In mid-March, when the epidemic in Jilin was very serious, a news story that "girls died when they sought medical treatment without opening a green channel" continued to ferment on the Internet, and "acute laryngitis", a common disease in children, attracted the attention of the public.
What is acute laryngitis?
Acute laryngitis is one of the more common respiratory diseases in pediatrics, and is an acute catarrhal inflammation of the laryngeal mucosa dominated by the glottis region, and children often involve the subglottic mucosa and submucosal tissues.
Occurs in infants and young children aged 6 months to 3 years. Acute laryngitis in children is more likely and progresses rapidly than in adults [1]. If not treated correctly and in a timely manner, the child may suffocate and die due to breathing difficulties.
Common pathogenic bacteria and clinical symptoms
Most are caused by viral infections, with secondary bacterial infections. Consists of rhinovirus, influenza virus, parainfluenza virus and adenovirus. Studies have shown that respiratory syncytial virus (RSV) is predominantly endemic in winter, influenza virus (IV) is high in autumn and winter, parainfluenza virus (PIV) is high in spring and Boka virus (hBoV) is high in summer, and Mycoplasma pneumoniae (MP) is endemic throughout the year, with the highest detection rate in summer and autumn [2].
Clinical features are hoarseness, dysphonia, pain in cough, and often fever, sore throat, or cough. Laryngeal edema, hyperemia, mild enlargement and tenderness of local lymph nodes, and stridor of the larynx may be heard on physical examination [3].
Why are children with acute laryngitis more severe?
On the one hand, the laryngeal cavity of children is relatively narrow, laryngeal cartilage is soft, the mucosal lymph and glandular tissue is rich, the submucosal tissue is more relaxed, compared with adults, the throat part of the child is easy to cause mucosal hyperemia after infection, laryngeal narrowing or even obstruction, prone to edema and spasm, which in turn causes breathing difficulties; on the other hand, children's cough ability is relatively weak, which can easily lead to respiratory secretions can not be discharged in time, and children are sensitive, and it is easy to cause laryngeal spasm and laryngeal obstruction after being stimulated; Children's resistance to infection and immunity are low, and the inflammatory response after laryngeal infection is also one of the important reasons for the frequent occurrence of laryngitis.
How acute laryngitis is treated[4]
Treatment includes local symptomatic and etiological therapy (antibiotic or antiviral therapy), and if severe laryngeal obstruction does not improve with medical therapy, endotracheal intubation and/or tracheostomy should be performed promptly. As an adjunctive therapy, nebulized inhalation can cause the drug to act directly on the airway mucosa, which can significantly reduce laryngeal edema and inflammation, relieve airway spasm, dilute sputum, and improve ventilation.
1. Treatment of the cause
Antiviral therapy: aggressive antiviral therapy is generally not required. It can be used early in immunocompromised patients. Broad-spectrum antiviral drugs ribavirin and oseltamivir have a strong inhibitory effect on respiratory syncytial virus, etc., and can shorten the course of the disease.
Antimicrobial therapy: simple viral infections do not require the use of antimicrobial agents. If there is a bacterial infection, timely intravenous injection of antibacterial drugs, generally given penicillin, macrolides or cephalosporins, etc., in severe cases, more than 2 kinds of antibiotics.
2. Local symptomatic
(1) Keep the respiratory tract unobstructed: oxygen inhalation, nebulization inhalation, reduce mucosal edema.
(2) Glucocorticoids: Glucocorticoids are given to reduce laryngeal edema and relieve symptoms. Prednisone is commonly used, 1 to 2 mg·kg-1·d-1, orally in divided doses; dexamethasone intravenous bolus can be given 2 to 5 mg each time in severe cases; followed by 1 mg·kg-1·d-1 intravenous infusion for 2 to 3 d days until symptoms resolve.
Prednisone is a moderate-potency glucocorticoid that is a hormone commonly used in infectious laryngitis and laryngeal obstruction.
Dexamethasone is a long-acting glucocorticoid, because of its low affinity with glucocorticoid receptors, poor lipophilicity, and the need for transformation in the liver to function, coupled with the relatively low concentration of intravenous drugs distributed in the throat, so the effect is slow, but the effect is long-lasting. In addition, dexamethasone has an immunosuppressive effect, such as prolonged, high-dose drug use can spread the infection, so it should not be used for a long time [5].
Nebulized inhaled budesonide suspensions have fewer adverse effects than oral dexamethasone, may have a faster onset of action, and may be more appropriate for patients with acute laryngitis, but should also be used with systemic glucocorticoids in patients with severe laryngeal obstruction [6].
Cates et al. [7] studies have concluded that budesonide's non-specific anti-inflammatory effects and anti-allergic reactions are 20 to 30 times stronger than those of dexamethasone, so that small doses can receive significant efficacy.
Inhalation of nebulization can cause the drug to act directly on the airway mucosa, significantly reduce laryngeal edema and inflammation, relieve airway spasm, dilute sputum, and improve ventilation. Inhaled glucocorticoid (ICS) nebulization therapy significantly reduces laryngeal edema and inflammation. ICS can be used as a combination of treatments to relieve acute exacerbations in the hospital.
Inhaled drugs have a strong local effect, and the higher the concentration of local drugs, the better the efficacy. Inhalation nebulization is the most inspiratory therapy that does not require deliberate cooperation from the child and is suitable for children of any age. At the same time, the dosage of general nebulization inhalation therapy is only a few tenths of the systemic dose, which can avoid or reduce the potential adverse reactions that may occur with systemic administration (such as glucocorticoids).
At present, there are three kinds of ICS suspensions for children's nebulization inhalation, including budesonide (BUD), beclomethasone propionate (BDP) and fluticasone propionate (FP). The mechanism of action, indications, contraindications, etc. are similar, but there are differences in pharmacodynamics, pharmacokinetics, etc., as follows[8]:
Commonly used ICS pharmacodynamics and pharmacokinetic features
LogP: Oil-water partition coefficient, the greater the value LogP, the stronger the lipophilicity, on the contrary, the stronger the hydrophilicity; hydrophilicity determines the speed of ICS through the airway mucus layer, the better the hydrophilicity of the original drug, the faster the speed through the airway mucus layer, so only the original drug molecules are compared, and no metabolites are involved.
Expert consensus recommends that acute laryngitis nebulize inhalation specific methods. Glucocorticoids: as budesonide suspension (1 mg/2 ml). Children: 0.5 to 1 mg/dose 2 times/day; duration: tapering depending on the condition, the entire nebulized inhalation therapy time is recommended to not exceed 10 days.
Budesonide is a synthetic, non-halogenated glucocorticoid. While retaining high lipophilicity, it has high hydrophilicity and is more likely to pass through the mucus layer of the airway.
Beclomethasone propionate is a precursor drug that is hydrolyzed to the active metabolite 17-monopropionic acid beclomethasone monopropionate under the action of a catalytic enzyme in the body, but this catalytic enzyme is also expressed in many tissues such as liver, colon, stomach, breast and brain tissues. Therefore, the potential risk of systemic adverse effects of 17-monopropionate beclomethasone monopropionate, which is activated in extrapulmonary tissues and has a high affinity with the recipient, requires vigilance.
Fluticasone propionate is a highly lipophilic ICS with a large apparent volume of distribution, a long half-life, and a potential risk of systemic adverse reactions at the same dose and the same inhalation device than budesonide and beclomethasone propionate.
3.ICS adverse reactions
Although ICS is highly safe, due to the particularity of the mode of administration ICS deposited in the oropharynx and larynx after inhalation can cause local adverse reactions, and gargling and rinsing immediately after use can effectively reduce local adverse reactions. Common local adverse effects of ICS include oropharyngeal Candida infection, hoarseness, laryngitis (sore throat), bronchospasm cough, and so on.
4. Is adrenaline nebulized inhalation used?
Epinephrine: Zhang Junchao[9] observed that epinephrine nebulization inhalation therapy I.~ IV. laryngeal obstruction has achieved good results, Shen Jun et al. [10] using combined budesonide, epinephrine alternating nebulization inhalation treatment of laryngeal obstruction of second degree and above has obvious efficacy.
Epinephrine has a vasoconstrictive effect by activating α, β receptors, and inhibiting the release of histamine by some mast cells, and although there are few reports of empiric use as a nebulized inhalation, there is a lack of evidence-based medical evidence at home and abroad.
Curated: Spring Flowers
Source: Lilac Garden
bibliography:
ZHANG Yamei, ZHANG Tianyu. Practical Pediatric Otolaryngology[M]. Beijing: People's Medical Publishing House, 2011
Zhang Xinxing, Gu Wenjing, Chen Zhengrong, et al. Analysis of nonbacterial etiology in children with acute laryngitis[J]. J Clinical Pediatrics, 2016(7):529-532.
Chinese Medical Association, Journal of Chinese Medical Association, General Medicine Branch of Chinese Medical Association, et al. Guidelines for primary diagnosis and treatment of acute upper respiratory tract infection (2018)[J]. Chinese Journal of General Practitioners, 2019, 18(5):5.
[4] Anon. Expert consensus on the application of nebulized inhalation in the drug treatment of throat diseases[J]. Chinese Department of Otolaryngology Head and Neck Surgery, 2019, 26(5):8.
[5] Malan. Misunderstandings in the diagnosis and treatment of acute infectious laryngitis in children[J]. Chinese Journal of Clinicians, 2015, 000(004):11-15.
[6] Anon. Expert consensus on the application of glucocorticoid nebulization inhalation therapy in pediatrics (2018 revised edition)[J]. J Clinical Pediatrics, 2018, 36(2):13.
[7] Cates CJ，Lasserson TJ． Ｒegular treatment withnformoterol and an inhaled cortieosteroid versus regular treatment with salmeterol and aninhaled corticosteroid for chronic asthma: serious adverse events［J］．Cochrane Database Syst Ｒev，2010，20( 1) ∶ CD007694．
[8] Anon. Expert Consensus on Rational Use of Drugs in Nebulized Inhalation Therapy (2019 Edition)[J]. Herald of Medicine, 2019, 38(2):12.
ZHANG Junchao. Clinical analysis of epinephrine nebulization inhalation in the treatment of laryngeal obstruction in children with acute laryngitis[J]. China Journal of Practical Medicine,2012,39( 19) ∶116.
Shen Jun,Lu Jiaming. Efficacy of different nebulized inhalation methods in the treatment of acute infectious laryngitis complicated with laryngeal obstruction in children[J]. Chinese Clinician,2013,41(4)∶61-62.
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