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