Upperairwayobstruction
Upperairwayobstruction
Upperairwayobstruction
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REVIEW ARTICLE
Received: 31 March 2015 / Accepted: 28 May 2015 / Published online: 25 June 2015
# Dr. K C Chaudhuri Foundation 2015
Abstract Children with upper airway obstruction are both Keywords Upper airway obstruction . Stridor . Croup .
unique and variable in their presentation and management, often Epiglottitis . Bacterial tracheitis . Foreign body .
posing a challenge to the pediatrician. Several anatomical and Bronchoscopy . Airway malacia
physiologic peculiarities make a child vulnerable to develop an
obstruction of upper airways. The characteristic finding in upper
airway obstruction is stridor–inspiratory, biphasic or expiratory.
Introduction
The etiologies vary widely throughout the age groups and ac-
cording to the mode of presentation. The approach starts with
Upper airway obstruction is a common and potentially serious
suspicion, mandates careful clinical evaluation of the degree of
problem in pediatric practice. The etiology varies from simple
obstruction and many a times emergency measures precede any
nasal blockage in a newborn to near fatal epiglottitis in a child.
investigation or even precise diagnosis. Maintaining an open
The presentation can be insidious and even intermittent in a
and stable airway is of the utmost importance, often requiring
baby with airway malacia or stormy, as in a toddler with in-
a team approach of emergency physician, pediatrician, otorhi-
haled foreign body. Similarly, from the management perspec-
nolaryngologist and pediatric pulmonologist. The commonest
tive, it can range from merely careful observation to cardio-
condition presenting with upper airway obstruction in pediatric
pulmonary resuscitation. Diseases leading to severe compro-
population is viral croup. Croup is a clinical diagnosis in a fe-
mise of the upper airway are the most frequent causes of
brile child, with barking cough and stridor preceded by upper
cardiac arrest in pediatric population. In one study, severe
respiratory infection. It is treated with systemic or inhaled ste-
upper airway obstruction accounted for 3.3 % of all pediatric
roids and nebulized epinephrine. Epiglottitis and bacterial tra-
intensive care unit (PICU) admissions [1].
cheitis are acute bacterial infections of upper airways, presenting
as true airway emergencies. Though the mainstay of therapy is
IV antibiotics, the prime concern is maintenance of airway,
which frequently requires endotracheal intubation. Rigid bron- Pathophysiology
choscopy is the procedure of choice for airway foreign bodies, a
common cause of upper airway obstruction in children below There are several anatomical peculiarities in the airways of a
3 y of age. Airway malacias are the commonest cause of chronic child, which makes it more prone to obstruction. These ‘de-
stridor and are mostly managed conservatively. velopmental disadvantages’ are
The Poiseuille’s law beautifully explains how even a mar- nasopharyngeal obstruction) and wheeze (musical, high pitched,
ginal reduction in the caliber of the small pediatric airways can polyphonic/monophonic and usually during expiration).
precipitate dangerous obstruction to airflow. But one should According to the ‘Holinger’s laws’ of airway obstruction
also remember that, during periods of turbulent airflow (as in [3], in a child with noisy breathing, if the noise is worse during
case of a struggling child), the resistance to airflow becomes sleep, the obstruction is nasal or pharyngeal. If the symptoms
inversely related to fifth power of the radius of the airways! are worse when the child is awake or exacerbated, the obstruc-
Newborns and small infants are obligate nose breathers; there- tion is typically laryngeal, tracheal or bronchial. However,
fore, mere nasal block can predispose them to have significant there are exceptions, e.g., a child with recurrent respiratory
obstruction to ventilation, a feature exemplified by choanal papillomatosis of larynx presents with progressive airway ob-
atresia/ stenosis. struction most evident during sleep.
During inspiration, the intraluminal pressure in the upper
(extra-thoracic) airway becomes negative, causing collapse of
the airways. The resultant narrowing makes the airflow turbu- Causes
lent producing inspiratory stridor. During exhalation, on the
other hand, the intraluminal pressure exceeds the atmospheric Causes of upper airway obstruction are grouped into acute and
pressure and the pressure exerted by the surrounding tissue, chronic and then further reclassified into infectious and non
dilating the airway in cases of dynamic obstruction and im- infectious (Table 1). Though, in the west, the etiology and
proving the airflow. The configuration of the glottis may also incidence of infectious upper airway obstruction has changed
predispose it to collapse during inspiration than exhalation. dramatically during the past few decades, especially following
The characteristic auditory finding of upper airway ob- introduction of vaccines against Diphtheria and Haemophilus
struction is stridor; associated with extrathoracic lesions influenzae, they continue to remain one of the common causes
(e.g., laryngomalacia, vocal cord lesion) when heard on inspi- of upper airway obstruction in the pediatric population.
ration; associated with intrathoracic lesions (e.g.,
tracheomalacia, extrinsic compression) when heard on expira-
tion; associated with fixed lesions (e.g., croup, laryngeal mass Approach to Upper Airway Obstruction
or web) when biphasic [2].
Stridor should be differentiated from stertor (a low pitched Upper airway obstruction is most often a medical emergency
inspiratory snoring sound typically produced by nasal or requiring rapid evaluation with simultaneous therapy to
ensure adequate ventilation and oxygenation. It is very impor- Down syndrome, cerebral palsy) which increase the risk of
tant to note that, in most of the cases, the diagnosis is essen- more severe airway compromise should be looked for.
tially clinical; there may not be enough time to perform labo-
ratory investigations, arterial blood gases or even simple Clinical Examination
radiography.
During the initial assessment of a child with suspected upper
When to Suspect airway obstruction, the first priority is always to establish a
stable, patent airway. Approach to such a patient must be with
Any child with respiratory distress with or without noisy extreme caution and with minimal manipulation, as cata-
breathing may have airway obstruction. Patients with up- strophic obstruction can be precipitated even with trivial mea-
per airway obstruction usually present with inspiratory sures like placing a tongue blade!
stridor which can be biphasic as well. However one must Stridor is a musical, high-pitched, harsh sound that may be
be careful as profound degrees of obstruction may man- heard over the upper airways or even at a distance without a
ifest silently if airflow is nearly absent (Fig. 1). stethoscope. The timing of stridor and its exacerbating/ reliev-
ing factors help in anatomical localization of the obstruction
History and knowing whether it’s dynamic or fixed. Look at the child’s
appearance, posture, craniofacial abnormalities, drooling; check
Onset of stridor: Sudden/acute/intermittent; precipitation by for respiratory rate, chest retraction, oxygen saturation, pulsus
feeding or choking; any relation to posture or cry. Occasion- paradoxus, neck adenopathy and any palpable neck mass.
ally there may be history of witnessed foreign body inhalation Movement of chest and bilateral air entry should be checked.
(e.g., child playing with a foreign body in the mouth prior to A sweating, restless child is probably hypoxemic and a drowsy,
the onset). Associated symptoms should be asked for, e.g., aphonic child may be in impending respiratory arrest.
fever, cough, change in voice, hoarseness, drooling, swelling Following severe obstruction of upper airway, hypoxemia
of lips, erythematous rash, itching etc. Exposure to any known with resultant cardiac arrest and death can ensue within mi-
allergen or smoke. Underlying medical conditions (e.g., nutes. Prompt recognition of the pattern of symptoms and
signs may guide to a probable diagnosis and buy precious time Croup
for the emergency physician for subsequent detailed evalua-
tion and planning patient care. The following clues obtained Croup or laryngotracheobronchitis (LTB) is the commonest
thus far help to point out the diagnosis: cause of infectious upper airway obstruction in children. It is
almost always viral in etiology with parainfluenza virus being
& Sudden onset – foreign body, anaphylaxis the commonest offending agent. Children affected are usually
& Soft or low pitched stridor – epiglottitis, foreign body, between 1 and 6 y of age, commonest 12–24 mo, with a slight
tracheitis male preponderance (1.4: 1). The 17 point Westley’s clinical
& Toxic appearance with high fever – epiglottitis, tracheitis, scoring system [4] is the objective way of severity assessment
retropharyngeal or peritonsillar abscess but is cumbersome in busy clinic or casualty settings. ‘Steeple
& Drooling, open mouth, sitting forward – epiglottitis, sign’ is the radiological hallmark seen in neck radiograph but
retropharyngeal abscess is seldom required for diagnosis. Mild croup presents with
& Muffled voice with dysphagia – tonsillar/ peritonsillar barking cough, with or without inspiratory stridor present only
abscess on exertion and there are no other signs of respiratory distress.
& Epistaxis, foul smelling blood stained nasal discharge, bull It may be treated at home with antipyretics and plenty of
neck, incomplete immunisation – Diphtheria fluids. A single dose of oral corticosteroids may be considered
& Swelling of lips, erythematous rash with itching – anaphy- [5]. Humidified air has been proven to be ineffective [6]. A
laxis/angioneurotic edema child with moderate croup has stridor even at rest and may
& Bleeding, bruising or subcutaneous emphysema – trauma also have some evidence of respiratory distress (tachycardia,
(penetrating/ blunt) mild tachypnea and chest retractions) but is accepting orally
& History of previous tracheal intubation – subglottic stenosis and interactive with SpO2 >92 % in room air. Whereas, chil-
& Intermittent stridor, more on crying/feeding and relieved dren with severe croup will be appearing anxious, tired or
in prone position – airway malacia restless and agitated with decreased oral intake. There is
an evidence of marked respiratory distress and hypoxemia
on pulse oximetry. The mainstay of therapy is corticosteroids.
Initial Airway Stabilization All the practiced routes (nebulized, oral or intramuscular)
seem to be equally effective [5]. Though the conventional
Once initial assessment is over, the most skilled and experi- practice has been to use intramuscular dexamethasone at a
enced personnel available are gathered to stabilize the airway dose of 0.6 mg/kg, doses as low as 0.15 mg/kg are currently
and this is best done under controlled conditions in the PICU advocated [5]. Ceiling dose of parenteral dexamethasone used
or operating room. Bag-mask ventilation may be of particular in various studies has been 10 mg, while oral doses up to
value in stenting open the airway in a child who has cardio- 20 mg have been used. In addition to corticosteroids, nebu-
pulmonary arrest (Fig. 1). lized epinephrine at a dose of 0.3–0.5 ml/kg (maximum 5 ml)
The following general points should be remembered when- of 1:1000 solution is used for rapid relief of symptoms [7].
ever encountered in a child with suspected airway obstruction: Heliox was not found to be beneficial in the management of
croup [8].
& Leave the child with parent in a comfortable position.
& DO NOT insert tongue depressor or attempt IV access or Epiglottitis
blood tests.
& DO NOT force an oxygen mask over face; provide sup- It is a true pediatric airway nightmare! There is acute onset of
plementary oxygen by the least frightening method. Oxy- symptoms with high fever and rapid deterioration over hours.
gen should be administered to decrease work of breathing Historically, the commonest causative organism is
even if the oxygen saturation is normal. H. influenzae; the epidemiology is changing with
& DO NOT sedate the child until airway is secured. immunisation practices and other agents (Streptococcus and
& Pulse oximetry is a poor indicator of severity of obstruction Staphylococcus) coming to the forefront. Often the mnemonic
especially when supplementary oxygen is being given. 4D’s (Drooling, Dysphagia, Dysphonia and Dyspnea) is used
to describe this condition [9] with classical description of a
child sitting in a ‘tripod position’. If lateral radiograph of neck
could be obtained, it shows the characteristic Bthumb sign^,
Management though it is not indicated in an acute setting. All the airway
stabilization measures described earlier are to be strictly
Specific management of common conditions presenting as followed as these children frequently need advanced airway
upper airway obstruction are discussed here. support [10]. Some experts even suggest elective intubation to
Indian J Pediatr (August 2015) 82(8):737–744 741
only 57 % cases [23]. Other clinical features include stridor, recovery rates of up to 70 % are reported, an interval of at
tachypnea, dyspnea, hoarseness, cyanosis and fever. The chron- least a year is often given before an airway widening proce-
ic or missed cases may present with persistent/recurrent pneu- dure is undertaken [31]. CO2 laser is the treatment modality of
monia, collapse, bronchiectasis or lung abscess. Plain radio- choice [33].
graphs of neck and chest are routinely obtained in suspected
cases and the findings may vary from visualized foreign body Laryngomalacia
in the airway, unilateral/ localised hyperinflation, collapse, me-
diastinal shift but radiographs should never be relied upon to It is the commonest congenital laryngeal anomaly and
rule out foreign body aspiration [24]. Even virtual bronchosco- commonest cause of stridor in infancy [34]. The onset of stri-
py has no role in acute setting [25]. Rigid bronchoscopy is the dor is usually within the first weeks of life. There may be
procedure of choice in all cases of suspected airway foreign associated feeding problems and gastroesophageal reflux dis-
body for both diagnosis and management and should be under- ease (GERD) as well. Laryngoscopy is undertaken to confirm
taken without delay. It is successful in removing the FB in 95 % the diagnosis and rule out synchronous airway lesion (SAL).
of cases, with a very low complication rate (<1 %) [23]. The management is largely reassurance, as the symptoms tend
Though flexible bronchoscopy is considered a safe and effec- to wean off with increasing age and subside by 2 y of age. In a
tive tool for diagnosis and even removal of airway FB [26], it minority of patients (<10 %), surgical management is warrant-
requires a skilled personnel. American Thoracic Society recom- ed, when they present with acute life threatening events or
mends use of only rigid bronchoscopy for this purpose [27]. failure to thrive. Surgical options are supraglottoplasty/
aryepiglottoplasty and tracheostomy (especially when associ-
Angioneurotic Edema ated with neurological or neuromuscular conditions) [35].
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