Upper Airway Obstruction - KwaZulu-Natal … commonest cause of upper airway obstruction •...

Pietermaritzburg Department of Paediatrics

Upper Airway Obstruction

Many causes, 3 outcomesMany causes, 3 outcomes

By Dr M Patrick


Outcomes

••

DeathDeath––

If we donIf we don’’t do it properlyt do it properly

••

DisabilityDisability––

If we donIf we don’’t do it properlyt do it properly

••

A normal lifeA normal life––

If we do do it properlyIf we do do it properly


Respiratory Difficulty: Signs

•

Stertor

⇒

oropharyngeal obstruction

•

Stridor ⇒

upper airway obstruction

••

Wheeze Wheeze ⇒⇒

lower airway obstructionlower airway obstruction


Stridor: Causes

• Croup-

Viral laryngotracheitis very common

• Recurrent croup common• Bacterial tracheitis common now• Laryngeal foreign body uncommon• Epiglottitis rare• Diphtheria rare• Retropharyngeal abscess common now• Infectious mononucleosis rare• Angioneurotic

oedema rare


When it’s not croup

••

TracheitisTracheitis––

Coarse Coarse stridorstridor••

Foreign bodyForeign body––

Dramatic onset of severe obstruction, Dramatic onset of severe obstruction, stridorstridor, cough/, cough/””chokingchoking””••

Diphtheria Diphtheria ––

Incomplete immunisationIncomplete immunisation••

EpiglottitisEpiglottitis, retropharyngeal abscess , retropharyngeal abscess ––

DysphagiaDysphagia

or the patient prefers a sitting positionor the patient prefers a sitting position––

Systemic Systemic ““toxicitytoxicity””

with with erythematouserythematous

rash (Staphylococcus), rash (Staphylococcus), soft soft stridorstridor

••

Laryngeal Laryngeal papillomatosispapillomatosis––

AphoniaAphonia

in a child with a previously hoarse voicein a child with a previously hoarse voice••

Secretions Secretions ––

Poor cough reflexPoor cough reflex


Stridor: Bacterial tracheitis

••

Emergency treatmentEmergency treatment––

OxygenOxygen

––

Seek expert help to Seek expert help to intubateintubate

and ventilateand ventilate––

IV antibioticsIV antibiotics

AVOID UNNECESSARY UPSET FOR CHILDAVOID UNNECESSARY UPSET FOR CHILD


Stridor: Epiglottitis

••

Emergency treatmentEmergency treatment–

Oxygen

–

Seek expert help to intubate

and ventilate

–

IV antibiotics



Stridor: Laryngeal foreign body

••

Emergency treatmentEmergency treatment––

Seek urgent help to Seek urgent help to anaesthetiseanaesthetise

and remove FBand remove FB

––

Choking child procedure Choking child procedure ––

Direct Direct laryngoscopylaryngoscopy

––

CricothyroidotomyCricothyroidotomy/ surgical / surgical airwayairway


Stridor: Viral croup

••

Emergency treatment Emergency treatment ––

OxygenOxygen

––

Adrenaline (Epinephrine) Adrenaline (Epinephrine) ••

1:1000 (5ml 1:1000 (5ml nebulisednebulised))––

Seek expert help if intubation and ventilation Seek expert help if intubation and ventilation requiredrequired

––

Give Give dexamethasonedexamethasone/prednisone /prednisone



CROUP (LARYNGOTRACHEOBRONCHITIS)

••

The commonest cause of upper airway obstructionThe commonest cause of upper airway obstruction

••

CClinicallinical

diagnosis diagnosis ––

PPreviously wellreviously well––

< 2 years of age< 2 years of age––

Gradually progressive inspiratory obstruction which Gradually progressive inspiratory obstruction which manifests as STRIDORmanifests as STRIDOR

––

Barking coughBarking cough––

Onset a day or 2 after an upper respiratory infectionOnset a day or 2 after an upper respiratory infection––

Mild fever (<38Mild fever (<38°°C) may be presentC) may be present––

The child is well, apart from the respiratory obstructionThe child is well, apart from the respiratory obstruction


Investigations

••

Chest XChest X--ray is not necessary ray is not necessary ••

Neck XNeck X--ray is not necessary ray is not necessary ––

XX--ray lateral neck and AP is necessary only if ray lateral neck and AP is necessary only if there is serious doubt about the diagnosis of there is serious doubt about the diagnosis of viral croupviral croup

••

Blood gassesBlood gasses––

Cross of deathCross of death

––

May aggravate the problem by making the child May aggravate the problem by making the child crycry


The Cross of Death

0

5

10

15

20

Time

pCO2DiameterpO2

R = l / r4


Assessment of Severity

•

This is an assessment of severity of Airway Obstruction–

Grade I

INSPIRATORY stridor only–

Grade II

Inspiratory and EXPIRATORY stridor–

Grade III

ACTIVE EXPIRATION and/or PALPABLE PULSUS PARADOXUS

–

Grade IV

APATHY and/or CYANOSIS

•

Applicable

to UAO caused by CROUP only•

Watch out–

Stridor becomes softer as the obstruction becomes more severe


Management

••

All gradesAll grades

of obstructionof obstruction……––

Antibiotic (Antibiotic (amoxilamoxil) if bacterial infection is ) if bacterial infection is suspected:suspected:

••

fever > 38 Cfever > 38 C••

““toxictoxic””••

purulent sputumpurulent sputum••

concommitant ARIconcommitant ARI––

ACYCLOVIR (IV) if oral Herpes simplex and if ACYCLOVIR (IV) if oral Herpes simplex and if post measlespost measles


All grades…••

KEEP THE CHILD COMFORTABLEKEEP THE CHILD COMFORTABLE––

the mother/carer is best at doing thisthe mother/carer is best at doing this––

crying and hyperventilation increase the oedema (Bernoulli crying and hyperventilation increase the oedema (Bernoulli again)again)

••

Continue oral feedingContinue oral feeding••

Avoid painful proceduresAvoid painful procedures••

ParacetamolParacetamol

if febrileif febrile••

STEROIDS: PREDNISONE 2 mg/Kg orally or STEROIDS: PREDNISONE 2 mg/Kg orally or dexamethazonedexamethazone

0,5 mg/kg intravenously, provided that:0,5 mg/kg intravenously, provided that:––

no measles in the past monthno measles in the past month––

no oral Herpesno oral Herpes––

repeat in 24 hours if no improvementrepeat in 24 hours if no improvement


Grade I

••

Manage at home, provided:Manage at home, provided:––

conditions are favourableconditions are favourable

––

the obstruction is not getting worsethe obstruction is not getting worse––

in our setting, it is probably advisable to admit in our setting, it is probably advisable to admit allall


Grade II

••

HospitaliseHospitalise––

ADRENALINE NEBULISATIONS ADRENALINE NEBULISATIONS

••

1 ml of 1:1 000 in 1 ml saline1 ml of 1:1 000 in 1 ml saline••

every 15 minutes, or more often, till improved, then every 15 minutes, or more often, till improved, then every 30 minutes till grade I, then prnevery 30 minutes till grade I, then prn

––

Consider nebulised steroidConsider nebulised steroid


Grade III

••

Monitor OMonitor O22

saturation (pulse saturation (pulse oximeteroximeter))••

CONTINUOUS ADRENALINE CONTINUOUS ADRENALINE NEBULISATIONS NEBULISATIONS ––

for two hours and hope that the child improves for two hours and hope that the child improves to Grade IIto Grade II

••

If the obstruction remains at Grade III, If the obstruction remains at Grade III, consult the Paediatrician on callconsult the Paediatrician on call

••

If the obstruction progresses (at any time) If the obstruction progresses (at any time) to Grade IV thento Grade IV then……


Grade IV

••

Continuous adrenaline nebulisations using 100% 0Continuous adrenaline nebulisations using 100% 022

••

URGENT INTUBATIONURGENT INTUBATION––

preferably in theatrepreferably in theatre

••

Intubation in casualty or ward Intubation in casualty or ward ––

only if time does not permit transfer to theatreonly if time does not permit transfer to theatre––

use an ETT 1 size smaller than usual for ageuse an ETT 1 size smaller than usual for age––

intubateintubate

under under etomidateetomidate

0,3mg/kg IV slowly0,3mg/kg IV slowly••

Transfer to the nearest ICU with the ETT well Transfer to the nearest ICU with the ETT well secured and with the child in head box oxygen secured and with the child in head box oxygen after making contact with the ICU personnelafter making contact with the ICU personnel


Stertor

/ Snoring: Causes

Big tonsils and/or adenoidsBig tonsils and/or adenoids

““FloppyFloppy””

airwayairway

Small airwaySmall airway


Snoring/Stertor

••

In children, snoring is NEVER normalIn children, snoring is NEVER normal

••

Consequences of snoringConsequences of snoring Obstructive Obstructive ssleepleep apnoeaapnoea

––

Daytime drowsiness and irritabilityDaytime drowsiness and irritability––

Learning problemsLearning problems

––

EnuresisEnuresis––

Cor pulmonaleCor pulmonale


Oropharyngeal

Obstruction

The commonest MISSED cause The commonest MISSED cause of upper airway obstructionof upper airway obstruction


OPO

••

Clinical FeaturesClinical Features

––

Mouth breathingMouth breathing––

Nasal speechNasal speech

––

Recurrent otitis mediaRecurrent otitis media––

Postnasal discharge with nightPostnasal discharge with night--time coughtime cough

––

SSnoring at night which may wake the childnoring at night which may wake the child––

Obstructive sleep apnoeaObstructive sleep apnoea

––

Child AND mother are sleepy during the dayChild AND mother are sleepy during the day


Aetiology

••

Allergic rhinitisAllergic rhinitis

••

Adenoidal hypertrophyAdenoidal hypertrophy

••

TonsillarTonsillar

hypertrophyhypertrophy

••

PierrePierre--Robin SequenceRobin Sequence

••

"Floppy pharynx" as in Down Syndrome"Floppy pharynx" as in Down Syndrome


Investigations

••

XX--ray posterior nasal space (lateral view)ray posterior nasal space (lateral view)

••

Oxygen saturation awake and especially Oxygen saturation awake and especially during sleepduring sleep

••

Chest XChest X--ray and ECG if ray and ECG if corcor

pulmonalepulmonale presentpresent


Adenoidectomy and Tonsillectomy

••

Three or more episodes of acute Three or more episodes of acute otitisotitis

media in media in preceding 12 monthspreceding 12 months

••

SecretorySecretory

otitisotitis

mediamedia••

Obstructive sleep apnoea Obstructive sleep apnoea

••

All children undergoing tonsillectomy All children undergoing tonsillectomy ••

Two or more of the following:Two or more of the following:––

mouth breathingmouth breathing––

snoringsnoring––

recurrent sinusitisrecurrent sinusitis


When to Admit or Refer

••

ADMIT ADMIT ––

if ANYTHING on history or examination if ANYTHING on history or examination suggests obstructive sleep apnoeasuggests obstructive sleep apnoea

••

REFER TO ENT REFER TO ENT ––

if any indications for Tif any indications for T’’s and s and

––

AA’’s are presents are present••

URGENT referral to ENT URGENT referral to ENT ––

if there is a history of obstructive sleep if there is a history of obstructive sleep apnoea. Do not waste time with an Xapnoea. Do not waste time with an X--ray (or an ray (or an echo!)echo!)


Remember, for children…

Bernoulli sucks

Upper Airway Obstruction - KwaZulu-Natal … commonest cause of upper airway obstruction •...

Documents

Transcript of Upper Airway Obstruction - KwaZulu-Natal … commonest cause of upper airway obstruction •...