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ED fellowship paeds > Upper airway > Flashcards

Upper airway Flashcards

1
Q

Compare and contrast stridor and sterdor

A

Harsh vibratory sound of varible pitch caused by partial airway obstruction or collapse and the resultant turbulent airflow through some portion of the airway from the nose to trachea

Inspiratory stridor is usaully associated with obstruction above the glottis- expiratory stridor with intrathoracic obsturction and biphasic typically with crtical or fixed obstruction at any level

Snoring or stertor is a low pitched inspiratory noise caused by nasal or nasopharyngeal osbtruciton

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2
Q

Discuss congential differential of stridor

A

Supraglottic (nose, epiglottis, pharynx) -

  • Micrognathia
  • Pierre RObin syndrome
  • Treacher collins syndrome
  • macroglossia
  • downs
  • storage disease
  • lingual thyroid
  • thyroglossal cyst

Glottic (larynx, vocal cords)

  • Layrngomalacia
  • vocal cord paralysis
  • layngeal web
  • laryngocele

Subglottic trachea

  • subglottic stenosis
  • tracheomalacia
  • tracheal stenosis
  • vascular ring
  • haemangioma cyst
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3
Q

Discuss Acquired differentials of stridor

A

Supraglottic

  • Adenopathy
  • tonsillar hypertrophy
  • Quinsey
  • foreign body
  • pharyngeal abscess
  • epiglottitis

Glottic

  • papilloma
  • foreing body

Subglottic

  • croup
  • bacterail tracheitis
  • subglottic stenosis
  • foreign body

Other anaphylaxis

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4
Q

Discuss IX of stridor

A

lateral and AP neck x-rays may be helpful to assess the adenoid and tonsillar size, contour of the epiglottis, thickness of the retropharyngeal soft tissue space, valecular and aryepiglottic folds and tracheal air colum.

CXR can assess the heart size, trachea and bronchi, location of the aortic arch and presese of other bronchial pathology.

Bedisde fiberoptic nasopharyngscopy allows for visulalization and assessment of the supraglotic structures and vocal cords.

CT and MRI may be needed

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5
Q

Discuss retropharyngeal abcess

A

Potentially life threatening airway emergency resulting from infection of the retropharyngeal soft tissue space. The retropharyngeal space is a potential space between the posteiror pharyngeal wall and the prevertebral fascia

usually seen in infants to toddlers because the lymphatic chains are prominent in the young and atrophy before puberty

Approximately 50% of paediatric cases occur in children 6-12 months of age and most occur before 3 years of age.

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6
Q

Discuss caustive organims for retrophayngeal abcesses

A

Most commonly polymicrobial with streptococcus and anaerobes(fuscibacterium, bacteroids, peptostreptococcus) the most commonly isolated organisms.

Consider MRSA in severe infection such as juglar venous thrombosis or mediastinal extensions

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7
Q

Discuss clinical features of retropharyngeal abcess

A

Typically progress from cellulitis to organised phlegmon to mature abcess.

Common sings and symptoms include fever, sore throat, neck stiffness or nuchal rigidity, torticolis, trismus, neck swelling, drolling stridor and muffled voice.

Stridor and respiratory distress may occur if a large abscess compresses the trachea – typically appearance can resemble that of epiglottitis.

reluctance to extend the neck and an unwillingness to look side to side is often seen with retropharyngeal abscess

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8
Q

Discuss IX of retropharyngeal abscess and list complications

A

Soft tissue lateral x-ray of the neck may be helpful to establish the diagnosis- in a normal patient the retrophayrgneal space should not exceed the diameter of the adjacent verebral body. An airfluid level may be present in perforation or anaereboic infection.

Complicaiotns

  • Airway obstruction
  • mediastinitis
  • septicaema
  • aspiration pneumonia if rupture
  • internal jugfular vein thrombosis
  • jugular vein suppurative thrombophlebitis (Lemierre’s syndrome)
  • carotid artery rupture
  • atlantoaxial dislocation
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9
Q

Discuss management of retropharyngeal abscess

A

Depends on patient and how unwell
A- severe airway compromise requires urgent airway securing and drainage – abcess can distort anatomy ideal inutbation would be in theatre with fibreoptics after gas induction
BCD

If nil airway compromise can receive a trail fo antibitioc therapy for 24-48 horus without surgical drainage–initial ABS include clindamycin 15mg/kg TDS + Augmentin 50mg/kg QID
if not responding add in vanc to cover for MRSA

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10
Q

Discuss peritonsilar abcess

A

Most common deep neck infection and usually occurs in children and teenages – drolling and a muffled hot potatoe voice can occur but severe respiratory distress is unusual.

Associated with trismus, buldging or asymmetry of the tonsils and deviation of the uvula away from the abcess side

IVABs are insufficient to treat peritonsillar abcess but may resolve a phlegmon

Predominantly bacterail - strep and staph (including MRSA) and respiratory anaerobes

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11
Q

Discuss ludwigs Angina

A

Agressive, rapidly spreading woody induration or brawny cellulitis of the sublingual, submandibular and submaxillary spaces with potential for airway obstruction

Most patient have dental sources of infection which are usually polymicrobial - the spread of the infeciton is direct and not lymphatic and most patients will have bilateral involvement wihtout lymphadenopathy

Enlargment and elevation of the tongue above the lower teeth, a tender woody induration in the sublingual space, trismus and odynophagia are hallmark signs.

Same bacteria as retropharyngeal and peritonsillar abcess

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12
Q

Discuss management of Ludwigs Angina

A

A:- pending airway emergency – difficult airway due to distorted anatomy – theatre awake fibreoptic – double set up

Antibiotics - immunocompetent

  • Augmentin 1.2gram QID
  • Ceftriaxone 2g BD + metronidazole 500mg IV TDS
  • Meropenum 1G TDS

Antibiotics immoncompromised
-Cefepime 2g TDS
Meropenum 2G TDS
-Piptaz 4.5 G QID

Early sugrical decompression is unlikley to locate pus and at best may only moderately improve the airway – needle aspiration can be performed

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13
Q

Discuss epiglottitis

A

Invasive bacterial disease that causes inflammation and oedema of the epiglottis, aryepiglottic folds, arytenoids and surrounding supraglottic tissues.
As these structures become inflamed and distended they protrude downward and over the flottic opening. - Supraglottic swelling reduces the upper airway caliber and causes turbulent airflow during inspiration. – Since the advent of the HIB vaccine epiglottis is relatively more common in older children

HIB is still the most common infectious cause of epiglottitis in chlidren - Additional bugs include Hi influenzae types A and F, strep and staph. Immunocompromised can suffer from pseudomonaes aerugniosa and Candida

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14
Q

Discuss clinical features of epiglottis

A

Classicaly acute onset however with bacteria other than HIB can be slwoer. Is marked by high fever, intense sore throat, toxicity and rapid progression.
Children with epiglotitis appear anxious and maintain a sniffing position with the jaw jutting foward and the neck extended to maximize airway patency

Drooling is common due to inability to swallow. Toxicity altered mental status, dyspnea, stridor, retraction and fecer are common initial symptoms.

Thumbprint sign will be seen on lateral soft tissue x-ray - thickened aryepiglottic fold and lack of air in the vallecula and a dilated hypopharynx are all seen on x-ray n

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15
Q

Discuss management of epiglottis

A

Securing the airway takes precedent over diagnostic evaluation. A stable patient his is maintaining their airway and oxygenating should not be moved or repositioned for examination or labs

If unstable BVM should be used to attempt to assist ventilation – if successful continued until inutbation can be complete if not double set up with front of neck access (needle cric or scaple bougie)

Ideal fibreoptic in theatre with anaethetics and ENT

Ceftriaxone 1G bD or 50mg/kg

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16
Q

Discuss layngomalacia

A

Most common cause of chronic stridor in children and accounts of 60-75% of congenital laryneal anomalies.
It is a result fo incomplete develpoment of the supporting cartilage of the larynx.
On inspiration the long floppy epiglottis, arytenoids and aryepiglottic folds are drwan into the larynx and create a partial obsturciton.

basline stridor begins several weeks after birth and worsens with supine positioing, neck flexion and increased respiratory effort. - Rarely is it associated with significant respiraotry distress, feeding difficulties or failure to thrive. Most completely resovle by 2 years of age

Diagnosis is usually by fiberoptic bronchoscopy - in severe cases in wchih the child suffers from apneoic events respiraotry compromise pulmonary hypertension or failure to thrive surgical intervention may be warranted

17
Q

Discuss vocal cord paralysis

A

Second most common cause of chonic infantile stridor
Bilateral vocal cord paralysis usually presents with severe respiratory distress and stridor and typically requires intervention for airway protection – associated with serious CNS abnormalities such as Arnold-Chiari malformations.

Unilateral cord paralysis is usually left sided due to traction on the recurrent larygneal nerve at birth or via compression of the mediastinal structurs.

18
Q

Discuss laryngeal webs

A

Results from failure of complte canalizatioln of the airway
Most lie between the cords and appear as a partial anterior fusion. The spectrum of symtpoms reflext the size of the web. Small webs may cause a hoarse weak cry and mild stridore where as larger more complete wbes are associated with aphonia and severe resp distress

19
Q

Discuss Croup

A

Commonest cause of infectious upper airway distress and obstruction in childhood. It accounts for more than 90% of all cases of stridor in children
Usually seen between the ages of 6-36
Parainfluenza accounts for 50-75% of cases with RSV, Flu A and B and rhinovirus the remainder.

Caused by inlfammation, exudates and oedema of the loosely adherent mucosal and submucosal tissues of the sub glottic space.

20
Q

Discuss clinical features of Croup

A

1-3 day prodome of mild fever and URI symptoms followed by a fairly abrupt onset of barky cough, hoarse voice and high pitched inspiratory stridor. - Typically resolve within 4-7 days

21
Q

Discuss risk stratification in croup

A

Mild disease-

  • Behaviour normal
  • Stridor - nil or only when active or upset
  • Resprate- normal
  • Acessory muscle none or minimal

Moderate disease-

  • Behaviour intermittent mild agitation
  • Stridor - Intermittent stridor at rest
  • Resprate- Increased
  • Acessory use moderate chest wall retraction

Severe disease-
-Behaviour increasing agitation or drowsiness
-Stridor - Persistent stridor at rest
-Resprate- Marked increase or decrease
-Acessory use marked chest wall retraction
Hypoxia – late sign suggest involvement of lower airways may be periarrest

22
Q

Discuss risk factors for severe croup

A

Risk factors for severe croup include:

pre-existing narrowing of upper airways
previous admissions with severe croup
young age: uncommon <6 months old, rare <3 months of age. Consider alternative diagnosis and causes of upper airway obstruction

23
Q

Discuss management of Croup

A

Minimal handaline to avoid worsening of symptoms
Allow child to adopt position of comfort
Mild and moderate croup should recieve dex 0.15mg/kg and observation
Severe 0.6mg/kg and neb adrenaline require minimum of 4 hour observation post adrenaline

24
Q

Discuss indication for admission in croup

A

Severe respiratory distress or failure
Unusual symptoms (hypoxia, hyperpyrexia)
Dehydration
Persistence of stridor at rest after epi and steroids
Persistence of tachycardai, tachynpea
Complex past medical history

25
Q

Discuss tracheomalacia

A

Results from abnormally soft underdeveloped supporting cartilage of the tracheal rings.

Primary disease is seen in healthy term newborns as well as those with conditions such as Downs or DiGeorge syndrome.

Healthy infants with isolated disease have good prognosis as cartilage strengthens with growth

Secondary disease is associated with compression of the trachea ( vascular rings, tumor, nodes or cysts) –

should be suspected with a history of stridor during the first weeks of life and worsens with agitation

26
Q

Discuss bacterial tracheitis

A

Otherwise known as membrnaous croup, bacterial croup.

Caused by severe inflammation of the tracheal epithelium and production of thick mucopurulent secretions. Microabcesses may be present. Perforation with pneumomediastinum have been described,

Traditional it has been caused by staph aureas (risk of MRSA). Other respiratory flora common. Less common and in the immunocomprimised are gram-ve bacilli. Pseudomonas, klebsiella, ecoli, corynebacterium

27
Q

Discuss clinical features of bacterail tracheitis

A

classic presentation is of a toxic child with high fevers and rapidly worsening stridor that fails to improve with racemic epinephrine.

Symptoms often overlap with croup and epiglottits.
Signs of respiratory failure and obsruction may develop rapidly

Features suggestive of bacterial tracheitis include – viral prodrome with rapid deterioation, toxic child, minimal to nil response to epinephrine and biphasic stirdor

28
Q

Discuss IX of bacterial tracheitis

A

Lateral and AP neck x-ray – subglottic narrowingm a ragged edge of the usually smooth tracheal air column, and a hazt density within the trqacheal lumen

29
Q

Discuss management of bacterial trachiaits

A

A - assess whether the child is in need of intubation – severe airway obsturction or impending failure ( marked retractions, poor air entry, fatigue, listlessness, depressed LOC) – best place is in theatre with ENT and anathesetics – double set up if needed
-endoscopic tracheal debridement may result in significant improvement and reduce need for intubation

B: maintain sats - Neb epinephrine dosing as per croup

C: fluid bolus 20mg/kg if toxic –> may require pressor if not responsive and toxic

D

AB– Vancomycin + thrid gen cephlaopsirin or augmentin

30
Q

Discuss complications of bacterial tracheitis

A 
TSS
Septic shock 
Rneal failure 
postintubation pulonary oedema 
ARDS
microabcess
mediostinitis
31
Q

Discuss CICO

A

Sugrical cricothyrotomy is not recommended for infants and young children younger than 6-`0 years. The anatomy changes with growth and it may be difficult to locate anatomy - tracheal compressibility also increase complications risk.

Needle cric is an option in these children but significant co2 retention limits its long term effectiveness.

Percutaneous transtracheal ventilation is given at an oxygen flow rate of 1L/min/year with a 1:4 inspiration to expiration ratie

32
Q

Discuss airway foreign bodies’

A

Potentially life threatening event becuase it can block respiration by obstructing the airway thereby impairing oxygenation and ventilation

The majority of aspirated foreign bodies are located in the bronchi, laryngeal and tracheal FBs are less common

  • Larynx 3%
  • trachea/carina 13%
  • right lung 60% (52 percent in the main bronchus, 6 perent in the lower bronchus and <1% in the middle lobe bronchus)
  • Left lung 23%
  • Bialteral 2%
33
Q

Discuss clinical features of airway foreign bodies

A

Depends on degree of obstruction

Children who present with severe respiratory distress cyanosis and altered mental status have tru medical emergency that demands prompt recognition life support and rigid bronchoscopic removal

More common children present with partial obstruction
-cough
- tachypnoea and stridor
focal monophonic wheeze or decreased air entry

Depending on site

1) laryngotracheal -rare but life threatening
- stridor
- wheeze
- salivation
- dyspnoea
- voice change
2) large bronchi more common
- wheeze
- dyspnoea
- choking
- shortness of breath
- resp distress
- decreased breath sounds
- fever
- cyanosis
3) larger oesophageal FB
- cab cause upper airway obstruction due to adjacent airway compression

History of witnessed choking is the most specific and sensisitive sign of forien body

34
Q

Discuss ix of foreign body in children

A

Depends on degree of suspicion

Low level of suspicion
-CXR

Moderate to high suggested by

  • witnessed FBA regardless of symptoms
  • history of choking with any subsequent symptoms or suspicious characteristics on imaging
  • young children with symptoms without other explanation especially if there are suspicious finding on CXR

IF moderate to high and stable –> organise bronch, ior can consider CT

35
Q

Discuss signs of foreing body on CXR

A

Hyperinflated lung (lucency distal to the obstruction ) - this is caused by partial airway obstruction with air trapping such that air passes with inspiration but not exhalation - obstructive emphysema

Atelectasis - usuaolly caused by complete obsturction of an airway since air is resorbed from the distal alveoli over time

Mediastinal shift - tends to shift away from the lung filed containing the FB

Pneumonia

Pulmonary abscess and bronchiectasis are late manifestations

CXR is normal in 30% of cases sensitivty if between 68-76%

36
Q

Discuss management of foreign body

A

IF well with confirmed FB –> rigid bronch, flexi bronch (multiple small), rarely thoracotomy if unable to remove with bronch

If unstable - urgent call for ENT and anaethetics

  • If becomes unresponsive start CPR checking for FB prior to each ventilation in the cycle
  • If responsive give 5 back slap and 5 chest thrusts
  • over 1 year old can consider 5 abdominal thurst

If nil releif in 1 minute direct laryngoscopy with magill forceps to visualise and remove FB
-if not able to remove find location of FB - if above cords need cric, if below intentional right main ETT to advance FB and then pull back ETT —> bronch/thoracotoamy to remove

ED fellowship paeds (15 decks)

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