Acute Laryngitis
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Acute laryngitis, often referred to as acute subglottic laryngitis or pseudo croup (MKN-10: Template:MKN), is swelling of the larynx in the subglottic region. It is usually of viral origin (parainfluenza viruses, adenoviruses, RSV), but non-inflammatory irritations (such as allergens) can cause similar symptoms. It occurs more often than acute epiglottitis and tends to be less dramatic, occurring mainly in the winter months (November – April). It most commonly affects children from infancy up to age 6 but is described even in adulthood. [1]
The Clinical Picture
The symptoms of the disease appear suddenly, mostly in previously healthy children or follow previous upper respiratory tract infection. The onset is sudden, often at night in the form of paroxysmal inspirational dyspnea with inspirational stridor, accompanied by a typical barking cough. The child is restless, subfebrile and has a rough voice (hoarseness). In severe cases, symptoms may include anxiety or confusion, agitation and cyanotic skin. There is no sore throat, no difficulty in swallowing. The child is generally in good condition (with a low degree of shortness of breath). Progression can occur within tens of minutes. Clinical status is assessed according to Downes (0-10 points). [2][1]
| Feature | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Lung asultation | Normal | Weakend, harsh | Scilence |
| Stridor | None | Inspiratory | Inspiratory and expiratory |
| Difficulty of breathing | None | Suprasternal retraction, allar deflecton | Retration all soft parts of the chest, open mouth when breathing |
| Cough | None | Rough, unproductive | Barking, dry |
| Cyanosis | None | In room air | Even with FiO2 > 0,4 |
- Downes score 2 or less – the child can be left in home care (cool humid air, fluids, mucolytics)
- Downes score 3 and more – hospitalization required, ambulance transport (dexamethasone p.o., i.m. or i.v., adrenaline inhalation)
- Downes score 7 and more – Consider tracheal intubation under inhalation anaesthesia [3].
Diagnostics
It is essential to distinguish between acute laryngitis and acute epiglottitis.
| Acute epiglottitis | Acute laryngitis | |
|---|---|---|
| Average age | 3–4 years | 6–36 months |
| Prodromy | – | Runny nose |
| Cough | – / mild | Barking |
| Feeding | No | Yes |
| Mouth | Saliva flows out | Closed |
| Toxicity | Yes | No |
| Temperatue | > 38,5 °C | < 38,5 °C |
| Stridor | Fine | Wheezing |
| Voice | Weak / quiet | Rough |
| Recurrences | No | Yes |
Differential diagnosis should rule out epiglottitis, retropharyngeal abscess, bacterial laryngotracheitis, allergic or hereditary upper airway edema. Neck examination is done quickly by inspection with the help of tongue depressor. [1]
Treatment
- Monitoring of vital functions (pulse, respiratory rate, blood preassure, SaO2);
- Cold nebulization (a mixture of gases of different FiO2, that the child breathes);
- Inhalation of adrenaline (nebulized adrenaline) (5 mg in 5 ml 1/1 0.9% NaCl, the effect appears after 10-30 minutes, after inhalation lasts 60 minutes);
- Dexamethasone i.v. or i.m. (0.6 mg/kg per dose , the effect occurs within 120 min)[3];
- Prednisone per rectum;
- Eventually non-codeine type antitussives;
- Sedatives are contraindicated (risk of respiratory depression), for sedative effect use antihistamines (promethazine 1-2 mg/kg/24 hours)
Guideline postupu dle tíže onemocnění
- Downes score 0-2
- ambulantní postup;
- inhalace studeného vzduchu (není EBM);
- dexamethason 0,6 mg/kg p.o. nebo i.m..
- Downes score 3–4
- hospitalizace na standardním oddělení;
- studená nebulizace plynů s FiO2 cca 0,3–0,4;
- dexamethason 0,6 mg/kg p.o. nebo i.m..
- Downes score 5–7
- hospitalizace na JIP, zajištění i.v. vstupu;
- studená nebulizace plynů s FiO2 cca 0,3–0,4;
- dexamethason 0,6 mg/kg i.v.;
- nebulizace adrenalinu 1:1 000 v dávce 5 ml, případně 2 mg nebulizovaného budesonidu;
- opatrná sedace (midazolam).
- Downes score 7-10
- konzervativní terapie (viz předchozí postup) po dobu 20 minut, při nezlepšení stavu tracheální intubace;
- u kritické dušnosti intubujeme ihned, řídíme se klinikou, nelze „čekat“ na hypoxii nebo hyperkapnii;
- intubujeme neapnoickou technikou při inhalační anestezii, alternativně midazolam 0,2 mg/kg + ketamin 3 mg/kg i.v.;
- tracheální rourku volíme bez manžety s průměrem o 0,5–1 mm menším než je průměr rourky pro daný věk;
- po intubaci zahajujeme standardní UPV;
- extubujeme v době, kdy již významně uniká vzduch kolem ET kanyly, zpravidla do 48 hodin.[1]
Následná opatření
Laryngitida se s oblibou opakuje, ale každá ataka může být jinak závažná. Při recidivách vyšetřujeme ev. alergickou složku – „spasmodic croup“. Je třeba dále vyloučit GER, vliv adenoidních vegetací. Při > 3 recidivách ASL nebo atypickém průběhu je zpravidla nutná laryngotracheobronchoskopie.[1]
Links
Related articles
External links
- Template:Akutně
- Akutní laryngitis (onemocnění hlasu a řeči)
- Chronická laryngitis (onemocnění hlasu a řeči)
References
- ↑ Jump up to: a b c d e HAVRÁNEK, Jiří: Infekce horních dýchacích cest
- ↑
- ↑ Jump up to: a b c
Kategorie:Pediatrie
Kategorie:Pneumologie
Kategorie:Otorhinolaryngologie
