Croup Disease Assignment: Respiratory Disease In Children

Question

Task: For this assessment, you will produce an informative article that describes the pathophysiology of a specific disease or condition, as well as present the pharmacology used to address this. The target lay audience will be chosen by you, and you will specify this within your abstract.
Your topic is to focus on the disease/disorder plus pharmacology that you have selected using the StudyDesk Topic Selection activity. This topic selection activity will open at 9:00am on Monday 24th February and will close at 12:00pm MIDDAY on Wednesday 18th March. After this date, any student who has not chosen a topic will be randomly assigned to one. Students affected will be notified of their topic via an email to their USQ email address.
Please note that each topic is also capped, with only 100 students able to select each topic on a first-come first-served basis. So, if there is one particular topic that you are interested in, please ensure that you enter your selection as early as possible so that you don’t miss out!
You will then research your specific disease/disorder and the indicated pharmacology for your chosen audience. From this you will produce an informative article that describes the affected system (the normal physiology), what has gone wrong to cause the disease (the pathophysiology), and then how the related pharmacology is used to address it. Ensure that you use the marking criteria (included below) to ensure that you are addressing all of the required details.
You must also complete and submit a short (250 word) abstract. This abstract will be presented to an educated audience (for example, your peers), and must provide a succinct summary of the article, as well as include a statement about your chosen target audience.

Answer

Abstract:
The investigation carried on the scenario of croup disease assignment signifies that in United States, approximately 15 percent of the children admitted in the emergency department for a respiratory illness are due to the Croup disease. The early symptoms of the disease include infection in the upper respiratory tract, which is accompanied by coryza and low-grade fever, which is then followed by respiratory distress of different degrees and barking cough. In majority of the cases in children, with reduction of cough by the second day, the symptoms diminish. Various viruses are the main reason behind the disease, with most common being parainfluenza virus, types 1, 2, and 3. Most of the child patients, who show the symptoms of the disease like acute barking cough, chest-wall in drawing and stridor, are diagnosed with the same. In order to confirm diagnosis, a careful physical examination and history check is done. This way, it can be ensured that the child does not have any potentially dangerous disease like epiglottitis, per tonsillar abscess, foreign body aspiration or bacterial tracheitis. All the patients suffering from the disease are given a single dose of dexamethasone orally, approximately 0.15-0.60 mg per Kg. The same is administered on the patients with mild symptoms as well. For temporary relief from the airway obstruction, epinephrine is administered through a nebulizer. Treatment of the disease mainly relies on corticosteroids, which has proven to be effective in child cases of all different levels of severity, even the mild ones. Generally, the cases of croup are mild, wherein roughly 1 to 8 percent of the patients require admission into a hospital and even lesser share (less than 3 percent) of patients needing intubation.

Introduction:
Croup, which is also called laryngotracheobronchitis, is related to the beginning of acute barking cough along with stridor due to the infection in upper respiratory tract. This respiratory disease explored in the present context of croup disease assignment is common amongst children and causes obstruction in the airway. Nebulized adrenaline and corticosteroids is the mainstay used in the therapy of the disease, for reducing the narrowing of airway and prevention of endotracheal intubation. In cases where these measures do not work, to impede the airway obstruction, definitive airway management is needed. From the early 1990s, there has been various studies, first on intubated children and then on non-intubated children, which were later supported by more subsequent studies, have led to a widespread use of corticosteroids, due to which there has been a reduction in the morbidity and severity of the disease (Ortiz-Alvarez, 2017). Due to these effective interventions, use of airway intervention during the treatment of croup is decreasing. In Australia and New Zealand, a recent emergency department physician’s survey shows almost everyone recommending the use of corticosteroids for patients with mild to severe croup. But, the management of the disease in children who are admitted in the intensive care is not yet well described.

It is observed in this croup disease assignment that the disease is more common in boys as compared to girls (with a ratio of 14:1), affecting children between the age of 6 months to 3 years more often as compared to younger infants and older ones (Bjornson & Johnson, 2013). The disease is caused in respiratory tract due to viral infection which causes inflammation of upper airway and edema, and airway’s subglottic region getting narrowed due to laryngeal mucosa. The most common pathogen for the disease is human parainfluenza virus, type 1 and 3. The peak of the number of cases of the disease occurs in the late fall, indicating a seasonal pattern. And with approximately 50 percent higher cases in years that are odd numbered, there seems to be an annual pattern too.

Physiological factors:
A research conducted over a long duration on the scenario of croup disease assignment, suggests that children of age between 6 months to 3 years are more prone to the disease, at the same time the disease can also affect children younger than 3 months and older than 12 years. The study also suggests that the chances of the disease happening in adults are very rare. The infection can occur in any season, but the chances are higher in the late autumn. Numerous viral agents can be the reason behind the disease and sometimes the cause can be Mycoplasma pneumonia. Almost 75 percent of the cases are due to parainfluenza, type 1 parainfluenza being most common amongst those. The researches considered to prepare this croup disease assignment have shown that the rest of the cases can be due to rhinovirus, human metapneumovirus, respiratory syncytial virus, adenovirus, influenza A and B viruses and coronavirus (Lin, et al., 2017). When laryngeal mucosa is invaded by virus, inflammation, oedema and hyperaimia occur. As a result, the subglottic region narrows down. Children are able to compensate the narrowing of the region by breathing deeply and rapidly. As the narrowing increases in children with more severe illness, the increase in effort of breathing which was helpful in milder cases becomes counter-productive. The flow of air becomes turbulent through the upper airway, due to which the compliant wall of chest starts caving in during respiration, making the breathing to be paradoxical, as a result of which the child is fatigued all the time. In the extreme cases, if the child is not treated on time, they might become hypercapnoeic and hypoxic, which might end up in respiratory failure.

Pathophysiology:
The disease, as a result of white blood cell’s infiltration causes swelling in the trachea, large bronchi and larynx. The swelling causes partial obstruction in the airway, which can dramatically increase the pressure on breathing and stridor (noisy airflow), if the swelling becomes significant. The virus causing the disease also leads to airway oedema, as it activates secretion of chloride and inhibition of sodium absorption throughout the tracheal epithelium. As a result, there is narrowing of the subglottic region, resulting in barking cough, indrawing of chest-wall, and stridor and turbulent airflow. The study outlined in this section of croup disease assignment illustrates that any further narrowing leads to asynchronous chest-wall, fatigue and eventually respiratory failure.

What are the underlying mechanisms responsible for the disease mentioned in the croup disease assignment?
The most common cause of the disease is virus. But, it is also stated herein croup disease assignment that it can also be caused by allergies, reflux or bacteria. Following bacteria are known to cause the illness:

• Parainfluenza virus
• Enteroviruses
• Respiratory syncytial virus (RSV)
• Adenovirus
• The flu (influenza virus)

The disease examined in the present context of croup disease assignment can spread when someone comes in direct contact of an infected person or his/her body fluids. The infection generally begins in the nose and throat and then proceeds to the lings. The voice box (larynx) and the windpipe (trachea) are affected by swelling due to the illness.

The disease affects the younger children more as they have a smaller airway. Even a little swelling can make breathing difficult for a baby or young child. The peak age for the disease to occur is 2 years, while it more often affects children in the age bracket of 3 months to 3 years (Gelbart, et al., 2016).

Pharmacology:
Anti-inflammatory action:
Glucocorticoids are most commonly prescribed medication for the illness due to their anti-inflammatory effects. The use of this medication has been extended to numerous diseases over the time. Their anti-inflammatory activity spectrum is very broad, covering both cellular and humoral system. As a response to various stimuli like mechanical, radiant, chemical, infectious and immunological, they suppress or prevent the swelling.

Action Mechanism:
As per the research on croup disease assignment, corticosteroids regulate the functioning of corticosteroid-responsive genes in the target tissues by binding to the particular intracellular receptors in the tissues, as a result of which the levels of proteins produced by the tissues is changed. Since the time required modulating the protein synthesis and gene expression is longer, the effects of such genomically mediated medicines are not immediate. This finding obtained in the croup disease assignment is important clinically due to the reason that the desired effects of a therapy involving corticosteroid are visible after a certain delay. In mechanisms where the corticosteroid is through non-genomic route, the response can be seen immediately (Muñoz-Osores & Arenas, 2017).

Pharmacokinetics:
Oral route has been identified to be helpful in the absorption and effectiveness of all types of corticosteroids (Cutrera, et al., 2017). In order to achieve high concentrations of the medicine in the fluids of the body, it is mentioned in the croup disease assignment that few water-soluble esters of hydrocortisone may be given intravenously. Systematic absorption of glucocorticoids happens when it is administrated at local sites. More than 90 percent of the plasma cortisol gets reversibly bound to proteins after absorption. A small amount of corticosteroid is free and can enter the cells.

All corticosteroids those are biologically active in nature, metabolize extensively in liver. Synthetic steroids containing 11-keto group like prednisone and cortisone should reduce enzymatically to 11β-hydroxyl derivatives in order to be biologically active in nature.

In circumstances in which this activity is disturbed, it is desirable to use steroids those don’t require activation by enzyme (e.g. Prednisolone or hydrocortisone). Furthermore, solution of prednisolone produces about 20% higher plasma level of prednisolone. Almost 15 min before than tablets does. So, liquid form of prednisolone is much more suitable to use for the children compare to tablets that are hard to swallow.

Route of Administration:
There have been numerous studies done in the scenario of croup disease assignment in order to determine the most suitable method to administer corticosteroids to children suffering from croup. Oral or intramuscular route has been identified to be most effective through the studies. In instances where the patient is vomiting, the practicality of the method to be used comes into the picture, as for such a patient administering the drug orally becomes impossible. Even the cost of using the treatment method is considered while decision making.

Symptoms:
The symptoms of the disease get worse during the night and can vary rapidly depending upon the mental state of the child, whether the child is agitated or calm. Generally, the symptoms do not last for long, with barking cough going away in approximately 48 hours in about 60 percent of child patients, and symptoms continuing for more than 5 nights in less than 2 percent cases in children (Sizar & Carr, 2019).

Croup has different symptoms associated with it. They may vary between:

• Fever
• Barking Cough
• Runny or stuffy nose
• Stridor
• Laryngitis

Precautions:
One of the major causes of croup mentioned herein croup disease assignment is laryngeal diphtheria, which occurs very rarely in current population due to immunization. In non-immunized children, the main cause of the illness is measles. Rare instances of the illness amongst the children who are immunized indicate that significant progress can be made in developing countries to immunize their population in order to fight against such pathogens.

Other lifestyle methods that can improve the health status:

• A child should take proper rest and drink plenty of water
• Discontinue smoking at your home as it can make worsen your child cough.
• For elevation of your child head put few extra pillows under his/her head. In case of babies below 1 year of age, pillows should not be used.
• A wet and warm washcloth can be used to ease breathing by covering nose and mouth with it.

The spread of the disease can be prevented by the following points mentioned below within the croup disease assignment:

• Washing hands regularly and correctly.
• Cups and other dishware should not be shared amongst children
• The patient must stay at home till they are fine.

Other Medications:
Epinephrine: In cases of moderate to severe croup, nebulized epinephrine is prescribed. Use of the medication in children suffering from severe croup, resulted in lesser instances of requirement of intubation. The drug shows better signs of improvement within 10-30 minutes of initiation as compared to the placebo.

Heliox: This is the mixture of helium and oxygen, which is used to reduce the distress in severe cases of croup in children. Helium gas being of lower density reduces the turbulence of airflow in the narrowed airway. This method outlined in the croup disease assignment does not improve the symptoms of croup and hence is not usually prescribed.

Conclusion: The above discussion presented in the croup disease assignment concludes that use of corticosteroids is still widespread in the treatment of croup in children, even after 50 years of controversy over its usage. On the other hand, it is also clear on this croup disease assignment that there is comparatively lesser research done on epinephrine; hence it is used to relieve the symptoms in short-run till the time corticosteroids can show their effect. There is conclusive evidence present based on numerous research, that proves the ineffectiveness of mist as a treatment for croup. Use of corticosteroids and epinephrine, have shown significant results in children suffering from croup, which results in a decrease in intubations, number of hospital admission and revisits to doctors, hence reducing the health care cost and the burden of the illness on the patient’s family.

References
Bjornson, C. L., & Johnson, D. W. (2013). Croup in children. Canadian Medical Association Journal.

Cutrera, R., Baraldi, E., Indinnimeo, L., Giudice, M. M. D., Piacentini, G., Scaglione, F., Ullmann, N., Moschino, L., & Marzia, F. G. D. (2017). Management of acute respiratory diseases in the pediatric population: the role of oral corticosteroids. Italian Journal of Pediatrics.

Gelbart, B., Parsons, S., Sarpal, A., Ninova, P., & Butt, W. (2016). Intensive care management of children intubated for croup: a retrospective analysis. Anaesth Intensive Care, 245–250.

Lin, S. C., Lin, H. W., & Chiang, B. L. (2017). Association of croup with asthma in children: A cohort study. Medicine, 96(35).

Muñoz-Osores, E., & Arenas, D. ( 2017). What is the effectiveness of systemic corticosteroids in children with croup? . Croup disease assignment Medwave.

Ortiz-Alvarez, O. (2017). Acute management of croup in the emergency department. Paediatrics & Child Health, 166–169.

Sizar, O., & Carr, B. (2019). Croup. Treasure Island: StatPearls Publishing.