upper airway obstruction dr juhina clinical serise
DESCRIPTION
TRANSCRIPT
Done by : Dr.Juhaina Al Musawi
Mentor : Dr.Salma Al Mawali
Outline
• Introduction.
• Anatomy.
• Causes.
• Clinical Management.
• Conclusion.
INTRODUCTION
Upper airway obstruction is a common cause of pediatric emergency department visits .
Can be a life-threatening emergency.
Complete obstruction will result in respiratory failure followed by cardiac arrest .
Compared to adults, infants and young children have small airways and can quickly develop clinically significant upper airway obstruction.
Anatomy of the upper airway
A) Nasopharynx Nasal turbinates to the hard palate.
B) Retropalatal (RP)oropharynx hard palate to the caudal margin of the soft palate .
C) Retroglossal (RG) region caudal margin of the soft palate to the base of the epiglottis .
D) Hypopharynx base of the tongue to the larynx.
2010 UpToDate
The difference between pedsand adult airway?
Prpominent occiput
Tounge large in relation to
mouth
Larynx is higher in neck
Narrowest portion at
cricoid ring Larynx
Stridor
Clssic sound associated with upper
upper airway obstruction .
Caused by partial airway
obstruction & the resultant
turbulent airflow through a portion
of the airway from the nose to the
trachea .
Time : inspiratory expiratory Biphasic .
Quality : Coarse High pitched .
SupraglotticGlotticSubglottic
Trachea
SoundSonorous, gurgling
Coarse ,
expiratory stridor ,
Biphasic stridor High-pitched stridor
Inspiratory stridor
Structures Nose / Pharynx / EpiglottisLarynx
Vocal cords
Subglottic trachea
CongenitalMicrognathia ,Pierre Robin
Macroglossia ,
Down syndrome
Storage disease
Choanal atresia
Lingual thyroid
Thyroglossal cyst
Laryngomalacia
Vocal cord paralysis
Laryngeal web
Laryngocele
Subglottic stenosis
Tracheomalacia
Tracheal stenosis
Vascular ring
Hemangioma cyst
AcquiredAdenopathy
Tonsillar hypertrophy
Foreign body
Pharyngeal abscess
Epiglottitis
Papillomas
Foreign body
Croup
Bacterial tracheitis
Subglottic stenosis
Foreign body
Causes of Stridor: Anatomic Location, Sound, and Etiology
Evaluation of acute upper airway obstruction in children
Observation History O/E
InvestigationsManagement
At rest Breathing .
RR .
Alertness .
Color
During activity
Crying .
Feeding .
Onset / Duration .
Associated symptoms Respiratory distress , fever , toxicity , drooling , cyanosis .
Progression with age .
Exacerbation : Supin versus pron position , URI , crying . Feeding pattern : Dysphagia , feeding abnormalities .
Airway procedure : Intubation in neonatal period . Choking episode .
Baseline noises , quality of cry & voice .
• Sevirity of the distress : RR , Retraction , flaring , HR .
• Respiratory failure : Extreme distress , altered mental
status , cynosis , hypoventilation ,
hypotension .
• Stridor : character / timing .
Management
Management of complete airway obstruction in children
Management of severe upper airway obstruction in children
Imaging may be Imaging may be
useful in identifying useful in identifying
the location and the location and nature nature
of the airway of the airway
obstruction but obstruction but should never should never
interfere interfere
with the stabilization with the stabilization of a child with of a child with
a critical obstructiona critical obstruction..
Causes of acute upper airway obstruction that are commonly life-threatening
EpiglottitisRetropharyngeal abscessBacterial tracheitisCroup Foreign bodyAnaphylaxsisNeck traumaBurns thermal or caustic
UpToDate 2010
A 42 yrs old previously healthy woman presented with bad sore throat & painfull swallowing . She is febriel , but nontoxic & in no respiratory distress . A lateral soft tissue neck film is ordered as shown which of the following is the cause of this
pt illnes ?
A. Retropharyngeal abscess . B. Epiglottitis .C. Peritonsillar abscess . D. Bacterial tracheitis .E. Ludwig angina .
Epiglottitis :
The most feared peds emergency .
Children 3-7 yrs
Epiglottitis: Lateral neck radiograph
Epiglottic width > 8 mm
Aryepiglottic width > 7 mm
A 12 yrs old child presents to the
ED with sore throat ; dysphagia ,
odynophagia & drooling .
The examination of the oropharynx is
normal . Which of the following is the
most likely diagnosis ?
A. Peritonsillar abscess .
B. Bacterial croup .
C. Epiglottitis or supraglottitis .
D. Bacterila tracheitis .
Which of the following is true regarding adult epiglottitis ?
(A) Airway obstruction is usually caused by inflammation of the infraglottic tissues .
(B) Drooling & stridor are infrequent presenting signs .
(C) The disease is more common in winter .
(D) Nebulizated racemic epinephrine has been shown to decrease the need for intubation .
(E) Normal lateral neck XR can safely exclude epiglottitis .
Adult Presenting features of epiglottitis :
• Sore throat or odynophagia (90 - 100 % )• Fever ≥37.5ºC (26 - 90 %) • Muffled voice (50 - 80 % )• Drooling (15 - 65 % )• Stridor or respiratory compromise ( 33 %)• Hoarseness (20 - 40 %)
Uptodate 2010
Rapid overview: Epiglottitis (supraglottitis) in children Signs and symptoms that may indicate epiglottitis
Respiratory distress: stridor, tachypnea, anxiety, refusal to lie down, "sniffing" or "tripod" posture.
Sore 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 .
Consider epiglottitis in:
Febrile, toxic-appearing children with rapid onset and progression of dysphagia, drooling, and respiratory distress
Evaluation
Secure airway before diagnostic evaluation if respiratory distress is severe.
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)
Examination:
Defer examination of the pharynx in children with signs of moderate/severe respiratory distress
Examine the patient in the upright position
Attempt to visualize the epiglottis (with aid of tongue depressor, direct or indirect laryngoscopy) only in patients with mild distress and not in those with more severe distress
Maintain the child in a position of comfort with parent present
Avoid invasive procedures
Findings:
Stridor, drooling, suprasternal and subcostal retractions
Swollen, erythematous epiglottis, inflammation of the supraglottic structures
Look for signs of extra-epiglottic infection (eg, pneumonia)
Imaging:
Soft-tissue radiograph of the lateral neck (portable if possible) when the clinical diagnosis is in doubt
Defer imaging in patients with severe respiratory distress or in whom it will delay definitive visualization of the epiglottis
Findings:
Enlarged epiglottis ("thumb" sign), loss of vallecular air space, thickened aryepiglottic folds, distended hypopharynx, loss of cervical lordosis
Management:
Airway
Secure the airway, if time allows, in the operating room by anesthesia or otolaryngologist (artificially or surgically if necessary)
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 (<8 years of age) or surgical cricothyrotomy (>8 years of age) if unable to ventilate or intubate
Laboratory studies:
Epiglottal cultures after establishment of artificial airway
Blood cultures after the airway is secured
Antimicrobial therapy
Administer empiric antimicrobial therapy:
Cefotaxime OR ceftriaxone
PLUS
Clindamycin OR vancomycin
Monitor
patient in the intensive care unit
Uptodate 2010
Appropirate initial therapy in a
pt with adult epiglottitis inclueds
which of the following?
A. Nebulized racemic epinephrine ,IV levofloxacin.
B. Humidified oxygen , IV ceftriaxone .
C. Nebulized racemic epinephrine ,IV dexamethasone , IV ampicillin .
D. Humidified oxygen , IV levofloxacin.
E. IV dexamethasone , IM penicillin G benzathine .
Diagnosis ? .…
Retropharyngeal abscess
Which of the following is most correct :
A. Most cases of retrophargneal abscess occur in children older than 3 yrs .
B. Organisms that cause retropharngeal abscess include staph species , group A strp & anaerobes .
C. Soft tissue film should be taken during expiration .
D. Symptoms of retropharyngeal abscess are easly distinguishable from epiglottitis .
E. Width of the retropharyngeal space should be no more than 3 times the width of the vertebral body at the same level .
A 4 yrs old boy brought to the ED with sever sore throat & h/o refusing to eat . O/E he has sever pharyngitis .Lateral neck XR is taken that you feel is consistent with a retropharyngeal abscess. You are surprised to fined ,however that the pt subsequent CT was normal . The radiologist tells you this was probably due to poor technique .What technique should be used to most accurately assess the prevertebral space on XR ?
(A)XR should be taken in flexion during expiration . (B)The pt should be sitting upright when XR is taken .(C)The XR should be taken in flexion during inspiration . (D)The XR should be taken in extension during expiration (E)The XR should be taken in extension & inspiration .
Retropharyngeal space :
>7 mm @ C2 Retrotracheal space : 14 mm@ C6 .. Ped 22 mm @ C6 .. Adult
Pediatric Infectious diseases 2009 Uptodateretropharyngeal space
Abnormal retropharyngeal space:
Which of the following is true regarding retropharyngeal abscess?
A. RPAs are usually preceded by FB aspiration in children .
B. Pt with RPAs prefer to lie supine . C. Prevertabral soft tissue swelling is
excess of 22 mm at the level of C 2 is diagnostic for an RPA in children & adult
D. Mycobacterium spp are the most common cause of RPAs .
E. Atlantoaxial separation is the most common fatal complication of RPAs .
Surgical drainage and antimicrobial therapy for
children if CT showed abscess >2 cm .
Antibiotic therapy without surgical drainage for
children without airway compromise if the CT
findings are not consistent with mature abscess, or
the abscess is <2 cm .
Uptodate 2010
Management of RPAs
• Airway obstruction • Septicemia • Aspiration pneumonia • Internal jugular vein
thrombosis • Carotid artery rupture • Mediastinitis
Uptodate 2010
COMPLICATIONS of RPAs :
A 6 yrs old girl is brought to the ED 4h after developing a brief choking episode while playing with her toys . Her CXR ….Where is the FB located ?
(A) Esophagus .(B) Hypopharynx . (C) Trachea . (D) Anterior mediastinum . (E) Not possible to
determine from the information provided .
How to know if the FB in esophagus or trachea from XR?
Esophageal FB :
(( en face )) in AP view & on edge in lat view.
Trachea FB :
(( en face )) in lat & on edge in AP .
In a review of 1160 suspected FBA aspirations in children, a FB was successfully removed in 1068 children (92%).
The sites of the FB were as follows:
Larynx: 3 % Trachea/carina: 13 % Right lung: 60 % (52 % in the main bronchus, 6 % in the
lower lobe bronchus, and <1 % in the middle lobe bronchus )
Left lung: 23 % (18 % in the main bronchus and 5 % in
the lower bronchus( Bilateral: 2 %
UpToDate 2010
7 yrs old girl brought in by her father after choking on a plastic toy . She was coughing violently & gasping in the car , so the farther tried the Heimlich maneuver & a blind finger sweep but she seemed to get worse . Hid daughter is now unconscious & cyanotic . After performing a jaw thrust maneuver , you fail to locate a FB . Attempts to place an endotracheal tube fail , as the tube seems to be striking an object . What is the best next step ?
(A)Laryngeal mask airway . (B)Surgical cricothyrodotomy . (C)Back blows to discharge the FB . (D)Blind figer sweeps to remove the FB .(E)Needle cricothyroidoctomy .
At what age in years is it acceptable
to use cuffedendotracheal tubes ? Why?
(A) 5
(B) 6
(C)7
(D)8
(E) 9
The narrowest part of the airway in young children is the ?
Cricoid ring .
Endotracheal tube size for children
> 1yr :
( Age in yrs /4 ) + 4
In children from 6 m – 4 yrs of age
which of the following the most
common cause of accidental
death INSIDE the home ?
(A) Falls
(B) Poisoning
(C) FB aspiration
(D) Drowning
2 yrs old had a cold for 3 days.Tonight he has developed a
barking cough . He is afebriel ; O/E you note dyspnea ,
retraction , inspiratory stridor & tachypnea.
PA CXR shows “ steepling “ of the subglottic
trachea .
Which of the following is the most likely diagnosis ?
(A) Epiglottitis .
(B) Viral croup .
(C) Bacterial tracheitis .
(D) Retropharyngeal abscess .
(E) Pneumonia .
Croup:
Most common cause of upper
respiratory obstruction in childhood.
Peak incidance at 2 yrs
( range from 6 m – 6 yrs ) .
Croup / steepling of the subglottic trachea
A child presents with toxicity & findings more
suggestive of epiglotittis than croup , but the
lateral neck XR is suggestive of croup or shows
narrowing or irregularity on the trachea . The most
likely diagnosis is :
(A) Epiglotittis .
(B) Viral croup ( laryngotracheobronchitis ) .
(C) Spasmodic croup .
(D) Bacterial tracheitis .
(E) Retropharyngeal abscess .
(F) Pneumonia
Mild stridor at rest and mild retractions :
Dexamethasone (0.6 mg/kg, maximum of 10 mg) oral if oral intake is tolerated / IV / IM .
Moderate stridor at rest and moderate retractions, or more severesymptoms :
epinephrine nebulizer in addition to dexamethasone
• Racemic epinephrine 0.05 mL/kg / dose
• L-epinephrine is administered as 0.5 mL/kg per dose. Nebulized epinephrine can be repeated every 15 to 20 minutes.
Budesonide inhaled steroid ( 2 mg ) As effective as dexamethasone In pt unable to take oral medication ( vomiting ) .
Treatment of croup :
Most commom causes of chronic stridor in children
• Laryngomalacia : Incomplete development of the supporting cartilage of the
larynx . Inspiratory stridor begin at birth Complete resolution by 2 yrs .
• Vocal cord paralysis : B/L vocal cord paralysis result in sever respiratory distress .
• Laryngeal Web : Failure of complete canalization of the airway
Noise decreases as obstruction worsens
Noise NOT indicative of degree of obstruction
Therefore
THE WORST OBSTRUCTION IS SILENT
Child with classic presentation of acute epiglottitis Tripod posture
)toxic appearance(