1. Ambo university
College of medicine and health sciences
Department of medicine
Presented By ;- Million Negasa( C2, B
pharm, nutritionist )
Seminar presentation on Air way obstruction
Modulators - Dr Ararsa ( pediatrician,MD)
Dr Bekelcha (MD)
2. Outlines
Introduction
Couses of air way obstruction
Epidemiology
Pathophysiology
Clinical manifestation
Diagnosis
Management of air way obstructions.
7/22/2019by Million2
3. Introduction
7/22/2019by Million3
The respiratory system consists of all the
structures that make up the airway and help
us breathe and ventilate.
The airway is divided anatomically into the
upper and lower airway.
Functionally divided into
Conducting portion(from tip of mouth or
nose to alveoli- conducts air),
Respiratory portion(places where gas
exchange takes place-small airways called
respiratory bronchioles & alveolar ducts as
well as air sucs called alveoli).
5. Cont….
7/22/2019by Million5
Airway Obstruction :
Refers to narrowing of any portion of the
airway, including the oropharynx, larynx,
trachea or bronchi.
Airflow obstruction can occur at either:-
extrathoracic sites (eg, above the thoracic inlet) or
intrathoracic sites (eg, below the thoracic inlet).
6. cont…
After assessing whether the obstruction is extrathoracic
or intrathoracic ,
determine if the obstruction is fixed or variable.
Fixed obstructions disrupt each breath and the
abnormal sounds are consistently heard.
Variable obstruction leads to abnormal sounds with
breathing that are softer or absent with normal quiet
breathing and may sound different with every breath.
The onset and progression of the obstruction can provide
important clues as to the etiology and help determine the
urgency of evaluation and management.
7/22/2019by Million6
7. Where in the Airway is the
Obstruction
7/22/2019by Million7
SNORING STRIDOR WEEZE
NASOPHRNEX + + -
LARNEX +/- + + in case of
severe obstruction
TRACHEA AND
BRONCHI
+ +
SMALL
AIRWAYS
+
10. History and phsical examination
HISTORY
Snoring or noisy breathing
Chronic cough
Productive cough
Sudden onset of new cough
Inspiratory stridor
7/22/2019by Million10
13. Cont…
Size of mouth
Loose/missing teeth,
Size and configuration of palate and mandible
Location of larynx
Presence of stridor
Baseline O2 saturation
congenital anomalies
7/22/2019by Million13
14. Causes of acute upper airway obstruction that are
commonly life-threatening:
7/22/2019by Million14
Foreign body
Croup
Epiglottitis
Bacterial tracheitis
Retropharyngeal abscess
Peritonsilar abcess
Congenital anomalies like:
Neck trauma
15. 1.Foreign body
Children <5 yr old are particularly susceptible to
foreign body aspiration and choking.
Choking is the leading cause of morbidity and
mortality among children < 4 years of age.
Mainly due to
developmental vulnerabilities of their air way
Under developed ability to swallow food
Most common objects that children choke on are
food, coins, balloons and toys, nuts in one third of
cases, hard candy and chewing gum.
7/22/2019by Million15
16. Clinical presentation
Three stages of symptoms result
1. Initial event :-violent paroxysms coughing, chocking
,gagging and possibly airway obstruction occur
immediately when foreign body is aspirated.
2. Asymptomatic interval:- foreign body becomes
lodged reflexes fatigue and immediate irritating
symptoms subside , accounts for large number of
delayed diagnosis.
3. Complications:- obstruction, erosion, or infection
develops to direct attention again to the presence of
foreign body
7/22/2019by Million16
17. 7/22/2019by Million17
Severity and nature of symptoms varies with location of
foreign body in respiratory tract
Most lodge in the bronchi right bronchus -58% of cases and
are not immediately life-threatening
when in the larynx or trachea can cause complete or partial
airway obstruction requiring immediate treatment.
>90% of pediatrics death due to foreign body aspiration
occur in children <5 years and 65% in infants.
18. Diagnosis
A history consistent with foreign body aspiration is
considered diagnostic.
Chocking or coughing accompanied by new onset of
wheezing
Broncoscopy despite negative imaging.
CT for radiolucent foreign bodies such as fish bones
7/22/2019by Million18
19. Management
Emergency first aid for choking
Prompt endoscopic removal with rigid
instruments
Broncoscopy is deferred only until preoperative
studies have been obtained and patient has been
adequately hydrated and stomach is emptied.
7/22/2019by Million19
20. Back blows (top) and chest thrusts(bottom) to relieve foreign body airway
obstruction in the infant and over 1 year of age .
7/22/2019by Million20
22. 2. Croup (laryngotrachobronchities)
Is the most common form of acute upper respiratory
obstruction
Refers to viral infection of the glotic and the sub glottic
regions
Croup is a disease of the upper air way and alveolar gas exchange
is usualy normal .
Hypoxia and low oxygen saturation are seen when complete
airway obstruction is imminent .
7/22/2019by Million22
23. Etiology
Para influenza type 1,2, 3 account for 75 % of cases croup.
Influenza A and B viruses,adenoviruses, measles, respiratory
syncytial virus, and echovirus cause most of the rest,
severe form of laryngotrachobronchities is associated with
influenza A.
Mycoplasma has rarly been isolated in older children.
7/22/2019by Million23
24. Cont…
Most patients are between 3 months to 5years of
age .
And peaks in the second year of life .
Most commonly occurs in the late fall and winter
and also through out the year
7/22/2019by Million24
25. Clinical features
most patients have upper respiratory tract infections with
some combination of rhinorrhea , phrengities, mild cough
and
low grade fever for 1 to 3 days before signs of air way
obstruction become apparent.
Follwed by barking cough, hoarseness, and inspiratory
stridor
temprature may occasional reach 39-40°C
Symptoms are often worse at night.
Agitation and crying aggravate the symptoms.
7/22/2019by Million25
26. Diagnosis
Diagnosis of croup is mainly clinical
Phsical examination
Hoarse voice coryza , normal to modratly inflamed phrynex
Slightly raised respiratory rate
Nasal flaring, suprasternal ,infrasteral, intercostal retraction,stridor
Radiography of neck (Typical sub glottic narrowing
or ’’ steeple sign’’) but it does not usually correlate
with disease severity .
7/22/2019by Million26
29. Modified Westley Clinical Scoring System
for Croup
7/22/2019by Million29
The total score ranges from 0 to 17.
Mild croup a score of ≤ 2.
- barking cough, hoarse cry, but no stridor at
rest,stridor when upset or crying (i.e., agitated) and
none, or only mild chest wall/subcostal retractions .
Moderate croup score of 3 to 7
-stridor at rest, mild retractions, other symptoms or
signs of respiratory distress, but little or no agitation
Severe croup score of ≥ 8.
-significant stridor at rest,
-Retractions are severe (including indrawing of the
sternum) and the child may appear anxious, agitated,
or fatigued.
-Prompt recognition and treatment of are paramount.
30. Croup management
7/22/2019by Million30
The main stay of management is air way and treatment of
hypoxia
Treatment of respiratory distress
Children with acute spasmodic croup can be treated safely at
home
Antibiotics are not indicated in croup over the counter cough
and cold medications should not be used in childeren <4 year
of age .
31. Moderate or severe croup
7/22/2019by Million31
Nubilized recemic epinephrine is used
Traditionaly recemic epinephrine 1;1 mixture of D and L
isomers of epinephrine has been adimnsterd
A dose of 0.25-0.5ml of 2.25% recemic epinephrine in 3ml
normal saline every 20 min.
There is evidence that L-epinephrine (5ml of 1;1000 solution
)is equally effective as recemic epinephrine.
Frequent aerosol treatments may be needed for the first few
hours
A single PO or IM dose of dexamethasone, 0.6 mg/kg,
decreases the length and severity of respiratory symptoms
that are associated with viral croup.
32. Cont…
7/22/2019by Million32
Supportive care administration of humidified air or
humidified oxygen as indicated for hypoxemia (oxygen
saturation <92% in room air) or respiratory distress.
Monitoring — pulse oximetry and close observation of
respiratory status, including level of consciousness, stridor,
cyanosis, air entry, and retractions.
Fluids — Administration of IV fluids may be necessary in
some children.
Intubation — Endotracheal intubation is required in less
than 1% of those who are seen in the emergency department
and 2 to 6% of those who are hospitalized
33. Admission criteria
progressive stridor
severe stridor at rest
respiratory distress
hypoxia
cyanosis
depressed mental status or
the need for reliable observation
7/22/2019by Million33
34. Discharge criteria
Children who require hospital admission may be
discharged when they meet the following criteria:
No stridor at rest
Normal pulse oximetry
Good air exchange
Normal color
Normal level of consciousness
Demonstrated ability to tolerate fluids by mouth
7/22/2019by Million34
35. 3.Spasmodic croup
7/22/2019by Million35
Occurs most often in children 1-3 yr of age.
Clinically similar to acute laryngotracheobronchitis,
except a viral prodrome and fever.
"frequently recurrent croup."
Laryngoscopy reveals pale, watery oedema with
preservation of the epithelium
The cause is viral in some cases, but allergic and
psychological factors may be important in others
may represent more of an allergic reaction to viral
antigens than direct infection, although the
pathogenesis is unknown
Dx and treatment is the same
36. 4.Epiglottitis
7/22/2019by Million36
Is a dramatic, potentially lethal condition is
characterized by:-
an acute fulminating course of high fever,
sore throat,
dyspnea, and stridor
rapidly progressing respiratory obstruction
Drooling and hyperextended neck are usually
present.
Cyanosis, coma and death.
The child may assume the tripod position sitting upright
and leaning forward with the chin up and mouth open
while bracing on the arms
37. Cont...
7/22/2019by Million37
Previously HiB was the most common cause of epiglottis; currently
decreased by 80-90% due to vaccine
An increase in the median age of children with epiglottitis from 3
years of age to approximately 6 to 12 years of age.
s. pyogenes, s. pneumoniea, s. aureus are common causes of
epiglottis currently.
40. Treatement
It is an emergency
Establishing an airway by nasotracheal intubation or, less often, by
tracheostomy is indicated in patients with epiglottitis, regardless of
the degree of apparent respiratory distress.
Because as many as 6% with epiglotities with out artifical air way die
compared to <1% those with artificial air way
Duration of intubation of intubation depends on the clinical course
and duration of epiglotic swelling as determind by direct
larngeoscopy.
Children with epiglotities are intubated for 2 to 3 days since response
to antibiotics is usully rapid.
7/22/2019by Million40
41. Cont……..
Oxygen 100%
Ceftriaxone, cefotaxime, or A combination of ampicillin and
sulbactam
Rifampin prophylaxis (20 mg/kg orally once a day for 4 days;
maximum dose, 600 mg)
Acute laryngeal swelling - allergic basis responds to ;-
epinephrine (1:1,000 dilution in dosage of 0.01 mL/kg to a
maximum of 0.5 mL/dose) administered subcutaneously or
racemic epinephrine (dose of 0.25-0.75 mL of 2.25% racemic
epinephrine in 3 mL of normal saline).
Corticosteroids are frequently required (2-4 mg/kg/24 hr of
prednisone).
7/22/2019by Million41
42. 5.Bacterial Tracheitis
7/22/2019by Million42
Bacterial tracheitis is an acute bacterial infection of the upper airway
that is potentially life threatening.
The mean age is between 5 and 7 yr.
There is a slight male predominance.
Often follows a viral respiratory infection (especially
laryngotracheitis).
S. aureus is the most commonly isolated pathogen with isolated
reports of methicillinresistant S. aureus.
S. pneumoniae, S. pyogenes, Moraxella catarrhalis, nontypeable H.
influenzae, and anaerobic organisms have also been implicated.
43. Clinical manifestations
7/22/2019by Million43
similar to severe viral croup.
High grade Fever
toxic appearance
barking cough
stridor ,tachypnea
Hoarseness of voice
sore throat,
Dysphonia
44. Cont…
7/22/2019by Million44
Unlike epiglottitis, the patient can lie flat, does not drool, and does
not have dysphagia.
About 50-60% of patients require intubation for management(
young <, adult).
The major pathologic feature appears to be mucosal swelling at
the level of the cricoid cartilage;-
complicated by copious, thick, purulent secretions,
sometimes causing pseudomembranes.
45. Cont’d….
7/22/2019by Million45
Diagnosis
clinically: the diagnosis is based on evidence of
bacterial upper airway disease, which includes;-
high fever,
purulent airway secretions, and
an absence of the classic findings of
epiglottitis.
X-rays: are not needed but can show the classic
findings- pseudomembrane detachment in the trachea .
Bronchoscopy: Purulent material is noted.
47. Treatment
7/22/2019by Million47
I. Appropriate antimicrobial therapy, which usually includes
antistaphylococcal agents, should be instituted in any patient
whose course suggests bacterial tracheitis.
II. Current empiric therapy recommendations for bacterial tracheitis
include vancomycin or clindamycin and a thirdgeneration
cephalosporin (e.g., cefotaxime or ceftriaxone).
III. When bacterial tracheitis is diagnosed by direct laryngoscopy or is
strongly suspected on clinical grounds, an artificial airway should
be strongly considered.
IV. Supplemental oxygen is usually necessary.
48. Complications
7/22/2019by Million48
Cardio-respiratory arrest can occur if airway
management is not optimal.
Toxic shock syndrome has been associated
with staphylococcal and group A streptococcal
tracheitis.
Subglottic narrowing and a rough and ragged
tracheal air column .
49. Prognosis
7/22/2019by Million49
The prognosis for most patients is excellent.
Patients usually become afebrile within 2-3 days.
prolonged hospitalization may be necessary.
To see decrease in mucosal edema and purulent
secretions,
extubation can be accomplished safely, and
the patient should be observed carefully while
antibiotics and oxygen therapy are continued.
50. Comparisons
7/22/2019by Million50
Croup Similarity Bacterial tacheitis
Age 6m- 3 yrs
Patient is sick
Fever is low grade
Insidious onset
cough
Responds to
racemic epinephrine
Negative blood
culture
Cough
Fever
Sore throat
Rhinnorrhea
Barky cough
Stridor
Increase work
of breathing
Normal CBC
Age 6m-14yrs
Patient is toxic
High grade fever
Acute worsy cough
No response to
epinephrine
May be positive blood
culture
52. Diagnosis
7/22/2019by Million52
I. clinical manifestations :
Sore throat, malaise, cervical lymphadenopathy,
and low-grade fever,
Mild pharyngeal erythema.
II. Definitive diagnosis
culture of C. diphtheria,
Routine laboratory test (elevated white blood cell
count and proteinuria).
54. Treatment
7/22/2019by Million54
Antitoxin
Diphtheria antitoxin is a hyperimmune antiserum
(binds to and inactivates the diphtheria toxin).
Antibiotics
The antibiotics of choice are erythromycin (500 mg
QID for 14 days) or
procaine penicillin G (300,000 units BID for
patients ≤10 kg and 600,000 units BID for patients
>10 kg intramuscularly) until the patient can take
oral medicine, followed by oral for a total treatment
course of 14 days .
55. 7.Retropharyngeal and lateral
pharyngeal abscess
7/22/2019by Million55
The retropharyngeal and the lateral pharyngeal
lymph nodes that drain the mucosal surfaces of the
upper airway and digestive tracts.
located between the pharynx and the cervical
vertebrae and extending down into the superior
mediastinum.
The lymph nodes in these deep neck spaces
communicate with each other.
56. Cont…
7/22/2019by Million56
a deep neck infection filling the potential space between
the prevertebral fascia of the cervical vertebrae and the
posterior wall of the pharynx.
58. Cont…
7/22/2019by Million58
A retropharyngeal abscess can also result from ;-
penetrating trauma to the oropharynx,
dental infection, and vertebral osteomyelitis.
Once infected, the nodes may progress through 3 stages:
cellulitis,
phlegmon, and
abscess.
airway compromise.
59. Cont…
7/22/2019by Million59
Retropharyngeal abscess occurs most commonly
in children younger than 3-4 yr of age,
less common in older children and adults.
More in boys.
2/3 of pts have hx of recent ear, nose or throat
infections.
60. Physical examnation
7/22/2019by Million60
Retropharyngeal abscess;-
reveal bulging of the posterior pharyngeal wall(
50%),
Cervical lymphadenopathy,
Lateral pharyngeal abscess commonly presents as fever,
dysphagia, and a prominent bulge of the lateral
pharyngeal wall, sometimes with medial
displacement of the tonsil.
DDx;-
acute epiglottitis,
foreign body aspiration,
lymphoma,
hematoma, and
vertebral osteomyelitis.
61. Diagnosis
7/22/2019by Million61
The laboratory evaluation is non-specific with leukocytosis.
contents of the abscess should be cultured,
Computed tomography (CT) is the imaging
modality of choice for retropharyngeal abscess.
lateral neck radiograph may show an increase in
width of the soft tissues anterior to the vertebrae.
63. treatment
7/22/2019by Million63
assessment of the patency of the airway and adequacy of
oxygenation and ventilation must be performed.
endotracheal intubation
presence of a large abscess requires drainage,
Eradication of the bacterial organism by antibiotics
(nafcillin and cefuroxime or ceftriaxone or cefotaxime ).
Combinations of both.
64. Cont…
7/22/2019by Million64
intravenous antibiotics(cephalosporin combined with
ampicillin-sulbactam or clindamycin).
surgical drainage(in pt with respiratory distress or
failure to improve with intravenous antibiotic
treatment).
The optimal duration of therapy unknown( several
days of IV Abx until improvement seen).
65. Complications
7/22/2019by Million65
upper airway obstruction,
rupture leading to aspiration pneumonia,
and extension to the mediastinum.
Thrombophlebitis of the internal jugular
vein and
erosion of the carotid artery sheath can
occur
embolic abscesses in the lungs
infection of the parapharyngeal space
(Lemierre disease).
66. 8.Peritonsillar cellulitis
and/or abscess
7/22/2019by Million66
relatively common compared to the deep neck
infections,
is caused by bacterial invasion through the
capsule of the tonsil, leading to cellulitis and/or
abscess formation in the surrounding tissues.
Typically seen in adolescent of acute
pharyngiotonsilitis.
67. Cont…
7/22/2019by Million67
Pathogenesis: one of the tonsillar crypts usually
crypta magna gets infected and sealed off
leading to intra tonsillar abscess which then
bursts through tonsillar capsule Peritonsillitis
then peritonsillar abscess.
Organisms: streptococcus pyogenes, staph. Aureus, anaerobic
organisms or Most often growth is mixed.
68. Clinical presentation
General symptoms Local symptoms:
7/22/2019by Million68
due to septicemia
Fever up to 104 degree
F
Chills and rigor
Malaise
body ache,
head ache
Severe throat pain
Painful swallowing
Muffled and thick
speech
Foul breath
Ear pain
trismus
70. Diagnosis
7/22/2019by Million70
Clinically;-sore throat, fever, trismus and dysphagia.
Physical examination reveals an asymmetric tonsillar
bulge with displacement of the uvula.
CT is helpful for revealing the abscess.
Needle aspiration.
Intraoral ultrasound.
71. Treatment
7/22/2019by Million71
Hydration, pain relief
surgical drainage( I,D or tonsillectomy). and
antibiotic therapy( Metronidazole).
Approximately 95% of peritonsillar abscesses resolve
after needle aspiration and antibiotic therapy(5% needs
repeat needle aspirations).
Tonsillectomy should be considered if there is failure to
improve within 24 hr of antibiotic therapy and needle
aspiration.
73. 9.Congenital anomalies
7/22/2019by Million73
a)Laryngomalacia
Congenital laryngeal anomaly of the newborn
characterised by flaccid laryngeal tissue and
inward collapse of the supraglottic structure
leading to upper airway obstruction.
Epidemiology
commonest cause (~ 65%) of stridor in infants
– (17% have another intercurrent airway lesion).
• Association with other syndromes and
neurologically-impaired (e.g. cerebral palsy,GERD).
74. Aetiology
7/22/2019by Million74
Cartilage immaturity
Anatomic abnormality
Neuromuscular immaturity
Inflammatory
Clinical presentation
Stridor is the hallmark;-
lower pitched,
inspiratory,
worsens with agitation,
crying,and
feeding or in the supine position.
spontaneous resolution In 9 month and 75% resolve
within 18month.
75. Classification
7/22/2019by Million75
Several classification systems,
Based on anatomic variant, can be ;-
Type 1 ( mucosal excess prolapse)
Type 2 (foreshortened aryepiglotic fold)
Typ3 ( dorsal epiglottic position)
Investigation
Flexible fibreoptic laryngoscopy
Microlaryngioscopy and Bronchoscopy
Sleep study and other adjuvants are used.
Treatment
Observation
Medical
Surgical (Supraglottoplasty ,Epiglottopexy, Tracheostomy)
76. Cont…
7/22/2019by Million76
b) Tracheomalacia
refers to a weakness of the trachea, due to reduction and/or
atrophy of the longitudinal elastic fibers of the pars
membranacea.
Classification
Primary/Congenital TM,
Idiopathic TM
Secondary/Acquired TM
Prolonged intubation
Severe tracheobronchitis
78. Treatment
7/22/2019by Million78
Medical
Most children can be treated non-surgically, and
symptoms are expected to improve by age 1.
Surgical
Reserved for children with severe symptoms
Primary indications include
Dying spells
Recurrent pneumonia
Intermittent respiratory obstruction
Options
Tracheal resection
Aortopexy
Anterior and or posterior tracheopexy
Young age, particularly those <4 to 6 years old
Severe respiratory distress (eg, "sniffing“ or "tripod" posture stridor, drooling, cyanosis)
Epiglottic abscess
Rapid onset and progression of symptoms
>50 percent obstruction of laryngeal lumen