Pediatrics

Lecture notes
Faculty of Medicine Oradea

CRISTIAN SAVA, MD, PHD

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 Lecture 5

Respiratory pathology
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Acute inflammatory upperway
obstruction

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 ACUTE INFLAMMATORY
UPPER AIRWAY OBSTRUCTION
• the lumen of an infant’s or child’s airway is narrow
• minor reductions in cross-sectional area as a result
of mucosal edema or other inflammatory processes
cause an increase in airway resistance and a
significant increase in the work of breathing
• inflammation involving the vocal cords and
structures inferior to the cords is called laryngitis,
laryngotracheitis, or laryngotracheobronchitis,
• inflammation of the structures superior to the
cords is called supraglottitis (epiglottitis)
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4
 ACUTE INFLAMMATORY
UPPER AIRWAY OBSTRUCTION
Laryngitis
1. Acute infectious laryngitis
2. Acute laryngotracheobronchitis (viral
croup)
3. Acute spasmotic laryngitis (spasmodic
croup)
4. Acute epiglottitis (acute supraglottitis)
Bacterial tracheitis

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 LARYNGITIS
Definitions
• Laryngitis
– acute inflammation of the larynx caused by a bacterial or viral
infection, or an allergy, preventing the passage of air
• Croup
– heterogeneous group of mainly acute and infectious processes
that are characterized by:
• a bark-like or brassy cough
• may be associated with
– hoarseness
– inspiratory stridor
– respiratory distress
• Stridor
– harsh, high-pitched respiratory sound, usually inspiratory but it
can be biphasic and is produced by turbulent airflow
– it is a sign of upper airway obstruction

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 1. ACUTE INFECTIOUS LARYNGITIS

• The most frequent clinical form of laryngitis

• Etiology - viral
• Usually associated with an upper respiratory tract
infection like common cold or pharyngitis
• Characteristic symptoms are sore throat, cough, and
hoarseness
• Physical examination shows pharyngeal inflammation
• Signs of laryngeal obstruction are absent (dyspnea,
stridor)
• Evolution
– Most cases are relatively benign and self-limiting,
resolving spontaneously only with supportive therapy

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 1. ACUTE INFECTIOUS LARYNGITIS

Treatment
• General measures: fluid intake, air humidification
• Etiologic: antibiotics are not recommended
• Symptomatic similar to common cold or rhinopharyngitis
– Acetaminophen or Ibuprofen
– Nasal instillation
– Cough suppression

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

• The most common form of acute upper respiratory

obstruction
• Distinctive barking cough, hoarseness, and inspiratory
stridor in a young child, usually between six months and
five years old (peak – age 2)
• Usually triggered by an acute viral infection of upper airway
• Etiology – viral; 75-80% parainfluenza virus

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Pathophysiology
• inflammatory soft-tissue edema affecting predominantly
subglottic area
• the larynx, trachea and bronchi can be all affected
• subglottic narrowing due to edema produces airway
obstruction
• the impeded flow of air through this narrow area produces
the classic high pitched vibrator sounds or stridor
• if the degree of obstruction worsens, the work of breathing
may increase – respiratory distress occur

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Clinical presentation
• Croup is characterized by a “barking” cough (resembling a
seal), stridor, hoarseness, and difficult breathing
• Symptoms characteristically worsen at night or if the
patient presents agitation and crying
• Most children have a prodrome and mild respiratory tract
signs of rhinorrhea, cough, and sometimes fever, 12 to 48
hours before the onset of upper airway obstruction
Physical examination
• hoarse voice, coryza, inflamed pharynx
• respiratory distress
– increasing respiratory rate, nasal flaring, suprasternal or
supraclavicular retraction
– hypoxia and low oxygen saturation when airway obstruction is
complete

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)
• The symptoms are generally solved in 3 to 7 days
• Most children have mild symptoms which do not progress
to airway obstruction
• The Westley Croup Score describes the gradations of croup
severity and corresponding treatment
• The major findings on physical examination used for this
score are the degree of stridor, chest wall retractions, air
entry, level of consciousness or fatigue, and presence of
cyanosis
• Croup grading system:
– mild – Westley score of 0 to 2
– moderately severe – scores of 3 to 7,
– severe – scores of 8 to 11
– imminent respiratory failure having scores of 12 to 17

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 2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Diagnosis
• Croup is a clinical diagnosis
• Differential diagnoses to exclude other obstructive
conditions of upper airway
– epiglottitis
– airway foreign body
– subglottic stenosis
– angioedema
– retropharyngeal abscess
– bacterial tracheitis

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Diagnosis
• Diagnostic procedures that upset the child may worsen the
respiratory distress and should be avoided
• Laboratory analysis generally should be limited to tests
necessary for management of a more severely ill child, such
tests used to assess dehydration and oxygenation
• WBC count and differential are rarely helpful or distinctive
in diagnosing croup
• Identification of the specific viral agent also is usually
unnecessary
• Examination by ENT specialist – direct laryngoscopy

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Diagnosis
• The characteristic manifestation of viral croup noted on an
anteroposterior neck film is a 5-to 10 mm narrowed shadow
of the trachea in the subglottic area – the “hourglass” or
“steeple” sign
• The diagnostic value is questionable
• Not consistently observed in all cases of the viral croup
• Low specificity and sensitivity for confirming or ruling out
viral croup
• Radiography of the neck is useful only for differential
diagnosis: foreign body or epiglottitis

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“Steeple” sign 17
 2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Treatment
• Goals: airway management and treatment of hypoxia
• Appropriate therapy for croup is determined by the severity
of the child’s illness
• Accurate assessment of the child’s clinical status is essential
• Croup scoring systems have been used to assess the severity
of croup (croup grading system – grade 1 - 4)
• Therapies recommended vary according to the assessment
level of severity

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Treatment
• Most children with mild croup may be cared for at
home
• Indication for hospitalization:
– progressive stridor or severe stridor at rest
– respiratory distress, hypoxia, cyanosis
– depressed mental status
– or the need for reliable observation
• Grades 1-2: nebulised epinephrine together with
systemic glucocorticoids
• Grade 3: if no response to epinephrine and GCS,
exhausted child –airway intervention is required
• Grade 4: emergency situation requiring airway
intervention – intubation or tracheotomy
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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)
Supportive care
• Keep children as comfortable as possible
• Avoid any situations that may cause agitation, respiratory
distress, and lead to increased oxygen requirements
• Cool mist or humidification therapy – there is no evidence
to support the effectiveness
• The child should be given adequate liquids and antipyretic
if necessary
Etiologic treatment
• Antibiotics
– not usually indicated in viral croup
– Lack of improvement or worsening of symptoms – may be due
to secondary bacterial infection
– Ampicillin + Sulbactam or 3rd generation Cephalosporin 5-7
days

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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Pathogenetic treatment
• Glucocorticoids
• the mainstay of therapy for croup
• decrease the edema in the laryngeal mucosa due to anti-
inflammatory effect
• orally, parenterally or as nebulized medications
• oral dexamethasone 0.6 mg/kg (maximum dose 10 mg)
is commonly prescribed (severe croup)
• lower doses of oral dexamethasone, 0.3 mg/kg and 0.15
mg/kg appear to be equally effective (mild/moderate
severe)
• inhalatory budesonide 2 mg/dose – equally effective
• oral dose of prednisolone (1 mg/kg) – less effective
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2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Pathogenetic treatment
• Nebulized epinephrine
• Racemic epinephrine
• 1:1 mixture of dextro (D) isomers and levo (L) isomers
of epinephrine
• adrenergic stimulation, which causes constriction of
the precapillary arterioles, reducing the laryngeal
mucosal edema
• Its effectiveness is immediate with evidence of
therapeutic benefit within the first 30 minutes and
then, lasts from 90-120 minutes (1.5-2 h)
• A dose of 0.25-0.5 mL of 2.25% racemic epinephrine
in 3 mL of normal saline can be used as often as every
20 min
2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Pathogenetic treatment
• Nebulized epinephrine
• L-epinephrine
• 5 mL of 1 : 1,000 solution is equally effective as
racemic epinephrine and does not carry the risk of
additional adverse effects
• 0.5-0.3 ml/kg/dose, maximum 5 mg
• repeated at every 4 hour
• indications for the administration of nebulized
epinephrine
– moderate to severe stridor at rest, respiratory
distress, hypoxia
– the need for intubation
2. ACUTE LARYNGOTRACHEOBRONCHITIS (VIRAL CROUP)

Pathogenetic treatment
• Oxygen
• Severe moderate/forms: with hypoxia and respiratory distress
• Heliox
• helium-oxygen mixture (70/30 or 80/20)
• effective short-term treatment for refractive respiratory
distress due to croup
• It should be used in conjunction with glucocorticoids
• Endotracheal intubation
• Most children do not need intubation after using epinephrine
and dexamethasone
• The procedure should be performed in a patient with an
imminent airway obstruction
• The internal diameter of the canula – 0.5 mm less than ideal
calculated for child’s age
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 3. ACUTE EPIGLOTITTIS
• Epiglottitis, also termed supraglottitis, is an inflammation
of structures above the insertion of the glottis
• Rare, but still dramatic and potentially lethal condition
• Most often caused by bacterial infection
• Haemphilus influenzae type b
• Before widespread Haemophilus influenzae type b (Hib) vaccination, H
influenzae caused almost all pediatric cases of epiglottitis
• Even vaccinated children can develop epiglottitis due to non – type b H
influenzae
• Streptococcus pyogenes, Streptococcus pneumoniae, and
Staphylococcus aureus, in vaccinated children
• Pathophysiology
• Infection of the epiglottis leads to acute onset of inflammatory
edema
• Swelling significantly reduces the airway aperture
• Frank airway obstruction, aspiration of oropharyngeal secretions, or
distal mucous plugging can cause respiratory arrest
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 3. ACUTE EPIGLOTITTIS
Clinical manifestations
• Usually, no prodromal symptoms occur in children
• Abrupt onset of severe symptoms
– acute  course of high fever, sore throat, inspiratory dyspnea
– rapidly progressing upper respiratory obstruction
– suprasternal, intercostal retraction, rapidly increasing cyanosis
and coma may occur
– muffled (ie, guttural) or hoarse voice, sore throat, and anxiety
are common
– stridor is moderate and a late finding
– the barking cough is absent or rare
– peak of respiratory distress after 4-7 hours
• The clinical triad of drooling, dysphagia, and distress is the
classic presentation
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 3. ACUTE EPIGLOTITTIS
Physical Examination
• The child appears toxic
• Shock may occur early in the course of the disease
• Marked restlessness, irritability, and extreme anxiety are common
• The child may assume the tripod (sniffing) position to maximize
air entry and improve diaphragmatic excursion
– siting with his or her chin hyperextended
– body leaning forward
– mouth opened
• The tongue may protrude
• Cyanosis, which occurs late in the course of the condition,
indicates a poor prognosis

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 3. ACUTE EPIGLOTITTIS
Diagnosis
• Based on clinical manifestations
• Securing an airway is the overriding priority
Laboratory findings
• Increased leucocytes with neutrophilia
Radiography
• Classic cases of epiglottitis require no radiographic
evaluation
• May be needed in some cases to confirm the diagnosis and to
exclude other potential causes of acute airway obstruction
• Classic radiographs show the “thumb sign”
Laryngoscopy:
• visualization of a large, “cherry-red” swollen epiglottis
• it is not advised to attempt any procedures without securing
the airway 30
Thumb sign 31
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 3. ACUTE EPIGLOTITTIS
Differential diagnosis
• The other types of laryngitis
• Accidental ingestion of very hot liquid determine epiglottitis,
with drooling or dysphagia and stridor
• Aspiration of foreign body
• Retropharyngeal or peritonsillar abscess
Evolution
• Favorable in case of early and adequate treatment
• Death may occur by apneea and respiratory arrest in case of
complete obstruction of the airway unless adequate or
delayed treatment

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 3. ACUTE EPIGLOTITTIS
Treatment
• Epiglottitis is a medical emergency
• Treatment in patients with epiglottitis is directed toward
relieving the airway obstruction and eradicating the
infectious agent
• Avoid procedures that might increase the child's anxiety until
after the child's airway is secured
• When a child has respiratory arrest, the first step is to
administer bag-valve-mask ventilation with 100% oxygen
• Once the child is oxygenated and ventilated, the airway can
be secured with an endotracheal tube, cricothyrotomy, or
tracheostomy
• Once an airway is established, admit the child with
epiglottitis to an intensive care unit (ICU)
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Cricothyrotomy 35
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 3. ACUTE EPIGLOTITTIS
Treatment
• Racemic epinephrine and corticosteroids are ineffective
• 10-40% of H. influenzae type b cases are resistant to
ampicillin
• Appropriate antibiotics include ceftriaxone, cefotaxime, and
cefuroxime – 7-10 days
• Contacts should receive rifampin chemoprophylaxis (20
mg/kg orally once a day for 4 days; maximum dose: 600 mg)

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 4. ACUTE SPASMODIC LARYNGITIS
(SPASMODIC CROUP)
• Acute spasm of the larynx characterized by the sudden onset
of cough and inspiratory stridor
• Non-inflammatory edema of the subglottic tissues
• Age of onset: between 1-3 years of age (stridor)
• Some children present recurrences
• Etiology
• Viral in some cases (allergic reaction to viral antigen rather
than a viral infection?)
• Allergic factors
• Psychologic factors
• Risk factors
• most often in children 1–3 yr of age
• hypertrophy of adenoids

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 4. ACUTE SPASMODIC LARYNGITIS
(SPASMODIC CROUP)
Clinical manifestations
• Sudden obstruction of upper airways during night
– the child awakens with a characteristic barking, metallic cough, noisy
inspiration, and respiratory distress and appears anxious and
frightened
– symptoms/signs of upper airway obstruction: stridor, suprasternal
retraction
– fever is absent
• Sometimes onset after common cold or tracheobronchitis
• The severity of the symptoms diminishes within 1-2 hours
and, the following day, a slight hoarseness and cough may
persist

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 4. ACUTE SPASMODIC LARYNGITIS
(SPASMODIC CROUP)
Treatment
• General measures
• Air humidification
• Cold air will be avoided
• Symptomatic treatment
• Sedatives in some cases
• Recommendation for adenoidectomy

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 5. BACTERIAL TRACHEITIS
Definition
• acute bacterial infection of the upper airway that determines
life-threatening airway obstruction by mucosal swelling at
the level of the cricoid cartilage, copious thick, purulent
secretions, causing pseudomembranes
Etiology
• Staphylococcus aureus is the most commonly
• Moraxella catarrhalis, nontypable H. influenzae, anaerobic
organisms
• often follows a viral respiratory infection
• may be bacterial complication of a viral disease, rather than a
primary bacterial illness
Epidemiology
• 5-7 years, peak under 3 years

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 5. BACTERIAL TRACHEITIS
Clinical Manifestations
• Onset: with brassy cough, similar to viral
laryngotracheobronchitis, became purulent
• High fever
• Toxic status: patient can lie flat
• Severe respiratory distress
• Drooling, dysphagia associated with epiglottitis are absent
Laboratory findings
• Acute reactants phase positive: increased leucocytes with
neutrophils, ESR, CRP
X-ray:
• lateral radiograph of the neck evidences pseudomembrane
detachment in the trachea
• chest radiography show patchy infiltrates or focal densities

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 5. BACTERIAL TRACHEITIS
Diagnosis
• Clinical manifestations
• high fever, toxic status, purulent airway secretions
• absence of the classic findings of epiglottitis
• Radiologic examination
• Bronhoscopy
Complications
• Cardiorespiratory arrest
• Toxic shock syndrome associated with staphylococcal
tracheitis
Prognosis
• Total recovery with appropriate antimicrobial therapy

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 5. BACTERIAL TRACHEITIS
Treatment
• General measures
• Parenteral hydration, nutrition
• Artificial airway: intubation, tracheostomy
• Suctioning secretions
• Etiologic treatment
• appropriate antimicrobial therapy - antistaphylococcal agents
• Pathogenetic therapy
• Oxygen
• Nebulised epinephrine is ineffective

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