Upper airway obstruction

Approach to child with :

Halima Al.Dhali98181

outline

• Case scenario• Anatomy• Pathophysiology of stridor• Differential Diagnosis

Anatomy

• Upper airway includes • Nose• Pharynx• Larynx)• Trachea

case

• A 2 years child presented with sudden onset of stridor

Febrile 38.2 Alert not sick

Mild inspiratory stridorRR 30Sat :98%Capillary Refill :2secChest :clear , CVS:S1S2 , No murmurAbd : Soft , No liver or spleen felt

History

Age of onset, duration, severity, and progression of the stridor

Birth Vocal cord paralysis, congenital lesions such as choanal atresia

4 to 6 weeks Laryngomalacia

1 to 4 years Croup, epiglottitis, foreign body aspiration

Age Related Differential Diagnosis of Upper Air way obstruction

Newborn Infancy Toddlers

• Choanal atresia• DigGeorge syndrome• Laryngeal web ,

atresia• Vocal cord paralysis• Pharyngeal collapse

• Laryngomalacia• Viral croop• Subglottis stenosis• Laryngeal web• Vascular ring• Rhinitis

• Viral croop• Bacteria tracheitis • Foreign body • Retrolaryngeal

abscess• Hypertrophied

tonsil• Laryngeal

papillomatosis

o Precipitating factors (e.g. Crying, feeding, straining,

antecedent URTI, choking, at night)

o Positioning (e.g. prone, supine, or sitting)

o Quality and nature of crying

o Other associated symptoms (e.g. paroxysms of cough,

aspiration, difficulty in feeding, drooling, hoarseness,

dysphagia, snoring, or sleep-disordered breathing)

Past medical/ surgical Hx

Previous admission due to respiratory diseases

Hx of atopy

Indotracheal intubation or surgery

Perinatal Hx

Birth trauma, infections, prematurity

Immunization/developemental Hx

Nutrional Hx

Family/ social Hx

Examination

Anthropometric measure: Vital sign Inspection• Toxic appearance (ill looking)• Level of consciousness• Dysmorphic features• Surgical scars • Neck edema• Work of breathing/distress (cyanosis, nasal flaring, use accessory

muscles and retractions) • Drooling saliva

General examination:• peripheral lymphadenopathy• Clubbing • Hydration

Specific examination:• Dyspnea\ cough • Stridor

Stridor

• High pitched , often harsh noise produce by airway turbulence through partial obstruction of the upper airway.

• Commonly in inspiration

Supraglottic and subglottic obstruction Features Supraglottic obstruction Subglottic Obstruction Common causes

Stridor

Voice

Dysphagia

Barking cough

Fever

Trismus

Drooling

Arching Posture

Epiglottitis ,Peritonsillar and Retropharyngeal abscess .

Quit

Muffled

Yes

No

High Grade

Yes

Yes

Yes

Croup , angioedema ,foreign body ,Tracheitis .

Loud

Hoarse

No

Yes

Low Grade

No

No

No

Basic management of acute upper airways obstruction• Do not examine the throat!• Reduce anxiety by being calm, confident• Observe carefully for signs of hypoxiaor deterioration.• If severe, administer nebulisedepinephrine (adrenaline) and contact ananaesthetist.• If respiratory failure develops fromincreasing airways obstruction,exhaustion or secretions blocking theairway, urgent tracheal intubation isrequired.

Bacterial trachietis

• invasive exudative bacterial infection of the soft tissues of the trachea

• Diffuse inflammatory process(larynx, pharynx,Trachea)

• Result in production of (Thick Excaudate ,ulcerative of mucous membrane) .

• Result in Airway obstucction• Age : (6month -14years) • Organisms : S.Aureus , S.pyogense , Moraxella ,H.influenza

Clinical Manifestation

• similar to severe viral croup.• High grade Fever• toxic appearance• barking cough• stridor ,tachypnea• Hoarseness of voice• sore throat, • Dysphonia

•What are the differences btw croup and Bacterial tracheitis ??

Diagnosis

Laryngoscopy laryngotracheal inflammation and mucopurulent secretions.

bacterial culture and Gram stain of tracheal secretionsImaging Studies :not essential.

subglottic narrowing on anteroposterior (AP) views - Steeple sign, clouding of tracheal air column or irregular tracheal margin on

lateral view

Management

•Airway• Maintenance of an adequate airway is of primary

importance.• Avoid agitating the child. If the patient's respiratory status

deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.

• Artificial airway use an endotracheal tube 0.5-1 size smaller than expected

• Supplemental oxygen

Medication

• Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.

• Antibiotic regimens included a third-generation cephalosporin, clindamycin against community acquired–methicillin-resistant S aureus (CA-MRSA)

• Vancomycin (45 mg/kg/d IV, divided every 8 h), with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if MRSA is prevalent in the community.

Case

• 5-year-old girl developed a severe sore throat, drooling of saliva, a high fever and

increasing difficulty breathing over 8 h

Epiglottitis was diagnosed and her airway was guaranteed with a nasotracheal tube. Antibiotics were started immediately She made a full recovery.

Epiglottitis

Epiglottis

• Inflammation of structure above glottis• has significant morbidity and mortality• most common in children aged 1–6 years

Organisms

• S. pneumoniae , S. aureus• H.infleuna • Moraxella catarrhalis , H. parainfluenzae • N. meningitidis , Pseudomonas species• Candida albicans, • Klebsiella pneumoniae • Pasteurella multocida

Fever is usually the first symptom. rapidly followed by stridor and labored

breathing Dysphagia, refusal to eat hoarse voice sore throat Cough and ear pain are less frequent

Drooling of saliva due to inability and pain on swallowing Dyspnea – Shortness of breath or difficulty in breathing Dysphonia – Hoarseness of voice Dysphagia – Difficulty in swallowing

Physical Examination

• child appears toxic; shock , restlessness, irritability

• tripod or sniffing position• Stridor• tender adenopathy• erythematous and classic swollen, cherry red

epiglottis

Management

• Securing the airway (endotracheal intubation)• Rarely, this is impossible and urgent tracheostomy is life-

saving.• Never place a child in a supine position.• Oxygen supplement.• Taken blood for culture.

Medication

• use antibiotics for the most likely organisms• After trauma : Staphylococcus aureus• presence of white patches: Candida albicans• Some antibiotic like: Ceftriaxone , Cefotaxime ,

Cefuroxime ,Clindamycin• Rifampin is used for chemoprophylaxis in Hib

infections.

Features Croup EpiglottitisOnset

Preceding Coryza

Cough

Able to drink

Drooling saliva

Appearance

Fever

Stridor

Over days

Yes

Sever, Barking

Yes

No

Unwell

Less than 38.5

Harsh, rasping

Over hours

No

Abscent ,slight

No

Yes

Toxic, very ill

More than 38.5

Soft,

Case 3 :

• 2 years old child presented to the emergency department with a one-week history of URI symptoms and a one-day history of more severe throat pain and swelling.

• Upon physical examination the patient was febrile and although she did not demonstrate any signs of respiratory distress, examination of her neck revealed fullness on the right.

• A lateral plain film of the neck showed soft tissue swelling anterior to the vertebral bodies

Retropharyngeal abscess

• a deep neck infection filling the potential space between the prevertebral fascia of the cervical vertebrae and the posterior wall of the pharynx.

pathophysiology Infection can spread from a contiguous area

The space can be directly inoculated from penetrating trauma

Common organism

group A -hemolytic streptococcus,S. aureus, viridans streptococci, S. epidermisE. coli, H. infl uenzae, Neisseria, Klebsiella, Salmonella, 

Presentation • fever, chills, malaise, decreased appetite, and irritability

• a sore throat, difficulty in swallowing, pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness .

• a muffled voice, the sensation of a lump in the throat, or pain in the back and shoulders upon swallowing.

• fever (70%) and neck pain (62%)

Examination Febrile, toxic and irritable.

Tender cervical lymphadenopathy, usually unilateral

decreased or painful range of motion of their necks or jaws.

• A “tracheal rock sign”

Diagnosis

• The laboratory evaluation is non-specifi with leukocytosis.

• contents of the abscess should be cultured• Computed tomography (CT) is the imaging

modality of choice for retropharyngeal abscess.• lateral neck radiograph may show anincrease in width of the soft tissues anterior to the vertebrae.

Management

assessment of the patency of the airway and adequacy of oxygenation and ventilation must be performed.

endotracheal intubationpresence of a large abscess requires drainage,Eradication of the bacterial organism (nafcillinand cefuroxime or ceftriaxone or cefotaxime )

Case

• previously healthy 24-month old male infant was initially presented to the family pediatrician for a recurring fever over a period of two weeks

• physical examination(alert and vitals were normal except for a temperature of 38 °C and tachypnea .

• CBC : leukocytosis of 24 × 109/L and CRP was 457.15 nmol/L, suggesting a bacterial etiology

• empirical antibiotic were prescribed.

• visit 3 days later :symptoms had not subsided. temperature was even higher than before 40 °C

• auscultation revealed markedly diminished breath sounds over the right lung.

• At that time, the most probable differential diagnosis was pneumonia due to a resistant bacterial pathogen .

• eventually the mother recall an event, one day after the initial presentation to the family pediatrician, boy was eating peanuts and suddenly developed a major coughing episode. But since the coughing finally subsided, the mother did not ascribe any relevancy to it

Potentially life-threatening event Suspected on the basis of a choking episode Common: 6 months-5years

Location:• laryngotracheal :

Acute respiratory distressStridor & hoarseness Increased respiratory effort or complete airway obstruction

• Lower airway :Little acute distress after the initial choking episode

Site of Foreign body

Right lung – 60 % Left lung – 23 Trachea/carina – 13 %Larynx – 3 %Bilateral – 2 %

Presentation

classic triad (ie, coughing, wheezing, decreased breathing sounds) 40%

fever, hemoptysis, dyspnea, and chest painMimic( croup, pneumonia, bronchiolitis, or

asthma.)

• the initial stage :history of a choking episode, followed by violent paroxysms of coughing, gagging,and occasionally complete airway obstruction .

• An asymptomatic• interval generally follows the aspiration, during which the

foreign body becomes lodged, the refl exes become fatigued, and the immediate irritating symptoms subside.

• 3 stage • caused by the foreign body, such as obstruction, erosion,• or infection. Chronic cough, hemoptysis, pneumonia, lung• abscess, unexplained fever, and malaise are common

presentations• of chronic airway foreign bodies

Physical Examination

• may be asymptomatic.• stridor, • localized wheeze,• diminished breath sounds.• Cyanosis (Severe case)

Investigations

Arterial blood gas

Bronchioscopy : ( diagnostic & therapeutic)

Radiographic : only 6% to 17% of aspirated foreign bodies are radiopaque

Management

Initial :adequate oxygenation and ventilation.Incomplete obstruction : bronchoscopy complete airway obstruction : dislodgement • back blows and chest compressions in infants, • the Heimlich maneuver in older children,

back blows and chest compressions• Give 5 back blows. First, deliver five back blows

between the person's shoulder blades with the heel of your hand.

• Give 5 abdominal thrusts. Perform five abdominal thrusts (also known as the Heimlich maneuver).

• Alternate between 5 blows and 5 thrusts until the blockage is dislodged.

the Heimlich maneuver

None of these should be applied if patient is able to speak or cough

Finger sweep / grasp Should be done only if object is visible and will not be wedged

deeper

?