Pediatric Airway Emergencies

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  • 1. Pediatric Airway Emergencies: Evaluation and Management Shashidhar S. Reddy, MD, MPH Ronald Deskin, MD January 2002
  • 2. Anatomic and Physiologic Considerations of the Pediatric Airway:
  • 3. Initial Assessment:
    • Signs of impending respiratory failure:
      • Reduced level of consciousness or lethargy
      • Quiet, shallow breathing
      • Apnea
    • The above require immediate progression to endoscopy and/or intubation.
  • 4. History:
    • Description of Onset
    • Age at onset
    • History of foreign body aspiration/ingestion
    • Aggravating factors: feeding/sleeping
    • History of intubation
    • Birth history (syndromes, birth trauma)
  • 5. Physical Exam:
    • Inspection
    • Ascultation
    • Repositioning
  • 6. Flexible Laryngoscopy:
    • Proper Equipment
    • Assess nares/choanae
    • Assess adenoid and lingual tonsil
    • Assess TVC mobility
    • Assess laryngeal structures
  • 7. Radiology:
    • Plain films:
      • Chest and airway AP and lateral
      • Expiratory films
      • High vs. low kilovoltage
    • Fluoroscopy
    • Barium Swallow
    • CT, MRI, Angiography
  • 8. Flexible Bronchoscopy:
    • Does not require general anasthesia
    • Mainly diagnostic purposes
    • Limited intervention (e.g. suctioning)
    • Can be used for intubation
    • Limited airway control
  • 9. Direct Laryngoscopy and Rigid Bronchoscopy
    • Indications:
      • Severe or progressive airway obstruction
      • No diagnosis after flexible laryngoscopy and radiology
      • Subglottic pathology suspected
    • Advantages over flexible bronchoscopy:
      • Better control of the airway
  • 10. Direct Laryngoscopy
  • 11. Direct Laryngoscopy
    • Insufflation technique:
  • 12. The Ventilating Bronchoscope
    • Light source and telescope
    • B. Prismatic light detector and attachment to light source
    • C. Aspiration and instrumentation channel
    • D. Connector to anesthesia
    • E. Telescope bridge
  • 13. Rigid Bronchoscopy
  • 14. Rigid Bronchoscopy:
    • Complications:
      • Loss of airway control
      • Injury to subglottic space
      • Damage to teeth or gums
      • Airway bleeding
      • Pneumothorax
      • Failure to recognize pathology
  • 15. Specific Etiologies of Airway Emergency
  • 16. Laryngotracheobronchitis
  • 17. Bacterial Tracheitis (Membranous Tracheitis)
  • 18. Epiglottitis
  • 19. Choanal Atresia
  • 20. Pyriform stenosis
  • 21. Laryngomalacia
  • 22. Vocal Cord Paralysis
  • 23. Subglottic Stenosis
  • 24. Subglottic Hemangioma
  • 25. Tracheoesophageal Fistula
  • 26. Laryngeal Cleft
  • 27. Vascular Anomaly
  • 28. Recurrent Respiratory Papillomatosis
  • 29. Airway Foreign Bodies
  • 30. Case Study: History
    • Consult from the Neonatal ICU:
      • Newborn infant in increasing respiratory distress since birth.
      • Oxygen saturation is now 100%, but the child has begun to use accessory muscles.
      • Feeding aggravates the distress.
      • Infant has a weak cry, and pediatritians notice noisy breathing.
      • No abnormal birth history.
  • 31. Case Study: Physical Examination
    • Newborn female infant supine in the bed, sat’ing 100% on room air
    • Moderate use of accessory muscles
    • Moderate biphasic stridor
    • Audible breaths through both nares
    • Repositioning has little effect on stridor
  • 32. Case Study: Endoscopy