Child With Airway Obstruction Flashcards
A 2-year-old female patient is brought into the emergency department with difficulty breathing. She is otherwise fit and well, has no allergies, was born at term and has had all her vaccinations.
You are asked to review her urgently.
What are potential causes of respiratory distress in this patient?
- Infective:
- Laryngotracheobronchitis (croup).
- Peritonsillar abscess.
- Bronchiolitis.
- Epiglottitis.
- Bacterial pneumonia.
- Obstructive/non-infective:
- Foreign body obstruction.
- Laryngotracheal malacia.
- Anaphylaxis.
- Malignancy.
- Exacerbation of asthma.
- Pneumothorax.
- Pulmonary oedema.
- Pulmonary infiltrates.
- Non-respiratory cause.
How would you assess her airway?
- Carry out a rapid initial ABCDE assessment to identify airway patency and any imminent risk of complete airway obstruction or respiratory arrest. Escalate to a consultant anaesthetist/ENT early and as appropriate.
- If there is no immediate threat to the airway, avoid worsening the situation by upsetting the child. Consider a quiet room with the child seated on the parent’s lap and avoid interventions that may cause distress precipitating total airway obstruction.
History:
* Onset and duration, course (step-wise, insidious) of dyspnoea and other associated symptoms.
- Exacerbating and relieving factors.
- Type of delivery, gestation, post-delivery course (oxygen requirement, NICU, intubation or non-invasive ventilation).
How would you assess her airway?
Continued…
Examination:
- General – GCS, rash, activity levels, cough, coryza.
- Chest movement – effort, symmetry, efficacy.
- Signs of respiratory distress – cyanosis, tracheal tug, recession, grunting, drooling.
- Breath sounds – stridor, stertor, grunting, wheeze, crackles.
Investigations:
* Respiratory rate and oxygen saturations.
* Temperature.
* Heart rate and blood pressure.
* Chest X-ray – portable. Do not attempt to move the child from a place of relative comfort and safety to obtain departmental imaging.
* Treat with oxygen to maintain saturations of 94%–98% as required.
On examination you note stridor and a barking cough. Her oxygen saturations are 94% but she is alert.
What are the likely pathogens underlying her illness?
- A diagnosis of viral laryngotracheobronchitis, or croup (80% of presentations of acute stridor in the UK), is likely.
- The most common cause of this is the parainfluenza virus, but it can also occur due to human coronavirus, adenovirus, influenza and respiratory syncytial virus.
- Epiglottitis is less likely as she is up to date with her vaccinations and this is usually caused by Haemophilus influenza type B.
What is the initial treatment for this patient?
Treatment for croup is largely supportive. In this patient, the following measures should be considered.
- Oral dexamethasone (0.15 mg/kg) (should show clinical improvement within 30 minutes).
- Nebulised budesonide (2 mg) if unable to take oral steroids.
- Nebulised adrenaline (400 mcg/kg) (transient improvement for up to
2hours). - Humidifed oxygen through a facemask.
- Early consideration of intubation and ventilation if any signs of clinical deterioration.
What is the Westley Croup Score?
- The Westley Croup Score was devised to assess the severity of a child’s illness based on their GCS, and the presence of cyanosis, recession or stridor.
- The total score denotes a diagnosis of mild, moderate or severe croup that can direct management.
An hour later you review the patient. She is drowsy and has oxygen saturations of 86% despite being on high flow oxygen.
What is your plan for airway management?
- Ensure rapid escalation to paediatric and anaesthetic senior teams, ENT surgeons capable of performing a tracheotomy, and discussion with the tertiary paediatric unit and transfer teams.
- Preparation for intubation:
- Emergency resuscitation and difficult airway trolleys present.
- Induction and emergency drugs drawn up appropriate to the patient’s weight.
- Airway equipment – have an appropriately sized cuffed oral endotracheal tube (with smaller tubes readily available as airway
likely swollen). - Full AAGBI monitoring attached.
- Airway plan:
- Where, when and how should be decided as a multidisciplinary team based upon the urgency of intubation, ease of safe transfer to theatres, a thorough airway assessment and the skill mix of the clinicians.
- Pre-oxygenate the patient using an Ayre’s T-piece with a sensible level of CPAP to splint the airways.
- Option 1: gas induction with sevoflurane in 100% oxygen.
- Option 2: IV induction (e.g. with ketamine) and muscle paralysis (rocuronium).
Consider heliox although rarely used (30:70 oxygen:helium mix) - high viscosity and low density, low reynolds number, more laminar flow –> reduced respiratory effort
