PEDIATRIC UPPER AIRWAY OBSTRUCTION

DR. MOHAMED AADILDCH MRCPCH CONSULTANT PEDIATRICIAN, TGH

Upper Airways

LowerAirways

Anatomy

Tongue Large compared to the size of

the oral cavity

Epiglottis Relatively large and floppy in

infants Epiglottis covers more of the

glottic aperture

Physiologic: Edema EffectsPoiseuille’s law

Physiologic ConsiderationsMore rapid cardiopulmonary decline

Increased risk of upper airway obstruction Prone to bradycardia

Laryngeal stimulation and hypoxia Higher oxygen consumption Lower functional residual capacity

Less oxygen reserve

DEFINITION

EXTENTRanges from nasal obstruction till larynx and upper trachea.

Obstruction of the portion of the airways located above the thoracic inlet.

Clinical manifestation

Stridor : ( Inspiratory stridor ) - Harsh sound produced by vibration of upper airway structure - Indicates upper airway obstruction Hoarseness: Indicates involvement of vocal cords Respiratory distress / suprasternal

retraction

Clinical manifestation : cont.

Cough Signs of hypoxemia - Anxiety - Restlessness - Tachycardia - Pallor - Cyanosis: late sign

Causes of acute UAO :

• Infectious (Commonest )•Non- Infectious

INFECTIOUS

Croup ( Acute laryngotracheobronchitis ).

Bacterial trachitis ( membranous croup ). Acute epiglottitis. Diphtheria. Retropharyngeal abscess / peritonsillar. abscess.

Foreign body inhalation.Spasmodic laryngitisMediastinal mass

Non-INFECTIOUS

Rapid AssessmentHow Bad is it?

If distress is severe stridor at rest cyanosis, severe retractions, toxic appearing quickly examine and intervene

If stridor is mild: Then obtain a more complete and accurate history develop a plan based on the differential diagnosis

Focused history 5 A's

Age : Acuity Hyperacute , acute , chronic , acute on chronic Acoustics – Harsh or soft strider Associated symptoms – fever , dysphagia, drooling Aggravating factors Quality of stridor – Hoarse or muffled

A 20 month old male chief complaint of •cough. • rhinorrhea, •fever, a• hoarse cry and a •progressively worsening, harsh, "barky," cough. "whistling" sound when he breathes, so his parents brought him to the emergency department. •past medical history is unremarkable. • 6 year old brother also has cold symptoms.

SCENARIO 1

•VS T 37.5, P 140, R 36, BP 90/64,

•spo2 96% in ra.

•He is alert, with good eye contact,

• pharynx – Congested .

• RS - mild respiratory distress. lung exam shows good aeration slight inspiratory stridor at rest. very slight subcostal retractions. No wheeze or rhonchi are noted.

•CVS – Normal • Abdomen is flat, soft, and non-tender. •His extremities are warm and pink with good perfusion.

Examination

•ABC

• treated oral dexamethasone• nebulized racemic epinephrine •PAT assessment / Croup scoring

•His coughing subsides and his stridor resolves. • neck X-ray - The subglottic region is mildly narrowed.

TREATMENT

Repeat dose of Adrenaline nebulisation was given

He is discharged home after one hour of monitoring parents were instructed to treat him with humidified mist therapy.

Oral fluids as tolerated

Paracetamol syrup PRN

Review next day

Mild symptoms (Westley score of ≤2 )

treated symptomatically a single oral dexamethasone nebulized epinephrine is not required Oral fluids Paracetamol Humidified mist air.

DANGER SIGNS

Stridor at rest Difficulty breathing Pallor or cyanosis Severe coughing spells Drooling or difficulty swallowing Fatigue Fever (>38.5ºC) Prolonged symptoms (longer than seven days) Suprasternal retractions

A 23-month-old thriving boy, presents to the emergency department of the local hospital with viral croup.

He has been hospitalised for croup on three previous occasions, twice having been admitted to PICU .Between bouts of croup, he is well .

Scenario 2

•He has become agitated since waking 30 minutes earlier.

•loud inspiratory stridor at rest

• using his sternomastoid and abdominal muscles to aid breathing

• tracheal tug

•palpable pulsus paradoxus.

•His parents gave him a dose of oral prednisolone earlier in the evening.

Examination findings

Management

ABC Humidified Oxygen by Parents Oral/Injectable Dexamethasone Nebuliser Adrenaline Paracetamol IV fluids Or oral fluids PAT ongoing assessment

On going management

Continue PAT assessment / Croup scoring

Oxygen non threatening manner , if saturation less than 92 – 94 %

IV Fluids / oral fluids as tolerated

Repeat Adrenaline nebulisation

Other symptomatic measures

After 4 hours discharge if

PAT assessment normal Normal conciousness Tolerating fluids No stridor at rest Normal pulse oximetry Normal colour FOLLOW UP ARRANGED after 24 hours

Moderate croup usually show Immediate improvement & should be observed in ER for 4 hours with ongoing PAT assessment.Can be discharged home with the review after 24 hours.Parents should be instructed to return if the danger signs appear

Indications for admission

Not improving within 4 hours Requiring multiple doses of Epinephrine nebulisations Persistent moderate symptoms at 4 hours Severe croup impending respiratory failure Oxygen requirement Dehydration Toxic appearing

Moderate croup Westley score 3 to 7

stridor at rest and mild to moderate retractions, but no agitation

Severe croup Westley croup score ≥8

stridor at rest and marked retractions Agitation, lethargy, or cyanosis

 Dexamethasone  nebulized epinephrine humidified air or oxygen Antipyretics Fluid intake nebulized Budesonide alternative option Mechanical ventilation very rare

Scenario 3

A 3 years old presents to ER acute onset of fever , irritability, throat pain , difficulty in swallowing & drooling of saliva

On examination Toxic appearance , febrile & adopts position of comfort with chin

up Mouth open drooling

WHAT WILL YOU DO ???

EPIGLOTTIS

In a patient with severe airway obstruction

Don’t inspect the oropharynx send the patient to radiology for a lateral neck or

chest X-Ray insert an IV take blood gases

Do’s

Be calm Let the baby be in mother’s lap or beside mother

to make him calm and comfortable Observe the signs of hypoxia or deterioration Oxygen to be given by mother ( non threatening

manner) In severe cases or respiratory failure: Inform consultant Pediatrician / Anesthesiologist / ENT secure the airway ( intubation / trachesotomy)

When stridor is atypical for croup

: Fixed stridor or isolated exhalatory stridor. Poor/No response to inhaled racemic epinephrine and/or

steroids Sydromic / dysmorphic features Associated medical conditions – Neuromuscular disorders

Extremes of age Greater than age 6, less than 6 month

Toxic appearing Persistently high fever. No viral prodrome, sudden onset

Work-up Atypical Stridor

Not all atypical stridor needs a work-up Admit and observe Physical Exam maneuvers Lateral and AP Neck CXR CT scan chest / neck ENT consult

Physical Exam Maneuvers

Lay the infant Laryngomalacia worse with laying flat

Pass nasal catheter to determine the patency

Place in sniffing position and/or jaw thrust If the stridor lessens, obstruction may be at the level of the larynx

or higher

Atypical Stridor

Heavy drooling High fever Refusing to move neck

Retropharyngeal Abscess

Typical presents 6-36 months

Look at prevertebral space

Complications include: Mediastinitis, pericarditis,

airway obstruction

Radiographs in Atypical StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign bodies Mediastinal masses Congenital anomalies

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign Epiglottitis Radio-opaque foreign bodies Mediastinal masses Congenital anomalies

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign bodies Mediastinal masses Congenital anomalies

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign bodies Mediastinal masses Congenital anomalies

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign bodies Mediastinal masses Congenital anomalies

Radiographs in StridorOther Findings

•Steeple’s sign•Thumb sign•Radio-opaque

foreign bodies•Mediastinal

masses•Congenital

anomalies

Right Sided Aortic Arch

Aberrant left subclavian artery gives rise to ductus arterious and compresses trachea

Surgery involves clipping of ligamentous arterious

Case 4 11 mo brought to ED after

brother was feeding child with GEMS

Case

Mother heard coughing and gagging on child monitor

EMS called

Treatment

Children should be allowed to use their own cough reflex to extrude the foreign body in case of partial obstruction.

If obstruction increases acute intervention is needed.

If obstruction worsens

Essentials of diagnosis Acute onset of cyanosis and choking

*Inability to cough or vocalize (complete obstruction) *Drooling with stridor (partial obstruction)

Risk age group: 6months-4 years of age

Complete obstruction

Unable to speak Unable to breath Unable to cough

First-aid for a choking baby:

Infant <1 year of age: According to AAP and AHA

* Place the infant face down over rescue arm with head position below the trunk. Five back slaps are delivered rapidly between infant’s scapula with the heel of hand.

* If obstruction persists infant should be rolled over and five rapid chest compression should be performed.

Repeat if not successful and call for help

First-aid for a choking baby

Children >1 year of age

Abdominal thrust ( Heimlich maneuver )5 thrusts

Repeat if not successful and call for help

If FB is directly visualized in the mouth, it can be removed by forceps.

F.B. in trachea or lower airway: Endoscopy removal

Sometimes emergency tracheostomy is needed.

Summary

Evaluation if severity PAT Assessment Croup scoring Focused History – 5 A’s Intervention based on evaluation & history Ongoing assessment Discharge / Advise