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(