Upper Airway Obstruction

Noisy Breathing

Upper Airway

• Nose• Nasopharynx• Oropharynx• Larynx (supraglottis, subglottis)• Trachea (extrathoracic)

Upper Airway Obstruction

Noisy Breathing

Noise during INSPIRATION Noise during EXPIRATION

Difficulty breathing OUT

Distal to Thoracic InletTrachea, bronchi, peripheral

airways

Difficulty breathing IN

Proximal to Thoracic InletNose, pharynx, larynx

Upper Airway Obstruction

Difficulty breathing IN

Awake/Crying IMPROVES

Awake/CryingDETERIORATES

LarynxNose / Pharynx

Upper Airway ObstructionNoise decreases as obstruction worsens

0102030405060708090

100

Noise NOT indicative of degree of obstruction

therefore

THE WORST OBSTRUCTION IS SILENT

Upper Airway ObstructionWhich clinical signs are indicative of the severity of obstruction?

Recession (sternal, lower costal margin)TachypnoeaTachycardiaExpiratory difficulty (abdominal muscles contract)Depressed consciousnessCyanosis Noise soft/absent

Where in the Airway is the Obstruction

+Small airways

+ +Trachea &bronchi

+Severe obstr

+ ±Small babies

Larynx

-++Nasopharynx

WheezeStridorSnoring

Obstruction in Upper Airway versus Lower Airway

AIR TRAPPING - PERCUSSION

Upper border of liver displaced downwards

Cardiac dullness not detected

Upper Airway ObstructionApproach

• History• Age • Clinical examination

Site of obstructionSeverity

Upper Airway Age

• Short• Narrow• Elastic• Tendency to collapse

Upper Airway

Resistance to airflow through

a tube is inversely proportional to

the radius4

Upper AirwayInfant/Child

Scenario: Airway 4 – 5 mm diameter 1 mm oedema

• Resistance increases 16 times (adult 3 times)

• Surface area decreases by 75%(adult 45%)

Upper airway of a child not a miniature replica

Upper AirwayNose

• “Blocked” nose (infants < 6 months)• Choanal atresia• Foreign body• Polyps• Allergy

Upper AirwayNose

• “Blocked nose”(0 – 6 months)

• Choanal atresia• Foreign body• Polyps• Allergy

Upper AirwayOropharynx

• Adenoidal hypertrophy (Obstructive sleep apnoea)

• Micrognathia• Craniofacial

abnormalities• Large tongue

Upper AirwayOropharynx

OBSTRUCTIVE SLEEP APNOEA

Adenoidal hypertrophySnoringSudden death during sleep

Craniofascial abnormalitiesMicrognathia

Oropharynx

Obstructive sleep apnoeaHigh index of suspicion (10%)Examine child while asleepEarly diagnosis and treatmentPrevent complications

HypoxaemiaGrowth failure Sudden death

Upper AirwaySupraglottis

Epiglottitis(H.influenza type B)

Acute onsetDroolingPyrexiaPosture

AIRWAYANTIBIOTICS

Upper AirwayLarynx

• Laryngomalacia

• Webs, cysts

• Vocal cords(paralysis, papillo-mata)

Larynx

LaryngomalaciaObstruction

Inspiratory, variable Newborn infant, stridor (awake)Improves: prone, sleep, ageVoice normal

Larynx

Laryngeal papillomata6 months – 5 yearsInspiratory stridorVoice HOARSENot associated with infectionREFERRAL

Upper AirwaySubglottis

Laryngotracheobronchitis (Croup)6 months – 2 yearsPreceded by a cold (Parainfluenza)StridorNormal voiceBarking coughGrade severity of obstruction

Croup Grading according to Severity of Obstruction

+Active+Grade 3

(Grade 4 apathy,

cyanosis)

-Passive +Grade 2

--+Grade 1

PulsusParadoxus

Expiratory Obstruction

InspiratoryObstruction

Severity

Croup

TreatmentAdrenaline inhalationsSteroidsAvoid cryingAirway – intubation

tracheostomy

Upper AirwaySubglottis

Congenital subglottic stenosis<6 monthsNo preceding infectionHistory of intubationEndoscopyTracheostomy

Upper AirwayBacterial Tracheitis

• Older child (<2 years)• Toxic, erythematous rash• Thick secretions• Airway (tracheostomy)• Staphylococcus aureus

Upper AirwayForeign Body

• May lodge in any part of airway• HISTORY• X-rays• Endoscopy

Upper AirwayRetropharyngeal Abscess

• <6 months• Sore throat (anorexia) for several days• Pyrexia, drooling, stridor• X-ray: prevertebral space increased• Surgical drainage• Antibiotics