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

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. 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. 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. Paediatric Airway Problems
•
•
•
•
Inhaled Foreign Body
Exacerbation of the previous airway problem
Trauma
INFECTIVE / INFLAMMATORY

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. 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. Acute Airway Management
Medical –
• Oxygen Therapy
• Adrenaline Nebulization
• Steroids iv
• Helium-Oxygen Mixture (He 80%-O2 20%)
• Positioning

8. Acute Airway Management
Emergency Airway access
• Cricothyroid Puncture
• Intubation
• Tracheostomy

9. Sub Acute Stridor

10. Assessment
History –
• Onset & Progression
• Cycle of Respiration
• Volume
• Pitch
• Ag./Rel. Factors (Positions, URTI, Feeding,
Activity)

11. Assessment
History
• Voice/Cry
• Feeding
• Associated Symptoms
• H/O Intubation

12. Assessment
Examination
General Examination
• Dysmorphism
• Growth Parameters
• Haemagiomata
Systems
• Respiratory & Cardiac
• Listen for Stridor

13. Assessment
Investigations
Radiological
• Plain X-ray – Soft Tissue Neck (Cincinnati View)
Chest PA
• Imaging – CT, CTA, MRI, MRA
• Contrast Studies

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

18. 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

19. 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

20. Laryngomalacia videos

21. Laryngo Tracheal Stenosis

24. 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

25. Laryngotracheal stenosis videos

26. Other Congenital Conditions
Videos

27. 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

28. 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

29. Inflammatory Conditions
Infective
• Bacterial – Acute Epiglottitis, Diphtheria,
Retropharyngeal Ab.
• Viral – Croup
Non-infective Inflammatory
• Angioedema
• C1 esterase deficiency

30. Acute Epiglottitis

31. 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

32. 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

33. 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

34. 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

35. Inflammatory Conditions Videos

36. 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

37. Respiratory Papillomatosis

38. 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

39. Traumatic Conditions Videos

40. Any Questions?
lakshent@gmail.com
LearnENT.net
@mtdlakshan
Thank You