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RESP 5017 > 14. Upper Airway Disorders > Flashcards

14. Upper Airway Disorders Flashcards

1
Q
  1. What is choanal atresia? Is unilateral or bilateral more common?
  2. What % are bony? Membranous? Have associated congenital abnormalities (and which ones)?
  3. What is a partial obstruction or narrowing of the nare called?
  4. How long are infants obligate nose breathers for?
A
  1. Obstruction of the nasal cavity, unilateral more common
  2. 90% are bony obstructions, 10% are membranous, 50% have associated congenital abnormalities (craniofacial, CHARGE syndrome)
  3. Choanal stenosis
  4. 3-4 months old
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2
Q

When does the nasal cavity separate from the oral cavity during gestation? If these fail to separate, what happens?

A

They separate at 5 weeks, and if they fail, it results in choanal atresia

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3
Q
  1. How does bilateral choanal atresia present?
  2. What happens on inspiration? What does this lead to?
  3. The infant is startled now, what does this lead to? What happened when this stops?
A
  1. Immediate resp. distress shortly after birth, baby okay when crying through mouth but when attempts to nasal breathe, airway obstructed
  2. Negative alveolar pressure sucks the tongue back causing further obstruction, leading to resp. distress, retraction, cyanosis
  3. Startled infant starts to cry, allowing them to breathe through their mouth, but when crying stops the cycle of obstruction repeats
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4
Q
  1. How does unilateral choanal atresia present? What is the most common finding?
  2. Does it usually require immediate surgical correction?
  3. What issues will babies with unilateral choanal atresia typically have? How long does it take to be detected?
A
  1. Rarely causes acute resp. distress, most common finding is unilateral nasal discharge
  2. No
  3. Feeding issues and increased distress with colds, may not be detected for years
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5
Q

If choanal atresia is suspected, what are the 3 possible methods to check for severity?

A
  1. Try to pass a 6 or 8 Fr catheter through the nares, solid feeling will be felt at level of posterior choana (2-3 cm)
  2. Place cotton in front of nares and watch for air movement
  3. Absence of fog on a mirror under nostrils
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6
Q
  1. How is choanal atresia initially diagnosed?

2. What is the best method for confirming/evaluating this? 3. What type of X-ray can also be done? (but there are risks)

A
  1. Flexible fiberoptic visualization
  2. CT, best for confirming diagnosis, excluding other possible nasal sites of obstruction
  3. Skull x-ray with radiopaque dye instilled into nasal cavities
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7
Q
  1. What does the word CHARGE in CHARGE Syndrome stand for?
  2. What exams should be performed on these patients?
  3. Who is CHARGE syndrome usually seen in, and what %?
A 
1. C: Coloboma (hole in structure of eye)
   H: Heart 
   A: Atresia 
   R: Retarded
   G: Genital 
   E: Ear 
2. Full medical and genital exam 
3. Choanal atresia patients, seen in roughly 50%
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8
Q

What are the 4 possibilities to initially manage choanal atresia?

A
  1. Place an oral airway to open the mouth (often taped/tied in place)
  2. Intraoral nipple with a hole to allow for breathing
  3. Orogastric tube for feeding
  4. Tracheostomy (rarely)
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9
Q
  1. What is the surgical treatment for choanal atresia if there is a membrane blocking the nare? How about a bone?
  2. What may need to be placed as the nares heal?
  3. What should be done post-op to the nares?
A
  1. Membrane - perforate hole, Bone - drill hole (may need to be re-drilled as baby grows)
  2. A temporary stent
  3. Suction the nares/stent to prevent blockage, stent should be mobilized every 4 hours to prevent stenosis and degranulation tissue formation
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10
Q
  1. What are the 3 abnormalities commonly seen in Pierre Robin Syndrome, and what are they defined as?
  2. What is worsened by the placement of the tongue?
  3. Does Pierre Robin Syndrome present by itself or with accompanying genetic disorders?
A
  1. Cleft palate (opening in roof of mouth), micrognathia (small mandible), glossoptosis (backwards position of the tongue base)
  2. Obstruction
  3. Either or
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11
Q
  1. What is the respiratory issue in patients with Pierre Robin Syndrome, and what position is this the worst in? What position helps to relieve this?
  2. What adjunct can be used to overcome some of the difficulty?
  3. How long does it take to outgrow this?
  4. In severe cases, how are patients treated?
A
  1. Respiratory distress, especially when supine. Prone/side lying helps relieve obstruction
  2. Nasal airway past the based of the tongue
  3. 3-6 months as their airway grows
  4. Surgical jaw lengthening, tracheostomy
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12
Q
  1. What do deep neck infections usually result from? (2 things)
  2. These rapidly become severe. What 2 problems are seen, and what 4 issues can result due to spread?
A
  1. Complication of upper respiratory and upper GI infections
  2. Airway obstruction and aspiration are seen, and these infections can spread causing: tonsillar enlargement, peritonsillar abscess, retropharyngeal abscess, and/or obstructive apnea.
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13
Q
  1. How does tonsillar enlargement present in a child?
  2. What can develop as a result of this, that can progress to what?
  3. What infections can lead to this issue? (bacterial, viral, pathogen involved?)
  4. How is this diagnosed and treated?
A
  1. Acute fever, sore throat
  2. Can develop swelling of oropharyngeal tissues, which can progress to airway obstruction
  3. Tonsillitis, streptococcal pharyngitis, or viral
  4. Diagnosed by cultures, treated with antibiotics
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14
Q
  1. Is peritonsillar abscess unilateral or bilateral? Common bacterial pathogens? (2 of them)
  2. How does peritonsillar abscess present? (pathophysiology)
  3. S&S? (4 things)
  4. How is it diagnosed? (3 possible things)
  5. How is it treated? (2 things)
A
  1. Unilateral, typically caused by streptococcus or staphylococcus aureus
  2. Swelling and protrusion of tonsil into oropharynx with uvula deviation to unaffected side
  3. Trismus (lockjaw), sore throat, torticollis (twisted neck), hoarse voice
  4. S&S, cultures, AP and lateral neck xray
  5. Surgical drainage and antibiotics
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15
Q
  1. What age group is retropharyngeal abscess common in?
  2. What bacterial pathogens can cause this? (2 of them)
  3. What anatomical abnormality results from this?
  4. S&S? (4 of them)
  5. How is it diagnosed, and how is it treated?
A
  1. Children less than 3
  2. Streptococcus, staphylococcus aureus
  3. Obstruction from forward displacement of the posterior pharyngeal wall
  4. Sore throat, fever, dysphagia, and voice changes (hot potato voice)
  5. Diagnosed with a lateral neck X-ray, treated with surgical drainage and antibiotics
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16
Q
  1. What will the child have history of if obstructive apnea is suggested? (2 things)
  2. What is obstructive apnea usually caused by? (2 things)
  3. When is this more severe and why?
  4. What may aid with this problem? (2 things)
A
  1. Noisy snoring, air flow loss despite active chest wall movement
  2. Large adenoids or tonsils
  3. More severe during sleep when muscle tone is decreased
  4. Weight loss or nasal CPAP may help (but often outgrown)
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17
Q
  1. What is tracheomalacia and what can it lead to?

2. What are the possible causes of tracheal malacia? (6 of them)

A
  1. Defective tracheal cartilaginous support (tracheal wall softening), can lead to tracheal wall collapse
  2. Long term ventilation, chronic trauma from ETT/trach, external vascular ring, pressure from aorta, post TEF repair, idiopathic
18
Q
  1. Is extra-thoracic or intra-thoracic tracheomalacia more common and why?
  2. With intra-thoracic tracheomalacia, collapse and airway sounds occur primarily during _____?
  3. With extra-thoracic tracheomalacia, collapse and airway sounds occur primarily during _____?
A
  1. Intrathoracic, because most of trachea is inside thorax
  2. Exhalation
  3. Inhalation
19
Q
  1. How does wheezing present in tracheomalacia? When is it worse? Can you also have stridor?
  2. What may happen with a severe form of tracheomalacia?
  3. How is tracheomalacia diagnosed?
A
  1. Wheezing is centrally located, low-pitched. Worse with increased WOB, colds, agitation. Yes, stridor can also happen.
  2. May result in a complete obstruction esp. during forced exhalation
  3. Flexible bronchoscopy
20
Q
  1. How is mild tracheomalacia treated?

2. How is severe tracheomalacia treated?

A
  1. Wait it out, improves with time and growth

2. CPAP, tracheal stent, tracheostomy

21
Q
  1. What bacterium is pertussis caused by?
  2. Pathophysiology of pertussis?
  3. How does it spread?
  4. What is the incubation period?
  5. Follows a ______ clinical course but disease severity and prognosis are ______.
A
  1. Bordetella pertussis
  2. Irritation and inflammation infecting the ciliated respiratory tract epithelium
  3. Aerosol droplets expelled with coughing or sneezing
  4. Incubation period of 7-14 days
  5. predictable, variable
22
Q
  1. What age group is pertussis serious and possibly fatal? Why?
  2. Hospitalization rate of this age?
  3. Complications? (4 of them)
A
  1. Infants < 6 months old because of inadequate vaccinations
  2. 80% hospitalization
  3. Encephalopathy, pneumonia, apnea, seizures
23
Q
  1. How long is the Catarrhal Phase in pertussis?
  2. Specific or non-specific?
  3. S&S?
A
  1. 1-2 weeks
  2. Non specific
  3. Mild fever, cough, runny nose
24
Q
  1. How long is the Paroxysmal Phase in pertussis?
  2. How do the characteristic coughing episodes present?
  3. What can it be associated with at this stage? (3 things)
  4. How is the child between episodes? During episodes?
  5. How do infants > 6 months present? (3 things)
A
  1. 2-6 weeks
  2. 5-10 coughs followed by a whoop as patient rapidly inhales
  3. Cyanosis, salivation, post-tussive emesis
  4. Between episodes relatively well, during can be exhausting and interfere with sleep and nutrition
  5. Gasping, gagging, possible apnea
25
Q
  1. What happens during the Convalescent Phase in pertussis?

2. How long is this phase?

A
  1. Improvement in resp. tract integrity and function associated with decreasing frequency and severity of coughing episodes
  2. Weeks to months
26
Q
  1. How is pertussis diagnosed? (2 things)
  2. How is pertussis treated? (many options)
  3. What is the vaccination given for this called and what does it protect against?
  4. What is the intervals the vaccine is given at? What about boosters?
A
  1. Cultured nasopharyngeal swab or aspirate, patient history and presentation
  2. Majority of older patients just need supportive treatment, otherwise need antibiotics, oxygen, breathing treatments, mcvent as necessary, observe carefully for apnea, cyanosis, hypoxia
  3. DTaP - diphtheria, tetanus, and pertussis
  4. Given at 2, 4, 6 months, with boosters at 16 months and 4-6 years
27
Q
  1. Is croup a viral respiratory tract illness or bacterial?
  2. What is it also called?
  3. What does croup possibly inflame in the resp tract? What is this whole area called?
  4. Most common cause of ____ in children?
A
  1. Viral
  2. Laryngotracheobronchitis
  3. Lower larynx, trachea, occasionally bronchi. Affects subglottic area!
  4. Upper airway obstruction
28
Q
  1. What is stridor and what airflow produces it?
  2. Would stridor be heard more on insp. or exp. with croup?
  3. What does insp. stridor suggest? Expiratory?
A
  1. Audible harsh, high-pitched musical sound produced by turbulent airflow through a partially obstructed upper airway
  2. Inspiration b/c extrathoracic (but could also be biphasic if infection moves to trachea and bronchi)
  3. Insp stridor suggests laryngeal obstruction, expiratory stridor suggests tracheobronchial obstruction
29
Q
  1. What is the most common cause of croup, and which type is most prevalent?
  2. What may croup also be caused by (6 things)
  3. How does croup spread?
  4. What precautions should be taken in the hospital?
A
  1. Parainfluenza virus, type 1 > type 3 > type 2
  2. Influenza A & B, RSV, HSV, Mycoplasma pneumoniae, rhinovirus, adenoviruses
  3. From cough/sneeze
  4. Droplet/contact precautions
30
Q
  1. What age group does croup commonly affect, and what is the most common age?
  2. After what age is croup uncommon? (although can still occur)
  3. Fast or slow onset?
  4. What seasons is croup more common?
  5. Worse during the day or at night?
A
  1. Children between 6 months and 3 years, most common around age 2
  2. Age 6, although can still be diagnosed in teens and adults
  3. Slow onset
  4. Most common in late fall and early winter
  5. Nocturnal worsening
31
Q
  1. With regards to pathophysiology of croup, what is seen in the subglottic larynx, trachea, and possible bronchi?
  2. Where is swelling seen?
  3. What is damaged during croup, and what functionality is lost?
  4. What substance partially occludes the lumen of the trachea?
  5. Decreased vocal cord mobility due to edema leads to _____?
  6. ______ may occur from progressive airway narrowing and impaired ventilation.
A
  1. Mucosal edema and exudate
  2. Cricoid cartilage
  3. Endothelial damage, loss of ciliary function
  4. Fibrinous exudate
  5. Hoarseness
  6. Hypoxemia
32
Q
  1. What is croup often preceded by? How long does it take for symptoms to progressively increase?
  2. How does the cough present in croup?
  3. Other clinical signs? (8 of them)
  4. How may croup with severe obstruction present?
  5. What does the need for O2 depend on?
A
  1. URI or cold, progressively increase over 1-2 days
  2. Brassy or barking
  3. Hoarse voice, insp. stridor (loud and high pitched, can be biphasic), nasal rhinorrhea, nasal flaring, tracheal tugging, retractions, accessory muscle use
  4. Hypoxia, hypercarbia, tachycardia, acidosis
  5. Severity
33
Q

How is croup diagnosed? (3 things)
How is this confirmed?
How long does croup usually last, and how long can it last?
Are lab tests necessary?

A
  1. Clinical presentation, history, and physical exam
  2. Subglottic narrowing (steeple sign)
  3. 48 hours, but can last up to 5-7 days
  4. Usually not necessary, don’t want to agitate child
34
Q

How is mild croup treated? (4 things)

How is moderate croup treated? (5 things)

A
  1. Systemic steroids (Dexamethasone, prednisone, oral over IM), educate parents, stand in bathroom with cold shower running, maintain fluid intake
  2. Minimize agitation, systemic steroid, cooled humidified air/oxygen to maintain SpO2, nebulized epi, inhaled steroids (budesonide (pulmicort))
35
Q
  1. What does aerosolized epi do to the airways to aid with croup?
  2. Used to give racemic epi, now we give ______.
  3. What is the infant dose < 1 yr? Child dose > 1 yr?
  4. What do you need to be aware of when using epi?
  5. How long should the pt be monitored after administration?
  6. Side effects?
A
  1. Vasoconstriction of the vasculature, reducing edema
  2. Topical
  3. Infant: 2.5 ml (1:1000), Child: 5 ml (1:1000)
  4. Be aware of rebound!!
  5. Monitor for 2 hours
  6. Tachycardia
36
Q
  1. How is severe croup treated? (6 things to consider)
  2. How are most patients managed? Why is hospitalization ever needed?
  3. What % of hospitalized patients require intubation?
A
  1. If child worsens airway must be maintained, use ETT 1 mm smaller than normal, intubated by most experienced person, difficult airway adjuncts ready, ensure positive leak test prior to extubation, Heliox may benefit
  2. Outpatients, hospitalization due to oxygen requirements and need for IV fluids
  3. Less than 2%
37
Q

What is acute epiglottitis, what structures are affected, and what does this cause?

A

Acute epiglottitis is inflammation of structures above the glottis (supraglottic regions, such as epiglottis, aryepiglottic folds, false vocal cords), causes acute airway obstruction

38
Q
  1. What is the most common age range for epiglottitis?
  2. What age group is this increasing in?
  3. What is it most commonly caused by? What is the name of this pathogen? What other pathogen can cause this? How is it transmitted?
  4. Since the vaccine for the most common pathogen was introduced, what % of cases has decreased?
  5. What else can it be caused by that is non-infectious?
A
  1. 2-6 yrs
  2. Adults
  3. Bacterial infection, haemophilus influenzae type B, or can also be seen in B-hemolytic streptococcus
    - Transmitted by aerosol droplets
  4. 95%
  5. Can also be caused by non-infectious inflammation such as thermal or chemical injury, or neck trauma
39
Q

What is the pathophysiology of epiglottitis? (6 key things)

A
  1. Bacteremia and seeding in epiglottis and surrounding tissues
  2. Infected epiglottis becomes swollen and cherry red
  3. Swelling in aryepiglottic folds and false vocal cords
  4. As epiglottis edema increases, lateral borders curl
  5. During inspiration, swollen epiglottis is sucked over laryngeal opening
  6. Severe airway obstruction
40
Q
  1. Epiglottitis: Acute or chronic onset? Rapid or slow progression, and how long?
  2. How does the patient present? (4 findings)
  3. What do the 4 D’s and an S stand for to help remember S&S?
  4. Is a cough associated with epiglottitis? Does the patient appear ill? How does the stridor sound?
A
  1. Acute onset, rapid progression over 2-4 hrs
  2. High fever, sore throat and difficulty swallowing, muffled or quiet speech, sitting bolt upright in sniffing position and tripoding (restless, anxious, mouth may be wide open)
  3. Dysphagia, drooling, dysphonia, distress/dyspnea, stridor (softer and lower pitch)
  4. Cough not usually associated, patient appears acutely ill, stridor is softer and lower in pitch
41
Q
  1. How is epiglottitis diagnosed? Should you visualize the epiglottis?
  2. When is bloodwork indicated? What would this show?
  3. What type of diagnostic test/exam can be done to rule out other DDX? What would show with this?
A
  1. Based on clinical picture and history, do not visualize the epiglottis!!! Can provoke anxiety and irritate the epiglottis causing complete obstruction
  2. When artificial airway is in place, will show elevated WBC
  3. Lateral neck xray, would see thumb sign
42
Q
  1. How is epiglottitis managed? What should you also prepare for?
  2. Where, who, and how should intubation be performed? What size ETT should be used? Who should be present in the OR?
  3. What is done to prevent self extubation? What needs to be ensured before extubation?
  4. What is the mortality rate of children with an artificial airway compared to without?
A
  1. Secure the airway! Prepare for emergency tracheostomy
  2. Intubation should be done in OR, under general anesthesia by most experienced intubator
    - ETT one size smaller should be used
    - paediatrician, anesthesiologist, and ENT present
  3. Heavy sedation, ensure positive leak test
  4. <1% with artificial airway, 10% in children without

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