UpperUpper AAirwayirway EmergencyEmergency

林口長庚醫院兒童一般醫學科 吳志德醫師 2010.9.15

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v8 month boy presented to the emergency department with fever and cough for 2 days vCough is described as barky, and non-productive vNormal behavior, not irritable, but decreased appetite

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vVital signs: T 39.3, HR 130, RR 40, SaO2 95% on RA vChest: coarse breath sounds, but no wheezing. Inspiratorystridor at rest without increased work of breathing. No retraction vRemainder of exam unremarkable

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vDexamethasoneIM and nebulized epinephrine inhalation were given with minimal improvement. vWhile in ER, biphasic stridorat rest with severe retractions, becomes toxic appearing. § Some mild improvement to repeat nebulized epinephrine inhalation § Admitted to ward for observation

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vCroup § 6 mo to 6 years § URI symptoms § Stridor § +/-fever vCould there be an alternative diagnosis?

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1 Overview

2 Stridor

3 Specificdisorders

4 Airwayforeignbody

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v Onset and duration (acute, chronic) v Associated symptoms (respiratory distress, fever, toxicity, drooling, cyanosis) v Progression with age v Exacerbations (supine vs. prone position, upper respiratory infection [URI], crying) v Feeding pattern (dysphagia, feeding abnormalities) v Airway procedures (intubation in the neonatal period) v Choking episode (foreign body aspiration) v Baseline noises, quality of cry and voice (location of obstructive lesion) 10

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vSeverity of respiratory distress (respiratory rate, retractions, flaring, heart rate) vPresence of (extreme distress, hypoventilation, altered mental status, dusky skin color, cyanosis, hypotonia) vCharacter and timing of stridor, as well as the symmetry and quality of breath sounds

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vLateral and AP view of and CXR vAdenoid and tonsillarsize, the contour of the , the thickness of the retropharyngeal soft tissue space, the vallecula, the aryepiglotticfolds, and the tracheal air column

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vClassic sound associated with upper airway obstruction vDerived from the Latin stridulus, meaning harsh or grating vCaused by partial airway obstruction and the resultant turbulent airflow through a portion of the airway from the nose to the vTiming (inspiratory, expiratory, biphasic) and quality (coarse, high pitched) 15

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vAge § foreign body aspiration: 6 mo to 2-3 years § : 6 to 36 mo § : less than 4 years vAbrupt of onset and severity § acute onset with fever: infection § chronic and recurrent: external compression vAssociated symptoms

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PDF created with pdfwww.pdffactory.comFactory trial version SUBGLOTTIC FEATURES SUPRAGLOTTIC GLOTTIC TRACHEA Sonorous Biphasic stridor High-pitched stridor Gurgling Inspiratorystridor Sound Coarse Expiratory stridor Nose Subglottictrachea Structures Epiglottis Micrognathia Subglotticstenosis Pierre Robin syndrome Vocal cord paralysis Tracheomalacia TreacherCollins syndrome Laryngeal web Tracheal stenosis Macroglossia Laryngocele Vascular ring Congenital Down syndrome Hemangioma cyst Storage diseases Choanal atresia Lingual thyroid Thyroglossal cyst Adenopathy Papillomas Croup Tonsillar hypertrophy Foreign body Bacterial Acquired Foreign body Subglottic stenosis Pharyngeal abscess Foreign body 17 PDF created with pdfwww.pdffactory.comFactory trial version Specific disorders: Supraglottic airway diseases

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PDF created with pdfwww.pdffactory.comFactory trial version vNose, pharynx, epiglottis, and surrounding structures vCongenital: § choanal atresia, macroglossia, micrognathia, thyroglossal duct cyst, and lingular thyroid vAcquired causes: § nasal foreign body, nasal polyps, hypertrophic tonsils and adenoids, epiglottitis, retropharyngeal abscess, , , mononucleosis, and upper airway foreign body

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vPersistence of the bucconasal membrane or a bony septum in the posterior naris vBilateral choanal atresia is a life- threatening emergency that is identified shortly after birth vUnilateral choanal atresia may go undetected in the nursery and become apparent only when the normal, patent nares are obstructed by swelling or secretions

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vAssociated with a number of conditions, including Down syndrome, glycogen storage disease, and congenital hypothyroidism vThe tongue is abnormally large and protrudes posteriorly into the hypopharynx

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vAssociated with syndromes such as Pierre Robin and Treacher Collins vA small mandible posteriorly displaces the normally sized tongue vSigns of obstruction often worsen when the patient is supine

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vThe retropharyngeal space is a potential space between the posterior pharyngeal wall and the prevertebral fascia that extends from the base of the skull to the level of T2 vMost cases are seen in children younger than 4 years vCommonly polymicrobial, with Group A Streptococcus, Staphylococcus aureus (including MRSA)and anaerobes

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vFever, sore throat, dysphagia, odynophagia, neck stiffness/nuchal rigidity, torticollis, trismus, neck swelling, drooling, stridor, and a muffled voice vPotential complication: § sepsis, aspiration , , and empyema

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vCareful evaluation of airway patency takes precedence vExamination of the pharynx may reveal bulging of the posterior pharyngeal wall vA soft tissue lateral view of the neck may be helpful vThe need for intubation or surgical drainage is determined on an individual basis

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vEmpiric antibiotic treatment § ampicillin-sulbactam(50 mg/kg/dose Q6H IV) § clindamycin(13 mg/kg/dose Q8H IV) § vancomycin(40 to 60 mg/kg/day divided in 3 to 4 doses) § linezolid(<12 years: 30 mg/kg/day divided in 3 doses; ≥12 years: 20 mg/kg/day in 2 doses)

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vIndications for surgical drainage § airway compromise or other life-threatening complications § a large lesion (>2 cm hypodense area on CT scan) § failure to respond to parenteral antibiotic therapy vObtain specimen sample for culture

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vIncidence of acute epiglottitis has declined markedly since widespread administration ofHib vaccine vInvasive bacterial disease that causes inflammation and of the epiglottis, aryepiglottic folds, and surrounding supraglottic tissues vH. influenzae type b, Group A beta- hemolytic Streptococcus, S. aureus, and Streptococcus pneumoniae

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vHigh fever, intense sore throat, drooling, change in voice or cry, stridor, toxicity, and rapid progression v“Sniffing” or “tripod” position with the jaw jutting forward and the neck extended to maximize airway patency vDirect examination or manipulation of the pharynx should be avoided

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PDF created with pdfwww.pdffactory.comFactory trial version vThe subglottic space is the narrowest part of the airway in children younger than 8 years and is completely surrounded by the cricoid ring vResults from a congenital anomaly, inflammation from infection, and trauma associated with prolonged intubation

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vCongenital laryngotracheal (“subglottic”) stenosis § congenital defect in canalization of the subglottic trachea § deformity of the cricoid ring is usually seen § prolonged intubation or blunt trauma to the neck vSubglottic hemangioma § symptoms generally peak at 6 months § cutaneous hemangiomas are seen in approximately half of cases

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vMost commonly in late fall, early winter, and spring, with a peak incidence at 2 years of age vParainfluenza, RSV, , rhinovirus vInflammation, exudate, and edema of the loosely adherent mucosal and submucosal tissues of the subglottic space

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vMost children with croup have an uncomplicated course vBarky cough, hoarse voice, and high- pitched, inspiratory stridor with viral prodrome vThe classic radiological finding in croup is a tapered narrowing of the normal shouldered appearance of the subglottic trachea such that it has the appearance of a pencil or steeple

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Empire State Chrysler Building Building

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§ Level of consciousness: Normal, including sleep = 0; disoriented = 5 § Cyanosis: None = 0; with agitation = 4; at rest = 5 § Stridor: None = 0; with agitation = 1; at rest = 2 § Air entry: Normal = 0; decreased = 1; markedly decreased = 2 § Retractions: None = 0; mild = 1; moderate = 2; severe = 3 vMild ≦2, moderate 3-7, severe ≧8

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vReassurance vHumidified air or oxygen vNebulized epinephrine inhalation vGlucocorticoid vNebulized beta 2 agonist inhalation?

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vGlucocorticoids bring about clinical improvement in children with croup within six hours. vNebulised budesonide or dexamethasone, given either orally or intramuscularly, is effective in treating croup. vThe use of glucocorticoids is associated with a lower rate of epinephrine use, fewer return visits and/or (re)admission (NNT= 17) and shorter time spent in hospital 51

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Severe respiratory distress or respiratory failure

Unusual symptoms (hypoxia, hyperpyrexia)

Dehydration Persistence of stridor at rest after aerosolized epinephrine and steroids Persistence of tachycardia, tachypnea Complex past medical history (prematurity, pulmonary and/or cardiac disease)

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vTracheomalacia § abnormally soft, undeveloped supporting cartilage of the tracheal rings § history of stridor since birth which worsens with supine positioning vTracheal stenosis § complete tracheal rings § symptoms worsen with agitation and age

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vVascular ring § anomaly of the aortic arch and related vessels in which a ring is formed that encircles the trachea, esophagus, or both § double aortic arch, right-sided aortic arch with a persistent left ligament, aberrant right subclavian artery, and a pulmonary sling § should be considered in any infant with persistent, unexplained respiratory and feeding problems § barium esophagogram, CT, MRI, angiography

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vSevere inflammation of the tracheal epithelium and the production of thick mucopurulent secretions vMay be a secondary bacterial infection complicating a preexisting viral infection vS. aureus, H. influenzae type b, Moraxella catarrhalis, S. pneumoniae, alpha-hemolytic and group A streptococci, and anaerobes

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vViral prodrome of fever, barky cough, and inspiratory stridor vThe child appears toxic, and signs of airway obstruction and respiratory failure may develop acutely vPlain radiograph findings include subglottic narrowing, a ragged edge of the usually smooth tracheal air column, and a hazy density within the tracheal lumen

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PDF created with pdfwww.pdffactory.comFactory trial version BACTERIAL CROUP EPIGLOTTITIS TRACHEITIS 3–5 years, but seen Peak age 6 months to 3 years 3–7 years throughout childhood

Bacterial superinfection Inflammation and edema with inflammation of the Subglottic inflammation, Pathology of the epiglottis, tracheal mucosa, copious edema aryepiglottic folds mucopurulent secretions obstructing the trachea

Haemophilus influenzae, Parainfluenza virus, RSV, Staphylococcus aureus or Organisms Strep sp, Staphylococcus adenovirus mixed flora aureus

Onset follows URI Several-day prodrome of prodrome consisting of Rapid progression of high croup like illness Clinical features croupy cough, hoarse fever, toxicity, drooling, progressing to toxicity, voice, low-grade fever, stridor inspiratory stridor, inspiratory stridor marked distress

Thumbprint sign on lateral aspect of the neck, Normal upper airway Laboratory and on PA view thickened aryepiglottic structures, shaggy radiographic findings of the neck, or normal folds, loss of air in the tracheal air column vallecula

Steroids, aerosolized Intubation common, Management Intubation, antibiotics epinephrine antibiotics

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vMajority of cases and deaths occur in toddlers younger than 3 years vA foreign body can lodge in any part of the airway and can move vLarge objects that lodge in the upper airway and trachea § dyspnea, drooling, stridor, and cyanosis vSmall objects usually lodge in a , or in a more terminal part of the airway

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vLarynx: 3 % vTrachea/carina: 13 % vRight lung: 60 % (52 % in the main bronchus, 6 % in the lower lobe bronchus, and <1 % in the middle lobe bronchus) vLeft lung: 23 % (18 % in the main bronchus and 5 % in the lower bronchus) vBilateral: 2 %

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vComplete obstruction: § dislodgement using back blows and chest compressions in infants, and the Heimlich maneuver in older children § "blind" sweeping of the mouth should be avoided § intubation may permit some ventilation until rigid bronchoscopy is possible vSuspected foreign body aspiration § rigid bronchoscopy with ventilation under general anesthesia

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vIntravenous catheter (14–18 gauge) is passed through the midline of the inferior edge of the cricothyroid membrane

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