Laryngotracheobronchitis (LTB) and croup: Nursing process (ADPIE)

LARYNGOTRACHEOBRONCHITIS (LTB) AND CROUP
	KEY POINTS	NOTES
PATIENT REPORT	2-year-old Emergency department High-pitched, barking cough Previous cold symptoms Not eating or drinking Anxious at night, difficult to soothe Wheezing Diagnosis: LTB (croup)
PATHOPHYSIOLOGY	Inflammation of upper airway Common causative viruses Parainfluenza Adenovirus Influenza A or B Respiratory syncytial virus (RSV) Occurs seasonally Most often in late fall Also common in early winter Risk factors Children ages 3 months to 6 years Biological males Family history Recurrent croup Transmission methods Airborne respiratory droplets Saliva contact Physical contact with infected person Contact with contaminated surfaces Pathophysiology Starts in nasal passages and pharynx Spreads to larynx trachea and bronchi Inflammation and edema Mucus secretion Narrowing of subglottic area and airway Symptoms of airway narrowing Hoarseness Inspiratory stridor Seal like barking cough Nasal flaring Substernal retractions Subcostal retractions Intercostal retractions Aggravating factors Crying increases oxygen demand Agitation worsens airway obstruction Complications Dehydration Hypoxia Cyanosis Respiratory acidosis Respiratory failure
DIAGNOSIS AND TREATMENT	Diagnosis History Physical assessment Diagnostic imaging Chest X-ray Steeple sign Laboratory testing Treatment Airway management Bronchodilators Corticosteroid Antipyretics Humidified oxygen Intubation Mechanical ventilation
ASSESSMENT	Audible inspiratory stridor Barking cough present Lungs clear to auscultation Substernal retractions Mucous membranes appear dry Skin turgor appears normal Capillary refill < 3 seconds Vital signs Respiratory rate 45/min Oxygen saturation 92 % room air Heart rate 130/min Axillary temperature 101.8 ℉ (38.8 ℃)
NURSING DIAGNOSES	Ineffective breathing pattern related to upper airway inflammation and obstruction Fluid volume deficit related to decreased fluid intake, fever, and increased respiratory rate Fear related to difficulty breathing and unfamiliar surroundings Deficient parental knowledge related to unfamiliarity with the disease process and treatments
PLANNING	By end of shift, patient will Have an effective breathing pattern as evidenced by respiratory rate within the normal range, unlabored breathing, absence of stridor and barking cough, and a SpO2 above 92% Display adequate fluid volume as evidenced by moist mucous membranes and wet diapers Have decreased fear as evidenced by a calm appearance and calm, easy respirations The patient's mother will verbalize an understanding of croup, home management of mild symptoms, and when to seek medical attention
IMPLEMENTATION	Keep patient on mother’s lap Monitor Respiratory status Vital signs Oxygen saturation Administer Humidified oxygen Racemic epinephrine via nebulizer Dexamethasone IM Acetaminophen Provide supportive care Offer flavored ice pops as tolerated Encourage fluid intake Ask patient's mother to report wet diaper Provide discharge teaching Emphasize importance of fluid intake Give acetaminophen as directed for fever Keep patient's head elevated at night Allow breathing cool air to ease symptoms Seek medical attention if symptoms worsen or return
EVALUATION	Patient alert and sitting comfortably Playing with stuffed bear Breathing comfortably Respiratory rate 32/min No stridor No respiratory retractions No nasal flaring No cough Oxygen saturation 98 % room air Clear breath sounds Consumed 3 ice pops Had 2 wet diapers Mucous membranes appear moist Temperature normal Patient's mother verbalizes understanding of home care Plans follow up with pediatrician in 24 hours

Two year old Sara Little is brought to the Emergency Department, or ED, by her mother.

She has a high-pitched, barking cough that started in the evening and worsened throughout the night.

Mrs. Little explains that Sara has had “cold symptoms” for about 3 days.

She initially had a runny nose and slight cough but began running a fever yesterday.

She hasn’t been eating or drinking well and seems more anxious and difficult to soothe at night.

When Mrs. Little noticed wheezing, she called the pediatrician who directed her to bring Sara to the ED.

Upon arrival, Sara has a barking cough, inspiratory stridor, and a respiratory rate of 42 per minute.

Sara will be treated for laryngotracheobronchitis, or LTB, also known as croup.

Croup is an inflammation of the upper airway, typically caused by a virus, such as parainfluenza, adenovirus, influenza A or B, or respiratory syncytial virus, or RSV.

Cases of croup are seen seasonally, most often in late fall and early winter.

It affects children ages 3 months to 6 years and is most common in boys and in children where there is a family history of croup or recurrent croup.

Croup is spread through airborne respiratory droplets, saliva and physical contact with an infected person or contaminated surface.

The droplets enter the body, initially infecting the nasal passages and pharynx, subsequently spreading to the larynx, trachea and bronchi.

The infection causes inflammation, edema and mucus secretion, leading to narrowing of the subglottic area, which is composed of the lower part of the vocal cords and the upper trachea.

Not only is this area the narrowest portion of a child’s upper airway, but it has a complete ring of cartilage around it which doesn’t expand.

When the airway becomes significantly narrowed, it results in hoarseness, a harsh high-pitched sound during inspiration referred to as inspiratory stridor, and a distinctive seal-like barking cough.

Nasal flaring, substernal, subcostal or intercostal retractions occur as the child works hard to breathe past the narrowed airway.

Crying and agitation causes increased oxygen demand and further airway obstruction.

In addition, dehydration may result due to reluctance to drink fluids, fever, and breathing through the mouth.

Signs of severe croup include fatigue and inability to keep up with the needed respiratory effort resulting in diminished breath sounds, hypoxia, and cyanosis.

Eventually, inadequate ventilation can lead to respiratory acidosis and respiratory failure.

A diagnosis of croup is based on the client’s history and clinical findings.

Other diagnostic studies such as labs and radiological studies are not indicated unless there is concern for other serious problems such as pneumonia.

A chest X-ray, if done, will often reveal a pattern known as a steeple sign, which is an inverted V shape resembling a church steeple, visualized below the vocal cords.

Treatment of croup is focused on airway management and is guided by the severity of symptoms.

Commonly prescribed treatments include inhaled bronchodilators such as racemic epinephrine and albuterol; a corticosteroid like dexamethasone to decrease inflammation; and antipyretics such as acetaminophen to reduce fever.

Other treatments include humidified supplemental oxygen, and in the case of respiratory impending failure, intubation and mechanical ventilation.

OK, now that we understand croup, let’s get back to Sara and her mother.

You wash your hands and don a mask and gloves as you enter Sara’s room.

After introducing yourself and confirming Sara’s identity, you begin your assessment by asking Mrs. Little about how Sara has been feeling before coming to the ED.

Mrs. Little states Sara started to have a runny nose a few days ago and her fever started yesterday.

She hasn’t felt like eating or drinking and has had fewer wet diapers than normal.

The barking cough started this evening.

You gently approach Sara, keeping in mind agitation can further compromise her airway.

You can easily hear stridor with inspiration and the distinctive barking cough that characterizes croup.

Laryngotracheobronchitis (LTB) and croup: Nursing process (ADPIE)

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