Paediatrics: Laryngeal and tracheal inflammation

Laryngeal and tracheal inflammation

There are a number of laryngeal and tracheal causes of inflammation and airway obstruction. In the acute setting you will be concerned with three common conditions.

·  Viral laryngotracheobronchitis (croup): mucosal inflammation affecting anywhere from the nose to the lower airway that is commonly due to parainfluenza, influenza, and respiratory syncytial virus in children aged 6mths to 6yrs.

·  Spasmodic or recurrent croup: barking cough and hyperreactive upper airways with no apparent respiratory tract symptoms.

·  Acute epiglottitis: life-threatening swelling of the epiglottis and septicaemia due to Haemophilus influenzae type b infection—most commonly in children aged 1–6yrs. This is now rare since routine HiB immunization.

Diagnosis

History In practice the two main conditions that require differentiating are viral croup and acute epiglottitis. The history may help in this process (see Table 9.2).

Examination

Do not examine the throat. Take a careful assessment of severity including:

·  Degree of stridor and subcostal recession.

·  Respiratory rate.

·  HR.

·  LOC (drowsiness), tiredness, and exhaustion.

Pulse oximetry.

Treatment

Priority

The main priority in the emergency setting is to differentiate between acute epiglottitis and viral croup (see Table 9.2). If you are unsure, stabilize the child and ensure that nothing precipitates distress and possible airway obstruction. Try and keep the child, family, and staff calm. Alert emergency otolaryngologist and anaesthetist to the possibility of a need for emergen-cy airway support.

Viral croup

Children with mild illness can be managed at home, but advise parents that if there is recession and stridor at rest then they will need to return to hospital. Infants <12mths may need closer attention. Treatments include the following.

·Moist or humidified air: although widely used to ease breathing the benefit of these physical measures is unproven.

·Steroids: oral prednisolone (2mg/kg for 3 days) or oral dexamethasone (0.15mg/kg stat dose) or nebulized budesonide (2mg stat dose) reduces the severity and duration of croup. They are also likely to reduce the need for endotracheal intubation.

·Nebulized adrenaline (epinephrine): can provide transient relief of symptoms.

In cases that require endotracheal intubation steroids should be given and, if there is evidence of secondary bacterial infection or bacterial tracheitis, antibiotics should be added.

Acute epiglottitis

The child with acute epiglottitis will need to be managed in the intensive care unit after endotracheal intubation. Once this procedure has been completed take blood cultures and start IV antibiotics.

·2nd or 3rd generation cephalosporin (e.g. cefuroxime, ceftriaxome, or cefotaxime) IV for 7–10 days.

·Rifampicin prophylaxis to close contacts.