Pediatric Airway Emergencies


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Pediatric Airway Emergencies

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