Inflammatory Upper Airway Emergencies

Question 1

Discuss Stridor

Answer 1

harsh, raspy noise produced by air flow through a partially obstructed airway; common to ALL upper airway obstructions;
Inspiratory stridor = @ or ABOVE larynx;

Biphasic stridor (during inspiration & expiration) = obstruction @ trachea;

Expiratory stridor = obstruction BELOW carina

Question 2

Discuss wheezing

Answer 2

noise generated by airflow obstruction distal to the carina – unilateral or bilateral; caused by narrowing of airways = limited airflow

Question 3

Discuss Rales and Rhonchi

Answer 3

Noise made when air goes through fluid in lower airways

Rales = CHF
Rhonchi= Pneumonia

Question 4

Discuss Grunting

Answer 4

Occurs during exhalation when the glottis is partially closed

Question 5

Airway signs

Answer 5

Tachypnea: Early sign of respiratory distress; Correlated with severity
Newborn (40-50)
1 y/o (30-35)
4 y/o (20-25)
Adult (12 -20)

Question 6

Why are retractions significant?

Answer 6

indicate an increased negative pressure of chest; Obstructive lung disease

Question 7

Discuss nasal flaring

Answer 7

attempt to dec airway resistance b/c resistance is high in infants who are obligate nose breathers

Question 8

Neural innervation of the upper airway

Answer 8

-Visceral Innervation of the Epiglottis via superior laryngeal n. (Vagus) that can be palpated ANTERIOR to the cervical TP w/in the deep cervical fascia; sensory & motor; subdivided

 internal laryngeal (1° sensory to the epiglottis), recurrent & external laryngeal (motor & sensory)

-Phrenic n. – C3, C4, C5 keep diaphragm alive; shoulder pain w/ irritation of diaphragm; located in middle mediastinum, travels along anterior scalene m. deep to carotid sheath

Question 9

Discuss Viral Laryngotracheo-bronchitis

Answer 9

MC croup syndrome; almost always caused by parainfluenza type 1

Question 10

Clinical presentation of Viral Laryngotracheo-bronchitis

Answer 10

1. Sudden hoarse, barky cough w/ inspiratory stridor in the middle of the night
2. Restlessness & agitation may indicate serious hypoxemia

DO NOT use the INTENSITY of stridor as an indicator of severity of obstruction

Question 11

Diagnostic evaluation of Viral Laryngotracheo-bronchitis

Answer 11

1. Classic steeple sign (subglottic narrowing) on AP/PA xray

2. Normal epiglottis

Question 12

Managment of Viral Laryngotracheo-bronchitis

Answer 12

Goal is to shrink luminal mucosal swelling

1. Oxygen if hypoxemic
2. Racemic Epi if severe stridor
3. Heliox
4. Steroid

Question 13

What causes epiglotidis in children?

Answer 13

H. influenza; Vaccine preventable

Question 14

Where is the epiglottis in children? Adults?

Answer 14

-Epiglottis lies at C2-3 in the infant/child & is at C5-6 in adults

Question 15

How does epiglottidis present in children?

Answer 15

1. Rapid onset respiratory distress in ill pt for <24 hrs
2. Child will drool rather than swallow to avoid pain
3. Don’t use tongue deprsseor when examing oropharynx

Question 16

How do you manage epiglottidis in adults?

Answer 16

Acute ICU care w/ intubation &/or tracheostomy or crichothyrotomy; broad spectrum IV Abx,

Get blood culture and CBC

Question 17

Discuss Bacterial Tracheitis

Answer 17

Most commonly via S. aureus

1. Infection of the subglottic airway
2. Airway obstruction from subglottic edema & copious mucopurulent secretions that become thickened &form casts in the bronchopulmonary tree
3. May mimic foreign body aspiration on neck x-rays

Question 18

How does Bacterial Tracheitis present?

Answer 18

1. Insidious stridor, high fever and toxic apperance
2. Pts generally DONT DROOL
   3 Sudden onset respiratory distress & obstruction is common & may be repetitive 2° to secretions
3. Barky or brassy cough

Question 19

How do you manage Bacterial Tracheitis?

Answer 19

1. directly to OR for intubation w/ ENT & anesthesia;

2. Abx covering S.aureus as well as broad spectrum

Question 20

Which organism usually causes Retropharyngeal absesses?

Answer 20

Group A strep

Question 21

How does a retropharyngeal absess present?

Answer 21

-Cervical adenopathy w/ meningiasmus;

Increased width in soft tissue anterior to vertebrae

Question 22

Discuss peritonsilar abscess

Answer 22

Hx of tonsillitis that was partially or never treated

Trismus, tonsils displaced medially with deviation of uvula to contralateral side

Question 23

Discuss Parapharyngeal abscess

Answer 23

Marked trismus, fever, painful swallowing

parapharyngeal swelling w/ displaced tonsils, but rarely tonsillitis

Question 24

Discuss Diptheria

Answer 24

Corynebacterium diptheria

Will present with a membrane of diptheria on the tonsils
-Equine antitoxin should be AFTER a sensitivity test is done as soon as diphtheria is suspected & BEFORE culture results are available;

Question 25

Discuss Tetanus

Answer 25

Clostriidium Tetani
Pt may not remember injury
Expect Trismus, risus sardonicus grin

Question 26

How do you manage Tetanus?

Answer 26

1. Admit these pts even if tetanus is only suspected
2. Tetanus Immunoglobulin (TIG) bind toxin that has NOT already attached to tissues
3. Flagyl or PCN