- Acute inflammatory upper airway obstruction is usually caused by croup (89% of cases), epiglottitis (8% of cases), or less commonly non-bacterial tracheitis (2% of cases). - Croup is a viral infection causing subglottic swelling and narrowing of the airway, while epiglottitis is a potentially life-threatening bacterial infection of the epiglottis. - Management of croup involves cool mist, racemic epinephrine, steroids, and intubation if needed; epiglottitis requires rapid diagnosis and treatment due to risk of complete airway obstruction.

1. Acute
Inflammatory
Upper Airway
Obstruction
Dr. S. Ismat
Bukhari

2. • Acute respiratory tract infections are the most
common of the acquired infections with an
increasing tendency in childhood.
• Out of all the causes that can causes inflammatory
obstruction; 89% of the cases are found to be croup,
8% have epiglottitis and nearly 2% have non-
bacterial tracheitis.

3. • Croup (laryngotracheitis) is almost always benign,
but very rarely can produce severe obstruction.
• The age of those presenting with epiglottitis is
younger than historically described.
• Bacterial tracheitis is a rare but potentially lethal
disease that presents with a prodrome similar to
that of mild croup and then an abrupt, toxic
decompensation.
• Laboratory tests are generally not helpful in the
management of these severe cases.

5. • CROUP
• EPIGLOTTITIS
• LARYNGTIS
• TRACHEITIS

6. CROUP

7. • Croup is a disease of viral origin, causing
subglottic and tracheal swelling.
• The narrow diameter of the subglottic
structures, notably the cricoid ring in the
upper trachea, renders the child
physiologically vulnerable to inflammation in
this area.
• The narrowed airway is responsible for the
hallmark of the clinical presentation, which is
stridor, and for its physiologic consequence,
which is increased respiratory effort.

8. • Rarely, the child may tire and progress to
respiratory failure.
• More than 95% of the patients will not require
hospitalization.
• In a toddler, 1 mm of edema will result in a 65%
reduction in the cross-sectional area of the
subglottis.
• Thick secretions may exacerbate the symptoms.

9. Epidemiology
• The majority of cases of croup occur in
children 6 months to 3 years of age.
• It occurs twice as frequently in males as in
females.
• Most cases occur during fall and winter.
• The infecting agents are predominantly viral;
parainfluenzae type 1, 2, and 3 cause the
majority of cases.

10. • Influenza and mycoplasma infection may be
implicated rarely as causes of croup in
children older than 5 years.
• Endemics are associated closely with the
incidence of parainfluenzae viral infections
during the fall and winter months.
• Adenovirus, respiratory syncytial virus,
influenza, and measles virus are less
common.

11. Pathogenesis
• Inflammation is not confined to the upper airway.
• Inflammation of small airways produces increased secretions.
• Subsequent atelectasis and the plugging of airways by mucus
causes ventilation perfusion inequality and results in hypoxia.
• Carbon dioxide accumulates primarily from obstruction and the
increased work of breathing, fever, and distress.
• “Air hunger” reflects the increased respiratory drive
associated with hypoxia and hypercarbia.

12. • The prominent cough associated with croup probably is caused
by a pharyngeal irritation and accumulated secretions in the
upper and lower airways.
• Gas exchange abnormalities lead to anxiety, lethargy, and
obtundation.
• The presence of these latter symptoms signals the need for
intervention.
• This negative pleural pressure alters the balance of hydrostatic
and oncotic forces within the pulmonary vasculature,
predisposing the infant to pulmonary edema.
• Edema and secretions cause further atelectasis and airway
closure.
• These contribute to further hypoxia, higher respiratory drive,
and increased air hunger.

13. Clinical features
• The stereotypical presentation of croup is a child 6
months to 3 years of age who has a several-day
history of a progressive upper respiratory
infection.
• Usually, a cough begins, classically described as
“barking” or “seal-like,” on the second or third day
of illness.
• This is associated with fluctuating inspiratory
stridor unaffected by posture.
• Breathing is frequently noisy, and secretions may
be copious or meager.
• Fever is common, but usually less low grade.

14. Signs
• Is the color normal, dusky or cyanosis?
• Is the air entry normal or decreased?
• Is the stridor mild or severe?
• If restractions are present, are they minimal or maximal?
• Is the child agitated, restless or obtunded?
A child who demonstrates severity in two or more of
these signs merits consideration for further intervention
or observation in the hospital.

15. Laboratory investigations
• Laboratory investigations are not helpful in the early
assessment of the child suspected of having croup
and have no place in the management of the acutely
ill child.
• Antero-posterior radiograph views of the neck
confirm the diagnosis of croup by the presence of
the “steeple sign” in the upper airway.
• Viral cultures are not valuable in the routine
management of croup; nor are serologic tests.

17. Management
• The vast majority of patients who have croup do not require
hospitalization.
• Of those admitted, fewer than 10% will require monitoring in the
intensive care unit; only a fraction of these will require
intubation.
• If symptoms progress, the child must be intubated or
transferred prior to the onset of hypoxia and hypercarbia.
• There is no substitute for ongoing serial bedside assessment.
• Pulse oximetry, though helpful, cannot substitute for nursing
observations of respiratory distress.

18. • In the case of upper airway obstruction, oxygen saturation
measured by pulse oximetry can exceed 90% despite the
presence of hypercapnea severe enough to produce agitation
or obtundation.
• A decision to admit the patient to a continuous observation or
intensive care unit should be based on the severity of
symptoms.
• Contact isolation is recommended.

19. Management protocol for Croup

20. • The administration of cool mist has been a mainstay of
treatment for decades. Several hazards to this generally
beneficial therapy should be considered, however. Small
children can be excessively cooled. The traditional “mist tent”
may obscure the child from view, preventing the discovery of
cyanosis and obtundation.
• Rarely, bronchospasm can be triggered by cold air, in which
case its use must be discontinued.
• Racemic epinephrine has a long history of successful use,
although dose-effect studies are not available.
• Commonly, 0.5 mL of a 2.25% solution is diluted in 6 to 9 times
that amount of normal saline and delivered by hand-held
nebulizer.

21. • Pressure delivery systems are cumbersome, frightening to the
child, and of unproven benefit.
• Steroid treatment produced salutary benefits at 12 and 24
hours after a single systemic dose at admission.
• The incidence of intubation fell from 1.27% to 0.17% in the
patients treated with steroids.
• Patients who received therapy with racemic epinephrine and
steroid had a tendency to develop modest respiratory alkalosis.
• Doses of dexamethasone (0.3 to 0.6 mg/kg) now are given
systemically at admission.

22. • Intubation will be required in fewer than 1% of all patients
needing hospitalization.
• Guides to intubation are necessarily subjective. The
primary principle is to avoid respiratory arrest and
hypoxia.
• Admission to an intensive care unit should be
anticipatory.
• The child who requires racemic epinephrine more
frequently than every hour is in danger of respiratory
failure and merits continuous nursing observation and
monitoring of heart and respiratory rate and oxygen
saturation by pulse oximetry.

23. Prognosis
• The overall prognosis of crop is good.
• Development of bronchial reactivity is common
following the infection.

24. EPIGLOTTITIS

25. • Epiglottitis or supraglottitis is a lifethreatening
condition that is caused by bacterial infection of the
epiglottis, aryepiglottis, and arytenoids.
• It is differentiated from viral croup and foreign body
aspiration by the acutely ill appearance of its victims
and its fulminant onset.
• All facilities caring for children should have a
detailed protocol for the management of epiglottitis.

26. Epidemiology
• Acute disease generally occurs in children between
the ages of 2 and 6 years.
• More than 75% of cases are caused by H. influenzae
type b. Rarely, other bacterial causes include beta-
hemolytic streptococci, staphylococci, and
pneumococci.
• There is no seasonal incidence, and no gender
preference has been described.

27. Pathogenesis
• The supraglottic structures, swollen with
inflammation, can obstruct the passage of air. The
subglottic airway is not affected.
• Pneumonitis occurs in less than 20% of cases.
• Although the majority of patients are bacteremic (as
many as 90% having positive blood cultures), distant
infections are rare.

28. • Circulatory collapse is rare but, when present,
usually is caused by a combination of hypoxia and
dehydration.
• Pulmonary edema has been described in 25% of
cases. Notably, this occurs both with the acute
obstruction and after its relief by intubation.
• Large intrathoracic pressure fluctuations, damage
to the alveolarcapillary membrane, enhanced
yenous return to the right heart, and cievated
systemic resistance secondary to catecholamine
release are proposed mechanisms

29. Clinical presentation
• Epiglottitis in the child older than 2 years is distinguished
easily by its severe, abrupt presentation.
• Children are usually ill less than 12 hours and have fever.
• In older child will complain of sore throat; difficulty in
swallowing or refusal of liquids is common.
• Three findings are associated with epiglottitis:
– stridor
– the absence of spontaneous cough
– the presence of drooling and agitation.

30. Signs
• Acutely ill appearance
• Febrile
• Muffled speech
• Cough may or may not be present
• Refusal to lie down, preferral to sit, with arms extended behind
in a “tripod” position
• Open mouth
• Frequesnt drooling,
• Jaw is thrust forward
• Inspiratory stridor is prominent
• The use of accessory muscles of breathing, when present, is
associated with a high degree of airway obstruction
• The presence of cyanosis, obtundation, or extreme agitation
signal the presence of severe compromise.

32. Laboratory investigation
• Laboratory evaluation has no place in the management of
supraglottitis.
• Blood gas measurements, cultures, radiographs, and
blood cell counts are not required to establish the
diagnosis in the critically ill, and agitating the child may
precipitate complete airway obstruction.
• Lateral neck radiographs should not be required to
establish the need to notify appropriate team members.
• In less severe cases of obstruction, when time is not an
issue, the lateral neck radiograph is confirmatory.

33. • The classic radiographic sign is the “thumbprint-like” swollen
epiglottis,
• seen just at the level of the hyoid bone.
• Often, “ballooning” of the hypopharynx is seen on inspiration.
• Cultures of blood and epiglottis are obtained after the airway is
stabilized in the operating room.
• These may prove helpful later by identifying resistant strains or
unusual pathogens.
• Blood cultures are reported positive in 50% to 90% of cases,
but epiglottic swabs are positive in fewer than 33% of cases.

35. • The definitive diagnosis is made by direct
laryngoscopy in the operating room.
• Extreme agitation, obtundation, pronounced stridor
with use of accessory muscles of breathing, and a
compatible history are indications for intubation.

36. Management
• Establishing an airway supersedes the need to
establish a diagnosis in the most severe cases.
• The most widely accepted approach is naso-tracheal
intubation in the operating room.
• Once intubated, the child should be placed in an
intensive care unit and mildly sedated with
midazolam alone or in conjunction with morphine.
• Mechanical ventilation is not routinely indicated.

37. • Intubation should be maintained for a minimum of 24 hours.
• Most patients will be extubated within 36 hours and the vast
majority within 72 hours.
• The patient is extubated after the presence of a leak around the
endotracheal tube is apparent.
• Direct laryngoscopy or indirect fiberoptic laryngoscopy is
employed to confirm resolution of swelling in the supraglottic
region.
• The fiberoptic examination has the advantage of requiring less
sedation and being less uncomfortable for the patient.
• Antibiotics are administered for 5 to 7 days.

38. • Once an airway is established, we administer parenteral
ceftriaxone.
• It should be appreciated that 30% of Haemophiius species are
resistant to ampicillin.
• The use of chloramphenicol mandates the monitoring of serum
levels.
• Parenteral therapy is discontinued after extubation and therapy
is switched to oral medication.
• If there are household contacts younger than 4 years and H.
influenzae is the causative agent, a 4- day course of rifampin
should be administered to family members or daycare
providers and to the patient upon completion of the initial
antibiotic course.
• Complete recovery is the rule; recurrences are rare.

39. LARYNGITIS

40. • It causes hoarse voice or temporary complete loss
of the voice because of irritation to the vocal cords.
• It is one of the causes of dysphonia.
• Laryngitis is categorised as:
– Acute: lasts less than three weeks.
– Chronic: may last over three weeks.

41. Laryngitis can be infectious or non-
infectious
Infectious
• Viral
rhinovirus, influenza,
parainfluenza, adenovirus,
coronavirus, RSV
• Bacterial
group A streptococcus, S.
pneumoniae, C. diphtheriae,
M. catarrhalis, H. influenzae,
B. pertussis, B. anthracis, M.
TB
• Fungal
histoplasma, blastomyces,
candida, cryptococcus,
coccidioides
Non-infectious
• GERD
• Allergies
• Over use of vocal cords
• Prolonged use of inhaled
corticosteroids
• Thermal or chemical burns
• Laryngeal trauma (iatrogenic
/ intubation)

42. Symptoms
• Dysphonia (hoarseness) or aphonia (inability to speak)
• Dry, sore, burning throat
• Coughing
• Dysphagia (difficulty in swallowing)
• Cold or flu-like symptoms (which, like a cough, may also be the causal
factor for laryngitis)
• Lymphadenopathy
• Fever
• Hemoptysis (coughing out blood)
• Dyspnea (difficulty in breathing), predominantly in children
• Increased production of secretion

43. Signs
• Erythema and edema of the epiglottis, aryepiglottic folds,
arytenoids and centricular folds occurs in the early
stages.
• In late stages, vocal cords and sub-glottic structures are
also involved.
• Increased secretions
• Submucous haemorrhage (vocal abuse)
• Acute membranous laryngitis (no-specific pyogenic
organisms, to be differentiated from diphtheria)

44. Management
• General measures:
• H-2 inhibitor (ranitidine) or Proton pump inhibitor
(omeprazole)
• Steroids (thermal or chemical burns)
• Fluid resuscitation (viral laryngitis)
• Antibiotic /antifungal
• Speech therapy (persistent nodules)

45. Prognosis
• Most cases of laryngitis are viral and resolve without
treatment with sufficient voice rest.
• Laryngitis, hoarseness, or breathiness that lasts for
more than two weeks may signal a voice disorder
and should be followed up with a voice pathologist.

46. TRACHEITIS

47. • Bacterial tracheitis is rare, but has the potential for
serious sequelae and a difficult course.
• Case reports are notable for the frequent
occurrence of cardiac arrest.
• The illness produces symptoms similar to those of
croup, but is characterized by prominent, copious
tracheal secretions.
• These children appear gravely ill and have
symptoms compatible with septicemia.

48. Epidemiology
• Affected children range in age from several
months to adolescence.
• A viral-like prodrome is common; bacterial
infection may be secondary.
• The most common pathogens reported are
staphylococci, H influenzae, streptococci, and
Neisseria species.
• There is no seasonal variance.

49. Pathogenesis
• The trachea, larynx, and bronchi can become
obstructed from inflammation or with purulent
debris.
• The formation of adherent pseudomembranes over
inflamed friable mucosa commonly 0is noted on
bronchoscopy.

50. Clinical aspects
• The majority of patients have a mild prodrome of
upper respiratory symptoms for 2 to 3 days and then
worsen precipitously during the next 8 to 10 hours.
• The course is often described as being between that
of croup and epiglottitis.
• The children appear systemically ill.
• Paroxysms of coughing may produce tenacious
sputum.
• Older children may complain of burning substernal
pain.

51. • The voice may be hoarse, but swallowing is
unaffected.
• Fever is high, and stridor is prominent.
• Those affected may be tachypneic.
• Breathing is noisy and rhonchi are coarse.
Retractions are common.
• Toxic shock syndrome has been reported in
association with staphylococcal tracheitis.

52. • Laboratory tests are not indicated as part of the acute
management of bacterial tracheitis.
• The white blood count will be high, and blood cultures are
rarely positive.
• Gram stains of tracheal secretions are invaluable in
determining antimicrobial choice.
• Cultures should be obtained when bronchoscopy is performed.
• Chest radiographs may demonstrate small dense material
resembling foreign bodies in the trachea.
• Pseudomembranes may produce an irregular “scalloping” of
the tracheal borders; the trachea may appear narrow.

53. Diagnosis
• Diagnosis is confirmed at bronchoscopy by the
observation of pseudomembranes and purulent
secretions.
• In less severe cases, the history, radiography,
purulent secretions, and culture results may support
a clinical diagnosis.

54. Management
• Although racemic epinephrine and steroids have no
proven effect in cases of bacterial tracheitis, they should
be employed while the diagnosis is in doubt.
• A decision to intubate must be made clinically.
• These patients must be managed in consultation with
otolaryngologists.
• Long hospitalization is required, often in intensive care
units. Significant acute complications, such as sepsis
and cardiac arrest from endotracheal tube obstruction,
are common.
• Late sequelae, such as granulation tissue and tracheal
stricture, can emerge.

55. • Vancomycin and ceftriaxone, chosen
empirically, will cover staphylococcal,
streptococcal, and Haemophilus species.
• Antibiotics are continued for 10 to 14 days.
• A tracheostomy may be required if stricture or
granulation tissue are discovered on serial
fibreoptic examination of the trachea.
• In general, recovery is uncomplicated.