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Pediatric Airway Emergencies:Evaluation and Management

Shashidhar S. Reddy, MD, MPH

Ronald Deskin, MD

January 2002

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Anatomic and Physiologic Considerations of the Pediatric Airway:

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Initial Assessment:

Signs of impending respiratory failure: Reduced level of consciousness or lethargy Quiet, shallow breathing Apnea

The above require immediate progression to endoscopy and/or intubation.

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History:

Description of OnsetAge at onsetHistory of foreign body aspiration/ingestionAggravating factors: feeding/sleepingHistory of intubationBirth history (syndromes, birth trauma)

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Physical Exam:

InspectionAscultationRepositioning

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Flexible Laryngoscopy:

Proper EquipmentAssess nares/choanaeAssess adenoid and

lingual tonsilAssess TVC mobilityAssess laryngeal

structures

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Radiology:

Plain films: Chest and airway AP and

lateral Expiratory films High vs. low kilovoltage

FluoroscopyBarium SwallowCT, MRI, Angiography

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Flexible Bronchoscopy:

Does not require general anasthesiaMainly diagnostic purposesLimited intervention (e.g. suctioning)Can be used for intubationLimited airway control

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Direct Laryngoscopy andRigid Bronchoscopy

Indications: Severe or progressive airway obstruction No diagnosis after flexible laryngoscopy and

radiology Subglottic pathology suspected

Advantages over flexible bronchoscopy: Better control of the airway

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Direct Laryngoscopy

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Direct Laryngoscopy

Insufflation technique:

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The Ventilating Bronchoscope

A. Light source and telescopeB. Prismatic light detector and

attachment to light sourceC. Aspiration and

instrumentation channelD. Connector to anesthesiaE. Telescope bridge

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Rigid Bronchoscopy

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Rigid Bronchoscopy:

Complications: Loss of airway control Injury to subglottic space Damage to teeth or gums Airway bleeding Pneumothorax Failure to recognize pathology

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Specific Etiologies of Airway Emergency

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Laryngotracheobronchitis

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Bacterial Tracheitis (Membranous Tracheitis)

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Epiglottitis

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Choanal Atresia

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Pyriform stenosis

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Laryngomalacia

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Vocal Cord Paralysis

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Subglottic Stenosis

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Subglottic Hemangioma

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Tracheoesophageal Fistula

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Laryngeal Cleft

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Vascular Anomaly

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Recurrent Respiratory Papillomatosis

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Airway Foreign Bodies

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Case Study: History

Consult from the Neonatal ICU: Newborn infant in increasing respiratory

distress since birth. Oxygen saturation is now 100%, but the child

has begun to use accessory muscles. Feeding aggravates the distress. Infant has a weak cry, and pediatritians notice

noisy breathing. No abnormal birth history.

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Case Study: Physical Examination

Newborn female infant supine in the bed, sat’ing 100% on room air

Moderate use of accessory musclesModerate biphasic stridorAudible breaths through both naresRepositioning has little effect on stridor

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Case Study: Endoscopy