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laryngotracheobronchitisWidespread inflammation of the voice box (LARYNX), the wind-pipe (TRACHEA) and the main air passages of the lungs (the BRONCHI). Laryngotracheobronchitis commonly causes croup, especially in children.
|Mean LOS:||3.1 days|
|Description:||MEDICAL: Otitis Media and Upper Respiratory Infection Without Major CC|
Laryngotracheobronchitis (LTB) is an inflammation and obstruction of the larynx, trachea, and major bronchi of children. In small children, the air passages in the lungs are smaller than those of adults, making them more susceptible to obstruction by edema and spasm. Because of the respiratory distress it causes, LTB is one of the most frightening acute diseases of childhood and is responsible for over 250,000 emergency department visits each year.
LTB is sometimes called croup, although croup can be more specifically described as one of three entities: LTB, laryngitis (inflammation of the larynx), or acute spasmodic laryngitis (obstructive narrowing of the larynx because of viral infection, genetic factors, or emotional distress). Acute spasmodic laryngitis is particularly common in children with allergies and those with a family history of croup. Acute LTB usually occurs in the fall or winter in North America and is often mild, self-limiting, and followed by complete recovery.
More than 85% of LTB cases are caused by a virus. Parainfluenza 1, 2, and 3 viruses; respiratory syncytial virus; Mycoplasma pneumoniae; and rhinoviruses are the most common causes. The measles virus or bacterial infections such as pertussis and diphtheria are occasionally the cause. Epiglottitis, a life-threatening emergency caused by acute inflammation of the epiglottis and surrounding area, differs from LTB because it usually results from infection with the bacteria Haemophilus influenzae type B. Another rare occurrence is subglottic hemangioma, which can initially produce symptoms of croup. Recurrent croup may be associated with gastroesophageal reflux disease (GERD).
Although some anatomical structural anomalies have been associated with an increased incidence of croup, no direct genetic link has been made.
Gender, ethnic/racial, and life span considerations
Children susceptible to LTB are generally between the ages of 3 months and 4 years, with peak incidence from 6 months to 3 years. The susceptibility decreases with age, although some children seem more prone to repeat episodes of LTB. Acute spasmodic laryngitis occurs in the same age group and peaks at age 18 months. As with many respiratory diseases, boys younger than 6 months are affected more often than girls, but in older children, the male-to-female ratio is equal. Croup is more common in white, European American children than in black, African American children.
Global health considerations
Epiglottitis usually results from infection with the bacteria H. influenzae type B. This condition is more prevalent in developing nations that do not vaccinate for influenzae type B. Generally, children contract the illness during the cool months in their climate.
The child usually has a history of an upper respiratory infection and a runny nose (rhinorrhea). The child may have dysphonia (impairment in the ability to make vocal sounds). After 12 to 48 hours of respiratory symptoms, such as cough and increased respiratory rate, the child develops a barking, seal-like cough; a hoarse cry; and inspiratory stridor. The symptoms tend to occur in the late evening and improve during the day, which may be due to the lower cortisol levels at night. The initial sign of LTB is increasing respiratory distress. The child may develop flaring of the nares, a prolonged expiratory phase, and use of accessory muscles. When you auscultate the child’s lungs, the breath sounds may be diminished and you may hear inspiratory stridor. The child may have a mild fever. Increasing respiratory obstruction is indicated by any of the following: increasing stridor, suprasternal and intercostal retractions, respiratory rate above 60, tachycardia, cyanosis, pallor, and restlessness. Assessment is done using the Westley scale, which evaluates the severity of symptoms based on five factors: (1) stridor, (2) retractions, (3) air entry, (4) cyanosis, and (5) level of consciousness. In addition, each type of croup can have particular symptoms, as shown in Table 1.
The course of the infection lasts several days to several weeks, although 60% resolve within 48 hours. Some children may have a lingering, barking cough. A child may have LTB more than once but will outgrow it as the size of the airway increases.
|FORMS OF CROUP||SYMPTOMS|
|LTB||Fever, breathing problems at night, inability to breathe out because of bronchial edema, decreased breath sounds, expiratory rhonchi, scattered crackles|
|Laryngitis||Mild respiratory distress in children, increased respiratory distress in infants; sore throat and cough, inspiratory stridor, dyspnea; late phases: severe dyspnea, fatigue, exhaustion|
|Acute spasmodic laryngitis||Hoarseness, rhinorrhea, cough, noisy inspiratory phase that worsens at night, anxiety, labored breathing, cyanosis, rapid pulse; the most severe symptoms may occur on the first night, with lessening symptoms on each of the following nights|
The parents and child will be apprehensive. Assess the parents’ ability to cope with the emergency situation, and intervene as appropriate. Note that many children are treated at home rather than in the hospital; your teaching plan may need to consider home rather than hospital management.
General Comments: Most children require no diagnostic testing and can be diagnosed by the history and physical. If diagnostic testing is needed, it involves identifying the causative organism, determining oxygenation status, and ruling out masses as a cause of obstruction.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Blood culture; throat culture||No growth; no organism identified||Causative organism identified||Distinguishes between bacterial and viral infections|
|Pulse oximetry||≥ 95%||< 95%||Low oxygen saturation is present if there is obstruction in the lung passages|
|X-rays||Normal structure||Narrowing of the upper airway and edema in epiglottal and laryngeal areas||Narrowing and/or blocked airway is characteristic of LTB|
Primary nursing diagnosis
DiagnosisIneffective airway clearance related to tracheobronchial infection and obstruction
OutcomesRespiratory status: Airway patency; Respiratory status: Gas exchange; Respiratory status: Ventilation
InterventionsAirway management; Respiratory monitoring; Vital signs monitoring; Anxiety reduction
Planning and implementation
The aim of treatment is to maintain a patent airway and provide adequate gas exchange. Medical management includes bronchodilating medications, corticosteroids, nebulized adrenaline, cool mist in a croup tent during sleep, and intravenous hydration if oral intake is inadequate. Oxygen may be used, but it masks cyanosis, which signals impending airway obstruction. Sedation is contraindicated because it may depress respirations or mask restlessness, which indicate a worsening condition. Sponge baths may be needed to control temperatures above 102°F. You may need to isolate the child if the physician suspects syncytial virus or parainfluenza infections.
Laryngoscopy may be necessary if complete airway obstruction is imminent. A flexible nasopharyngoscopy can be used; an intubation or a tracheostomy is performed only if no other method of airway maintenance is available. Keep intubation and tracheostomy trays near the bedside at all times for use in case of emergencies.
|Medication or Drug Class||Dosage||Description||Rationale|
|Racemic epinephrine||Per nebulizer, varies depending on size of child||Sympathomimetic||Dilates the bronchioles, opening up respiratory passages|
|Corticosteroids||Varies with drug||Anti-inflammatory||Decrease airway inflammation if epinephrine is not effective|
|Antipyretics||Varies with drug||Salicylates, acetaminophen, NSAIDs||Reduce fever, often present in LTB|
|Antibiotics||Varies with drug||Type of antibiotic depends on the causative organism||Fight bacterial infections|
Ongoing, continuous observation of the patency of the child’s airway is essential to identify impending obstruction. Prop infants up on pillows or place them in an infant seat; older children should have the head of the bed elevated so that they are in Fowler’s position. Sore throat pain can be decreased by soothing preparations such as iced pops or fruit sherbet. If the child has difficulty swallowing, avoid thick milkshakes.
Children should be allowed to rest as much as possible to conserve their energy; organize your interventions to limit disturbances. Provide age-appropriate activities. Crying increases the child’s difficulty in breathing and should be limited if possible by comfort measures and the presence of the parents; parents should be allowed to hold and comfort the child as much as possible. Children sense anxiety from their parents; if you support the parents in dealing with their anxiety and fear, the children are less fearful. A child’s anxiety and agitation will most likely exacerbate the symptoms and need to be avoided if possible. Carefully explaining all procedures and allowing the parents to participate in the care of the child as much as possible help relieve the anxieties of both child and parents.
Provide adequate hydration to liquefy secretions and to replace fluid loss from increased sensible loss (increased respirations and fever). The child also might have a decreased fluid intake during the illness. Clear liquids should be offered frequently. Apply lubricant or ointment around the child’s mouth and lips to decrease the irritation from secretions and mouth breathing.
Evidence-Based Practice and Health Policy
Tibballs, J., & Watson, T. (2011). Symptoms and signs differentiating croup and epiglottitis. Journal of Paediatrics and Child Health, 47(3), 77–82.
- In a prospective study that included 203 children who were admitted to an intensive care unit with acute upper airway obstruction, misdiagnoses occurred in 54% prior to a definitive diagnosis of either croup (102 children) or epiglottitis (101 children).
- Both illnesses presented with stridor; however, children with croup were more likely to present with coughing (p < 0.001), breathing difficulty (p = 0.029), and noisy breathing (p = 0.018). Children with epiglottitis were more likely to present with drooling (p < 0.001), fever (p = 0.012), dysphonia (p < 0.001), preference to sit (p < 0.001), refusal of food (p < 0.001), dysphagia (p < 0.001), sore throat (p < 0.001), and vomiting (p < 0.001).
- Coughing had a sensitivity of 100% (95% CI, 96% to 100%) in identifying croup and 98% (95% CI, 93% to 99%) specificity in ruling out epiglottitis. Drooling had a sensitivity of 79% (95% CI, 70% to 86%) in predicting epiglottitis and a specificity of 94% (95% CI, 88% to 97%) in ruling out croup.
- Respiratory status: Rate, quality, depth, ease, breath sounds
- Response to treatment: Cool mist tent, bronchodilators, racemic epinephrine, fluid, and diet
- Child’s emotional response
- Child’s response to rest and activity