An Approach To Upper Airway Obstruction

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Acute upper airway obstruction
Prepared by Ghassan Al-Maimani
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Upper Airways
Lower Airways
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• DEFINITION

• 
  

Obstruction of the portion of the airways located
above the thoracic inlet.

• EXTENT

Ranges from nasal obstruction till larynx and
upper trachea.
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Clinical manifestation

• Stridor ( Inspiratory stridor )
• - Harsh sound produced by vibration of
  upper airway structure
• - Indicates upper airway obstruction
• Hoarseness Indicates involvement of vocal
  cords
• Respiratory distress / suprasternal retraction

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Clinical manifestation cont.

• Cough
• Signs of hypoxemia
• - Anxiety
• - Restlessness
• - Tachycardia
• - Pallor
• - Cyanosis late sign

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Causes of acute UAO

• Infectious
• Non- Infectious

( commonest )
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INFECTIOUS

• Croup ( Acute laryngotracheobronchitis ).
• Bacterial trachitis ( membranous croup ).
• Acute epiglottitis.
• Diphtheria.
• Retropharyngeal abscess / peritonsillar. abscess.

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Non-INFECTIOUS

• Foreign body inhalation.
• Spasmodic laryngitis
• Caustic burn and trauma.

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Croup ( laryngotracheobronchitis )

• Term applied to group of inflammatory
  conditions involving larynx , trachea and
  characterized by Triad
• Inspiratory stridor
• Brassy cough
• Hoarseness of voice /_ resp.distress

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• Usually viral in origin
• - Parainfluenza virus (type 1)
• - Influenza virus
• - RSV , adenovirus , measles
  virus
• It is the most common cause of Acute Airway
  Obstruction in children
• Age group 3m-3 years (peak 2years)
• Affects boys more often than girls
• Peak occurrence is in fall and winter

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Clinical features

• Usually h/o preceding URTI
• Gradual or sudden in onset
• Triad
• Inspiratory stridor
• Brassy cough
• Hoarseness of voice /_ resp.distress

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Diagnosis

• It is clinically diagnosed
• Neck x-ray and CBC all should be done in
  clinically stable pt .
• - AP neck film show a pencil tip or steeple
  sign of the subglottic trachea
• - CBC , it may helps .

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Pencil shaped or steeple sign
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• Do not use a radiograph to make management
  decisions in a pt. with an unstable airway

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Treatment

• - Some children improve spontaneously because
  of natural fluctuations in the disease
• - Mist therapy / Steam inhalation
• Oxygen
• Adequate hydration
• Nebulization with Racemic epinephrine

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Steroid

• Used in moderate to severe croup
• A child who needs admission in ICU for croup
  management needs steroid.
• Preparations
• Dexamethasone
• Nebulized Budesonide
• Not as effective as dexamethasone
• Much more expensive than dexamethasone

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• Do we use steroid in mild croup ?
• for Children with mild croup , dexamethasone
  is an effective treatment that results in
  consistent and small but important clinical and
  economic benefits ( level Ib)

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• Which is more effective oral or nebulized
  dexamethasone for children with mild croup ?
• Children with mild croup who receive oral
  dexamethasone Rx are less likely to seek
  subsequent medical care and demonstrate more
  rapid symptom resolution compared with children
  who receive nebulized dexamethasone or placebo Rx
  ( level Ib )

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• Most children with croup doesn't need
  hospitalization because symptoms typically
  resolve within a few days

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ICU admission

• Signs of hypoxia
• Severe distress with exhaustion
• Decision about ventilation

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Bacterial causes of acute airway obstruction

• Acute epiglottitis --- Hemophilus influenzae
  type B
• Bacterial tracheitis --- Staph Aureus
• Cornybactrium diphtheria

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Acute epiglottitis

• It is a rapidly progreesive bacterial infection
  causing acute inflammation and edema of the
  epiglottis and adjacent structures
  aryepiglottic folds and arytenoids
• Also known as supraglottitis
• It is life threatening condition may lead to
  sudden and complete airway obstruction

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• Age 2-6 years ( peak at 3 year)
• Infant , older children and adult are rarely
  affected
• Causative agents
• - HIB
• - pneumococci , staphylococci,
• streptococci

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Clinical features

• Previously well child
• Sudden onset , history is short, 4-12 hours of
  sore throat and high fever
• 4 D Distress
• Dysphagia
• Dysphonia
• Drooling of saliva
• may lead to death if complete airway obstruction

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Diagnosis

• History
• Presentation
• Appearance of the child
• Pharynx examination at this stage in ER is
  absolutely contraindicated
• Next step admission in ICU
• Neck x-ray Not the priority
• Do not leave the patient unattended

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Minutes count in acute epiglottitis
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Management

• Protection of the airways is the primary
  priority
• Quickly proceed with epiglottitis protocol
• It is better to initiate a false epiglottitis
  drill than to miss this disease

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Epiglottitis protocol

• - Safe and supervised transfer to skilled hand
• - Inform consultant Pediatrics, ENT, ICU,
  Anesthesia
• - Don't attempt to examine throat in ER
• - Keep patient as comfortable as possible
• - Administering 100 O2

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Epiglottitis protocol, cont.

• - Assembling at bedside CPR equipment including
  resuscitation bag and mask, intubation equipment
• - Taking the pt. to OR
• - Attempt IV line or sampling only after
  intubation in OR /or Tracheostomy

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• After epiglottitis protocol has been performed
  and pt has secure airways you can do
• - blood culture usually positive for HIB
• - CBC WBC may be moderately elevated
• - lateral neck radiograph shows a
  thickened epiglottis ( thumb sign )

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Thumb sign
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• Diagnosis confirmed by seeing an edematous
  cherry-red epiglottis on endoscopy
• Endoscopic examination should not be performed in
  advance of the epiglottitis protocol

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• The main components of Rx is
• - maintain adequate airways until inflammation
  and edema resolve often 36-72hrs
• - Parentral Abx directed agiants HI assuming
  this is the cause ceftriaxone or cefotaxime
• if not available may use chloramphenicol
• - Duration of Rx 7-10 days

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• Prophylaxis
• if there is another child in the house 4 y
  not vaccinated to HI give Rifampicin to all
  family members

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Viral croup (Subglottic) Acute Epiglottitis (Supraglottic)
Age 3m-3 yr 2-6 year
Preceding coryza Yes No
Stridor Loud quiet
Onset Over days Over hours
Toxicity no yes
Fever Low grade High grade
Drooling no yes
Voice Hoarse Muffled
Dysphasia no yes
Comparison between croup and acute epiglottitis
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Bacterial trachitis

• It is uncommon infectious cause of acute UAO
• pt may present with croup like symptoms
• Etiology Staph Aureus
• On intubation copious thick secretion
  ( pus)
• with appropriate airway support and Abx most pt
  . Improve within 5 days

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Spasmodic laryngitis

• Also known as recurrent croup
• Presentation like acute onset of croup
• No h/o fever or viral infection
• Etiology Allergic in nature
• May develop asthma or atopy later on
• It typically resolves spont.
• rarely associated with severe RD

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In a patient with severe airway obstruction

• Dont
• inspect the oropharynx
• send the patient to radiology for a lateral neck
  or chest X-Ray
• insert an IV
• take blood gases

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Dos

• Be calm and confidant
• Transfer the baby to ICU settings
• Let the baby be in mothers lap or beside mother
  to make him clam and comfortable
• Observe the signs of hypoxia or deterioration
• In severe cases or respiratory failure secure
  the airway ( intubation / trachesotomy)

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Choking baby
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Foreign body inhalation

• Essentials of diagnosis
  
• Acute onset of cyanosis and choking
• Inability to cough or vocalize (complete
  obstruction)
• Drooling with stridor (partial obstruction)
• Risk age group 6months-4 years of age

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Complete obstruction

• Unable to speak
• Unable to breath
• Unable to cough

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Treatment

• Children should be allowed to use their own cough
  reflex to extrude the foreign body in case of
  partial obstruction.
• If obstruction increases acute intervention is
  needed.

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First-aid for a choking baby

• Infant lt1 year of age According to AAP and AHA
• Place the infant face down over rescue arm with
  head position below the trunk. Five back slaps
  are delivered rapidly between infants scapula
  with the heel of hand.
• If obstruction persists infant should be rolled
  over and five rapid chest compression should be
  performed.

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• Repeat if not successful and call for help

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First-aid for a choking baby

• Children gt1 year of age
• Abdominal thrust ( Heimlich maneuver )
• 5 thrusts
• Repeat if not successful and call for help

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• If FB is directly visualized in the mouth, it
  can be removed by forceps.
• F.B. in trachea or lower airway Endoscopy
  removal
• Sometimes emergency tracheostomy is needed.

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• Thank you

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References

• 1- www.fpnotebook.com
• 2- www.emedicine.com
• 3- www.caep.com
• 4- www.pubmed.com
• 5- Canadian journal of emergency medicine
• 6- illustrated textbook of pediatrics

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Croup scoring system of Westley et al1 Croup scoring system of Westley et al1 Croup scoring system of Westley et al1 Croup scoring system of Westley et al1 Croup scoring system of Westley et al1 Croup scoring system of Westley et al1
Symptoms Croup score Croup score Croup score Croup score Croup score
Symptoms 0 1 2 3 5
Stidor at rest None Audible with stethoscope Audible without stethoscope
Retractions None Mild Moderate Severe
Air entry Normal Decreased Severely decreased
Cyanosis None With agitation At rest
Level of consciousness Normal Altered