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Nursing Care Plan | Laryngotracheobronchitis (Croup)

Laryngotracheobronchitis (LTB) is an inflammation and obstruction of the larynx, trachea, and major bronchi of children. In small children, the air passages in the lungs are smaller than those of adults, making them more susceptible to obstruction by edema and spasm. Because of the respiratory distress it causes, LTB is one of the most frightening acute diseases of childhood and is responsible for over 250,000 emergency department visits each year.

It is sometimes called croup, although croup can be more specifically described as one of three entities: LTB, laryngitis (inflammation of the larynx), or acute spasmodic laryngitis (obstructive narrowing of the larynx because of viral infection, genetic factors, or emotional distress). Acute spasmodic laryngitis is particularly common in children with allergies and those with a family history of croup. Acute LTB usually occurs in the fall or winter and is often mild, self-limiting, and followed by a complete recovery.
Nursing care plan
More than 85% of the cases of LTB are caused by a virus. Parainfluenza 1, 2, and 3 viruses, respiratory syncytial virus, Mycoplasma pneumoniae, and rhinoviruses are the most common causes. The measles virus or bacterial infections such as pertussis and diphtheria are occasionally the cause. Epiglottitis, a life-threatening emergency caused by acute inflammation of the epiglottis and surrounding area, differs from LTB because it usually results from infection with the bacteria Haemophilus influenzae type B.

Nursing care plan assessment and physical examination
The child usually has a history of an upper respiratory infection and a runny nose (rhinorrhea). After several days of respiratory symptoms, such as cough and increased respiratory rate, the child develops a barking, seal-like cough; a hoarse cry; and inspiratory stridor. The symptoms tend to occur in the late evening and improve during the day. A child may have LTB more than once but will outgrow it as the size of the airways increases. The course of the infection lasts several days to several weeks, and the child may have a lingering, barking cough.

The initial sign of LTB is increasing respiratory distress. The child may develop flaring of the nares, a prolonged expiratory phase, and use of accessory muscles. When you auscultate the child’s lungs, the breath sounds may be diminished and you may hear inspiratory stridor. The child may have a mild fever. Increasing respiratory obstruction is indicated by any of the following: increasing stridor, suprasternal and intercostal retractions, respiratory rate above 60, tachycardia, cyanosis, pallor, and restlessness.

The parents and child will be apprehensive. Assess the parents’ ability to cope with the emergency situation, and intervene as appropriate. Note that many children are treated at home rather than in the hospital; your teaching plan may need to consider home rather than hospital management.

Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to tracheobronchial infection and obstruction.

Nursing care plan intervention and treatment plan
The aim of treatment is to maintain a patent airway and provide adequate repiratory exchange. Medical management includes bronchodilating medications, cool mist in a croup tent during sleep, and intravenous hydration if oral intake is inadequate. Oxygen may be used, but it masks cyanosis, which signals impending airway obstruction. Sedation is contraindicated because it may depress respirations or mask restlessness, which indicate a worsening condition. Sponge baths may be needed to control temperatures above 102°F. You may need to isolate the child if the physician suspects syncytial virus or parainfluenza infections. Laryngoscopy may be necessary if complete airway obstruction is imminent. A flexible nasopharyngoscopy can be used; an intubation or a tracheostomy is performed only if no other method of airway maintenance is available. Keep intubation and tracheostomy trays near the bedside at all times, for use in case of emergencies.

Ongoing, continuous observation of the patency of the child’s airway is essential to identify impending obstruction. Prop infants up on pillows or place them in an infant seat; older children should have the head of the bed elevated so that they are in Fowler’s position. Sore throat pain can be decreased by soothing preparations such as iced pops or fruit sherbet. If the child has difficulty swallowing, avoid thick milkshakes. Children should be allowed to rest as much as possible to conserve their energy; organize your interventions to limit disturbances. Provide age-appropriate activities. Crying increases the child’s difficulty in breathing and should be limited if possible by comfort measures and the presence of the parents; parents should be allowed to hold and comfort the child as much as possible. If the child is in a cool mist tent, parents may need to be enclosed with the child, or the child may need to be held by the parents with the mist directed toward them. Children sense anxiety from their parents; if you support the parents in dealing with their anxiety and fear, the children are less fearful. A child’s anxiety and agitation will most likely exacerbate the symptoms and need to be avoided if possible. Careful explanation of all procedures and allowing the parents to participate in the care of the child as much as possible help relieve the anxieties of both child and parents. Provide adequate hydration to liquefy secretions and to replace fluid loss from increased sensible loss (increased respirations and fever). The child also might have a decreased fluid intake during the illness. Clear liquids should be offered frequently. Apply lubricant or ointment around the child’s mouth and lips to decrease the irritation from secretions and mouth breathing.

Nursing care plan discharge and home health care guidelines
Children may have recurring episodes of LTB; parental instruction on mechanisms to prevent airway obstruction is therefore important. Cool mist humidifiers may be used in the child’s room during the fall and winter months. Teach the parents to clean the humidifier every week with a vinegar mixture run through the machine for 30 minutes. If the child has an upper respiratory infection, encourage the parents to maintain an open airway by using a croup tent that may be improvised by draping sheets over a crib and using a cool mist humidifier. Another option is to take the child into a closed bathroom with the shower or tub running to create an environment that has high humidity.

If antibiotics have been prescribed, tell the parents to make sure the child finishes the entire prescription. Instruct the parents to recognize the signs of increasing respiratory obstruction, and advise them when to take the child to an emergency department. Remind the parents that ear infections or pneumonia may follow croup in 4 to 6 days. Immediate medical attention is needed if the child has an earache, productive cough, fever, or dyspnea.

If the child is cared for at home, provide the following home care instructions: (1) Keep the child in bed or playing quietly to conserve energy; (2) Prop the child in a sitting position to ease breathing; don’t let him or her stay in a flat position; (3) Do not use aspirin products because of the chance of Reye’s syndrome; (4) Give plenty of fluids, such as sherbet, ginger ale left to stand so there are no bubbles, gelatin dissolved in water, and iced pops; withhold solid food until the child can breathe easily; and (5) Provide a cool mist humidifier.
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