Acute upper airway obstruction is Blockage of any portion of the airway above the thoracic inlet. Stridor, suprasternal retractions, and change of voice are the sentinel signs children . tx

Most common life-threatening emergencies in pediatric practice.
Little time for deliberation, and it may lead to significant morbidity and indeed mortality.
Blockage of any portion of the airway above the thoracic inlet.
Stridor, suprasternal retractions, and change of voice are the sentinel signs

1. Acute upper airway obstruction Dr R ita Panyang Kataki Associate Professor Pediatrics

2. Most common life-threatening emergencies in pediatric practice. L ittle time for deliberation, and it may lead to significant morbidity and indeed mortality. B lockage of any portion of the airway above the thoracic inlet . Stridor , suprasternal retractions, and change of voice are the sentinel signs

3. Stridor is a harsh, vibratory sound of variable pitch caused by partial obstruction of the respiratory passages that result in turbulent airflow through the airway .

4. Type of stridor Inspiratory stridor - Harsh, high pitched sound produced when child inspires through a spasmodically closed glottis. Expiratory stridor -Singing sound due to semi approximated vocal cords offering resistance to exhalation or to due to tracheo -bronchial obstruction. Biphasic stridor - harsh sound of vibratory quality produced due to little change in airway size with respiration caused by a fixed obstruction and, heard during both phases of respiration.

5. If a child’s stridor becomes softer but the work of breathing remains increased, the obstruction may begetting worse; if the child is unable to sustain increasedwork of breathing he is getting tired

6. Pathophysiology of upper airway obstruction in children

7. Common causes of upper airway obstruction in children

8. History Characteristics of the onset of illness Development of respiratory signs Characteristics of voice and voice change—if present Pattern of fever, duration as well as the severity History of trauma to head or neck— Neurogenic stridor History of choking—to exclude foreign body aspiration Epidemiological conglomeration of similar cases— Diphtheria, Viral croup

9. Physical Examination General appearance and posture Cry or voice (pitch, aphonia , muffled, hoarse) Difficulty in a child’s ability to handle oral secretions. Nasal flaring Degree of dyspnea and respiratory pattern Use of accessory muscles of respiration (degree of retractions) Look for craniofacial anomalies (maxillary hypoplasia , nasal septal deviation, micrognathia, retrognathia, platybasia, or macroglossia ) Throat examination : look for acute inflammation of tonsils, faucial pillars, evident exudates and membrane. Neck examination: look for any extrinsic mass, evidence of trauma and tracheal position

10. Classic features of common upper airway disorders

11. Diagnostic algorithm in a child with stridor

12. Laboratory Testing and Imaging No investigation is warranted before stabilizing the airway. A physician who is competent in providing airway support may accompany to stable patients to the X-ray department

13. X-RAY CROUP

14. EPIGLOTTITIS

15. croup Croup - term used to describe the clinical picture of laryngotracheitis . Hoarse voice Barking cough Inspiratory stridor Possible respiratory distress

16. etiology Laryngotracheobronchitis (croup) Parainfluenza virus Adenovirus Echovirus Influenza viruses Respiratory Syncytial viruses Mycoplasma H.influezae

17. Pathogenesis Subglottic narrowing due to inflammation. Cricoid ring allows fixed area for obstruction. 1mm swelling causes 65% obstruction in infant

18. pathogenesis Atelectasis /mucus plugging Ventilation/perfusion mismatch Negative intrapleural pressure may lead to varying degrees of pulmonary edema. Hypoxia/ hypercarbia Air hunger Anxiety/Lethargy/ Obtundation .

19. Specific Management Guidelines Croup Syndrome Management Assess the child for severity of respiratory distress Give resuscitative or supportive therapy accordingly. Westley’s clinical croup score may be used to determine the severity

20. Westley’s clinical croup score

21. Management guidelines for croup based on Westley’s croup score Score 0–2 : Mild Budesonide nebulization therapy one dose or Dexamethasone one dose of 0.6 mg/kg iv / im If child is older than 6 months and parents are reliable, child can be discharged. Advise cold mist therapy at home.

22. Cont. Score : 3–5 Moderate Dexamethasone 0.6 mg/kg im or iv stat Cold humidified oxygen; Minimize situations that may precipitate distress in the child. Monitor using Westley’s score at 30 min interval and re-classify. Child can be discharged only if he improves to mild category at the end of 6 h, has age more than 6 months and parents are reliable

23. Cont. Score :6–11 Severe As moderate plus Administer Adrenaline 5 ml 1:1000 (5 mg) solution as nebulization . Monitor using Westley’s score at 30 min interval and re-classify according to score. Responsive to initial therapy Child can be observed in ER if the score improves to be classified as moderate category. Recurrence of respiratory distress can be treated with repeat adrenaline nebulization , Dexamethasone 0.6 mg/kg/dose q6 hourly × four doses Poor response to initial therapy Airway stabilization and ICU care are indicated in a child who remains in severe category even after the above mentioned therapy

24. Cont. Score :12–17 , Acute life-threatening Proceed to Airway stabilization (Intubation/ Tracheostomy ) and ICU care

25. Acute Epiglottitis Management Give Oxygen: Start high flow oxygen through rebreathing mask. Try not to upset the child Do not attempt to look inside the mouth as this may precipitate airway obstruction Call for anesthetist and/ or ENT specialist for help. While waiting for help, give adrenaline nebulization 5 ml of 1:1000 (1 mg/ml) solution. Airway assessment. Try to answer following questions: unsecure airway? Obstruction severe? Epiglottitis on direct laryngoscopy ? If answer to any of these questions is yes, child should be intubated by a specialist preferably in operation theatre under inhalational anesthesia

26. Send a blood culture. Start Cefotaxime 50 mg/kg/ dose,IV q 6 hourly following a loading dose of 100 mg/kg. Continue the supportive management and arrange for PICU transfer. Prophylactic Rifampicin 20 mg/kg/dose OD × 4 days to be given for all household contacts

27. Bacterial Tracheitis Give oxygen in nonthreatening manner Active management of airways. Endotracheal intubation should be done in any child with audible stridorat presentation. It is recommended to start with Cloxacillin :100–200 mg/ kg in four divided doses/day Amikacin:15mg/kg/day in once a day dose and Clindamycin : 10 mg/kg/ doseTID .

28. Airway Burns Management Give oxygen in nonthreatening manner Early tracheostomy is indicated in any child with audible stridor at presentation. Child with facial burns and suspected smoke inhalation having soon to-be obstructed airway should receive endotracheal intubation. Preferably intubation should be done in a controlled atmosphere by a specialist. Endotracheal intubation can later be converted to tracheostomy after the management of surface burns

29. Angioneurotic Edema Management Give oxygen in nonthreatening manner Active management of airways. Endotracheal intubation should be done in any child with audible stridor at presentation. This condition is treated by administration of - adrenaline (1:1000), subcutaneously 0.01 ml/kg (maximum 0.3 ml); - hydrocortisone 10 mg/kg IV -antihistamines like chlorpheniramine

30. Diphtheria Management Laryngeal Diphtheria Membranous pharyngitis progress over a period of 2 to 3 days to manifest with hoarseness of voice, dysphagia and minimal to severe inspiratory stridor . The patient is usually nontoxic in appearance but may have low grade fever.

31. Give Oxygen. Send throat swab for bacteriological studies (Albert’s stain and culture) to confirm the diagnosis. Airway management: Endotracheal intubation should be avoided, and early tracheostomy to establish emergency airway Give diphtheria antitoxin 80,000 to 120,000 units IV infused over 1 h.

32. Crystalline penicillin 40,000 U/kg/dose iv, q 6 hourly × 14 days; Erythromycin 15 mg/kg/dose q 8 hourly (not to exceed 2 g/day) × 14 days may be used in those sensitive to penicillin. Patients should be isolated until three consecutive cultures is negative after completion of treatment. Contacts should receive erythromycin15 mg/kg/dose q 8 hourly for 7 days

33. Retropharyngeal Abscess Management Start oxygen in nonthreatening manner. Try not to upset child Airway management: Endotracheal intubation should be done in any child with audible stridor at presentation. Orotracheal intubation is preferred because of the risk of rupture of abscess. Start with Cloxacillin (50 mg/kg/dose q 6 hourly) Amikacin (15 mg/kg/day in once a day dose) along with clindamycin (10 mg/kg/dose TID). Surgical drainage

34. Thank you