Intensive Care Medicine
Intens. Care Med. 4, 52 - 53 (1978)
9 by Springer-Verlag 1978
The I.C.U. Treatment of Acute Laryngotracheobronchitis in a Developing Country R. Dansky, N. Buchanan, and R.D. Cane Intensive Care Unit, and the Department of Paediatrics, Baragwanath Hospital, Johannesburg, South Africa
Abstract. The management of 50children with acutelaryngotracheobronchitis (LTB) in a general I.C.U. in a developing country is presented. The overall mortality was 16 %, with no patient demising from LTB. It is stressed that LTB in developing countries is a very different disorder to that seen in Western societies, due to complicating factors such as bronchopneumonia, malnutrition and measles. Guidelines for therapy are proposed. Key words: Laryngotracheobronchitis, I.C.U., Developing countries, Complicating factors.
It was hoped that this data would provide a more rational approach to therapy. Results The duration of ICU stay was 6.7 -+ 6.3 days and mortality 16 %. There were 47 premorbid complicating factors in these 50 patients, 21 had significant LRTD, 15 were post measles, 5 had herpes stomatitis, 3 suffered from kwashiorkor and 3 had gastroenteritis. Several patients suffered from a combination of these complications.
Patients
Blood gas analysis showed that on admission to ICU, 19 patients had a respiratory acidosis (pa CO2 > 50 mm Hg) and 16 were hypoxemic (pa 02 < 60 mm Hg FiO2 0.4). Ten patients were intubated either in the general ward or in ICU purely on clinical grounds, before blood gas assessment was performed. Therapy consisted of humidified oxygen delivered by a head box; intravenous therapy was instituted in all instances. Pharmacological therapy (Table 1) revealed that all patients received antibiotics, predominantly penicillin and gentamicin. Corticosteroids were employed in 27 cases, all of whom had been intubated Racemic adrenaline was administered by a nebulizer mask in 15 patients of whom 7 obtained relief, although in most cases it was shorflived (3 - 6 h), and 13 of them subsequently required intubation.
Data on 50 Black children aged 17.7. -+ 19.0 months with LTB over a 2 year period (1975- 1977) was retrospectively analysed to assess a variety of variables including: (a) Duration of ICU stay. (b) Premorbid complicating factors. (c) Complications arising in ICU. (d) Blood gas status. (e) Efficacy of therapy. (f) Mortality.
Airway management is summarised in Table 2; 40 patients required artificial airways, the majority receiving endotracheal intubation, the duration of which was variable, 5.5 -+ 6.5 days (1 - 31). Tracheostomy was performed as a secondary event in 4 patients who required long term ventilatory support, 2 other patients, both with oral and laryngeal herpes, had tracheostomies as primary therapy. Twelve children required full ventilation because of the severity of their LRTD, whilst 9 patients received CPAP
Acute laryngotracheobronchitis (LTB) is a common paediatric disorder in all societies. In most instances the disorder is mild and self limiting and may be treated in a general ward. On occasion however, LTB may be sufficiently severe or may be complicated by lower respiratory tract disease (LRTD) necessitating special care in an intensive care unit (ICU). There is a paucity of literature on LTB in the past decade and for this reason it was felt appropriate to review 50 cases admitted to a general ICU.
0340-0964/78/0004/0051/$1.00
52
R. Dansky et al.: Acute Laryngotracheobronchitis
Table 1. Pharmacological therapy employed in 50 cases of LTB Management
No. of Patients
(1) Antibiotics Ampicillin Ampicillin and Gentamicin or CloxaciUin Penicillin and Gentamicin + Cloxacillin Penicillin (2) Corticosteroids
16 t2 20 2 27
(3) Racemic adrenaline
15
Table 2. Akway management in 50 cases of severe LTB Drug
No. of Patients
(1) Endotracheal intubation (a) Nasal (b) Oral
25 11
(2) Tracheostomy Previosly intubated
6 4
Table 3. Details of the 8 deaths occurring in the present series. Cause of Death (1) Cardio respiratory arrest (2) Progressive pneumonia (3) Myocarditis (4) Progressive consolidation (5) Hypokalemia (6) Bronchopneumonia (7) Progressive pneumonia (8) Brain Death
Discussion
Comments On admission to ICU Severe oral herpes, cardiac failure, died 8 days after admission. Postmeasles pneumonia. Died 2 days after admission. Died 11 days after admission Je junal atressia, ileostomy, concomitant LTB. Died on admission to ICU. Died on admission Hydro-haemothorax. Died 7 days after admission. Cardiac arrest on intubatlon in casualty. Deeerebrate. Died 4 days later.
essentially for the treatment of mild to moderate hypoxaemia (pa 02 50 - 60 mm Hg (FiO2 0.4) in the presence o f a normal pa CO2). Complications arose in 11 patients all of whom had been intubated. Five patients developed pneumonia, 5 right upper lobe atelectesis and 1 subglottic stenosis requiring tracheostomy. Eight children (16 %) died (Table 3); 3 died within 2 hours of ICU admission. In the 5 remaining cases, three patients demised of severe LRTD, one of brain death and one from my ocarditis. No patient demised due to LTB per se.
The oberservation made by Wesley [ 1] that LTB in developing countries with a milieu of undernutrition is a more severe disease than in developed societies, is borne out by the present study. LTB in underpriviliged children rarely occurs alone as it does in more sophisticated societies. Perhaps the most c o m m o n accompanying disease is measles, with or without pneumonia, which in association with malnutrition produces a devastating combination [2,3]. For these reasons, antibiotics were prescribed in all cases, which compares favourably with 80 % incidence of use in LTB without associated complication [4,5]. Racemic adrenaline in our experience was dissapointing, and avoided intubation in but 20 % of cases where it was employed. The observations are similar to those of Taussig et al [6] who noted an initial beneficial effect which was short lived (+- 2h). Corticosteroids were only used in patients who had been intubated in an attempt to prevent further laryngeal oedema; these agents per se have little effect on the natural history of LTB, and their use is not indicated. [7,8]. In the present series 6 children required tracheostomy, 2 of which were in association with oral and laryngeal herpes. The other 4 were for prolonged airway management associated with servere LRTD requiring mechanical ventilation. Schuller and Birch [9] compared the results of tracheostomy versus endotracheal intubation in patients with uncomplicated LTB. Both the mortality, complication rate and duration of hospital stay were lower in the endotracheal tube group. They concluded that endotracheal intubation was the procedure of choice. The predominant problem is that of exactly when to intubate. The scoring system by Downes and Raphaely [10] represents a practical approach to this problem, but excludes the presence of LRTD. However in our experience it has become obvious with the passage of time that no absolute indications exist. The following suggestions, a combination of our experience and that of Wesley in a similar population group are proposed. 1) Certain patients require intubation on clinical grounds with a combination of the following clinical criteria: (a) Tachycardia > 180/rain (b) Cyanosis. (c) R R > 50/min. (d) Pulsus paradoxus. 2) Significant arterial hypercarbia (pCO2 > 5 0 m m Hg), after adequate physiotherapy in the face of LRTD. 3) Significant arterial hypoxaemia (pa 02 < 50 m m Hg on 50 % oxygen) after adequate physiotherapy in the presence of LRTD. 4) Significant LRTD, especially with a postmeasles state of oral herpes. The latter is probably an indication for trache0stomy.
R. Dansky et al.: Acute Laryngotracheobronchitis References 1. Wesley, A.G.: Indications for intubation in laryngotracheobronchitis in black children. S. Aft. Med. J. 49, 1126 (1975) 2. Coovadia, H.M., Brain, P., Hallet, A.F. et al.: Immunoparesis and autcome in measles. Lancet 1977, 619 3. Wesley, A.G., Desai, S., Holloway, R. et al.: Nasotracheal intubation in the management of infective croup. S. Air. Med. J. 46,839 (1972) 4. Thompson, P.D., Olinsky, A.: Nasotracheal intubation in acute laryngotracheobronchitis. S. Afr. Med. J. 49, 785 (1975) 5. Court, S.D.M.: The management and outcome of children admitted to hospital. Postgrad. Med. J. 49, 812 (1973) 6. Taussig, LM., Castro. O., Beaudry, P.H. et al.: Treatment of laryngotracheobronchitis:-Use of intermittent positive--pressure breathing and racemic epinephrine. Amer. J. Dis. Child. 129,790 (1975)
53 7. Eden, A.N., Larkin, V.: Corticosteroid treatment of croup. Pediatrics 33,768 (1964) 8. Eden, An., Kaufman, A., Renato, Y.: I. Amer, med Ass. 200, 403 (1967) 9. Schuler, D.E., Birck, H.G.: The safety of intubation in croup and epiglottitis:-an eight year follow-up. Laryngoscope 85, 33 (1975) 10. Dowries, J.J., Raphaely, R.C.: Paediatric intensive care. Anesthesiology 43, 238 (1975)
Dr. N. Buchanan Intensive Care Unit Baragwanath Hospital PO Bertsham 2013 Johannesburg South Africa
Intens. Care Med. 4, 52 - 53 (1978)
9 by Springer-Verlag 1978
The I.C.U. Treatment of Acute Laryngotracheobronchitis in a Developing Country R. Dansky, N. Buchanan, and R.D. Cane Intensive Care Unit, and the Department of Paediatrics, Baragwanath Hospital, Johannesburg, South Africa
Abstract. The management of 50children with acutelaryngotracheobronchitis (LTB) in a general I.C.U. in a developing country is presented. The overall mortality was 16 %, with no patient demising from LTB. It is stressed that LTB in developing countries is a very different disorder to that seen in Western societies, due to complicating factors such as bronchopneumonia, malnutrition and measles. Guidelines for therapy are proposed. Key words: Laryngotracheobronchitis, I.C.U., Developing countries, Complicating factors.
It was hoped that this data would provide a more rational approach to therapy. Results The duration of ICU stay was 6.7 -+ 6.3 days and mortality 16 %. There were 47 premorbid complicating factors in these 50 patients, 21 had significant LRTD, 15 were post measles, 5 had herpes stomatitis, 3 suffered from kwashiorkor and 3 had gastroenteritis. Several patients suffered from a combination of these complications.
Patients
Blood gas analysis showed that on admission to ICU, 19 patients had a respiratory acidosis (pa CO2 > 50 mm Hg) and 16 were hypoxemic (pa 02 < 60 mm Hg FiO2 0.4). Ten patients were intubated either in the general ward or in ICU purely on clinical grounds, before blood gas assessment was performed. Therapy consisted of humidified oxygen delivered by a head box; intravenous therapy was instituted in all instances. Pharmacological therapy (Table 1) revealed that all patients received antibiotics, predominantly penicillin and gentamicin. Corticosteroids were employed in 27 cases, all of whom had been intubated Racemic adrenaline was administered by a nebulizer mask in 15 patients of whom 7 obtained relief, although in most cases it was shorflived (3 - 6 h), and 13 of them subsequently required intubation.
Data on 50 Black children aged 17.7. -+ 19.0 months with LTB over a 2 year period (1975- 1977) was retrospectively analysed to assess a variety of variables including: (a) Duration of ICU stay. (b) Premorbid complicating factors. (c) Complications arising in ICU. (d) Blood gas status. (e) Efficacy of therapy. (f) Mortality.
Airway management is summarised in Table 2; 40 patients required artificial airways, the majority receiving endotracheal intubation, the duration of which was variable, 5.5 -+ 6.5 days (1 - 31). Tracheostomy was performed as a secondary event in 4 patients who required long term ventilatory support, 2 other patients, both with oral and laryngeal herpes, had tracheostomies as primary therapy. Twelve children required full ventilation because of the severity of their LRTD, whilst 9 patients received CPAP
Acute laryngotracheobronchitis (LTB) is a common paediatric disorder in all societies. In most instances the disorder is mild and self limiting and may be treated in a general ward. On occasion however, LTB may be sufficiently severe or may be complicated by lower respiratory tract disease (LRTD) necessitating special care in an intensive care unit (ICU). There is a paucity of literature on LTB in the past decade and for this reason it was felt appropriate to review 50 cases admitted to a general ICU.
0340-0964/78/0004/0051/$1.00
52
R. Dansky et al.: Acute Laryngotracheobronchitis
Table 1. Pharmacological therapy employed in 50 cases of LTB Management
No. of Patients
(1) Antibiotics Ampicillin Ampicillin and Gentamicin or CloxaciUin Penicillin and Gentamicin + Cloxacillin Penicillin (2) Corticosteroids
16 t2 20 2 27
(3) Racemic adrenaline
15
Table 2. Akway management in 50 cases of severe LTB Drug
No. of Patients
(1) Endotracheal intubation (a) Nasal (b) Oral
25 11
(2) Tracheostomy Previosly intubated
6 4
Table 3. Details of the 8 deaths occurring in the present series. Cause of Death (1) Cardio respiratory arrest (2) Progressive pneumonia (3) Myocarditis (4) Progressive consolidation (5) Hypokalemia (6) Bronchopneumonia (7) Progressive pneumonia (8) Brain Death
Discussion
Comments On admission to ICU Severe oral herpes, cardiac failure, died 8 days after admission. Postmeasles pneumonia. Died 2 days after admission. Died 11 days after admission Je junal atressia, ileostomy, concomitant LTB. Died on admission to ICU. Died on admission Hydro-haemothorax. Died 7 days after admission. Cardiac arrest on intubatlon in casualty. Deeerebrate. Died 4 days later.
essentially for the treatment of mild to moderate hypoxaemia (pa 02 50 - 60 mm Hg (FiO2 0.4) in the presence o f a normal pa CO2). Complications arose in 11 patients all of whom had been intubated. Five patients developed pneumonia, 5 right upper lobe atelectesis and 1 subglottic stenosis requiring tracheostomy. Eight children (16 %) died (Table 3); 3 died within 2 hours of ICU admission. In the 5 remaining cases, three patients demised of severe LRTD, one of brain death and one from my ocarditis. No patient demised due to LTB per se.
The oberservation made by Wesley [ 1] that LTB in developing countries with a milieu of undernutrition is a more severe disease than in developed societies, is borne out by the present study. LTB in underpriviliged children rarely occurs alone as it does in more sophisticated societies. Perhaps the most c o m m o n accompanying disease is measles, with or without pneumonia, which in association with malnutrition produces a devastating combination [2,3]. For these reasons, antibiotics were prescribed in all cases, which compares favourably with 80 % incidence of use in LTB without associated complication [4,5]. Racemic adrenaline in our experience was dissapointing, and avoided intubation in but 20 % of cases where it was employed. The observations are similar to those of Taussig et al [6] who noted an initial beneficial effect which was short lived (+- 2h). Corticosteroids were only used in patients who had been intubated in an attempt to prevent further laryngeal oedema; these agents per se have little effect on the natural history of LTB, and their use is not indicated. [7,8]. In the present series 6 children required tracheostomy, 2 of which were in association with oral and laryngeal herpes. The other 4 were for prolonged airway management associated with servere LRTD requiring mechanical ventilation. Schuller and Birch [9] compared the results of tracheostomy versus endotracheal intubation in patients with uncomplicated LTB. Both the mortality, complication rate and duration of hospital stay were lower in the endotracheal tube group. They concluded that endotracheal intubation was the procedure of choice. The predominant problem is that of exactly when to intubate. The scoring system by Downes and Raphaely [10] represents a practical approach to this problem, but excludes the presence of LRTD. However in our experience it has become obvious with the passage of time that no absolute indications exist. The following suggestions, a combination of our experience and that of Wesley in a similar population group are proposed. 1) Certain patients require intubation on clinical grounds with a combination of the following clinical criteria: (a) Tachycardia > 180/rain (b) Cyanosis. (c) R R > 50/min. (d) Pulsus paradoxus. 2) Significant arterial hypercarbia (pCO2 > 5 0 m m Hg), after adequate physiotherapy in the face of LRTD. 3) Significant arterial hypoxaemia (pa 02 < 50 m m Hg on 50 % oxygen) after adequate physiotherapy in the presence of LRTD. 4) Significant LRTD, especially with a postmeasles state of oral herpes. The latter is probably an indication for trache0stomy.
R. Dansky et al.: Acute Laryngotracheobronchitis References 1. Wesley, A.G.: Indications for intubation in laryngotracheobronchitis in black children. S. Aft. Med. J. 49, 1126 (1975) 2. Coovadia, H.M., Brain, P., Hallet, A.F. et al.: Immunoparesis and autcome in measles. Lancet 1977, 619 3. Wesley, A.G., Desai, S., Holloway, R. et al.: Nasotracheal intubation in the management of infective croup. S. Air. Med. J. 46,839 (1972) 4. Thompson, P.D., Olinsky, A.: Nasotracheal intubation in acute laryngotracheobronchitis. S. Afr. Med. J. 49, 785 (1975) 5. Court, S.D.M.: The management and outcome of children admitted to hospital. Postgrad. Med. J. 49, 812 (1973) 6. Taussig, LM., Castro. O., Beaudry, P.H. et al.: Treatment of laryngotracheobronchitis:-Use of intermittent positive--pressure breathing and racemic epinephrine. Amer. J. Dis. Child. 129,790 (1975)
53 7. Eden, A.N., Larkin, V.: Corticosteroid treatment of croup. Pediatrics 33,768 (1964) 8. Eden, An., Kaufman, A., Renato, Y.: I. Amer, med Ass. 200, 403 (1967) 9. Schuler, D.E., Birck, H.G.: The safety of intubation in croup and epiglottitis:-an eight year follow-up. Laryngoscope 85, 33 (1975) 10. Dowries, J.J., Raphaely, R.C.: Paediatric intensive care. Anesthesiology 43, 238 (1975)
Dr. N. Buchanan Intensive Care Unit Baragwanath Hospital PO Bertsham 2013 Johannesburg South Africa
