Managing Upper airway problems in children for ENT / Paediatric / Anaesthetic trainees

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Information about Managing Upper airway problems in children for ENT / Paediatric /...
Health & Medicine

Published on February 5, 2014

Author: lakshent



Here I discuss approach to managing an obstructed upper airway of a child. Details about clinical assessment, investigations and management stratergies are outlined.

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

Laryngomalacia videos

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

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

Respiratory Papillomatosis

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? @mtdlakshan Thank You

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