UPPER AIRWAY OBSTRUCTION
Dr. Bhavesh Mithiya*
Consultant Pediatrician, Mumbai*
Upper Obstruction Vs Lower Obstruction (Clinical differentiation)

Upper Airway

  • Interferes mainly with inspiration
  • Inspiratory stridor
  • Severe retractions
  • Croupy/brassy cough

Lower Airway

  • Interferes mainly with expiration
  • Expiratory wheeze
  • Mild retractions prolonged expiration
  • Hacking/repetitive cough


Adult airway is cylindrical with narrowest portion is at glottic opening
Pediatric/Infant upper airway is conical with narrowest portion is at cricoid cartilage (subglottic area)

Causes of Upper Airway Obstruction
(a) Congenital(b) Acquired
Presents with persistent/recurrent stridorPresents with acute stridor, associated features


Stridor
Acute

Chronic (Congenital)

  • Persistent
  • Recurrent
"Toxic"Non Toxic
  • Epiglottitis*
  • Tracheitis*
  • Diphtheria
  • Retropharyngeal abscess*
  • Severe croup*
  • Angioedema
  • Croup*
  • Laryngitis
  • Foreign Body*
  • Post-extubation



Clinical features of Stridor:

• Inspiratory high pitched sound, if severe obstruction it may be expiratory as well
• Retractions Suprasternal, intercostals, sternal depression
• Cough - "brassy/barky"
• Voice - Muffled, hoarse
• Associated Tachycardia, Tachypnea
• Altered sensorium worsening hypoxia

Commonest causes of upper airway obstruction in Pediatric seen in office practice:

• Croup
• Epiglottitis
• Retropharyngeal abscess
• Foreign body
• Bacterial tracheitis

1) CROUP (VIRAL LARYNGO TRACHEO BRONCHITIS)
  • Benign, self-limiting upper airway obstruction
  • Due to Parainfluenza, Adeno, RSV, Rhino, Influenza A virus
  • Age group - Usually (3 mon) 1 year 3(6) years, Boys> girls 2:1
  • 90% of stridor with fever
  • URTI days - stridor, brassy cough
  • Seasonal more in winter and monsoon months
  • Varying degree of lower airway involvement
  • (May have associated wheezing)


Signs and Symptoms (croup):
MildSevere
  • 1-3 day h/o URL
  • Barking cough
  • Fever - low grade usually
  • Tachypnea
  • Stridor
  • Retraction and wheezing
  • Agitation, Lethargy
  • Progressive tachycardia and tachypnea
  • Hypoxia (cyanosis)
  • Decrease in tidal volume
  • Apnea


Clinical Croup Score (Downers & Raphaely)
Score012
Inspiratory BSNHarsh/RhonchiDelayed
StridorNoInspiratoryInsp/Exp
CouchNoHoarse  Bark
Retraction, flaringNoFlaring + SubcostalSuprasternal Intercostal
CyanosisNoIn room air  In 40% oxygen

Score <3 = Mild airway obstruction,
Score >4 = Moderately severe airway obstruction,
Score >7 = (with oxygen <70 and carbon dioxide> 45) impending respiratory failure.

Treatment
For (mild-moderate)
If reliable parents,> 6 mo age, able to drink fluids, well hydrated:
  • Out patient treatment
  • Avoid agitation, Position of comfort, Parent's participation
  • Cool, humidified oxygen, Cool Mist therapy
  • Nebulization with Epinephrine
  • Dexamethasone / Inhaled Budesonide

For (moderate-severe)
After 3 hrs of nebulization, if the score is increasing, <6 mo age, Stridor at rest - inspiratory and expiratory, unreliable parents, needs oxygen, fatigue.
  • Admit, Intensive care
  • Nebulized Epinephrine 0.5 ml/kg (5 ml), 1:1000 diluted NS, q2-6 hrs
  • Dexamethasone IM/Oral 0.15-0.6 mg/kg stat
  • Aerosolized Budesonide 2-4 mg
  • Heliox (mixture of Helium + Oxygen)
  • Intubation RARELY needed

Do not rush for:
  • Immediate X-rays, blood counts in typical cases of viral croup
  • Antibiotics, in typical case
  • Cough mixtures, expectorants
  • Sedation


2) ACUTE EPIGLOTTIS
  • 3-7 years age, Rapidly progressive, Severe, Quiet stridor
  • Aphonic, muffled voice
  • High fever, Toxic agitated*
  • Airway obstruction with Drooling of saliva


Treatment
  • Avoid procedures unless confirmed
  • Examination under controlled setting by most experienced personal (ENT, anesthetists, Intensivist)
  • Most will need intubation
  • I.V. antibiotics (Cefotaxime/Ceftriaxone/Amoxyclav)
  • Supportive care


3) RETROPHARYNGEAL ABSCESS

Pus in the potential space between the posterior pharyngeal wall and the pre-vertebral fascia.

Etiology:
Complication of bacterial pharyngitis, Cx. Lymphadenopathy, extension from vertebral osteomyelitis, penetrating injury to posterior pharynx.

Presentation:
Preschool-school going age, URTI, fever, stridor, neck swelling, torticollis*, dysphagia*, refusal to feed, severe distress*, drooling*.

Findings:
Febrile, toxic, edematous anterior bulge in posterior pharyngeal wall, neck stiffness.

Treatment:
  • Antibiotics
  • (Polymicrobic, Staph, Strept, H. Influ, Pneumo, Anaerobes):
    • Penicillin + Metrogyl or Cefoxitin;
    • Clinda or Ticarcillin/Clavulanate or Piperacillin/Tazobactum or Ampi/Sulbactam

  • Intubation in 1/3 rd
  • Surgery - I & D under GA in OT


4) UPPER AIRWAY FOREIGN BODY

Typical Presentation
A toddler presented with a history of sudden onset bouts of coughing and respiratory distress since 3 hours. The first step in diagnosis of a foreign body is to think of it ....

Extrathoracic Foreign Bodies
Laryngeal, tracheal, upper esophageal

Presentation
Croupy cough, stridor, RD, cyanosis

Diagnosis:
  • History, X-ray neck for radio-opaque FB (AP, Lat)
  • For complete airway obstruction-PALS protocol (Heimlich's Maneuver)
  • For non urgent case ENT surgeon's help


Other causes of Upper Airway Obstruction are Relatively Uncommon
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