assessment & management of acute upper airway obstruction in children

Assessment & Management of Acute Upper Airway Obstruction

in Children

Differential Diagnosis:

Acute Upper Airways Obstruction

Croup:

• Viral Laryngotracheobronchitis (very common)• Recurrent or spasmodic croup (common)• Bacterial tracheitis (rare)

Differential Diagnosis: Acute Upper Airways Obstruction

Rare Causes:• Epiglottis• Inhalation of smoke and hot air in fires• Trauma to the throat• Retropharyngeal abscess• Laryngeal foreign body• Angioedema• Infectious mononucleosis• Measles• Diphtheria• Acute-on-chronic stridor e.g. a floppy larynx

(laryngomalacia)

Acute Laryngotracheobronchitis-1

Age

Location

Aetiology

Onset

Stridor

Retractions

Voice

Position & appearance

Acute Laryngotracheobronchitis-1Age 6/12 – 3 years

Location Subglottic

Aetiology Parainfluenza, influenza, RSV; rarely Mycoplasma, adenoV, measles

Onset Insidious, URTI

Stridor Yes

Retractions Yes

Voice Hoarse

Position & appearance

Normal

Acute Laryngotracheobronchitis-2

Swallowing

Barking cough

Toxicity

Fever

X-ray

WBC count

Treatment

Prevention

Acute Laryngotracheobronchitis-2

Swallowing NormalBarking cough

Yes

Toxicity Rare

Fever <38C

X-ray Subglottic narrowing/ steeple sign

WBC count Normal

Treatment Oral Dexamethasone/Neb. Budesonide

Prevention None

Sign ?

Sign ?

Spasmodic Croup-1

Age

Location

Aetiology

Onset

Stridor

Retractions

Voice

Position & appearance

Spasmodic Croup-1

Age 3/12 – 3 years

Location Subglottic

Aetiology Unknown

Onset Sudden onset at night; prior episodes

Stridor Yes

Retractions Yes

Voice Hoarse

Position & appearance

Normal

Spasmodic Croup-2

Swallowing

Barking cough

Toxicity

Fever

X-ray

WBC count

Treatment

Prevention

Spasmodic Croup-2

Swallowing NormalBarking cough

Yes

Toxicity No

Fever None

X-ray Subglottic narrowing

WBC count Normal

Treatment Occasionally Steroids needed

Prevention None

?

Epiglottitis - 1

Age

Location

Aetiology

Onset

Stridor

Retractions

Voice

Position & appearance

Epiglottitis - 1Age 2 – 6 years

Location Supraglottic

Aetiology HIb & HIa

Onset Rapid short prodrome

Stridor Yes – soft inspiratory

Retractions Yes

Voice Muffled

Position & appearance

Tripod, leaning forward; agitated

Epiglottitis -2Swallowing

Barking cough

Toxicity

Fever

X-ray

WBC count

Treatment

Prevention

Epiglottitis - 2Swallowing Drooling

Barking cough

No

Toxicity Severely toxic

Fever > 38.5 C

X-ray Thumb sign of thickened epiglottis

WBC count High Neutrophil count

Treatment Entotracheal Intubation involve senior Anaesthetist/ ENT Consultant. IV antibiotic

Prevention None

?

Retropharyngeal Abscess-1

Age

Location

Aetiology

Onset

Stridor

Retractions

Voice

Position & appearance

Retropharyngeal Abscess-1Age < 6 years

Location Posterior pharynx

Aetiology S aureus, anaerobes

Onset Insidious to sudden

Stridor None

Retractions Yes

Voice Muffled

Position & appearance

Arching of neck or normal

Retropharyngeal Abscess-2Swallowing

Barking cough

Toxicity

Fever

X-ray

WBC count

Treatment

Prevention

Retropharyngeal Abscess-2

Swallowing Drooling

Barking cough

No

Toxicity Severely toxic

Fever > 38 C

X-ray Thickened Retropharyngeal space

WBC count High Neutrophil count

Treatment IV antibiotic +/- surgical drainage

Prevention None

Angioedaema-1

Age

Location

Aetiology

Onset

Stridor

Retractions

Voice

Position & appearance

Angioedaema-1

Age All ages

Location Variable

Aetiology Congenital C1-esterase deficiency

Onset Sudden

Stridor Yes

Retractions Yes

Voice Hoarse, may be normal

Position & appearance

Normal; may have facial oedema, anxiety

Angioedaema-2

Swallowing

Barking cough

Toxicity

Fever

X-ray

WBC count

Treatment

Prevention

Angioedaema-2Swallowing Normal

Barking cough

Possible

Toxicity No, unless anaphylactic shock/severe anoxia

Fever None

X-ray Subglottic narrowing/ steeple sign

WBC count Normal

Treatment High Flow O2, Epinephrine, IV fluids, IV Hydrocortisone; danazol, C1-esterase Infusion

Prevention Avoid allergens; FFP; danazol

?

Laryngeal Papillomatosis-1

Age

Location

Aetiology

Onset

Stridor

Retractions

Voice

Position & appearance

Laryngeal Papillomatosis-1Age 3/12 – 3 years

Location Larynx, vocal cords, trachea

Aetiology Human Papilloma Virus (HPV)

Onset Chronic

Stridor Possible

Retractions No

Voice Hoarse

Position & appearance

Normal

Laryngeal Papillomatosis-2

Swallowing

Barking cough

Toxicity

Fever

X-ray

WBC count

Treatment

Prevention

Laryngeal Papillomatosis-2Swallowing Normal

Barking cough

Variable

Toxicity None

Fever None

X-ray May be normal

WBC count Normal

Treatment Laser Therapy, repeated excision, Bleomycin, interferon

Prevention Treat maternal genitourinary lesions; consider Caesarean Section

Can a haemangioma cause an airway obstruction ?

Lower Airway Diseases - Acute

• Asthma

• Bronchiolitis

• FB

• Aspiration of Gastric contents

Asthma - assessment of severity

• Altered consciousness or agitation• Exhaustion• Ability to talk – sentences, phrases or words• Feeding & drinking• Central cyanosis• Accessory muscle use• Sternal recession• Heart rate ( >6 years) 100, 100-120, >120• Wheeze• Pre-neb sats: >93%, 91-93% & <90%• PaCO2: > 5 kpa

Acute severe asthma

• High flow oxygen 10-15 litres (mask & res)• Neb Salbutamol +/- Ipratobium – 20 -30min• IV access• IV Hydrocortisone 4mg/kg x 4 hours• IV Salbutamol 15 mcg/kg (5mcg/kg <2 yrs) over

10 min – 1-5 mcg/kg infusion• +/- IV Aminophylline Infusion 5mg/kg 15-20 min•

• Asthma – reactive airway disease• Hypersensitivity reactions• Tracheo-bronchomalacia• Vocal cord adduction• Airway compression• Aspiration (FB, GOR, Swallowing dysfunction,

TOF)• Bronchiectasis, CF, PCD (ICS), Tumours,

Bronchiolitis obliterans, post BPD• CCF

Lower Airway Diseases - Chronic