Managing Upper airway problems in children for ENT / Paediatric / Anaesthetic trainees

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Here I discuss approach to managing an obstructed upper airway of a child. Details about clinical assessment, investigations and management stratergies are outlined.

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Managing Upper airway problems in children for ENT / Paediatric / Anaesthetic trainees

  1. 1. Management of Paediatric Upper Airway Problems Dr. MTD Lakshan MBBS, MS(Oto), DOHNS(UK), FEB ORL-HNS, FRCSEd ORL-HNS Consultant ENT and Head and Neck Surgeon DGH Hambantota
  2. 2. Credits Dr. A.D.K.S.N. Yasawardene MS(Oto) FRCSEd Consultant ENT Surgeon - Lady Ridgeway Hospital for Children – Training, Guidance and Multimedia LRH - Staff
  3. 3. 5 Important Points 1. 2. 3. 4. Tricky Situations Rapid Deteriorations High Morbidity / Mortality Team involvements – Paed / ENT/ Anaes /ICU 5. Clinical and High Tech Mix
  4. 4. Paediatric Airway Problems • • • • Inhaled Foreign Body Exacerbation of the previous airway problem Trauma INFECTIVE / INFLAMMATORY
  5. 5. Manifestations of Upper Airway Obstruction • Stridor- Abnormal breath sound caused by upper airway obstruction – due to turbulent airflow and collapse of walls caused by drop of pressure. • Stertor- Pharyngeal level obstruction
  6. 6. Assessment • Initial Adequacy of Respiration – Central Cyanosis, Tachypnea, Tachycardia, Use of Acc. Mus.of respiration, Chest wall recessions, Lev. of Consciousness, Neonates-spells of Apnea Pulse Oxymetry, Blood gases
  7. 7. Acute Airway Management Medical – • Oxygen Therapy • Adrenaline Nebulization • Steroids iv • Helium-Oxygen Mixture (He 80%-O2 20%) • Positioning
  8. 8. Acute Airway Management Emergency Airway access • Cricothyroid Puncture • Intubation • Tracheostomy
  9. 9. Sub Acute Stridor
  10. 10. Assessment History – • Onset & Progression • Cycle of Respiration • Volume • Pitch • Ag./Rel. Factors (Positions, URTI, Feeding, Activity)
  11. 11. Assessment History • Voice/Cry • Feeding • Associated Symptoms • H/O Intubation
  12. 12. Assessment Examination General Examination • Dysmorphism • Growth Parameters • Haemagiomata Systems • Respiratory & Cardiac • Listen for Stridor
  13. 13. Assessment Investigations Radiological • Plain X-ray – Soft Tissue Neck (Cincinnati View) Chest PA • Imaging – CT, CTA, MRI, MRA • Contrast Studies
  14. 14. Assessment Airway Endoscopy • Flexible - Under LA only up to LarynxOffice Procedure • Rigid – Micro-laryngo-bronchoscopy -MLB Under GA, Using Laryngoscope, Ventilating Bronchoscope together with Hopkins rod lenses(telescopes) & Operating Microscope. Preferably with digital recording facility
  15. 15. Conditions Congenital • Laryngomalacia is the commonest. 15% may show an another abnormality. • Vocal cord palsy – exclude CNS pathology by CT/MRI • Laryngotracheal Stenosis • Webs, Cysts, Clefts, Haemangioma, Vascular Compression, external compression, TOF related abnormalities
  16. 16. Management of Sub-acute Stridor Clinical Assessment – MOST Important Typical uncomplicated Laryngomalacia Pros & Cons of MLB Vs. Watchful waiting Typical Laryngomalacia with complications MLB for Surgical correction Protocol at LRH – Courtesy Dr. ADKSN Yasawardene Atypical MLB for definitive Diagnosis & Treatment
  17. 17. Laryngomalacia videos
  18. 18. Laryngo Tracheal Stenosis
  19. 19. Surgery for Laryngotracheal Stenosis Myer Cotton staging of stenosis & length LTP with castellated incision – Not done now LTR with anterior /posterior Costal cartilage graft; SSP; Stenting –short term/long term CTR for stage 3 & 4 and for failures
  20. 20. Laryngotracheal stenosis videos
  21. 21. Other Congenital Conditions Videos
  22. 22. Choanal Atresia • • • • • Clinical tests – Mirror test; NG tube Emergency Oral Airway/ET Tube CT scan Exclude CHARGE – 2D EHCO Surgery – Puncture & dilatation, Drilling, Laser, Microdebrider, 1200 Telescope, Mitomicin C, Stenting-type & duration • Resurgery rate 2.5 times at GOS
  23. 23. Congenital High Airway Obstruction Syndrome - CHAOS Caused by extreme LT stenosis, External compression Prenatal diagnosis with anomalies U/S Scan & Maternal MRI Extra uterine Intrapartum Treatment ProcedureEXIT-P – Elective LSCS under GA; Head & Neck out & baby is oxygenated by placenta; Endoscopy; Intubation/tracheostomy
  24. 24. Inflammatory Conditions Infective • Bacterial – Acute Epiglottitis, Diphtheria, Retropharyngeal Ab. • Viral – Croup Non-infective Inflammatory • Angioedema • C1 esterase deficiency
  25. 25. Acute Epiglottitis
  26. 26. Acute Epiglottitis Clinical suspicion on rapidly progressive sore throat to total dysphagia (Drooling) & noisy breathing Classical Don'ts – • No Throat examinations • No IV canulations • No X-rays • Do Not disturb the child
  27. 27. Acute Epiglottitis Confirm the Diagnosis in safe environment Personal – ENT/Paed Ana./ Pediatricians Equipment – Anae. Gases; Intubation Equipment; Bronchoscopy; Tracheostomy ( in OT) Elective Intubation/Tracheostomy (rare) IV antibiotics in ICU/HDU setup for few days & extubation (3rd generation cephalosporins
  28. 28. Compare Feature Croup Bacterial Tracheitis Epiglotitis Age <2 Y Any 3-5 Y Organism RSV Para Influenza Staph aureus Haemophilus Influemzae Site of Involvement Subglottic Trachea Supraglottic Stridor Bi Phasic Expiratory Inspiratory Voice Barking Cough Hoarse Unaffected Position Forward Not Characteristic Not Characteristic Characteristic Swallowing Unaffected Unaffected Odynophagia
  29. 29. Infective / Inflammatory • Croup – EBM recommends Adrenaline nebulization & Steroids(dexamethasone) Does not recommend antibiotics. • RP Abscess – can easily be drained through the tonsilar mouth gag. Experienced Anesthetist is a must. • C1 Esterase deficiency - C1 Esterase therapy & EACA, Danazol
  30. 30. Inflammatory Conditions Videos
  31. 31. Neoplastic Conditions Benign • RRP – HPV types 6 & 11 –Repeated conservative Surgical debridement with cold steel, Laser(KTP), Microdebrider. Interferon(variable response), Intralesional Cidofovir(?carcinogenic) Trachy to be avoided Malignant – Rhabdomyosarcoma, Malig. Teratoma, Mediastinal lymphoma
  32. 32. Respiratory Papillomatosis
  33. 33. Traumatic Conditions • Foreign Bodies – History is most important as exam. & Ix can be normal • Intubation Trauma – increasing Prevention by proper training & optimal post Intubation care • Blunt & Penetrating Trauma –early assessment of the extent of the injury & repair
  34. 34. Traumatic Conditions Videos
  35. 35. Any Questions? lakshent@gmail.com LearnENT.net @mtdlakshan Thank You

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