Chapter 377 Acute Inflammatory Upper Airway Obstruction (Croup, Epiglottitis, Laryngitis, and Bacterial Tracheitis)

The lumen of an infant’s or child’s airway is narrow; because airway resistance is inversely proportional to the 4th power of the radius (Chapter 365), minor reductions in cross-sectional area due to mucosal edema or other inflammatory processes cause an exponential increase in airway resistance and a significant increase in the work of breathing. The larynx is composed of 4 major cartilages (epiglottic, arytenoid, thyroid, and cricoid cartilages, ordered from superior to inferior) and the soft tissues that surround them. The cricoid cartilage encircles the airway just below the vocal cords and defines the narrowest portion of the upper airway in children <10 yr of age.

Inflammation involving the vocal cords and structures inferior to the cords is called laryngitis, laryngotracheitis, or laryngotracheobronchitis, and inflammation of the structures superior to the cords (i.e., arytenoids, aryepiglottic folds [“false cords”], epiglottis) is called supraglottitis. The term croup refers to a heterogeneous group of mainly acute and infectious processes that are characterized by a bark-like or brassy cough and may be associated with hoarseness, inspiratory stridor, and respiratory distress. Stridor is a harsh, high-pitched respiratory sound, which is usually inspiratory but can be biphasic and is produced by turbulent airflow; it is not a diagnosis but a sign of upper airway obstruction (Chapter 366). Croup typically affects the larynx, trachea, and bronchi. When the involvement of the larynx is sufficient to produce symptoms, they dominate the clinical picture over the tracheal and bronchial signs. Traditionally, a distinction has been made between spasmodic or recurrent croup and laryngotracheobronchitis. Some clinicians believe that spasmodic croup might have an allergic component and improves rapidly without treatment, whereas laryngotracheobronchitis is always associated with a viral infection of the respiratory tract. Others believe that the signs and symptoms are similar enough to consider them within the spectrum of a single disease, in part because studies have documented viral etiologies in both acute and recurrent croup.

377.1 Infectious Upper Airway Obstruction

Genie E. Roosevelt

Etiology and Epidemiology

With the exceptions of diphtheria, bacterial tracheitis, and epiglottitis, most acute infections of the upper airway are caused by viruses. The parainfluenza viruses (types 1, 2, and 3; Chapter 251) account for ∼75% of cases; other viruses associated with croup include influenza A and B, adenovirus, respiratory syncytial virus (RSV), and measles. Influenza A has been associated with severe laryngotracheobronchitis. Mycoplasma pneumoniae has rarely been isolated from children with croup and causes mild disease (Chapter 215). Most patients with croup are between the ages of 3 mo and 5 yr, with the peak in the 2nd yr of life. The incidence of croup is higher in boys; it occurs most commonly in the late fall and winter but can occur throughout the year. Recurrences are frequent from 3-6 yr of age and decrease with growth of the airway. Approximately 15% of patients have a strong family history of croup.

In the past, Haemophilus influenzae type b was the most commonly identified etiology of acute epiglottitis. Since the widespread use of the HiB vaccine, invasive disease due to H. influenzae type b in pediatric patients has been reduced by 80-90% (Chapter 186). Therefore, other agents, such as Streptococcus pyogenes, Streptococcus pneumoniae, and Staphylococcus aureus, now represent a larger portion of pediatric cases of epiglottitis in vaccinated children. In the prevaccine era, the typical patient with epiglottitis due to H. influenza type b was 2-4 yr of age, although cases were seen in the 1st year of life and in patients as old as 7 yr of age. The typical patient with epiglottitis is an adult with a sore throat, although cases still do occur in underimmunized children; vaccine failures have been reported.

Clinical Manifestations

Croup (Laryngotracheobronchitis)

Viruses most commonly cause croup, the most common form of acute upper respiratory obstruction. The term laryngotracheobronchitis refers to viral infection of the glottic and subglottic regions. Some clinicians use the term laryngotracheitis for the most common and most typical form of croup and reserve the term laryngotracheobronchitis for the more severe form that is considered an extension of laryngotracheitis associated with bacterial superinfection that occurs 5-7 days into the clinical course.

Most patients have an upper respiratory tract infection with some combination of rhinorrhea, pharyngitis, mild cough, and low-grade fever for 1-3 days before the signs and symptoms of upper airway obstruction become apparent. The child then develops the characteristic “barking” cough, hoarseness, and inspiratory stridor. The low-grade fever can persist, although temperatures can reach 39-40°C (102.2-104°F); some children are afebrile. Symptoms are characteristically worse at night and often recur with decreasing intensity for several days and resolve completely within a week. Agitation and crying greatly aggravate the symptoms and signs. The child may prefer to sit up in bed or be held upright. Older children usually are not seriously ill. Other family members might have mild respiratory illnesses with laryngitis. Most young patients with croup progress only as far as stridor and slight dyspnea before they start to recover.

Physical examination can reveal a hoarse voice, coryza, normal to moderately inflamed pharynx, and a slightly increased respiratory rate. Patients vary substantially in their degrees of respiratory distress. Rarely, the upper airway obstruction progresses and is accompanied by an increasing respiratory rate; nasal flaring; suprasternal, infrasternal, and intercostal retractions; and continuous stridor. Croup is a disease of the upper airway, and alveolar gas exchange is usually normal. Hypoxia and low oxygen saturation are seen only when complete airway obstruction is imminent. The child who is hypoxic, cyanotic, pale, or obtunded needs immediate airway management. Occasionally, the pattern of severe laryngotracheobronchitis is difficult to differentiate from epiglottitis, despite the usually more acute onset and rapid course of the latter.

Croup is a clinical diagnosis and does not require a radiograph of the neck. Radiographs of the neck can show the typical subglottic narrowing, or steeple sign, of croup on the posteroanterior view (Fig. 377-1). However, the steeple sign may be absent in patients with croup, may be present in patients without croup as a normal variant, and may rarely be present in patients with epiglottitis. The radiographs do not correlate well with disease severity. Radiographs should be considered only after airway stabilization in children who have an atypical presentation or clinical course. Radiographs may be helpful in distinguishing between severe laryngotracheobronchitis and epiglottitis, but airway management should always take priority.

Figure 377-1 Radiograph of an airway of a patient with croup, showing typical subglottic narrowing (steeple sign).

Acute Epiglottitis (Supraglottitis)

This dramatic, potentially lethal condition is characterized by an acute rapidly progressive and potentially fulminating course of high fever, sore throat, dyspnea, and rapidly progressing respiratory obstruction. The degree of respiratory distress at presentation is variable. The initial lack of respiratory distress can deceive the unwary clinician; respiratory distress can also be the 1st manifestation. Often, the otherwise healthy child suddenly develops a sore throat and fever. Within a matter of hours, the patient appears toxic, swallowing is difficult, and breathing is labored. Drooling is usually present and the neck is hyperextended in an attempt to maintain the airway. The child may assume the tripod position, sitting upright and leaning forward with the chin up and mouth open while bracing on the arms. A brief period of air hunger with restlessness may be followed by rapidly increasing cyanosis and coma. Stridor is a late finding and suggests near-complete airway obstruction. Complete obstruction of the airway and death can ensue unless adequate treatment is provided. The barking cough typical of croup is rare. Usually, no other family members are ill with acute respiratory symptoms.

The diagnosis requires visualization of a large, cherry red, swollen epiglottis by laryngoscopy. Occasionally, the other supraglottic structures, especially the aryepiglottic folds, are more involved than the epiglottis itself. In a patient in whom the diagnosis is certain or probable based on clinical grounds, laryngoscopy should be performed expeditiously in a controlled environment such as an operating room or intensive care unit. Anxiety-provoking interventions such as phlebotomy, intravenous line placement, placing the child supine, or direct inspection of the oral cavity should be avoided until the airway is secure. If epiglottitis is thought to be possible but not certain in a patient with acute upper airway obstruction, the patient can undergo lateral radiographs of the upper airway first. Classic radiographs of a child who has epiglottitis show the thumb sign (Fig. 377-2). Proper positioning of the patient for the lateral neck radiograph is crucial in order to avoid some of the pitfalls associated with interpretation of the film. Adequate hyperextension of the head and neck is necessary. In addition, the epiglottis can appear to be round if the lateral neck is taken at an oblique angle. If the concern for epiglottitis still exists after the radiographs, direct visualization should be performed. A physician skilled in airway management and use of intubation equipment should accompany patients with suspected epiglottitis at all times. An older cooperative child might voluntarily open the mouth wide enough for a direct view of the inflamed epiglottis.

Figure 377-2 Lateral roentgenogram of the upper airway reveals the swollen epiglottis (thumb sign).

Establishing an airway by nasotracheal intubation or, less often, by tracheostomy is indicated in patients with epiglottitis, regardless of the degree of apparent respiratory distress, because as many as 6% of children with epiglottitis without an artificial airway die, compared with <1% of those with an artificial airway. No clinical features have been recognized that predict mortality. Pulmonary edema can be associated with acute airway obstruction. The duration of intubation depends on the clinical course of the patient and the duration of epiglottic swelling, as determined by frequent examination using direct laryngoscopy or flexible fiberoptic laryngoscopy. In general, children with acute epiglottitis are intubated for 2-3 days, because the response to antibiotics is usually rapid (see later). Most patients have concomitant bacteremia; occasionally, other infections are present, such as pneumonia, cervical adenopathy, or otitis media. Meningitis, arthritis, and other invasive infections with H. influenzae type b are rarely found in conjunction with epiglottitis.

Acute Infectious Laryngitis

Laryngitis is a common illness. Viruses cause most cases; diphtheria is an exception but is extremely rare in developed countries (Chapter 180

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