Upper Airway Obstruction

Module 3: Pulmonology Pediatrics II
Lecture 1: Upper Airway Obstruction ZPY2017

Dr. Olivia Go
PPT/emphasized Additional Notes/Nelson
CROUP SYNDROME Stridor
Heterogenous group of mainly acute and infectious processes Harsh high-‐pitched respiratory sound produced by turbulent
characterized by bark-‐like or brassy cough, hoarseness, stridor & airflow (Area of involvement: Upper airway obstruction)
respiratory distress
History
• Acute – most likely an infectious process
• Chronic
• Other pulmonary symptoms: URTI (viral croup), suddent
onset of sore throat (epiglottitis), changes in the voice,
difficulty in breathing, tachypnea, choking/gagging
(foreign body), difficulty in breathing

Physical Examination
• Vital signs (tachypnea, tachycardia, temperature and O2
saturation)
• Listen for stridor at rest an increase in stridor when
patient is agitated
• Look at the timing of the stridor: inspiratory, expiratory
or both
o Inspiratory: extrapulmonary/extrathroacic
problem

o Expiratory: intrathoracic
Differences between adult and pediatric upper airway
o Both: area between upper and lower airways
1. Small oral cavity and large tongue
(trachea)
2. Small nares and nasopharynx • Listen for hoarseness
3. Lymph tissues grows rapidly in early childhood o Involvement of vocal cords, larynx
4. When related to body size – airways of a child are large but o Barky / brassy cough: involvement of trachea
the absolute diameter is small (5-‐6 mm) o Muffled voice: epiglottis
5. Epiglottis is narrow, omega shaped and vertically positioned • Intercostal retractions
6. The larynx of a neonate is high in the neck (larynx more • Cyanosis
anterior in location) • Any sign of stress or confusion
7. Large amount of soft tissue and loosely anchored mucous o In very young infants, any sign of irritability is
membrane à prone to developing edema an indirect sign of hypoxemia
8. Softer cartilage à prone to collapse
9. Cricoid cartilage most narrow part of the upper airway In identifying the problem, we should
10. Trachea is narrow and less rigid compared to adults • Impending respiratory failure
• Angiodedema
• Foreign body aspiration
• Presence of pus or abscess

ACUTE CAUSES OF STRIDOR CHRONIC CAUSES OF STRIDOR
Infectious Causes -‐ Congenital anomalies à
-‐ Viral Croup (LTB) recurrent/persistent
-‐ Epiglottitis symptoms
-‐ Bacterial tracheitis -‐ Laryngomalacia
-‐ Retropharyngeal abscess -‐ Vascular ring
-‐ Peritonsillar abscess -‐ Subglottic stenosis
-‐ Vocal cord paralysis
Non-‐Infectious Causes -‐ Tracheal cyst
Demarcation of upper and lower airway: -‐ Spasmodic croup -‐ Foreign body
• Accdg to Nelson: Larynx -‐ Foreign body -‐ Laryngeal papilloma
• Other books: -‐ Aspiration
o Extrathoracic: upper airways -‐ Angioedema
o Intrathoracic: lower airways -‐ Mass lesion
o So the trachea partly belongs to the upper and
lower airways

1
Dr. Olivia Go
Croup Syndrome Differential Diagnosis

LTB Epiglottitis Bacterial tracheitis Spasmodic croup

2-‐6 y/o
Age 3 mo-‐6 y/o (prior to the onset of Hib 5-‐7 y/o 1-‐3 y/o
vaccination)
Parainfluenza (most H. influenza Viral
S. aureus
common) S. pyogenes Allergic
Etiology Moraxella catarrhalis
RSV S. pneumoniae Psychologic
Anaerobes
Adenovirus S. aureus
Location Influenza A,B
Subglottic Supraglottic Trachea Subglottic
Biphasic illness
Variable Rapid, short (usually start with viral croup
Onset before deterioration)
Sudden
(12 hrs-‐7 days) (4-‐12 hrs)
with rapid deterioration
URTI
None or mild URTI Purulent airway
Prodrome URTI None
Sore throat secretions
Fever Low/High High High None
Voice Hoarse Muffled N/Hoarse Hoarse
Cough Barking None Brassy Barking
Present
Drooling of saliva
Dysphagia Absent (epiglottis between esophagus
Absent Absent
and airway, secretions cannot
be swallowed)
Toxicity +/-‐ + + -‐
Tripod position
(epiglottis falls forward and
Comfortable in different opens airways) Comfortable in Comfortable in different
Position positions different positions positions
Very toxic looking
(never examine the throat of the
patientàagitatedàspasm)
Stridor I>E I I & E I

(late sign)
Crackles
Lung findings +/-‐ Wheezing Mucus rales or rhonchi No abnormal findings
+/-‐ Wheezing
Thumb sign
Steeple sign
(swollen epiglottis)
Radiographic Ragged air column

(debris, sloughed off mucus Normal
findings
membranes)

Endoscopic Deep red mucosa Cherry red epiglottis Deep red mucosa Pale mucosa
findings Subglottic narrowing Ary-‐epiglottic swelling Copious secretions Subglottic narrowing
WBC Normal / Leucopenia Leukocytosis with Leukocytosis with left Normal
left shift shift
Racemic Intubation Cool mist
Epinephrine Steroids Intubation
Treatment Antibiotics (sudden symptoms recur for
Cool mist Antibiotics 2-‐3 nights)
Tracheal suctioning
Prognosis Excellent Excellent with proper Excellent Excellent
treatment
Prevention Flu vaccine HIB vaccine None None
2
Dr. Olivia Go
EPIGLOTTITIS
*If you want to inspect the throat: Double set-‐up à OR + Anesthesiologist à to prepare for intubation/tracheostomy as needed
*Radiology: Lateral X-‐ray view but may cause asphyxia (prepare double set-‐up)

Croup Syndrome Differential Diagnosis
Feature Peritonsillar abscess Retropharyngeal Foreign body Angioneurotic edema
abscess
<4 y/o
Age >10 y/o (younger – increase in Any age group Any age group
lymphnode tissues)
Group A Group A
Etiology Streptococcus Streptococcus S. Small objects C1 esterase deficiency
aureus
Anaerobes
Anaerobes
Location Oropharynx Posterior pharynx Variable Variable
Biphasic illness Insidious to
Onset (first, tonsillitis) then, Sudden Sudden
sudden worsening sudden
High fever High fever Choking / Gagging

Sore throat Sore throat Coughing
Clinical
Muffled voice Muffled voice Aphonia (larynx) Hoarseness
manifestations
Drooling Drooling Unilateral wheezing
(lower airways-‐bronchus)
Dysphagia Dysphagia Hoarseness
Trismus Thickened
(spasm of the jaw muscles)
retropharyngeal
Radiographic
(displaced uvula; space Radioopaque Subglottic narrowing
findings
asymmetric (posterior object
tonsilar bulge) pharyngeal bulge;
neck stiffness)
WBC
Leucocytosis w/ Leucocytosis w/ Normal Normal
left shift left shift
Endoscopic
Tonsillar abscess Retropharyngeal Foreign body Supra and subglottic
findings mass/bulge swelling
Antibiotics
Treatment
Antibiotics Incision and Endoscopic Epinephrine
Aspiration drainage removal Steroids
(Trendelenberg position)
Prevention None None Avoid small objects Avoid allergens

Supervision

Croup Syndrome Management
GOAL: Provide adequate ventilation
1. Cool Mist
Benefits
-‐ Moistens airway secretions
-‐ Soothes inflamed mucosa
-‐ Decreases viscosity of tracheal secretions
-‐ Avoids risk of burns with steam inhalation Adverse effect
-‐ May intensify bronchospasm in children with asthma or wheezing

2. L-‐epinephrine
Dose: 0.01 ml/g of the 1:1000 dilution to a max of 5 ml/dose SC
Indications
-‐ Moderate to severe stridor at rest
-‐ Possible need for intubation
-‐ Presence of respiratory distress
-‐ Hypoxia
-‐ No response to cool mist
-‐ Given by aerosol Dose
-‐ 0.01 mL/kg of the 1:1000 dilution to a maximum of 5.0 mL/dose SC
3
Dr. Olivia Go
Use with caution in patients with
-‐ Tachycardia
-‐ Congenital heart disease
o Tetralogy of Fallot
o Ventricular Outlet Obstruction

3. Racemic Epinephrine (not available in the Ph)
Dose
-‐ 0.25-‐0.75 mL of a 2.25% in 3 mL normal saline

4. Corticosteroids
-‐ Dexamethasone: 0.15-‐0.6 mg/kg (maximum 10 mg/dose) oral, IV or IM, stat dose
-‐ Budesonide nebulization: 200-‐400 mcg, stat dose
-‐ Oral Corticosteroids 2-‐4 mg/kg/day

Discharge criteria at the ER
-‐ No stridor at rest
-‐ Normal air entry
-‐ Normal color
-‐ Normal level of consciousness
-‐ Received a dose of 0.6 mg/kg of dexamethasone, orally or intramuscularly

Endotracheal intubation
-‐ Hypercarbia
-‐ Increasing stridor
-‐ Impending respiratory failure
-‐ Exhaustion à bradypnea à respiratory arrest

Helium-‐oxygen mixture (heliox)
(Low density and viscosity)
-‐ Easily moves through obstructed airways
-‐ Improves laminar gas flow
-‐ Decreases mechanical work of respiratory muscles

Antibiotics
-‐ Philippines: Ampicillin and Chloramphenicol
-‐ Developed countries: higher generation drugs
o Cefuroxime alone or with a semi-‐synthetic penicillin such as Oxacillin
o Ampicillin-‐sulbactam
o Ceftriaxone
o Cefotaxime

Rifampicin
20 mg/kg QD for 4 days (Chemoprophylaxis for contacts of patients with invasive HIB infection)
-‐ Contact <4years incompletely immunized
-‐ Contacts <1year with no vaccination series
-‐ Immunocompromised child in the household
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Upper Airway Obstruction

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Module 3: Pulmonology Pediatrics II

Lecture 1: Upper Airway Obstruction ZPY2017

Stridor I>E I I & E I

Radiographic Ragged air column

High fever High fever Choking / Gagging

Prevention None None Avoid small objects Avoid allergens

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