15.3.2 Lower Resp Tract Infection Flashcards
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Paediatric upper airway
Slide 4
- More likely to obstruct upper airway
- More difficult to intibate- several levels, tongue, glottis
- Carefult to avoid subglottic injury following intubation
- Increased risk of upper airway obstruction
- More difficult endotracheal intubation
- Risk of subglottic injury with endotracheal intubation
Airway obstruction
- from outside (glands, blood vessels)
- inside airway (FB, mucus)
- thickening of airway wall
Airway inspiration and expiration physiology
Slide 7 & 8
Upper airway obstruction signs
- Causes turbulent airflow - noise
- Snoring: vibration of pharyngeal soft tissue; implies partial upper airway obstruction
- Stridor: indicative of obstruction in larynx or trachea (extrathoracic airways) – mainly inspiratory
- Wheeze: narrowing of intrathoracic airways – mainly expiratory
Child vs Adult narrowest part in Larynx / Airway
Adult = vocal cords
Child = cricoid
Physiology: effect of oedema
Slide 11
Stridor: Obstruction of extra thoracic airways
Where is the lesion?
- Level of obstruction?
What is the lesion?
- Differential diagnosis of cause at that level
- Age of child
➡️Young child: congenital
➡️Older child: acquired
- Duration of stridor: acute vs chronic
Classification + causes
Acute - Acquired
- ALTB (CROUP)
- FB
- epidlottitis
- bacterial tracheitis
- retrophyryngeal abscess
continue on slide 14
ACUTE: Acquired
Viral croup (ALTB)
: Foreign body
CHRONIC
Congenital: Laryngomalacia (young child, onset early)
Acquired: Subglottic stenosis
Viral Croup
- Most common cause parainfluenza 1-3
- Previously well child
- Age 6 months – 5 years, most commonly in 2nd year
- Preceding URTI, mild fever
- Barking cough, hoarse, inspiratory stridor
- start as resp stridor then increases in severity
Grading
- Grade 1: Inspiratory stridor
- Grade 2: Inspiratory and expiratory stridor
- Grade 3: Inspiratory and expiratory stridor, pulsus paradoxus, active expiration
- Grade 4: Severe obstruction, cyanosis, apathy, pre-terminal (EMERGENCY)
Differential diagnosis of stridor
- Other causes of croup (bacterial; post-intubation)
- Foreign body
- Epiglottitis
- Bacterial tracheitis
- Retropharyngeal abscess
- Trauma
STRIDOR: Foreign Body
- Sudden onset of stridor
- History of choking (sometimes pt don’r remember or don’t want to tell their parents)
- Consider if non-resolving stridor
- Radio-opaque FB on X-ray of neck
- Rx: bronchoscopy & remove FB
STRIDOR: Epiglottis
- Aetiology: Haemophilus Influenzae type b
- Acutely ill, usually older child
- Fever, soft voice, low-pitched stridor
- Sits upright, protects airway, dysphagia
- EMERGENCY!!
- Total airway obstruction may occur without warning
- Thumb sign??? (lateral chest X-ray)
STRIDOR: Retropharyngeal abscess
- Bacterial infection: strep pyogenes; staph aureus; anaerobes
- Enlarged, suppurating glands in retropharyngeal space
- Child previously well
- Clinical presentation: ill child, high fever, dysphagia, opisthotonus, stridor
- Diagnosis: swelling in pharynx; XR neck: widened retropharyngeal space
- Rx: IVI antibiotics: cefuroxime
Surgical drainage
STRIDOR: Bacterial Tracheitis
- Pseudomembrane formation in trachea and larynx
- Toxically ill child
- Aetiology: Staph aureus and Haemophilus influenzae
- Clinically: acutely ill child, high fever, coughing up thick sticky sputum
- Diagnosis: clinical, bronchoscopy
- Rx: Airway if indicated
IVI antibiotics: cefuroxime
STRIDOR: Diphtheria
- Unimmunised children
- White membrane over pharynx, larynx
STRIDOR: Trauma
Post-intubation stridor
CHRONIC EXTRATHORACIC AIRWAY OBSTRUCTION: Laryngomalacia
- Excessive supraglottic tissue sucked into laryngeal opening
- Inspiratory obstruction
- Symptoms begin at about 2 weeks of age
- NOT FROM BIRTH!!
- Changes with position
- Improves with time, usually resolves by about 2 years of age
Other chronic causes of stridor
- < 4 months (congenital subglottic stenosis)
- Sudden onset (foreign body)
- Toxically ill, drooling, dysphagia (epiglottitis, retropharyngeal abscess)
- Previous intubation (acquired subglottic stenosis)
- Repeated episodes (spasmodic croup, gastrooesophageal reflux)
- Oral thrush (Candida infection, ?AIDS)
- immune compromised children have to think of other things
SNORING:(STERTOR) OROPHARYNGEAL OBSTRUCTION (OPO)
- Obstructive apnoea: cessation of airflow at nose and mouth despite respiratory efforts
- Obstructive sleep apnoea or oropharyngeal obstruction: partial airway obstruction (snoring) to complete apnoea
- Central apnoea: cessation of airflow unaccompanied by respiratory effort
SNORING: Obstructive sleep aponea syndrome (OSAS)
- Disturbed relationship between factors maintaining airway patency and components of upper airway load promoting collapse
- Important factors:
➡️Anatomy
➡️Adenoids / tonsils
➡️Muscle tone
Pathogenesis
Slide 34
Clinical features
- Difficult breathing with recession
- Restless sleep with frequent arousal
- Snoring
➡️Snoring > 3 months requires regular follow up for adverse effects
➡️Snoring every night > 6 months requires Rx
Complications
Sleep disturbance
- Developmental delay
- Failure to thrive
- Learning difficulties
- Restless sleep, sleepwalking, nightmares
Hypoxia
- Death
- Brain damage
- Pulmonary hypertension
- Cardiac arrhythmias
- Cardiac failure
- Behavioural disorders
