1. Upper Airway Emergencies
Gregory L Geers, MD
Synergy Medical Education Alliance
November 1, 2007

2. Outline
Anatomy
Adult
Pediatric
Initial airway assessment
Cases

3. Anatomy

4. Pediatric Anatomy Infant larynx:
Higher and more superior in the neck
Epiglottis shorter, floppier, angled more over glottis
Vocal cords slanted: anterior commissure more inferior
Larynx cone-shaped: narrowest at subglottic cricoid ring
Infant tongue and epiglottis are relatively larger
Head is naturally flexed when supine due to large occiput
Mild extension

5. Initial Assessment Assess the urgency of the situation
How does the patient look
Reduced level of consciousness
Lethargy
Quiet shallow breathing indicating respiratory fatigue
Apnea – especially in infants
What interventions are needed?
Oxygen, repositioning, suction, BiPAP, intubation
Secure the airway if there is any doubt

6. History Take a thorough medical history
May help to get history from multiple people
Onset of respiratory difficulty
Choking, etc.
Alleviating factors
In pediatrics
Birth history
Congenital anomalies
Immunization status

7. Physical Exam Signs of severe respiratory distress
Significant increase in respiratory rate
Average respiratory rates, by age:
Newborns: Average 44 breaths per minute
Infants: breaths per minute
Preschool children: breaths per minute
Older children: breaths per minute
Adults: 12 to 20 breaths per minute...
Use of accessory muscles
Nasal flaring
Vital signs
Cyanosis – late sign
Audible respiratory sounds
Stridor, cough, muffled voice

8. Quick tube review ET-tube guidelines Adults Children/Infants
Males: 7.5 – 9.0
Females: 7.0 – 8.0
Children/Infants
The appropriate uncuffed ETT size may be determined by the following formula (age in years):
4 + (1/4)(age)
Broslow tape
Have more than one tube size out and ready

9. Quick Tube review The appropriate depth of ETT insertion Adults
Males: 22 – 24 cm
Females: 20 – 22 cm
Children: (Lau et al, 2006):
Over one year of age:
oral: 13 + (1/2)age nasal: 15 + (1/2)age
Infants (weight in kg):
oral: 8 + (1/2)(weight) nasal: 9 + (1/2)(weight)

10. Case #1
A 41-yr-old male presents with a sudden onset of sore throat, stridor and dyspnea. He was previously fit but regularly used heroin. On arrival to the emergency department, he rapidly develops complete airway obstruction resulting in respiratory arrest. Manual ventilation by facemask proved ineffective and no i.v. access could be secured.

11. Crap!
What are you going to do now?

12. This is what you see!
Now what? Besides changing your shorts.

13. Acute epiglottitis Epidemiology Pathophysiology
Previously considered a disease of children
Now more common in adults – 0.4 to 1
Hib vaccine
Adults
Incidence: 1 to 2 per 100,000
Peak: 35 to 47 years of age
Mortality: 7 %
Children
Peak: 2 to 6 years of age
Mortality: 1%
Pathophysiology
Local inflammation of the epiglottis and surrounding structures
Single organism usually cannot be identified
Usually Hib and β-hemolytic strep

14. Acute epiglottitis History Physical Exam
Fever, sore throat, odynophagia, shortness of breath, hoarse or muffled voice
Physical Exam
Anterior neck tenderness
Lymphadenopathy
Drooling
Stridor
Tripod position
Sitting upright, leaning forward with mouth open and jaw thrust forward

15. Acute epiglottitis Diagnosis
Suspect in all patients who have relatively acute onset of sore throat, fever and odynophagia
Direct or fiberoptic laryngoscopy is the gold standard
In the ED, fiberoptic is OK in adults, but not kids
Peds with moderate to severe symptoms should go to the OR for simultaneous airway control and diagnosis confirmation
With mild symptoms
Lateral soft tissue neck films
Thumbprint sign
Vallecular sign
More sensitive and specific

17. Acute epiglottitis Management Airway control is paramount Antibiotics
One third require intubation
Adults
RSI is recommended, may need emergency cricothyroidotomy
Peds
Place in quiet nonstimulating environment
Allow them to assume most comfortable position
Airway management optimally performed in the OR
Antibiotics
2nd or 3rd generation cephalosporin to cover Hib and β Strep
Humidified oxygen, IV fluids
Steroids and racemic epi remain controversial

18. Case #2
A 6 month old female presents in mild to moderate respiratory distress. According to her parents, she has had a slight cold, but was fine until tonight when she developed an unusually loud, resonant cough. Over the next few hours this increased in frequency and she developed a fever. Each breath was making a worrisome crowing noise unlike anything the parents had ever heard. They brought her to the ER, but in the parking lot, she seemed much better and was sleeping peacefully. They decided to return home, only to be woken up again an hour later by a harsh, barking cough. They return to the ER and this time are seen by you.
This is what you see.

19. http://video. google. com/videoplay
What do you want to do?

20. Croup Acute laryngotracheobronchitis Epidemiology Pathophysiology
Typically affects children from 6 mo to 6 yrs
Peak – 2 years
Most common in fall and early winter
Pathophysiology
Viral – most often parainfluenza type 1
Causes respiratory distress secondary to subglottic edema
Younger children manifest symptoms due to the smaller diameter of their upper airway

21. Croup History/Physical Prodromal symptoms typical of viral URI
Fever is common
On day 3 – Classic symptoms develop
Barky cough
Hoarseness
Varying degrees of stridor
Possible respiratory distress
Croup is usually worse at night
Children typically improve if exposed to cool or humidified air

22. Croup History/Physical Diagnosis Indicators of more severe disease
Stridor with agitation or even at rest
Marked increased work of breathing
Hypoxia
Majority of patients have only a barky cough and URI symptoms
Diagnosis
Clinical suspicion

24. Croup Management Generally treated with supportive care
If more severe disease
Decadron
0.6 mg/kg PO or IM
Racemic epinephrine
0.25 to 0.5 ml neb, may repeat up to 3 times
How long do you need to watch after treatment?
Budesonide
2 mg via neb
Shown to be equivalent to oral dex, but much more expensive

25. Croup Admission criteria
If after optimal ED management, the child exhibits…
Cyanosis, hypoxia, or both
Depressed sensorium
Moderate respiratory distress
Stridor at rest
Progressive symptoms
Poor oral intake, dehydration, or both
Hospital admission is also advised if the child is young or if the family is unable to properly care for the child at home or cannot return to the ED if needed.

26. Case #3
A 6-year-old male presents to the emergency department with fever, respiratory distress and inspiratory stridor. The patient’s mother states that he has been mildly ill for past 3-4 days with rhinorrhea, hoarseness, cough and low grade fever. Just before presentation he began to develop high fever to 103° F, with gradually increasing respiratory distress. Initial evaluation revealed the child to be in moderate distress with tachypnea greater than 30 breaths per minute and fever of 102.7° F. Oxygen saturations were 95-97% on room air. Substernal retractions were noted and the patient had a harsh barking cough. Lung sounds were decreased in the right lower lobe with fine crackles.
What are you going to do?

27. WBC: 21,000

29. Bacterial Tracheitis Epidemiology Pathophysiology
Cases usually occur in the fall or winter months, mimicking the epidemiology of viral croup
Mortality rate has been estimated at 4-20%
Ages 6 mo to 8 yrs, peak at 5 yrs
Pathophysiology
diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea
Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea

30. Bacterial Tracheitis History
Symptoms may be intermediate between those of epiglottitis and croup
high fevers, toxic appearance, stridor, respiratory distress, and high WBC counts
croup–like symptoms and either do not respond to standard treatment or clinically worsen

31. Bacterial Tracheitis Physical
Inspiratory stridor (with or without expiratory stridor)
Barklike or brassy cough
Hoarseness
Worsening or abruptly occurring stridor
Varying degrees of respiratory distress
Retractions
Dyspnea
Nasal flaring
Cyanosis
Sore throat, odynophagia
Dysphonia
No drooling
No specific position of comfort (The patient may lie supine.)

32. Bacterial Tracheitis Management
Early ENT consultation for laryngotracheobronchoscopy
Only definitive means of diagnosis
Direct visualization and culture of purulent tracheal secretions
May be therapeutic by performing tracheal toilet and stripping purulent membranes

33. Bacterial Tracheitis Management Airway
Maintenance of an adequate airway is of primary importance.
Avoid agitating the child. If the patient's respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.
If intubation is required, use an endotracheal tube size smaller than expected in order to minimize trauma in the inflamed subglottic area

34. Bacterial Tracheitis Management Intravenous access and Antibiotics
Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.
Antibiotic regimens have traditionally included a penicillinase-resistant penicillin and a third-generation cephalosporin or clindamycin in patients who are allergic to penicillin.

36. Bacterial Tracheitis Management
Vancomycin, with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if methicillin-resistant S aureus is prevalent in the community.
This is us!

37. Case #4
An 8-month-old infant boy presents with fever and a stiff neck. According to the mother, the baby has not been moving his neck as much as usual. The mother also reports decreased oral intake. His temperature is 100° F, pulse is 104 beats per minute, respirations are 48 per minute, oxygen saturation is 98% on RA. The left tympanic membrane is inflamed and nonmobile. Left submandibular and left postauricular nodes are noted.
What do you want to do?

38. CBC: 26,000

39. Retropharyngeal Abscess
Epidemiology
Occurs much less commonly today than in the past because of the widespread use of antibiotics
Once almost exclusively a disease of children, is observed with increasing frequency in adults
Rare – results in a diagnostic challenge
Occurs across all age groups, but still more common in pediatrics

40. Retropharyngeal Abscess
Pathophysiology
Pharyngeal infection that results in pus accumulating in the retropharyngeal space
Develops from viral URI or OM that leads to inflammation  suppuration  necrosis of the retropharyngeal lymph nodes
Mixed aerobic and anaerobic flora
Group A strep and S. aureus most common

41. Retropharyngeal Abscess
History
Symptoms in adults
Sore throat
Fever
Dysphagia
Odynophagia
Neck pain
Dyspnea
Symptoms in children older than 1 year
Sore throat (84%)
Neck stiffness
Cough
Symptoms in infants
Fever (85%)
Neck swelling (97%)
Poor oral intake (55%)
Rhinorrhea (55%)
Lethargy (38%)
Cough (33%)

42. Retropharyngeal Abscess
Physical signs in adults
Posterior pharyngeal edema (37%)
Nuchal rigidity
Cervical adenopathy
Fever
Drooling
Stridor
Physical signs in infants and children
Cervical adenopathy (83%)
Retropharyngeal bulge (43%; do not palpate in children)
Fever (86%)
Stridor (3%)
Torticollis (18%)
Neck stiffness (59%)
Drooling (22%)
Agitation (43%)
Neck mass (91%)
Lethargy (42%)
Respiratory distress (4%)
Associated signs including
tonsillitis
peritonsillitis
pharyngitis
otitis media

43. Retropharyngeal Abscess
Diagnosis
Made clinically and confirmed with lateral neck and/or CT
Lateral soft tissue neck
CT of the neck and soft tissues
Lab studies
Blood cultures
Usually negative
CBC
WBC can be normal in up to 20%

44. General rule
>6mm at C2
>22mm at C6

45. Retropharyngeal Abscess
Management
Airway management
Apply supplemental oxygen
Endotracheal intubation may be required if the patient has signs of upper airway obstruction.
Be prepared for possible cricothyrotomy (surgical or needle)
Antibiotic treatment
Zosyn, Unasyn, Clindamycin, Cefoxitin
ENT consultation for possible drainage

46. Case #5
A 20 yr old female presents to your ER with worsening sore throat over the last 4 days. She has noted some tender nodules in her anterior neck. Today, she had a fever of 102 and said she hasn’t been able to eat anything because of the severe pain so thought she better get this checked out.
What’s your plan?

48. Peritonsillar Abscess
Epidemiology
Relatively common
30 cases per 100,000
Most commonly seen in the age group
Pathophysiology
Usually results from progression of acute pharyngitis  pharyngeal cellulitus  abscess
Most common organism is Group A Strep but most infections are polymicrobial

49. Peritonsillar Abscess
History
Symptoms usually begin 3-5 days prior to evaluation.
Sore throat, which may be unilateral
Dysphagia
Change in voice
Headache
Malaise
Fever
Neck pain
Otalgia
Odynophagia

50. Peritonsillar Abscess
Physical
Mild/moderate distress
Fever
Tachycardia
Dehydration
Drooling, salivation, trouble handling oral secretions
Trismus (inability or difficulty in opening the mouth)
Hot potato/muffled voice (sounds like they are talking with hot food in their mouth)
Cervical lymphadenitis in the anterior chain
Asymmetric tonsillar hypertrophy
Localized fluctuance
Inferior and medial displacement of the tonsil
Contralateral deviation of the uvula
Erythema of the tonsil
Exudate on the tonsil 

51. Peritonsillar Abscess
Diagnosis
Clinical
Imaging may help
Lateral soft tissue neck to rule out other causes
CT w/ IV contrast
useful if incision and drainage (I&D) failed, if the patient cannot open his or her mouth, or if the patient is young (<7 y)
Ultrasonography
Intraoral ultrasonography has a sensitivity of 95.2% and specificity of 78.5%.
Transcutaneous ultrasonography has a sensitivity of 80% and specificity of 92.8%. This method is cost-effective and fast.

53. Peritonsillar Abscess
Management
ABCs, paying attention to the patient's airway
Fluid resuscitation
Antipyretics and adequate analgesia
Needle aspiration should be performed to drain the abscess and should provide moderate pain relief. Larger abscesses may require incision and drainage.
If uncomfortable with these procedures, consult ENT
Antibiotics for empiric treatment of a streptococcal infection should be administered
Patients can be managed on an outpatient basis unless they show signs of toxicity, sepsis, airway compromise, or complications. 

54. Peritonsillar Abscess
Needle aspiration
Needle aspiration is used for symptom relief and is the criterion standard for diagnosis
Lidocaine with epinephrine should be used to anesthetize the area
A 16- to 18-gauge needle with a 10-mL syringe should be used to aspirate from the area that is most fluctuant
Abscess I&D
After lidocaine with epinephrine local infiltration, a No. 11 blade scalpel may be used to incise a very large incision, allowing the purulent drainage to flow freely as the abscess cavity decompresses. Allow the patient to hold the Yankauer catheter tip and to suction the pus, rather than swallow it.
Tonsillectomy: Tonsillectomy may be used for recurrent peritonsillar abscesses.

55. Case #6
A 48-year-old woman with a history of hypertension, newly diagnosed heart failure, hypercholesterolemia, and bipolar disorder was rushed to the hospital by ambulance. Her chief complaint was shortness of breath, which had started the previous day and had become progressively worse. She also complained of chest "heaviness," sweating, anxiety, light-headedness, and "tight and swollen" skin. She said that her tongue felt swollen and that she "could not talk right." Her husband reported that she had been acting "bizarrely" today. The patient said she felt "cross-eyed." She denied any new skin lesions or itching. She had seen her cardiologist on the previous day for her newly diagnosed heart failure, at which time she was started on Lasix and Zestril. The patient stated that she had been urinating less frequently since yesterday.

57. ACE-I Induced Angioedema
Epidemiology
Usually occurs within the first two months of ACE-inhibitor treatment
More common in African Americans
Pathophysiology
Hypothesized to be caused by a bradykinin-dependent increase in vascular permeability
Rapid onset, non-pitting edema

58. ACE-I Induced Angioedema
Other causes
Angioedema can occur as a result of
hereditary angioedema (HAE)
acquired angioedema (AAE)
angioedema associated with allergic reactions, which is often associated with urticaria
angioedema secondary to medications
idiopathic angioedema
Does not always involve the face
Can also involve the extremities, genitalia, and GI tract
Pruritis and urticaria are generally seen in cases not attributable to ACE inhibitors

59. ACE-I Induced Angioedema
History/Physical
Acute swelling, usually of the head and neck region
Mouth, tongue, pharynx, larynx
In severe cases involving the upper airway, stridor may be present
Short symptom duration before presentation
Diagnosis
Based on clinical presentation and history of ACE-inhibitor usage

60. ACE-I Induced Angioedema
Management
ABCs
Patients with impending airway compromise need an immediate definitive airway
Consider fiberoptic nasotracheal intubation
Medical
Treat like an allergic reaction
Subcutaneous epinephrine, mg of 1:1000 SC
Antihistamines
Steroids

61. Case #7
A thirty-eight year old Caucasian man with advanced AIDS presents to your ED complaining of a worsening sore throat, odynophagia, trouble swallowing his oral secretions, difficulty breathing, decreased appetite, and a fever of 102 F for three days. On review of his chart, you note that two weeks ago, the patient was seen for complaints of sore throat, sinus congestion and cough. He was discharged with a ten day course of Cefuroxime. Following treatment, he reported some improvement. The patient then returned to the emergency department two days ago complaining of neck stiffness, headache, sore throat and decreased appetite. Work up for meningitis was negative and the patient was discharged home. Today, on exam, the patient is in significant distress sitting upright, drooling, with some use of accessory muscles of respiration. Due to swelling and upward/posterior displacement of his tongue, the patient is limited to one word, garbled responses to questions.
This is what he looked like…

63. Ludwig’s Angina Pathophysiology
Cellulitis originating in the submandibular space of the mouth
Extraction or infection of teeth allows oral flora to enter the submandibular space
Strep and Staph species in addition to anaerobes
Edema and abscess formation in the tissues under the tongue leads to airway encroachment  respiratory compromise

64. Ludwig’s Angina History/Physical Diagnosis
Symptoms include sore throat, dysphonia, dysphagia, submandibular swelling, halitosis
Fever
Signs of dehydration
Floor of the mouth appears full, +/- tongue elevation
Submandibular region is tender to palpation
Erythema
Trismus and drooling may be seen
Diagnosis
Clinical

65. Ludwig’s Angina Management Maintain the airway!
Fiberoptic nasotracheal intubation is preferred
IV fluids for dehydration
IV antibiotics after blood cultures
Pen G with Flagyl
Unasyn
Zosyn
Clindamycin
IV corticosteroids are controversial

66. Case #8
A two year old female is brought in by her parents with difficulty breathing. She was eating breakfast this morning when she suddenly started to cough violently. This resolved after a short time, but now her breathing seems more labored than previously. On exam, you notice diminished breath sounds and scattered wheezes on the right.
What will the CXR show?

67. On further questioning, you learn that the child was inadvertently given a banana-nut muffin for breakfast.

69. Other Causes of Acute Upper Airway Emergencies
Tracheal foreign body
Orofacial trauma
Laryngospasm
Laryngeal trauma
Airway mass

70. Heliox
Graham’s Law: flow rate is inversely proportional to the square root of its density
Helium 7x less dense than Nitrogen
Shown to be effective in upper airway obstruction, viral croup, postextubation stridor

71. References
Emergency Medicine: A Comprehensive Study Guide, Tintinalli, Judith E. Tintinalli, 6th Edition
Greenberg's Text-Atlas of Emergency Medicine by Michael I Greenberg
Google images

72. MedWAR 2007!