[Interdisciplinary therapeutic concept in severe bacterial infections of the central respiratory tract in childhood].

BACKGROUND: Apart from all advances made in the management of central airway infections, Acute Epiglottitis (AE) and Bacterial Tracheitis (BT) continue to be causes of life-threatening airway obstruction in children. The aim of this retrospective study was to evaluate deficiencies in the diagnostical protocol, to clarify the role of airway endoscopy in acute childhood stridor, and to identify current reasons for fatalities in these diseases.

MATERIAL: In the observation period between 1980-92, we found 12 patients suffering from BT and 21 from AE managed in close cooperation of the involved disciplines at the pediatric intensive care unit of the University of Cologne.

RESULTS: Laryngoscopy with fiberoptic or small rigid endoscopes allowed in awake cooperative children accurate diagnose of AE, and the exclusion of supraglottic inflammation in BT without complications. Furthermore, additional endoscopic information of the degree of inflammation was helpful in the next critical decision, whether artificial airway or rigid tracheobronchoscopy was required. Nasotracheal intubation was necessary in 76% of our patients, in one child tracheostomy was performed (5%). Premature extubation necessitating reintubation occurred in 33% of the children suffering from BT. In these patients, our method of advancing a flexible endoscope for tracheoscopy through the respiration tube failed because of a low tube diameter. Another remarkable finding was the high mortality in AE (14%). Affected children were admitted in poor post-hypoxia conditions following outdoor cardiorespiratory arrest.

CONCLUSION: In the analysis of the clinical course we found three decisive turning points in managing the disorder; First, the confirmation of the correct admission diagnosis; second, the decision, as to whether an artificial airway should be established; and third, the proper time of extubation. The most decisive factor in decreasing mortality seems to be timely, appropriate presentation at referral centers if AE or BT is suspected. Clinically, progressive management of childhood stridor requires close cooperation between the Pediatric, Anesthesiologic, and ENT Departments. Fiberoptic endoscopy as a guide to current airway management is a major step forward and should be a part of every established protocol.