Upper Airway Obstruction Paeds Flashcards
Management steps in acute management of unstable patient with upper airway obstruction?
1) Stabilise airway, breathing & circulation
2) +/- intubate or place a surgical airway
3) Obtain IV access
4) Continuous vital sign monitoring
5) +/- supplemental O2
Typical history in epiglottitis?
- Rapid onset of high fever
- Difficulty breathing & swallowing
- Drooling
- NO cough
What does exam typically reveal in epiglottitis?
- Anxious-appearing child
- Sitting forward w/ neck extended in a tripod position w/ chin forward.
- Muffled voice
- Audible stridor w/ laboured breathing
- Cherry red epiglottis
What imaging can be ordered in susepcted epiglottitis?
Laternal neck XR
What will a lateral neck XR reveal in epiglottitis? (2)
1) Thumb sign
2) Swelling of epiglottic folds
Typical history in bacterial tracheitis?
1) Viral URTI
2) Rapid onset of:
- high fever
- progressive stridor
- respiratory distress
- hoarseness
3) Not responsive to nebulised adrenaline
Physical exam findings in bacterial tracheitis? (2)
1) Toxic appearing child
2) Biphasic stridor
What is a toxic appearing child?
Toxic appearance is a clinical presentation characterised by:
1) lethargy
2) poor perfusion
3) marked hypo/hyperventilation
4) cyanosis
What are 4 causes of nasopharyngeal obstruction?
1) Retropharyngeal abscess
2) Peritonsillar abscess
3) Tonsillitis
4) Adenotonsillar hypertrophy
Typical history in retropharyngeal abscess?
1) Typically a preceding viral URTI
2) Neck pain
3) Dysphagia –> poor oral intake
4) Chest pain +/- dyspnoea
Physcial exam findings in retropharyngeal abscess?
1) Anxious & ill appearing
2) Stiff neck & limited neck mobility
3) Palpable neck mass
4) Drooling
5) Respiratory distress
Position of child with epiglottitis vs retropharyngeal abscess?
Epiglottitis –> drool & lean forward in tripod position
Retropharyngeal abscess –> drool & hyperextend neck
Typical history in peritonsillar abscess?
- Worsening sore throat
- Decreased oral intake
- Classic ‘hot potato’ voice
- +/- dysphagia
- +/- unilateral otalgia
Physical exam findings in peritonsillar abscess?
Unilateral tonsillar bulging +/- uvular deviation, drooling or trismus.
How is a diagnosis of peritonsillar abscess made?
Clinical –> doesn’t require imaging
Typical history of tonsillitis?
- Sore throat
- Constitutional symptoms: fever, fatigue
Physical exam findings in tonsillitis?
- Erythematous pharynx
- Enlarged tonsils often w/ exudates
- +/- cervical lymphadenopathy
What is the most common cause of paediatric upper airway obstruction?
Adenotonsillar hypertrophy
What is adenotonsillar hypertrophy?
Abnormal growth of the pharyngeal tonsil and palatine tonsils.
Typical history in adenotonsillar hypertrophy?
- Nightime snoring
- Daytime sleepiness
- Attention or behavioural problems
- +/- apnoeic episodes
Physical exam findings in adenotonsillar hypertrophy?
- Mouth breathing
- Significantly enlarged tonsils
Some craniofacial malformations can cause upper airway obstruction shortly after birth.
Name 3
1) Bilateral choanal atresia –> causes neonatal respiratory distress during feeding (relieved w/ crying)
2) Nasal deformities e.g. cleft lip/palate
3) Micrognathia
Assess patient for stridor or wheezing.
If stridor during inspiration is present, what should you consider?
Supraglottic or glottic causes of upper airway obstruction.
What are 3 causes of supraglottic or glottic upper airway obstruction?
1) Croup
2) Laryngomalacia
3) Vocal cord dysfunction
Typical age of croup?
6 months to 3 years
Typical history in croup?
- Low grade fever
- URT symtoms e.g. rhinorrhoea, nasal congestion
- Hoarseness
- Barking/seal-like cough
What does physical exam reveal in croup?
- Tachypnoea
- Normal O2 sats
- +/- suprasternal, intercostal & subcostal retractions
What imaging can be done in suspected croup?
Lateral neck XR
What is seen on a lateral neck XR in croup?
‘Steeple sign’ w/ suglottic narrowing
What age is laryngomalacia typically seen?
3-5 months
When is stridor worse in laryngomalacia?
During feeding, activity & supine position
When does stridor improve in laryngomalacia?
In prone position (i.e. on tummies)
Typical history in vocal cord obstruction?
Acute onset of dyspnoea - triggered by physical activity or strong emotions.
Laboured breathing.
Key investigation in vocal cord dysfunction?
Flexible fiberoptic laryngoscopy
Typical age of presentation of vocal cord dysfunction?
Older child or adolescent
What will flexible fiberoptic laryngoscopy show in vocal cord dysfunction?
Inappropriate adduction of vocal cords during inspiration.
What can vocal cord dysfunction ofen be confused with?
Asthma
What does a biphasic stridor mean?
Present during inspiration and expiration.
What should you consider as cause of obstruction in a biphasic stridor?
Subglottic causes of airway obstruction.
- Vascular ring or sling
- Subglottic stenosis
What is a pulmonary sling?
The left pulmonary artery (transports oxygen-depleted blood from the heart to the lungs) has an unusual origin –> origin of the left pulmonary artery from the posterior aspect of the right pulmonary artery.
This anatomical vascular anomaly can compress nearby structures.
What vessel is anomalous in pulmonary sling?
Left pulmonary artery
Typical history in pulmonary sling?
1) Infant w/ dyspnoea & noisy breathing
- improves with neck extension
- worsens with neck flexion
2) Biphasic stridor
3) Monophonic wheeze
Key investigation in pulmonary sling?
Barium swallow
Mx of croup?
Single dose of dexamethasone
What is the most common organism causing croup?
Parainfluenza
What does barium swallow reveal in pulmonary sling?
Anterior indentation of oesophagus.
Typical history in subglottic stenosis?
- History of prolonged or recurrent intubation
- Chronic barking cough
- Biphasic stridor that is louder w/ increased respiratory effort
Diagnostic investigation in subglottic stenosis?
Bronchoscopy
What is a typical preceding factor in subglottic stensois?
Prolonged or recurrent intubation
What will bronchoscopy show in subglottic stenosis?
Narrowing below vocal cords
What is tracheomalacia?
The walls of trachea collapse (can happen because the walls of the windpipe are weak, or because something is pressing on it.).
What age does tracheomalacia typically occur/resolve?
Occur –> 0-2y
Resolve –> 2y
Typical history in tracheomalacia?
Cough & intermittent cyanotic episodes:
- worse after bronchodilator use
- improve with prone positioning
Typical exam findings in tracheomalacia?
1) Monophonic, central expiratory wheeze
2) +/- audible biphasic stridor
What is diagnostic investigation in tracheomalacia?
Bronchoscopy
What is seen on bronchoscopy in tracheomalacia?
Collapse of the tracheobronchial tree
1st line investigation in suspected foreign body inhalation?
Bronchoscopy
3 typical causes of airway obstruction in UNSTABLE patients?
1) Epiglottitis
2) Bacterial tracheitis
3) Anaphylaxis
ABCDE management of acute asthma?
1) ABCDE approach
2) O2 (keep sats >94%)
3) Nebulised salbutamol +/- ipratropium bromide
4) Steroids
5) IV therapy e.g. magnesium sulphate, salbutamol, aminophylline
What are some signs of poor asthma control?
- regular symptoms
- multiple hospital admissions
- poor exercise tolerance
- faltering growth
- missing school, poor educational achievement
- risk of death
What can be an unpleasant side effect of LTRA therapy (e.g. montelukast)?
Night terrors
What time of the year is bronchiolitis typically seen?
Winter months
Pathophysiology of bronchiolitis
Virus invades respiratory epithelium:
1) Increased mucus production
2) Bronchiolar obstruction
3) Pulmonary hyperinflation & atelectasis
Features of croup?
1) Coryzal prodrome
2) Barking cough
3) Low grade fever
4) Inspiratory stridor
5) Hoarse voice
Croup management?
1) ABCDE
2) Keep child calm, avoid throat exam
3) Steroids (oral dex)
4) Nebulised adrenaline
5) Intensive care
What causes bacterial tracheitis?
HiB
