Air Way Obstruction
) ) upper air way
Is defined as blockage of the portion of the air ways
located above thoracic inlet , manifested during
inspiration because the pressure within upper air way
is negative related to atmosphere ( negative pressure
)causing collapse of the air way
-- 1
Upper air way obstruction classified clinically into :1- congenital
2- acquired
Also classified into supra glottis or subglottis obstruction •
•
presented as stridor which is whistled sound occurred during
inspiration which reverse to wheezing that resulting from lower air
.way obstruction , occurred during expiration
:-Upper air way obstruction classified according to to causes
) :---A- new born ( until one month of age
•
foreign material-1
•
bilateral cho-anal atresia-2
•
cong. Sub-glottic stenosis-3
•
micrognathia-4
•
macroglosia-5
•
.cong. Anomalies of the larynx , pharynx & trachea-6
•
vocal cord paralysis-7
)laryngospasm ( as in intubation and aspiration-8
•
•
)B- infancy ( 1—12 month of age
)laryngomalacia ( commonest-1
•
sub-glotic stenosis 3- rhinitis 4- vascular ring-2
•
tongue tumor & ectopic thyroid- 5
•
):---C-Toddler ( 1—3 years
viral croup ( commonest ) 2- spasmodic croup-1
F.B inhalation
4- bacterial trachitis -3
•
tonsil & adenoid hyperatrophy-5
)retropharyngial abscess
7- diphteria ( rare- 6
•
-3-
•
•
•
•
:---D- above 3 years
•
epiglotitis
2- F.B
3- trauma- 1
)angio-edema
5-IMN ( infec. Mono nucleosis-5
anaphylaxasis 7- peritonsilar abscess in adolescent
) 8- diphtheria ( rare
•
-6
•
:----Cong. Anomalies
•
:-Laryngiomalacia
•
is defined by collapse or flabiness of epiglotis or arytenoid
cartilage during inspiration resulting in air way obstruction which
.usually benign & self limited
•
The symptom usually appear in the first two weeks of life and
severity increased for upto 6 months
•
.--4--
•
Clinical features :--stridor is main presentation appear at birth or shortly after birth &
become symptomatic during first year of life ( but may delay to several
•
is audible inspiratory sound Years if infant has very large,
arytenoid
•
:---stridor is loudest at
feeding of child
2- quit relaxing 3- supine position or - 1
.And crying
neck flexion •
•
:--stridor is deminished at
sleep- •
Stridor is exacerbated by viral infection •
•
Symptom usually begin at birth or shortly after birth and become •
symptomatic in first year of life & dissappeare by 18-24 month of
age
Laryngoscope used in diagnosis of disease •
Treatment :--no treatment is needed unless infant has growth •
retarded or failure or hypoxia which needs tracheostomy or
-epiglotoplasty
-5
Subglottic stenosis :---either cong. Or acquired ( which more common due to aggressive
management in preterm baby with intubation or mechanical ventilation
.resulting residual air way damage to larynx •
•
stridor is main presentation ( recurrent or persistant croup ),
occurred in both inspiration and expiration and worsen with age
Treatment by tracheostomy or reconstructive surgery •
:---Foreign Body •
most victims are older than infant and toddler ( children of less than
3 years of age account for 73% of cases , 33% of objects aspirate
.are nuts particularly peanuts
:--ClF :--- 3 stages of symptoms •
•
initial event chacterised by violent coughing , chocking ,-1
.gagging , possibly air way occur immediately
•
asymptomatic interval :-- F.B become lodged , reflex- 2
fatigue , immediately irritated symptoms subside ( account in large
.number or% of delay diagnosis & overlooked F.B
•
.
complication :---obstruction , erosion or infection - 3
. developed to direct attention again to presence of F.B
A positive history must never be ignored ( a negative •
) .history may be misleading
Sudden chocking or coughing episode accompany by •
.wheezing are highly suggestive of an air way F.b
)F.B mostly lodged in a bronchus ( right bronchus in 58%
•
-7-
•
Acquired causes of upper air way obstruction :involved either supra or sup glottic structures
:----How to diffrentiated between them •
Example
supra glotic
, epiglot., peritonsilar abscess
croup,retro-pharangial abscess
F.B
,trachitis
.angio-ed
stridor
2- quit
voice
3-muffled
dysphagia
4-yes
sitting up or arching posture 5-yes
barking cough
6- no
fever
7-high 40 c
.toxicity
8-yes very toxic
trismus
9-yes
•
supglotic
•
1
•
•
•
2-loud-2 •
3-hoarse-3 •
4-no-4 •
5-no-5 •
6- yes-6 •
7-low 38-39-7 •
8-no unless trach-8 •
9-no-9 •
Epiglotitis :--is pediatric emergency , dramatic & potentially lethal condition because of
.inflamed air way may obstruct suddenly& totally leading to death
Caused by H. influenza type B which recovered from surface of epiglotitis or from
.blood culture
•
)Age of incidence is 2—7 years ( peak age 3.5 year
•
:---ClF
•
•
.no other family members are ill -1
•
,is fulminating course of high fever , sore throat , dysphagia- 2
•
dyspnea, stridor, drooling , more progress to total obstruction
•
prostration unless adeguate treatment are given( stridor is
&
•
).late finding& suggest near complete air way obstruction
•
moderate to sever respiratory distress( S.T. fulminating- 3
•
) pulmonary edema may present
•
.cynosis occurs in sever cases- 4
•
cherry red enlarged epiglotis by laryngoscope- 5
•
X-ray of lateral film of neck showing thumb sign as swollen epiglotis-6
•
in young patient ---- neck is hyper-extended, while in older patients- 7
•
prefer sitting up position ,learning forward , mouth open &tongue
•
--protruded .
--9
most pts have concomitant bacteremia ocasionally ( other infection are-8
present like pneumonia , O.M , cervical LAP , while meningitis , arthritis are rare
.
DD :--
1- croup
2- bacherial trachitis
3- F.B aspiration
•
:--Treatment
4- ludwig angina
5- retropharyngial & peritonsilar abscess
admission for any suspicion of disease where close -1
•
.observation should be done
•
endotrachial intubation is currently prefered method of -2
treatment ( 6% of children die without artificial airway , compared to
.)less than 1% of those with artificial airway
•
Antibiotic – ceftrixone or cefotaxime-3
•
or combination of ampiciline + chlormphenicol
•
or ampiciline + sublactum
•
duration of treatment is 7—10 days ( most patients safely
. )extubated within 2—3 days
•
.Prevention :--- by H. infl. Vaccine
•
-10-
•
Croup :---is defined as term referred to a heterogeneous group of
mainly acute & infectious process that are characterized by
bark like or brassy cough , may be associated with insp. stridor
Is caused by viral infection mostly •
.Commonly occur in late fall & early winter •
.Has 2 types --- 1- infectious type •
•
)spasmodic type( recurrent type- 2
:--Etiology •
,by PIV , can be caused by adeno, measles, influeza 75%
•
.RSV , Can be caused in 3.6% by mycoplasma
Pathology :-- 1- inflammatory edema •
•
destructed ciliated epithilia-2
•
exudate-3
:----ClF •
age is between 6 month to 3 years ( now age is 3 month to - 1
--5years ) with peak age in second year
--11
•
•
•
most patients proceeded by URTI of several days of less than 5 days- 2
3-at first mild brassy cough with intermittent stridor & if obstruction is
( resp. distress is
increased , the stridor become continuous ass. with resp.d
.unusual except in young infant
infection going down to reach bronchi & bronchiols leading to -4 •
.resp. distress with elevation of temperature with reach to 40
if croup is suspected , examination is deferred & O2 is -5 •
administered until patient is transferred to place of hospital where
Optimal management possible •
)X-ray reveals steeple sign ( mean narrow subglotic space -6 •
•
.is not assoc. with disease severity &
duration of illness ranged from several days to rarely several wKs
•
):---Spasmodic croup :----( recurrent croup •
•
clinically is similar to infectious croup except that finding of
. infection in a patients & family are absent
•
Age of presentation is 1—3 years
:-- precipitating factors are •
•
.viral infection in some cases only- 1
allergic & psychological factors
3- G.E.R which may -2
role important
Pathology :-- normal epithilial & pale watery edema •
•
•
ClF :---1- most frequently occurs at night or evening .
2-occurred in sudden onset that may proceed mild to moderate
.
coryza
.Note :- croup may be early sign of asthma •
& The child may be awaken with barking cough , noisy inspiration
•
respiratory distress and may be appeared anxious &
.frightened
•
afebrial- 3
•
distress may be exacerbated by excitation & usually-4
.diminished within several hours & following days
.Such episode usually several times •
:---DD •
•
epiglotitis
2- trachititis 3- diphtheria ( present gray -1
) .white appearances on pharyangial examination
•
measles croup
5-F.B aspiration 6- angio-edema-4
retropharangial & peritonsilar abscess 8- hypocalcaemia with-7
laryngial tetany
9-extrensic compression of air way like
•
hematoma , or mass
•
•
CX :-- occurs in 15% with viral croup .
1- commonest cx. Is extension of infection to involve other region
.
of resp. tract like middle ear , bronchial & pul. Parenchyma
.( trachitis
3- interstial pneumonia
4-broncho pneum - 2
is unusual unless aspiration of gastric contents occurred during
)period of resp. distress although 2nd bacterial infection is rare
pneumothorax & pneumomediastinum ( common CX. Of-5
•
) .tracheostomy
:---Causes of death in croup •
•
laryngial obstruction- 1
•
trachiostomy Cx like pneumo thorax & mediastinal- 2
•
.emphysema
•
—14•
•
•
•
•
How differentiate clinically between laryngomalacia and
:--subglttic stenosis
Clinical
laryngomalacia
subgltticstenosis
age of onset
first month &increased upto
•
month 6
stridor
inspiratory
expiratory
fate
improved with age
•
at birth -1
•
both inspiratory -2
•
worse with age -3 •
•
How differentiate clinically between epiglotitis and croup
Factors
age
onset
other member
•
of family
stridor
dysphagia
fever & toxicity
barking cough
epiglotitis
2-7years( 3.5years)
sudden
no
quit
yes
yes
no
croup •
3months-5years-1
gradual-2 •
yes-3 •
loud-4 •
no-5 •
no-6 •
yes-7 •
•
:--How differentiate between types of croup
Factors
age of onset
onset
fever
–duration of stridor
thanks
infectious
3months-5years
gradual
low grade fever
days
•
spasmodic •
1-3years-1 •
sudden-2 •
afebril-3 •
hours-4 •