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Acute upper airway obstruction

Prepared by :

Dr Lulwah AlThumali

Pediatric Resident

TCH

Upper Airways

LowerAirways

• DEFINITION

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

• EXTENT

Ranges from nasal obstruction till larynx and upper trachea

Adult’s vs Children’s Airway

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

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Upper airway Anatomy

Extrathoracic obstruction Intrathoracic

obstruction

• Supraglottic area nasopharynx, epiglottis, larynx, aryepiglottic folds, and false vocal cords.• Glottic and subglottic

area

includes the portion of the trachea that lies within the thoracic cavity, as well as the mainstem bronchi

CROUP ( LARYNGOTRACHEOBRONCHITIS )

• Most patient with croup are between ages of 3 months & 5 years ( peak in 2nd year of life )

• The incidence is higher in boys• Common in late fall & winter Usually viral in origin - Parainfluenza virus (type 1) - Influenza virus - RSV , adenovirus , measles virus

Clinical Presentation

HISTORY :• Rhinorrhea , sore throat , cough• Fever• Hoarseness , barking cough & inspiratory stridor• Respiratory distress

Physical Examination :• Hoarse cry• Respiratory distress• Respiratory failure• Suprasternal , intercostal & subcostal retractions• Lethargy , agitation• Hypoxemia , Hypercarbia• Tachypnea , Tachycardia• Dehydration • Cyanosis ( late )

Diagnosis It is clinically diagnosed Neck x-ray and CBC all should be

done in clinically stable pt .

- AP neck film : show a pencil tip or steeple sign of the subglottic trachea

Treatment • Cool mist administration• Corticosteroids :Used in moderate to severe croupA child who needs admission in ICU for croup

management needs steroid. Preparations

Dexamethasone Nebulized Budesonide

○ Not as effective as dexamethasone○ Much more expensive than

dexamethasone

• Nebulized racemic epinephrine• Heliox

 

Epiglottitis

Medical emergency (sudden )RareCaused by : group A streptococcal or staphylococcus aureus infections

sniffing position Thumb sign

Signs and symptoms :• Respiratory distress: stridor,

tachypnea, anxiety, refusal to lie down, "sniffing" or "tripod" postureSore throat, dysphagia, drooling, anterior neck pain (at the level of the hyoid)

• Muffled "hot potato" voice• Marked retractions and labored

breathing indicate impending respiratory failure

Epiglottitis

Consider epiglottitis in ‼

Febrile, toxic-appearing children with rapid onset and progression of dysphagia, drooling, and respiratory distress, especially if unimmunized .

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Evaluation :

• Secure airway

• Communicate early with otolaryngologist, anesthesiologist, and intensivist

• Keep the patient in a setting where the airway can be rapidly managed if necessary (eg, the emergency department, operating room, or intensive care unit)

Findings:

• Stridor, drooling

• Suprasternal and subcostal retractions

• Swollen, erythematous epiglottis, inflammation of the supraglottic structures

 

Imaging:

Soft-tissue radiograph of the lateral neck:Enlarged epiglottis ("thumb" sign)

Management :

AirwayIn patients with moderate to severe respiratory distress, secure the airway in the operating room or similarly equipped setting (endotracheal tube or surgically if necessary) with an anesthesiologist and otolaryngologist present

If abrupt obstruction:Attempt bag-valve mask ventilation first During laryngoscopy, pressure on the chest by an assistant may produce bubbling and help indicate the location of the glottis Perform needle cricothyrotomy or surgical cricothyrotomy if unable to ventilate or intubate

Laboratory studies:

Epiglottal cultures Blood cultures

Antimicrobial therapy :Administer empiric antimicrobial therapy:Cefotaxime OR ceftriaxonePLUSIf community- or hospital-acquired Staphylococcus aureus is suspected, add clindamycin OR vancomycin based upon local antimicrobial susceptibility patterns

MonitorMonitor patient in the intensive care unit

• Bacterial tracheitis is an invasive exudative bacterial infection of the soft tissues of the trachea

Staphylococcus aureus, Streptococcus pneumoniae, gram-negative enteric bacteria, Pseudomonas aeruginosa

• Aspiration of bacteria-laden secretions into the trachea during bacterial infection of the upper respiratory tract (eg, acute bacterial sinusitis, streptococcal pharyngitis) or after tonsillectomy also may lead to bacterial tracheitis

Bacterial tracheitis

Occurs during the first six years of lifeCommon in the fall and winter, coinciding with the typical seasonal epidemics of parainfluenza, respiratory syncytial virus (RSV), and seasonal influenza

 

Symptoms and signs  :

●Fever ●Stridor (inspiratory or expiratory)●Cough (not painful; membranous exudates may be expectorated)●Respiratory distress●Drooling is uncommon, but may be present

Radiographic features — Lateral neck or anteroposterior radiographs typically show narrowing (steeple sign )

• Laboratory features  

• Neither a complete blood count (CBC) with differential nor inflammatory markers are helpful in confirming or excluding the diagnosis of bacterial tracheitis.

• The white blood cell (WBC) count is highly variable. Mild leukopenia is as common as leukocytosis. Increased proportion of bands and/or absolute band counts are common

• White blood cell count does not correlate with severity of illness or ultimate length of hospitalization

• In the only series that evaluated inflammatory markers, erythrocyte sedimentation rate or C-reactive protein were elevated in 26 of 38 patients (68 percent) but these markers are nonspecific.

• Gram stain of exudates typically shows neutrophils and may show one or more bacterial morphologies

• . Blood cultures are rarely positive

DIAGNOSISDefinitive diagnosis of bacterial tracheitis requires direct visualization of an inflamed, exudate-covered trachea

TREATMENT :

AIRWAY MANAGEMENT• Supplemental oxygen• Artificial airway• Bronchodilators• Glucocorticoids • FLUID MANAGEMENT• ANTIMICROBIAL THERAPY

 

PREVENTION :

Vaccination against pneumococci and viruses (eg, measles, influenza) that may predispose children to bacterial tracheitis and other secondary bacterial infections of the respiratory tract is the primary means of prevention.

• infectious disease caused by the gram-positive bacillus Corynebacterium diphtheriae.

• The word diphtheria comes from the Greek word for leather, which refers to the tough pharyngeal membrane that is the clinical hallmark of infection.

• There is :

Respiratory diphtheria Systemic manifestations Cutaneous diphtheria 

Diphtheria

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DIAGNOSIS 

• clinical manifestations :

• Sore throat, malaise, cervical lymphadenopathy, and low-grade fever• Mild pharyngeal erythema typically progresses to areas of white exudate;

these coalesce to form an adherent gray pseudomembrane that bleeds with scraping

Definitive diagnosis of diphtheria requires culture of C. diphtheriae  from respiratory tract secretions or cutaneous lesions and a positive toxin assay Routine laboratory results are usually nonspecific and may include a moderately elevated white blood cell count and proteinuria.

 

TREATMENT

Antitoxin  Diphtheria antitoxin is a hyperimmune antiserum produced in horses that binds to and inactivates the diphtheria toxin

Antibiotics  The antibiotics of choice are erythromycin (500 mg four times daily for 14 days) or procaine penicillin G (300,000 units every 12 hours for patients ≤10 kg and 600,000 units every 12 hours for patients >10 kg intramuscularly) until the patient can take oral medicine, followed by oral penicillin V (250 mg four times daily) for a total treatment course of 14 days .

Airway Foreign Bodies

• Tracheobronchial foreign body aspiration (FBA) is a potentially life-threatening event,

• It can block respiration by obstructing the airway, thereby impairing oxygenation and ventilation

• Approximately 80 % of pediatric FBA episodes occur in children younger than three years, with the peak incidence between one and two years of age .

• The majority of aspirated FBs in children are located in the bronchi . Laryngeal and tracheal FBs are less common.

In a review of 1160 suspected FBA aspirations in children, a FB was successfully removed in 1068 children (92 percent) . The sites of the FB were as follows:

●Larynx – 3 %●Trachea/carina – 13 %●Right lung – 60 % ●Left lung – 23 % (18 percent in the main bronchus and 5 percent in the

lower bronchus)●Bilateral – 2 %

RADIOLOGIC EVALUATION 

• Plain radiographic evaluation of the chest may or may not be helpful

• Depending upon whether the object is radioopaque, and whether and to what degree airway obstruction is present.

• Most objects aspirated by children are radiolucent (eg, nuts, food particles) , and are not detected with standard radiographs unless aspiration is accompanied by airway obstruction or other complications .

• Normal findings on radiography do not rule out FBA, and the clinical history is the main determinant of whether to perform a bronchoscopy .

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 References

Essential Nelson 6th EditionNelson text book 20th EditionUpToDate

 

Thank you