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-1 Age 6/12 – 3 years LocationSubglottic AetiologyParainfluenza, influenza, RSV; rarely Mycoplasma, adenoV, measles OnsetInsidious, URTI StridorYes RetractionsYes VoiceHoarse Position & appearance Normal

Acute Laryngotracheobronchitis-2 Swallowing Barking cough Toxicity Fever X-ray WBC count Treatment Prevention

Acute Laryngotracheobronchitis-2 SwallowingNormal Barking cough Yes ToxicityRare Fever<38C X-raySubglottic narrowing/ steeple sign WBC countNormal TreatmentOral Dexamethasone/Neb. Budesonide PreventionNone

Sign ?

Spasmodic Croup-1 Age Location Aetiology Onset Stridor Retractions Voice Position & appearance

Spasmodic Croup-1 Age 3/12 – 3 years LocationSubglottic AetiologyUnknown OnsetSudden onset at night; prior episodes StridorYes RetractionsYes VoiceHoarse Position & appearance Normal

Spasmodic Croup-2 Swallowing Barking cough Toxicity Fever X-ray WBC count Treatment Prevention

Spasmodic Croup-2 SwallowingNormal Barking cough Yes ToxicityNo FeverNone X-raySubglottic narrowing WBC countNormal TreatmentOccasionally Steroids needed PreventionNone

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Epiglottitis - 1 Age Location Aetiology Onset Stridor Retractions Voice Position & appearance

Epiglottitis - 1 Age 2 – 6 years LocationSupraglottic AetiologyHIb & HIa OnsetRapid short prodrome StridorYes – soft inspiratory RetractionsYes VoiceMuffled Position & appearance Tripod, leaning forward; agitated

Epiglottitis -2 Swallowing Barking cough Toxicity Fever X-ray WBC count Treatment Prevention

Epiglottitis - 2 SwallowingDrooling Barking cough No ToxicitySeverely toxic Fever> 38.5 C X-rayThumb sign of thickened epiglottis WBC countHigh Neutrophil count Treatment Entotracheal Intubation involve senior Anaesthetist/ ENT Consultant. IV antibiotic PreventionNone

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Retropharyngeal Abscess-1 Age Location Aetiology Onset Stridor Retractions Voice Position & appearance

Retropharyngeal Abscess-1 Age < 6 years LocationPosterior pharynx AetiologyS aureus, anaerobes OnsetInsidious to sudden StridorNone RetractionsYes VoiceMuffled Position & appearance Arching of neck or normal

Retropharyngeal Abscess-2 Swallowing Barking cough Toxicity Fever X-ray WBC count Treatment Prevention

Retropharyngeal Abscess-2 SwallowingDrooling Barking cough No ToxicitySeverely toxic Fever> 38 C X-rayThickened Retropharyngeal space WBC countHigh Neutrophil count Treatment IV antibiotic +/- surgical drainage PreventionNone

Angioedaema-1 Age Location Aetiology Onset Stridor Retractions Voice Position & appearance

Angioedaema-1 Age All ages LocationVariable AetiologyCongenital C1-esterase deficiency OnsetSudden StridorYes RetractionsYes VoiceHoarse, 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-2 SwallowingNormal Barking cough Possible ToxicityNo, unless anaphylactic shock/severe anoxia FeverNone X-raySubglottic narrowing/ steeple sign WBC countNormal Treatment High Flow O2, Epinephrine, IV fluids, IV Hydrocortisone; danazol, C1-esterase Infusion PreventionAvoid allergens; FFP; danazol

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Laryngeal Papillomatosis-1 Age Location Aetiology Onset Stridor Retractions Voice Position & appearance

Laryngeal Papillomatosis-1 Age 3/12 – 3 years LocationLarynx, vocal cords, trachea AetiologyHuman Papilloma Virus (HPV) OnsetChronic StridorPossible RetractionsNo VoiceHoarse Position & appearance Normal

Laryngeal Papillomatosis-2 Swallowing Barking cough Toxicity Fever X-ray WBC count Treatment Prevention

Laryngeal Papillomatosis-2 SwallowingNormal Barking cough Variable ToxicityNone FeverNone X-rayMay be normal WBC countNormal TreatmentLaser Therapy, repeated excision, Bleomycin, interferon PreventionTreat 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, , >120 Wheeze Pre-neb sats: >93%, 91-93% & <90% PaCO2: > 5 kpa

Acute severe asthma High flow oxygen litres (mask & res) Neb Salbutamol +/- Ipratobium – min 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 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