Ranges from nasal obstruction till larynx and upper trachea. Obstruction of the portion of the airways located above the thoracic inlet.

 Stridor : ( Inspiratory stridor ) - Harsh sound produced by vibration of upper airway structure - Harsh sound produced by vibration of upper airway structure - Indicates upper airway obstruction - Indicates upper airway obstruction  Hoarseness: Indicates involvement of vocal cords  Respiratory distress / suprasternal retraction

 Cough  Signs of hypoxemia - Anxiety - Anxiety - Restlessness - Restlessness - Tachycardia - Tachycardia - Pallor - Pallor - Cyanosis: late sign - Cyanosis: late sign

Infectious Infectious Non- Infectious Non- Infectious ( commonest )

 Croup ( Acute laryngotracheobronchitis ).  Bacterial trachitis ( membranous croup ).  Acute epiglottitis.  Diphtheria.  Retropharyngeal abscess / peritonsillar. abscess.

Foreign body inhalation. Foreign body inhalation. Spasmodic laryngitis Spasmodic laryngitis Caustic burn and trauma. Caustic burn and trauma.

Term applied to group of inflammatory conditions involving larynx, trachea and characterized by Triad : Term applied to group of inflammatory conditions involving larynx, trachea and characterized by Triad :  Inspiratory stridor  Brassy cough  Hoarseness of voice +/_ resp.distress

Usually viral in origin - Parainfluenza virus (type 1) - Influenza virus - RSV, adenovirus, measles virus It is the most common cause of Acute Airway Obstruction in children Age group 3m-3 years (peak 2years) Affects boys more often than girls Peak occurrence is in fall and winter

 Usually h/o preceding URTI  Gradual or sudden in onset  Triad : Inspiratory stridor Inspiratory stridor Brassy cough Brassy cough Hoarseness of voice +/_ resp.distress Hoarseness of voice +/_ resp.distress

 It is clinically diagnosed  Neck x-ray and CBC all should be done in clinically stable pt. - AP neck film : show a pencil tip or steeple sign of the subglottic trachea - AP neck film : show a pencil tip or steeple sign of the subglottic trachea - CBC, it may helps. - CBC, it may helps.

 Do not use a radiograph to make management decisions in a pt. with an unstable airway

- Some children improve spontaneously because of natural fluctuations in the disease - Some children improve spontaneously because of natural fluctuations in the disease - Mist therapy / Steam inhalation - Mist therapy / Steam inhalation Oxygen Oxygen Adequate hydration Adequate hydration Nebulization with Racemic epinephrine Nebulization with Racemic epinephrine

 Used in moderate to severe croup  A child who needs admission in ICU for croup management needs steroid.  Preparations Dexamethasone Nebulized Budesonide ○ Not as effective as dexamethasone ○ Much more expensive than dexamethasone

Do we use steroid in mild croup ? for Children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits ( level Ib)

Which is more effective oral or nebulized dexamethasone for children with mild croup ? Children with mild croup who receive oral dexamethasone Rx are less likely to seek subsequent medical care and demonstrate more rapid symptom resolution compared with children who receive nebulized dexamethasone or placebo Rx ( level Ib )

 Most children with croup doesn't need hospitalization because symptoms typically resolve within a few days

 Signs of hypoxia  Severe distress with exhaustion  Decision about ventilation

 Acute epiglottitis --- Hemophilus influenzae type B  Bacterial tracheitis --- Staph Aureus  Cornybactrium diphtheria

 It is a rapidly progreesive bacterial infection causing acute inflammation and edema of the epiglottis and adjacent structures : aryepiglottic folds and arytenoids  Also known as supraglottitis  It is life threatening condition may lead to sudden and complete airway obstruction

 Age : 2-6 years ( peak at 3 year)  Infant, older children and adult are rarely affected  Causative agents : - HIB - HIB - pneumococci, staphylococci, - pneumococci, staphylococci, streptococci streptococci

 Previously well child  Sudden onset, history is short, 4-12 hours of sore throat and high fever  4 “ D ” Distress Dysphagia Dysphagia Dysphonia Dysphonia Drooling of saliva Drooling of saliva  may lead to death if complete airway obstruction

 History  Presentation  Appearance of the child Pharynx examination at this stage in ER is absolutely contraindicated  Next step = admission in ICU  Neck x-ray : Not the priority Do not leave the patient unattended

 Protection of the airways is the primary priority  Quickly proceed with epiglottitis protocol  It is better to initiate a “false” epiglottitis drill than to miss this disease

- Safe and supervised transfer to skilled hand - Inform consultant Pediatrics, ENT, ICU, Anesthesia - Don't attempt to examine throat in ER - Keep patient as comfortable as possible - Administering 100% O2

- Assembling at bedside CPR equipment including resuscitation bag and mask, intubation equipment - Taking the pt. to OR - Attempt IV line or sampling only after intubation in OR /or Tracheostomy

* After epiglottitis protocol has been performed and pt has secure airways you can do : * After epiglottitis protocol has been performed and pt has secure airways you can do : - blood culture : usually positive for HIB - blood culture : usually positive for HIB - CBC : WBC may be moderately elevated - CBC : WBC may be moderately elevated - lateral neck radiograph : shows a thickened epiglottis ( thumb sign ) - lateral neck radiograph : shows a thickened epiglottis ( thumb sign )

 Diagnosis confirmed by seeing an edematous cherry-red epiglottis on endoscopy  Endoscopic examination should not be performed in advance of the epiglottitis protocol

 The main components of Rx is : - maintain adequate airways until inflammation and edema resolve often 36-72hrs - maintain adequate airways until inflammation and edema resolve often 36-72hrs - Parentral Abx directed agiants HI assuming this is the cause : ceftriaxone or cefotaxime - Parentral Abx directed agiants HI assuming this is the cause : ceftriaxone or cefotaxime if not available may use chloramphenicol if not available may use chloramphenicol - Duration of Rx : 7-10 days - Duration of Rx : 7-10 days

Prophylaxis if there is another child in the house ≤ 4 y not vaccinated to HI give Rifampicin to all family members if there is another child in the house ≤ 4 y not vaccinated to HI give Rifampicin to all family members

3m-3 yr 2-6 year YesNo Loudquiet Over days Over hours noyes Low grade High grade noyes HoarseMuffled noyes

 It is uncommon infectious cause of acute UAO  pt may present with croup like symptoms  Etiology : Staph Aureus  On intubation: copious thick secretion ( pus)  with appropriate airway support and Abx most pt. Improve within 5 days

 Also known as recurrent croup  Presentation like acute onset of croup  No h/o fever or viral infection  Etiology = Allergic in nature  May develop asthma or atopy later on  It typically resolves spont.  rarely associated with severe RD

Don’t  inspect the oropharynx  send the patient to radiology for a lateral neck or chest X-Ray  insert an IV  take blood gases

 Be calm and confidant  Transfer the baby to ICU settings  Let the baby be in mother’s lap or beside mother to make him clam and comfortable  Observe the signs of hypoxia or deterioration  In severe cases or respiratory failure: secure the airway ( intubation / trachesotomy)

 Essentials of diagnosis Acute onset of cyanosis and choking Acute onset of cyanosis and choking *Inability to cough or vocalize (complete obstruction) *Drooling with stridor (partial obstruction) *Drooling with stridor (partial obstruction)  Risk age group: 6months-4 years of age

 Unable to speak  Unable to breath  Unable to cough

 Children should be allowed to use their own cough reflex to extrude the foreign body in case of partial obstruction.  If obstruction increases acute intervention is needed.

Infant <1 year of age: According to AAP and AHA *Place the infant face down over rescue arm with head position below the trunk. Five back slaps are delivered rapidly between infant’s scapula with the heel of hand. * If obstruction persists infant should be rolled over and five rapid chest compression should be performed.

Repeat if not successful and call for help

Children >1 year of age Abdominal thrust ( Heimlich maneuver ) Abdominal thrust ( Heimlich maneuver ) 5 thrusts Repeat if not successful and call for help Repeat if not successful and call for help

 If FB is directly visualized in the mouth, it can be removed by forceps.  F.B. in trachea or lower airway: Endoscopy removal  Sometimes emergency tracheostomy is needed.

Canadian journal of emergency medicine 6- illustrated textbook of pediatrics

Croup scoring system of Westley et al 1 Symptoms Croup score Stidor at restNone Audible with stethoscope Audible without stethoscope –– RetractionsNoneMildModerateSevere– Air entryNormalDecreased Severely decreased –– CyanosisNone With agitation At rest–– Level of consciousness Normal–––Altered