Assessment Management of Acute Upper Airway Obstruction in

Assessment & Management of Acute Upper Airway Obstruction in Children

Differential Diagnosis: Acute Upper Airways Obstruction q. Croup: • Viral Laryngotracheobronchitis (very common) • Recurrent or spasmodic croup (common) • Bacterial tracheitis (rare)

Differential Diagnosis: Acute Upper Airways Obstruction q 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 Location Subglottic Aetiology Onset Parainfluenza, RSV; rarely Mycoplasma, adeno. V, measles Insidious, URTI Stridor Yes Retractions Yes Voice Hoarse Position & appearance Normal

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

Acute Laryngotracheobronchitis-2 Swallowing Normal Barking cough Yes Toxicity Rare Fever <38 C X-ray Subglottic narrowing/ steeple sign WBC count Normal Treatment Oral Dexamethasone/Neb. Budesonide Prevention None

Sign ?

Sign ?

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

Spasmodic Croup-1 Age Location Aetiology Onset 3/12 – 3 years Subglottic Unknown Sudden onset at night; prior episodes Stridor Yes Retractions Yes Voice Hoarse Position & Normal appearance

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

Spasmodic Croup-2 Swallowing Normal Barking cough Yes Toxicity No Fever X-ray None Subglottic narrowing WBC count Normal Treatment Occasionally Steroids needed Prevention None

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

Epiglottitis - 1 Age Location Aetiology Onset Stridor Retractions Voice Position & appearance 2 – 6 years Supraglottic HIb & HIa Rapid short prodrome Yes – soft inspiratory Yes Muffled Tripod, leaning forward; agitated

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

Epiglottitis - 2 Swallowing Drooling Barking cough No Toxicity Fever X-ray WBC count Severely toxic > 38. 5 C Thumb sign of thickened epiglottis High Neutrophil count Treatment Entotracheal Intubation involve senior Anaesthetist/ ENT Consultant. IV antibiotic Prevention None

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

Retropharyngeal Abscess-1 Age < 6 years Location Posterior pharynx Aetiology S aureus, anaerobes Onset Insidious to sudden Stridor None Retractions Yes Voice Muffled Position & appearance Arching of neck or normal

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

Retropharyngeal Abscess-2 Swallowing Drooling Barking cough No Toxicity Fever X-ray WBC count Severely toxic > 38 C Thickened Retropharyngeal space High Neutrophil count Treatment IV antibiotic +/- surgical drainage Prevention None

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

Angioedaema-1 Age All ages Location Variable Aetiology Congenital C 1 -esterase deficiency Onset Sudden Stridor Yes Retractions Yes Voice Position & appearance Hoarse, may be normal Normal; may have facial oedema, anxiety

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

Angioedaema-2 Swallowing Normal Barking cough Possible Toxicity No, unless anaphylactic shock/severe anoxia Fever None X-ray Subglottic narrowing/ steeple sign WBC count Normal Treatment High Flow O 2, Epinephrine, IV fluids, IV Hydrocortisone; danazol, C 1 -esterase Infusion Prevention Avoid allergens; FFP; danazol

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

Laryngeal Papillomatosis-1 Age 3/12 – 3 years Location Larynx, vocal cords, trachea Aetiology Human Papilloma Virus (HPV) Onset Chronic Stridor Possible Retractions No Voice Hoarse Position & appearance Normal

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

Laryngeal Papillomatosis-2 Swallowing Normal Barking cough Variable Toxicity Fever X-ray WBC count None May be normal Normal Treatment Laser Therapy, repeated excision, Bleomycin, interferon Prevention Treat 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, 100 -120, >120 Wheeze Pre-neb sats: >93%, 91 -93% & <90% Pa. CO 2: > 5 kpa

Acute severe asthma • • • High flow oxygen 10 -15 litres (mask & res) Neb Salbutamol +/- Ipratobium – 20 -30 min IV access IV Hydrocortisone 4 mg/kg x 4 hours IV Salbutamol 15 mcg/kg (5 mcg/kg <2 yrs) over 10 min – 1 -5 mcg/kg infusion • +/- IV Aminophylline Infusion 5 mg/kg 15 -20 min •

Lower Airway Diseases - Chronic • • • 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