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OBJECTIVE: To present current concepts on diagnosis and treatment of upper airway obstruction, mainly related to differential diagnosis between acute viral laryngotracheobronchitis and epiglottitis.METHODS: Bibliographic review covering the last ten years, using both Medline system and direct research. The most relevant articles published about the subject were selected.RESULTS: Viral laryngotracheobronchitis is an acute self-limited disease of the upper airway in a child, clinically characterized by barking cough, stridor, hoarse voice, and upper respiratory symptoms. The disease is diagnosed by clinical signs and symptoms. Rarely, if no immediate airway management is needed, radiography of the neck may help to exclude other entities that cause laryngeal obstruction. In contrast to viral laryngotracheobronchitis, epiglottitis is characterized by inflammation of the supraglottic tissues and is caused mainly by Haemophilus influenzae type b. A previously healthy child suddenly develops a sore throat and fever. Within hours after the onset of symptoms the patient looks toxic, swallowing is painful and breathing is difficult. Drooling and cervical hyperextension are frequently present. Lateral neck radiograph is rarely required to the diagnosis and may delay appropriate management of the airway. Moderate viral laryngotracheobronchitis with stridor at rest and retractions should be treated with steroids (systemic or nebulized) and nebulized epinephrine. Severe viral laryngotracheobronchitis should be treated aggressively while arregements are made for endotracheal intubation. The diagnosis of epiglottitis requires immediate endotracheal intubation in the appropriate unit (emergency department, intensive care unit or surgical unit) and antimicrobial therapy. Alternatively at some medical centers children with severe upper airway obstruction have been treated with a mixture of helium and oxygen (70 to 80% concentration of helium) instead of room air or pure oxygen to avoid intubation.CONCLUSIONS: There are different levels of care for patients with upper airway obstruction, depending on their clinical presentation. The clinical manifestations of viral laryngotracheobronchitis may be confused with the presentation of epiglottitis. Despite this observation we believe that differential diagnosis between viral laryngotracheobronchitis and epiglottitis rests on clinical grounds.
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OBJECTIVES: The authors review the current literature on acute viral bronchiolitis discussing the points still subject to controversy in regard to its treatment. At the same time, a personal point of view on the management of this disorder based on the authors experience is also expressed.METHODS: The main published papers from the last twenty years were selected from a Medline database search.RESULTS: Acute viral bronchiolitis is an acute viral illness of the lower respiratory tract occuring most frequently during the first year of life. In spite of its important prevalence and the relative risk that this disorder may pose to pediatric patients there is still a lot of controversy in regard to its treatment. However, it seems of paramount importance to mainten an adequate hidration, to prevent cross infection and to offer supplementary oxygen. There are many doubts as to the role of bronchodilators and antivirals such as ribavirin. There are new hopes with the introduction of specific immunoglobulin, mostly as a prophylactic role in respiratory syncycial virus infection in at risk populations. Steroids seem to have no place in the treatment at least in the acute stages of the disease. CONCLUSIONS: Acute viral bronchiolitis is still a disorder which lacks a specific treatment. The routine treatment has little changed for the last 30 years and there is controversy in regard to its management in the different clinical centers.
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OBJECTIVE: The authors describe their experience with theuse of intravenous Beta2 adrenergic (IV terbutaline) in patientsadmitted to a PICU with severe lower airway obstruction. PATIENTS AND METHODS: A retrospective study of all admissions to a PICU was conducted in Santo Antonio Hospital in Porto Alegre (Brazil) during the winter of 1995. The files ofall the patients that were treated with intravenous Beta2 adrenergicas a bronchodilator were selected. The analysis included lengthof use, initial doses, maximal doses, associated phenomena,arterial blood gases and plasma level of potassium. RESULTS: During the three months of study 367 patients wereadmitted to the PICU and 38 (10.3%) used IV terbutaline. Thisgroup of patients had a mean age of 13.8-/+12.2 months old andused IV terbutaline for a mean length of 7.24-/+3.6 days. Theinitial rate of infusion was 0.55-/+0.25 mcg/kg/min with a meantherapeutic dose of 2.45-/+1.18 mcg/kg/min. Twelve patients(31.5%) had increase in their heart rate (over 180 bpm) thatprevented increases in the infusion rate. However this was atemporary effect. The patients under 12 months of age startedwith low infusion rates (0.45-/+0.22 mcg/kg/min), when comparedto children over 1 year old (0.57-/+0.3 mcg/kg/min), p <0.01. No patient developed pathologic heart rate attributed to the drug. The serum levels of potassium decreased significantly (p <0.01) only in the group of patients under 1 year (4.1-/+0.7 to 3.47-/+0.52 mEq/L), but this difference had no clinical relevance. COMMENTS: In view of these results the authors showed that the infusion of IV terbutaline in children is safe and presents alow risk if the criteria of administration and monitoring are followed. In this manner, IV terbutaline is an excellent therapeuticoption for children with severe lower airway obstruction andno response to the conventional treatment.
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The authors discuss a case of a two-years-old girl, who had a unilateral previous enucleated retinoblastoma, that died with a suprasellar mass and distant metastasis.