Paediatric Upper Airway Issues Flashcards
What are some of the symptoms of upper airway obstruction?
Coughing Drooling Difficulty Breathing Gagging Inspiratory Stridor
Why might stridor be considered a good sign after aspirating a foreign object?
Stridor indicates that there is a partial obstruction creating the turbulent flow and audible sound
If there is a complete obstruction there is no ventilation and no breath sounds may be audible
What is the BLS approach for a choking patient?
5 Back Slaps
5 Abdominal thrusts
Note- if older ask for two big cough before starting back slaps.
What investigations may be done in a stable child thought to have aspirated something?
CXR or Neck Radiograph to locate the object
Laryngoscopy/Bronchoscopy can both visualise and remove the object
What symptoms might be experienced if a foreign object is aspirated into the nasal cavity?
Unilateral foul smelling rhinorrhea
Difficulty breathing
Epistaxis
Obstructed air outflow from nose
What is laryngomalacia?
Congenital abnormality of the laryngeal cartilage, shortened aryepiglottic folds pull the epiglottis causing airway obstruction. Most common cause of stridor in newborns.
How do most cases of laryngomalacia correct?
Many children grow out of it with age
Why is it important to monitor weight and feeding in children with laryngomalacia?
Difficulty breathing leads to issues with feeding and so nutrition may be poor.
Why might laryngomalacia lead to or worsen reflux?
Negative pressure is created due to obstruction which can draw up stomach acid causing reflux. This causes irritation and swelling which can worsen the laryngomalacia.
How is laryngomalacia diagnosed?
Laryngoscopy or bronchoscopy
How can you divide the causes of rhinitis?
Infectious and non-infectious
What are some causes of non-infectious rhinitis?
Allergic Rhinitis- Pollen, Dust, Dander
Irritant- Tobacco smoke, Cold or dry air
Exercise
What are some of the symptoms of rhinitis?
Nasal congestion
Rhinorrhoea
Sneezing
Sniffling
What treatments might be used for non-infection rhinitis?
Avoid the trigger Intranasal Antihistamines Intranasal Steroids Nasal Douching Oral Antihistamines Oral Steroids if severe atopic crisis Ipratropium bromide (antimuscarinic may be used to reduce nasal secretions)
Are the majority of infectious rhinitis cases due to viral or bacterial infections?
Viral
What are the common viral causes of infectious rhinitis?
Rhinovirus Influenza virus RSV (Respiratory Syncytial Virus) Parainfluenza Virus Adenovirus
What are the common bacterial causes of infectious rhinitis?
Strep pneumoniae
Haemophilus Influenzae
Moraxella catarrhalis
What can a fungal cause of rhinitis be an indicator of?
Immunocompromised child- aspergillus could be the fungal cause
What are the common viral causes of pharyngitis?
Rhinovirus
Coronavirus
Infection may begin as rhinitis and then travel to cause infection of the pharynx
What is a common bacterial causes of pharyngitis?
Group A Strep
What criteria should be used to differentiate between a viral and a bacterial cause of pharyngitis/tonsillitis?
CENTOR Criteria
What are the CENTOR criteria?
C- Cough Absent +1
Exudate Visibile +1
Nodes- Tender Cervical Lymphadenopathy +1
Temperature >38 + 1
What CENTOR score should an antibiotic prescription be written for?
Scores of 3 or More
A score of 0, 1 or 2 should not be offered an antibiotic prescription as the cause is likely to be viral
What advice should be given with a back-up antibiotic prescription?
Antibiotic is not needed immediately
Use prescription of no improvement in 3 to 5 days or if symptoms worsen
Seek medical help immediately if symptoms worsen rapidly or the person becomes very unwell
How do the symptoms of pharyngitis differ between bacterial and viral causes?
Cough is more likely to be present in viral causes
Other cold like symptoms are more likely to be present in a viral cause including- rhinorrhoea, nasal congestion
Bacterial causes are associated with fever
Cervical lymphadenopathy is more likely to be tender in bacteria causes
Exudate is more likely to be present if there is a bacterial cause
What should be used as the first line antibiotic for suspected bacterial causes of sore throat?
Phenoxymethylpenicillin (Penicillin V)
What should be used as the antibiotic choice for patients who are allergic to penicillin for suspected bacterial causes of sore throat?
Clarithromycin
Erythromycin
Where can abscesses form following bacterial infection of the pharynx?
Peritonsillar space (Over 10 years) Retropharyngeal space (Under 10 years)
What are some symptoms of a pharyngeal abscess formation?
High fever
Drooling
Dysphagia
Odynophagia
Trismus- difficulty opening mouth for peritonsillar
Torticollis- stiff neck for retropharyngeal abscess
Unilateral swelling with uvula deviation may be visible on examination
Hot potato voice- muffled voice with distorted vowels
What are some of the symptoms of a retropharyngeal abscess?
High fever Neck stiffness- torticollis Dysphagia Stridor Malaise Tender cervical lymph nodes
Difficult to see of physical examination but concerns may be raised when there is neck stiffness and feature of infection. It is a complication of untreated bacterial pharyngitis.
Why can a retropharyngeal abscess cause potential fatal infections further down the line?
The retropharyngeal space communicates with the mediastinum and so infection can spread here
Also, the abscess can grow to cause airway obstruction and death from this
What investigations should be done to check for a retropharyngeal abscess?
CT Head and Neck is diagnostic
Side profile/lateral head and neck radiograph
What is the treatment for an peritonsillar/retropharyngeal abscess?
Incision and drainage
IV ABx
What is the most common cause of croup?
RSV
Parainfluenza
Adenovirus
Influenza
What are the signs of croup?
Stridor
Barking cough
Hoarse Voice
During what time of year is croup more common?
Autumn
What are the symptoms of croup?
Prodrome of fever and nasal congestion
Barking cough
Hoarse voice
Inspiratory stridor
What scoring system may be used to grade the severity of croup?
Westley Croup Score
Grades croup as mild, moderate, severe or at risk of imminent respiratory failure
What is the medical name for croup?
Laryngotracheobronchitis
What is the treatment for mild croup?
If mild can be managed at home- anti pyrexial (e.g. paracetamol), keeping hydrated
Single dose of dexamethasone may be given
What features might suggest croup is mild?
Limited signs of respiratory distress No IC, SC or Sternal Recession No tracheal tug Maintaining oxygen saturations Alert Child Good air entry
What are some signs that croup is severe?
Stridor at rest Tracheal tug IC or SC or Sternal Recession Restlessness Cyanosis Tachypnea Tachycardia Altered Consciousness
What is the management for severe croup?
Nebulised Adrenaline
Dexamethasone
If risk of respiratory failure or PEWS very high transfer to ITU, may need to be intubated
Failure to respond to initial treatment for croup (dexamethasone nebulized adrenaline) should raise concern of what?
Bacterial tracheitis- thick mucopurulent exudate is difficult to clear and can cause airway obstruction
What are some signs of epiglottis?
Sudden onset Continuous stridor Muffled voice high fever Cough not prominent (barking cough is seen with croup and bacterial tracheitis)
What should be avoided in children with suspected epiglottitis?
Avoid examining the throat as it can cause laryngospasm and occlude the airway. Avoid anything that stresses out the child. Get senior help with ENT/Anaesthetics. May need inhalational induction in theatre or a tracheotomy.
What is the most common cause of epiglottitis?
Haemophilus Influenzae B- rates have fallen as it is one of the routine vaccinations for newborns
What is the treatment of epiglottitis?
ABC approach and ensure patent airway
Get senior help from ENT/Anaesthetics
Cefotaxime Abx
Note- Cough is absent unlike croup and bacterial tracheitis
What sign is seen on x-rays for epiglottitis?
Thumbprint sign- thickened epiglottis and aryepiglottic folds visible on a lateral x-ray
Note- An x-ray should not be done in suspected cases, it is an emergency and an ENT/Anaesthetic senior should be sought
How does diphtheria cause harm?
Production of the toxin by the corynebacterium diptheria
What are some of the features of diphtheria initially?
Tonsillitis
False membrane at the back of the throat
Dysphagia
Neck swelling
Note- Diphtheria means leather in Greek because the membrane looks a bit like leather
What are some of the serious features of diphtheria?
Myocarditis
Neuritis leading to paralysis
Neck swelling- bull neck appearance
How is diphtheria prevented?
Vaccinate
How should diphtheria be treated?
Diphtheria antitoxin
Erythromycin
Give contacts erythromycin syrup before swab results are known.
Isolate until 3 negative cultures separated by 48 hours.
