Upper airway Flashcards
Compare and contrast stridor and sterdor
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
Discuss congential differential of stridor
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
Discuss Acquired differentials of stridor
Supraglottic
- Adenopathy
- tonsillar hypertrophy
- Quinsey
- foreign body
- pharyngeal abscess
- epiglottitis
Glottic
- papilloma
- foreing body
Subglottic
- croup
- bacterail tracheitis
- subglottic stenosis
- foreign body
Other anaphylaxis
Discuss IX of stridor
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
Discuss retropharyngeal abcess
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.
Discuss caustive organims for retrophayngeal abcesses
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
Discuss clinical features of retropharyngeal abcess
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
Discuss IX of retropharyngeal abscess and list complications
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
Discuss management of retropharyngeal abscess
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
Discuss peritonsilar abcess
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
Discuss ludwigs Angina
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
Discuss management of Ludwigs Angina
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
Discuss epiglottitis
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
Discuss clinical features of epiglottis
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
Discuss management of epiglottis
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
Discuss layngomalacia
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
Discuss vocal cord paralysis
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.
Discuss laryngeal webs
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
Discuss Croup
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.
Discuss clinical features of Croup
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
Discuss risk stratification in croup
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
Discuss risk factors for severe croup
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
Discuss management of Croup
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
Discuss indication for admission in croup
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
Discuss tracheomalacia
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
Discuss bacterial tracheitis
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
Discuss clinical features of bacterail tracheitis
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
Discuss IX of bacterial tracheitis
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
Discuss management of bacterial trachiaits
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
Discuss complications of bacterial tracheitis
TSS Septic shock Rneal failure postintubation pulonary oedema ARDS microabcess mediostinitis
Discuss CICO
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
Discuss airway foreign bodies’
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%
Discuss clinical features of airway foreign bodies
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
Discuss ix of foreign body in children
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
Discuss signs of foreing body on CXR
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%
Discuss management of foreign body
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
