Acute laryngotracheobronchitis of young children

Acute laryngotracheobronchitis in young children (1-2 years) is one of the most severe diseases that complicate influenza infection, often ending in death despite all measures taken. In older children, this disease occurs less often. Acute laryngotracheobronchitis can occur sporadically, but it is especially common during influenza epidemics. The etiologic factor most often acts as a group of myxoviruses parainfluenza in association with coccal infection. Acute laryngotracheobronchitis caused by hemolytic streptococcus is the most severe.

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Pathological anatomy

The mucous membrane of the respiratory tract is hyperemic, bright red, covered with abundant purulent exudate, liquid at the beginning of the disease, then thickening and forming pseudomembranous fibrinous films fused with the underlying tissue. In other cases, with greening streptococcus and staphylococcus, yellowish-green crusts are formed, which fill the respiratory tract and cause obstruction. The indicated pathological changes often entail more or less widespread pulmonary edema and atelectasis.

Symptoms and clinical course of acute laryngotracheobronchitis in children

The disease debuts with an increase in body temperature to 38-39°C, accompanied by chills and signs of severe endogenous intoxication. At the same time, respiratory failure progresses. These phenomena are manifested by an ashen complexion, rapid breathing, and expansion of the wings of the nose in time with the respiratory movements of the chest. Breathing noises heard above, on, and below the sternum indicate that the stenosis affects both the larynx and the underlying respiratory tract. The main cause of airway obstruction is abundant exudation and difficulty in expectoration (exhalation), which contributes to the accumulation of pathological contents in the lumen of the larynx, trachea, and bronchi and the inability to cough it up and expectorate it. During laryngotracheoscopy, the laryngoscope tube "drowns" in abundant mucopurulent discharge, and its end becomes covered with purulent crusts, making examination difficult. The initial excitement stage quickly gives way to a state of prostration, and the child often dies between 24 and 48 hours after the onset of the disease. The causes of death are bronchopneumonia, hypoxia, and toxic myocarditis.

The diagnosis is made on the basis of an acute onset, rapidly increasing symptoms of apnea, hypoxia, signs of cardiac dysfunction, and a severe general condition.

Acute laryngotracheobronchitis should be differentiated from subglottic laryngitis, diphtheria, banal bronchopneumonia, asthmatic conditions, and especially from radiopaque foreign bodies of plant origin, which are often complicated by acute tracheobronchitis.

Treatment of acute laryngotracheobronchitis in children

Treatment of acute laryngotracheobronchitis in children is carried out in a specialized pediatric department and in the intensive care unit. From the very beginning, based on the clinical picture described above, massive doses of broad-spectrum antibiotics are prescribed, with a transition after receiving an antibiogram to "targeted" use of appropriate antibiotic drugs. Antibiotic treatment is supplemented by prescribing increased doses of corticosteroids in injections and per os. Aerosol inhalations of mucolytic agents in a mixture with hydrocortisone and antibiotics are also prescribed under the "cover" of inhalation of oxygen or carbogen. At the same time, drugs are used to normalize cardiac and respiratory activity, as well as antihistamines, decongestants and other drugs aimed at combating toxicosis. In this regard, the principles of intensive and detoxification therapy are used.

Intensive care is a type of specialized treatment for patients and victims who, due to a serious illness, injury, surgery or intoxication, develop or may develop life-threatening functional or metabolic disorders of the cardiovascular, respiratory, excretory and other body systems. One of the tasks of caring for patients in intensive care is the prevention of complications that may develop in a seriously ill person due to an immobile position (bedsores, hypostasis), the inability to independently eat, defecate and urinate, the presence of fistulas, etc. Intensive care includes intensive observation and the use of a set of therapeutic measures according to indications. Intensive observation consists of constant monitoring of the patient's consciousness, the most important hemodynamic parameters, the number of breaths, the rate of intravenous infusions, compliance with the order of therapeutic appointments, as well as other processes that are important for the implementation of intensive care. Intensive monitoring is more effective when using monitors that provide automatic visual and signal-acoustic recording of the patient's vital parameters. The actual therapeutic measures of intensive therapy include intravenous infusions, including puncture catheterization of veins, such as the subclavian, long-term artificial ventilation, methods of restoring and maintaining airway patency (tracheal intubation), oxygen therapy, and barotherapy.

HBO, oxygen therapy, peritoneal and extracorporeal dialysis, use of artificial kidney, hemosorption, cardiac stimulators, administration of various drugs, parenteral nutrition. In the process of implementing intensive observation, it may be necessary to revive the body in case of sudden clinical death, characterized by a reversible phase of dying, in which, despite the absence of blood circulation in the body and the cessation of oxygen supply to its tissues, the viability of all tissues and organs, primarily the brain and its cortex, is still preserved for a certain time. Due to this, the possibility of restoring vital functions of the body with the help of resuscitation measures and subsequent intensive care remains. The duration of clinical death in humans depends on the cause of the terminal condition, the duration of dying, age, etc. Under normal temperature conditions, clinical death lasts 3-5 minutes, after which it is impossible to restore normal CNS activity.

Detoxification therapy - therapeutic measures aimed at stopping or reducing the effect of toxic substances on the body. The scope and methods of detoxification therapy are determined by the causes, severity and duration of intoxication. In case of exogenous intoxications, detoxification therapy depends on the route of entry into the body, the nature of the action and the physicochemical properties of the toxin, as well as the rate of its neutralization in the body and excretion from it. In case of endogenous intoxications, typical for all infectious diseases, as well as with the accumulation of toxic substances (catabolites) in the body due to liver or kidney failure, detoxification therapy is necessary as an adjunct to the treatment of the underlying disease. A decrease in the concentration of toxins in the blood is achieved by administering a large amount of fluid (1.5 liters or more) in the form of drinking, intravenous infusion of isotonic sodium chloride solution, 5% glucose solution. At the same time, fast-acting diuretics are administered (lasix 80-100 mg intravenously). To prevent loss of potassium ions and other substances obligatory for normal metabolic processes in the body and functioning of vital organs with urine, after the administration of diuretics, it is necessary to administer an electrolyte solution (lactasol, 400-500 ml). Hemodesis and rheopolyglucin, administered intravenously, have significant antitoxic properties. Oral administration of enterodesis is effective (1 teaspoon per 100 ml of water 3-4 times a day). Exchange blood transfusion and dialysis are also used for detoxification - removal of low-molecular and medium-molecular toxic compounds by diffusion through special membranes.

In some cases, to prevent asphyxia, a tracheostomy is applied to the child, which in the following days is used to introduce various drugs (mucolytic and fibrinolytic agents, hydrocortisone, antibiotic solutions) through the tracheotomy tube. Before tracheotomy, it is advisable to perform bronchoscopy to suck out pathological contents from the trachea and bronchi and introduce appropriate drugs into the lower respiratory tract, after which, in more or less calm conditions, the lower tracheotomy is performed. Decannulation of the patient is carried out some time after normalization of breathing and the disappearance of inflammatory phenomena in the entire respiratory system. In complex treatment, one should not overlook the use of immunoprotectors, since acute laryngotracheobronchitis, as a rule, occurs in weakened children, often with signs of congenital immunodeficiency.

Prognosis for acute laryngotracheobronchitis in children

The prognosis, even with the most modern treatment methods, remains extremely serious, since most often children aged 1-2 years who suffer from this disease do not have acquired immunity, but only innate immunity, the intensity of which is insufficient to withstand such a formidable disease as acute laryngotracheobronchitis. According to the well-known French pediatrician and otolaryngologist J. Lemarie, the prognosis is greatly aggravated by complications that arise during urgent interventions carried out in cases of asphyxia, as well as due to secondary complications from the lungs and cicatricial stenosis of the larynx. According to the author's statistics, the mortality rate for this disease reaches 50% in children under 2 years of age.