Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during...

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Upper Airway Obstruction Noisy Breathing

Transcript of Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during...

Page 1: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper Airway Obstruction

Noisy Breathing

Page 2: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper Airway

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

Page 3: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet
Page 4: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

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

Page 5: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper Airway Obstruction

Difficulty breathing IN

Awake/Crying IMPROVES

Awake/CryingDETERIORATES

LarynxNose / Pharynx

Page 6: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper Airway ObstructionNoise decreases as obstruction worsens

0102030405060708090

100

Noise NOT indicative of degree of obstruction

therefore

THE WORST OBSTRUCTION IS SILENT

Page 7: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

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

Page 8: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Where in the Airway is the Obstruction

+Small airways

+ +Trachea &bronchi

+Severe obstr

+ ±Small babies

Larynx

-++Nasopharynx

WheezeStridorSnoring

Page 9: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Obstruction in Upper Airway versus Lower Airway

AIR TRAPPING - PERCUSSION

Upper border of liver displaced downwards

Cardiac dullness not detected

Page 10: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper Airway ObstructionApproach

• History• Age • Clinical examination

Site of obstructionSeverity

Page 11: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper Airway Age

• Short• Narrow• Elastic• Tendency to collapse

Page 12: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper Airway

Resistance to airflow through

a tube is inversely proportional to

the radius4

Page 13: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

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

Page 14: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayNose

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

Page 15: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayNose

• “Blocked nose”(0 – 6 months)

• Choanal atresia• Foreign body• Polyps• Allergy

Page 16: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayOropharynx

• Adenoidal hypertrophy (Obstructive sleep apnoea)

• Micrognathia• Craniofacial

abnormalities• Large tongue

Page 17: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayOropharynx

OBSTRUCTIVE SLEEP APNOEA

Adenoidal hypertrophySnoringSudden death during sleep

Craniofascial abnormalitiesMicrognathia

Page 18: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Oropharynx

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

HypoxaemiaGrowth failure Sudden death

Page 19: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwaySupraglottis

Epiglottitis(H.influenza type B)

Acute onsetDroolingPyrexiaPosture

AIRWAYANTIBIOTICS

Page 20: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayLarynx

• Laryngomalacia

• Webs, cysts

• Vocal cords(paralysis, papillo-mata)

Page 21: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Larynx

LaryngomalaciaObstruction

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

Page 22: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Larynx

Laryngeal papillomata6 months – 5 yearsInspiratory stridorVoice HOARSENot associated with infectionREFERRAL

Page 23: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwaySubglottis

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

Page 24: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Croup Grading according to Severity of Obstruction

+Active+Grade 3

(Grade 4 apathy,

cyanosis)

-Passive +Grade 2

--+Grade 1

PulsusParadoxus

Expiratory Obstruction

InspiratoryObstruction

Severity

Page 25: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Croup

TreatmentAdrenaline inhalationsSteroidsAvoid cryingAirway – intubation

tracheostomy

Page 26: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwaySubglottis

Congenital subglottic stenosis<6 monthsNo preceding infectionHistory of intubationEndoscopyTracheostomy

Page 27: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayBacterial Tracheitis

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

Page 28: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayForeign Body

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

Page 29: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

Upper AirwayRetropharyngeal Abscess

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

Page 30: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet
Page 31: Noisy Breathing - University of Pretoria · Upper Airway Obstruction Noisy Breathing Noise during INSPIRATION Noise during EXPIRATION Difficulty breathing OUT Distal to Thoracic Inlet

INTERVENTIONS FOR NOISY BREATHING IN PATIENTS NEAR TO DEATH Bee Wee, Richard Hillier Ana Isabel Yébenes Rubio.

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