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Saint Louis University

Baguio City
School of Nursing

CASE STudy

Acute
Laryngotracheobronchitis

Members:

Mejia, Ronnel
Candelario, Lorraine Anne
Indong, Roann Grace
Tolentino, Katrene Aira
Villator, Mary Denise

I.

INTRODUCTION

Agh-agh, that is what you can hear in a child with acute respiratory
distress. Coughing that causes fatigue and weakness is one of the signs and
symptoms that the health care professionals wanted to address.
Croup (or laryngotracheobronchitis) is a respiratory condition that is
usually triggered by an acute viral infection of the upper airway. The infection
leads to swelling inside the throat, which interferes with normal breathing and
produces the classical symptoms of a "barking" cough, stridor, and hoarseness. It
may produce mild, moderate, or severe symptoms, which often worsen at night. It
is often treated with a single dose of oral steroids; occasionally epinephrine is used
in more severe cases. Hospitalization is rarely required.
Croup is diagnosed on clinical grounds, once potentially more severe causes
of symptoms have been excluded (i.e. epiglottitis or an airway foreign body).
Further investigationssuch as blood tests, X-rays, and culturesare usually not
needed. It is a relatively common condition that affects about 15% of children at
some point, most commonly between 6 months and 56 years of age. It is almost
never seen in teenagers or adults.
Croup is characterized by a "barking" cough, stridor, hoarseness, and difficult
breathing which usually worsens at night. The "barking" cough is often described as
resembling the call of a seal or sea lion. The stridor is worsened by agitation or
crying, and if it can be heard at rest, it may indicate critical narrowing of the
airways. As croup worsens, stridor may decrease considerably.
Other symptoms include fever, coryza (symptoms typical of the common cold), and
chest wall indrawing. Drooling or a very sick appearance indicate other medical
conditions
Croup is usually deemed to be due to a viral infection. Others use the term more
broadly, to include acute laryngotracheitis, spasmodic croup, laryngeal diphtheria,
bacterial
tracheitis,
laryngotracheobronchitis,
and
laryngotracheobronchopneumonitis. The first two conditions involve a viral infection
and are generally milder with respect to symptomatology; the last four are due to
bacterial infection and are usually of greater severity.
Viral croup/acute laryngotracheitis is caused by parainfluenza virus, primarily types
1 and 2, in 75% of cases. Other viral etiologies include influenza A and B, measles,
adenovirus and respiratory syncytial virus (RSV). Spasmodic croup is caused by the
same group of viruses as acute laryngotracheitis, but lacks the usual signs of
infection (such as fever, sore throat, and increased white blood cell count).
Treatment, and response to treatment, are also similar.
Bacterial croup may be divided into laryngeal diphtheria, bacterial tracheitis,
laryngotracheobronchitis,
and
laryngotracheobronchopneumonitis.
Laryngeal
diphtheria is due to Corynebacterium diphtheriae while bacterial tracheitis,
laryngotracheobronchitis, and laryngotracheobronchopneumonitis are usually due
to a primary viral infection with secondary bacterial growth. The most common
bacteria implicated are Staphylococcus aureus, Streptococcus pneumoniae,
Hemophilus influenzae, and Moraxella catarrhalis.

The viral infection that causes croup leads to swelling of the larynx, trachea, and
large bronchidue to infiltration of white blood cells (especially histiocytes,
lymphocytes, plasma cells, and neutrophils). Swelling produces airway obstruction
which, when significant, leads to dramatically increased work of breathing and the
characteristic turbulent, noisy airflow known as stridor.

STATISTICS OF LARYNGOTRACHEOBRONCHITIS IN BAGUIO CITY

MORBIDITY AND MORTALITY

The prevalence of acute laryngotracheobronchitis in the year 2007 was


estimated to be 2,065 FHSIS (Field Health Services Information Sytems) 21 cases
in hospitals and R/100,000 of 704.83 with a total of 2,086. However in the year
2006, the City of Baguio in collaboration with the Department of Health-Baguio
Chapter and Baguio General Hospital and Medical Center presented a data with
R/100,000 in Baguio, 674.33 and there were 9 cases of t ransients with a total of
2,095. The implication of this is that it is included in the top ten causes of morbidity,
especially among children. In fact, it was listed as the top three causes of illnesses
and ailments. Fortunately, acute laryngotracheobronchitis, also known as croup is
not included among the top ten leading cause of mortality.

STATISTICS OF LARYNGOTRACHEOBRONCHITIS IN THE PHILIPPINES

MORBIDITY AND MORTALITY

In the year 2001, the prevalence of incidence of acute laryngotracheobronchitis


was estimated to be 694, 836. After a year, it declined to 629, 968. In 2003, it
lowered down and estimated to be 604, 107. In the year 2004, suddenly it started to
increase again with a total number of 719, 982 cases in the Philippines. However in
the
succeeding
years,
there
were
no
reported
cases
of
acute
laryngotracheobronchitis.
II.

OBJECTIVES

Why did we choose this?


Based on the above reports, there is an alarming increase in the cases of
Acute Laryngotracheobronchitis.
We chose the case because it is very informative, aside from that it can be
applied to most of our patients in the Pediatric ward.
Objectives why we chose the case

To explain further and share the information to the group regarding the

pathology and disease process of Acute Laryngotracheobronchitis.


To present newly discovered management to alleviate the signs and

symptoms of the said condition.


To identify home remedies and intervention to rule out the factors that

lead to acute laryngotracheobronchitis.


To present the background and statistics of the condition globally,

nationally and regionally.


To present the case of the patient and relate it with the case of the other
patients

III.

PATIENTS PROFILE

A. DEMOGRAPHIC DATA
Name of Patient
:
Age
:
Name of Father
Occupation
:
Name of Mother
:
Occupation
:
Gender
Birthdate
:
Civil Status
:
Address
Religion
Nationality
:
Date Admitted
Admitting physician
Admission Diagnosis

TAYNAN, RYDLE
2 years old
:
David Taynan
Farmer
Rhealyn Taynan
Housewife
:
Male
September 21, 2009
Single
:
Bongli, Paway Atak, Benguet
:
Roman Catholic
Filipino
:
February 06, 2012
:
Sharon B. Gawigauen M.D.
:
Acute Laryngotraceobronchitis

B. PATIENTS MEDICAL HISTORY


a. Chief Complaint
Coughing and poor oral intake
b. History of Present Illness
3 days prior to admission the child had dry hooking cough with poor oral
intake. The mother claimed that her son has productive cough and tenacious
secretions. Prior to admission there were no vomiting, diarrhea and fever noted. The
mother sought consultation to a private physician due to the persistent coughing.
They were advised for admission. Hence, patient was admitted.
c. History of Past Illness
At the age of 6 months old patient was diagnosed to have primary complex
disease and he is taking rifampicin at present.
At birth he has cough and colds and was previously diagnosed to have
asthma.
d. Family History

Family has history of hypertension, diabetes mellitus and stroke for noncommunicable disease. And for communicable disease, the family has history of
pulmonary TB.
e. Environmental History
At home, the family practices waste segregation. Currently, patient was confined,
therefore he is at risk of transferring and acquiring respiratory disease which are
communicable.
f. Immunizations
The child received and completed all immunizations before 1 year old, therefore the
child is fully immunized.
g. Laboratory Results
CHEST X-RAY
Date: February 18, 2012
Film No.: 1392
Finding: Chest APL
- Infiltrates are seen in right lower lobe
- Heart is not enlarged
- Bones are intact
Impression: Pneumonia
COMPLETE BLOOD COUNT
Result
Hemoglobin :
120 g/L
Leukocytes :
6.9 g/L
Lymphocyte :
5.3 g/L
Erythrocyte volume:
0.36 g/L
fraction

Normal Values
(135 180 g/L)
(4.5 11.0 x 10 g/L)
( 0.25 0.40 g/L)
(0.40 0 .54 %)

PATHOPHYSIOLOGY OF ACUTE LARYNGOTRACHEOBONCHITIS


Croup Cough starts when a person acquires a virus (e.g., adenovirus,
parainfluenza virus, respiratory syntactical virus) from coming in direct contact
with an individual who has the illness. One may get Croup Cough from touching
the infected objects and surfaces and then touching his nose or mouth too. The
virus will then travel to the sites commonly affected which are the larynx, trachea
and bronchial tubes.
As the Croup Cough virus occupies these regions of a persons airway, the
immune system of the body sends in the cellular combatants. These disease
fighters are usually the white blood cells (WBC). As the WBCs battle the foreign
microorganisms in the infected tissues, the biochemical reactions occurring will
result to inflammation and edema of the airways and surrounding areas.
The swelling may also be caused by one of the bodys defense mechanism. During
infectious processes, the body makes the vascular system of the affected areas
more permeable for the cellular fragments of WBC. This is for the WBCs to reach
the infection more easily.
The symptoms result from upper-airway obstruction due to generalised
inflammation and oedema of the airways. At the cellular level this progresses to
necrosis and shedding of the epithelium. The narrowed subglottic region is
responsible for the symptoms of seal-like barky cough, stridor (from increased
airflow turbulence), and sternal/intercostal indrawing. If the upper-airway
obstruction worsens, respiratory failure can result, leading to asynchronous chest
and abdominal wall motion, fatigue, hypoxia, and hypercarbia
Platelets (blood-clotting components) may accumulate in these regions as
well to repair the damage caused by the biological warfare.
The narrowed air passages would then lead to the Croup Cough symptoms
of barking cough, inspiratory stridor, voice hoarseness and sternal retractions. All
of these signs are due to either the constricted condition of the airways or from the
oxygen compensation brought about by the narrowing.
If this upper airway blockage worsens, it can lead to failure of the
respiratory system. As the airway is totally obstructed, no air and its oxygen
content could be inhaled. This would result to hypoxia or insufficient oxygen level
in the body. Serious Croup Cough signs of cyanosis or bluish discoloration will be
observed in areas like the mouth of an individual.

Since the airway is also the same path wherein carbon dioxide or used
oxygen is exhaled, a build-up of this system poisoning substance would result to
hypercabia the condition wherein dangerous levels of carbon dioxide is present in
the body.
During night, the patient will manifest signs of distress and these distress
will even wake them up. Because of the decrease lung expansion when on supine
position, patient will manifest dyspnea, orthopnea and evenretractions
Rajapaksa S, Starr M (May 2010). "Croup assessment and management". Aust
Fam Physician 39 (5): 2802. Retrieved on March 5, 2012
Klassen TP (December 1999). "Croup. A current perspective". Pediatr. Clin. North
Am. 46 (6): 116778. Retrieved from :doi:10.1016/S0031-3955(05)70180-2.
PMID 10629679 on March 05, 2012
Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP (2011). Klassen, Terry P.
ed. "Glucocorticoids for croup". Cochrane Database Syst Rev 1 (1): CD001955.
Retrieved from : doi:10.1002/14651858.CD001955.pub3. PMID 21249651 on March
05,2012

Entry of causative
agents via
respiratory tract
This includes the
adenovirus and

destruction of the ep

Shedding and irritation


of the mucosal lining
of the respiratory tract

This will cause


WBC aggregation
and inflammation
of the area
Narrowing of the
subglottic region
causing narrowing
of airway and
production of

The narrowing of the subglottic


region will cause seal-like
barking sound

The narrowing of the airway will also


cause difficulty in breathing on the part
of the patient
Orthpnea and presence
of sterna and abdominal

Secretion will go to the lower


lung fields and too much
coughing will cause respiratory
pressure thus resulting in
hyperinflated alveoli

IV.

PATHOPHYSIOLOGY
virus

Entry of organism and causative


agents
Direct invasion of mucosal
lining
Low level of
haemoglobin &
hematocrit
125
g/L

Causative agent go to
respiratory tract

Release of
toxins

Production of
secretion in
tracheobronchial tree

Necrosis and
shedding of
epithelium

Ineffective airway
clearance r/t retained
secretion

WBC goes to the area


of infection

Inflammati
on
Swelling of larynx, trachea, and major
bronchus
Increase in body
temperature
37.8 degrees
Celsius
Hyperthermia r/t
infectious process

Irritation of
mucosa
Compensatory
mechanism to release
irritants
coughin
g

Infiltration of WBC
chistocytes, lymphocytes
0.73
neutrophils
Narrowed subglottic
region
Seal like barking sound /
cough
Fatigue and
weakness

anxie
ty

Decrease oxygen supply

High pitch rubbing leather-like


sound

Use of accessory
muscles

Inspiratory
stridor

Ineffective gas
exchange

Impaired breathing
pattern

V.

Activity
intolerance

Increase airflow
turbulence
Chest indrawing sternal
and subcostal

DRUG STUDY

Generic name
Trade name
Drug Classification
Mechanism of action
susceptible
Indications

Contraindication :
Side effect
headache,

:
:
:
:

Rifampicin
Natricin Forte
Antibiotic
Inhibits DNA- dependent RNA polymerase activity in

bacteria thus causing bacterial death


Treatment of pulmonary tuberculosis
Gram (-) bacteria in infant
Infection caused by H. influenza.
Allergy to any rifampicin
Acute hepatic disease.
Heart burns, nausea and vomiting, diarrhea, fever, rash,

drowsiness
Nursing Responsibility :
Take drug regularly, avoid missing any dose, report
fever, chills, muscle
pain and bleeding, empty stomach, given single dose.
Generic name
Trade name
Drug classification
Meachanism of action
biosynthesis in actively

:
:
:
:

Isoniazid
Curazid
Anti-tuberculotic
Bactericidal: Interfere with lipid and nucleic acid

growing tubercle bacilli.


Indication
:
Tuberculosis, all forms in which organs susceptible.
Contraindication :
With allergy to Isoniazid, acute hepatic damage.
Side effects
:
Nausea and vomiting, jaundice, fever, vasculitis,
skin eruption, seizure.
Nursing Responsibility :
Give on empty stomach, decrease foods containing
tyramine/
histamine, avoid missing any dose.
Generic name

Salbutamol (albuterol)

Trade name
Drug classification
Indications
:
Obstructive

:
Aero vent
:
Beta-2 adrenergic agonist, Bronchodilator
Relieve reversible bronchospasm caused by Chronic

Pulmonary Disease treatment of activity-induced


bronchospasm
Contraindications
:
Allergy to any component of the drug.
Side effects
:
Respiratory tract: tachypnea, respiratory distress
Gastrointestinal tract: nausea and vomiting, heartburn
Nursing responsibility :
Auscultate lung fields prior before and after
nebulisation, advise mother
to feed the child 30 minutes before and after nebulization
to prevent
nausea and vomiting

PRIORITIZATION OF THE PROBLEM


1. Ineffective airway clearance related to retained secretions in the
tracheobronchial tree.
2. Impaired gas exchange related to alveolar capillary membrane changes
secondary to respiratory distress.
3. Ineffective breathing pattern related to alteration on clients respiration
secondary to airway obstruction.
4. Fluid volume deficit related to failure of regulatory mechanism specifically
fever.
5. Hyperthermia related to infectious process.
6. Anxiety related to physiologic factors such as drug therapy secondary to IV
push and nebulization.
7. Activity intolerance related to generalized weakness.
PROBLEMS
1. Ineffective airway clearance
related to retained secretions in
the tracheobronchial tree.

2. Impaired gas exchange


related to alveolar capillary
membrane changes secondary
to respiratory distress.
3. Ineffective breathing pattern
related to alteration on clients
respiration secondary to airway
obstruction.

JUSTIFICATION
Based on OFFTERAS, oxygenation should be
prioritized first. The reason why the patient
experience respiratory distress is due to the
secretions he is not able to expectorate. If the
problem is resolved the 2nd and 3rd problems will
also be resolved respectively.
According to OFFTERAS, it is under oxygenation.
It was only under second prioritization because
the reason for respiratory distress is due to the
secretions on the tracheobronchial tree.
It is also under the oxygenation related
problems. impaired gas exchange is prioritized
more since it already involves oxygen and carbon
dioxide exchange and it is more vital than
breathing pattern.

4. Fluid volume deficit related


to failure of regulatory
mechanism specifically fever.

According to OFFTERAS, fluid-related problems


should be prioritized second. Fluid volume deficit
on client is evidenced by dry circum-oral mucosa.

5. Hyperthermia related to
infectious process.

According to OFFTERAS, problems related to


increase in body temperature is on the 4th
prioritization.
Anxiety is included on rest and sleep and it is
considered to be one of the least prioritized
according to OFFTERAS.

6. Anxiety related to physiologic


factors such as drug therapy
secondary to IV push and
nebulization.
7. Activity intolerance related to
generalized weakness.

It is considered as activity-related problem and it


is least prioritized.

Name of Patient: Taynan, Rydle


Problem: Acute Laryngotracheobronchitis
ASSESSMENT
A> Ineffective
airway clearance
related to retained
secretions on the
tracheobroncial
tree.

EXPLANATION OF
THE PROBLEM
Croup is a
respiratory
conditions that is
triggered by an
acute viral infection
Organism

S> Parang
tumatahol yung
ubo niya at hindi
niya mailabas iyong
plema.
Minsan noong
sobrang ubo niya
napasuka siya ng
plema, as
verbalized by the
mother.
O> Respiratory rate
of 46 cycles per
minute.
> productive
cough, thick
tenacious, greenish
in color and about 2
cc.
> inspiratory stridor
auscultated on both
lung fields.
> (+) sternal

Release of toxin
Necrosis and
shedding of
epithelium
Infiltration of WBC
Inflammation
Swelling of larynx,
trachea and bronchi
Production of
secretions and
narrowing of
subglottic region
High pitch seal like
barky cough

OBJECTIVES
LTO> After 3 days of
nursing
interventions, the
patient will manifest
absence of
respiratory distress
as evidenced by:
a. (-) nasal
flaring on
airway
patency
b. (-) chest
indrawing and
abdominal
retractions
and use of
accessory
muscles
(trapezius and
sternocleidom
astoid)
c. Normal range
of RR (30-33
cycles per
minute)
d. Absence of
stridor heard
on both lung
fields.

Inspiratory stridor
STO> After 8 hours

NURSING
INTERVENTIONS
Dx
> Monitor vital signs
especially respiratory
rate.

RATIONALE

> Increased in
respiration suggests
hypoxia

> Observe breathing


patterns, chest
indrawing and
expansions, nasal
flaring, use of accessory
muscles when
breathing, retractions
and skin color.

> Cyanosis, nasal


flaring, chest indrawing,
abdominal retractions,
reflect respiratory
distress and need for
medical interventions.
They also suggest
development of the
treatment.

> Auscultate lung fields,


note areas if decreased
or absence of ventilation
and presence of
adventitious breath
sounds.

> Auscultating lung


fields will show if there
is occurrence of
complications such as
pneumonia.

> Characterized
pulmonary secretions:
note the amount, color,
odor and consistency of
phlegm or mucous.

> The changes in the


consistency, odor and
amount of secretion
may indicate healing or
developing of other
complications.

Tx
> Position patient in an
upright position or head

> It promotes the


maximal expansion of

EVALUATION
FULLY MET IF:
Patient will be able to
manifest absence of
respiratory distress as
evidenced by:
a. (-) nasal flaring
on airway
patency
b. (-) chest
indrawing and
abdominal
retractions and
use of accessory
muscles
(trapezius and
sternocleidomast
oid)
c. Normal range of
RR (30-33 cycles
per minute)
Mother will verbalize
understanding on
breastfeeding
importance and
demonstrate proper
back tapping for
patient.
PARTIALLY MET IF:
The patient will still
manifest signs of

retraction
> Use of accessory
muscles when
breathing
(trapezius and
sternocleidomastoi
d)
> nasal flaring and
not patent right
nose
> Deep abdominal
breathing.

Ineffective airway
clearance related to
retained secretion in
tracheobronchial
tree
Reference:
Fergin, Ralph.
(2004).Textbook of
Pediatric Infectious
Disease.
Philadelphia:
Saunders. Retrieved
on February 27,
2012

of nursing
interventions, the
patient will manifest
decreased signs of
respiratory distress
as evidenced by:
a. RR of 30-35
cpm from 43
com
b. Absence of
nasal flaring
c. Reduced chest
indrawing and
abdominal
retractions
After 3 hours of
parent teaching, the
mother of the patient
will be able to:
a. Perform back
tapping for
home
management
if croup of the
child will recur
b. Verbalize that
she
understands
the
importance of
continuous
breastfeeding
of the child.
c. Increase the
fluid intake of

elevated.
> Initiate coughing
exercise and deep
breathing exercises.

> Administer mist tent


and vaporize as ordered
by the physician.
> Administered racemic
epinephrine and
salbutamol as
prescribed by the
physician through
nebulisation.

the lungs thus facilitates


in respiration and
prevents aspiration.
> It promotes maximal
lung expansion and
coughing exercise aids
in clearing airway.
> The moisture helps
loosen secretion and
helps inflamed mucous
membranes in the
airway.
> Epinephrine dilates
and relieves mucous
membranes thus
clearing airway.
Salbutamol causes
bronchodilation.

> Perform suctioning as


prescribed by the
physician.

> Suctioning removes


secretions in the
tracheobronchial tree.

> Increase fluid intake


as tolerated

> Fluids loosen


secretions and thus
facilitates in sputum
expectoration

Edx.
> Instructed the mother
to continuously
breastfeed the child.

> Breastmilk contains


antibodies which helps
in improving the
immune system to fight
respiratory distress and

respiratory distress
such as stridor and
respiratory rate more
than 35 cpm but with
absence of nasal
flaring.
Mother is able to
perform proper back
tapping and verbalize
understanding on
importance of
breatfeeding.
NOT MET IF:
> There are still
presence of respiratory
distress and if the case
of patient worsens.

the child as
tolerated by
the child.

loosens secretions.
> Educate mother
regarding the
importance of proper
backtapping.

> Back tapping provides


comfort to the child and
it helps in loosening
secretions.