1. Tricia Falgiani, MD Assistant Professor University of Florida Pediatric Emergency Medicine

2. Objectives Identify unique characteristics of the pediatric airway Identify upper and lower airway diseases Distinguish between airway urgencies and emergencies 3. The Pediatric Airway Passive flexion due to a large occiput Relatively large tongue Mass of adenoidal tissue U-shaped and floppy epiglottis Larynx is more anterior 4. The Pediatric Airway Cricoid ring is the smallest diameter Narrow tracheal diameter and short distance between the tracheal rings Airway cartilage is softer and more flexible Short tracheal length Large airways are more narrow 5. The Pediatric Airway 6. Airway Assessment History Acute or gradual onset? Fever? Drooling? Voice changes? Difficulty swallowing? URI symptoms? Significant past medical history? 7. Airway Assessment Physical Exam Appearance Alertness Muscle tone Ability to cry or speak Work of breathing Circulation Pallor Cyanosis Mottling Skin temperature 8. First Impressions. http://youtu.be/Ksl7Z3iwyL8 http://youtu.be/-4OhWQ8Ppko 9. Respiratory Status Bradypnea is more concerning than tachypnea Normal rate/min Newborn 30-60 6 months 25-35 1-3 years 20-30 4-6 years 18-26 Adolescent 12-18 10. Signs of Respiratory Distress Increased work of breathing Retractions Nasal flaring Grunting Head bobbing 11. Signs of Respiratory Distress Altered mental status Agitation Irritability Lethargy Coma 12. Signs of Respiratory Distress Color Cyanosis Pallor Position Sniffing position Tripod position 13. Signs of Respiratory Distress Auscultation Snoring Grunting Stridor Wheezing Rales (crackles) Rhonchi 14. Practical Points Children have unique airway anatomy Airway assessment begins with a good history First impressions give us a lot of information Signs of respiratory distress Increased work of breathing Altered mental status Color Position Auscultation findings 15. Common Pediatric Airway Diseases Upper Airway Diseases Lower Airway Diseases Croup Foreign Body Epiglottitis Bacterial tracheitis Asthma Bronchiolitis Pneumonia Foreign Body 16. Laryngotracheobronchitis Croup! Upper airway disease Viral infection of larynx, trachea and bronchi Parainfluenza (75%) Influenza RSV Adenovirus Age 6months-3 years Male > female Winter months 17. Clinical Presentation Fever Rhinorrhea Nasal congestion Barking cough Inspiratory stridor Respiratory distress Worse at night 18. Clinical Presentation Gradual onset of URI symptoms (days) Mild fever, hoarseness, barking cough Sudden stridor and retractions Dyspnea and tachypnea 19. Westley Scoring System 0 1 2 3 Stridor None Only with agitation Mild at rest Severe at rest Retraction None Mild Moderate Severe Air entry Normal Mild decrease Moderate decrease Marked decrease Color Normal N/A N/A Cyanotic Level of consciousness Normal Restless when disturbed Restless when undisturbed Lethargic 20. Westley Scoring System Score Degree Management 0-2 Mild Mist therapy 3-7 Moderate Racemic epi, steroids >8 Severe Racemic epi, steroids, admit 21. Treatment Labs and x-ray unnecessary Mist therapy Racemic epinephrine Dexamethasone 0.6mg/kg 22. https://www.youtube.com/watch?v=Z1_uKqmPyLA&f eature=player_detailpage https://www.youtube.com/watch?v=Qbn1Zw5CTbA&f eature=player_detailpage 23. Foreign Body Basics: Airway emergency? The airway is a funnel Typically under 3 years of age Impaired mentation Candy and food High index of suspicion 24. Clinical Presentation Sudden coughing or choking Dyspnea Stridor (upper) Wheezing, rhonchi or rales (lower) Unequal breath sounds (lower) 25. Treatment Maintain suspicion Keep child calm with parent Blow by oxygen if tolerated Dont agitate patient Advanced airway maneuvers as indicated 26. Epiglottitis 27. Epiglottitis Upper airway disease Airway emergency Life threatening bacterial infection of epiglottis and surrounding structures Rare Age 3-7 years Winter months Pathophysiology H. Influenzae S. Pneumoniae Group A streptococcus Staph aureus 28. Clinical Presentation Abrupt onset (hours) Toxic appearing Fever Stridor Drooling Inability to swallow Sore throat Respiratory distress Tripod position Sudden obstruction 29. Treatment Secure airway Dont agitate child Antibiotics Ceftriaxone Cefotaxime Meropenem Clindamycin/vanc ? 30. Bacterial Tracheitis 31. Bacterial Tracheitis Rare (0.1 cases per 100,000 children per year) Invasive exudative bacterial infection of the trachea Male > Female Age 3 weeks- 16 years Pathophysiology Staph aureus (MRSA) Strep pyogenes Strep pneumoniae Moraxella catarrhalis H. influenza type B (unvaccinated) 32. Clinical Presentation Similar to croup URI prodrome Fever Stridor Barky cough Hoarseness Sore throat No drooling Respiratory distress 33. Treatment Secure airway Antibiotics Ceftriaxone Meropenem Clinda or vanc 34. Epiglottitis vs. Croup vs. Bacterial tracheitis Epiglottitis Croup Bacterial Tracheitis Anatomy Supraglottic Subglottic Tracheal lumen Etiology Bacterial Viral Bacterial Age Range 3-7 years, adults 6months-3 years 3weeks-16 yrs Onset 6-24 hours 2-3 days 1-3 days Toxicity Marked Mild to moderate Mild- marked Drooling Frequent Absent Absent Cough Unusual Frequent Frequent Hoarseness Unusual Frequent Frequent WBC Leukocytosis Normal Leukocytosis 35. Causes of Stridor Spasmodic croup Retropharyngeal abscess Peritonsillar abscess Subglottic stenosis Allergic reaction Foreign body Tracheomalacia Laryngeal web Laryngeal papillomatosis Laryngeal hemangioma Trachea fracture Vocal cord paralysis Inhalation injury Uvulitis Vascular ring Double aortic arch Aberrant subclavian artery Pulmonary artery sling Epiglottitis Bacterial tracheitis Diphtheria Croup 36. Asthma Lower airway disease Airway urgency/emergency Chronic and recurrent Bronchospasm Airway inflammation Ventilation problem with air trapping 37. Assessment Respiratory rate Work of breathing Oxygen saturation Expiratory time Mental status 38. Clinical Presentation Dyspnea Retractions Tachypnea Nasal flaring Inability to speak Wheezing Prolonged expiratory phase Beware of the quiet chest 39. Treatment ABCs Give oxygen Nebulized albuterol Steroids Upright position Severe attacks Epinephrine Magnesium sulfate 40. Treatment Secure airway Surgical drainage Antibiotics Unasyn Clindamycin Vancomycin Augmentin 41. Asthma Caveats Many patients/parents do not take this disease seriously Parents may not have an asthma action plan at home Albuterol is a short acting drug If patient is requiring multiple albuterol treatments at home, they should be evaluated immediately 42. Bronchiolitis Lower airway disease Airway urgency 2 months- 2 years Chronically ill are at higher risk Premature Congenital heart disease Less than 1 month old Inflammation, edema and mucous in the lower airways Viral etiology 43. Clinical Presentation Dyspnea Tachypnea Retractions Nasal flaring Wheezing Long expiratory phase Rales Rhonchi Decreased air movement 44. Treatment SUPPORTIVE!!! Oxygen Suctioning Upright position ?nebulized albuterol ?nebulized hypertonic saline 45. Pneumonia Lower airway disease Airway urgency All ages Younger patients can be very ill Chronically ill at higher risk Bacterial or viral etiology 46. Clinical Presentation Rales (may be localized) Rhonchi Tachypnea Variable fever +/- Respiratory distress Hypoxemia 47. Treatment Oxygen Fluids Upright position Antibiotic therapy 48. Practical Points Upper vs. Lower airway diseases- listen for the diagnosis! Airway urgencies can quickly progress to airway emergencies Beware of the neonate! Trust the parents Look for visual cues Try not to agitate the patient 49. Questions?