Pediatric Upper Airway Emergencies

8/9/2019 Pediatric Upper Airway Emergencies

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Pediatric Upper Airway

Emergencies

Sangeeta Schroeder, MD

Resident Noon Conference


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Infectious

Croup

Bacterial Tracheitis

Epiglottitis

Other Infectious

Infectious Mono

Neck Abscess

Retropharyngeal

Paratonsillar

2Pediatric Upper Airway Emergencies

Usual Suspects


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Extrathoracic/SupraglotticLacks cartilaginous

support

Composed mostly of

soft tissue and muscle

Glottic/SubglotticSmallest part of the

pediatric airway

Some cartilaginous

support

Intrathoracic

Tracheo-Bronchial Tree



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Epiglottitis

Laryngomalacia

Croup

Subglottic Stenosis

Subglottic HemangiomaLaryngeal Webs


Tracheomalacia

Vascular Rings/Slings

Bronchomalacia



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History

Fever

High fevers with sudden onset: bacterial infections

URI symptoms

Acute onset of symptoms

Acute worsening of insidious symptoms

Incomplete Hib immunization: Epiglottitis

Associated Varicella infection: Epiglottitis

Pediatric Upper Airway Emergencies 6

Clinical Presentation:

Infectious


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Exam

Anxious appearing child; tripod positioning:

epigottitis, bacterial tracheitis

Gurgling sounds without stridor: epiglottitis

Severe respiratory distress: bacterial tracheitis,

severe croup

Nasal congestion: croup


Clinical Presentation


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Epiglottitis

Acute process of edema andinflammation

Two age groups:


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Inflammation and mucous production in the subglottis

Parainfluenza (1,2,3), Influenza (A,B), RSV, Adenovirus

Mild nasal congestion that progresses to a barking

cough and/or stridor Categorized into Mild, Moderate or Severe

Mild: no stridor at rest; can have stridor with activity

Moderate: stridor and retractions at rest

Severe: stridor and severe retractions at rest associatedwith behavioral changes (extreme agitation or lethargy)

Laryngotracheitis (Croup)



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Croup: Steeple Sign on AP view

Epiglottitis: Thumb Sign on Lateral view

NOT WARRANTED

X-Ray only if you suspect a foreign body

Bacterial Tracheitis: Laryngoscopy


Diagnostics


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Epiglottitis Bacterial Tracheitis


Endoscopic Visualization


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Humidified Air and Cool Mist are not effective treatments

0.6mg/kg Decadron PO/IM for ALL croup Do not need to repeat dose

Racemic epi nebs for moderate and severe croup

If there is stridor at rest: use racemic epi Continuous to Q4 PRN

Observe for 2-3 hrs after treatment for epi to wear off

Rebound Effect: likely not real

Admission Criteria: 2 or more racemic epi treatments

Poor PO intake or inadequate follow-up

Admit to PICU if on continuous racemic nebs


Treatment: Croup


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Airway Management

Bronchoscopy to suction purulent and necrotic

debris

Continued suctioning while intubated

IV Antibiotics

Vancomycin + 3rd Generation Cephalosporin

PICU admission


Treatment:



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Do all kids with epiglottitis need intubation? Prospective study done in Germany in 1996

International Journal of Pediatric Otorhinolaryngology

Fiberoptic visualization of airway Assess degree of inflammation and airway involvement

Kids managed without intubation increased from 8% to 45% Mean age of child intubated: 3.4

Mean age of child not intubated: 6.1

Regardless, current practice is to still intubate all kids with

epiglottitis in a controlled environment IV Antibiotics and PICU Admission

Vancomycin + 3rd Generation Cephalosporin


Treatment: Epiglottitis


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History Overview

Insidious and/or intermittent symptoms

Past history of prolonged intubation or severe GERD:

subglottic stenosis Trisomy 21: congenital subglottic stenosis

DiGeorge Syndrome: laryngeal webs

Congenital Cardiac Lesions: laryngeal webs, vascular

rings Underlying neuromuscular disorder/hypotonia:

tracheo/bronchomalacia


Clinical Presentation:

Anatomic/Congenital


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Exam Overview

Hypotonia: Malacia

Skin Hemangiomas: Subglottic hemangioma Biphasic Stridor: Subglottic hemangioma

Surgical Scars: Subglottic stenosis

Abnormal Facies: Laryngeal webs

Caf au lait spots: Neurofibromas of the airway

Clinical Presentation


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Laryngomalacia

Intermittent episodes of stridor without fever

Usually Mild without evidence of respiratory

distress Worsens with activity/URIs

Worse in the supine position

Most self-resolve by 1 year

Male predilection

Associated GERD (more severe)


Congenital Causes Clinical

Presentations


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Tracheo/Bronchomalacia

Symptoms are more persistent and severe than

laryngomalacia

Significant distress with mild URIs and basic

activities (coughing/feeding/stooling)

Underlying hypotonia


Congenital Causes Clinical

Presentations


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Congenital Causes:

Subglottic Stenosis

Acquired V congenital If no hx of intubation, considered to be congenital

Males >> Females

Two forms Mucosal: Submucosal hypertrophy (more common)

Cartilaginous: Narrow cricoid cartilage (more severe)

Usually presents with biphasic stridor during

URIs Recurrent Croup

Acquired is usually more severe



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Congenital Causes:

Subglottic Hemangioma

Females >> Males

Insidious presentation of biphasic stridor without fever

Recurrent Croup

Rapidly enlarges from 2 months to 1 year of age

Resolve by 2-5 yrs of life

Most need surgical management prior to 2 years

50% will have a face/neck hemangioma

Enlarging hemangioma: sudden upper airway

obstruction and distress



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Congenital Causes:

Laryngeal Webs

Weak cry, horseness

Varying degress of resp distress

Type 1 (75% webbing)

Caused by failure of normal embryonic tissueregression

Type 4 usually diagnosed at birth with respiratoryfailure

1/3 associated with other anomalies of the airway Subglottic stenosis (most common)

Recurrent croup



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Congenital Causes:

Vascular Rings/Slings

Tracheo-esophageal compression

Caused by the abnormal persistence of embryonictissue that comprises the aortic arch

Double aortic arch (50-60%)

Right aortic arch with an aberrant left subclavian (12-25%)

Pulmonary artery sling

Wheezing (from the ring/sling) and stridor (from

ass. GERD) Often diagnosed as recurrent bronchiolitis

Can present with sudden apneic and cyanotic spells



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Laryngomalacia: Usually not warranted

Tracheo/bronchomalacia: Bronchoscopy

Subglottic Stenosis: Rigid Bronchoscopy

Subglottic Hemangioma: MRI Airway endoscopy to rule out other causes

Laryngeal Webs: Laryngoscopy, Lateral neck films

Sail sign: persistent tissue from the glottis to thesubglottis

Vascular Rings: Barium Swallow, MRI


Diagnostics


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Laryngomalacia Self-resolves by 1 year as the larynx travels into the

neck

Treat concurrent GERD

Surgical correction is rare: Supraglottoplasty

Tracheomalacia/Bronchomalacia Self resolve by 1-2 years

If pt has underlying hypotonia, can be persistent

Treatment focused on concurrent infections Often will need Positive Pressure ventilation until the

airways grow in size (CPAP, BiPAP)


Treatment: Malacia


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Subglottic Stenosis

More than self resolve by

2 years of age

Surgical Interventions: Stenting

Tracheostomy

Usually can de-cannulate by

3-4 yrs of age

Reconstruction(Laryngotracheoplasty)

Reserved for severe cases

Subglottic Hemangioma

Regress completely by 5

years of age

Most require intervention Small/Medium hemangiomas:

Steroid Injections, Endoscopic

Laser Ablation

If a circumferential area is

ablated at one treatment:subglottic stenosis

Large hemangiomas:

resection, tracheostomy


Treatment


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Laryngeal Webs

Child is observed until they are 3-4 yrs of age if able

Types I-II: knife or laser ablation

Types III-IV: early larygo-tracheal reconstruction

Complicated webs may require revision surgeries

Vascular Rings

Corrected early Decrease the risk of malacia

Allow for normal growth of the tracheo-bronchial tree


Treatment:

Webs and Rings


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Dexamethasone 0.6mg/kg IM or PO has become the mainstay

of treatment for croup, regardless of severity.

Bacterial Tracheitis is now the most common infectious cause

of pediatric upper respiratory emergencies, with the most

common bacterial agents being Staphylococcus aureus and

Streptococcus pyogenes.

Epiglottitis is no longer a disease of infants. Since

Haemophilus type B immunization, the most common causes

of epiglottitis are Streptococcus pneumonia and group Astrep. With this change in bacterial etiology, the average age

of children with epiglottitis is now 6-7 years.


Key Points


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1Hopkins A, Lahiri T, Salerno R, Heath B. Changing epidemiology of life-threatening upper

airway infections: the reemergence of bacterial tracheitis. Pediatrics 2006; 118:1418-1421

2Hartnick CJ, Cotton RT. Congenital laryngeal anomalies. Laryngeal atresia, stenosis, webs and

clefts. Otolaryngol Clin North Am 2000; 33(6):1293-1308

3Kussman BD, Geva R, McGowan F. Cardiovascular causes of airway compression. Pediatric

Anaesthesia 2004; 14:60-74

4Leung A, Cho J. Diagnosis of stridor in children.American Family Physician 1999; 60 (8)

5Long S, Pickering L, Prober C. Upper respiratory tract and oral infections. In: Principles andPractice of Pediatric Infectious Diseases, 2nded. 2003; Ch 26, 31.

6Grattan-Smith T, Forer M, Kilham H, Gillis J. Viral supraglottitis.J Pediatrics 1987; 110:434

7Bjornson C, Johnson D. Croup. The Lancet2008; 317:329-339

8Damm M, Eckel HE, Jungehulsing M, Roth B. Airway endoscopy in the interdisciplinary

management of acute epiglottitis. Int J Pediatric Otorhinolaryngology1996; 38:41-51

9Scolnik D, Coates A, Stephens D et al. Controlled delivery of high vs. low humidity vs. mist

therapy for croup in emergency departments: a randomized controlled trial.JAMA 2006;

295:1274-1280

10Cruz M, Stewart G, Rosenberg N. Use of dexamethasone in the outpatient management of

acute laryngotracheitis. Pediatrics 1995; 96:220-223

11Bjornson C, Klassen T, Williamson J et al. A randomized trial of single dose of oral

dexamethasone for mild croup. New England Journal of Medicine 2004; 351:1306-1313Pediatric Upper Airway Emergencies 30

References

Pediatric Upper Airway Emergencies

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