LARINGITA ACUTA SUBGLOTICA

Ghid de Diagnostic si Tratament

Autori:

Dr. Dragos Predescu

Dr. Mihai Iordachescu

Continut:

I. Introducere

II. Obiective

III. Populatie “tinta”

IV. Adresabilitate / utilizatori

V. Aspecte de diagnostic si tratament studiate

VI. Metodologia culegerii dovezilor

VII. Stabilirea nivelului de dovezi

VIII. Sinteza concluziilor rezultate din analiza dovezilor si recomandari

IX. Bibliografie

X. Instructiuni pentru parinti

I Introducere:

Laringita acuta subglotica (LAS) reprezinta o urgenta pediatrica deoarece edemul inflamator de la nivelul mucoasei laringiene poate sa produca asfixie fiind necesara scurt-cicuitarea cailor respiratorii superioare prin intubatie traheala sau traheostomie

De o importanta majora in abordarea copilului cu laringita acuta subglotica (LAS) este urmarirea permanenta a evolutiei bolii de la prima examinare pina la vindecare.

Forme de LAS.Terminologie.

In functie de localizare, procesul inflamator poate afecta preponderent regiunea subglotica sau cea supraglotica. Inflamatia regiunii supraglotice produce epiglotita. Inflamatia regiunii subglotice produce laringita acuta subglotica (1)

In functie de intensitatea si extinderea inflamatiei se disting urmatoarele forme de LAS:

-laringita acuta simpla , in care lipsesc modificarile clinice de obstructie laringiana; aceasta forma de b 919k1015j oala se manifesta prin tuse latratoare si raguseala

-laringita edematoasa subglotica, in care exista manifestari clinice de obstructie laringiana: stridor, dispnee inspiratorie;

-laringo-traheo-bronsita, in care procesul inflamator intereseaza laringele, traheea si bronsiile.

Laringita edematoasa subglotica se mai numeste crup viral (2).

Laringita striduloasa sau spasmodica reprezinta o forma evolutiva de laringita acuta subglotica care se caracterizeaza prin debutul brusc al simptomelor de obstructie laringiana (stridor, dispnee inspiratorie), rezolutia rapida (in ore) si posibilitatea unor noi recidive. Aceasta evolutie s-ar datora rolului preponderent al spasmului musculaturi laringiene in realizarea obstructiei lumenului (2,3). Uniii autori (2,3) considera irelevanta abordarea separata a celor 2 forme de boala (LAS si laringita striduloasa) intrucit tratamentul si prognosticul sunt identice.

Laringotraheobronsita bacteriana este o forma de laringita obstructiva severa, de etiologie bacteriana. Debuteaza cu simptome de laringita cu fenomene obstructive, care se agraveaza progresiv datorita extinderii procesului inflamator la trahee si bronsii. Necesita intubatie traheala, interventie care amelioreaza pasager dar nu suprima simptomatologia de obstructie. Evolutia este severa, deseori spre deces.

Etiologie (3,4-9):

Boala este cel mai frecvent de etiologie virala:virusuri paragripale I, II, III (impreuna cca 75%), virusul sincitial respirator (VSR), adenovirusuri, virusurile gripale A si B, herpes, rujeolos, coxsackie A si B, echovirus.

Mycoplasma pneumoniae produce exceptional LAS.

Frecventa (1,4,5,12,13):

Nu exista date in Rominia despre morbiditatea laringitelor. Diferite studii efctuate in SUA( 1,4,5,12,13) au aratat:

II. Obiectivele ghidului

III. Populatia “tinta”

IV. Adresabilitate / utilizatori

V. Aspecte de diagnostic si tratament studiate (Întrebari / probleme “cheie”)

1. Diagnostic

4. Utilitatea algoritmului decizional in LAS

VI. Metodologia culegerii dovezilor

Datele din literatura medicala despre diagnostic si tratament au fost cautate pe Medline (Pubmed) accesând cuvintele cheie: “croup”, “laryngitis”, “children”, “epiglottitis”, “bacterial tracheitis”, “treatment of croup”, “antibiotics AND children”, “pulmonary edema in croup”, “pulse oximetry in croup”, “lateral radiograph of the neck”, “severity score”, “croup AND asthma”, “corticosteroids in croup”, “L-epinephrine in croup”, “randomized controlled trial”, “systematic review”, “meta-analysis”.

Pentru situatiile în care nu erau dovezi sau acestea erau contradictorii recomandarile au fost formulate prin consensul specialistilor.

Specificarile fara indice bibliografic s-au bazat pe reguli de buna practica medicala general valabile sau pe adevaruri medicale evidente.

VII. Stabilirea nivelului de dovezi

a) Categorii de evidenta

Sinopsis al recomandarilor

Aprecierea severitatii LAS. Utilitatea algoritmului decizional in unitatile de primiri urgente

Recomandari:

Urmatoarele modificari clinice reprezinta criterii de severitate intr-o LAS: cianoza, paloarea marcata instalata in evolutia bolii, agitatia sau senzoriul alterat, stridor si tiraj intens in repaus, variatii ale ritmului respirator si cardiac. Grad C

Scorurile clinice de apreciere a severitatii reprezinta o modalitate acceptabila de cuantificare a obstructiei, de apreciere a raspunsului la tratament si de stabilire a conduitei medicale. Grad D.

Oximetria, masurata cu puls oximetru, este un parametru care se modifica tardiv. Grad C

Algoritmul decizional este un instrument foarte util in unitatile de primiri urgente. Grad B.

Criterii de internare in LAS

Prezenta oricaruia dintre factorii de mai jos (dupa aplicarea tratamentului initial) recomanda internarea:

Recomandari:

Dexametazona pe cale orala este tratamentul de electie al crupului viral mediu si sever. Grad A

Dozele de dexametazona preferate sunt de 0.15-0.30mg/kg iar intervalul intre doze de 12 ore. Grad D

Alternativa la dexametazona sunt Prednisonul si Prednisolonul in doze de 1-2mg/kg administrate la 12 ore. Grad D

In situatia in care nu se poate utiliza calea orala, pot fi folosite calea inhalatorie sau intramusculara. Grad D

In absenta Budesonidului, se poate utiliza pentru nebulizari dexametazona sulfat de sodiu – sol. injectabila – in doza de 160mg.    Grad D

In forma usoara de crup viral, dexametazona orala in priza unica si doza de 0.6mg/kg s-a dovedit benefica, insa decizia de a o administra este o problema de judecata clinica. Grad D

Nebulizarile cu adrenalina in LAS

Recomandari:

1. In forma medii si severe de LAS administrarea de adrenalina amelioreaza detresa/insuficienta respiratorie. Grad A
2. in timpul administrarii de adrenalina se recomanda monitorizarea cardiorespiratorie. Grad D
3. Administrarea de adrenalina in forma medie de LAS este o chestiune de judecata clinica. Grad D.
4. Nu se recomanda administrarea de adrenalina in forma usoara de LAS. Grad D.

Indicatia medicatiei OTC in LAS

Eficienta antitusivelor, antihistaminicelor, decongestionantelor nazale sau a altor remedii.

Nu exista date care sa ateste utilitatea acestor medicamente in crupul viral.

VIII. Sinteza concluziilor rezultate din analiza dovezilor

Manifestari clinice în LAS (1,3,5,9,10/IV)

Cateva elemente sugestive pentru diagnosticul diferential

Comparatie intre epiglotita, crupul viral si laringotraheobronsita bacteriana

Modificat dupa DeSoto H. Epiglottitis and croup in airway obstruction in children. Anesthesiol Clin North Am 1998;16:855.

*Crupul spasmodic

Complicatii in crupul viral

Aprecierea severitatii. Algoritmul decizional (3/IV, 19/IV, 20/IIa, 52/IV, 53/IV, 54/IIa, 67/IV)

Scorul Taussig modificat

Modificat după Taussig LM, Castro O, Beaudry PH. Treatment of laryngotracheobronchitis Am J Dis Child. 1975; 129: 790-793.

Tabelul 5. Scorul Westley

Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484-7.

Scorurile clinice au cateva dezavantaje: sunt subiective si greoaie pentru practica zilnica (3).

copilul are stare generala buna, primeste alimentatia si lichidele, nu are stridor in repaos, nu are tiraj;

stridorul este prezent si in repaus, tiraj moderat, tahipnee, tahicardie, mentine interesul pentru persoane si mediul inconjurator.

Daca un copil cu obstructie medie incepe sa devina agitat sau obosit este semn de progresie catre forma severa.

stridor si tiraj amplu, prezente si in repaus, cianoza, tahicaredie, agitatie sau obnubilare, pierde interesul pentru persoanele din jur, nu se poate alimenta si hidrata, oboseala marcata, epuizare;.

Detresa respiratorie poate fi mai putin marcata decat in forma medie din pricina epuizarii.

Agitatia, comportamentul irational, paloarea sau cianoza, hipotonia si alterarea senzoriului sunt semne tarzii, ce premerg stopul respirator.

Premise:

Etiologia LAS este virala in peste 90% din cazuri (57)

Doar formele severe de LAS se preteaza la diagnostic diferential cu epiglotita acuta sau laringotrahobronsita bacteriana (1,3,10,17,18,52,54).

Formele severe de LAS pot fi ingrijite ca o epiglotita acuta (1,18,52,57), cu initierea terapiei antiinfectioasa vizind Haemoffilus Influenzae.

Copii cu forme usoare sau medii de LAS pot avea infectii bacteriene associate (de ex. otita medie)

Suprainfectia bacteriana este rara in LAS, iar antibioticoterapia “profilactica” nu scade riscul de suprainfectie, in schimb selecteaza flora rezistenta

Alte surse bibliografice recomanda, nediferentiat, neutilizarea antibioticelor in LAS (54,55,56,58) (grad D).

Recomandari:

Recomandari:

Dexametazona pe cale orala este tratamentul de electie al crupului viral mediu si sever. Grad A

Dozele de dexametazona preferate sunt de 0.15-0.30mg/kg iar intervalul intre doze de 12 ore. Grad D

Alternativa la dexametazona sunt Prednisonul si Prednisolonul in doze de 1-2mg/kg administrate la 12 ore. Grad D

In situatia in care nu se poate utiliza calea orala, pot fi folosite calea inhalatorie sau intramusculara. Grad D

In lipsa Budesonidului, se poate utiliza pentru nebulizari dexametazona sulfat de sodiu – sol. injectabila – in doza de 160mg.    Grad D

In forma usoara de crup viral, dexametazona orala in priza unica si doza de 0.6mg/kg s-a dovedit benefica (Ib), insa decizia de a o administra este o problema de judecata clinica. Grad D

Eficienta adrenalinei (epinefrinei) (v. tabelul 7)

Medicatie   Indicatie Doza Comentarii

Oxigen

Forma severa (SpO<90-92%)

Flux minim 4L/min, masca faciala

Se vor administra de asemenea nebulizari cu adrenalina si corticoizi sistemici

Corticoizi sistemici (oral)

Forma medie, severa

Dexametazona 0,15-0,13 mg/kg SAU prednisone/prednisolone 1-2 mg/kg

Debutul ,actiunii in 1 ora; doza poate fi repetata dupa 12-24 ore; adminstrarea IM poate fi folosita pentru un copil care refuza sa inghita sau varsa.

Corticoizi in nebulizare umeda (cind copilul varsa repetat la adm. de corticoizi oral.)

Forma medie, severa.

Budesonide (Pulmicort), 2mg (4 mL), nediluat

Dexametazona 160mg

Debutul actiunii in 30 minute; doza poate fi repetata 2 zile la interval de 12 ore.

Nebulizari cu adrenalina 1:1000

Forma medie, severa

0,5mL/kg, pina la un maxim de 5mg, per nebulizare

Debutul actiunii in citeva minute; se vor administra si corticoizi; pot fi necesare nebulizari

repetate.

Sunt necesare reevaluari frecvente pentru a monitoriza raspunsul la tratament

Prognosticul

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