Acute narrowing of larynx, conditioned by the
inflammatory edema of vocal cords and membranous space, hypersecretion of
glands, viral etiology, that is accompanied by the hard breathing (croup).
Etiology: paraenfluenza I, ІІ type, flu I, rarely
RS-, adenovirus infection.
Children are ill from 6
months till 3 years old.
It is acute widespread infection-inflammatory
disease with the phenomena of stenosis. In most cases it arises up under action
of different respiratory viruses, mainly paraenfluenza, more frequent in age
from 6 months to 3 years.
The most common pathogens are influenza viruses
(56.8%), second in frequency space occupied by parainfluenza viruses (20,1%),
third - adenovirus (16,7%), at 6.4% of
patients with acute laryngotracheitis there is a manifestation of a mixed viral
infection.
Mostly in the development of acute
laryngotracheitis a bacterial process is joined and may change the clinical
picture.
Laryngoscopic picture with stenosing
laryngotracheitis is characterized by the formation of rollers under the vocal ligaments
and the presence of mucous-purulent discharge in the tracheobronchial tree.
Some authors, except edematous form of stenotic laryngotracheitis, allocate
purulent, fibrinous, necrotic, and other forms. After the obstruction at the
level of the larynx there is a violation of drainage function of
tracheobronchial tree, resulting in the appearance of inflammation in the lower
respiratory tract, including lung tissue.
Optical laryngoscope Airtraq
Stenosis is a result of mucus and submucous tissue edema
of larynx below vocal ligaments, accumulation of mucus, reflex spasm of
muscles.
Schematic stages of the introduction of a
laryngoscope with the direct laryngoscopy and the corresponding laryngoscopic
picture – the end of a laryngoscope blade presses the epiglottis to the root of
the tongue: 1 - aryepiglottic cartilage, 2 - interaryepiglottic hollow, 3 -
vocal cords, 4 - folds of the laryngeal vestibule.
Endoscopy
image of larynx
Aquied
undercord stenosis
(narrowing
of respiratory tract)
The thickness of respiratory tracts is decreased,
resistance of air grows. Inflammation, edema, spasm, presence of inflammatory
exudation of respiratory tracts are the basic links of pathogenesis, which
result in violation of breathing, hypoxia, hypercapnia. An inflammatory process
can spread on a trachea, bronchial tubes.
Clinical classification of acute
laryngotracheitis:
I. Type of respiratory viral
infection: 1) influenza, parainfluenza, adenovirus infection, etc., and 2) ARVI
(is specified in the impossibility of clinical interpretation and the absence
of express-diagnostics).
II. Degrees of laryngeal
stenosis: 1) compensation, 2) incomplete compensation, 3) decompensation, 4)
terminal.
Clinic. The
characteristic is triad of symptoms: the change of voice, rough, “barking”
cough, stenotic breathing. More frequent stenosis laryngitis develops
suddenly among night. There are 4 degrees of larynx stenosis.
I degree (compensated stenosis): hoarse of voice, rough
“barking” cough, compensated hyperventilation of lungs, рО2 – within
the limits of norm.
The ІІ degree
(subcompensated stenosis): the child is excited, voice getting hoarse, rough,
cough increases, the inciter shortness of breath appears. A skin is moist, pallor, cyanosis of perioral triangle.
Breathing is with participation of auxiliary muscles. Hyperventilation of lungs
gradually changes on hypoventilation. Considerable tachycardia, рО2 is not reduced. Metabolic acidosis develops.
The ІІІ degree
(decompensated form of stenosis) is the severe state. A child is excited. There
are loosened voice, expressed inciter shortness of breath (inspiration is
prolonged with stenotic noise). Breathing with participation of all auxiliary
muscles. Frequent “barking” unproductive cough. A skin is pale, covered by a
cold sweat, considerable cyanosis of nasooral triangle, lips, tongue, nail
phalanges. Tones of heart are deaf, tachycardia, decreased arterial preassure,
a pulse is frequent, weak. In lungs there is decreased breathing, superficial,
is badly listened, sternum is down in. рО2 of arterial blood is reduced, рСО2 is
promoted, mixed acidosis develops (metabolic and respiratory).
The ІV degree (asphyxia): a child is in the extraordinarily severe
condition, without consciousness. Cyanosis of skin, a pallor develops later.
Breathing is superficial, frequent, with the quick stops with next deep
inspiration. At auscultation the breathing is not listened. Tones of heart are deaf, decreased
arterial preassure, a pulse is
threadlike, later bradycardia, arrhythmia develop, which
precede to the stop of heart. In a blood рСО2considerably grows
(to 100 ml Hg and higher) and рО2 considerably goes down (to 40 ml
Hg.). The child dies from the asphyxia.
Differential diagnosis of real and false croup
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Real croup
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False
croup
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Acute start
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Permanent start
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Febril high t°
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Subfebril t°
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Catarrhal sings are expressed
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Catarrhal sings are absent
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Skin is moist, cyanotic
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Skin is “toxic”, pale
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Hyperemia,
edema of pharynx
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Grey-dirty tapes on tonsils after their
scopes
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Voice is hoarse
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Aphonia
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Edema of
subcutaneous tissue is absent
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Edema of
subcutaneous tissue of neck
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Absence of signs of palate paresis
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Effluence of liquid through a nose
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Primary aim of treatment is
to pick up thread passage of respiratory tracts and remove hypoxia.
Help on prehospital stage
The volume of medical manipulations depends on the
degree of stenosis severity.
I degree:
1.
Distracting procedures:
–warm
tender baths, it is possible with mustard
–mustard plasters on a thorax, on an area of laryngs
–at allergy to mustard semialcoholic hot compress on
a thorax,
on the area of neck
–warm alkaline drink: mineral water, tea with 2
% solution of soda,
warm milk
2.
Oxygentherapy:
–warm,
moistened air
–soda
inhalations.
3.
In children with the
allergic reactions – Suprastin orally, in a dose 2 mg
per the kg
of mass; from 2 years 1 tea-spoon of Claritini in syrup.
4.
Hospitalization in the
diagnostic or infectious unit.
ІІ degree.
1.
Intramuscular 2 % solution
of Suprastini 2 mg per the kg of mass.
2.
In excitation – 0,5 %
solution of Seduxeni (Sibasoni, Relanium) in a
dose 0,3-0,5
mg per the kg of mass intramuscular, or 20 % solution
of Oxybutirati sodium in a dose 50 mg per the kg
of mass
intramuscular.
3.
Distracting procedures:
–
warm tender baths, it is possible with mustard;
–
mustard plasters on a thorax, on an area of laryngs;
– at allergy to mustard semialcoholic hot compress on a thorax, on the
area of neck.
4.
Warm alkaline drink:
mineral water, tea with 2 % soda solution, warm
milk.
5.
Oxygentherapy:
– warm,
moistened air;
– soda
inhalations.
6.
Hospitalization in the
intensive unit or chamber of intensive therapy for diagnostic or infectious
separation.
ІІІ degree.
1.
Sucking of mucus from a
mouth cavity, respiratory tracts;
2.
Oxygentherapy: warm,
moistened air through a mask;
3.
0,5 % solution of Seduxeni
(Sibasoni, Relanium) in a dose 0,3-0,5 mg
per the kg of mass intramuscular, or 20 %
solution of Oxybutirati
sodium in a dose 50 mg per the kg of mass
intramuscular;
4.
Hydrocortisoni intramuscular
in a dose 5 mg per the kg of mass or 3 %
solution of
Prednisoloni intravenously in a dose 1 mg/kg of mass.
5.
Distracting procedures:
–
mustard plasters on a thorax, on an area of laryngs;
– at
allergy to mustard semialcoholic hot compress on a thorax,
on the area of neck.
6.
Oxygentherapy through a
mask.
7.
Hospitalization in the
intensive unit of child's hospital.
ІV degree.
1.
Sucking of mucus from the
cavity of mouth, respiratory tracts.
2.
Oxygentherapy through a
mask, aerotherapy with the warm moistened
air.
3.
Intravenously streamly 3 %
solution of Prednisoloni in a dose 1-2 mg
per the kg of
mass of body.
4.
Intravenously streamly 10 %
solution of Calcium gluconatis in a dose 1
ml per the year of life.
5.
At departure on the call of
the specialized brigade and equipped
ambulance
the intubation of patient.
6.
Hospitalization in the
intensive unit of child's hospital.
Help on a hospital stage
Permanent observation of a patient who is hospitalized, the unit must be
equipped by the inhalators of the «fog» type, ІP-2 and others, by oxygen tents, in which the proper microclimate is
created (temperature 30 0C,
moisture 100 %, 40-50 % oxygen).
I degree.
1.
Inhalations by the
moistened 40 % oxygen, oxygen is possible to skip
through Bobrov apparatus,
through the water extract of camomile, clary,
infusion of
eucalyptus, 2 % alkaline solution. Treatment in a oxygen tent
2-3 times per day.
Apparatus Bobrov 1l (plastic cover with
thread, needle, syringe)
Depending on the modification Bobrov
apparatus may be used for puncture of the pleural cavity or for moistening of
oxygen.
Oxygen tent for babies and young children (up
to 3 years) is used in maternity hospitals and children's hospitals for oxygen
therapy procedures.
Oxygen therapy in the oxygent tent.
2.
Salt-alkaline inhalations or inhalations of
such composition:
–
5 % solution of ascorbic acid – 5,0;
–
5 % solution of Ephedrine – 1,0;
–0,1 % solution
of Adrenalin – 1,0;
–Hydrocortisoni
25 mg;
–3% solution of sodium
hydrocarbonatis 6,0.
On inhalation - 4 ml of solution. In the first 2 days inhalations are
done 4
times per day, on 3th day – 3 times, on 4-6th days – 1-2 times per day.
3.
Distracting therapy:
mustard plasters on a thorax, tender baths, ozocerite
or paraphine “knee-boots”, warm drink.
4.
Sucking of mucus.
ІІ degree.
1.
At the protracted stenosis
there is direct laryngoscopy for diagnostics of
inflammatory process, sucking of mucus
(clearning of tracheobronchial
tree and larynx);
2.
Protracted inhalations of
warm, moistened air, stream through mask or
under framework which covers a bed, in which a
patient is (moisture to
90-100 %, temperature to 26-30 0С) for 3-4 hours; oxygen tent.
Oxygen therapy through a mask.
3.
Inhalations with the
medicine mixture:
1)
5 % solution of Ephedrine –
0,5 (1) ml, Hydrocortisone 12,5 (25)
mg,
1 % Dimedroli
solution – 0,5 (1) ml, 0,5 % solution of sodium
chloride
– 3-4 ml (in handles there are the indicated doses for children more
senior than 1
year old),
2)
antiedema mixture: 5 % solution of
Ephedrine 1,0; 0,1 % solution of
Adrenalini 1,0; 0,1 % solution of sulfate
Atropine – 0,5; 1 % solution
of Dimedroli - 1,0; 2,5 % solution of
Pipolpheni 1,0; Hydrocortisoni
25 mg;
Hymotripsini 2 mg in 1 ml of liquids; 5 % solution of ascorbic
acid – 5,0. On one inhalation 4 ml of mixtures
are used.
Stream
inhalator
4.
At the excitation 20 %
solution of Oxybutiratis sodium intravenously
streamly slowly in a dose 50 mg per the kg of
mass.
5.
2,4 % solution of
Euphyllini intravenously streamly slowly in a dose
1 ml per the year of life on
10 % glucose solution.
6.
Intravenously in drops 10 %
Glucose solution , 0,9 % solution of sodium
chloride (in the ratio 3:1) + 5 % solution of
ascorbic acid – 1-2 ml,
Cocarboxilazae 5 mg per the kg of mass; 15-20
drops in 1 minute.
7.
Distracting therapy:
mustard plasters on a thorax, tender baths, ozocerite
or paraphine “knee-boots”.
ІІІ degree.
1. Hospitalization in intensive unit.
2. Inhalation therapy in oxygen tent, 4-6
inhalations per day.
3. 20 % solution of Oxybutiratis
sodium intravenously streamly slowly in
a
dose 50 mg per
the kg of mass; in 3-4 hours –
0,25 % solution of
Droperidoli 0,3-0,5 ml/kg of mass.
4. Direct laryngoscopy
for diagnostics of inflammatory process, clearning
of larynx, respiratory tract.
5. 3 % solution of
Prednisoloni intravenously streamly in a dose 2-3 mg per
the kg of mass.
6. Inhalations to the
aerosol: 0,1 % solution of Adrenalini 0,5-1 ml per
3 ml of isotonic solution of sodium chloride
together with oxygen
during 5-10 minutes; with a antiedema mixture.
Dummy-
inhalator that is compatible with standard sockets inhalator supply gas or
mixed medication to the nose of the child. Dummy is reusable, capable of being
sterilized by standard autoclaving or disinfectants.
Inhaler ultrasound MUSSON-1 for spray
inhalations
8. 2,4 % solution of
Euphyllini intravenously streamly slowly in a dose 1
ml per the year of life on 5-10 ml of 0,9 % isotonic solution.
9. Intravenously
in drops (20-25 drops for a minute) 10 %
solution of
Glucose, 10-20 % solution of Albumini or
similar group Plasma in a
dose 5-10 ml on the kg of mass of body;
Reopoliglucini in a dose 10 ml
on the kg of mass of body, correlation of
glucose to the salt and colloid
solutions 2:1. Common amount of liquid is a
30-50 ml/kg of mass
daily.
10. 4 % solution of
Hydrocortisoni 4-8 ml per the kg of mass intravenously
in
drops, in 2 injections under the control of acid- alkaloid balance.
11. 10 % solution of
Calcium gluconatis intravenously streamly slowly in a
dose 1 ml per the year of life.
12. Antibiotics:
1)
Cephalosporins: Duracef
(Cefadroxil), suspensia 50 mg per the kg of mass per day for 2 receptions in interval 12 hours;
Kefsoli 75-100 mg/kg of the masses per
day for 2 receptions intramuscular;
2)
Macrolides: suspensia of
Macropeni a 50 mg/kg of mass per day in 2 receptions, summamed a 10
mg/kg of mass per day.
13. Indication to intubation:
hypoxemia (рО2 below 50
mm Hg) with
concentration of oxygen during inspiration
higher 50 %; hypercapnia,
acidosis( рСО2 higher than 55
mm Hg, рН less than 7,35); encreasing
of languor,
somnolence.
Exercise
performance intubation on a mannequin (a modern
technique with using
a laryngoscope).
IV degree.
1.
Intubation with soon
artificial breathing. Advantage it to give
nasotracheal intubation, as to more sparing
and simple method.
2.
Clearning of respiratory
tract with the use of warm isotonic solution with
hydrocortisoni, euphyllini;
1 % by solution of hydrocarbonatis,
antibiotics of wide-spread action (a few times
per days);
3.
Oxygentherapy with
moistened oxygen.
Ventilator Vent201, created by the most
modern technologies, provides high quality ventilation and provides an easy
transition from noninvasive to invasive ventilation.
Ventilation, neuro-controlled respiratory
support (NAVA) Servo-I (Maquet). Allows you to maintain respiratory activity of
the patient using his own neuro impulses.
4.
3 % solution of
prednisoloni intravenously streamly in a dose of 3-5 mg
per the kg of mass or hydrocortisoni
intravenously in drops (15-30
drops in 1 minute) in a dose 15-20 mg per the
kg of mass on 100-150
ml 0,9 % sodium chloride solution.
5.
Intravenously in drops 10 %
solution of glucose, 0,9 % sodium chloride
solution, Reopoliglucini in a dose of 10 ml
per the kg of mass.
Correlation of glucose and salt solutions to
the children upto 1 year old
is 3:1 or 4:1, from 1 to 2
- 1:1. Fresh-frozen plasma in a dose 10 ml per
the kg of mass. Common amount of liquid is
40-50 ml per kg of mass
daily. To conduct infusion therapy 2 times per
day.
6.
With infusion solutions intravenously enter 5 %
solution of ascorbic
acid 1-2 ml, 10 % solution of chloride
calcium 1 ml per the year of life,
Cocarboxilazae in a dose of 5 ml per
the kg of mass.
7.
Symptomatic therapy.
8.
Dynamic observation of
paediatrician, reanimatologist, otolaryngologist.
9. Determination
of рО2, рСО2, ЕCG.
In all stages of stenosis must be indicated:
1.
Antienfluenza
gamma-globulini in 1 dose till 1 year; 2 doses till 3 years,
3 doses to the children more senior then 3 years.
2.
Observation
for the exception of diphtheria (stroke from a nose and pharynx).
3.
Consultation
of otolaryngologist.
4.
At
saving of swallowing- warm alkaline drink (mineral water, flora tea with 2 % soda solution ), milk.
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