seminar upper airway obstruction edited (1).PPTX

Ppt

1. 1 COLLEGE OF MEDICINE AND HEALTH SCIENCE DEPARTMENT OF PUBLIC HEALTH SEMINAR ON UPPER AIRWAY OBSTRUCTION IN THE PEDIATRICS WARD NAME ……………………….ID NO . SOLOMON MESENA------ 1938/13 DAGMAWIT TAMRAT DEMSEW TADELE Moderator - dr.Shemsu YARED Gebremedhen Submissio n date Date 25/12/2015 ASRAT MULATU

2. CONTENT Introduction Foreign body aspiration Epiglottitis Croup Bacterial tracheitits 2 UPPER AIR WAY OBSTRUCTION

3. 3 Anatomy of the airway

4. Airway obstruction is a blockage of respiration in the airway that hinders the free flow of air. is a life-threatening condition and requires urgent attention and assistance when it is needed. It can be classified into upper airway (UAO ) and lower airway(LAO) anatomical complete and partial airway obstruction reversible or fixed airway obstruction 4 Introduction

5. UAO is defined as occlusion or narrowing of the airways leading to compromise in ventilation . Stridor (high pitch sound, audible without stescope) mainly on inspiration. Acute upper airway obstruction from any cause can be life threatening emergency. Complete obstruction will result in respiratory failure followed by cardiac arrest in a within short of time. Infectious etiologies accounts for 90% of these, with viral croup accounting for 80% of the case. 5 Introduction…

6. A. Extrinsic airway compression & narrowing Masses Enlarged lymph nodes Enlarged tonsils 2. Trauma Neck & Chest injury 3. Infection Peritonsillar Abscess Retropharyngeal Abscess 6 Classification of causes of UAO

7. B . Intrinsic airway narrowing & collapse 1.Malformations Laryngotracheomalacia Laryngeal stenosis 2.Masses Foreign body in the airway Laryngeal polyps or papillomatosis 3. Trauma Intubation Burns Neck injury 7 Classification…

8. 4. Infection 90 % Laryngeal diphtheria Epiglottitis Croup ( Laryngotracheobronchitis ) 80 % Bacterial tracheitis 5 . Allergic reactions Anaphylaxis(edema) 6.Miscellaneous Vocal cord paralysis Laryngospasm 8 Classification…

9. It occurs when a foreign body enters to the airway which can cause difficulty breathing or choking. Foreign body aspirated in to air passages can lodge in the larynx, trachea or bronchi. Site of lodgment depends on the size & nature of the foreign body. Aspiration of foreign bodies is most common in children between 1 and 4 years of age . Accidental aspiration occurs when they suddenly inspire during play or fight while having something in the mouth . Particularly in children with neurologic disorders or delayed development 9 Foreign Body Aspiration

10. Non-irritating type ( inorganic) plastic , glass or metallic objects are relatively non irritating & remain symptomless for a long time. Irritating type ( organic) Vegetables like peanuts, beans, peas set up a diffuse violent reaction leading to congestion & edema of the airway mucosa. They may swell up with time causing airway obstruction & latter suppuration 10 Nature of foreign body

11. 11 Clinical features Symptomatology is divided in to three stages ; 1 . Initial period of chocking , gagging & wheezing : lasts for short time, foreign body may be coughed out or it may lodge in the larynx or further down in the tracheobronchial tree . 2.Symptomless interval - Respiratory mucosa adapts to the presence of foreign body & initial s ymptom disappear. 3.Later symptoms They are caused by obstruction to the airway, inflammation or trauma induced by foreign body & would depend on the site of its lodgment

12. A large foreign body may totally obstruct the airway leading to sudden death unless resuscitative measures are taken urgently. A partially obstructive foreign body will cause discomfort or pain in the throat, hoarseness of voice, croupy cough, aphonia , dyspnea , wheezing or hemoptysis . Tracheal foreign body A sharp foreign body will only produce cough & hemoptysis. A loose foreign body like seed may move up & down the trachea b/n the carina & the under surface of vocal cords causing ‘audible slap’. Wheeze may also present. 12 Laryngeal foreign body

13. Most foreign bodies enter the right bronchus. - There are three possible types of obstruction; Stop valve (complete obstruction) T here is neither entry nor exit of air distal to obstruction resulting in obstructive atelectasis ( collapse). Ball valve( one way obstruction) – there is only entry of air distal to obstruction resulting in obstructive emphysema. Bypass valve(partial obstruction) – both entry & exit of air distal to obstruction is possible 13 Bronchial foreign body

14. Clinical, detailed history of foreign body ingestion & physical examination of neck & chest. Radiopaque objects can be seen clearly on radiographs. 14 Diagnosis

15. 15

16. Pleural effusion Lung emphysema Lung abscess Pulmonary embolism Pulmonary hemorrhage Respiratory infection 16 complication S

17. If a child presents with complete airway obstruction (if unable to speak or cough) dislodgement by Back blows and chest compressions in infants Heimlich maneuver in older children should be attempted. In contrast, these interventions should be avoided in children who are able to speak or cough since they may convert a partial to a complete obstruction 17 Emergency Management of FBA

18. 18

19. Four back blows followed by 4 chest trusts The back blows loosen the FB and the chest trust increases the intra thoracic pressure After the chest trust the mouth should be opened and a visualized FB should be grasped and removed 19 Infants

20. Heimlich’s maneuver Child placed on his back Rescuer kneels next to the patient and using the heal of one hand performs 6-10 abdominal thrusts by pushing upwards and inward from the mid abdomen, midway between the umbilicus and rib cage. If FB not removed repeat after rescue breathing Cricothyrotomy or emergency tracheostomy should be done if Heimlich’s maneuver fails. 20 Age greater than one year

21. Once acute respiratory emergency is over, foreign body can be removed by direct laryngoscopy. Tracheal & Bronchial foreign bodies can be removed bronchoscopy with full preparation & under general anesthesia. Any child suspected of foreign body aspiration should be reffered immediately to facilities with bronchoscopy for confirmation of diagnosis & removal 21 Cont...d

22. EPIGLOTTITIS 22

23. Epiglottitis is an acute inflammatory (infectious) process involving the epiglottis and surrounding structures. Epiglottitis is commonly caused by an infection. The resulting inflammation causes swelling, which blocks air to the lungs. 23 Epiglottitis

24. Epidemiology Children between the ages of 2 and 7 years are affected and the peak incidence occurs at about 3 and a half years of age. the male to female ratio is 3:2. There is no seasonal variation. 24 Cont …

25. Etiology Epiglottitis is usually caused by an infection from Haemophilus influenza type b ( Hib ) bacteria , the same bacteria that cause pneumonia and meningitis. Rarely streptococcus pneumoniae and streptococcus pyogeanes can lead to epiglottitis. 25 Cont …

26. Clinical manifestations Classically epiglottitis starts suddenly with rapid progression to complete obstruction. Patients are toxic with High grade fever, Sore throat, Dysphagia, Tachycardia, Restlessness, Drooling of saliva and stridor Elder children may hyperextend their neck & sit leaning forward. 26 Cont …

27. Mainly clinical Lateral neck X-Ray –show swollen epiglottis(thumb sign). Laryngoscope –Shows swollen & erythematous epiglottis, if it is done with proper preparation for respiratory support or intubation . CBC -may show leukocytosis 27 Diagnosis

28. Epiglottitis is a medical emergency and warrants immediate treatment with Tracheostomy or Intubation placed under controlled conditions, either in an operating room or intensive care unit. Antibiotics Chloramphenicol 75-100mg/kg/day for 1-3 weeks , is the drug of choice. Ampicillin, Cefotaxime or Ceftriaxone may also be used. Oxygen therapy 28 Management

29. Acute Laryngotracheobronchitis (Viral Croup) 29

30. 30 is a type of respiratory infection that is usually caused by a virus . Is an illness which causes swelling of the voice box or larynx Inflammation of the vocal cords and structures inferior to the cords is called laryngitis, laryngotracheitis . Acute Laryngotracheobronchitis (Viral Croup)

31. 31

32. Epidemiology Viral croup mainly affects children between the age of 3 months to 5 years of age. Males are more affected than females. The rate of viral croup increases in cold season. Fifteen percent (15%) of cases have a positive family history. 32 Cont …d

33. Etiology Parainfluenza viruses account for 75% of cases. Other viruses such as adenoviruses, respiratory synctitial viruse and measles virus can also be involved in few cases . Rarely, mycoplasma pneumoniae and diphtetria can be isolated. 33 Cont …

34. Clinical manifestations The degree of airway obstruction in children is severe compared to adults for the following reasons: Small size of the airways Loosely attached mucous membrane Abundant mucous glands of the airways Frequent respiratory infections 34 Cont …

35. Disease starts as URTI, with hoarseness, barking cough & low grade fever. As disease progress, patient will have continuous stridor, signs of severe respiratory distress, restlessness & lethargy Fever and runny nose in drawing of the chest wall known may also be present. 35 Clinical manifestations

36. 36 T he severity of croup can be assessed&followed using croup score

37. Croup Score 5 – Mild 6-7 - Moderate, most cases need admission. 8 & above - Severe or if the child has any one of severe category needs admission for tracheostomy . 37 cont …

38. Spasmodic croup is characterized by thesudden onset of inspiratory stridor at night, short duration and sudden cessation. This is often in the setting of a mild upper respiratory infection, but without fever or inflammation. It is recurrent croup and Allergic 38

39. Mostly d iagnosis is clinically based on symptoms Blood culture and help for diagnosis lateral neck X-Ray (narrowing of trachea) or steeple sign 39 Diagnosis

40. 40 Croup-anterior or posterior X-Ray shows classic steeple sign with narrowing of the tracheal air column at the larynx and distination of the hypopharynx .

41. Signs of Respiratory distress Progressive stridor Severe stridor at rest Depressed mental status Poor oral intake 41 Admission criteria

42. Supportive Humidified air given by vaporizer or inhalation of steam at home or by croup tent in hospital is the mainstay of therapy. Oxygen therapy ,IV fluids to prevent DHN Drug treatment Dexamethasone 0.6mg/kg IM , for severe cases & repeated every 46hrs if no improvement.  Aerosol of racemic epinephrine (2.25%), nebulized with 100% oxygen Helium-oxygen mixture ( Heliox ) may be effective in children with severe croup for whom intubation is being considered. Tracheostomy If the distress get worse, despite the above treatment 42 Treatment

43. Respiratory failure. Involvement of lower airways . Bacterial super infection (rare) Bacterial tracheitis , pneumonia, pulmonary oedema (rare) 43 Complications

44. 44 Bacterial tracheitis

45. is a bacterial infection of the trachea . Is superinfection of a previous tracheal (croup, influenza virus) viral pro cess and usually caused by s.aureus . Usually, bacterial tracheitis happens after an upper respiratory infection like the flu, measles, or parainfluenza . 45 Bacterial tracheitis

46. 46

47. As expected, given the relationship with viral epidemics, bacterial tracheitis is more common in the winter months. Although it may affect adults, it is primarily a disease of children between the ages of six months and 14 years, with a peak incidence around three to eight years of age Males are more commonly affected than females, ratio is quite variable, between 1:1 and 5:1 most of the time. 47 Epidemiology

48. Staphylococcus aureus is the most commonly isolated Moraxella catarrhalis Non typable H. influenza virus and Anaerobic organisms 48 Etiology

49. Typically Increasing deep or barking croup cough following a recent upper respiratory infection Crowing sound when inhaling (inspiratory stridor ) 'Scratchy' feeling in the throat Chest pain Fever Headache Dizziness (light headed ) The major pathologic feature appears to be mucosal swelling. 49 Clinical features…

50. 50 D iagnosis The diagnosis is based on evidence of bacterial upper airway disease, which includes high fever , purulent airway secretions , and an absence of the classic findings epiglottitis . Lateral radiograph of the neck shows pseudomembrane detachment in the trachea . Rigid bronchoscopy Thick tracheal membranes. Thick adherent membranous secretions. In contrast to croup, tenacious secretions are seen throughout the trachea, and In contrast to bronchitis, the bronchi are not affected.

51. Antimicrobial therapy Vancomycin and a β- lactamase–resistant β- lactam antimicrobial agent ( e.g naficillin or oxacillin ). Supplemental oxygen Artificial airway 51 Treatment

52. Cardiorespiratory arrest CXR patchy infiltrates and may show focal densities . Toxic shock syndrome 52 Complications

53. 53

54. 1.Nelson Text book of Pediatrics 21th edition 2. Up-to-date 3.Medscape 3. Nelson pediatrics symptom based diagnosis 2 nd edition 54 References

55. THANK YOU 55