Upper Airway Obstruction Dr Juhina Clinical Serise

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  • 1. <li>Done by : Dr-&gt;Juhaina Al Musawi Mentor : Dr-&gt;Salma Al Mawali Upper airway obstruction </li><li>Outline <ul><li>Introduction-&gt; </li></ul><ul><li>Anatomy-&gt; </li></ul><ul><li>Causes-&gt; </li></ul><ul><li>Clinical Management-&gt; </li></ul><ul><li>Conclusion-&gt; </li></ul></li><li>INTRODUCTION <ul><li>  Upper airway obstruction is a common cause of pediatric </li></ul><ul><li>emergency department visits -&gt; </li></ul><ul><li>Can be a life - threatening emergency -&gt; </li></ul><ul><li>Complete obstruction will result in respiratory failure </li></ul><ul><li>followed by cardiac arrest -&gt; </li></ul><ul><li>Compared to adults, infants and young children have small </li></ul><ul><li>airways and can quickly develop clinically significant upper </li></ul><ul><li>airway obstruction -&gt; </li></ul></li><li>Anatomy of the upper airway </li><li><ul><li>A) Nasopharynx </li></ul><ul><li>Nasal turbinates to the hard </li></ul><ul><li>palate-&gt; </li></ul><ul><li>B ) Retropalatal ( RP ) oropharynx </li></ul><ul><li>hard palate to the caudal </li></ul><ul><li>margin of the soft palate -&gt; </li></ul><ul><li>C ) Retroglossal ( RG ) region </li></ul><ul><li>caudal margin of the soft palate </li></ul><ul><li>to the base of the epiglottis -&gt; </li></ul><ul><li>D ) Hypopharynx </li></ul><ul><li>base of the tongue to the larynx -&gt; </li></ul><ul><li>2010 UpToDate </li></ul></li><li>The difference between peds and adult airway? Prpominent occiput Tounge large in relation to mouth Larynx is higher in neck Narrowest portion at cricoid ring Larynx </li><li>Stridor <ul><li>Clssic sound associated with upper </li></ul><ul><li>upper airway obstruction -&gt; </li></ul><ul><li>Caused by partial airway </li></ul><ul><li>obstruction &amp; the resultant </li></ul><ul><li>turbulent airflow through a portion </li></ul><ul><li>of the airway from the nose to the </li></ul><ul><li>trachea -&gt; </li></ul></li><li><ul><li>Time : </li></ul><ul><li>inspiratory </li></ul><ul><li>expiratory </li></ul><ul><li>Biphasic -&gt; </li></ul><ul><li>Quality : </li></ul><ul><li>Coarse </li></ul><ul><li>High pitched -&gt; </li></ul></li><li>Causes of Stridor: Anatomic Location, Sound, and Etiology Croup Bacterial tracheitis Subglottic stenosis Foreign body Papillomas Foreign body Adenopathy Tonsillar hypertrophy Foreign body Pharyngeal abscess Epiglottitis Acquired Subglottic stenosis Tracheomalacia Tracheal stenosis Vascular ring Hemangioma cyst Laryngomalacia Vocal cord paralysis Laryngeal web Laryngocele Micrognathia ,Pierre Robin Macroglossia, Down syndrome Storage disease Choanal atresia Lingual thyroid Thyroglossal cyst Congenital Subglottic trachea Larynx Vocal cords Nose / Pharynx / Epiglottis Structures High-pitched stridor Inspiratory stridor Biphasic stridor Sonorous, gurgling Coarse, expiratory stridor, Sound Subglottic Trachea Glottic Supraglottic </li><li>Evaluation of acute upper airway obstruction in children </li><li>Observation History O/E Investigations Management </li><li><ul><li>At rest </li></ul><ul><li>Breathing -&gt; </li></ul><ul><li>RR -&gt; </li></ul><ul><li>Alertness -&gt; </li></ul><ul><li>Color </li></ul><ul><li>During activity </li></ul><ul><li>Crying -&gt; </li></ul><ul><li>Feeding -&gt; </li></ul></li><li><ul><li>Onset / Duration -&gt; </li></ul><ul><li>Associated symptoms </li></ul><ul><li>Respiratory distress , fever , toxicity , drooling , cyanosis -&gt; </li></ul><ul><li>Progression with age -&gt; </li></ul><ul><li>Exacerbation : </li></ul><ul><li>Supin versus pron position , URI , crying -&gt; </li></ul><ul><li>Feeding pattern : </li></ul><ul><li>Dysphagia , feeding abnormalities -&gt; </li></ul><ul><li>Airway procedure : </li></ul><ul><li>Intubation in neonatal period -&gt; </li></ul><ul><li>Choking episode -&gt; </li></ul><ul><li>Baseline noises , quality of cry &amp; voice -&gt; </li></ul></li><li><ul><li>Sevirity of the distress : </li></ul><ul><li>RR , Retraction , flaring , HR -&gt; </li></ul><ul><li>Respiratory failure : </li></ul><ul><li>Extreme distress , altered mental </li></ul><ul><li>status , cynosis , hypoventilation , </li></ul><ul><li>hypotension -&gt; </li></ul><ul><li>Stridor : </li></ul><ul><li>character / timing -&gt; </li></ul></li><li><ul><li>Management </li></ul></li><li>Management of complete airway obstruction in children </li><li>Management of severe upper airway obstruction in children </li><li><ul><li>Imaging may be </li></ul><ul><li>useful in identifying </li></ul><ul><li>the location and nature </li></ul><ul><li>of the airway </li></ul><ul><li>obstruction but should never interfere </li></ul><ul><li>with the stabilization of a child with </li></ul><ul><li>a critical obstruction -&gt; </li></ul></li><li>Causes of acute upper airway obstruction that are commonly life - threatening <ul><li>Epiglottitis </li></ul><ul><li>Retropharyngeal abscess </li></ul><ul><li>Bacterial tracheitis </li></ul><ul><li>Croup </li></ul><ul><li>Foreign body </li></ul><ul><li>Anaphylaxsis </li></ul><ul><li>Neck trauma </li></ul><ul><li>Burns thermal or caustic </li></ul>UpToDate 2010 </li><li>&nbsp;</li><li><ul><li>A 42 yrs old previously healthy woman presented with </li></ul><ul><li>bad sore throat &amp; painfull swallowing -&gt; </li></ul><ul><li>She is febriel , but nontoxic &amp; in no respiratory distress -&gt; </li></ul><ul><li>A lateral soft tissue neck film is ordered </li></ul><ul><li>as shown which of the following is the cause of this </li></ul><ul><li>pt illnes ? </li></ul><ul><li>Retropharyngeal abscess -&gt; </li></ul><ul><li>Epiglottitis -&gt; </li></ul><ul><li>Peritonsillar abscess -&gt; </li></ul><ul><li>Bacterial tracheitis -&gt; </li></ul><ul><li>Ludwig angina -&gt; </li></ul></li><li><ul><li>Epiglottitis : </li></ul><ul><li>The most feared peds emergency -&gt; </li></ul><ul><li>Children 3-7 yrs </li></ul></li><li>Epiglottitis : Lateral neck radiograph Epiglottic width &gt; 8 mm Aryepiglottic width &gt; 7 mm </li><li><ul><li>A 12 yrs old child presents to the </li></ul><ul><li>ED with sore throat ; dysphagia , </li></ul><ul><li>odynophagia &amp; drooling -&gt; </li></ul><ul><li>The examination of the oropharynx is </li></ul><ul><li>normal -&gt; Which of the following is the </li></ul><ul><li>most likely diagnosis ? </li></ul><ul><li>Peritonsillar abscess -&gt; </li></ul><ul><li>Bacterial croup -&gt; </li></ul><ul><li>Epiglottitis or supraglottitis -&gt; </li></ul><ul><li>Bacterila tracheitis -&gt; </li></ul></li><li><ul><li>Which of the following is true regarding adult epiglottitis ? </li></ul><ul><li>Airway obstruction is usually caused by inflammation of the infraglottic tissues -&gt; </li></ul><ul><li>Drooling &amp; stridor are infrequent presenting signs -&gt; </li></ul><ul><li>The disease is more common in winter -&gt; </li></ul><ul><li>Nebulizated racemic epinephrine has been shown to decrease the need for intubation -&gt; </li></ul><ul><li>Normal lateral neck XR can safely exclude epiglottitis -&gt; </li></ul></li><li><ul><li>  Adult Presenting features of epiglottitis : </li></ul><ul><li>Sore throat or odynophagia ( 90 - 100 % ) </li></ul><ul><li>Fever ≥37-&gt;5ºC ( 26 - 90 %) </li></ul><ul><li>Muffled voice ( 50 - 80 % ) </li></ul><ul><li>Drooling ( 15 - 65 % ) </li></ul><ul><li>Stridor or respiratory compromise ( 33 %) </li></ul><ul><li>Hoarseness ( 20 - 40 %) </li></ul><ul><li>Uptodate 2010 </li></ul></li><li>Rapid overview : Epiglottitis ( supraglottitis ) in children Secure airway before diagnostic evaluation if respiratory distress is severe-&gt; Communicate early with otolaryngologist, anesthesiologist, and intensivist-&gt; 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) Evaluation Febrile, toxic - appearing children with rapid onset and progression of dysphagia, drooling, and respiratory distress  Consider epiglottitis in : Respiratory distress : stridor, tachypnea, anxiety, refusal to lie down, &amp;quot; sniffing &amp;quot; or &amp;quot; tripod &amp;quot; posture -&gt; Sore throat, dysphagia, drooling, anterior neck pain ( at the level of the hyoid)-&gt; Muffled &amp;quot; hot potato &amp;quot; voice Marked retractions and labored breathing indicate impending respiratory failure -&gt; Signs and symptoms that may indicate epiglottitis </li><li>Stridor, drooling, suprasternal and subcostal retractions Swollen, erythematous epiglottis, inflammation of the supraglottic structures Look for signs of extra-epiglottic infection (eg, pneumonia) Findings: 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 Examination : </li><li>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 (&lt;8 years of age) or surgical cricothyrotomy (&gt;8 years of age) if unable to ventilate or intubate Secure the airway, if time allows, in the operating room by anesthesia or otolaryngologist (artificially or surgically if necessary) Airway Management : Enlarged epiglottis (&amp;quot;thumb&amp;quot; sign), loss of vallecular air space, thickened aryepiglottic folds, distended hypopharynx, loss of cervical lordosis Findings : 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 Imaging : </li><li>Uptodate 2010 patient in the intensive care unit Monitor Cefotaxime OR ceftriaxone PLUS Clindamycin OR vancomycin Administer empiric antimicrobial therapy: Antimicrobial therapy Epiglottal cultures after establishment of artificial airway Blood cultures after the airway is secured Laboratory studies : </li><li><ul><li>Appropirate initial therapy in a </li></ul><ul><li>pt with adult epiglottitis inclueds </li></ul><ul><li>which of the following? </li></ul><ul><li>Nebulized racemic epinephrine ,IV levofloxacin-&gt; </li></ul><ul><li>Humidified oxygen , IV ceftriaxone -&gt; </li></ul><ul><li>Nebulized racemic epinephrine ,IV dexamethasone , IV ampicillin -&gt; </li></ul><ul><li>Humidified oxygen , IV levofloxacin-&gt; </li></ul><ul><li>IV dexamethasone , IM penicillin G benzathine -&gt; </li></ul></li><li>Diagnosis …-&gt; ? Retropharyngeal abscess </li><li><ul><li>Which of the following is most correct : </li></ul><ul><li>Most cases of retrophargneal abscess occur in children older than 3 yrs -&gt; </li></ul><ul><li>Organisms that cause retropharngeal abscess include staph species , group A strp &amp; anaerobes -&gt; </li></ul><ul><li>Soft tissue film should be taken during expiration -&gt; </li></ul><ul><li>Symptoms of retropharyngeal abscess are easly distinguishable from epiglottitis -&gt; </li></ul><ul><li>Width of the retropharyngeal space should be no more than 3 times the width of the vertebral body at the same level -&gt; </li></ul></li><li><ul><li>A 4 yrs old boy brought to the ED with sever sore </li></ul><ul><li>throat &amp; h/o refusing to eat -&gt; O/E he has sever </li></ul><ul><li>pharyngitis -&gt;Lateral neck XR is taken that you feel is </li></ul><ul><li>consistent with a retropharyngeal abscess-&gt; You are </li></ul><ul><li>surprised to fined ,however that the pt subsequent CT </li></ul><ul><li>was normal -&gt; The radiologist tells you this was </li></ul><ul><li>probably due to poor technique -&gt; </li></ul><ul><li>What technique should be used to most accurately </li></ul><ul><li>assess the prevertebral space on XR ? </li></ul><ul><li>XR should be taken in flexion during expiration -&gt; </li></ul><ul><li>The pt should be sitting upright when XR is taken -&gt; </li></ul><ul><li>The XR should be taken in flexion during inspiration -&gt; </li></ul><ul><li>The XR should be taken in extension during expiration </li></ul><ul><li>The XR should be taken in extension &amp; inspiration -&gt; </li></ul></li><li><ul><li>Retropharyngeal space : </li></ul><ul><li>&gt;7 mm @ C2 </li></ul><ul><li>Retrotracheal space : </li></ul><ul><li>14 mm@ C6 -&gt;-&gt; Ped </li></ul><ul><li>22 mm @ C6 -&gt;-&gt; Adult </li></ul><ul><li>Pediatric Infectious diseases 2009 Uptodate </li></ul>retropharyngeal space Abnormal retropharyngeal space: </li><li><ul><li>Which of the following is true </li></ul><ul><li>regarding retropharyngeal abscess? </li></ul><ul><li>RPAs are usually preceded by FB aspiration in children -&gt; </li></ul><ul><li>Pt with RPAs prefer to lie supine -&gt; </li></ul><ul><li>Prevertabral soft tissue swelling is excess of 22 mm at the level of C 2 is diagnostic for an RPA in children &amp; adult </li></ul><ul><li>Mycobacterium spp are the most common cause of RPAs -&gt; </li></ul><ul><li>Atlantoaxial separation is the most common fatal complication of RPAs -&gt; </li></ul></li><li><ul><li>Surgical drainage and antimicrobial therapy for </li></ul><ul><li>children if CT showed abscess &gt;2 cm -&gt; </li></ul><ul><li>Antibiotic therapy without surgical drainage for </li></ul><ul><li>children without airway compromise if the CT </li></ul><ul><li>findings are not consistent with mature abscess, or </li></ul><ul><li>the abscess is &lt;2 cm -&gt; </li></ul><ul><li>Uptodate 2010 </li></ul>Management of RPAs </li><li><ul><li>Airway obstruction </li></ul><ul><li>Septicemia </li></ul><ul><li>Aspiration pneumonia </li></ul><ul><li>Internal jugular vein thrombosis </li></ul><ul><li>Carotid artery rupture </li></ul><ul><li>Mediastinitis </li></ul><ul><li>Uptodate 2010 </li></ul>COMPLICATIONS of RPAs : </li><li><ul><li>A 6 yrs old girl is brought to </li></ul><ul><li>the ED 4h after developing a </li></ul><ul><li>brief choking episode while </li></ul><ul><li>playing with her toys -&gt; </li></ul><ul><li>Her CXR …-&gt; </li></ul><ul><li>Where is the FB located ? </li></ul><ul><li>Esophagus -&gt; </li></ul><ul><li>Hypopharynx -&gt; </li></ul><ul><li>Trachea -&gt; </li></ul><ul><li>Anterior mediastinum -&gt; </li></ul><ul><li>Not possible to determine from the information provided -&gt; </li></ul></li><li>How to know if the FB in esophagus or trachea from XR ? <ul><li>Esophageal FB : </li></ul><ul><li>(( en face )) in AP view &amp; on edge in lat view-&gt; </li></ul><ul><li>Trachea FB : </li></ul><ul><li>(( en face )) in lat &amp; on edge in AP -&gt; </li></ul></li><li>In a review of 1160 suspected FBA aspirations in children, a FB was successfully removed in 1068 children ( 92%)-&gt; The sites of the FB were as follows : <ul><li>Larynx : 3 % </li></ul><ul><li>Trachea / carina : 13 % </li></ul><ul><li>Right lung : 60 % </li></ul><ul><li>( 52 % in the main bronchus, 6 % in the lower lobe bronchus, and &lt;1 % in the middle lobe bronchus ) </li></ul><ul><li>Left lung : 23 % </li></ul><ul><li>( 18 % in the main bronchus and 5 % in the lower bronchus ( </li></ul><ul><li>Bilateral : 2 % </li></ul><ul><li>UpToDate 2010 </li></ul></li><li><ul><li>7 yrs old girl brought in by her father after choking on a plastic toy -&gt; She was coughing violently &amp; gasping in the car , so the farther tried the Heimlich maneuver &amp; a blind finger sweep but she seemed to get worse -&gt; Hid daughter is now unconscious &amp; cyanotic -&gt; After performing a jaw thrust maneuver , you fail to locate a FB -&gt; Attempts to place an endotracheal tube fail , as the tube seems to be striking an object -&gt; What is the best next step ? </li></ul><ul><li>Laryngeal mask airway -&gt; </li></ul><ul><li>Surgical cricothyrodotomy -&gt; </li></ul><ul><li>Back blows to discharge the FB -&gt; </li></ul><ul><li>Blind figer sweeps to remove the FB -&gt; </li></ul><ul><li>Needle cricothyroidoctomy -&gt; </li></ul></li><li><ul><li>At what age in years is it acceptable </li></ul><ul><li>to use cuffedendotracheal tubes ? Why? </li></ul><ul><li>5 </li></ul><ul><li>6 </li></ul><ul><li>7 </li></ul><ul><li>8 </li></ul><ul><li>9 </li></ul></li><li><ul><li>The narrowest part of the airway in young children is the ? </li></ul><ul><li>Cricoid ring -&gt; </li></ul><ul><li>Endotracheal tube size for children </li></ul><ul><li>&gt; 1yr : </li></ul><ul><li>( Age in yrs /4 ) + 4 </li></ul></li><li><ul><li>In children from 6 m – 4 yrs of age </li></ul><ul><li>which of the following the most </li></ul><ul><li>common cause of accidental </li></ul><ul><li>death INSIDE the home ? </li></ul><ul><li>Falls </li></ul><ul><li>Poisoning </li></ul><ul><li>FB aspiration </li></ul><ul><li>Drowning </li></ul></li><li><ul><li>2 yrs old had a cold for 3 days-&gt;Tonight he has developed a </li></ul><ul><li>barking cough -&gt; He is afebriel ; O/E you note dyspnea , </li></ul><ul><li>retraction , inspiratory stridor &amp; tachypnea-&gt; </li></ul><ul><li>PA CXR shows “ steepling “ of the subglottic </li></ul><ul><li>trachea -&gt; </li></ul><ul><li>Which of the following is the most likely diagnosis ? </li></ul><ul><li>Epiglottitis -&gt; </li></ul><ul><li>Viral croup -&gt; </li></ul><ul><li>Bacterial tracheitis -&gt; </li></ul><ul><li>Retropharyngeal abscess -&gt; </li></ul><ul><li>Pneumonia -&gt; </li></ul></li><li>Croup : <ul><li>Most common cause of upper </li></ul><ul><li>respiratory obstruction in childhood-&gt; </li></ul><ul><li>Peak incidance at 2 yrs </li></ul><ul><li>( range from 6 m – 6 yrs ) -&gt; </li></ul></li><li>Croup / steepling of the subglottic trachea </li><li><ul><li>A child presents with toxicity &amp; findings more </li></ul><ul><li>suggestive of epiglotittis than croup , but the </li></ul><ul><li>lateral neck XR is suggestive of croup or shows </li></ul><ul><li>narrowing or irregularity on the trachea -&gt; The most </li></ul><ul><li>likely diagnosis is : </li></ul><ul><li>Epiglotittis -&gt; </li></ul><ul><li>Viral croup ( laryngotracheobronchitis ) -&gt; </li></ul><ul><li>Spasmodic croup -&gt; </li></ul><ul><li>Bacterial tracheitis -&gt; </li></ul><ul><li>Retropharyngeal abscess -&gt; </li></ul><ul><li>Pneumonia </li></ul></li><li><ul><li>Mild stridor at rest and mild retractions : </li></ul><ul><li>Dexamethasone  (0-&gt;6 mg/kg, maximum of 10 mg) </li></ul><ul><li>oral if oral intake is tolerated / IV / IM -&gt; </li></ul><ul><li>Moderate stridor at rest and moderate retractions, or more </li></ul><ul><li>severesymptoms : </li></ul><ul><li>epinephrine nebulizer  in addition to dexamethasone </li></ul><ul><li>Racemic epinephrine  0-&gt;05 mL/kg / dose </li></ul><ul><li>L-epinephrine is administered as 0-&gt;5 mL/kg per dose-&gt; </li></ul><ul><li>Nebulized epinephrine can be repeated every 15 to 20 minutes-&gt; </li></ul><ul><li>Budesonide inhaled steroid ( 2 mg ) </li></ul><ul><li>As effective as dexamethasone </li></ul><ul><li>In pt unable to take oral medication ( vomiting ) -&gt; </li></ul>Treatment of croup : </li><li>Most commom causes of chronic stridor in children <ul><li>Laryngomalacia : </li></ul><ul><li>Incomplete development of the supporting cartilage of the larynx -&gt; </li></ul><ul><li>Inspiratory stridor begin at birth </li></ul><ul><li>Complete resolution by 2 yrs -&gt; </li></ul><ul><li>Vocal cord paralysis : </li></ul><ul><li>B/L vocal cord paralysis result in sever respiratory distress -&gt; </li></ul><ul><li>Laryngeal Web : </li></ul><ul><li>Failure of complete canalization of the airway </li></ul></li><li><ul><li>Noise decreases as obstruction worsens </li></ul><ul><li>Noise NOT indicative </li></ul><ul><li>of degree of obstruction </li></ul><ul><li>Therefore </li></ul><ul><li>THE WORST OBSTRUCTION IS </li></ul><ul><li>SILENT </li></ul></li><li>THANK YOU </li><li>&nbsp;</li><li>Child with classic presentation of acute epiglottitis Tripod posture (toxic appearance) </li><li>&nbsp;</li>