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Controversies in the Management of Supraglottitis and Croup
mposium on Pediatric Emergencies
Controversies in the Management of Supraglottitis and Croup Marvin P. Fried, M.D.*
Inflammatory obstruction of the major airways in children is a rious problem. Although survival statistics have improved steadily as a sult of earlier diagnosis and more effective therapy, serious pitfalls still rsist in the management of these diseases. Inflammation and subquent obstruction of the supraglottis and sub glottis are the most rious of these disorders in the infant and small child. This article will dress the current controversies surrounding these entities and will fer some recommendations for current diagnosis and management.
he Significance of Airway Obstruction
Airway problems in the neonate are most often the result of congenimalformation. Inflammatory airway disorders occur in the older infant d are rarely associated with airway anomalies. Yet the normal infant's ynx is more susceptible to obstruction than the child's or adult's larynx g. 1).8 Smaller laryngeal size is only one of the anatomic differences. e infant supraglottis (the region of the larynx superior to the level of e vocal cords) lends itself to airway obstruction. The angle between the iglottis and the glottis is more acute than in the adult, making direct yngoscopic visualization more difficult. Further, the infant epiglottis relatively long and tubular with redundant aryepiglottic folds (giving e to the characteristic "omega" shape), and the cartilaginous mework is less rigid in the infant, being composed or elastic cartilage her than the firmer hyaline cartilage. Finally, edema spreads easily rough the submucosal connective tissue of the supraglottis, diffusely larging the entire structure including the ventricular bands (false cal cords), aryepiglottic folds, and epiglottis. The subglottis, the region from the vocal cords to the inferior margin the cricoid cartilage, is the only rigidly confined space in the upper way inferior to the nasal chamber, being fully encircled by nonelastic rtilage (cricoid).13 Any inflammatory change can cause edema with sistant Professor of Otolaryngology, Harvard Medical School; Associate Chief of Otolaryngology, Beth Israel Hospital; Assistant in Otolaryngology, Children's Hospital Medical Center; Junior Associate in Surgery, Peter Bent Brigham Hospital, Boston, Massachusetts
iatric Clinics of North America- Vol. 26, No.4, November 1979
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SUPRAGLOTTIS SUPRAGLOTTIS
GLOTT IS } GLOTTIS } (Voca l Cord) l Vocal Cord)
}
} SUBGLOTTIS SUBGLOTTIS
LATERAL LATERAL VIEWVIEW (CUT)(CUT)
Figure 1.
Lateral views of the infant (left) and the adult (right) larynx. (Left: from Bosma,
J., and Donner, M.: Physiology of the pharynx. In Paparella and Shumrick (eds.): Otolaryngology, 2nd ed., in press. Right: adapted from Warwick, R., and Williams, P. (eds.): Gray's Anatomy. 35th British ed. Philadelphia, w. B. Saunders Co., 1973.)
rapid expansion of the loose submucosal connective tissue, as in the supraglottis, and significant narrowing of the airway. The alterations in the airway that are caused by supraglottitis or laryngotracheobronchitis are relatively acute, lasting hours to a few days. Slower progression of airway compromise can more easily be tolerated, and compensation made, both in children and adults. The child, however, will deteriorate quite rapidly when exhaustion is reached, changing a stable or partially compensated situation into an emergency. Steps to stabilize the condition should be undertaken as soon as the appropriate diagnosis is made. The primary consideration is the maintenance of any airway. The diagnoses of supraglottitis and croup are essentially clinical, made by history and examination. Laboratory studies will only confirm the initial diagnosis. These disorders are dissimilar enough to be thought of as separate entities, and they will be dealt with here individually. Foreign Bodies
The presence of a foreign body within the airway should always be considered in the age group prone to supraglottitis and croup (up to 5 years old). Foreign bodies account for approximately 2000 annual deaths in the United States. 9 Although the most common object that causes obstruction in adults is meat, safety pins are most common in children under one year of age, and nuts and coins are most common in the two to
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four year age group. If obstruction is complete, death can be rapid. Partially obstructing objects can mimic croup, but also cause choking, gagging, coughing, or wheezing. If the foreign body lies above or within the larynx, there is associated hoarseness or aphonia, odynophagia, hemoptysis, or dyspnea. If the initial episode goes unnoticed, then a period of relatively few symptoms follows. Intermittent pneumonitis or tracheobronchitis, as well as episodic "croup," may occur at a later date. Radiography is essential in making the diagnosis and in localizing the foreign body. The exclusion of a foreign body may actually be the most important justification for x-ray films when supraglottitis or more typical croup is being considered. A lateral soft tissue film of the neck, inspiratory and expiratory chest films with the benefit of fluoroscopy, and a lateral chest film with the arms held posteriorly in order to visualize the tracheobronchial tree, should be obtained initially. Contrast studies should be avoided since the dye may be aspirated in an obstructing esophageal foreign body and make endoscopic removal much more difficult. If the foreign body is not visualized, then a region of obstructive atelectasis or emphysema, augmented by changes in respiration, may be a clue to a foreign body.a' If the airway is not in immediate jeopardy, there is no need for hasty attempts at removal, since oropharyngeal or hypopharyngeal objects may be pushed further into the airway in an uncontrolled situation. 27 Also, turning an infant over with head down may cause a tracheobronchial foreign body to lodge in the narrow sub glottis , leading to total obstruction. Emetics should not be given since aspiration may be precipitated. Definitive care most often requires endoscopic removal by individuals experienced in these techniques. In any emergency situation, the prime consideration is the establishment of an airway. If the foreign body is causing total or near-complete obstruction and cannot be easily visualized, a tracheostomy should be performed. An attempt at the Heimlich maneuver may be appropriate if no other facilities are available. However, tracheostomy is the mainstay of therapy in these emergency situations. Supraglottitis
Supraglottitis is known most commonly as epiglottitis. The former term is used in preference because any portion of the supraglottic larynx may give rise to this symptom complex. Moreover, specific regions of the supraglottis may be involved in isolation. Classically, supraglottitis is described as an infectious process of the epiglottis, most often caused by Hemophilus influenzae, leading to edema and inflammation and producing a swollen, cherry-red epiglottis. 24 This can rapidly cause airway obstruction and is a life-threatening emergency. However, other bacteria, such as pneumococcus, streptococcus, and staphylococcus have been implicated as pathogenic organisms in this disease. Because the causative agent may not always be isolated by a pharyngeal culture, blood cultures as well as serum counterimmunoelectrophoresis may be needed for etiologic diagnosis. 26
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The location of the inflammation can be as variable as the pathogen. Tucker has noted the isolated involvement of the lingual surface of the epiglottis and aryepiglottic folds with minimal endolaryngeal swelling. 32 The author has cared for both children and adults with culture-proven Hemophilus influenzae supraglottitis with edema and erythema limited only to the ventricular bands and a minimally edematous epiglottis. In fact, swelling of the ventricular bands may be the most significant factor in airway obstruction in supraglottitis. Supraglottitis most commonly affects children between the ages of three to six years, but can occur even to adulthood. There is no seasonal predilection. Progress is rapid, in terms of hours rather than days. There is significant throat pain, dysphagia, and "toxicity." The child is usually febrile and soon becomes aware of difficulty in breathing. Activity is restricted and the patient prefers sitting or leaning forward. Lying down causes the supraglottic swelling to further compromise the airway. Drooling is common. Speech is limited because of pain. A cough is usually not present. The diagnosis is often suspected on a brief history from the parents and general inspection of the patient. The controversies associated with supraglottitis essentially center on establishing the diagnosis, and care of the airway. The primary consideration, which is not a subject of controversy, is maintenance of an adequate airway, and procedures are measured against adequacy of ventilation and the need for rapid intervention. Direct visual inspection of the epiglottis to confirm the diagnosis has become less controversial over the years. The tip of the swollen epiglottis can often be easily visualized in younger children, especially before laryngeal descent occurs. The infant larynx lies at the level of the second and third cervical vertebra. In the adult it is situated opposite the body of the fifth vertebra. If, however, the swelling is limited to a region of the endolarynx such as the ventricular bands, this may not be recognized by inspection using a flashlight and tongue-blade. Moreover, depression of the base of the tongue may stimulate the already compromised larynx to spasm, completing an already partial airway obstruction. Confirmatory inspection should be held off until means are available to control the airway, such as intubation or tracheostomy. The need for radiologic studies is also controversial. There is no doubt that supraglottitis can be diagnosed by x-ray examination. The thumbshaped epiglottis, widened aryepiglottic folds, loss of the vallecular shadow, and narrowing of the posterior airway are characteristic (Fig. 2). The question is whether the procedure is necessary. A lateral cervical radiograph is useful to rule out a radiodense foreign body. The diagnosis of supraglottitis by physical examination is most often correct; radiographs merely confirm it. With the diagnosis established, management decisions raise the most controversial of all aspects of this disease. Historically, once acute supraglottitic laryngitis had been described as a distinct pathologic entity, it became quickly apparent that survival was closely related to establishment of an adequate airway.3 For years, this meant early tracheostomy. In many centers throughout the world, tracheostomy is
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Figure 2. In this lateral radiograph of neck in a child with supraglottitis, the rounding of the epiglottic shadow, the thickening of the aryepiglottic folds, and the distention ofthe hypopharynx secondary to airway obstruction are demonstrated. Forward thrust of the mandible and spine is also noted. (Courtesy of William R. Cranley, M.D., Department of Radiology, Boston City Hospital.)
still done with little risk to the patient and very few complications. 18.29 This has remained the yardstick against which to measure other modes of therapy. Over the past 15 years, reports have appeared describing the safety and efficacy of tracheal intubation for supraglottitis. 2,11,19,23 Complications have been comparable to tracheostomy, and in many series even lower. The rationale for this approach is based on the rapid response of the infectious process to appropriate antibiotic therapy. The obstructing edema often subsides within two to three days, allowing removal of the tracheostomy or endotracheal tube. The third mode of initial management is the use of steroids, humidification, and antibiotics (such as ampicillin) in patients who can be closely observed and whose airway is not in immediate jeopardy. 19,28 The status of the airway may be difficult to assess, an~ one risks rapid respiratory collapse if the patient is not closely monitored. The syndrome of cyanosis, exhaustion, and severe sternal retraction indicates a poor medical response and the necessity for establishment of an airway. Management of airway problems such as supraglottitis at the Children's Hospital Medical Center and at Boston City Hospital is a team effort. When the pediatrician, either in the office or in the emergency room, suspects that the patient has a disease that compromises the airway, members of the otolaryngology and anesthesiology departments are summoned to meet the patient in the emergency room. If the clinical suspicion is supraglottitis, the child is not disturbed. Blood samples and blood gases are not obtained, nor are intravenous fluids begun, The patient is accompanied by a physician until an airway is established. If the child feels most comfortable and reassured remaining with the parents, this is allowed. If time permits, a stop is made in the radiology department to obtain a lateral x-ray film of the neck. Thereafter the child is taken to the operating room where a slow face mask general anesthesia is performed. Only after adequate anesthesia is obtained are blood samples drawn for a blood count, blood cultures, or counterimmunoelectrophoresis. Appropriate cultures are taken. A preliminary orotracheal intubation is performed by the anesthesiologist. The larynx is examined by the otolaryngologist to confirm the diagnosis and to rule out any other
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abnormality. An orderly nasotracheal intubation is then carried out, with the oro tracheal tube removed. A full spectrum of bronchoscopes and a tracheostomy set, with appropriately sized tracheostomy tubes, is available ifintubation cannot be performed and should the otolaryngologist be called upon to intercede. A nasotracheal tube is preferred to an orotracheal one because there is less motion of the tube with less subglottic irritation. The tube can be easily taped in place. Some children may require restraints so that the tube is not dislodged. The use of intubation to control the airway necessitates close monitoring of the patient by personnel familiar with such devices. In hospital settings in which this cannot easily be done, tracheostomy may indeed be a safer method of airway control. Appropriate intravenous antibiotic therapy is begun, most often ampicillin. However, chloramphenicol is used in children with sensitivity to penicillin. Adequate humidification and endotracheal tube care is given. The patient is brought back to the operating room in two or three days, depending upon the clinical response. The larynx is once again visualized and if the disease has resolved, the endotracheal tube is removed. Croup Syndromes
The term "croup" is often used to define a symptom complex of varying respiratory obstruction, barking cough, suprasternal and intercostal retractions, and hoarseness that is common to many conditions. One of the most severe of these obstructing diseases is laryngeal diphtheria, which fortunately has become a rare entity. This still leaves, however, spasmodic or allergic croup, acute bacterial laryngC'tracheobronchitis, and viral laryngotracheitis. 6,22 Spasmodic croup usually affects the child at night with dyspnea, croupy cough, and inspiratory stridor. 5 The only prodrome, ifany, may be a mild cold. The child is almost always afebrile. Therapy consists of humidification such as a shower running in the bathroom, or taking the child out in the night air. Medications such as diphenhydramine elixir, Syrup of Ipecac, corticosteroids, and subcutaneous epinephrine have all been used with success. The subglottis, when visualized endoscopically, is edematous, pale, and watery in appearance. These symptoms clear quite rapidly. Some individuals may have recurrent nocturnal symptoms on subsequent days, Airway intubation or tracheostomy is rarely necessary. The etiology of spasmodic croup is still speculative, and may represent either an allergic response or a low-grade viral infection. Bacterial laryngotracheobronchitis, although not so rare as to be a past curiosity, is not as common as it was 30 or more years age. 4 ,22 This process is a diffuse, infectious involvement of the entire airway associated with significant crusting of transudate on the respiratory epithelium. The submucosal swelling appears most limiting in the narrow subglottis. This disorder has its onset in a manner similar to the more common viral laryngotracheitis; however, with progression, a secondary infection occurs which then becomes more fulminant than the initial process. The organisms cultured include Streptococcus pyogenes,
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StreptococcuS pneumonia, Staphylococcus aureus and, occasionally, Hemophilus influenzae. Therapy includes the appropriate antibiotics for the pathogen, humidification to loosen the crusting, oxygenation when needed, and, occasionally, bronchoscopic removal ofthe crusts. The need for a tracheostomy is more common once the secondary bacterial infection has begun. The reports of30 to 60 per cent mortality in the 1930s and 1940s has now been reduced almost to zero.4 The most common entity known as croup is viral laryngotracheitis. Bronchitis is specifically omitted from the name because rarely can inflammatory disease of the more distal airways be documented. Certainly radiographic evidence for bronchitis is sparse. Viral laryngotracheitis usually afflicts children less than three years of age, and begins gradually with an upper respiratory infection. Although it may occur in any season, it is by far most common in the winter months, and appears to have yearly variations. For example, the number of admissions for viral laryngotracheitis at Boston City Hospital and Children's Hospital Medical Center in the winter of 1977 to 78 was over five times as great as either the winter before or after. These children appear to be ill but are not toxic, have a croupy cough, hoarse voice, and stridor that can be both inspiratory and expiratory. There is no significant dysphagia, throat pain, drooling, or preferred position. Fever is common but is not spiking or significantly elevated. 11 The common characteristic of, all the diseases just listed is edema within the sub glottis. As noted before, any swelling within this space is confined by the intact cricoid ring, causing rapid and significant airway compromise. Moreover, the airway may be previously narrowed by undiagnosed congenital subglottic stenosis. This can go undetected until the infant has his first cold that rapidly becomes "croup." This may not clear entirely or can recur frequently (because of the underlying persistent narrowed airway) or progress rapidly to airway collapse. If croup should occur more than three times within a year, or does not clear entirely between recurrences, endoscopic evaluation of the airway is indicated to rule out congenital subglottic stenosis. A second consideration should be a foreign body within the airway, mimicking croup. Intubation for general anesthesia, for any condition, may cause a croup syndrome because of subglottic swelling. Children between the ages of one and four are most susceptible. Factors contributing to subglottic swelling are a tight endotracheal tube, trauma during intubation, a long operative procedure, and repeated attempts at intubation. This syndrome has been reported to occur in 1 per cent of intubated children at the Children's Hospital Medical Center. 16 Controversies about croup probably stem, in good part, from the lack of clear definition of the disease treated. 5 There is no doubt that seasonal or yearly variation of viral laryngotracheitis occurs, and that variation in severity depends on the geographic location. The disease may be altogether different in cold, dry climates from that in warmer, more humid regions. Added to this is variability in the response of the patient to the disease, as well as the grouping of many syndromes under one term. The remainder of this discussion is limited to viral laryngotracheitis,
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which is the most common of the croup syndromes. The viral agent causing this disease may vary from year to year and includes parainfluenza, respiratory syncytial virus, and adenovirus. '2 ,'4 Influenza A2 has been associated with a more severe disease,'4 and the increased shedding of viruses has been correlated with progression of disease from upper respiratory infections to the croup syndrome. The diagnosis of viral laryngotracheitis is most often made on a clinical basis. The question of additional information from radiographs has not been fully explored although there appears to be no correlation between the x-ray findings and the degree of hypoxemia. 20 Uncomplicated disease should not produce parenchymal pulmonary changes, and pneumonia should signify progression of the disease beyond simple laryngotracheitis (Fig. 3). Probably the only aspect of management of viral laryngotracheitis that is not controversial is the need for humidification. This can be delivered in a croupette, in a high humidification room, or occasionally by face mask. The n~ed for oxygen in an obviously cyanotic or hypoxic patient should also be straightforward. Because laryngotracheitis is almost entirely a clinical diagnosis, very few objective criteria have been used to measure degree of severity so that results of treatment can be judged, even if similar disease processes are compared. Clinical scoring systems have been utilized, with none gaining universal acceptance largely because of the subjective nature of the evaluation. 17,3o.33 The parameters of respiratory rate, pulse, fever,
Figure 3. Chest (A) and anteroposterior neck (B) radiographs are shown in a child with viral laryngotracheitis. Note the "steeple" contour of the subglottis rather than the normal rounded or "shoulder" configuration. Also pulmonary infiltrates are absent on the chest film. (Courtesy of William R. Cranley, M.D., Department of Radiology, Boston City Hospital.)
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blood gases, and radiographic findings have as yet to be correlated with severity of disease. The use of racemic epinephrine inhalation in croup syndrome has been the subject of debate for at least the past 10 years. The study by Adair et al. in 1971, covering a 10 year period and use in over 550 patients, reported improved airway patency.! Moreover, in the last five years of their study, no patient required a tracheostomy. It is important to note that the racemic epinephrine was delivered by meticulous intermittent positive pressure breathing CIPPB) technique. Subsequent studies, not utilizing IPPB, but rather nebulization, could not duplicate the prolonged beneficial responses. lO However, initial improvement was noted. The length of hospitalization or need for tracheostomy was not altered. Most recent studies confirm the immediate improvement experienced by the patients and generally recommend its use for the acute stages of virallaryngotracheitis. 3o •33 It is doubtful that racemic epinephrine would be of value in bacterial laryngotracheobronchitis. The response in patients with spasmodic croup should theoretically be beneficial, since the edema tends to be rapidly reversible. Complications of racemic epinephrine should always be considered, including central nervous system stimulation, tachycardia, hypertension, and potential ventricular ectopic activity. It can be concluded, currently, that the use of 0.5 cc of 2 per cent racemic epinephrine diluted with sterile water to a total volume of 3. 5 cc, and delivered by IPPB (by face mask) is effective therapy for the acute airway obstruction of laryngotracheitis. The IPPB pressure setting is usually 20 cm of water, and the treatment is delivered for 15 minutes, while the patient is closely monitored for side effects. If no response is obtained in two or three treatments, further attempts would probably be of no benefit. The use of steroids is another area of therapeutic controversy and has been so for nearly 20 years. In a prospective double blind study of 208 patients, divided into steroid (prednisone) and non-steroid groups, Novik reported a three-fold increased incidence of tracheostomies in the nonsteroid group.2! Subsequent studies did not confirm this finding. 7•25 The possibility of adrenal suppression from use of steroids has not been confirmed. In studies utilizing higher initial doses of steroids, specifically dexamethasone, additional improvement was noted, especially in the first 12 hours after treatment. 15 A second benefit, recently noted by Lockhart and Battaglia, is an apparent potentiating effect of steroids on racemic epinephrine, in which a dramatic increase in clinical responsiveness to racemic epinephrine occurs after steroid therapyY In addition, patients with subglottic edema, due either to spasmodic croup or post intubation croup, appear to benefit from steroid therapy. Patients ill enough to require hospitalization can reasonably be treated with a trial of steroid therapy. An initial high dose of dexamethasone is recommended, varying from 0.5 mg per kg to 1.5 mg per kg up to a total of30 mg in one administration. An assessment of the efficacy of such therapy, however, still awaits a controlled double blind study in
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patients appropriately subdivided into the various croup syndrome categories. The role of antibiotics is not as open to debate. Bacterial laryngotracheobronchitis, although not common, requires antibiotic therapy for resolution. A suitable drug may best be determined by appropriate cultures. Antibiotic therapy, however, should be directed towards Streptococcus pyogenes and pneumoniae, Staphylococcus aureus, and Hemophilus influenzae. 4 ,22 Currently, this would be a penicillin-resistant agent such as methacillin, or nafcillin in combination with chloramphenicol. The effectiveness of single agent therapy with a cephalosporin still needs to be proven. The use of antibiotics in the other croup syndromes is less tenable. Secondary pulmonary infections should be treated when they arise. They are most often seen in children who require either intubation or tracheostomy and should be looked for by physical examination and chest radiography. The role of airway intervention remains in some dispute. Unless the disease process is overwhelming, rapid initial intubation or tracheostomy is rarely required. If there is progressive airway obstruction not responsive to medical management, the airway should be inspected in a cO"ltrolled situation, such as the operating room, to rule out any anatomic abnormality. Whether an endotracheal tube should be inserted or a tracheostomy performed is often at the discretion of the individual or team responsible for the management of the airway.2,11,23,29 It would seem, however, that placing an endotracheal tube through an already inflamed and narrowed subglottis, limited by the cricoid cartilage, may only aggravate the already precarious situation. Placing a tracheostomy below the area of airway limitation may be of greater subsequent benefit in preventing complications. If, however, intubation is decided upon, the smallest caliber tube compatible with adequate ventilation should be used. Since croup syndromes tend not to respond as quickly to therapy as does supraglottitis, patients with croup oftern require airway support for somewhat longer periods. One measure of timing for extubation or decannulation is when the child can breathe around the endotracheal tube or tracheostomy tube. Extubation should be done in the operating room, so that a tracheostomy may be performed if required. The child should also be observed in the hospital for at least 24 hours after removal of the airway device to make certain that reintervention is not needed. Summary The presence of a foreign body must always be considered in young children with airway obstruction. Once this has been ruled out, then inflammatory disease of the major airway assumes prime importance. Supraglottitis may often be suspected after simple history and examination. "Croup" describes various disorders that have the common de-
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nominator of inflammatory subglottic swelling. Appropriate therapy remains controversial.
REFERENCES 1. Adair, J. G., Ring, W. H., Jordan, W. S., et al.: Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth. Analg., 50:649-655, 1971. 2. Allen, T. H., Steven, 1. M.: Prolonged nasotracheal intubation in infants and children. Brit. J. Anesth., 44:835-840, 1972. 3. Berenberg, W., Kevy, S.: Acute epiglottitis in childhood. New Engl. J. Med., 258:870874,1958. 4. Brighton, G. R.: Laryngotracheobronchitis. Ann. Otol. Rhinol. Laryngol., 49: 1070-1082, 1940. 5. Cherry, J. D.: The treatment of croup: Continued controversy due to a failure of recognition of historic, ecologic, etiologic and clinical perspectives. J. Pediatr., 94: 352-354, 1979. 6. Davidson, F. W.: Acute laryngeal obstruction in children. J.A.M.A., 171 :1301-1305, 1959. 7. Eden, A. N., and Larkin, V. D.: Corticosteroid treatment of croup. Pediatrics, 33: 768-769, 1964. 8. Ferguson, C. F.: Congenital abnormalities of the infant larynx. Otolaryngol. Clin. North Am., 3:185-200,1970. 9. Friedberg, S. A., and Bluestone, C. D.: Foreign body accidents involving the air and food passages in children. Otolaryngol. Clin. North Am., 3:395-403, 1970. 10. Gardner, H. G., Powell, K. R., Roden, V. J., et al.: The evaluation of racemic epinephrine in the treatment of infectious croup. Pediatrics, 52:52-55, 1973. 11. Gross, C. W.: Medical management, nasotracheal intubation, and tracheotomy in the treatment of upper airway obstruction in children. Otolaryngol. Clin. North Am., 10:157-166, 1977. 12. Hall, C. B., Geiman, J. M., Breese, B. B., et al.: Parainfluenza viral infections in children: Correlation of shedding with clinical manifestations. J. Pediatr., 91 : 194-198, 1977. 13. Holinger, P. H., Brown, W. T., and Maurizi, D. G.: Tracheostomy in the newborn. Am. J. Surg., 109:771-779, 1965. 14. Howard, J. B., McCracken, G. H., Jr., and Luby, J. P.: Influenza A2 virus as a cause of croup requiring tracheotomy. J. Pediatr., 81: 1148-1150, 1972. 15. James, J. A.: Dexamethasone in croup. Am. J. Dis. Child., 117:511-516, 1969. 16. Koka, B. V., Jean, 1. S., Andre, J. M., et al.: Postintubation croup in children. Anesth. Analg., 56:501-505, 1977. 17. Lockhart, C. H., Battaglia, J. D.: Croup (laryngotracheal bronchitis) and epiglottitis. Pediatr. Ann., 6:262-269, 1977. 18. Margolis, C. Z., Ingram, D. L., and Meyer, J. H.: Routine tracheotomy in hemophilus influenza type b epiglottitis. J. Pediatr., 81: 1150-1153, 1972. 19. Milko, D. A., Marshak, G., and Striker, T. W.: Nasotracheal intubation in the treatment of acute epiglottitis. Pediatrics, 53:674-677, 1974. 20. Newth, C. J. L., Levinson, H., and Bryan, A. C.: The respiratory status of children with croup. J. Pediatr., 81 :1068-1073, 1972. 21. Novik, A.: Corticosteroid treatment of non-diphtheritic croup. Acta Otolaryngol., 158(Suppl.):20-22, 1960. 22. Orton, H. B., Smith, E. L., Bill, H. 0., et al.: Acute laryngotracheobronchitis: Analysis of 62 cases with report of autopsies in 8 cases. Arch. Otolaryngol., 33:926--960, 1941. 23. Schuller, D. E., and Birck, H. G.: The safety of intubation in croup and epiglottitis: An 8-year follow-up. Laryngoscope, 85:33-46, 1975. 24. Sinclair, S. E.: Haemophilus influenza type b in acute laryngitis with bacteremia. J.A.M.A., 117:170-173,1941. 25. Skowran, P. N., Turner, J. A. P., and McNaughton, G. A.: The use of corticosteroid (dexamethasone) in the treatment of acute laryngotracheitis, Canad. Med. Assoc. J., 94:528-531, 1966. 26. Smith, E. W. P., and Ingran, D. L.: Counterimmunoelectrophoresis in Hemophilus influenzae type b epiglottitis and pericarditis. J. Pediatr., 86:571-573, 1975. 27. Strome, M.: Tracheobronchial foreign bodies: An updated approach. Ann. Otol. Rhinol. Laryngol., 86:649-654, 1977.
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28. Strome, M., and Jaffe, B.: Epiglottitis-individualized management with steroids. Laryngoscope,84:921-928,1974. 29. Tarkkanen, J. Kohonen, A.: Tracheostomy in subglottic laryngitis (pseudocroup) and acute epiglottitis. Acta Otolaryngol., 74:283-286, 1972. 30. Taussig, L. M., Castro, 0., Beaudry, P. H., et al.: Treatment oflaryngotracheobronchitis (croup). Am. J. Dis. Child., 129:790-793, 1975. 31. Tucker, G. F., Jr.: Foreign bodies in the esophagus or respiratory tract. InPaparella, M. M., and Shumrick, D. A. (eds.), Otolaryngology. Vol. 3, pp. 753-765. Philadelphia, W. B. Saunders Co., 1973. 32. Tucker, J. A.: Obstruction of the major pediatric airway. Otolaryngol. Clin. North Am., 12:329-341, 1979. 33. Westley, C. R., Cotton, E. K., and Brooks, J. G.: Nebulized racemic epinephrine by IPPB for the treatment of croup. Am. J. Dis. Child., 132:484-487, 1978.
Beth Israel Hospital 330 Brookline Avenue Boston, Massachusetts 02215
Controversies in the Management of Supraglottitis and Croup Marvin P. Fried, M.D.*
Inflammatory obstruction of the major airways in children is a rious problem. Although survival statistics have improved steadily as a sult of earlier diagnosis and more effective therapy, serious pitfalls still rsist in the management of these diseases. Inflammation and subquent obstruction of the supraglottis and sub glottis are the most rious of these disorders in the infant and small child. This article will dress the current controversies surrounding these entities and will fer some recommendations for current diagnosis and management.
he Significance of Airway Obstruction
Airway problems in the neonate are most often the result of congenimalformation. Inflammatory airway disorders occur in the older infant d are rarely associated with airway anomalies. Yet the normal infant's ynx is more susceptible to obstruction than the child's or adult's larynx g. 1).8 Smaller laryngeal size is only one of the anatomic differences. e infant supraglottis (the region of the larynx superior to the level of e vocal cords) lends itself to airway obstruction. The angle between the iglottis and the glottis is more acute than in the adult, making direct yngoscopic visualization more difficult. Further, the infant epiglottis relatively long and tubular with redundant aryepiglottic folds (giving e to the characteristic "omega" shape), and the cartilaginous mework is less rigid in the infant, being composed or elastic cartilage her than the firmer hyaline cartilage. Finally, edema spreads easily rough the submucosal connective tissue of the supraglottis, diffusely larging the entire structure including the ventricular bands (false cal cords), aryepiglottic folds, and epiglottis. The subglottis, the region from the vocal cords to the inferior margin the cricoid cartilage, is the only rigidly confined space in the upper way inferior to the nasal chamber, being fully encircled by nonelastic rtilage (cricoid).13 Any inflammatory change can cause edema with sistant Professor of Otolaryngology, Harvard Medical School; Associate Chief of Otolaryngology, Beth Israel Hospital; Assistant in Otolaryngology, Children's Hospital Medical Center; Junior Associate in Surgery, Peter Bent Brigham Hospital, Boston, Massachusetts
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SUPRAGLOTTIS SUPRAGLOTTIS
GLOTT IS } GLOTTIS } (Voca l Cord) l Vocal Cord)
}
} SUBGLOTTIS SUBGLOTTIS
LATERAL LATERAL VIEWVIEW (CUT)(CUT)
Figure 1.
Lateral views of the infant (left) and the adult (right) larynx. (Left: from Bosma,
J., and Donner, M.: Physiology of the pharynx. In Paparella and Shumrick (eds.): Otolaryngology, 2nd ed., in press. Right: adapted from Warwick, R., and Williams, P. (eds.): Gray's Anatomy. 35th British ed. Philadelphia, w. B. Saunders Co., 1973.)
rapid expansion of the loose submucosal connective tissue, as in the supraglottis, and significant narrowing of the airway. The alterations in the airway that are caused by supraglottitis or laryngotracheobronchitis are relatively acute, lasting hours to a few days. Slower progression of airway compromise can more easily be tolerated, and compensation made, both in children and adults. The child, however, will deteriorate quite rapidly when exhaustion is reached, changing a stable or partially compensated situation into an emergency. Steps to stabilize the condition should be undertaken as soon as the appropriate diagnosis is made. The primary consideration is the maintenance of any airway. The diagnoses of supraglottitis and croup are essentially clinical, made by history and examination. Laboratory studies will only confirm the initial diagnosis. These disorders are dissimilar enough to be thought of as separate entities, and they will be dealt with here individually. Foreign Bodies
The presence of a foreign body within the airway should always be considered in the age group prone to supraglottitis and croup (up to 5 years old). Foreign bodies account for approximately 2000 annual deaths in the United States. 9 Although the most common object that causes obstruction in adults is meat, safety pins are most common in children under one year of age, and nuts and coins are most common in the two to
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four year age group. If obstruction is complete, death can be rapid. Partially obstructing objects can mimic croup, but also cause choking, gagging, coughing, or wheezing. If the foreign body lies above or within the larynx, there is associated hoarseness or aphonia, odynophagia, hemoptysis, or dyspnea. If the initial episode goes unnoticed, then a period of relatively few symptoms follows. Intermittent pneumonitis or tracheobronchitis, as well as episodic "croup," may occur at a later date. Radiography is essential in making the diagnosis and in localizing the foreign body. The exclusion of a foreign body may actually be the most important justification for x-ray films when supraglottitis or more typical croup is being considered. A lateral soft tissue film of the neck, inspiratory and expiratory chest films with the benefit of fluoroscopy, and a lateral chest film with the arms held posteriorly in order to visualize the tracheobronchial tree, should be obtained initially. Contrast studies should be avoided since the dye may be aspirated in an obstructing esophageal foreign body and make endoscopic removal much more difficult. If the foreign body is not visualized, then a region of obstructive atelectasis or emphysema, augmented by changes in respiration, may be a clue to a foreign body.a' If the airway is not in immediate jeopardy, there is no need for hasty attempts at removal, since oropharyngeal or hypopharyngeal objects may be pushed further into the airway in an uncontrolled situation. 27 Also, turning an infant over with head down may cause a tracheobronchial foreign body to lodge in the narrow sub glottis , leading to total obstruction. Emetics should not be given since aspiration may be precipitated. Definitive care most often requires endoscopic removal by individuals experienced in these techniques. In any emergency situation, the prime consideration is the establishment of an airway. If the foreign body is causing total or near-complete obstruction and cannot be easily visualized, a tracheostomy should be performed. An attempt at the Heimlich maneuver may be appropriate if no other facilities are available. However, tracheostomy is the mainstay of therapy in these emergency situations. Supraglottitis
Supraglottitis is known most commonly as epiglottitis. The former term is used in preference because any portion of the supraglottic larynx may give rise to this symptom complex. Moreover, specific regions of the supraglottis may be involved in isolation. Classically, supraglottitis is described as an infectious process of the epiglottis, most often caused by Hemophilus influenzae, leading to edema and inflammation and producing a swollen, cherry-red epiglottis. 24 This can rapidly cause airway obstruction and is a life-threatening emergency. However, other bacteria, such as pneumococcus, streptococcus, and staphylococcus have been implicated as pathogenic organisms in this disease. Because the causative agent may not always be isolated by a pharyngeal culture, blood cultures as well as serum counterimmunoelectrophoresis may be needed for etiologic diagnosis. 26
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The location of the inflammation can be as variable as the pathogen. Tucker has noted the isolated involvement of the lingual surface of the epiglottis and aryepiglottic folds with minimal endolaryngeal swelling. 32 The author has cared for both children and adults with culture-proven Hemophilus influenzae supraglottitis with edema and erythema limited only to the ventricular bands and a minimally edematous epiglottis. In fact, swelling of the ventricular bands may be the most significant factor in airway obstruction in supraglottitis. Supraglottitis most commonly affects children between the ages of three to six years, but can occur even to adulthood. There is no seasonal predilection. Progress is rapid, in terms of hours rather than days. There is significant throat pain, dysphagia, and "toxicity." The child is usually febrile and soon becomes aware of difficulty in breathing. Activity is restricted and the patient prefers sitting or leaning forward. Lying down causes the supraglottic swelling to further compromise the airway. Drooling is common. Speech is limited because of pain. A cough is usually not present. The diagnosis is often suspected on a brief history from the parents and general inspection of the patient. The controversies associated with supraglottitis essentially center on establishing the diagnosis, and care of the airway. The primary consideration, which is not a subject of controversy, is maintenance of an adequate airway, and procedures are measured against adequacy of ventilation and the need for rapid intervention. Direct visual inspection of the epiglottis to confirm the diagnosis has become less controversial over the years. The tip of the swollen epiglottis can often be easily visualized in younger children, especially before laryngeal descent occurs. The infant larynx lies at the level of the second and third cervical vertebra. In the adult it is situated opposite the body of the fifth vertebra. If, however, the swelling is limited to a region of the endolarynx such as the ventricular bands, this may not be recognized by inspection using a flashlight and tongue-blade. Moreover, depression of the base of the tongue may stimulate the already compromised larynx to spasm, completing an already partial airway obstruction. Confirmatory inspection should be held off until means are available to control the airway, such as intubation or tracheostomy. The need for radiologic studies is also controversial. There is no doubt that supraglottitis can be diagnosed by x-ray examination. The thumbshaped epiglottis, widened aryepiglottic folds, loss of the vallecular shadow, and narrowing of the posterior airway are characteristic (Fig. 2). The question is whether the procedure is necessary. A lateral cervical radiograph is useful to rule out a radiodense foreign body. The diagnosis of supraglottitis by physical examination is most often correct; radiographs merely confirm it. With the diagnosis established, management decisions raise the most controversial of all aspects of this disease. Historically, once acute supraglottitic laryngitis had been described as a distinct pathologic entity, it became quickly apparent that survival was closely related to establishment of an adequate airway.3 For years, this meant early tracheostomy. In many centers throughout the world, tracheostomy is
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Figure 2. In this lateral radiograph of neck in a child with supraglottitis, the rounding of the epiglottic shadow, the thickening of the aryepiglottic folds, and the distention ofthe hypopharynx secondary to airway obstruction are demonstrated. Forward thrust of the mandible and spine is also noted. (Courtesy of William R. Cranley, M.D., Department of Radiology, Boston City Hospital.)
still done with little risk to the patient and very few complications. 18.29 This has remained the yardstick against which to measure other modes of therapy. Over the past 15 years, reports have appeared describing the safety and efficacy of tracheal intubation for supraglottitis. 2,11,19,23 Complications have been comparable to tracheostomy, and in many series even lower. The rationale for this approach is based on the rapid response of the infectious process to appropriate antibiotic therapy. The obstructing edema often subsides within two to three days, allowing removal of the tracheostomy or endotracheal tube. The third mode of initial management is the use of steroids, humidification, and antibiotics (such as ampicillin) in patients who can be closely observed and whose airway is not in immediate jeopardy. 19,28 The status of the airway may be difficult to assess, an~ one risks rapid respiratory collapse if the patient is not closely monitored. The syndrome of cyanosis, exhaustion, and severe sternal retraction indicates a poor medical response and the necessity for establishment of an airway. Management of airway problems such as supraglottitis at the Children's Hospital Medical Center and at Boston City Hospital is a team effort. When the pediatrician, either in the office or in the emergency room, suspects that the patient has a disease that compromises the airway, members of the otolaryngology and anesthesiology departments are summoned to meet the patient in the emergency room. If the clinical suspicion is supraglottitis, the child is not disturbed. Blood samples and blood gases are not obtained, nor are intravenous fluids begun, The patient is accompanied by a physician until an airway is established. If the child feels most comfortable and reassured remaining with the parents, this is allowed. If time permits, a stop is made in the radiology department to obtain a lateral x-ray film of the neck. Thereafter the child is taken to the operating room where a slow face mask general anesthesia is performed. Only after adequate anesthesia is obtained are blood samples drawn for a blood count, blood cultures, or counterimmunoelectrophoresis. Appropriate cultures are taken. A preliminary orotracheal intubation is performed by the anesthesiologist. The larynx is examined by the otolaryngologist to confirm the diagnosis and to rule out any other
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abnormality. An orderly nasotracheal intubation is then carried out, with the oro tracheal tube removed. A full spectrum of bronchoscopes and a tracheostomy set, with appropriately sized tracheostomy tubes, is available ifintubation cannot be performed and should the otolaryngologist be called upon to intercede. A nasotracheal tube is preferred to an orotracheal one because there is less motion of the tube with less subglottic irritation. The tube can be easily taped in place. Some children may require restraints so that the tube is not dislodged. The use of intubation to control the airway necessitates close monitoring of the patient by personnel familiar with such devices. In hospital settings in which this cannot easily be done, tracheostomy may indeed be a safer method of airway control. Appropriate intravenous antibiotic therapy is begun, most often ampicillin. However, chloramphenicol is used in children with sensitivity to penicillin. Adequate humidification and endotracheal tube care is given. The patient is brought back to the operating room in two or three days, depending upon the clinical response. The larynx is once again visualized and if the disease has resolved, the endotracheal tube is removed. Croup Syndromes
The term "croup" is often used to define a symptom complex of varying respiratory obstruction, barking cough, suprasternal and intercostal retractions, and hoarseness that is common to many conditions. One of the most severe of these obstructing diseases is laryngeal diphtheria, which fortunately has become a rare entity. This still leaves, however, spasmodic or allergic croup, acute bacterial laryngC'tracheobronchitis, and viral laryngotracheitis. 6,22 Spasmodic croup usually affects the child at night with dyspnea, croupy cough, and inspiratory stridor. 5 The only prodrome, ifany, may be a mild cold. The child is almost always afebrile. Therapy consists of humidification such as a shower running in the bathroom, or taking the child out in the night air. Medications such as diphenhydramine elixir, Syrup of Ipecac, corticosteroids, and subcutaneous epinephrine have all been used with success. The subglottis, when visualized endoscopically, is edematous, pale, and watery in appearance. These symptoms clear quite rapidly. Some individuals may have recurrent nocturnal symptoms on subsequent days, Airway intubation or tracheostomy is rarely necessary. The etiology of spasmodic croup is still speculative, and may represent either an allergic response or a low-grade viral infection. Bacterial laryngotracheobronchitis, although not so rare as to be a past curiosity, is not as common as it was 30 or more years age. 4 ,22 This process is a diffuse, infectious involvement of the entire airway associated with significant crusting of transudate on the respiratory epithelium. The submucosal swelling appears most limiting in the narrow subglottis. This disorder has its onset in a manner similar to the more common viral laryngotracheitis; however, with progression, a secondary infection occurs which then becomes more fulminant than the initial process. The organisms cultured include Streptococcus pyogenes,
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StreptococcuS pneumonia, Staphylococcus aureus and, occasionally, Hemophilus influenzae. Therapy includes the appropriate antibiotics for the pathogen, humidification to loosen the crusting, oxygenation when needed, and, occasionally, bronchoscopic removal ofthe crusts. The need for a tracheostomy is more common once the secondary bacterial infection has begun. The reports of30 to 60 per cent mortality in the 1930s and 1940s has now been reduced almost to zero.4 The most common entity known as croup is viral laryngotracheitis. Bronchitis is specifically omitted from the name because rarely can inflammatory disease of the more distal airways be documented. Certainly radiographic evidence for bronchitis is sparse. Viral laryngotracheitis usually afflicts children less than three years of age, and begins gradually with an upper respiratory infection. Although it may occur in any season, it is by far most common in the winter months, and appears to have yearly variations. For example, the number of admissions for viral laryngotracheitis at Boston City Hospital and Children's Hospital Medical Center in the winter of 1977 to 78 was over five times as great as either the winter before or after. These children appear to be ill but are not toxic, have a croupy cough, hoarse voice, and stridor that can be both inspiratory and expiratory. There is no significant dysphagia, throat pain, drooling, or preferred position. Fever is common but is not spiking or significantly elevated. 11 The common characteristic of, all the diseases just listed is edema within the sub glottis. As noted before, any swelling within this space is confined by the intact cricoid ring, causing rapid and significant airway compromise. Moreover, the airway may be previously narrowed by undiagnosed congenital subglottic stenosis. This can go undetected until the infant has his first cold that rapidly becomes "croup." This may not clear entirely or can recur frequently (because of the underlying persistent narrowed airway) or progress rapidly to airway collapse. If croup should occur more than three times within a year, or does not clear entirely between recurrences, endoscopic evaluation of the airway is indicated to rule out congenital subglottic stenosis. A second consideration should be a foreign body within the airway, mimicking croup. Intubation for general anesthesia, for any condition, may cause a croup syndrome because of subglottic swelling. Children between the ages of one and four are most susceptible. Factors contributing to subglottic swelling are a tight endotracheal tube, trauma during intubation, a long operative procedure, and repeated attempts at intubation. This syndrome has been reported to occur in 1 per cent of intubated children at the Children's Hospital Medical Center. 16 Controversies about croup probably stem, in good part, from the lack of clear definition of the disease treated. 5 There is no doubt that seasonal or yearly variation of viral laryngotracheitis occurs, and that variation in severity depends on the geographic location. The disease may be altogether different in cold, dry climates from that in warmer, more humid regions. Added to this is variability in the response of the patient to the disease, as well as the grouping of many syndromes under one term. The remainder of this discussion is limited to viral laryngotracheitis,
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which is the most common of the croup syndromes. The viral agent causing this disease may vary from year to year and includes parainfluenza, respiratory syncytial virus, and adenovirus. '2 ,'4 Influenza A2 has been associated with a more severe disease,'4 and the increased shedding of viruses has been correlated with progression of disease from upper respiratory infections to the croup syndrome. The diagnosis of viral laryngotracheitis is most often made on a clinical basis. The question of additional information from radiographs has not been fully explored although there appears to be no correlation between the x-ray findings and the degree of hypoxemia. 20 Uncomplicated disease should not produce parenchymal pulmonary changes, and pneumonia should signify progression of the disease beyond simple laryngotracheitis (Fig. 3). Probably the only aspect of management of viral laryngotracheitis that is not controversial is the need for humidification. This can be delivered in a croupette, in a high humidification room, or occasionally by face mask. The n~ed for oxygen in an obviously cyanotic or hypoxic patient should also be straightforward. Because laryngotracheitis is almost entirely a clinical diagnosis, very few objective criteria have been used to measure degree of severity so that results of treatment can be judged, even if similar disease processes are compared. Clinical scoring systems have been utilized, with none gaining universal acceptance largely because of the subjective nature of the evaluation. 17,3o.33 The parameters of respiratory rate, pulse, fever,
Figure 3. Chest (A) and anteroposterior neck (B) radiographs are shown in a child with viral laryngotracheitis. Note the "steeple" contour of the subglottis rather than the normal rounded or "shoulder" configuration. Also pulmonary infiltrates are absent on the chest film. (Courtesy of William R. Cranley, M.D., Department of Radiology, Boston City Hospital.)
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blood gases, and radiographic findings have as yet to be correlated with severity of disease. The use of racemic epinephrine inhalation in croup syndrome has been the subject of debate for at least the past 10 years. The study by Adair et al. in 1971, covering a 10 year period and use in over 550 patients, reported improved airway patency.! Moreover, in the last five years of their study, no patient required a tracheostomy. It is important to note that the racemic epinephrine was delivered by meticulous intermittent positive pressure breathing CIPPB) technique. Subsequent studies, not utilizing IPPB, but rather nebulization, could not duplicate the prolonged beneficial responses. lO However, initial improvement was noted. The length of hospitalization or need for tracheostomy was not altered. Most recent studies confirm the immediate improvement experienced by the patients and generally recommend its use for the acute stages of virallaryngotracheitis. 3o •33 It is doubtful that racemic epinephrine would be of value in bacterial laryngotracheobronchitis. The response in patients with spasmodic croup should theoretically be beneficial, since the edema tends to be rapidly reversible. Complications of racemic epinephrine should always be considered, including central nervous system stimulation, tachycardia, hypertension, and potential ventricular ectopic activity. It can be concluded, currently, that the use of 0.5 cc of 2 per cent racemic epinephrine diluted with sterile water to a total volume of 3. 5 cc, and delivered by IPPB (by face mask) is effective therapy for the acute airway obstruction of laryngotracheitis. The IPPB pressure setting is usually 20 cm of water, and the treatment is delivered for 15 minutes, while the patient is closely monitored for side effects. If no response is obtained in two or three treatments, further attempts would probably be of no benefit. The use of steroids is another area of therapeutic controversy and has been so for nearly 20 years. In a prospective double blind study of 208 patients, divided into steroid (prednisone) and non-steroid groups, Novik reported a three-fold increased incidence of tracheostomies in the nonsteroid group.2! Subsequent studies did not confirm this finding. 7•25 The possibility of adrenal suppression from use of steroids has not been confirmed. In studies utilizing higher initial doses of steroids, specifically dexamethasone, additional improvement was noted, especially in the first 12 hours after treatment. 15 A second benefit, recently noted by Lockhart and Battaglia, is an apparent potentiating effect of steroids on racemic epinephrine, in which a dramatic increase in clinical responsiveness to racemic epinephrine occurs after steroid therapyY In addition, patients with subglottic edema, due either to spasmodic croup or post intubation croup, appear to benefit from steroid therapy. Patients ill enough to require hospitalization can reasonably be treated with a trial of steroid therapy. An initial high dose of dexamethasone is recommended, varying from 0.5 mg per kg to 1.5 mg per kg up to a total of30 mg in one administration. An assessment of the efficacy of such therapy, however, still awaits a controlled double blind study in
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patients appropriately subdivided into the various croup syndrome categories. The role of antibiotics is not as open to debate. Bacterial laryngotracheobronchitis, although not common, requires antibiotic therapy for resolution. A suitable drug may best be determined by appropriate cultures. Antibiotic therapy, however, should be directed towards Streptococcus pyogenes and pneumoniae, Staphylococcus aureus, and Hemophilus influenzae. 4 ,22 Currently, this would be a penicillin-resistant agent such as methacillin, or nafcillin in combination with chloramphenicol. The effectiveness of single agent therapy with a cephalosporin still needs to be proven. The use of antibiotics in the other croup syndromes is less tenable. Secondary pulmonary infections should be treated when they arise. They are most often seen in children who require either intubation or tracheostomy and should be looked for by physical examination and chest radiography. The role of airway intervention remains in some dispute. Unless the disease process is overwhelming, rapid initial intubation or tracheostomy is rarely required. If there is progressive airway obstruction not responsive to medical management, the airway should be inspected in a cO"ltrolled situation, such as the operating room, to rule out any anatomic abnormality. Whether an endotracheal tube should be inserted or a tracheostomy performed is often at the discretion of the individual or team responsible for the management of the airway.2,11,23,29 It would seem, however, that placing an endotracheal tube through an already inflamed and narrowed subglottis, limited by the cricoid cartilage, may only aggravate the already precarious situation. Placing a tracheostomy below the area of airway limitation may be of greater subsequent benefit in preventing complications. If, however, intubation is decided upon, the smallest caliber tube compatible with adequate ventilation should be used. Since croup syndromes tend not to respond as quickly to therapy as does supraglottitis, patients with croup oftern require airway support for somewhat longer periods. One measure of timing for extubation or decannulation is when the child can breathe around the endotracheal tube or tracheostomy tube. Extubation should be done in the operating room, so that a tracheostomy may be performed if required. The child should also be observed in the hospital for at least 24 hours after removal of the airway device to make certain that reintervention is not needed. Summary The presence of a foreign body must always be considered in young children with airway obstruction. Once this has been ruled out, then inflammatory disease of the major airway assumes prime importance. Supraglottitis may often be suspected after simple history and examination. "Croup" describes various disorders that have the common de-
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nominator of inflammatory subglottic swelling. Appropriate therapy remains controversial.
REFERENCES 1. Adair, J. G., Ring, W. H., Jordan, W. S., et al.: Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth. Analg., 50:649-655, 1971. 2. Allen, T. H., Steven, 1. M.: Prolonged nasotracheal intubation in infants and children. Brit. J. Anesth., 44:835-840, 1972. 3. Berenberg, W., Kevy, S.: Acute epiglottitis in childhood. New Engl. J. Med., 258:870874,1958. 4. Brighton, G. R.: Laryngotracheobronchitis. Ann. Otol. Rhinol. Laryngol., 49: 1070-1082, 1940. 5. Cherry, J. D.: The treatment of croup: Continued controversy due to a failure of recognition of historic, ecologic, etiologic and clinical perspectives. J. Pediatr., 94: 352-354, 1979. 6. Davidson, F. W.: Acute laryngeal obstruction in children. J.A.M.A., 171 :1301-1305, 1959. 7. Eden, A. N., and Larkin, V. D.: Corticosteroid treatment of croup. Pediatrics, 33: 768-769, 1964. 8. Ferguson, C. F.: Congenital abnormalities of the infant larynx. Otolaryngol. Clin. North Am., 3:185-200,1970. 9. Friedberg, S. A., and Bluestone, C. D.: Foreign body accidents involving the air and food passages in children. Otolaryngol. Clin. North Am., 3:395-403, 1970. 10. Gardner, H. G., Powell, K. R., Roden, V. J., et al.: The evaluation of racemic epinephrine in the treatment of infectious croup. Pediatrics, 52:52-55, 1973. 11. Gross, C. W.: Medical management, nasotracheal intubation, and tracheotomy in the treatment of upper airway obstruction in children. Otolaryngol. Clin. North Am., 10:157-166, 1977. 12. Hall, C. B., Geiman, J. M., Breese, B. B., et al.: Parainfluenza viral infections in children: Correlation of shedding with clinical manifestations. J. Pediatr., 91 : 194-198, 1977. 13. Holinger, P. H., Brown, W. T., and Maurizi, D. G.: Tracheostomy in the newborn. Am. J. Surg., 109:771-779, 1965. 14. Howard, J. B., McCracken, G. H., Jr., and Luby, J. P.: Influenza A2 virus as a cause of croup requiring tracheotomy. J. Pediatr., 81: 1148-1150, 1972. 15. James, J. A.: Dexamethasone in croup. Am. J. Dis. Child., 117:511-516, 1969. 16. Koka, B. V., Jean, 1. S., Andre, J. M., et al.: Postintubation croup in children. Anesth. Analg., 56:501-505, 1977. 17. Lockhart, C. H., Battaglia, J. D.: Croup (laryngotracheal bronchitis) and epiglottitis. Pediatr. Ann., 6:262-269, 1977. 18. Margolis, C. Z., Ingram, D. L., and Meyer, J. H.: Routine tracheotomy in hemophilus influenza type b epiglottitis. J. Pediatr., 81: 1150-1153, 1972. 19. Milko, D. A., Marshak, G., and Striker, T. W.: Nasotracheal intubation in the treatment of acute epiglottitis. Pediatrics, 53:674-677, 1974. 20. Newth, C. J. L., Levinson, H., and Bryan, A. C.: The respiratory status of children with croup. J. Pediatr., 81 :1068-1073, 1972. 21. Novik, A.: Corticosteroid treatment of non-diphtheritic croup. Acta Otolaryngol., 158(Suppl.):20-22, 1960. 22. Orton, H. B., Smith, E. L., Bill, H. 0., et al.: Acute laryngotracheobronchitis: Analysis of 62 cases with report of autopsies in 8 cases. Arch. Otolaryngol., 33:926--960, 1941. 23. Schuller, D. E., and Birck, H. G.: The safety of intubation in croup and epiglottitis: An 8-year follow-up. Laryngoscope, 85:33-46, 1975. 24. Sinclair, S. E.: Haemophilus influenza type b in acute laryngitis with bacteremia. J.A.M.A., 117:170-173,1941. 25. Skowran, P. N., Turner, J. A. P., and McNaughton, G. A.: The use of corticosteroid (dexamethasone) in the treatment of acute laryngotracheitis, Canad. Med. Assoc. J., 94:528-531, 1966. 26. Smith, E. W. P., and Ingran, D. L.: Counterimmunoelectrophoresis in Hemophilus influenzae type b epiglottitis and pericarditis. J. Pediatr., 86:571-573, 1975. 27. Strome, M.: Tracheobronchial foreign bodies: An updated approach. Ann. Otol. Rhinol. Laryngol., 86:649-654, 1977.
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28. Strome, M., and Jaffe, B.: Epiglottitis-individualized management with steroids. Laryngoscope,84:921-928,1974. 29. Tarkkanen, J. Kohonen, A.: Tracheostomy in subglottic laryngitis (pseudocroup) and acute epiglottitis. Acta Otolaryngol., 74:283-286, 1972. 30. Taussig, L. M., Castro, 0., Beaudry, P. H., et al.: Treatment oflaryngotracheobronchitis (croup). Am. J. Dis. Child., 129:790-793, 1975. 31. Tucker, G. F., Jr.: Foreign bodies in the esophagus or respiratory tract. InPaparella, M. M., and Shumrick, D. A. (eds.), Otolaryngology. Vol. 3, pp. 753-765. Philadelphia, W. B. Saunders Co., 1973. 32. Tucker, J. A.: Obstruction of the major pediatric airway. Otolaryngol. Clin. North Am., 12:329-341, 1979. 33. Westley, C. R., Cotton, E. K., and Brooks, J. G.: Nebulized racemic epinephrine by IPPB for the treatment of croup. Am. J. Dis. Child., 132:484-487, 1978.
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