DRG Category: 153
Mean LOS: 2.9 days
Description: Medical: Otitis Media and Upper Respiratory Infection Without Major Complication or Comorbidity
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). Croup is the most common pediatric illness and causes 15% of all clinic and emergency department visits for child-related respiratory infections. 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. Complications include secondary bacterial infections such as pneumonia, pulmonary edema, pneumothorax, dehydration, and otitis media. Factors that are related to asthma later in life include recurrent episodes of croup.
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). Risk factors include prematurity, children with narrow upper airways, and asthma.
Although some anatomical structural anomalies have been associated with an increased incidence of croup, no direct genetic link has been made.
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 as compared to Black children, but Black children are more likely to undergo diagnostic bronchoscopy or require intubation than other children. Experts suggest that this difference is related to a higher prevalence of subglottic stenosis in Black children. Sexual and gender minority status has no known effect on the risk for croup.
Epiglottitis usually results from infection with the bacteria H influenzae type B. This condition is more prevalent in developing countries that do not vaccinate for influenza B. Generally, children contract the illness during the cool months in their climate.
PLANNING AND IMPLEMENTATION
Collaborative
The aim of treatment is to maintain a patent airway and provide adequate gas exchange. Medical management includes bronchodilating medications, corticosteroids, nebulized adrenaline, and IV hydration if oral intake is inadequate. The role of cool mist or humidification therapy is controversial. 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 indicates a worsening condition. Sponge baths and antipyretic medications may be needed to control temperatures above 102°F (38.9°C). 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 | Dexamethasone, prednisone, prednisolone, budesonide inhaler | Decrease airway inflammation if epinephrine is not effective |
| Antipyretics | Varies with drug | Acetaminophen, NSAIDs | Reduce fever, often present in LTB |
| Antibiotics | Varies with drug | Type of antibiotic depends on the causative organism | Fight bacterial infections |
Independent
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 the Fowler 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
Coughran, A., Balakrishnan, K., Ma, Y., Vaezeafshar, R., Capdarest-Arest, N., Hamdi, O., & Sidell, D. (2021). The relationship between croup and gastroesophageal reflux: A systematic review and meta-analysis. Laryngoscope, 131, 209–217.
- The authors conducted a systematic review with a meta-analysis component to evaluate the relationship between recurrent croup and GERD. They aimed to assess for evidence of improvement in croup symptoms when GERD is treated. The authors searched five separate databases according to prespecified criteria.
- Thirteen of 15 articles support an association between recurrent croup and GERD. Most studies lacked a control group, and all carried a moderate-to-high risk of bias. Further research is needed to assess for causality as most studies were retrospective, lacked a control group, and had a study design exposing them to bias. Patients treated with reflux medication appeared to demonstrate a reduced incidence of croup symptoms.