acute upper airway obstruction Flashcards
LOOK
LISTEN
FEEL
LOOK: skin color, trauma, swelling, infection, foreign bodies, chest and abdomen movement, acessory muscle use - tracheal tug, subcostal/intercostal recessoin, tripoding
LISTEN: breath sounds, gurgling, stridor, air entry, wheeze, crepitation
FEEL: feel at nose and mouth for exhaled air, chest movement, trachea for position, skin temp / clammy / sweaty
basic airway manourvers
head tilt chin lift jaw thrust suction remove teeth
head tilt and chin lift
Aim is to open the airway
Stretches the submandibular tissues to pull the tongue forward and open the pharynx
Effective in supralaryngeal obstruction
Won’t work for obstruction at or below larynx
Evaluate effect after positioning
advantages and limitation s of using self inflated bag
Advantages:
Avoids direct person to person contact
Allows oxygen supplementation – up to 85%
Can be used with facemask, LMA, tracheal tube
Limitations: When used with a facemask: Risk of inadequate ventilation Risk of gastric inflation Need two persons for optimal use
advanced airway manouvers
Intubation
Cricothyroid cannula
Tracheostomy
ECMO
needle cricothyroidotomy
Indication
Failure to provide an airway by any other means
Complications Malposition of cannula Emphysema Haemorrhage Oesophageal perforation Hypoventilation Barotrauma
3 causes of stridor
congenital
childhood acquired
adult acquired
congenital causes of stridor
Laryngomalacia Laryngeal Stenosis Subglottic haemangioma Vocal cord(s) paralysis Laryngeal clefts Laryngeal cyst Vascular abnormalities Rare tumours
laryngeal stenosis
second most common cause of stridor
supraglottic, glottic and subglottic web
associated with other midline congenital abnormalities
laryngomalacia (congenital floppy larynx)
commonest cause of non infective stridor
the arytenoids, epiglottis and aryepiglottic folds fall in on inspiration. presents day 1-2 of birth to 1 month and usually disappears by 2 years.
subglottic hemangioma
Present <6 months
50% have haemangiomata elsewhere (eg skin)
Radiograph shows soft tissue swelling confirmed at endoscopy
Regression in first 2 years is the rule but may enlarge before it regresses
Conservative approach is preferred but tracheostomy may be necessary in the neonatal period if airway is compromised
hemangioma
benign tumor of capillaries
most frequently occurs in the subglottis, usually solitory but may be multiple
50% of cases are associated with cervicofacial cutaenous haemangioma
stridor at 6 weeks
childhood acquired causes of stirdor
Acute laryngo-tracheobronchitis Acute epiglottitis Foreign body ingestion Obstructive sleep apnoea Tumour Metabolic Iatrogenic
croup (acute laryngotracheobronchitis)
Commonest childhood infective cause of stridor
Tends to occur in epidemics in spring
Exclusively viral: influenza, para-influenza or respiratory syncitial virus
Inflamed larynx, trachea and bronchus
Presents initially with mild fever, runny nose progressing to sore throat, dysphagia and a dry irritating barking cough
Clinical diagnosis and conservative management
Some children need to be intubated and ventilated
acute epiglottitis
Rare specific infection by Haemophilus influenzae B (HIB vaccine)
Produces rapid oedema of the epiglottitis and aryepiglottic folds
Lethal airway obstruction can occur in hours
Toxic, septic child who drools saliva (unable to swallow)
Clinical diagnosis and treated in HDU with IV cefotaxime
60% needs intubation despite conservative management.
!!! Hazardous procedure only by Consultant Anaesthetists with ENT surgeon standby in theatre for emergency tracheostomy
how to treat stridor
Calm Environment Call for expert help ASAP Keep sat up if possible Nebulised Adrenaline Bronchodilators and steroids Call for expert help! Only when patient collapses and arrests do anything else unless an expert
foreign body
children put objects in mouth or nose.
BLS and ALS algorithm
rigid bronchoscopy under GA
obstructive sleep apnoea
central or peripheral
(central is related to CNS disorder)
peripheral presents with day time somnolence and cyclic airway obstruction and apnoea
history and sleep study
adenoid and tonsils
manage with adenoidecotmy and tonsillectomy
adult causes of stridor
acute: Aspiration of FB Allergic oedema Hereditary & acquired angiooedema Trauma Smoke & Fire infection
non acute: tumor tracheal compression neurological rheumatological OSA
allergic oedema and anaphylaxis
drugs, stings, nuts atopic hx (IgE) e.g instect stings usually lead to glottic and pharyngeal oedema
IgG or direct complement activation (strawberry/nuts)
A-E IM adrenaline 0.5-1mg IV if severe CVS collapse O2, fluid, position hydrocortisone antihistamine chlorampheniamine bronchodilators
hereditary and acquired angiodema
Secondary to reduced plasma C1esterase inhibitor
Hereditary: usually presents in infancy precipitated by local trauma (autodominant). ~30% die from asphyxia
Acquired: usually presents in adulthood associated with malignant/lymphoproliferative disease or the presence of autoantibodies to C1 esterase inhibitor
Treatment= supportive and C1 esterase inhibitor or FFP (has large amount of C4 & C2 which may worsen oedema)
adult airway burns
Upper airway obstruction due to heat injury and mucosal swelling usually develops within 24 hours of exposure
Look for evidence of conjunctivitis, burnt nasal hair and soot deposit. May suggest pending airway obstruction
Is VITAL to recognise Early and seek appropriate intervention and monitoring
laryngeal tumors
benign- papilloma, haemangioma, fibroma
malignant: Squamous cell carcinoma adenocarcinoma sarcoma lymphoma mucoepidermoid cancer adenoid cystic carcinoma
tumors
Papilloma – treated by immunotherapy and recurrent laser ablation under GA
Haemangioma as discussed before
Mediastinal tumour – lymphoma or T cell leukaemia. Extreme caution required. Most children should be treated with steroid prior to being subjected for a tissue biopsy for dx under GA (could be lethal)
Posttransplant lymphoproliferative disorder (PTLPD)- rare. Could be found in any lymphoid tissue in upper airway
what is a papilloma
Characterised by single or multiple benign, non- keratinising squamous growths.
(Progressive/ persistent) hoarseness or aphonia and airway obstruction but with little stridor since the mass of papillomata is too soft to vibrate the air column.
Diagnosed via direct laryngoscopy and removed using a carbon dioxide laser.
Increase in oral cancers associated with HPV
malignant tumors
most commonly squamous cell
50-60 y/o
smokers, alcohol
glottic carcinoma
60% squamous cell carcinoma.
Prime symptom is hoarseness.
Other symptoms include earache, pain, chronic cough, dysphagia, neck lumps and dysphonia especially where spread has occurred.
Excellent prognosis with early diagnosis.
supraglottic cancer
subglottic cancer
supraglottic: 30% squamous cell carcinoma.
Dysphonia.
May metastasize early particularly to upper cervical nodes.
Poorer prognosis due to late presentation and early spread.
subglottic: 10% malignant tumours. Produces less hoarseness but increasing airway obstruction
May be difficult to differentiate from chronic bronchitis or asthma.
Poorer prognosis due to late presentation and early spr ead.
hoarse voice
examined by direct laryngoscopy
6 week hoarsness= emergency referral
CXR to exclude co-existent bronchial cancer
CT to determine extent of spread
FNA of lymph nodes
tumors
RT total layngectomy cyto-toxic chemo tracheostomy oesophageal speech / artificial larynx o tracheo oesophageal fistula
vocal cord paralysis
Can be unilateral or bilateral; unilateral>bilateral
Birth trauma with neck and Recurrent Laryngeal Nerve (RLN) stretching may be a factor
Diagnosis made during endoscopy with patient breathing spontaneously to observe cords movement
Usually temporary and recovers within 4/52
tracheal compression in adults
Thyroid enlargement, thoracic aortic aneurysm and mediastinal mass (neurofibroma), anterior mediastinal tumours or nodes
