Published on February 5, 2014
Management of Paediatric Upper Airway Problems Dr. MTD Lakshan MBBS, MS(Oto), DOHNS(UK), FEB ORL-HNS, FRCSEd ORL-HNS Consultant ENT and Head and Neck Surgeon DGH Hambantota
Credits Dr. A.D.K.S.N. Yasawardene MS(Oto) FRCSEd Consultant ENT Surgeon - Lady Ridgeway Hospital for Children – Training, Guidance and Multimedia LRH - Staff
5 Important Points 1. 2. 3. 4. Tricky Situations Rapid Deteriorations High Morbidity / Mortality Team involvements – Paed / ENT/ Anaes /ICU 5. Clinical and High Tech Mix
Paediatric Airway Problems • • • • Inhaled Foreign Body Exacerbation of the previous airway problem Trauma INFECTIVE / INFLAMMATORY
Manifestations of Upper Airway Obstruction • Stridor- Abnormal breath sound caused by upper airway obstruction – due to turbulent airflow and collapse of walls caused by drop of pressure. • Stertor- Pharyngeal level obstruction
Assessment • Initial Adequacy of Respiration – Central Cyanosis, Tachypnea, Tachycardia, Use of Acc. Mus.of respiration, Chest wall recessions, Lev. of Consciousness, Neonates-spells of Apnea Pulse Oxymetry, Blood gases
Acute Airway Management Medical – • Oxygen Therapy • Adrenaline Nebulization • Steroids iv • Helium-Oxygen Mixture (He 80%-O2 20%) • Positioning
Acute Airway Management Emergency Airway access • Cricothyroid Puncture • Intubation • Tracheostomy
Sub Acute Stridor
Assessment History – • Onset & Progression • Cycle of Respiration • Volume • Pitch • Ag./Rel. Factors (Positions, URTI, Feeding, Activity)
Assessment History • Voice/Cry • Feeding • Associated Symptoms • H/O Intubation
Assessment Examination General Examination • Dysmorphism • Growth Parameters • Haemagiomata Systems • Respiratory & Cardiac • Listen for Stridor
Assessment Investigations Radiological • Plain X-ray – Soft Tissue Neck (Cincinnati View) Chest PA • Imaging – CT, CTA, MRI, MRA • Contrast Studies
Assessment Airway Endoscopy • Flexible - Under LA only up to LarynxOffice Procedure • Rigid – Micro-laryngo-bronchoscopy -MLB Under GA, Using Laryngoscope, Ventilating Bronchoscope together with Hopkins rod lenses(telescopes) & Operating Microscope. Preferably with digital recording facility
Conditions Congenital • Laryngomalacia is the commonest. 15% may show an another abnormality. • Vocal cord palsy – exclude CNS pathology by CT/MRI • Laryngotracheal Stenosis • Webs, Cysts, Clefts, Haemangioma, Vascular Compression, external compression, TOF related abnormalities
Management of Sub-acute Stridor Clinical Assessment – MOST Important Typical uncomplicated Laryngomalacia Pros & Cons of MLB Vs. Watchful waiting Typical Laryngomalacia with complications MLB for Surgical correction Protocol at LRH – Courtesy Dr. ADKSN Yasawardene Atypical MLB for definitive Diagnosis & Treatment
Laryngo Tracheal Stenosis
Surgery for Laryngotracheal Stenosis Myer Cotton staging of stenosis & length LTP with castellated incision – Not done now LTR with anterior /posterior Costal cartilage graft; SSP; Stenting –short term/long term CTR for stage 3 & 4 and for failures
Laryngotracheal stenosis videos
Other Congenital Conditions Videos
Choanal Atresia • • • • • Clinical tests – Mirror test; NG tube Emergency Oral Airway/ET Tube CT scan Exclude CHARGE – 2D EHCO Surgery – Puncture & dilatation, Drilling, Laser, Microdebrider, 1200 Telescope, Mitomicin C, Stenting-type & duration • Resurgery rate 2.5 times at GOS
Congenital High Airway Obstruction Syndrome - CHAOS Caused by extreme LT stenosis, External compression Prenatal diagnosis with anomalies U/S Scan & Maternal MRI Extra uterine Intrapartum Treatment ProcedureEXIT-P – Elective LSCS under GA; Head & Neck out & baby is oxygenated by placenta; Endoscopy; Intubation/tracheostomy
Inflammatory Conditions Infective • Bacterial – Acute Epiglottitis, Diphtheria, Retropharyngeal Ab. • Viral – Croup Non-infective Inflammatory • Angioedema • C1 esterase deficiency
Acute Epiglottitis Clinical suspicion on rapidly progressive sore throat to total dysphagia (Drooling) & noisy breathing Classical Don'ts – • No Throat examinations • No IV canulations • No X-rays • Do Not disturb the child
Acute Epiglottitis Confirm the Diagnosis in safe environment Personal – ENT/Paed Ana./ Pediatricians Equipment – Anae. Gases; Intubation Equipment; Bronchoscopy; Tracheostomy ( in OT) Elective Intubation/Tracheostomy (rare) IV antibiotics in ICU/HDU setup for few days & extubation (3rd generation cephalosporins
Compare Feature Croup Bacterial Tracheitis Epiglotitis Age <2 Y Any 3-5 Y Organism RSV Para Influenza Staph aureus Haemophilus Influemzae Site of Involvement Subglottic Trachea Supraglottic Stridor Bi Phasic Expiratory Inspiratory Voice Barking Cough Hoarse Unaffected Position Forward Not Characteristic Not Characteristic Characteristic Swallowing Unaffected Unaffected Odynophagia
Infective / Inflammatory • Croup – EBM recommends Adrenaline nebulization & Steroids(dexamethasone) Does not recommend antibiotics. • RP Abscess – can easily be drained through the tonsilar mouth gag. Experienced Anesthetist is a must. • C1 Esterase deficiency - C1 Esterase therapy & EACA, Danazol
Inflammatory Conditions Videos
Neoplastic Conditions Benign • RRP – HPV types 6 & 11 –Repeated conservative Surgical debridement with cold steel, Laser(KTP), Microdebrider. Interferon(variable response), Intralesional Cidofovir(?carcinogenic) Trachy to be avoided Malignant – Rhabdomyosarcoma, Malig. Teratoma, Mediastinal lymphoma
Traumatic Conditions • Foreign Bodies – History is most important as exam. & Ix can be normal • Intubation Trauma – increasing Prevention by proper training & optimal post Intubation care • Blunt & Penetrating Trauma –early assessment of the extent of the injury & repair
Traumatic Conditions Videos
Any Questions? email@example.com LearnENT.net @mtdlakshan Thank You
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