acute laryngotracheobronchitis- one of the croup syndromes that affects infants.

1. A C U T E
L A R Y N G O T R A C H E O B R O N C H I T I S
BY
S A S H A B O N D I
B S C 4 . 1
U Z C H S N U R S I N G S C I E N C E D E PA R T M E N T

2. DEFINITION
• Laryngotracheobronchitis, as the name implies, refers to inflammation of the larynx,
trachea, and bronchi.
• Acute laryngotracheobronchitis (ALTB) (bacterial tracheitis or laryngotracheobronchitis)
may progress rapidly and become a serious problem within a matter of hours.
• very common cause of a cough, stridor, and hoarseness in children with a fever.

3. PATHOPHYSIOLOGY
• Viruses causing acute infectious croup are spread through either direct inhalation from
a cough and/or sneeze, or by contamination of hands from contact with fomites with
subsequent touching the mucosa of the eyes, nose, and/or mouth
• first infects the nasal and pharyngeal mucosal epithelia, then spreads to the subglottic
space.
• Inflammation and oedema of the subglottic larynx and trachea, especially near the
cricoid cartilage, are most clinically significant.
• This narrowing results in the seal-like barky cough, turbulent airflow, stridor, and chest
wall retractions.
• Decreased mobility of the vocal cords due to oedema leads to the associated
hoarseness.

5. EPIDEMIOLOGY
• the most common paediatric illness that causes acute stridor,
• is primarily a disease of infants and toddlers, with an age peak incidence of age 6
months to 36 months (3 years).
• Although uncommon after age 6 years, croup may be diagnosed in the preteen and
adolescent years, and rarely in adults.
• The disease occurs most often early winter, but may present at any time of the year.
• Approximately 5% of children will experience more than 1 episode.
• It generally occurs after an upper respiratory infection with fairly mild rhinitis and
pharyngitis

6. AETIOLOGY
• This condition is usually of viral origin,
Parainfluenza viruses. Parainfluenza viruses (types 1, 2, 3) are responsible for about
80% of croup cases, with parainfluenza types 1 and 2, accounting for nearly 66% of
cases.
Other viruses that are known to cause ALTB include the respiratory syncytial virus
(RSV), rhinovirus, enterovirus, influenza, and adenovirus
• bacterial invasion, usually staphylococcal, follows the original infection.
• Mycoplasma pneumoniae, has also been identified in a few cases of ALTB

7. CLINICAL MANIFESTATIONS
• Within 1-2 days, the characteristic signs of hoarseness,
• barking cough
• inspiratory stridor develop
• along with a variable degree of respiratory distress
• symptoms are perceived as worsening at night
• fever that may reach 40°C to 40.6°C.
• As the disease progresses, marked laryngeal oedema occurs
• the child’s breathing becomes difficult
• the pulse is rapid, and cyanosis may appear
• Heart failure and acute respiratory embarrassment can result
• Respiratory embarrassment-the signs of being. embarrassed, namely. rapid and
shallow. breathing, blushing or. blanching of the skin. of the face and ears. diaphoresis.
and palpitations. Not to be confused. with feeling ashamed.

8. ASSESSMENT AND DIAGNOSTIC
FINDINGS
• primarily a clinical diagnosis, with the diagnostic clues based on presenting history and
physical examination findings.
• Pulse oximetry- oximetry readings are within the normal reference range for most
patients
• however, this monitoring is helpful to assess for the need for supplemental oxygen
support and to monitor for worsening respiratory compromise as evident with
tachypnea and poor maintenance of oxygen saturations
• Several scoring systems can evaluate the severity of respiratory distress. The Westley
score assesses the following:
Cyanosis
Level of consciousness
Inspiratory stridor
Retractions

9. CONT…..
• can also have wheezing
• crackles
• decreased air movement,
• tachypnea
• chest wall/subcostal retractions, nasal flaring, sitting in a sniffing position, suprasternal
suprasternal retractions, grunting, accessory muscle use
• vitals, mental status, hydration status, and air movement help determine the treatment
and disposition
Sniffing
position-
mouth open
jaw thrust
forward

10. CONT…..
• Radiographs are not necessary to diagnose croup but can be obtained if the diagnosis
is unclear.
• are not required in uncomplicated cases.
• The “steeple sign,” due to subglottic narrowing, can be seen on plain films of the chest
in patients

11. Steeple sign

12. TREATMENT
• The major goal of treatment for ALTB is to maintain an airway and adequate air
exchange
• Antimicrobial therapy is ordered.
• child is placed in a supersaturated atmosphere, such as a croupette or some other kind
of mist tent, that also can include the administration of oxygen
• To achieve bronchodilation, nebulized epinephrine may be administered
• Nebulization is usually administered every 3 or 4 hours
• Nebulization often produces rapid relief because it causes vasoconstriction
• the child requires careful observation for the reappearance of symptoms
• If necessary, intubation with a nasotracheal tube may be performed for a child with
severe distress unrelieved by other measures
• Antibiotics administered parenterally initially and continued after the temperature has
normalized.

13. Mist tent

14. CONT…
• History- initial assessment, child can be observed, preferably whilst seated on the
parent’s lap at a non-threatening distance
• Respiratory status- use of accessory muscles of respiration, tracheal tug, presence (or
absence) of central cyanosis.
• General appearance- A child, who is agitated, appears to be tiring from the effort of
breathing or has a decreasing level of consciousness needs to be closely monitored
• Degree of respiratory distress- presence of stridor at rest, tracheal tug, chest wall
retractions, changing RR, changing HR (indicate treatment is necessary)

15. NURSING DIAGNOSIS
• Ineffective airway clearance related to presence of thick, tenacious mucus, and swelling
or spasm of the epiglottis as evidenced by restlessness and irritability, persistent
barking cough
• Ineffective breathing pattern related to Laryngotracheobronchial obstruction as
evidenced by nasal flaring, inspiratory stridor, tachypnea, dyspnoea
• Fatigue related dyspnoea as evidenced by exhausted appearance, lethargy
• Anxiety related to change in health status of infant/small child as evidenced by
increased apprehension that condition might worsen and hospitalization might be
necessary or prolonged (parental)
• Deficient fluid volume related to decreased ability or aversion to swallowing, presence
of fever, and increased respiratory losses

16. NURSING INTERVENTIONS
• Humidified air. Cool mist from a humidifier and/or sitting with the child in a bathroom
(not in the shower) filled with steam generated by running hot water from the
help minimize symptoms.
• Antipyretics. Treat fever with an antipyretic such as acetaminophen (paracetamol).
• Fluid intake. Encourage oral intake, and frozen juice popsicles also can be given to
ease throat soreness.
• Education on smoking. Educate caregivers to avoid smoking in the home; smoke can
worsen a child’s cough.
• Head elevation. Keep the child’s head elevated; an infant can be placed in a car seat;
a child may be propped up in bed with an extra pillow; and pillows should not be
with infants younger than 12 months of age.
• Decreasing anxiety. Young children should be kept as comfortable as possible,
allowing him or her to remain in a parent’s arms and avoiding unnecessary painful
interventions that may cause agitation, respiratory distress, and lead to increased
oxygen requirements; persistent crying increases oxygen demands, and respiratory
muscle fatigue can worsen the airway obstruction.

17. CONT….
• Vital signs monitoring. Concurrently, careful monitoring of heart rate (for
tachycardia), respiratory rate (for tachypnea), respiratory mechanics (for sternal wall
retractions), and pulse oximetry (for hypoxia) are important.
• Cool mist administration. Historically, cool mist administration was the mainstay of
treatment for croup; hospitals had “croup rooms” filled with cool mist; theoretically,
mist moistens airway secretions, decreases their viscosity, and soothes the inflamed
mucosa.

18. REFERENCES
• Hatfield, N.T. Broadribbs Introductory to Paediatric Nursing 7th edition, pg. 425-428
• Ernest S, Khandhar PB. Laryngotracheobronchitis. [Updated 2019 Mar 22]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK519531/
• https://nurseslabs.com/croup-syndrome/ retrieved 20-08-2019