Pediatric airway obstruction

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 Upper airway includes  Nose  Nasopharynx  Oropharynx  Larynx (supraglottis, subglottis)  Trachea (extrathoraci...Normal Pediatric Airway Anatomy • Larynx composed of hyoid bone and a series of cartilages • Single: th...

Pediatric Anatomy cont. Laryngeal folds consist of:• Paired aryepiglottic folds extend from epiglottis p...Relatively larger tongue• Obstructs airway• Obligate nasal breathers• Difficult to visualize larynx• Straight laryngosco...Angled vocal cords• Infant’s vocal cords have more angled attachment to trachea, whereas adult vocal cords are more p...Differently shaped epiglottis Adult epiglottis broader, axis parallel to trachea Funneled shape larynxADULT INFANT • narrowest part of infant’s larynx is the ...Funneled shape larynxADULT INFANT • Uncuffed ETT preferred for patients < 8 years ...Pediatric Respiratory Physiology• Pulmonary surfactant produced by Type II pneumocytes at 24 wks GA• Sufficient pulmon...Pediatric Respiratory Physiology• Extrauterine life not possible until 24-25 weeks of gestation• Two types of pulmonary e...Pediatric Respiratory Physiology cont.• Work of breathing for each kilogram of body weight is similar in infants and adul...Pediatric Respiratory Physiology cont.• Minute alveolar ventilation is more dependent on increased respiratory rate than...Physiology: Effect Of Edema Poiseuille’s law R = 8nl/ πr4 ...Normal Inspiration and Expiration turbulenceImage from: http://ww...Obstructed Airways turbulence & wheezing Evaluation of acute upper airway obstruction in children Airway Evaluation Medical History• Inspiratory stridor (macroglossia, laryngeal web, laryngomalacia, extrathoracic f...Airway Evaluation Medical History• Previous anesthetic problems (difficulty intubation/extubation or difficulty wi...Signs of Impending Respiratory Failure • Increase work of breathing • Tachypnea/tachycardia • Nasal flaring • Droo...Supraglottic Glottic Subglottic ...Signs of Impending Respiratory Failure • Head bobbing • Use of accessory muscles/retraction of muscles • Cyanosis de...Causes of acute upper airway obstruction that are commonly life-threatening Epiglottitis Re...Airway Evaluation Physical Exam• Facial expression• Nasal flaring• Mouth breathing• Drooling• Color of...Airway Evaluation Physical Exam• Mallampati• Loose/missing teeth• Size and configuration of palate• Si...Diagnostic Testing• Laboratory and radiographic evaluation extremely helpful with pathologic airway• AP and lateral films...Imaging may be useful in identifying the location and nature of the airway obstruction but should never i...Diagnosis …. ? Retropharyngeal abscess Abnormal retropharyngeal space: Retropharyngeal space : >7 mm @ C2 Retrotracheal space : 14 mm@ C6 .. Ped ...F. B. ingestion MRI/CTUsually not useful in an acute settingMore reliable for evaluating neck masses and congenital anomalies of the lowe...Diagnostic Testing• Perform radiograph exam only when there is no immediate threat to the child’s safety and in the ...Flexible Laryngoscopy: Proper Equipment Assess nares/choanae Assess adenoid and lingual tonsil Assess TVC mobility A...Airway Management: Normal Airway • Challenging because of unique anatomy and physiology • Goals: protect the airway, ade...Bag-Mask Ventilation •Clear, plastic mask with inflatable rim •Place finge...Oropharyngeal Airway PROPER S...Oropharyngeal Airway Placement Image from: http://depts.Washington.edu/pccm/Pediatric%20Airway%20management.ppt Nasopharyngeal Airway •Distance from nares to angle of mandible approximates the proper length •Nasopharyngeal airway avai...Nasopharyngeal Airway •Distance from nares to angle of mandible approximates the proper length •Nasopharyngeal airway a...Selection of laryngoscope blade: Miller vs. Macintosh• Miller blade is preferred for infants and younger children...Endotracheal Tube Age Wt ETT(mm ID) Length(cm)Preterm 1 kg 2.5 6 1-2.5...Endotracheal Tube New AHA Formulas: Uncuffed ETT: (age in years/4) + 4 Cuffed ETT: (age in years/4) +3 ETT ...

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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 stridor RR 30 S...OBSTRUCTED AIRWAYS LOCATION OF OBSRTUCTION Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal t...POSITION OF OBSRTUCTION Snoring Stridor Wheeze Naso pharynx + + - Larynx ± Small babies + + Severe obstruction Trachea & b...Causes of upper airway obstruction • Common cause of UAO in outpatient practice is CROUP. • The term croup refers to “ a c...Other causes- • Extrathoracic foreign body obstruction • Bacterial tracheitis • Retropharyngeal abscess • Epiglottitis (ba...Assessment of upper airway obstruction • UAO is a life threatening medical emergency because of underlying progressive hyp...Contd.. • Children with croup presents with viral prodrome along with croupy cough, cough inspiratory stridor, hoarseness ...Clinical manifestations • Barking cough • Respiratory distress • Tachypnea • Inspiratory stridor • Hoarseness • Elevated t...Diagnostic evaluation • In addition to complete medical history and physical examination, diagnostic procedures for croup ...Croup score 0 1 2 Stridor None Inspiratory Inspiratory and expiratory Air entry Normal Decreased Minimal absent Retraction...Management 1. Monitor and facilitate respiration- • Monitor respirations for rate and depth • Observe for signs of respira...ii. Administer prescribed medications • In case of bacterial croup, administer antibiotics as prescribed by physician • Co...iv. Promote rest If the child is apprehensive and crying, his oxygen demand will increase, so, to avoid this and conserve ...v. Support and educate parents • Keep the parents informed about the condition, progress and treatment • Allow parents to ...FOREIGN BODY ASPIRATION SWALLOWED OR INHALED FOREIGN BODIES • Anyone can swallow a foreign object. • However, infants and toddlers are more likely...• Toddlers and infants often explore items by putting them in their nose and mouth. • A child’s risk of swallowing somethi...Identification of foreign body • Foreign body can lodge either In nose or in airway leading to partial or complete obstruc...Signs and symptoms • Usually, the symptoms of a swallowed foreign object are hard to miss. • They often appear immediately...Diagnosis • Physical examination • X-ray • If patient was not able to breath properly, bronchoscopy is used to have detail...Management • If coughing effectively, just encourage the child to cough, and monitor continuously. • If coughing is, or is...Management cont-- • Establishing a secure and patent airway is the most important goal in the resuscitation of a patient w...Guidance for management – foreign body obstruction Heimlich maneuver Back blows Chest thrusts note : none of these shou...• Heimlich maneuver is recommended for relief of the airway obstruction in adults and children one to eight years of age • Most important management is medical management which includes- • Endotracheal intubation (transnasally or orally) • Cor...• Surgical intervention which forms the most important part of treatment in severe emergency- • Fiberoptic intubation • Cr...QUICK MANAGEMENT ALGORITHM FOR UAO last DIPTHERIA • Diptheria is one of the acute infectious disease of childhood characterized by local inflammation of epithelia...Epidemiology • Agent: diptheria is caused by corynebacterium diptheriae • Source of infection: secretions and discharges f...Clinical features • Sites affected were- nasal mucosa, tonsils, pharynx, trachea, conjunctiva and vagina • Signs and sympt...Nasal Diptheria • It initially resembles cold, may be unilateral or bilateral, more often unilateral. • There may be mild ...Tonsillar and Pharyngeal Diphtheria • It is most common clinical variety • Initially anorexia, malaise, low grade fever, s...Laryngeal diphtheria • It is usually due to extension of membrane from tonsils and pharynx Common symptoms are- • Noisy di...Respiratory diphtheria • Breathing difficulty • Husky voice • Stridor • Enlarged lymph nodes • Heart rate • Nasal discharg...Diagnostic evaluation • Based on clinical examination • Confirmed with isolation of bacteria- Albert’s stain • Other lab i...Treatment • Diptheria is a serious illness which needs immediate management • The first step is to give antitoxin • This i...Prevention • With the use of antibiotics and vaccines, diphtheria is not only treatable, but preventable as well. • DPT va...Introduction • Laryngitis is when the voice box or vocal cords become inflamed from overuse, irritation, or infection. • T...Etiology Causes of acute laryngitis include: • viral infections • straining vocal cords by yelling/talking more than norma...Symptoms The most common symptoms of laryngitis include: • weakened voice • loss of voice • hoarse, dry throat • constant ...Diagnosis Laryngoscope is used to visualize the larynx for diagnosis Following were the findings for laryingitis- • irrita...Treatment • If it of viral cause, symptoms will disappear • If it of bacterial cause treatment of choice is antibiotics Ho...LOWER AIRWAY OBSTRUCTION LAO- • Lower airway obstruction is mainly caused by increased resistance in the bronchioles (usually from a decreased radi...COPD INTRODUCTION • Chronic obstructive lung disease (COPD) describes a group of lung conditions (diseases) that make it diffic...ETIOLOGY • Passive smoking • Exposure to chemical, air pollution • Inhalation of smoke • Hereditary factors SYMPTOMS Symptoms of COPD include: • Constant coughing • Shortness of breath while doing activities • Excess sputum produc...DIAGNOSIS • spirometry can detect COPD before symptoms become severe. • It is a simple, non-invasive breathing test that m...Treatment • Bronchodilators to relax the muscles around airways, to help open them and make it easier to breathe. • Inhale...ASTHMA INTRODUCTION • Many children with asthma develop symptoms before age 5. • There are a number of conditions that can cause ...WHAT IS ASTHMA • Asthma is a condition of chronic swelling of the airways. • These airways are sensitive to stimulation by...Definition • Asthma is a reversible, episodic, obstructive airway disease caused by hyperactivity of the bronchial tree to...Types • Intrinsic asthma: refers to triggering factors from environment • Extrinsic asthma: also called as allergic asthma ASSESSMENT Some children have few day-to-day symptoms, but have severe asthma attacks now and then. Other children have pe...ASTHMA EMERGENCIES For some children, severe asthma attacks can be life-threatening and require emergency room treatment. ...DIAGNOSIS • Diagnosing asthma can be tricky in young children. • Wheezing, coughing and other asthma-like symptoms can occ...Contd.. • For older children and adults, doctors can use breathing tests (lung function tests) such as spirometry or peak ...Medical Management • The goal of treatment for childhood asthma are prevention of acute episodes, maximum control of sympt...Pharmacological therapy • Medications are used in the preventive management of asthma as well as in the treatment of acute...Contd.. • Theophilline, aminophilline and its derivatives are effective bronchodilators frequently used in the management ...Contd.. • Antibiotics are indicated for those with secondary infections • Antihistamines are not advised due to their seda...Acute care 1. Providing emotional support and education: • Child who is experiencing an acute attack will be frightened, f...2. Positioning • The child in respiratory distress is better able to breathe in sitting position. • The child's bed should...3. Evaluating respiratory status • Nursing assessment of respirations should be ongoing and documented. • Frequent assessm...4. Administering Oxygen therapy • Oxygen therapy - humidified • Younger children are usually advised to keep in mist tent ...5. Monitoring intravenous medication • When intravenous medication therapy is required, the child must be closely monitore...Supporting family members • Parents and other family members needs to be allowed in promoting child’s care. • Parents shou...Summary- • Upper respiratory obstructions- 1. Croup 2. Foreign body obstruction 3. Diptheria 4. laryngitis • Lower respira...upper & lower airway obstructionupper & lower airway obstructionupper & lower airway obstructionupper & lower airway obstruction

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Child with stridor

Other causes of acute stridor:  metabolic hypocalcaemia.metabolic hypocalcaemia.  Tonsillitis.Tonsillitis.  Allergic ed...1- Causes of chronic stridor: » Supraglottic causes: • Laryngomalacia*: (most common) • Cysts: aryepiglottic cyst & dermoi...1- Causes of chronic stridor: •Laryngeal web* • Vascular ring*. • Haemangioma and lymphangioma. • Bilateral vocal cord par...Laryngotracheobronchitis or viralLaryngotracheobronchitis or viral croup: an infection of both thecroup: an infection of b...• Mild URTI with coryza,Mild URTI with coryza, • Nasal congestion,Nasal congestion, • Sore throat,Sore throat, • Insidious...Signs of RD.Signs of RD. Air entry may be poor.Air entry may be poor. Lethargy or agitation may be aLethargy or agitation ...CBC: lymphocytosis and leukopeniaCBC: lymphocytosis and leukopenia Transcutaneous oximetry:Transcutaneous oximetry: ABG...Treatment may include:Treatment may include: Humidification: “hHumidification: “humidifiedumidified oxygen” increased hum...Glucocorticoids:Glucocorticoids: ““Dexamethsone,Dexamethsone, PrednisonePrednisone” to” to decrease airway inflammationde...Sever airway obstruction.Sever airway obstruction. Pneumothorax andPneumothorax and pneumomediastinum.pneumomediastinum....is an acute inflammation of the epiglottis with inflammation in the supraglottic region Sex: M:F ratio is about 3:1. Age: ...Cause: H. influenzae type B. Streptococcus pneumoniae, Staphylococcus aureus, and group A beta- hemolytic streptococci wer...Rapid onset and progression of symptoms. Sore throat (95%). Odynophagia/dysphagia (95%). Muffled voice (54%). Usually...Cervical adenopathy Respiratory distress Very tender larynx Toxic appearance. Tripod position Fever Drooling Stridor “late...Secure airways first. Don’t use the tongue depressor. lateral view x-ray of the neck is confirmatory & should be perfor...The normal epiglottis in the image on the right is contrasted with the markedly thickened one on the left. A column of air...Soft-tissue lateral neck x-ray reveals edema of epiglottis consistent with acute epiglottitis A. Airway Management 1. immediate endotracheal intubation. based on clinical grounds. “extreme agitation and pronounced st...B. Antibiotic Therapy: 1. 3rd generation cephalosporins are the antibiotics of choice for acute epiglottitis b/c of the hi...2. Cephalosporins should be avoided in patients with a history of an allergic reaction to penicillin because of the 10% cr...C. On the ICU mildly sedation with midazolam. Humidification can be maintained by blow-by mist and oxygen. D. Intubation s...Pulmonary edema Epiglottic abscess Pneumonia Meningitis Cervical adenitis Septic arthritis Pericarditis Cellulitis...Prognosis: Most patients can be extubated within 1-2 days. Good prognosis with appropriate treatment B. T. is diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membr...Prodrome of URTI. Progression to higher fever. Cough. Inspiratory stridor. ①Inspiratory stridor ②Barklike or brassy cough ③Hoarseness ④Variable degrees of R.D.: Nasal flaring, Retractions, Dyspnea,...Tracheal secretions & blood for culture. X-ray lateral view of the neck May reveal subglottic narrowing Laryngotracheobron...Antibiotics is the main treatment of B. T. Bronchopneumonia. Exacerbation of COPD & may lead to respiratory failure. The m...The most common age group affected is b/w 6m & 5y. most commonly are lodged in the right main stem and lower lobe. Aspirat...Cough.Cough. Stridor.Stridor. Dyspnea.Dyspnea. Wheezing.Wheezing. Dysphagia.Dysphagia. Sudden choking after eatingSudden c...Inspiratory stridor or expiratory wheezing, with prolongation of the expiratory phase and medium-to-coarse rhonchi. Signs ...PA & lateral CXR are mandatory. Laryngoscopy if doubt diagnosis and to remove the foreign body. Tooth (molar) was dislodged during intubation a lobar pneumonia from the tooth Aspirated foreign body lodged in the right ...ABC management. Laryngoscope. Dexamethasone after laryngoscopy. laryngeal web is a congenital disorder due to partial canalisation of the epithelial lamina between the vestibulotracheal ...Most are situated anteriorly, involving a variable length of the vocal cord. They are often thick and fibrotic, and may ca...Laryngomalacia is a congenital abnormality of the laryngeal cartilage. It is the most common cause of chronic inspiratory ...It is due to an intrinsic defect or delayed maturation of supporting structures of the larynx. The airway is partially obs...The classic history and endoscopic examination usually suffice to establish a diagnosis of laryngomalacia. Most cases of laryngomalacia can be managed by observation, Surgical management is indicated in rare instances if respirat...Laryngomalacia generally is a self- resolving condition & have a good prognosis. Complications in rare cases include chest...Tracheal compression may result from vascular anomalies such as double aortic arch, right aortic arch with left ligamentum...The child may prefer to keep the neck hyperextended. The stridor resulting from tracheal compression is often aggravated b...Echo. Or Doppler U.S. Barium swallow. MRI also can be used in the diagnosis 1- Causes of chronic stridor: 1.Symptom complex, duration, acuity. 2.The age & the birth history. 3.History of URTI. 4.History of airway instrumentation...1.Inspiratory vs. expiratory vs. biphasic stridor. 2.Fever. 3.Drooling or hyperextension of neck and unusual sitting posit...6.Presence of cyanosis. 7.Degree of distress. 8.Facial deformities. 9.Presence of Haemangioma elsewhere. 10.Neck masses. K...Key points in physical exam. in child with stridor: A newborn infant with Pierre-Robin syndrome. Note the micrognathia. Key points in physical exam. in child with stridor: A two-year-old child with a cystic hygroma on the left side of the nec...1.AP and endolateral radiographs of the neck can assess adenoidal size, epiglottis, and trachea. 2.AP and lateral CXR to l...Diagnostic studies: Severe laryngomalacia: The epiglottis is rolled in from side to side, and the arytenoid mucosa is pull...Child with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridorChild with stridor

 

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