9.5.1 Acute Laryngo-tracheobronchitis
Laryngo-tracheobronchitis (croup) is acute inflammation of the larynx, trachea and bronchi which occurs in young children (usually between 6 months to 3 years of age). It arises as a result of narrowing of the airway in the region of the larynx. The most common cause is viral infection (particularly parainfluenza viruses) but may also be due to bacterial infection. The obstruction is due to inflammation and oedema.
Diagnostic Criteria
- The symptoms include paroxysmal “barking” cough, inspiratory stridor, fever, wheezing, hoarseness of voice and tachypnoea
- Such symptoms usually occur at night
- Respiratory failure and pneumonia are potentially fatal complications.
Non-Pharmacological Treatment
- Prevent asphyxiation
- Treat inflammatory oedema
- Humidification of inhaled air
- Hospitalization may be necessary
| Note | |
| | No stridor at rest, give no antibiotics |
| | Stridor at rest or chest in-drawing or fast breathing REFER IMMEDIATELY to hospital |
Mild Croup
- Only stridor when upset, no moderate/severe ARI
- Likely of viral origin
- Home care – steam inhalation
- Antibiotics NOT required
Severe Croup
- Likely bacterial origin
- Stridor in a calm child at rest
- Chest in drawing
- Antibiotics are NOT effective and should not be given
Pharmacological Treatment
Admit to hospital, give Oxygen therapy to all patients with chest in-drawing (using nasal prongs only, DO NOT use nasopharyngeal or nasal catheter) until the lower chest wall indrawing is no longer present
A: Dexamethasone 0.6 (PO) mg/kg daily in 1–2 divided doses
AND
C: Nebulized Adrenaline 400 mcg/kg every 2 hours if effective; repeat after 30 min if necessary.
9.5.2 Laryngeal Diphtheria
Is an infection caused by Corynebacterium diphtheria; it is directly transmitted from person to person by droplets. Children between 1–5 years of age are most susceptible although non-immune adults are also at risk.
Diagnostic Criteria
Diphtheria is characterized by grayish-white membrane, composed of dead cells, fibrin, leucocytes and red blood cells as a result of inflammation due to multiplying bacteria.
Non-Pharmacological Treatment
- Isolate the child
- Gently examine the child’s throat – can cause airway obstruction if not carefully done.
- NGT for feeding if unable to swallow
- Avoid oxygen unless there is incipient airway obstruction
- May need tracheostomy if there is incipient airway obstruction
Pharmacological Treatment:
Drug of choice
A: Penicillin V (250 mg four times daily) for a total treatment course of 14 days
OR
A: Erythromycin (PO) 125–250 mg every 6 hourly for 14 days OR
A: Azithromycin (PO) 500mg daily for 3 days
OR
A: Penicillin G (Benzyl Penicillin) 25,000–50,000 units/kg to a maximum of 1.2 million units IV every 12 hours until the patient can take oral medicine)
AND
Diphtheria antitoxin (IM or slow IV) dose depends upon the site and severity of infection:
- First give a test dose of 0.1ml of 1 in 10 dilution of antitoxin in 0.9% Sodium Chloride intradermal to detect hypersensitivity
- It should be given immediately because delay can lead to increased mortality
- The dose should be administered intravenously over 60 minutes in order to inactivate toxin rapidly
- 20,000–40,000 units for pharyngeal/laryngeal disease of <48 hours duration,
- 40,000–60,000 units for nasopharyngeal disease
- 80,000–120,000 units for >3 days of illness or diffuse neck swelling (“bullneck”)
Note: Tracheostomy may be required for airway obstruction
9.5.3 Whooping Cough
It is a highly infectious childhood disease caused by Bordetella pertussis. It is most severe in young infants who have not yet been immunized.
Diagnostic Criteria
- Paroxysmal cough associated with a whoop
- Fever
- Nasal discharge
Non-Pharmacological Treatment
- Place the child head down and prone, or on the side, to prevent any inhaling of vomitus and to aid expectoration of secretions.
- Care for the airway but avoid, as far as possible, any procedure that could trigger coughing, such as application of suction, throat examination
- Do not give cough suppressants, sedatives, mucolytic agents or anti-histamines. If the child has fever (>38.50C) give paracetamol.
- Encourage breastfeeding or oral fluids
- Whooping cough is preventable by immunization with pertussis vaccine contained in DPT-HepB-Hib vaccine at week 6, 10 and 14.
Pharmacological Treatment
A: Erythromycin (12.5 mg/kg 6 hourly) for 10 days.
This does not shorten the illness but reduces the period of infectiousness
- If there is fever give
A: Cotrimoxazole (PO) 18 mg/kg 12 hourly for 5 days to treat possible secondary pneumonia
Oxygen
- Give oxygen to children who have spells of apnoea or cyanosis, or severe paroxysms of coughing.
- Use nasal prongs, not a nasopharyngeal catheter or nasal catheter which can provoke coughing.
9.5.4 Bronchiectasis
Bronchiectasis is characterized by inflamed and easily collapsible airways, obstruction to airflow, and frequent hospital visits and admissions.
Diagnostic Criteria
The diagnosis is usually established clinically on the basis of chronic daily cough with viscid sputum production, and radiographically by the presence of bronchial wall thickening and luminal dilatation on chest x-rays.
Non-Pharmacological Treatment
- Physiotherapy and postural drainage
- Avoid smoking
- Respiratory care during childhood measles helps prevent the development of bronchiectasis in children
Pharmacological Treatment Acute exacerbation Adults:
A: Ciprofloxacin 500mg (PO) 12 hourly for 10 days AND
A: Metronidazole 400mg (PO) 8 hourly for 10 days Children:
A: Amoxicillin 40mg/kg (PO) in 2 divided doses for 7 days AND
A: Metronidazole 7.5 mg/kg 8 hourly for 5–7 days
Prevention of infection
A: Ciprofloxacin 500mg (PO) once daily for 7–14 days/month
OR
A: Erythromycin (PO) once 250–500mg for 7–14 days/month
9.5.5 Lung Abscess
Lung abscess is a cavity within the lung parenchyma filled with necrotic tissues, which occurs as a result of tissue-destroying infection.
Diagnostic Criteria
It is characterized by high fever, breathlessness, cough productive of large amounts of foul-smelling sputum and haemoptysis.
Non-Pharmacological Treatment
Postural drainage
Pharmacological Treatment
A: Ampicillin (start with IV for one week then oral) 500–1000mg 8 hourly for
3–6 weeks (children 50mg/kg/dose) AND
B: Metronidazole (start with IV for one week then oral) 400mg 8 hourly for 4–6 weeks (children 7.5mg/kg)
