Management of the compromised airway
The airway: a hollow path from the tip of the nose to the alveoli in furthest reach of the
lungs. The larynx is of particular interest to the E.N.T surgeon with its dynamic and
multifunctional structure including protection of the airway, phonation and respiration.
Pediatric airway is significantly narrower than adults, so any condition that reduces the
size of the lumen will have a greater effect on the neonate and child airway. It is usually
presented as a stridor which is due to turbulence of the airflow within a partially
obstructed respiratory tract.
The ENT surgeon is the airway expert in the medical field, so he is often called to
manage the compromised airway urgently. He should act quickly and properly.
The management includes:
1) history
2) examination
3) investigations
4) treatment
All these depend on the severity of the airway obstruction. A severe obstruction should
lead to immediate action to secure the airway. This includes oxygen supplement and
humidity, endotracheal intubation or even tracheotomy.
If the time and the condition of the child allows, the following steps may be taken:
History
Ask for duration, severity, age at onset, intermittent or continuous, relationship to crying,
feeding or exercise, previous trauma or foreign body inhalation, cough, drooling, color
change, and mental status changes.
Examination
The general appearance of the child will aid in assessing the severity of the pathology.
Listen to the sounds produced while breathing. Stertor is the noise produced by
supralaryngeal obstruction and it is usually a low pitched choking type of noise. On the
other hand stridor is high-pitched sound coming within a narrow larynx. It could be
inspiratory, expiratory, or biphasic. Hoarseness usually suggests a vocal cord lesion.
Look for pallor, cyanosis, sweating, restlessness, tachycardia, head retraction, by
assessing the accessory muscles of respiration, external and intercostals recession. Assess
the pattern of respiration to check if it is associated with periods of apnea. Increasing
pulse rate is good indication for increasing distress.
Fever: suggests an infectious cause.
Investigations
Radiology: Every child with stridor should have lateral soft tissue plain x-ray film of the
head, neck and upper thorax with a PA chest x-ray which will often reveal a surprising
amount of detail of the functional anatomy of the airway.
CT scan and MRI of the upper airway can now provide is with a more advanced details
of the upper and lower airways without increased stress to the patient.
Contrast studies using barium or gastrografin with fluoroscopic screening is helpful if
vascular ring or tracheoesophageal fistula is suspected.
Elevated WBC suggests an infectious cause.
Flexible nasopharyngoscopy could be done in stable child with a mild strider if the tool is
available associated with proper experience to evaluate the upper airway, especially if we
suspect laryngomalacia or vocal cord paralysis.
Laryngoscopy & bronchoscopy: All children with strider should be endoscoped. This
needs good cooperation between the otolaryngologist and the anaesthetist. Ventilating
Bronchoscope is a very good tool to perform precise and safe bronchoscopy for diagnosis
and management.
Treatment
Medical or surgical? This depends on the cause.
Many airway problems can be managed conservatively with medical therapy and close
observation. Humidified oxygen or croup tent and pulse oximiter are very useful in
management.
An emergency cricothyroidotomy may have to be done. This is done by a horizontal
incision over the middle third of the cricothyroid membrane and followed by the insertion
of a stenting tube (Fig. 2). After the patient is stabilized a proper tracheotomy is done to
avoid airway complications.
Differential diagnosis of upper airway obstruction in children
Supralaryngeal
 Choanal atresia
 Micrognathia
 Adeno-tonsillar hypertrophy
 Foreign body
 Craniofacial anaomloies
Laryngeal
congenital:
= laryngomalacia
= subglottic stenosis
= vocal cord paralysis
= laryngeal webs
= laryngeal cysts
= vascular ring
Acquired:
= foreign body
= laryngeal trauma
= acute laryngitis, epiglottis and
Laryngotracheobronchitis
= subglottic stenosis
= vocal cord palsy
= multiple laryngeal papillomata
High points
1) If you suspect acute epiglottitis in a child, avoid the use of tongue depressors or
endoscopy because it may precipitate laryngospasm.
2) The sudden onset of stridor in a formerly normal child is considered to be a
foreign body in the airway until proven otherwise.
3) Stridor in adults rarely progresses as rapidly as in children