Acute Fulminating Laryngotracheobronchitis in an Adult

Abstract

Acute fulminating laryngotracheobronchitis in children has been described by various writers. There is, however, a great paucity of literature concerning this condition in adults. The disease is usually seen in children from several months to about 9 years of age, the most frequent incidence being between 2 and 4 years. It is an extremely serious condition, owing to the obstruction of the respiratory tract by the swelling of the mucous membrane lining the trachea and bronchi and, lying on this swollen mucous membrane, a sticky, gummy exudate or secretion, which in turn causes more obstruction.The typical case history is as follows : The child awakens at night with symptoms resembling those of spasmodic croup, with inspiratory dyspnea and hoarseness. Fever is usually present. Remedies such as those administered in cases of croup have practically no effect on the respiratory difficulty, and one thinks of diphtheria, or possibly a foreign body in the larynx, as a cause of the dyspnea. Antitoxin has been given by many physicians in cases such as this, without any beneficial effect. In order to rule out a diagnosis of diphtheria or foreign body, the larynx of the child is examined by direct laryngoscopy. Then the true nature of the disease presents itself. The larynx has a mottled reddishgray appearance throughout; the vocal cords are injected and slightly thickened but move normally. The entire mucous membrane is velvety, but usually no exudate is found in the larynx itself. However, when the trachea is examined the cause of the dyspnea is apparent; the mucous membrane is thickened and velvety and is a dirty reddish gray, and lying on every part of it is a thick, tenacious secretion. The effect of the swollen mucous membrane and the secretion is to narrow the caliber of the lumen so that at times it is almost closed. The secretion is not always fluid or semifluid: often it is membranous and can be aspirated or even extracted with forceps as a cast of a part of the tracheobronchial tree. The removal of the secretion or membrane may give temporary relief, and the child may seem to be out of danger. However, in a short time the dyspnea reappears, with restlessness and cyanosis, and it becomes a question whether to perform tracheotomy or to insert an intubation tube in order to allow sufficient air to enter the lungs. Baum,1 of Denver, advocates intubation first, but if dyspnea continues he advises tracheotomy. He stated that there is less tendency for crust to form in the tracheobronchial tree after intubation but that it is necessary for the child to be hospitalized where some one trained in inserting intubation tubes is always present. Richards2 expressed the belief that tracheotomy is of more value as it is possible to aspirate the secretion more easily through a tracheotomy tube,