pediatric air way obstruction

Ambo university
College of medicine and health sciences
Department of medicine
Presented By ;- Million Negasa( C2, B
pharm, nutritionist )
Seminar presentation on Air way obstruction
Modulators - Dr Ararsa ( pediatrician,MD)
Dr Bekelcha (MD)

Outlines
 Introduction
 Couses of air way obstruction
 Epidemiology
 Pathophysiology
 Clinical manifestation
 Diagnosis
 Management of air way obstructions.
7/22/2019by Million2

Introduction
 The respiratory system consists of all the
structures that make up the airway and help
us breathe and ventilate.
 The airway is divided anatomically into the
upper and lower airway.
 Functionally divided into
 Conducting portion(from tip of mouth or
nose to alveoli- conducts air),
 Respiratory portion(places where gas
exchange takes place-small airways called
respiratory bronchioles & alveolar ducts as
well as air sucs called alveoli).

Upper airway includes;-
 Nose
 Nasopharynx
 Oropharynx
 Larynx (supraglottis, subglottis)
 Trachea (extrathoracic

Cont….
Airway Obstruction :
 Refers to narrowing of any portion of the
airway, including the oropharynx, larynx,
trachea or bronchi.
 Airflow obstruction can occur at either:-
 extrathoracic sites (eg, above the thoracic inlet) or
 intrathoracic sites (eg, below the thoracic inlet).

cont…
 After assessing whether the obstruction is extrathoracic
or intrathoracic ,
 determine if the obstruction is fixed or variable.
 Fixed obstructions disrupt each breath and the
abnormal sounds are consistently heard.
 Variable obstruction leads to abnormal sounds with
breathing that are softer or absent with normal quiet
breathing and may sound different with every breath.
 The onset and progression of the obstruction can provide
important clues as to the etiology and help determine the
urgency of evaluation and management.

Where in the Airway is the
Obstruction
SNORING STRIDOR WEEZE
NASOPHRNEX + + -
LARNEX +/- + + in case of
severe obstruction
TRACHEA AND
BRONCHI
+ +
SMALL
AIRWAYS
+

Upper air way obstruction

Anatomical difference of airway
of children

History and phsical examination
HISTORY
 Snoring or noisy breathing
 Chronic cough
 Productive cough
 Sudden onset of new cough
 Inspiratory stridor

Cont……….
 Hoarse voice
 Asthma and bronchodilator therapy
 Repeated pneumonias
 foreign body aspiration
 Atopy, allergy , Environmental

Physical examination
 Facial expression
 Nasal flaring and Mouth breathing
 Drooling
 intercostals or sub costal
retraction
 Respiratory rate
 Voice change
 Mouth opening

Cont…
 Size of mouth
 Loose/missing teeth,
 Size and configuration of palate and mandible
 Location of larynx
 Presence of stridor
 Baseline O2 saturation
 congenital anomalies

Causes of acute upper airway obstruction that are
commonly life-threatening:
Foreign body
 Croup
 Epiglottitis
Bacterial tracheitis
 Retropharyngeal abscess
Peritonsilar abcess
Congenital anomalies like:
Neck trauma

1.Foreign body
 Children <5 yr old are particularly susceptible to
foreign body aspiration and choking.
 Choking is the leading cause of morbidity and
mortality among children < 4 years of age.
 Mainly due to
 developmental vulnerabilities of their air way
 Under developed ability to swallow food
 Most common objects that children choke on are
food, coins, balloons and toys, nuts in one third of
cases, hard candy and chewing gum.

Clinical presentation
 Three stages of symptoms result
1. Initial event :-violent paroxysms coughing, chocking
,gagging and possibly airway obstruction occur
immediately when foreign body is aspirated.
2. Asymptomatic interval:- foreign body becomes
lodged reflexes fatigue and immediate irritating
symptoms subside , accounts for large number of
delayed diagnosis.
3. Complications:- obstruction, erosion, or infection
develops to direct attention again to the presence of
foreign body

 Severity and nature of symptoms varies with location of
foreign body in respiratory tract
 Most lodge in the bronchi right bronchus -58% of cases and
are not immediately life-threatening
 when in the larynx or trachea can cause complete or partial
airway obstruction requiring immediate treatment.
 >90% of pediatrics death due to foreign body aspiration
occur in children <5 years and 65% in infants.

Diagnosis
 A history consistent with foreign body aspiration is
considered diagnostic.
 Chocking or coughing accompanied by new onset of
wheezing
 Broncoscopy despite negative imaging.
 CT for radiolucent foreign bodies such as fish bones

Management
 Emergency first aid for choking
 Prompt endoscopic removal with rigid
instruments
 Broncoscopy is deferred only until preoperative
studies have been obtained and patient has been
adequately hydrated and stomach is emptied.

Back blows (top) and chest thrusts(bottom) to relieve foreign body airway
obstruction in the infant and over 1 year of age .

2. Croup (laryngotrachobronchities)
 Is the most common form of acute upper respiratory
obstruction
 Refers to viral infection of the glotic and the sub glottic
regions
 Croup is a disease of the upper air way and alveolar gas exchange
is usualy normal .
 Hypoxia and low oxygen saturation are seen when complete
airway obstruction is imminent .

Etiology
 Para influenza type 1,2, 3 account for 75 % of cases croup.
 Influenza A and B viruses,adenoviruses, measles, respiratory
syncytial virus, and echovirus cause most of the rest,
 severe form of laryngotrachobronchities is associated with
influenza A.
 Mycoplasma has rarly been isolated in older children.

Cont…
 Most patients are between 3 months to 5years of
age .
 And peaks in the second year of life .
 Most commonly occurs in the late fall and winter
and also through out the year

Clinical features
 most patients have upper respiratory tract infections with
some combination of rhinorrhea , phrengities, mild cough
and
 low grade fever for 1 to 3 days before signs of air way
obstruction become apparent.
 Follwed by barking cough, hoarseness, and inspiratory
stridor
 temprature may occasional reach 39-40°C
 Symptoms are often worse at night.
 Agitation and crying aggravate the symptoms.

Diagnosis
 Diagnosis of croup is mainly clinical
 Phsical examination
 Hoarse voice coryza , normal to modratly inflamed phrynex
 Slightly raised respiratory rate
 Nasal flaring, suprasternal ,infrasteral, intercostal retraction,stridor
 Radiography of neck (Typical sub glottic narrowing
or ’’ steeple sign’’) but it does not usually correlate
with disease severity .

Modified Westley Clinical Scoring System
for Croup

Modified Westley Clinical Scoring System
for Croup
 The total score ranges from 0 to 17.
 Mild croup a score of ≤ 2.
- barking cough, hoarse cry, but no stridor at
rest,stridor when upset or crying (i.e., agitated) and
none, or only mild chest wall/subcostal retractions .
 Moderate croup score of 3 to 7
-stridor at rest, mild retractions, other symptoms or
signs of respiratory distress, but little or no agitation
 Severe croup score of ≥ 8.
-significant stridor at rest,
-Retractions are severe (including indrawing of the
sternum) and the child may appear anxious, agitated,
or fatigued.
-Prompt recognition and treatment of are paramount.

Croup management
 The main stay of management is air way and treatment of
hypoxia
 Treatment of respiratory distress
 Children with acute spasmodic croup can be treated safely at
home
 Antibiotics are not indicated in croup over the counter cough
and cold medications should not be used in childeren <4 year
of age .

Moderate or severe croup
 Nubilized recemic epinephrine is used
 Traditionaly recemic epinephrine 1;1 mixture of D and L
isomers of epinephrine has been adimnsterd
 A dose of 0.25-0.5ml of 2.25% recemic epinephrine in 3ml
normal saline every 20 min.
 There is evidence that L-epinephrine (5ml of 1;1000 solution
)is equally effective as recemic epinephrine.
 Frequent aerosol treatments may be needed for the first few
hours
 A single PO or IM dose of dexamethasone, 0.6 mg/kg,
decreases the length and severity of respiratory symptoms
that are associated with viral croup.

Cont…
 Supportive care administration of humidified air or
humidified oxygen as indicated for hypoxemia (oxygen
saturation <92% in room air) or respiratory distress.
 Monitoring — pulse oximetry and close observation of
respiratory status, including level of consciousness, stridor,
cyanosis, air entry, and retractions.
 Fluids — Administration of IV fluids may be necessary in
some children.
 Intubation — Endotracheal intubation is required in less
than 1% of those who are seen in the emergency department
and 2 to 6% of those who are hospitalized

Admission criteria
 progressive stridor
 severe stridor at rest
 respiratory distress
 hypoxia
 cyanosis
 depressed mental status or
 the need for reliable observation

Discharge criteria
 Children who require hospital admission may be
discharged when they meet the following criteria:
 No stridor at rest
 Normal pulse oximetry
 Good air exchange
 Normal color
 Normal level of consciousness
 Demonstrated ability to tolerate fluids by mouth

3.Spasmodic croup
 Occurs most often in children 1-3 yr of age.
 Clinically similar to acute laryngotracheobronchitis,
except a viral prodrome and fever.
 "frequently recurrent croup."
 Laryngoscopy reveals pale, watery oedema with
preservation of the epithelium
 The cause is viral in some cases, but allergic and
psychological factors may be important in others
 may represent more of an allergic reaction to viral
antigens than direct infection, although the
pathogenesis is unknown
 Dx and treatment is the same

4.Epiglottitis
 Is a dramatic, potentially lethal condition is
characterized by:-
 an acute fulminating course of high fever,
 sore throat,
 dyspnea, and stridor
 rapidly progressing respiratory obstruction
 Drooling and hyperextended neck are usually
present.
 Cyanosis, coma and death.
 The child may assume the tripod position sitting upright
and leaning forward with the chin up and mouth open
while bracing on the arms

Cont...
 Previously HiB was the most common cause of epiglottis; currently
decreased by 80-90% due to vaccine
 An increase in the median age of children with epiglottitis from 3
years of age to approximately 6 to 12 years of age.
 s. pyogenes, s. pneumoniea, s. aureus are common causes of
epiglottis currently.

Diagnosis
 Laryngoscopy;- under controled circumstances
 large, "cherry-red" swollen epiglottis
 Radiology ;- "thumb sign"

Treatement
 It is an emergency
 Establishing an airway by nasotracheal intubation or, less often, by
tracheostomy is indicated in patients with epiglottitis, regardless of
the degree of apparent respiratory distress.
 Because as many as 6% with epiglotities with out artifical air way die
compared to <1% those with artificial air way
 Duration of intubation of intubation depends on the clinical course
and duration of epiglotic swelling as determind by direct
larngeoscopy.
 Children with epiglotities are intubated for 2 to 3 days since response
to antibiotics is usully rapid.

Cont……..
 Oxygen 100%
 Ceftriaxone, cefotaxime, or A combination of ampicillin and
sulbactam
 Rifampin prophylaxis (20 mg/kg orally once a day for 4 days;
maximum dose, 600 mg)
 Acute laryngeal swelling - allergic basis responds to ;-
 epinephrine (1:1,000 dilution in dosage of 0.01 mL/kg to a
maximum of 0.5 mL/dose) administered subcutaneously or
 racemic epinephrine (dose of 0.25-0.75 mL of 2.25% racemic
epinephrine in 3 mL of normal saline).
 Corticosteroids are frequently required (2-4 mg/kg/24 hr of
prednisone).

5.Bacterial Tracheitis
 Bacterial tracheitis is an acute bacterial infection of the upper airway
that is potentially life threatening.
 The mean age is between 5 and 7 yr.
 There is a slight male predominance.
 Often follows a viral respiratory infection (especially
laryngotracheitis).
 S. aureus is the most commonly isolated pathogen with isolated
reports of methicillinresistant S. aureus.
 S. pneumoniae, S. pyogenes, Moraxella catarrhalis, nontypeable H.
influenzae, and anaerobic organisms have also been implicated.

Clinical manifestations
 similar to severe viral croup.
 High grade Fever
 toxic appearance
 barking cough
 stridor ,tachypnea
 Hoarseness of voice
 sore throat,
 Dysphonia

Cont…
 Unlike epiglottitis, the patient can lie flat, does not drool, and does
not have dysphagia.
 About 50-60% of patients require intubation for management(
young <, adult).
 The major pathologic feature appears to be mucosal swelling at
the level of the cricoid cartilage;-
 complicated by copious, thick, purulent secretions,
sometimes causing pseudomembranes.

Cont’d….
Diagnosis
 clinically: 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 of
epiglottitis.
 X-rays: are not needed but can show the classic
findings- pseudomembrane detachment in the trachea .
 Bronchoscopy: Purulent material is noted.

 Figure-8. Lateral radiograph of
the neck showing
pseudomembrane detachment
in the trachea.

Treatment
I. Appropriate antimicrobial therapy, which usually includes
antistaphylococcal agents, should be instituted in any patient
whose course suggests bacterial tracheitis.
II. Current empiric therapy recommendations for bacterial tracheitis
include vancomycin or clindamycin and a thirdgeneration
cephalosporin (e.g., cefotaxime or ceftriaxone).
III. When bacterial tracheitis is diagnosed by direct laryngoscopy or is
strongly suspected on clinical grounds, an artificial airway should
be strongly considered.
IV. Supplemental oxygen is usually necessary.

Complications
 Cardio-respiratory arrest can occur if airway
management is not optimal.
 Toxic shock syndrome has been associated
with staphylococcal and group A streptococcal
tracheitis.
 Subglottic narrowing and a rough and ragged
tracheal air column .

Prognosis
 The prognosis for most patients is excellent.
 Patients usually become afebrile within 2-3 days.
 prolonged hospitalization may be necessary.
 To see decrease in mucosal edema and purulent
secretions,
 extubation can be accomplished safely, and
 the patient should be observed carefully while
antibiotics and oxygen therapy are continued.

Comparisons
Croup Similarity Bacterial tacheitis
Age 6m- 3 yrs
Patient is sick
Fever is low grade
Insidious onset
cough
Responds to
racemic epinephrine
Negative blood
culture
Cough
Fever
Sore throat
Rhinnorrhea
Barky cough
Stridor
Increase work
of breathing
Normal CBC
Age 6m-14yrs
Patient is toxic
High grade fever
Acute worsy cough
No response to
epinephrine
May be positive blood
culture

6.Diphtheria
infectious disease caused by the gram-positive
bacillus Corynebacterium diphtheriae.
There is :
 Respiratory diphtheria
 Systemic manifestations
 Cutaneous diphtheria

Diagnosis
I. clinical manifestations :
 Sore throat, malaise, cervical lymphadenopathy,
and low-grade fever,
 Mild pharyngeal erythema.
II. Definitive diagnosis
 culture of C. diphtheria,
 Routine laboratory test (elevated white blood cell
count and proteinuria).

Treatment
Antitoxin
 Diphtheria antitoxin is a hyperimmune antiserum
(binds to and inactivates the diphtheria toxin).
Antibiotics
 The antibiotics of choice are erythromycin (500 mg
QID for 14 days) or
 procaine penicillin G (300,000 units BID for
patients ≤10 kg and 600,000 units BID for patients
>10 kg intramuscularly) until the patient can take
oral medicine, followed by oral for a total treatment
course of 14 days .

7.Retropharyngeal and lateral
pharyngeal abscess
 The retropharyngeal and the lateral pharyngeal
lymph nodes that drain the mucosal surfaces of the
upper airway and digestive tracts.
 located between the pharynx and the cervical
vertebrae and extending down into the superior
mediastinum.
 The lymph nodes in these deep neck spaces
communicate with each other.

Cont…
 a deep neck infection filling the potential space between
the prevertebral fascia of the cervical vertebrae and the
posterior wall of the pharynx.

Cont…
 A retropharyngeal abscess can also result from ;-
 penetrating trauma to the oropharynx,
 dental infection, and vertebral osteomyelitis.
 Once infected, the nodes may progress through 3 stages:
 cellulitis,
 phlegmon, and
 abscess.
 airway compromise.

Cont…
 Retropharyngeal abscess occurs most commonly
in children younger than 3-4 yr of age,
 less common in older children and adults.
 More in boys.
 2/3 of pts have hx of recent ear, nose or throat
infections.

Physical examnation
Retropharyngeal abscess;-
 reveal bulging of the posterior pharyngeal wall(
50%),
 Cervical lymphadenopathy,
 Lateral pharyngeal abscess commonly presents as fever,
dysphagia, and a prominent bulge of the lateral
pharyngeal wall, sometimes with medial
displacement of the tonsil.
 DDx;-
 acute epiglottitis,
 foreign body aspiration,
 lymphoma,
 hematoma, and
 vertebral osteomyelitis.

Diagnosis
 The laboratory evaluation is non-specific with leukocytosis.
 contents of the abscess should be cultured,
 Computed tomography (CT) is the imaging
modality of choice for retropharyngeal abscess.
 lateral neck radiograph may show an increase in
width of the soft tissues anterior to the vertebrae.

treatment
 assessment of the patency of the airway and adequacy of
oxygenation and ventilation must be performed.
 endotracheal intubation
 presence of a large abscess requires drainage,
 Eradication of the bacterial organism by antibiotics
(nafcillin and cefuroxime or ceftriaxone or cefotaxime ).
 Combinations of both.

Cont…
 intravenous antibiotics(cephalosporin combined with
ampicillin-sulbactam or clindamycin).
 surgical drainage(in pt with respiratory distress or
failure to improve with intravenous antibiotic
treatment).
 The optimal duration of therapy unknown( several
days of IV Abx until improvement seen).

Complications
 upper airway obstruction,
 rupture leading to aspiration pneumonia,
and extension to the mediastinum.
 Thrombophlebitis of the internal jugular
vein and
 erosion of the carotid artery sheath can
occur
 embolic abscesses in the lungs
 infection of the parapharyngeal space
(Lemierre disease).

8.Peritonsillar cellulitis
and/or abscess
 relatively common compared to the deep neck
infections,
 is caused by bacterial invasion through the
capsule of the tonsil, leading to cellulitis and/or
abscess formation in the surrounding tissues.
 Typically seen in adolescent of acute
pharyngiotonsilitis.

Cont…
 Pathogenesis: one of the tonsillar crypts usually
crypta magna gets infected and sealed off
leading to intra tonsillar abscess which then
bursts through tonsillar capsule Peritonsillitis
then peritonsillar abscess.
 Organisms: streptococcus pyogenes, staph. Aureus, anaerobic
organisms or Most often growth is mixed.

General symptoms Local symptoms:
due to septicemia
 Fever up to 104 degree
F
 Chills and rigor
 Malaise
 body ache,
 head ache
 Severe throat pain
 Painful swallowing
 Muffled and thick
speech
 Foul breath
 Ear pain
 trismus

Diagnosis
 Clinically;-sore throat, fever, trismus and dysphagia.
 Physical examination reveals an asymmetric tonsillar
bulge with displacement of the uvula.
 CT is helpful for revealing the abscess.
 Needle aspiration.
 Intraoral ultrasound.

Treatment
 Hydration, pain relief
 surgical drainage( I,D or tonsillectomy). and
 antibiotic therapy( Metronidazole).
 Approximately 95% of peritonsillar abscesses resolve
after needle aspiration and antibiotic therapy(5% needs
repeat needle aspirations).
 Tonsillectomy should be considered if there is failure to
improve within 24 hr of antibiotic therapy and needle
aspiration.

Complications
 Parapharyngeal abscess,
 Laryngeal oedema,
 Septicemia: endocarditis, nephritis,brain abscess
 Pneumonitis or lung abscess
 Jugular venous thrombosis
 Spontaneous hemorrhage from carotid artery or jugular
vein.

9.Congenital anomalies
a)Laryngomalacia
 Congenital laryngeal anomaly of the newborn
characterised by flaccid laryngeal tissue and
inward collapse of the supraglottic structure
leading to upper airway obstruction.
Epidemiology
 commonest cause (~ 65%) of stridor in infants
– (17% have another intercurrent airway lesion).
• Association with other syndromes and
neurologically-impaired (e.g. cerebral palsy,GERD).

Aetiology
 Cartilage immaturity
 Anatomic abnormality
 Neuromuscular immaturity
 Inflammatory
Stridor is the hallmark;-
 lower pitched,
 inspiratory,
 worsens with agitation,
 crying,and
feeding or in the supine position.
 spontaneous resolution In 9 month and 75% resolve
within 18month.

Classification
 Several classification systems,
 Based on anatomic variant, can be ;-
 Type 1 ( mucosal excess prolapse)
 Type 2 (foreshortened aryepiglotic fold)
 Typ3 ( dorsal epiglottic position)
Investigation
 Flexible fibreoptic laryngoscopy
 Microlaryngioscopy and Bronchoscopy
 Sleep study and other adjuvants are used.
Treatment
 Observation
 Medical
 Surgical (Supraglottoplasty ,Epiglottopexy, Tracheostomy)

Cont…
b) Tracheomalacia
 refers to a weakness of the trachea, due to reduction and/or
atrophy of the longitudinal elastic fibers of the pars
membranacea.
Classification
 Primary/Congenital TM,
 Idiopathic TM
 Secondary/Acquired TM
 Prolonged intubation
 Severe tracheobronchitis

 inspiratory and/or expiratory stridor,
 wheezing, barking, croupy cough,
 recurrent respiratory infections and
 difficulty clearing endobronchial secretions,
Dx
 Rigid bronchoscopy with spontaneous ventilation or
 flexible bronchoscopy used.

Treatment
 Medical
 Most children can be treated non-surgically, and
symptoms are expected to improve by age 1.
 Surgical
 Reserved for children with severe symptoms
 Primary indications include
Dying spells
Recurrent pneumonia
Intermittent respiratory obstruction
Options
 Tracheal resection
 Aortopexy
 Anterior and or posterior tracheopexy

References
 Nelson text book of pediatrics 20th edn.
 Uptodate 21.6
 WHO pocket book of hospital care for children 2005

pediatric air way obstruction

In this document