Laryngeal & tracheal infections

1. characteristics
   1. stridor
      1. rasping sound heard mostly on inspiration
   2. hoarseness
      1. inflammation of vocal cords
   3. barking cough (like sea lion)
   4. dyspnoea
      1. variable degrees of
2. assessment of severity
   1. degree of chest retraction
      1. none
      2. only on crying
      3. at rest
      4. recession
         1. subcostal
         2. intercostal
         3. sternal
         4. more useful indicator of severity than RR
   2. degree of stridor
      1. none
      2. only on crying
      3. at rest or biphasic
3. if severe, complications...
   1. increasing resp rate
   2. increasing heart rate
   3. agitation
   4. central cyanosis or drowsiness
      1. means severe hypoxaemia
         1. need urgent intervention
         2. measure O2 sats
            1. pulse oximetry
4. Mx of acute upper airways obstruction
   1. don't examine throat!
      1. total obstruction of airway can be ppted by examn of throat using a spatula
      2. don't look at throat unless full resus eqpt & personnel are at hand
   2. reduce anxiety
      1. be calm, confident, well organised
   3. observe carefully for
      1. signs of hypoxia
      2. signs of deterioration
   4. if severe
      1. adminster nebulised adrenaline
      2. get anaesthetist!
   5. if resp failure develops

      Annotations:

      • from increasing airway obstruction, exhaustion or secretions blocking the airway
      1. urgent tracheal intubation

1. mucosal inflammn
2. increased secretions

1. may -> critical narrowing of trachea

1. virus
   1. account for > 95% of laryngotracheal infections
   2. parainfluenza
      1. commonest cause
   3. human metapneumovirus
   4. RSV
   5. influenza

1. 6mths- 6 years old
2. peak incidence @ 2 yrs old
3. commonest in autumn

1. severe barking cough
2. harsh, rasping stridor
3. hoarseness (voice, cry)
4. sx start & are worse @ night
   1. onset of sx over days
5. fever (<38.5 C) & coryza precede other sx
6. unwell appearance

1. inhalation of warm moist air
   1. often used but benefit unproven
2. steroids
   1. oral dexamethasone
   2. oral prednisolone
   3. nebulised steroids
      1. budesonide
   4. reduce severity & duration of croup
      1. reduce need for hospitalisation
3. mild upper airway obstruction
   1. stridor & chest recession disappear when @ rest
   2. manage child @ home
      1. parents observe child for signs for increasing severity
4. manage @ home or hosp?
   1. factors to consider
      1. severity of illness
      2. time of day
      3. ease of access to hosp
      4. parental understanding & confidence about illness
      5. child's age
         1. low threshold for admin for those <12 mths
            1. narrow airway calibre
5. severe upper airway obstruction
   1. nebulised adrenaline w/ O2 by facemask
      1. -> transient improvement
   2. close monitoring + anaesthetist/intensivist advice
      1. reduce risk of rebound sx
         1. rebound sx occur once effects of adrenaline diminish (after about 2 hrs)
   3. tracheal intubation
      1. few children

1. may be related to atopy

1. but
   1. high progressive fever
   2. toxic appearance
   3. rapidly progressive airway obstruction
      1. w/ copious thick airway secretions

1. Staph aureus

1. IV Abx
2. intubation (if need)
3. ventilation (if need)

1. due to high risk of resp obstruction

1. Haem influenzae type b
   1. Hib vaccine -> >99% decrease in incidence

1. assoc w/ septicaemia

1. commonest in 1-6 yr olds
   1. but all age groups affected

Annotations:

• note: must distinguish acute epiglottitis from croup AE  - NO PRECEDING CORYZA -absent or slight cough -fever &gt; 38.5 C -not able to drink -child appears v ill, toxic -soft, whispering stridor -muffled voice/cry, reluctant to speak 

1. acute onset (over hours)
2. v ill, toxic-looking child
3. intensely painful sore throat
   1. can't speak or swallow
   2. saliva drools down chin
4. soft inspiratory stridor
5. rapidly increasing resp difficulty over hours
6. child sits immobile, upright, w/ open mouth
   1. optimise airway
7. fever (>38.5 C)
8. absent or slight cough

1. urgent hosp admin & treatment
2. get
   1. senior anaesthetist
   2. paediatrician
   3. ENT surgeon
3. direct transfer to ICU or anaesthetic room
   1. intubate under controlled conditions under general anaesthetic
      1. if impossible (rare)
         1. urgent tracheostomy
      2. after securing airway
         1. take blood
            1. culture
            2. then give iv Abx e.g. cefuroxime
               1. 3-5 days
         2. remove tracheal tube after 24 hrs
            1. most recover completely within 2-3 days
4. prophylaxis offered to close household contacts
   1. riifampicin

1. lie child down
2. perform lateral neck X ray
   1. ppt total airway obstruction & death