stridor , Upper airway obstruction, pediatrics ,breathing difficulties

1. Upper airway
obstruction
Approach to child with :
Halima Al.Dhali
98181

2. outline
• Case scenario
• Anatomy
• Pathophysiology of stridor
• Differential Diagnosis

3. Anatomy
• Upper airway includes
• Nose
• Pharynx
• Larynx)
• Trachea

5. case
• A 2 years child presented with sudden onset of stridor
Febrile 38.2
Alert not sick
Mild inspiratory stridor
RR 30
Sat :98%
Capillary Refill :2sec
Chest :clear ,
CVS:S1S2 , No murmur
Abd : Soft , No liver or spleen felt

6. History
Age of onset, duration, severity, and progression of the
stridor
Birth Vocal cord paralysis, congenital lesions such as choanal atresia
4 to 6 weeks Laryngomalacia
1 to 4 years Croup, epiglottitis, foreign body aspiration

7. Age Related Differential Diagnosis of Upper Air way
obstruction
Newborn Infancy Toddlers
• Choanal atresia
• DigGeorge syndrome
• Laryngeal web ,
atresia
• Vocal cord paralysis
• Pharyngeal collapse
• Laryngomalacia
• Viral croop
• Subglottis stenosis
• Laryngeal web
• Vascular ring
• Rhinitis
• Viral croop
• Bacteria tracheitis
• Foreign body
• Retrolaryngeal
abscess
• Hypertrophied
tonsil
• Laryngeal
papillomatosis

8. o Precipitating factors (e.g. Crying, feeding, straining,
antecedent URTI, choking, at night)
o Positioning (e.g. prone, supine, or sitting)
o Quality and nature of crying
o Other associated symptoms (e.g. paroxysms of cough,
aspiration, difficulty in feeding, drooling, hoarseness,
dysphagia, snoring, or sleep-disordered breathing)

9. Past medical/ surgical Hx
 Previous admission due to respiratory diseases
 Hx of atopy
 Indotracheal intubation or surgery
Perinatal Hx
 Birth trauma, infections, prematurity
 Immunization/developemental Hx
 Nutrional Hx
 Family/ social Hx

10. Examination
 Anthropometric measure:
 Vital sign
 Inspection
• Toxic appearance (ill looking)
• Level of consciousness
• Dysmorphic features
• Surgical scars
• Neck edema
• Work of breathing/distress (cyanosis, nasal flaring, use
accessory muscles and retractions)
• Drooling saliva

11. General examination:
• peripheral lymphadenopathy
• Clubbing
• Hydration
Specific examination:
• Dyspnea cough
• Stridor

13. Stridor
• High pitched , often harsh noise produce by airway
turbulence through partial obstruction of the upper
airway.
• Commonly in inspiration

15. Supraglottic and subglottic obstruction
Features Supraglottic obstruction Subglottic Obstruction
 Common causes
 Stridor
 Voice
 Dysphagia
 Barking cough
 Fever
 Trismus
 Drooling
 Arching Posture
Epiglottitis ,Peritonsillar
and Retropharyngeal
abscess .
Quit
Muffled
Yes
No
High Grade
Yes
Yes
Yes
Croup , angioedema ,foreign body ,
Tracheitis .
Loud
Hoarse
No
Yes
Low Grade
No
No
No

16. Basic management of acute upper
airways obstruction
• Do not examine the throat!
• Reduce anxiety by being calm, confident
• Observe carefully for signs of hypoxia
or deterioration.
• If severe, administer nebulised
epinephrine (adrenaline) and contact an
anaesthetist.
• If respiratory failure develops from
increasing airways obstruction,
exhaustion or secretions blocking the
airway, urgent tracheal intubation is
required.

17. Bacterial trachietis
• invasive exudative bacterial infection of the soft tissues of the trachea
• Diffuse inflammatory process(larynx, pharynx,Trachea)
• Result in production of (Thick Excaudate ,ulcerative of mucous
membrane) .
• Result in Airway obstucction
• Age : (6month -14years)
• Organisms : S.Aureus , S.pyogense , Moraxella ,H.influenza

18. Clinical Manifestation
• similar to severe viral croup.
• High grade Fever
• toxic appearance
• barking cough
• stridor ,tachypnea
• Hoarseness of voice
• sore throat,
• Dysphonia

19. •What are the differences btw
croup and Bacterial
tracheitis ??

21. Diagnosis
Laryngoscopy laryngotracheal inflammation and
mucopurulent secretions.
bacterial culture and Gram stain of tracheal secretions
Imaging Studies :not essential.
 subglottic narrowing on anteroposterior (AP) views - Steeple
sign,
 clouding of tracheal air column or irregular tracheal margin on
lateral view

23. Management
• Airway
• Maintenance of an adequate airway is of primary
importance.
• Avoid agitating the child. If the patient's respiratory status
deteriorates, it is usually because of movement of the
membrane, and bag-valve-mask ventilation should be
effective.
• Artificial airway use an endotracheal tube 0.5-1 size smaller
than expected
• Supplemental oxygen

24. Medication
• Once the airway is stabilized, obtain intravenous access
for initiation of antibiotics.
• Antibiotic regimens included a third-generation
cephalosporin, clindamycin against community acquired–
methicillin-resistant S aureus (CA-MRSA)
• Vancomycin (45 mg/kg/d IV, divided every 8 h),
with or without clindamycin, should be started in patients
who appear toxic or have multiorgan involvement or if
MRSA is prevalent in the community.

25. Case
• 5-year-old girl developed a severe
sore throat, drooling of saliva, a high
fever and increasing difficulty
breathing over 8 h
Epiglottitis was diagnosed and her airway was guaranteed
with a nasotracheal tube. Antibiotics were started immediately
She made a full recovery.

26. Epiglottitis
Epiglottis
• Inflammation of structure above glottis
• has significant morbidity and mortality
• most common in children aged 1–6 years
Organisms
• S. pneumoniae , S. aureus
• H.infleuna
• Moraxella catarrhalis , H. parainfluenzae
• N. meningitidis , Pseudomonas species
• Candida albicans,
• Klebsiella pneumoniae
• Pasteurella multocida

27.  Fever is usually the first symptom.
 rapidly followed by stridor and labored
breathing
 Dysphagia, refusal to eat
 hoarse voice
 sore throat
 Cough and ear pain are less frequent

28. Drooling of saliva due to inability and pain on
swallowing
Dyspnea – Shortness of breath or difficulty in
breathing
Dysphonia – Hoarseness of voice
Dysphagia – Difficulty in swallowing

29. Physical Examination
• child appears toxic; shock , restlessness,
irritability
• tripod or sniffing position
• Stridor
• tender adenopathy
• erythematous and classic swollen, cherry red
epiglottis

32. Management
• Securing the airway (endotracheal intubation)
• Rarely, this is impossible and urgent tracheostomy is life-
saving.
• Never place a child in a supine position.
• Oxygen supplement.
• Taken blood for culture.

33. Medication
• use antibiotics for the most likely organisms
• After trauma : Staphylococcus aureus
• presence of white patches: Candida albicans
• Some antibiotic like: Ceftriaxone , Cefotaxime ,
Cefuroxime ,Clindamycin
• Rifampin is used for chemoprophylaxis in Hib
infections.

34. Features Croup Epiglottitis
Onset
Preceding Coryza
Cough
Able to drink
Drooling saliva
Appearance
Fever
Stridor
Over days
Yes
Sever, Barking
Yes
No
Unwell
Less than 38.5
Harsh, rasping
Over hours
No
Abscent ,slight
No
Yes
Toxic, very ill
More than 38.5
Soft,

35. Case 3 :
• 2 years old child presented to the emergency department
with a one-week history of URI symptoms and a one-day
history of more severe throat pain and swelling.
• Upon physical examination the patient was febrile and
although she did not demonstrate any signs of respiratory
distress, examination of her neck revealed fullness on the
right.
• A lateral plain film of the neck showed soft tissue
swelling anterior to the vertebral bodies

36. Retropharyngeal abscess
• a deep neck infection
filling the potential
space between the
prevertebral fascia of
the cervical vertebrae
and the posterior wall
of the pharynx.

37. pathophysiology  Infection can spread from a contiguous area
 The space can be directly inoculated from penetrating trauma
Common
organism
group A -hemolytic streptococcus,
S. aureus, viridans streptococci, S. epidermis
E. coli, H. infl uenzae, Neisseria, Klebsiella, Salmonella,
Presentation • fever, chills, malaise, decreased appetite, and irritability
• a sore throat, difficulty in swallowing, pain on swallowing (odynophagia),
jaw stiffness (trismus), or neck stiffness .
• a muffled voice, the sensation of a lump in the throat, or pain in the back
and shoulders upon swallowing.
• fever (70%) and neck pain (62%)
Examination
 Febrile, toxic and irritable.
 Tender cervical lymphadenopathy, usually unilateral
 decreased or painful range of motion of their necks or jaws.

38. Diagnosis
• The laboratory evaluation is non-specifi 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.

41. Management
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 (nafcillin
and cefuroxime or ceftriaxone or cefotaxime )

42. Case
• previously healthy 24-month old male infant was initially
presented to the family pediatrician for a recurring fever over a
period of two weeks
• physical examination(alert and vitals were normal except for
a temperature of 38 °C and tachypnea .
• CBC : leukocytosis of 24 × 109/L and CRP was
457.15 nmol/L, suggesting a bacterial etiology
• empirical antibiotic were prescribed.

43. • visit 3 days later :symptoms had not subsided.
temperature was even higher than before 40 °C
• auscultation revealed markedly diminished breath
sounds over the right lung.
• At that time, the most probable differential diagnosis was
pneumonia due to a resistant bacterial pathogen .

44. • eventually the mother recall an event, one day after
the initial presentation to the family pediatrician, boy was
eating peanuts and suddenly developed a major coughing
episode. But since the coughing finally subsided, the
mother did not ascribe any relevancy to it

45.  Potentially life-threatening event
 Suspected on the basis of a choking episode
 Common: 6 months-5years
Location:
• laryngotracheal :
Acute respiratory distress
Stridor & hoarseness
 Increased respiratory effort or complete airway obstruction
• Lower airway :
Little acute distress after the initial choking episode

47. Site of Foreign body
Right lung – 60 %
Left lung – 23
Trachea/carina – 13 %
Larynx – 3 %
Bilateral – 2 %

48. Presentation
classic triad (ie, coughing, wheezing,
decreased breathing sounds) 40%
fever,
 hemoptysis,
dyspnea,
and chest pain
Mimic( croup, pneumonia, bronchiolitis, or
asthma.)

49. • the initial stage :history of a choking episode, followed by
violent paroxysms of coughing, gagging,and occasionally
complete airway obstruction .
• An asymptomatic
• interval generally follows the aspiration, during which the
foreign body becomes lodged, the refl exes become fatigued,
and the immediate irritating symptoms subside.
• 3 stage
• caused by the foreign body, such as obstruction, erosion,
• or infection. Chronic cough, hemoptysis, pneumonia, lung
• abscess, unexplained fever, and malaise are common
presentations
• of chronic airway foreign bodies

50. Physical Examination
• may be asymptomatic.
• stridor,
• localized wheeze,
• diminished breath sounds.
• Cyanosis (Severe case)

51. Investigations
Arterial blood gas
Bronchioscopy : ( diagnostic & therapeutic)
Radiographic : only 6% to 17% of aspirated
foreign bodies are radiopaque

52. Management
Initial :adequate oxygenation and ventilation.
Incomplete obstruction : bronchoscopy
complete airway obstruction : dislodgement
• back blows and chest compressions in infants,
• the Heimlich maneuver in older children,

53. back blows and chest
compressions
• Give 5 back blows. First, deliver five back blows
between the person's shoulder blades with the heel of
your hand.
• Give 5 abdominal thrusts. Perform five abdominal
thrusts (also known as the Heimlich maneuver).
• Alternate between 5 blows and 5 thrusts until the
blockage is dislodged.

54. the Heimlich maneuver

56.  None of these should be applied if patient is able to speak or
cough
 Finger sweep / grasp
Should be done only if object is visible and will not be wedged
deeper

58. ?