Laryngotracheobronchitis [LTB] (Croup)

 

Laryngotracheobronchitis [LTB] (Croup) 

DEF: it is a severe inflammation and obstruction of the upper airway commonly affecting children between the age of 3 months – 3 years usually resulting from viral infections characterized by a sharp barklike cough and hoarseness of voice.

 

Causes

·                  LTB usually results from viral infection.

-                  Para-influenza virus

-                  Adeno virus

-                  Rhino virus

-                  Entero virus

-                  Coxsakie virus

-                  Respiratory syncytial virus

-                  Influenza viruses type A & B

-                  Measles viruses

·                  Bacteria infection

-                  B. pertusis

-                   Diphtheria

-                  Mycoplasma pneumonia

·                  Foreign bodies

·                  Trauma

Ø    Inflammation causes obstruction of the airway in different stages

ü    Narrowing of the subglotic airway causing obstruction of the subglotic air way and the larynx

ü    Narrowing of the larynx causing hoarseness of voice

ü    Narrowing of the bronchioles causing obstruction of the bronchiole tubes thus preventing air from entering or exiting the lung tissue

Signs and symptoms

·                  History of recurrent upper respiratory tract infections

·                  Nasal flaring and use of accessory muscles when breathing

·                  A sharp barklike cough and hoarseness or muffled vocal sound.

·                  Inspiratory stridor and reduced /diminished breath sounds, expiratory rhonchi and scattered crackles (on auscultation)

·                  Dyspnea

·                  Fever

·                  Breathing problems (occurring mostly at night)

·                  Restlessness and exhaustion

·                  Cyanosis

Stage I

-                  Fever, harsh brassy cough (croup cough), respiratory stridor when disturbed

Stage II

-                  Continuous respiratory stridor, chest in drawing (lower rib retraction), retraction of soft tissue of the neck, labored respirations

Stage III

-                  Signs of anoxia and carbon dioxide retention e.g. restlessness, anxiety, pallor, sweating, rapid respirations

Stage IV

-                  Intermittent cyanosis, permanent cyanosis, cessation of breathing

v    Symptoms are worse in the night especially the first two nights.

 

Diagnosis

·                  History and

·                  Physical examination – may reveal red and inflamed epiglottis 

·                  Throat culture for culture and sensitivity – identifies the offending organism and the drug they are sensitive to.

·                   Blood culture – to distinguish between bacterial and viral infection

·                  X-ray of the neck – may reveal narrowed airway and inflammation (edema) around the subglotic fold or a foreign body in the neck

·                  Laryngoscopy – reveals inflammation and obstruction in the epiglottal and laryngeal area.

·                  Complete blood count – may reveal raised white blood cells due to presence of infection.

·                  CT scan -

 

Treatment

AIMS

·                  Maintain a clear airway and provide for adequate gaseous exchange

·                  Promote Rest

·                  Cool humidification

·                  Analgesics e.g. Acetaminophen

·                  Oral or intravenous fluids

·                  Antibiotics in bacterial infection

·                  Oxygen therapy

·                    Corticosteroids /Epinephrine – reduce airway swelling

·                  Intubation – performed when other methods of preventing respiratory failure have failed.

 

Complications

 

1.                Airway obstruction

2.                Respiratory failure

3.                Dehydration

4.                Ear infection e.g. Otitis media 

5.                Pneumonia

 

Nursing management

·                  Nursing care plan

-                  Identified problems

i.                 Anxiety /fear

ii.                Hyperthermia

iii.               Impaired gas exchange

iv.               Ineffective airway clearance

v.                Knowledge deficit

 

Nursing management

Aims

1.                Promote adequate ventilation

2.                Promote rest and comfort

3.                Promote adequate nutrition and hydration

4.                Offer psychological care and alley anxiety

 

Environment

-                  Isolate patient suspected having respiratory syncytial virus and Para influenza virus

-                  Wash hands before and after attending to these patients to avoid transmitting the infection to others especially infants.

-                  Tepid sponge, open windows, offer a worm drink or provide a fan to control fever by evaporation, radiation, conversion or conduction.

 

Observation

-                  Monitor cough and breathe sounds, hoarseness, severity of retraction, respiratory stridor, cyanosis, respiratory rate, heart rate, fever, and restlessness.

-                  Watch for seizures in children with high fever

-                  Watch for signs of complete airway obstruction such as increased heart rate and respiratory rate, increased restlessness and nasal flaring

 

Rest and activity

-                  Keep the child as quiet as possible by providing a quiet environment, avoiding sedation which may depress the respiratory center

-                  Control the patient’s energy output and oxygen demand by age appropriate diversional activities to keep him quiet occupied

 

Position

-                  Nurse an infant in an infant seat or prop him up with a pillow, place an older child in a fowler position to aid in easy breathing

Hygiene

-                  Change beddings as necessary to keep the patient dry and comfortable as possible

 

Pain relief

-                  Relieve sore throat with soothing, water based ice,

-                  Avoid thicker,  milk based products if patient has difficulties in swallowing 

-                  Apply petroleum jelly on the nose and lips to reduce irritation from nasal discharge and mouth breathing

 

Psychological care

-                  Reassure the parents/care taker

-                  Explain the condition and all procedures done on the patient

-                  Allow the parents to ask questions if they have any

-                  Allow them to handle the baby

 

Medication

-                  Control fever with antipyretics e.g. Paracetamol

-                  Antibiotics can be administered to combat bacteria infection

 

Information, Education and Communication

i.                 Educate the parents on the use of cool-mist humidifier (vaporizer) or boiling cattle in the home to humidify the air.

ii.                Urge the parents to seek medical attention if the patient has earache, productive cough, high fever or increased shortness of breath.

iii.               Educate the parents on the importance of rest to the patient to conserve energy and limit oxygen needs

iv.               Educate the parent on the importance of keeping the patient in a prop up or semi-fowler position to aid in easy breathing

v.                Advice the parents to give the patient a lot of fluids to promote adequate hydration and electrolyte and to soothe the throat

vi.               Advice parents never to use NSAIDs e.g. Aspirin to reduce fever because of associated Reye’s syndrome.