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Vu JP, Jagannath D, Spielberg DR, Chiou EH, Hosek KE, Lambert EM. Triple endoscopy and recurrent croup in children: A single aerodigestive center experience. Auris Nasus Larynx 2024; 51:125-131. [PMID: 37550113 DOI: 10.1016/j.anl.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/22/2023] [Accepted: 07/19/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE To determine the utility of triple endoscopy (combined direct laryngoscopy, bronchoscopy (DLB), flexible bronchoscopy with bronchoalveolar lavage (FB + BAL), and esophagogastroduodenoscopy (EGD)) in the diagnosis and management of patients with recurrent croup (RC), and to identify predictors of endoscopic findings METHODS: A retrospective chart review was performed of pediatric patients (age <18 years) with RC evaluated by triple endoscopy at a tertiary care pediatric hospital from 2010 to 2021. Data including presenting symptoms, airway findings, BAL and EGD with biopsy findings were collected. RESULTS 42 patients with RC underwent triple endoscopy were included. The mean age was 4.55±2.84 years old. The most common symptom was chronic cough among 19 (45%) patients, while 23 (55%) patients had gastrointestinal (GI) symptoms. Airway findings included tracheomalacia in 19, laryngeal cleft in 17, and subglottic stenosis in 11 patients. On EGD with biopsy, abnormal gross findings were present in 6 and abnormal microscopic findings in 18 patients, including 6 with histologic findings suggestive of gastroesophageal reflux and 5 with eosinophilic esophagitis. Seventeen (40%) patients had positive culture on BAL. No findings in patient histories significantly predicted presence of lower airway malacia, subglottic stenosis, or abnormal EGD findings. CONCLUSIONS Children with recurrent croup presenting to aerodigestive centers may not have any pertinent presenting symptoms that correlate with significant findings on triple endoscopy. Further work is needed to determine which children with recurrent croup may benefit from aerodigestive evaluation. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Jennifer P Vu
- Division of Otolaryngology, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Houston, TX 77030, USA
| | - Deepak Jagannath
- Division of Otolaryngology, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Houston, TX 77030, USA.
| | - David R Spielberg
- Division of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA
| | - Eric H Chiou
- Division of Gastroenterology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kathleen E Hosek
- Department of Surgery, Texas Children's Hospital, Houston, TX 77030, USA
| | - Elton M Lambert
- Division of Otolaryngology, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Houston, TX 77030, USA
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So RJ, Franks Z, Espahbodi M, Ryan MA, Jenks C, Walsh J. Clinical Presentation of Pediatric Recurrent Croup: Implications for Diagnosis. Clin Pediatr (Phila) 2023; 62:871-878. [PMID: 37550866 DOI: 10.1177/00099228221150691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Recurrent croup is a common clinical entity afflicting the pediatric population, but is not well-characterized in the literature. We describe the largest series of recurrent croup in North America from a single tertiary care academic center, and differentiate subpopulations based on demographic characteristics and clinical presentation. We identified 114 patients for inclusion. Common symptoms included barky cough (86.0%) and inspiratory stridor (60.5%). Many (26.3%) experienced full symptom resolution within a day, and 41.2% reported onset of symptoms at any time of the day. Male patients had a higher number of prior croup episodes at presentation compared with female patients (mean of 9.8 ± 8.0 in males vs 6.6 ± 4.8 in females, P = .03). On multivariate regression, racial/ethnic minority patients were at higher risk for dyspnea (odds ratio [OR]: 58.6; 95% confidence interval [CI]: 7.2-475.4) and upper respiratory infection prodrome (OR: 7.6; 95% CI: 1.6-35.3) compared with non-Hispanic white patients.
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Affiliation(s)
- Raymond J So
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zechariah Franks
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mana Espahbodi
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carolyn Jenks
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sowa LE, Stillwell PC, Houin PR, Nguyen N, Prager JD, Wine T, Teynor NJ, Meier M, Hanson RB, Francom C, Gitomer SA. Prophylactic inhaled corticosteroids for the management of recurrent croup. Int J Pediatr Otorhinolaryngol 2023; 170:111600. [PMID: 37201337 DOI: 10.1016/j.ijporl.2023.111600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/18/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVES Croup is characterized by a barky cough, inspiratory stridor, hoarseness and varying degrees of respiratory distress. Acute croup episodes are often treated with oral, inhaled, or intravenous corticosteroids. Recurrent croup, defined as more than 2-3 episodes of acute croup in the same patient, can mimic asthma. We hypothesized that inhaled corticosteroids (ICS) given at the first sign of a respiratory viral prodrome can be a safe treatment to reduce the frequency of recurrent croup episodes in children without fixed airway lesions. METHODS A retrospective chart review of patients being treated over an 18-month period was performed at a large tertiary care pediatric hospital following Institutional Review Board (IRB) approval. Patients under 21 years old referred to Pediatric Pulmonology, Otolaryngology, or Gastroenterology for recurrent croup were analyzed for their demographics, medical history, evaluation, treatment and clinical improvement. A Fisher's two-tailed exact test was used to compare the number of croup episodes before and after interventions. RESULTS 124 patients were included in our analysis: 87 male and 34 female with a mean age of 54 months. Of these, 78 had >5 episodes of croup, 45 had 3-5, and 3 had 2 episodes prior to their first visit for recurrent croup. Operative direct laryngoscopy/bronchoscopy was performed in 35 patients (27.8%), with 60% showing a normal exam without fixed lesions. Ninety-two patients (74.2%) were treated with ICS, 24 were lost to follow up. Of the remaining 68 treated patients, 59 (86.7%) saw improvement with reduced severity and overall number of episodes of croup. Additionally, patients with >5 episodes of croup (47) as compared to <5 (12) were more likely to improve with ICS, (p = 0.003). There were no adverse reactions reported with ICS treatment. CONCLUSION The novel initiation of ICS at the earliest sign of a viral upper respiratory infection shows promise as a safe preventative treatment to mitigate the frequency of recurrent croup episodes.
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Affiliation(s)
- Lauren E Sowa
- Dr. Sowa is Currently with the Riley Hospital for Children, Department of Otolaryngology, Indiana University, United States
| | - Paul C Stillwell
- University of Colorado, Children's Hospital Colorado, Department of Pulmonology and Sleep Medicine, United States
| | - Paul R Houin
- University of Colorado, Children's Hospital Colorado, Department of Pulmonology and Sleep Medicine, United States
| | - Nathalie Nguyen
- University of Colorado, Children's Hospital Colorado, Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, United States
| | - Jeremy D Prager
- University of Colorado, Children's Hospital Colorado, Department of Otolaryngology - Head & Neck Surgery, United States
| | - Todd Wine
- University of Colorado, Children's Hospital Colorado, Department of Otolaryngology - Head & Neck Surgery, United States
| | - Nathan J Teynor
- Children's Hospital Colorado, Department of Pediatric Otolaryngology, United States
| | - Maxine Meier
- University of Colorado School of Medicine, United States
| | | | - Christian Francom
- University of Colorado, Children's Hospital Colorado, Department of Otolaryngology - Head & Neck Surgery, United States
| | - Sarah A Gitomer
- University of Colorado, Children's Hospital Colorado, Department of Otolaryngology - Head & Neck Surgery, United States.
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Hampton T, Ghazal Asswad R, Bhat J, Stevens K, Whitehall E, Milinis K, De S, Donne A, Krishnan M. Recurrent croup is a good indicator of underlying paediatric airway issues: A 10-year retrospective cohort study of airway endoscopy. EAR, NOSE & THROAT JOURNAL 2023:1455613231170087. [PMID: 37141917 DOI: 10.1177/01455613231170087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVE Children with a history of recurrent croup alert the ENT clinician to the potential for underlying laryngotracheal pathology. There is equipoise about the likelihood of identifying any underlying structural issues or subglottic stenosis in those children who undergo airway assessment. METHODS A retrospective cohort study in a tertiary UK paediatric hospital of a decade of children with recurrent croup who underwent a rigid laryngo-tracheo-bronchoscopy (airway endoscopy). MAIN OUTCOME(S) airway pathology seen on endoscopy and need for further airway surgery. RESULTS In ten years, 139 children underwent airway endoscopy for recurrent croup. Operative findings were abnormal in 62 (45 %) cases. Twelve cases (9%) had subglottic stenosis. Although recurrent croup was more common in males (78% of cases), this was not found to predispose them to operative findings. Children with previous intubations had >2 times the risk of abnormal findings and children born prematurely (<37 wks) had a trend towards abnormal operative findings versus children with no airway findings in our cohort. Even in those patients with abnormal findings, none necessitated further airway surgery. CONCLUSIONS Surgeons and parents can be reassured that rigid airway endoscopy for children with recurrent croup demonstrated high diagnostic utility but will rarely lead to further surgical intervention. Greater understanding about recurrent croup may require consensus clarification about definitions of recurrent croup and/or a universal adoption of a minimum standard operative record or grading system after rigid endoscopy for recurrent croup.
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Affiliation(s)
- Thomas Hampton
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Randa Ghazal Asswad
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- University of Liverpool School of Medicine, University of Liverpool, Liverpool, UK
| | - Jaya Bhat
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Kate Stevens
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Emma Whitehall
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Su De
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Adam Donne
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Madhan Krishnan
- ENT Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Abstract
BACKGROUND Glucocorticoids are the mainstay for the treatment of croup. The existing evidence demonstrates that glucocorticoids are effective in the treatment of croup in children. However, updating the evidence on their clinical relevance in croup is imperative. This is an update to a review first published in 1999, and updated in 2004, 2011, and 2018. OBJECTIVES To investigate the effects and safety of glucocorticoids in the treatment of croup in children aged 18 years and below. SEARCH METHODS We searched the Cochrane Library, which includes the Cochrane Central Register of Controlled Trials (CENTRAL; 2022 Issue 9), Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE (1946 to 4 March 2022), Embase (Ovid) (1974 to 4 March 2022). We also searched the WHO ICTRP and ClinicalTrials.gov on 4 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in children (aged 18 years and below) with croup. We assessed the effect of glucocorticoids compared to the following: placebo, any other pharmacologic agents, any other glucocorticoids, any combination of other glucocorticoids, given by different modes of administration, or given in different doses. The included studies must have assessed at least one of our primary outcomes (defined as the change in croup score or return visits, (re)admissions to the hospital or both) or secondary outcomes (defined as the length of stay in hospital or emergency departments, patient improvement, use of additional treatments, or adverse events). DATA COLLECTION AND ANALYSIS Review authors independently extracted data, with another review author verified. We entered the data into Review Manager 5 for meta-analysis. Two review authors independently assessed studies for risk of bias using the Cochrane risk of bias tool. Two review authors assessed the certainty of the evidence for the primary outcomes using the GRADE approach. MAIN RESULTS This updated review includes 45 RCTs with a total of 5888 children, an increase of two RCTs with 1323 children since the last update. We also identified one ongoing study and one study awaiting classification. We assessed most studies (98%) as at high or unclear risk of bias. Any glucocorticoid compared to placebo Compared to placebo, glucocorticoids may result in greater reductions in croup score after two hours (standardised mean difference (SMD) -0.65, 95% confidence interval (CI) -1.13 to -0.18; 7 RCTs, 426 children; low-certainty evidence); six hours (SMD -0.76, 95% CI -1.12 to -0.40; 11 RCTs, 959 children; low-certainty evidence); and 12 hours (SMD -1.03, 95% CI -1.53 to -0.53; 8 RCTs, 571 children; low-certainty evidence). The evidence for change in croup score after 24 hours is very uncertain (SMD -0.86, 95% CI -1.40 to -0.31; 8 RCTs, 351 children; very low-certainty evidence). One glucocorticoid compared to another glucocorticoid There was little to no difference between prednisolone and dexamethasone for reduction in croup score at two-hour post-baseline score (SMD 0.06, 95% CI -0.06 to 0.18; 1 RCT, 1231 children; high-certainty evidence). There was likely little to no difference between prednisolone and dexamethasone for reduction in croup score at six-hour post-baseline score (SMD 0.21, 95% CI -0.21 to 0.62; 1 RCT, 99 children; moderate-certainty evidence). However, dexamethasone probably reduced the return visits or (re)admissions for croup by almost half (risk ratio (RR) 0.55, 95% CI 0.28 to 1.11; 4 RCTs, 1537 children; moderate-certainty evidence), and showed a 28% reduction in the use of supplemental glucocorticoids as an additional treatment (RR 0.72, 95% CI 0.53 to 0.97; 2 RCTs, 926 children). Dexamethasone given in different doses Compared to 0.15 mg/kg, 0.60 mg/kg dexamethasone probably reduced the severity of croup as assessed by the croup scoring scale at 24-hour postbaseline score (SMD 0.63, 95% CI 0.16 to 1.10; 1 RCT, 72 children; moderate-certainty evidence); however, this was not the case at two hours (SMD -0.27, 95% CI -0.76 to 0.22; 2 RCTs, 861 children; high-certainty evidence). There was probably no reduction at six hours (SMD -0.45, 95% CI -1.26 to 0.35; 3 RCTs, 178 children; moderate-certainty evidence), and the evidence at 12 hours is very uncertain (SMD -0.60, 95% CI -4.39 to 3.19; 2 RCTs, 113 children; very low-certainty evidence). There was little to no difference between doses of dexamethasone in return visits or (re)admissions of children or both (RR 0.91, 95% CI 0.71 to 1.17; 3 RCTs, 949 children; high-certainty evidence) or length of stay in the hospital or emergency department (mean difference 0.12, 95% CI -0.32 to 0.56; 2 RCTs, 892 children). The need for additional treatments, such as epinephrine (RR 0.78, 95% CI 0.34 to 1.75; 2 RCTs, 885 children); intubation (risk difference 0.00, 95% CI -0.00 to 0.00; 2 RCTs, 861 children); or use of supplemental glucocorticoids (RR 0.77, 95% CI 0.51 to 1.15; 2 RCTs, 617 children), also did not differ between doses of dexamethasone. There were moderate to high levels of heterogeneity in the analyses for most comparisons. Adverse events were observed for some of the comparisons reported in the review. AUTHORS' CONCLUSIONS The evidence that glucocorticoids reduce symptoms of croup at two hours, shorten hospital stays, and reduce the rate of return visits or (re)admissions has not changed in this update. A smaller dose of 0.15 mg/kg of dexamethasone may be as effective as the standard dose of 0.60 mg/kg. More RCTs are needed to strengthen the evidence for effectiveness of low-dose dexamethasone at 0.15 mg/kg to treat croup.
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Affiliation(s)
- Alex Aregbesola
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Clara M Tam
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Asha Kothari
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Me-Linh Le
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Canada
| | - Mirna Ragheb
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Terry P Klassen
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
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Anderson BP, Shifman HP, Haupert MS, Thottam PJ. Utilization of intranasal ipratropium bromide in the prevention of recurrent croup events: Is it effective? Int J Pediatr Otorhinolaryngol 2022; 163:111341. [PMID: 36257168 DOI: 10.1016/j.ijporl.2022.111341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Recurrent croup (RC) is a common problem in the pediatric population. We theorize that reduced rhinorrhea and post-nasal drip as well as suppressed cough receptor activity by the anticholinergic, intranasal ipratropium bromide (IB), may lead to reduced inflammation and edema of the subglottis, decreasing RC symptoms. The aim of this study is to determine the effectiveness of IB in improving symptoms of RC and in reducing the need for alternative forms of management. METHOD A retrospective chart review combined with survey data of patients with RC was conducted to assess demographic data, comorbidities, and treatment outcomes. Pediatric patients less than 10 years of age diagnosed with RC through the department of pediatric otolaryngology between 2018 and 2020 were included. Results were compared between one group treated with IB for RC and a second group treated with medications other than IB. RESULTS Among the 67 patients treated for RC, 34 completed survey data and were included in the study. Overall, patients who were treated with IB for RC had 1.83 less croup episodes per year (p = 0.046), a 0.5-point improvement in child symptoms (p = 0.017) and 1.3 fewer doses of steroids per year than the patients not treated with IB (p = 0.018). Patients treated with IB were significantly more likely to answer "yes," that the use of medication helped improve symptoms (p < 0.01). CONCLUSION Intranasal IB is a novel therapeutic option that may reduce RC events, improve patient symptoms and reduce steroid use. Further prospective studies are needed to definitively characterize the benefits of IB in the treatment of RC.
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Affiliation(s)
- Brian P Anderson
- Department of Otolaryngology - Head and Neck Surgery, Ascension Macomb-Oakland Hospital, Madison Heights, MI, USA
| | - Holly P Shifman
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Michael S Haupert
- Beaumont Hospital, Royal Oak, MI, USA; Michigan Pediatric Ear Nose and Throat Associates, West Bloomfield Township, MI, USA
| | - Prasad John Thottam
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA; Beaumont Hospital, Royal Oak, MI, USA; Michigan Pediatric Ear Nose and Throat Associates, West Bloomfield Township, MI, USA.
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7
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Gerard R, Nolent P, Lerouge-Bailhache M, Sagardoy T, Dienst T. When Stridor is Not Croup: A Case Report. J Emerg Med 2022; 63:673-677. [PMID: 36369121 DOI: 10.1016/j.jemermed.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/17/2022] [Accepted: 09/04/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Croup is one of the most common causes of acute respiratory disorder in children. It presents as acute laryngeal symptoms in the context of viral infection. Treatment consists of systemic steroids and aerosolized adrenaline, after which the symptoms must resolve rapidly. There are many differential diagnoses, including neurological causes. In these cases, clinical presentation is atypical and the outcome can be less favorable. CASE REPORT We present the cases of three children who presented with stridor, which was initially treated as croup but eventually turned out to have a neurological origin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians need to be aware of the differential diagnoses of croup. We suggest a few key points to help emergency physicians manage these patients, including adequate use of monitoring and nasofibroscopy. Early identification is a key element in the effective management of certain rapidly progressive neurological diseases.
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Affiliation(s)
| | | | | | - Thomas Sagardoy
- Department of Otolaryngology and Skull Base Surgery, Bordeaux University Hospital, Bordeaux, France
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Mathew D, Cucalon Calderon J. Mild-to-Moderate Croup Presentations in Patients With COVID-19 Infection. Cureus 2022; 14:e27893. [PMID: 36110434 PMCID: PMC9464052 DOI: 10.7759/cureus.27893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/30/2022] Open
Abstract
This case series will describe two pediatric patients, aged nine months and two years, who presented to the emergency department with symptoms of croup. However, they were later found to have coronavirus disease 2019 (COVID-19). The two patients had no pre-existing medical conditions, and they were treated with steroids and nebulized epinephrine as required. They were discharged home with instructions to follow up with their primary care provider and to follow isolation guidelines. This report will illustrate how upper respiratory symptoms, including those consistent with croup, can be associated with or caused by an existing COVID-19 infection. More research is needed to determine if this association can lead to more long-term complications of COVID-19. Additionally, testing for COVID-19 should be incorporated into the assessment and management of this presentation. By recognizing this, clinicians can identify the cause of the illness sooner and initiate targeted treatment more effectively.
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Abstract
Croup refers to airway inflammation and edema leading to obstruction of the larynx, trachea, and bronchi. Croup is the most common cause of acute airway obstruction in young children. It is characterized by the onset of low-grade fever, barky cough, stridor, hoarseness, and respiratory distress. Croup is typically caused by a viral infection (viral croup) but can occur suddenly without a viral prodrome (spasmodic croup). Recurrent croup is defined as two or more episodes per year. Recurrent croup should be considered a symptom of an underlying structural or inflammatory airway abnormality and should prompt a work-up for the underlying cause.
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10
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Preece AS, Shu H, Knutz M, Krais AM, Wikström S, Bornehag CG. Phthalate levels in indoor dust and associations to croup in the SELMA study. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2021; 31:257-265. [PMID: 32952153 DOI: 10.1038/s41370-020-00264-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 08/21/2020] [Accepted: 09/08/2020] [Indexed: 06/11/2023]
Abstract
Phthalates are ubiquitous indoor pollutants which have been associated with child airway disease although results are inconclusive. This study examined associations between phthalate levels in residential indoor dust and croup during infancy. Settled indoor dust was collected in 482 homes of 6-month-old infants in the Swedish Environmental Longitudinal, Mother and child, Asthma and allergy (SELMA) study and analysed for seven phthalates and one phthalate replacement using gas chromatography tandem mass spectrometry. The incidence of parental reported croup at 12 months was 6.4% for girls and 13.4% for boys. Associations between phthalate dust levels and croup were analysed by logistic regression adjusted for potential confounders. We found significant associations between di-ethyl phthalate (DEP) and di-ethyl-hexyl phthalate (DEHP) in residential dust and parental reported croup (adjusted odds ratio (aOR) = 1.71; 95% CI: 1.08-2.73 and 2.07; 1.00-4.30, respectively). Stratified results for boys showed significant associations between DEP and butyl-benzyl phthalate (BBzP) in dust and infant croup (aOR = 1.86; 95% CI: 1.04-3.34 and 2.02; 1.04-3.90, respectively). Results for girls had questionable statistical power due to few cases. Our results suggest that exposure to phthalates in dust is a risk factor for airway inflammatory responses in infant children.
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Affiliation(s)
- Anna-Sofia Preece
- Department of Health Sciences, Karlstad University, Karlstad, Sweden
| | - Huan Shu
- Department of Health Sciences, Karlstad University, Karlstad, Sweden
| | - Malin Knutz
- Department of Health Sciences, Karlstad University, Karlstad, Sweden
| | - Annette M Krais
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Sverre Wikström
- School of Medical Science, Örebro University, Örebro, Sweden
| | - Carl-Gustaf Bornehag
- Department of Health Sciences, Karlstad University, Karlstad, Sweden.
- Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.
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11
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Coughran A, Balakrishnan K, Ma Y, Vaezeafshar R, Capdarest-Arest N, Hamdi O, Sidell DR. The Relationship between Croup and Gastroesophageal Reflux: A Systematic Review and Meta-Analysis. Laryngoscope 2020; 131:209-217. [PMID: 32040207 DOI: 10.1002/lary.28544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/07/2020] [Accepted: 01/10/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The mechanism by which recurrent croup occurs is unknown. Gastroesophageal reflux is commonly implicated, although this relationship is only loosely documented. We conducted a systematic review with a meta-analysis component to evaluate the relationship between recurrent croup and gastroesophageal reflux disease (GERD), and to assess for evidence of improvement in croup symptoms when treated. STYLE DESIGN Systematic Review and Meta Analysis. METHODS We searched five separate databases. Studies were included if they discussed the relationship between croup and GERD in children, >5 subjects, and available in English. Literature retrieved was assessed according to pre-specified criteria. Retrieved articles were reviewed by two independent authors and decisions mediated by a third author. If there was a difference of opinion after first review, a second review was performed to obtain consensus. Heterogeneity was calculated and summarized in forest plots. RESULTS Of 346 initial records, 15 met inclusion criteria. These were two retrospective cohort and 13 cross-sectional studies. Thirteen of 15 articles support an association between recurrent croup and GERD. Although heterogeneity is high among studies that reported prevalence of GERD, there is less uncertainty in results for improvement to recurrent croup after GERD treatment. Most studies lacked a control group and all carry a moderate-to-high risk of bias. CONCLUSION There is limited evidence linking GERD to recurrent croup; Further research is needed to assess for causality as most studies are retrospective, lack a control group, and have a study design exposing them to bias. Patients treated with reflux medication appear to demonstrate a reduced incidence of croup symptoms. LEVEL OF EVIDENCE 1 Laryngoscope, 131:209-217, 2021.
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Affiliation(s)
- Alanna Coughran
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Karthik Balakrishnan
- Department of Otorhinolaryngology and Mayo Clinic Children's Center, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Yifei Ma
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Reza Vaezeafshar
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | | | - Osama Hamdi
- Howard University College of Medicine, Washington, DC, U.S.A
| | - Douglas R Sidell
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
- Lucile Packard Children's Hospital Stanford Aerodigestive and Airway Reconstruction Center, Stanford, California, U.S.A
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Wilcox LJ, Rutter MJ. Subglottic cauterization: An atypical approach for atypical croup. Laryngoscope 2019; 130:E372-E374. [PMID: 31429936 DOI: 10.1002/lary.28246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/12/2019] [Accepted: 08/02/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Lyndy J Wilcox
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Michael J Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
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Trivedi M, Denton E. Asthma in Children and Adults-What Are the Differences and What Can They Tell us About Asthma? Front Pediatr 2019; 7:256. [PMID: 31294006 PMCID: PMC6603154 DOI: 10.3389/fped.2019.00256] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/06/2019] [Indexed: 12/30/2022] Open
Abstract
Asthma varies considerably across the life course. Childhood asthma is known for its overall high prevalence with a male predominance prior to puberty, common remission, and rare mortality. Adult asthma is known for its female predominance, uncommon remission, and unusual mortality. Both childhood and adult asthma have variable presentations, which are described herein. Childhood asthma severity is associated with duration of asthma symptoms, medication use, lung function, low socioeconomic status, racial/ethnic minorities, and a neutrophilic phenotype. Adult asthma severity is associated with increased IgE, elevated FeNO, eosinophilia, obesity, smoking, and low socioeconomic status. Adult onset disease is associated with more respiratory symptoms and asthma medication use despite higher prebronchodilator FEV1/FVC. There is less quiescent disease in adult onset asthma and it appears to be less stable than childhood-onset disease with more relapses and less remissions.
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Affiliation(s)
- Michelle Trivedi
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, United States
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Eve Denton
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia
- Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Shu H, Wikstrom S, Jönsson BA, Lindh CH, Svensson Å, Nånberg E, Bornehag CG. Prenatal phthalate exposure was associated with croup in Swedish infants. Acta Paediatr 2018; 107:1011-1019. [PMID: 29385277 DOI: 10.1111/apa.14245] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 10/24/2017] [Accepted: 01/23/2018] [Indexed: 12/13/2022]
Abstract
AIM This study examined whether prenatal phthalate exposure was associated with lower or upper airway inflammation in infants. METHODS From 2007 to 2010, we used liquid chromatography-tandem mass spectrometry, adjusted for creatinine, to analyse 14 phthalate metabolites and one phthalate replacement in the urine of 1062 Swedish mothers at a median of 10 weeks of pregnancy. This was used to determine any associations between prenatal phthalate exposure and croup, wheezing or otitis in their offspring until 12 months of age, using logistic regression, adjusted for potential confounders. RESULTS There were significant associations between phthalate metabolites of butyl-benzyl phthalate (BBzP) and di-ethyl-hexyl phthalate (DEHP) concentrations in maternal prenatal urine and croup in 1062 infants during the first year of life, when adjusted for potential confounders. A dose-response relationship was found between prenatal phthalates exposure and maternal reported croup in the children, with a significant association in boys. There was no clear indication with regard to associations between prenatal phthalate exposure and wheezing or otitis media in the children during the first year of life. CONCLUSION Our analysis suggests that exposure to BBzP and DEHP phthalates was associated with maternal reports of croup in infants up to 12 months of age.
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Affiliation(s)
- Huan Shu
- Department of Health Sciences; Karlstad University; Karlstad Sweden
| | - Sverre Wikstrom
- School of Medical Sciences; Örebro University; Örebro Sweden
| | - Bo A.G. Jönsson
- Division of Occupational and Environmental Medicine; Lund University; Lund Sweden
| | - Christian H. Lindh
- Division of Occupational and Environmental Medicine; Lund University; Lund Sweden
| | - Åke Svensson
- Department of Dermatology; Lund University; Lund Sweden
| | - Eewa Nånberg
- Department of Health Sciences; Karlstad University; Karlstad Sweden
| | - Carl-Gustaf Bornehag
- Department of Health Sciences; Karlstad University; Karlstad Sweden
- Department of Preventive Medicine; Icahn School of Medicine at Mount Sinai; New York NY USA
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Elliott AC, Williamson GR. A Systematic Review and Comprehensive Critical Analysis Examining the Use of Prednisolone for the Treatment of Mild to Moderate Croup. Open Nurs J 2018; 11:241-261. [PMID: 29290883 PMCID: PMC5738747 DOI: 10.2174/1874434601711010241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 10/25/2017] [Accepted: 11/10/2017] [Indexed: 12/04/2022] Open
Abstract
Background: Many randomised control trials and systematic reviews have examined the benefits of glucocorticoids for the treatment of croup in children, but they have reported mainly on dexamethasone as an oral treatment for croup. No systematic reviews have examined prednisolone alone. Aim: To determine in a systematic review of the literature whether a single dose of oral prednisolone is as effective as a single dose of dexamethasone for reducing croup symptoms in children. Search Strategy: A detailed search was conducted on the following databases: CINAHL, MEDLINE EBSCO, MEDLINE, OVID, PubMed, The Cochrane Library, ProQuest, EMBASE, JBI, Sum search, and OpenGrey. Study authors were contacted. Selection Criteria: Randomised Controlled Trials, clinical trials or chart reviews which examined children with croup who were treated with prednisolone alone, or when prednisolone was compared to a dexamethasone treatment and the effectiveness of the intervention was objectively measured using croup scores and re-attendance as primary outcomes. Data Collection and Analysis: Following PRISMA guidelines for systematic reviews, relevant studies were identified. Scores were graded agreed by two independent reviewers using QualSyst. Main Results: Four studies met the inclusion criteria, but were too heterogeneous to combine in statistical meta-analysis. The result suggests that although prednisolone appears as effective as dexamethasone when first given, it is less so for preventing re-presentation. Trial sample sizes were small, making firm conclusions difficult, however, a second dose of prednisolone the following day may be useful. More research including cost-benefit analysis is needed to examine the efficacy of prednisolone compared to dexamethasone.
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Affiliation(s)
- Anna Catherine Elliott
- Meneage Street Surgery, 100 Meneage Street, Helston, Cornwall TR17, 8RF, UK, 01326 555288
| | - Graham R Williamson
- Adult Nursing, School of Nursing and Midwifery, Plymouth University, Drake Circus, Plymouth, PL4 8AA. UK, 07976761858
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16
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Abstract
Asthma and croup are common inflammatory airway diseases involving the bronchus in children. However, no study has reported the effects of urbanization, sex, age, and bronchiolitis on the association of croup and its duration with asthma development. We used the Taiwan Longitudinal Health Insurance Database (LHID) to perform this population-based cohort study; here, the cluster effect caused by hospitalization was considered to evaluate the association between croup and asthma development and the risk factors for asthma in children of different age groups. We evaluated children with croup aged <12 years (n = 1204) and age-matched control patients (n = 140,887) by using Cox proportional hazards regression analysis within a hospitalization cluster. Of all 142,091 patients, 5799 (including 155 with croup [419 per 1000 person-y] and 5644 controls [106 per 1000 person-y]) had asthma during the 5-year follow-up period. During the 5-year follow-up period, the hazard ratios (HRs [95% CIs]) for asthma were 2.10 (1.81-2.44) in all children with croup, 2.13 (1.85-2.46) in those aged 0 to 5 years, and 2.22 (1.87-2.65) in those aged 6 to 12 years. Children with croup aged 7 to 9 years had a higher HR for asthma than did those in other age groups. Boys with croup had a higher HR for asthma. The adjusted HR for asthma was 1.78 times higher in children with croup living in urban areas than in those living in rural areas. In conclusion, our analyses indicated that sex, age, bronchiolitis, and urbanization level are significantly associated with croup and asthma development. According to our cumulative hazard rate curves, younger children with croup should be closely monitored for asthma development for at least 3 years.
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Affiliation(s)
- Sheng-Chieh Lin
- Department of Pediatrics, Shuang Ho Hospital
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University
| | - Hui-Wen Lin
- Department of Mathematics, Soochow University
- Evidence Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Bor-Luen Chiang
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University
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Hiebert JC, Zhao YD, Willis EB. Bronchoscopy findings in recurrent croup: A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2016; 90:86-90. [PMID: 27729160 DOI: 10.1016/j.ijporl.2016.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/03/2016] [Accepted: 09/03/2016] [Indexed: 12/01/2022]
Abstract
IMPORTANCE The etiology of recurrent croup is often anatomic. Currently there is no set criteria for determining who should undergo diagnostic bronchoscopy and which patients are at most risk for having a clinically significant finding. Few studies have addressed these questions. OBJECTIVE To identify risk factors for clinically significant findings on bronchoscopy in children with recurrent croup and the frequency of bronchoscopy findings in general. DATA SOURCES PUBMED, Ovid MEDLINE, EMBASE. STUDY SELECTION Articles addressing bronchoscopy in children with recurrent croup, up to July 2016, were reviewed. Related keywords and medical subject headings were used during the search. The abstracts were reviewed to determine suitability for inclusion based on a set of criteria. Manual crosscheck of references was performed. DATA EXTRACTION We analyzed the bronchoscopy findings of individual patients in each study and their associated risk factors when available. RESULTS We reviewed 11 articles, published between 1992 and 2016, including 885 patients (654 males, 237 females). Only 5 studies, including 455 patients, had sufficient data for meta-analysis. Our study revealed that the three most common bronchoscopy findings were subglottic stenosis, reflux changes, and broncho/tracheomalacia. Only 8.7% of patients were noted to have clinically significant findings on bronchoscopy. Meta analysis showed an association between significant bronchoscopy findings and History of Intubation [OR = 5.17, 95% CI 2.65-10.09], Inpatient Consultation [OR = 4.01, 95% CI 1.44-11.20], Age < 3 [OR = 3.22, 95% 1.66-6.27], Age < 1 [OR = 2.86, 95% CI 1.28-6.40], and Prematurity [OR = 2.90, 95% CI 1.39-6.06]. Our study found a high incidence of a History of GERD (20%) and Asthma/Allergies (35%) among patients with recurrent croup, but these variables did not reach statistical significance in patients with significant bronchoscopy findings ([OR = 1.62, 95% CI 0.79-3.30], [OR = 0.57, 95% CI 0.30-1.08] respectively). CONCLUSION The risk factors most associated with clinically significant bronchoscopy findings in recurrent croup are Intubation, Inpatient Consultation, Age < 3, Age <1, and Prematurity. A History of GERD and Asthma/Allergy, though highly prevalent in recurrent croup patients, were not statistically associated with significant bronchoscopy findings. RELEVANCE The results should guide physicians in selecting which recurrent croup patients are most at risk for significant findings and thus may warrant bronchoscopy.
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Affiliation(s)
- Jared C Hiebert
- Department of Otorhinolaryngology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd WP 1290, Oklahoma City, OK, 73104, USA.
| | - Yan Daniel Zhao
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, 801 NE 13th St, Room 327, Oklahoma City, OK, 73104, USA
| | - Elena B Willis
- Department of Otorhinolaryngology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd WP 1290, Oklahoma City, OK, 73104, USA
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Abstract
Stridor is a variably pitched respiratory sound, caused by abnormal air passage during breathing and often is the most prominent sign of upper airway obstruction. It is usually heard on inspiration (typically resulting from supraglottic or glottic obstruction) but also can occur on expiration (originating from obstruction at or below glottic level and/or severe upper airway obstruction). Stridor due to congenital anomalies may exist from birth or may develop within days, weeks or months. Various congenital and acquired disorders prevail in neonates, infants, children, and adolescents, and have to be distinguished. History, age of the child and physical examination together often allow a presumptive diagnosis. Further investigations may be necessary to establish a definite diagnosis, and flexible airway endoscopy is the diagnostic procedure of choice in most circumstances ("stridor is visible").
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Affiliation(s)
- Andreas Pfleger
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Austria.
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Duval M, Tarasidis G, Grimmer JF, Muntz HR, Park AH, Smith M, Asfour F, Meier J. Role of operative airway evaluation in children with recurrent croup: a retrospective cohort study. Clin Otolaryngol 2016; 40:227-33. [PMID: 25409938 DOI: 10.1111/coa.12353] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine which risk factors in children with recurrent croup warrant bronchoscopic evaluation. DESIGN Retrospective cohort study. SETTING Tertiary paediatric hospital. PARTICIPANTS Children with recurrent croup who underwent a rigid bronchoscopy between 2001 and 2013. MAIN OUTCOME MEASURES Bronchoscopy findings, classified as normal, mildly abnormal or significantly abnormal. RESULTS Two hundred and thirty-five children underwent a rigid bronchoscopy and 110 underwent a flexible oesophagoscopy. One hundred and forty-five children (61.7%) had a mildly abnormal exam, and 27 children (11.5%) had significant findings that required a surgical intervention or grade 2 or greater subglottic stenosis. The significantly abnormal group included 4 children with laryngomalacia, 2 with a subglottic cyst, 8 with grade 2 or 3 subglottic stenosis and 13 children who underwent a surgical procedure for subglottic stenosis. Sixty-seven children had a preoperative diagnosis of asthma, 62 were atopic and 78 had symptoms of gastro-oesophageal reflux. Oesophagoscopy was diagnostic of gastro-oesophageal reflux in 19 of 110 cases, and 106 children (45.1%) had bronchoscopic findings suggestive of GERD. Eight children had eosinophilic oesophagitis. After multivariate analysis, significantly abnormal bronchoscopy was significantly associated with chronic cough (P = 0.02), have a previous intubation (P = 0.002) or be younger than 3 years old (P = 0.01). CONCLUSION Significant findings on bronchoscopy that warranted further surgical intervention were uncommon in this cohort. Nearly half of the patients had evidence of gastro-oesophageal reflux. In patients without risk factors for significant abnormalities, empiric medical management may be beneficial prior to endoscopy.
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Affiliation(s)
- M Duval
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - G Tarasidis
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - J F Grimmer
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - H R Muntz
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - A H Park
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - M Smith
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - F Asfour
- Division of Pediatric Pulmonology, University of Utah, Salt Lake City, UT, USA
| | - J Meier
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
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Hodnett BL, Simons JP, Riera KM, Mehta DK, Maguire RC. Objective endoscopic findings in patients with recurrent croup: 10-year retrospective analysis. Int J Pediatr Otorhinolaryngol 2015; 79:2343-7. [PMID: 26574171 DOI: 10.1016/j.ijporl.2015.10.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE (1) To determine the incidence and severity of subglottic stenosis on endoscopic evaluation in a pediatric population of patients with recurrent croup. (2) To determine the incidence of abnormal findings on bronchoalveolar lavage and esophageal biopsy in a pediatric population with recurrent croup. METHODS Case series with historical chart review of clinical data for pediatric patients (age ≤18 years) at a tertiary care children's hospital who underwent endoscopic evaluation of the upper aerodigestive tract with a diagnosis of recurrent croup over a ten-year period (2002-2012). Subglottic stenosis was graded on Myer-Cotton scale. Lipid-laden macrophages on bronchoalveolar lavage were noted as none/small/moderate/large with evidence of reflux noted as moderate or large. Esophageal biopsy specimens were evaluated for evidence of esophagitis. Data is expressed as mean±SEM. RESULTS 1825 charts were reviewed of which 197 met inclusion criteria. Mean age at endoscopy was 53±3 months. Subglottic stenosis was noted in 41 patients (20.8%) with 95.1% being mild or Grade I. Abnormal findings on bronchoalveolar lavage were noted on 9.5% of bronchoalveolar lavage specimens. Abnormal esophageal biopsies were noted on 19.9% of specimens. Esophagitis was noted on 8.8% of biopsy specimens. CONCLUSIONS Subglottic stenosis is a risk factor for recurrent croup. Evidence suggestive of reflux may be noted on bronchoalveolar lavage or esophageal biopsy, but these findings may not correlate with subglottic stenosis in recurrent croup patients.
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Affiliation(s)
- Benjamin L Hodnett
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 3400 Spruce Street-5 Ravdin, Philadelphia, PA 19104, United States.
| | - Jeffrey P Simons
- Department of Otolaryngology, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh-UPMC, Suite 7119, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States.
| | - Katherine M Riera
- Department of General Surgery, Vanderbilt University Medical Center, 1161 21st Ave S, CCC-4312 MCN, Nashville, TN 37232-2730, United States.
| | - Deepak K Mehta
- Department of Surgery, Otolaryngology, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 640, Houston, TX 77030, United States.
| | - Raymond C Maguire
- Department of Otolaryngology, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh-UPMC, Suite 7121, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States.
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21
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Subglottic laryngitis – Changes in therapy approach over the past 20 years. Auris Nasus Larynx 2015; 42:390-5. [DOI: 10.1016/j.anl.2015.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/18/2015] [Accepted: 03/18/2015] [Indexed: 11/18/2022]
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Greifer M, Santiago MT, Tsirilakis K, Cheng JC, Smith LP. Pediatric patients with chronic cough and recurrent croup: the case for a multidisciplinary approach. Int J Pediatr Otorhinolaryngol 2015; 79:749-52. [PMID: 25818348 DOI: 10.1016/j.ijporl.2015.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 03/04/2015] [Accepted: 03/07/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the results of our multidisciplinary approach to recurrent croup and chronic cough. METHODS Retrospective chart review of all patients with recurrent croup and chronic cough managed at a tertiary care children's hospital by our Comprehensive Airway, Respiratory, and Esophageal (CARE) Team. Charts were reviewed for all patients who carried a diagnosis of recurrent croup or chronic cough. Patients were excluded if they did not receive a full workup, including micro-direct laryngoscopy, flexible and/or rigid bronchoscopy, bronchioalveolar lavage (BAL), and upper endoscopy with biopsies. We reviewed the records for the presence of gastrointestinal complaints, abdominal pain and failure to thrive (FTT) and compared the children with documented esophagitis to the remaining children. RESULTS Forty patients met inclusion criteria. 53% had airway abnormalities; the most common was tracheomalacia, followed by enlarged adenoids. 38% had esophagitis (group 1) while 62% had normal esophageal biopsies (group 2). Among the children in group 1, 27% met criteria for eosinophilic esophagitis (>15 eosinophils per high powered field). There was no significant difference between groups 1 and 2 based on the presence of gastrointestinal complaints, abdominal pain and/or FTT (p>0.05). There was no significant difference between the groups based on the location or presence of an airway abnormality (p>0.05). CONCLUSIONS Children with recurrent croup and chronic cough may benefit from a multidisciplinary approach to management. Our CARE Team approach led to a specific diagnosis in almost 95% of patients.
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Affiliation(s)
- Melanie Greifer
- Hofstra North Shore LIJ School of Medicine, United States; Division of Gastroenterology and Nutrition, The Steven and Alexandra Cohen Children's Medical Center of New York, United States
| | - Maria T Santiago
- Hofstra North Shore LIJ School of Medicine, United States; Division of Pulmonology, The Steven and Alexandra Cohen Children's Medical Center of New York, United States
| | - Kalliope Tsirilakis
- Hofstra North Shore LIJ School of Medicine, United States; Division of Pulmonology, The Steven and Alexandra Cohen Children's Medical Center of New York, United States
| | - Jeffrey C Cheng
- Hofstra North Shore LIJ School of Medicine, United States; Division of Pediatric Otolaryngology, The Steven and Alexandra Cohen Children's Medical Center of New York, United States
| | - Lee P Smith
- Hofstra North Shore LIJ School of Medicine, United States; Division of Pediatric Otolaryngology, The Steven and Alexandra Cohen Children's Medical Center of New York, United States.
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23
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Delany DR, Johnston DR. Role of direct laryngoscopy and bronchoscopy in recurrent croup. Otolaryngol Head Neck Surg 2014; 152:159-64. [PMID: 25389322 DOI: 10.1177/0194599814558562] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine risk factors in children with recurrent croup that predict moderate/severe findings on direct laryngoscopy and bronchoscopy and need for further operative interventions. STUDY DESIGN Retrospective chart review cohort. SETTING Tertiary care children's hospital. SUBJECTS AND METHODS Retrospective chart review of 103 patients diagnosed with recurrent croup who underwent diagnostic laryngoscopy and bronchoscopy from January 2004 to August 2013. Statistical analysis determined risk factors significantly associated with moderate/severe operative findings. A probability tree was formulated. RESULTS Of 103 patients, 30.1% had history of intubation, 6.8% had a history of subglottic stenosis, 6.8% had a history of previous airway procedure, 11.7% consultations were inpatient, 64.1% had asthma, 47.6% had seasonal allergies, 60.2% had gastroesophageal reflux disease, 15.5% were aged ≤ 12 months, and 51.5% were ≤ 36 months. Statistically significant risk factors in predicting moderately/severely abnormal operative findings included consultation location (P = .010), history of intubation (P = .003), age younger than 36 months (P = .013), and seasonal allergies (P = .035). When using location of consultation, history of intubation, and age in a statistical model, diagnostic accuracy equaled 93.5%. Of children without history of intubation but who underwent inpatient otolaryngology consultation, 28.6% had moderate/severe findings. Likewise, 41.2% of children with a history of intubation who were younger than 36 months of age had moderate/severe findings. CONCLUSION Moderate to severe operative findings are encountered in only 8.7% of children with recurrent croup. Using statistical modeling, 2 high-risk groups are (1) patients without a history of intubation but inpatient consultation and (2) patients with a history of intubation and age younger than 36 months.
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Affiliation(s)
- Dennis R Delany
- Division of Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Douglas R Johnston
- Division of Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
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Darveaux JI, Lemanske RF. Infection-related asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2014; 2:658-63. [PMID: 25439354 PMCID: PMC5516525 DOI: 10.1016/j.jaip.2014.09.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 09/21/2014] [Accepted: 09/22/2014] [Indexed: 11/26/2022]
Abstract
The role of infection in asthma is varied in that it may exacerbate established asthma or contribute to the initial development of the clinical onset of asthma. Mounting evidence implicates both roles with particular viral pathogens, namely human rhinovirus and respiratory syncytial virus, among the most likely culprits in asthma inception. Once asthma is present, infection, particularly viral infection, is a common precipitant of asthma exacerbations. Bacterial infections and colonization also have been associated with exacerbation and recurrent wheeze, an effect that may be independent or a cofactor with viruses. Atypical bacterial infections such as Mycoplasma pneumoniae and Chlamydia pneumoniae and fungi in the case of allergic bronchopulmonary aspergillosis, also play a potential role in inducing and exacerbating this disease. In addition, certain individuals may have a genetic predisposition toward viral-induced wheezing and the development of asthma. This article will discuss host and environmental factors, common pathogens, clinical characteristic, and genetic influences associated with infection-related asthma.
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Affiliation(s)
- Jared I Darveaux
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Division of Allergy/Immunology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Robert F Lemanske
- Division of Allergy/Immunology, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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25
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Joshi V, Malik V, Mirza O, Kumar BN. Fifteen-minute consultation: structured approach to management of a child with recurrent croup. Arch Dis Child Educ Pract Ed 2014; 99:90-3. [PMID: 24231112 DOI: 10.1136/archdischild-2013-303846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Recurrent croup is a distinct clinical entity from viral croup. It is not a specific diagnosis and its presence should alert the clinician to explore the underlying cause. We discuss an evidence-based structured approach to management of a child with recurrent croup.
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Affiliation(s)
- Vineeta Joshi
- Department of Paediatrics, Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, Lancashire, UK
| | - Vikas Malik
- Department of Otolaryngology Otolaryngology and Head and Neck Surgery, Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, Lancashire, UK
| | - Omar Mirza
- Department of Otolaryngology Otolaryngology and Head and Neck Surgery, Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, Lancashire, UK
| | - B Nirmal Kumar
- Department of Otolaryngology Otolaryngology and Head and Neck Surgery, Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, Lancashire, UK
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CD14 gene variants and their importance for childhood croup, atopy, and asthma. DISEASE MARKERS 2013; 35:765-71. [PMID: 24347797 PMCID: PMC3856132 DOI: 10.1155/2013/434920] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 10/01/2013] [Accepted: 10/09/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The CD14 gene has an important role in the detection of inflammatory provoking pathogens and in the ensuing signaling of the innate immune response. We assessed the role of CD14 C-159T, G-1359T in the expression of asthma, croup, and allergy in Canadian school children of ages 6 to 14 years. METHODS Children attending schools in a rural community participated in a cross-sectional survey of respiratory health. Following consent, we conducted clinical assessments to collect buccal swabs for genotyping and perform skin prick testing (SPT) to determine atopic status. Genotyping and SPT results were available for 533 and 499 children, respectively. Separate multivariable analyses that included both polymorphisms were conducted for each phenotype. RESULTS The prevalence of asthma, allergy, and croup was 18.6%, 22.4%, and 6.6%, respectively. Children with the T/T variant of CD14 G-1359T were more likely to have physician diagnosed asthma (26.8%). Children with C/C variant of CD14 C-159T had a significantly lower prevalence of croup (2.6%). Haplotype analyses of the two CD14 polymorphisms showed that individuals with the T|T haplotype combination were significantly more likely to have asthma (P = 0.014). CONCLUSIONS In this study, CD14 variants are important for the expression of croup and asthma but not atopy.
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Garbutt JM, Conlon B, Sterkel R, Baty J, Schechtman KB, Mandrell K, Leege E, Gentry S, Stunk RC. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr (Phila) 2013; 52:1014-21. [PMID: 24092872 PMCID: PMC4019394 DOI: 10.1177/0009922813504823] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Although common practice, evidence to support treatment of croup with prednisolone is scant. Methods. We conducted a community-based randomized trial to compare the effectiveness of prednisolone (2 mg/kg/d for 3 days, n = 41) versus 1 dose of dexamethasone (0.6 mg/kg) and 2 doses of placebo (n = 46). Participants were children 1 to 8 years old with croup symptoms ≤48 hours, categorized as mild (42%) or moderate (58%). Results. There were no differences for those treated with dexamethasone or prednisolone for additional health care for croup (2% vs 7%, P = .34), duration of croup symptoms (2.8 vs 2.2 days, P = .63), nonbarky cough (6.1 vs 5.9 days, P = .81), nights with disturbed sleep for the parent (0.68 vs 1.21 nights, P = .55), and days with stress (1.39 vs 1.56 days, P = .51). Conclusion. There were no detected differences in outcomes between the 2 croup treatments for either child or parent.
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Affiliation(s)
- Jane M. Garbutt
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO,Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Bridget Conlon
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Randall Sterkel
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO,St Louis Children’s Hospital, St. Louis, MO
| | - Jack Baty
- Division of Biostatistics, Department of Medicine, Washington University St Louis, St. Louis, MO
| | - Kenneth B Schechtman
- Division of Biostatistics, Department of Medicine, Washington University St Louis, St. Louis, MO
| | - Kathy Mandrell
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Erin Leege
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Shannon Gentry
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Robert C. Stunk
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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The management of recurrent croup in children. The Journal of Laryngology & Otology 2013; 127:494-500. [DOI: 10.1017/s0022215113000418] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:To review the aetiology, investigation, diagnosis, treatment and clinical outcome of children with recurrent croup.Method:Retrospective case note review of all children with recurrent croup referred to the otolaryngology service at our hospital from November 2002 to March 2011.Results:Ninety children with recurrent croup were identified. Twenty-five children (28 per cent) had anatomical airway abnormalities, of which 16 (18 per cent) demonstrated degrees of subglottic stenosis. Twenty-three children (26 per cent) had positive microlaryngobronchoscopy findings suggestive of reflux. Eleven children were treated for gastroesophageal reflux disease, 10 (91 per cent) of whom responded well to anti-reflux medication (p = 0.006). No cause was identified for 41 (45 per cent) of the children; this was the group most likely to continue having episodes of croup at follow up. One death occurred in this group.Conclusion:Airway anomalies are common in children that present with recurrent croup. Laryngobronchoscopy allows identification of the cause of croup and enables a more accurate prognosis. In the current study, laryngobronchoscopy findings that indicated reflux were predictive of benefit from anti-reflux medications, whereas the clinical presentation of reflux was not. Routine measurement of immunoglobulin E and complement proteins did not appear to be helpful.
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Cooper T, Kuruvilla G, Persad R, El-Hakim H. Atypical croup: association with airway lesions, atopy, and esophagitis. Otolaryngol Head Neck Surg 2012; 147:209-14. [PMID: 22588730 DOI: 10.1177/0194599812447758] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To report on airway endoscopic findings and gastrointestinal and atopic conditions in a large consecutive series of atypical croup. STUDY DESIGN Case series with chart review. SETTING Tertiary pediatric referral center. SUBJECTS AND METHODS A surgical database was searched for all children who underwent full airway endoscopy to investigate atypical croup. The primary outcome measure was the prevalence of large airway lesions in patients with atypical croup undergoing endoscopy. Demographics, secondary diagnoses, and rate of positive findings were documented. Age and atopy were correlated using Spearman's correlation coefficient, and multivariate analysis identified predictors of large airway lesions. RESULTS Eighty patients were identified over a period of 8 years (58 boys; mean [SD] age 4.8 [3.8] years; range, 46 days to 13.7 years). Of the 80 children, 31 had positive airway findings, with 33 large airway lesions demonstrated, including 10 subglottic stenosis, 7 laryngeal clefts, 6 subglottic hemangiomas, 4 tracheomalacia, and 3 laryngomalacia. Esophagitis was diagnosed in 36 children, 5 of whom had eosinophilic esophagitis. Thirty-five children had an atopic condition including asthma, allergic rhinitis, eosinophilic esophagitis, and food allergies. Age correlated with associated atopy (coefficient 0.4, P < .0001) and predicted the presence of any airway lesion (coefficient -0.0625, P < .001) and subglottic stenosis in particular (coefficient -0.0362, P = .001). Prior intubation predicted subglottic stenosis (coefficient 0.267, P = .011). CONCLUSION Thirty-nine percent of airway endoscopies demonstrated large airway lesions. When eosinophilic esophagitis was sought, it was confirmed in over 1:10 patients. The findings bolster the case for airway endoscopy coupled with allergy and gastrointestinal investigations.
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Affiliation(s)
- Timothy Cooper
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Jabbour N, Parker NP, Finkelstein M, Lander TA, Sidman JD. Incidence of Operative Endoscopy Findings in Recurrent Croup. Otolaryngol Head Neck Surg 2011; 144:596-601. [DOI: 10.1177/0194599810393883] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. Develop an evidence-based model for predicting operative endoscopy findings in patients with recurrent croup. Study Design. Case series with chart review. Setting. Tertiary care children’s hospital. Subjects and Methods. Retrospective chart review was performed on 124 patients who received consultation for recurrent croup between 2000 and 2009. Direct laryngoscopy and bronchoscopy findings were categorized as normal, mildly abnormal (incidental findings or grade I subglottic stenosis), moderately abnormal (grade II subglottic stenosis), or severely abnormal (grade III-IV subglottic stenosis). Results. Of 124 consultations for recurrent croup, 81 patients (average age 3.5 years) underwent operative endoscopy. Normal examinations occurred in 33 of 81 (41%). Abnormal findings were encountered with the following frequency: mildly abnormal, 40 of 81 (49%); moderately abnormal, 6 of 81 (7.5%); and severely abnormal, 2 of 81 (2.5%). Relative risk (RR) of either moderately abnormal or severely abnormal findings was increased for patients who had a history of previous intubation (RR = 9.8; P = .002), prematurity (RR = 6.4; P = .01), or inpatient consultation (RR = 5.3; P = .028). The rate of moderately or severely abnormal findings in patients without the risk factors of intubation and age younger than 1 year was 0 of 48 (0%; confidence interval, 0%-7.4%). Mild abnormalities in this group were encountered in 27 of 48 (56%). Conclusion. Mild airway abnormalities are common in children with recurrent croup and cannot be ruled out based on history. In the absence the risk factors of previous intubation, age younger than 1 year, or inpatient consultation, the incidence of a significantly abnormal finding is quite low. A predictive model based on this evidence is discussed.
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Affiliation(s)
- Noel Jabbour
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Noah P. Parker
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Timothy A. Lander
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
| | - James D. Sidman
- Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
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Lin CY, Chi H, Shih SL, Lee KS, Sheu JC, Chiu NC, Huang FY. A 4-year-old boy presenting with recurrent croup. Eur J Pediatr 2010; 169:249-51. [PMID: 19859734 DOI: 10.1007/s00431-009-1088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 09/29/2009] [Indexed: 10/20/2022]
Abstract
Croup is common in children but recurrent croup is unusual. A 4-year-11-month-old boy presented with recurrent croup. Physical examination revealed decreased breath sounds over left lower chest. Chest x-ray disclosed segmental atelectasis over left lower chest and a mass shadow over mediastinum.
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Affiliation(s)
- Chien-Yu Lin
- Division of Infectious Disease, Department of Pediatrics, Mackay Memorial Hospital, 92, Section 2, Chungshan North Road, Taipei, Taiwan
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Arslan Z, Cipe FE, Ozmen S, Kondolot M, Piskin IE, Yöney A. Evaluation of allergic sensitization and gastroesophageal reflux disease in children with recurrent croup. Pediatr Int 2009; 51:661-5. [PMID: 19419517 DOI: 10.1111/j.1442-200x.2009.02859.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Croup, which is seen commonly in childhood, is a disorder that can be recurrent and progress to bronchial asthma. In the present study the prevalence of gastroesophageal reflux (GER) and atopy and the response to therapy were investigated in children with recurrent croup. METHODS Between October 2003 and June 2004, 57 patients with acute stridor were admitted to the emergency room. The patients who had at least three croup episodes and patients with first croup episode were compared. RESULTS Thirty-two children had recurrent croup history, GER was found in of 62.5%, and atopy in 17.2%. Atopy was not found in any children with first croup episode. The difference was significant. In addition it was found that atopic dermatitis, previous history of wheezing and established atopy increased the risk of croup recurrence. Alone or combined inhaled corticosteroids and GER therapy were administered, and 77.7% of the patients responded very well. CONCLUSION GER and atopy should be investigated in patients with recurrent spasmodic croup. Recurrent croup is a non-specific manifestation of atopy. Patients with atopy should be followed closely for developing bronchial asthma.
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Affiliation(s)
- Zafer Arslan
- Pediatric Allergy Department, Dr Sami Ulus Children's Hospital, Ankara, Turkey
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Pruikkonen H, Dunder T, Renko M, Pokka T, Uhari M. Risk factors for croup in children with recurrent respiratory infections: a case-control study. Paediatr Perinat Epidemiol 2009; 23:153-9. [PMID: 19159401 DOI: 10.1111/j.1365-3016.2008.00986.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Croup accounts for approximately 15% of all lower respiratory disease in children, but little is known about risk factors or its recurrence rate. The aim of this study was to determine the risk factors for croup and recurrent croup and to find out whether it is possible to predict the course of the disease. We considered croup patients who visited the Paediatric Department of Oulu University Hospital as primary health care patients at night during 1996-2000. For most analyses we used sex- and age-matched control patients who had had other respiratory infection but for environmental factors we used population controls. We performed conditional logistic regression analysis on data applying to 182 pairs of patients and controls. The recurrence rate was high, as 61% of the croup patients had had at least three episodes. Family history of croup was the most significant risk factor for both croup itself and recurrent croup. In multivariable analysis the odds ratio (OR) for the parents having a history of croup was 3.2 (95% CI 1.5, 7.1, P < 0.01) and 4.1 (95% CI 1.4, 11.7, P < 0.01) for recurrent croup. Parental smoking appeared to be a risk factor for respiratory infections but not for croup. Patients with croup had a cat as a pet less often than the controls, with OR 0.5 (95% CI 0.2, 1.0, P = 0.04). Family history appeared to be an exceptionally strong predictive factor for croup and its recurrence. In this patient series prone to respiratory infections recurrence of croup was common.
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Abstract
The child who has recurrent infections poses one of the most difficult diagnostic challenges in pediatrics. The clinician faces a two-fold challenge in determining first whether the child is normal or has a serious disease, and then, in the latter case, how to confirm or exclude the diagnosis with the minimum number of the least invasive tests. It is hoped that, in the absence of good-quality evidence for most clinical scenarios, the experience-based approach described in this article may prove a useful guide to the clinician.
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Affiliation(s)
- Andrew Bush
- Imperial School of Medicine at National Heart and Lung Institute, London, UK.
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35
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Hoa M, Kingsley EL, Coticchia JM. Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study. Ann Otol Rhinol Laryngol 2008; 117:464-9. [PMID: 18646444 DOI: 10.1177/000348940811700610] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES We sought to correlate endoscopic findings with the clinical course of recurrent croup. METHODS Children were classified as having recurrent croup if they had had 2 or more episodes of barky cough, inspiratory stridor, and hoarseness. All study participants underwent direct laryngoscopy and bronchoscopy and were started on an antireflux regimen. A telephone questionnaire assessed the child's symptoms and treatment response. RESULTS Forty-seven children with recurrent croup were seen in our otolaryngology outpatient clinic. Demographics included a male-to-female ratio of 1.6 to 1 and an age range of 1 month to 11 years (median, 20 months). Thirty patients (63.8%) had a medical history of asthma, and 10 (21.3%) came with a prior diagnosis of gastroesophageal reflux. Gastroesophageal reflux-related laryngopharyngeal changes were seen during direct laryngoscopy and bronchoscopy in 87.2%. Of those with survey follow-up, 87.5% had improvement of respiratory symptoms after a 6- to 9-month course of antireflux medications. This finding was further reflected in a decreased number and duration of episodes (p < .0001). CONCLUSIONS The underlying narrowing process of recurrent croup can be attributed to gastroesophageal reflux and should be considered in any child with persistent barky cough, inspiratory stridor, and hoarseness. To confirm the diagnosis, diagnostic methods should be correlated with symptom progression after treatment initiation.
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Affiliation(s)
- Michael Hoa
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, MI 48201, USA
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36
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Kwong K, Hoa M, Coticchia JM. Recurrent croup presentation, diagnosis, and management. Am J Otolaryngol 2007; 28:401-7. [PMID: 17980773 DOI: 10.1016/j.amjoto.2006.11.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Revised: 11/21/2006] [Accepted: 11/28/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE The lack of clinical insight into recurrent croup often leads to underdiagnosis of an upper airway lesion, and subsequently, inadequate treatment. This study examined the underlying etiology, diagnosis, treatment, and clinical outcome of patients with a history of recurrent croup identified at initial presentation. The aim was to present common diagnostic features and suggest new diagnostic and management recommendations. MATERIALS AND METHODS A retrospective chart review of 17 children diagnosed with recurrent croup. Demographic, historical, and intraoperative data as noted in clinic charts were collected. Specific collected data included age, sex, chief complaint, presenting symptoms, past medical history, previous medication history, number of emergency room visits and inpatient admissions, tests/procedures performed and corresponding findings, current treatment given, and posttreatment clinical outcome. RESULTS Six (35.3%) patients presented initially with a past medical history of gastroesophageal reflux disease. Fourteen (82.3%) patients had positive endoscopic evidence of gastroesophageal reflux. For these 14 patients, 44 laryngopharyngeal reflux lesions were noted, with 32 (72.7%) occurring in the subglottis. All 14 patients demonstrated various degrees of subglottic stenosis ranging from 30% to 70% (Cotton-Myer grade I-II). All 17 patients (100%) demonstrated subglottic stenosis ranging from 15% to 70% airway narrowing. CONCLUSIONS History suggestive of recurrent croup requires close monitoring and expedient direct laryngoscopy/bronchoscopy for diagnosis. Long-term follow-up and antireflux treatment are necessary as well as endoscopic documentation of significant reflux resolution.
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Affiliation(s)
- Kelvin Kwong
- Wayne State University School of Medicine, Detroit, MI 48201, USA
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37
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Ramsey CD, Gold DR, Litonjua AA, Sredl DL, Ryan L, Celedón JC. Respiratory illnesses in early life and asthma and atopy in childhood. J Allergy Clin Immunol 2006; 119:150-6. [PMID: 17208596 DOI: 10.1016/j.jaci.2006.09.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 09/11/2006] [Accepted: 09/13/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND The relation between respiratory illnesses in early life and the development of asthma and atopy in childhood is incompletely understood. OBJECTIVE We sought to examine the relationship between respiratory illnesses in early life and atopic diseases at school age. METHODS We performed a prospective birth cohort study of the relationship between respiratory illnesses in the first year of life and asthma, atopy (sensitization to >or=1 allergen), and allergic rhinitis at school age in 440 children with a parental history of atopy. Logistic regression was used to examine the relationship between respiratory illnesses and asthma, atopy, and allergic rhinitis. The relationship between respiratory illnesses in early life and repeated measures of wheezing between the ages of 1 and 7 years was investigated by using a proportional hazards models. RESULTS Physician-diagnosed croup (adjusted odds ratio [OR], 0.30; 95% CI, 0.12-0.72) and having 2 or more physician-diagnosed ear infections (adjusted OR, 0.58; 95% CI, 0.35-0.98) in the first year of life were inversely associated with atopy at school age. Physician-diagnosed bronchiolitis before age 1 year was significantly associated with asthma at age 7 years (adjusted OR, 2.77; 95% CI, 1.23-6.22). Recurrent nasal catarrh (>or=3 episodes of a runny nose) in the first year of life was associated with allergic rhinitis at age 7 years (adjusted OR, 2.99; 95% CI, 1.03-8.67). CONCLUSION The relationship between early-life respiratory illnesses and asthma and atopy is complex and likely dependent on the type of infection and immune response it initiates. CLINICAL IMPLICATIONS Certain respiratory illnesses in early life modify the risk of atopy and asthma at school age.
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Affiliation(s)
- Clare D Ramsey
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Cherry JD. State of the evidence for standard-of-care treatments for croup: are we where we need to be? Pediatr Infect Dis J 2005; 24:S198-202, discussion S201. [PMID: 16378046 DOI: 10.1097/01.inf.0000188156.23182.eb] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Croup is a term that groups several different clinical syndromes with inspiratory stridor. The failure to delineate the specific syndromes has led to suboptimal treatment in many instances. METHODS A literature review and personal experience have been analyzed. RESULTS Specific croup syndromes have been identified. Most croup steroid-treatment studies have failed to adequately identify the specific illness being treated. With 2 exceptions, all studies done to date have been too small to sufficiently evaluate risks of steroids if the risk is 1% or less. CONCLUSIONS Three conclusions were reached: (1) no steroid treatment studies of moderate or severe laryngotracheitis have been of adequate size to determine the risk of progressive viral infection or secondary bacterial infection; (2) single dose steroid treatment or limited nebulized use is probably safe; and (3) we should encourage better clinical diagnosis of croup illnesses.
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Affiliation(s)
- James D Cherry
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California-Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095-1752, USA.
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Nafstad P, Brunekreef B, Skrondal A, Nystad W. Early respiratory infections, asthma, and allergy: 10-year follow-up of the Oslo Birth Cohort. Pediatrics 2005; 116:e255-62. [PMID: 16061578 DOI: 10.1542/peds.2004-2785] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE It has been hypothesized that early infections protect against the development of atopic disease, but there have been few long-term follow-up studies. We estimated the associations between early respiratory infections and doctor-diagnosed asthma, allergic rhinitis, and skin-prick sensitization in children at 10 years of age in the Oslo Birth Cohort, established in 1992-1993. We also considered birth order and attendance at a child care center as proxy measures of increased exposure to infections early in life. METHODS A total of 2540 children were followed from birth to the age of 10 years. Experiences of respiratory infections were recorded in follow-up surveys at 6 and 12 months. At age 10, questions were asked about current symptoms of asthma and allergic rhinitis and about having ever received a doctor diagnosis for these diseases. A subsample (n = 1740) of the cohort was tested for skin-prick test reactivity. RESULTS Current asthma was related to lower respiratory tract infection (adjusted odds ratio [OR]: 2.1; 95% confidence interval: 1.3-3.0) and croup (adjusted OR: 2.3; 95% confidence interval: 1.3-4.2) in the first year. ORs for allergic rhinitis and skin-prick sensitization were smaller but mainly positive. Birth order and child care attendance at age 1 year were not significantly associated with any of the studied outcomes. CONCLUSIONS Early respiratory infections did not protect against the development of asthma, allergic rhinitis, or sensitization to common allergens during the first 10 years of life but increased the risk for asthma symptoms at age 10 in this population.
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MESH Headings
- Allergens
- Asthma/complications
- Asthma/immunology
- Asthma/prevention & control
- Birth Order
- Child
- Child Day Care Centers
- Child, Preschool
- Cohort Studies
- Follow-Up Studies
- Humans
- Infant
- Intradermal Tests
- Respiratory Hypersensitivity/immunology
- Respiratory Tract Infections/complications
- Respiratory Tract Infections/immunology
- Rhinitis, Allergic, Perennial/complications
- Rhinitis, Allergic, Perennial/immunology
- Rhinitis, Allergic, Perennial/prevention & control
- Rhinitis, Allergic, Seasonal/complications
- Rhinitis, Allergic, Seasonal/immunology
- Rhinitis, Allergic, Seasonal/prevention & control
- Surveys and Questionnaires
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Affiliation(s)
- Per Nafstad
- Department of General Practice and Community Medicine, Medical Faculty, University of Oslo, Pb 1130 Blindern, 0316 Oslo, Norway.
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Cetinkaya F, Turgut S. The relation between recurrent acute subglottic laryngitis and asthma in children. Int J Pediatr Otorhinolaryngol 2001; 57:41-3. [PMID: 11165641 DOI: 10.1016/s0165-5876(00)00436-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Acute subglottic laryngitis is caused by some viruses and may recur several times in children. Risk factors underlying the recurrences of this disease are obscure. The present study was undertaken to investigate the relation between acute subglottic laryngitis, asthma and allergy. METHODS Twenty five children with recurrent acute subglottic laryngitis were evaluated for risk factors for recurrent respiratory tract infections and allergy. Eight of the children had high IgE levels and six of them were found to be allergic by skin prick tests. RESULTS During a 1 year follow-up period four children showed asthma symptoms and in three of these patients recurrences of croup attacks disappeared after asthma treatment with nebulized budesonide. CONCLUSION We concluded that recurrent acute subglottic laryngitis may be an early sign of subsequent asthma development.
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Leclerc F, Leteurtre S, Fayoux P, Martinot A, Dorkenoo A, Sadik A, Cremer B, Fourier C. [Upper airway obstruction (foreign bodies excluded)]. Arch Pediatr 2000; 7 Suppl 1:14S-20S. [PMID: 10793942 DOI: 10.1016/s0929-693x(00)88813-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Upper airway obstruction is a frequent cause of admission to the emergency department and the intensive care unit. Symptoms are mainly represented by dyspnea and stridor. Severity must be rapidly assessed to allow adapted treatment and avoid cardiac arrest and hypoxic encephalopathy. The possible etiologies are numerous, with acquired and congenital ones, but the majority is represented by laryngitis, lymphoid hypertrophy and laryngotracheomalacia. In case of respiratory failure, treatment must first establish airway patency with bag and mask ventilation, and then intubation. If vital prognosis is not threatened, biologic, radiologic or endoscopic examination can be performed to identify the cause of the obstruction and treat it.
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Affiliation(s)
- F Leclerc
- Hôpital Jeanne-de-Flandre, Lille, France
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