Upper Airway Flashcards
Stridor
Primary airway noise in upper airway disease. Airflow is forced through a narrowed airway segment. Local area of low pressure creates a vacuum effect distal to the narrowing. Airway walls collapse and vibrate. Generates a high pitched sound. Most prominent symptom of airway obstruction in infants
Steeple sign
AP and lateral x-ray. Classic with CROUP (Laryngotracheobronchitis)
Thumb print sign
AP and lateral x-ray. Classic with EPIGLOTTITIS.
Definition/Etiology of Croup (Laryngotracheobronchitis)
- Infection involving subglottic airway, larynx, trachea and bronchi
- Most commonly caused by parainfluenza type 1 &type 2
- Less commonly caused by adenovirus, RSV, influenza type A and B, parable type 3
- Infrequently caused by Mycoplasma pneumoniae
Symptoms of Croup (Laryngotracheobronchitis)
Barky or brassy cough, inspiratory stridor, retractions, persistent low grade fever, worsens at night and on day 2-3, hoarseness, wheezing, prolonged expiratory phase, Frequently begins 12-48 hours after non-specific upper respiratory tract symptoms
**Typically symptoms are worse at night
Croup (Laryngotracheobronchitis) diagnostic studies
- Diagnosis generally baed on H&P
- Viral studies may be sent to identify pathogen
- Lateral neck X-ray. STEEPLE SIGN
Treatment of Croup (Laryngotracheobronchitis)
Dexamethasone as single dose outpatient. Maybe 24 hour dose inpatient. Racemic epinephrine but controversial due to ineffectiveness over time.
Etiology of Tracheitis
Haemophilus-influenza (H-flu), Strep pneumoniae
Symptoms of Tracheitis
Stridor, tripod position, dysphagia, drooling, high fever >103. Ill appearing. Toxic appearing.
Tracheitis diagnostic studies
Lateral neck xray- THUMB SIGN = Epiglottitis
Tracheitis Treatment
Broad spectrum antibiotics, such as ceftriaxone or clindamycin. Symptom management. Steroids (dexamethasone).
Foreign Body Etiology (age)
Toddler age or infant with older sibling
Foreign body Symptoms
Acute cough, onset of choking, difficulty breathing, cyanosis, severe wheezing and/or stridor
Foreign body diagnostic studies
Inspiratory films, fluoroscopic evaluation
Foreign body treatment
Caution with transport, as object could progress and obstruct airway. Surgical emergency for bronchoscopy in the OR
Laryngotracheomalacia Etiology (age)
Infant age, previous injury or intubation, presence of lesion. Differentiate from vascular ring
Laryngotracheomalacia Symptoms
Chronic stridor, mild respiratory distress with exertion or illness
Laryngotracheomalacia Diagnostic Studies
Direct visualization with bronchoscopy
Laryngotracheomalacia Treatment
If lesion, surgical removal or repair
Retropharyngeal Abscess Etiology
Most commonly affects children less than 3-4 years. Group A strep, oropharyngeal anaerobic bacteria, Staph aureus.
Abscess in the retropharyngeal space following trauma or primary infection
Most common in children 1-5 years
Infections are polymicrobial
Common pathogens include Strep pyogenes, Staph aureus and Haemophilus species
Retropharyngeal Abscess Symptoms
Fever, malaise, decreased oral intake, neck stiffness, torticollis, sore throat and neck pain, stridor, respiratory distress, dysphagia, muffled voice, vertical adenopathy, retropharyngeal bulge, drooling
History may include recent intubation, oral foreign object, dental procedure, infection of structure draining into retropharyngeal space
Retropharyngeal Abscess Diagnostic Studies
H&P
CMC w/ dif –> leukocytosis
Soft tissue neck x-ray, CT
Retropharyngeal Abscess Treatment
Avoid noxious stimuli
Supplemental oxygen
Assure secured airway
Incision and Drainage by ENT, Culture for ID if abscess >2cm and failure to improve on IV abx in 24 hrs
Peritonsillar Abscess Etiology
Adolescent age, most common with history of acute pharyngitis, Group A Strep and mixed oropharyngeal anaerobes
A local cellulitis that progresses first to phlegm, then abscess; suppurative adenines is most common
Infections are polymicrobial
Common pathogens include Strep pyogenes, Staph aureus and Haemophilus species
Peritonsillar Abscess Symptoms
Recent history of pharyngitis, nonspecific symptoms, including lethargy and fever, sore throat, dysphagia, truisms (spasm of the jaw muscles, causing the mouth to remain tightly closed)
Sore throat, radiates to ear
Tender glands of throat and/or jaw
Chills
Facial swelling
Difficulty/discomfort with opening mouth, refusing to eat or drink
Halitosis
Voice may be muffled or difficult to understand - hot potato voice
Swollen tonsils with uvula deviation
Swollen tissues may obstruct the airway which can lead to a life threatening emergency
Peritonsillar Abscess Diagnostic Studies
CT scan w/ IV contrast – evlauate extent of infection and differentiate from cellulitis
Exam of throat, often displacement of uvula to opposite side
CBC w/ diff –> leukocytosis
Throat culture –> check for Group A strep
Peritonsillar Abscess Treatment
Incision and Drainage for ID
—-Consider surgical drainage if abscess is >2cm or if failure to respond to antibiotic therapy
Avoid noxious stimuli
-Abx: amp-sulbactam or clinda and consider vance for resistant organisms
-Analgesics
-IV hydration if needed
Acute respiratory distress and wheezing or stridor, always consider ___
Foreign body airway obstruction
Incidence of Croup (Laryngotracheobronchitis)
- Most commonly affects children 3 months-5 years of age
- Northern hemisphere, most common between October and March
Epiglottitis - Definition
- Acute severe inflammation of epiglottis
- Results in displacing epiglottis posteriorly
- May obstruct breathing
- Airway emergency!
Epiglottitis - Etiology
- Haemophilus influenzae, has decreased since Hib vaccine
- May be caused by other bacteria or viruses; Staph Aureus, Strep pneumo, Group A Strep
Epiglottitis - age of patient
Children 1-5 years
Epiglottitis - Clinical manifestations
- Sudden onset of symptoms
- Sore throat
- High fever
- Resp distress
- Difficulty swallowing/drooling/dysphagia
- Muffled voice/”Hot potato” voice
- Tripod position
- Anxious appearing child
- Stridor
Epiglottitis - Diagnosis
- Lateral neck radiograph: Enlarged epiglottis and distended hypopharynx (“thumb print sign”)
- Direct laryngoscopy: Beefy red, swollen epiglottis
- Blood and/or throat culture may reveal offending pathogen; obtained after airway is secure or no longer critical
- CBC may reveal leukocytosis (non-specific)
Epiglottitis - Management
- Noxious stimuli must be avoided
- Let child assume position of comfort
- Consult otolaryngology or anesthesia for possible intubation
- If not intubated, provide humidified oxygen
- Antibiotics: Third generation cephalosporin or third generation cephalosporin plus vancomycin if penicillin-resistant pneumococci or MRSA is suspected. 7-10 days of therapy.
- Consider systemic steroids
- IV fluids to prevent dehydration
Which organisms are common pathogens in epiglottis (since the inception of the Hib vaccine)
S. aureus
S. pneumo
Group A strep
Antibiotics for Retropharyngeal Abscess
Broad spectrum
Coverage for aerobic and anaerobic organisms
If patient afebrile and improving, can change to enteral antibiotic to complete 14 day course
Croup - dexamethasone dose
0.6 mg/kg IV/IM
Peritonsillar Abscess - Antibiotics
IV abx
- Ampicillin-sulbactam or Clindamycin
- Consider Vancomycin for resistant organisms
