uncertain (e.g., deep neck space infection), but do not delay securing airway if threatened.