Upper Obstruction Vs Lower Obstruction (clinical differentiation)
Upper Airway
- Interferes mainly with inspiration
- Inspiratory stridor
- Severe retractions
- Croupy/brassy cough
|
Lower Airway
- Interferes mainly with expiration
- Expiratory wheeze
- Mild retractions prolonged expiration
- Hacking/repetitive cough
|
- Adult airway is cylindrical with narrowest portion is at glottic opening
- Pediatric/Infant upper airway is conical with narrowest portion is at cricoid cartilage (sub glottic area).
Causes of Upper Airway Obstruction
| (a) Congenital |
(b) Acquired |
| Presents with persistent/recurrent stridor |
Presents with acute stridor, associated features |
| Stridor |
| Acute |
Chronic (Congenital)
|
| Toxic |
Non Toxic |
- Epiglottitis*
- Tracheitis*
- Diphtheria
- Retropharyngeal abscess*
- Severe croup*
- Angioedema
|
- Croup*
- Laryngitis
- Foreign Body*
- Post-extubation
|
Clinical features of Stridor:
Inspiratory high pitched sound, if severe obstruction it may be expiratory as well
Retractions Suprasternal, intercostals, sternal depression
Cough brassy/barky
Voice Muffled, hoarse
Associated Tachycardia, Tachypnea
Altered sensorium worsening hypoxia
Commonest causes of upper airway obstruction in pediatric seen in office practice:
Croup
Epiglottitis
Retropharyngeal abscess
Foreign body
Bacterial tracheitis
1) CROUP (VIRAL LARYNGO TRACHEO BRONCHITIS)
- Benign, self-limiting Upper airway obstruction
- Due to Parainfluenza, Adeno, RSV, Rhino, Influenza A virus
- Age group Usually (3 mon) 1 year 3(6) years, Boys> girls 2:1
- 90% of stridor with fever
- URTI days stridor, brassy cough
- Seasonal more in winter and monsoon months
- Varying degree of lower airway involvement
- (May have associated wheezing)
Signs and Symptoms (croup):
| Mild |
Severe |
- 1-3 day h/o URL
- Barking cough
- Fever low grade usually
- Tachypnea
- Stridor
- Retraction and wheezing
|
- Agitation, Lethargy
- Progressive tachycardia and tachypnea
- Hypoxia (cyanosis)
- Decrease in tidal volume
- Apnea
|
Clinical Croup Score (Downers & Raphaely)
| Score |
O |
1 |
2 |
| Inspiratory BS |
N |
Harsh/Rhonchi |
Delayed |
| Stridor |
No |
Inspiratory |
Insp/Exp |
| Couch |
No |
Hoarse |
Bark |
| Retraction, flaring |
No |
Flaring + Subcostal |
Suprasternal Intercostal |
| Cyanosis |
No |
In room air |
In 40% oxygen |
Score <3 = Mild airway obstruction,
Score> 4 = Moderately severe airway obstruction,
Score> 7 = (with oxygen <70 and carbon dioxide> 45) impending respiratory failure.
Treatment
For (mild-moderate)
If reliable parents,> 6 mo age, able to drink fluids, well hydrated:
- Out patient treatment
- Avoid agitation, Position of comfort, Parent's participation
- Cool, humidified oxygen, Cool Mist therapy
- Nebulization with Epinephrine
- Dexamethasone / Inhaled Budesonide
For (mod severe)
After 3 hrs of nebulization, if the score is increasing, <6 mo age, Stridor at rest inspiratory and expiratory, unreliable parents, needs oxygen, fatigue.
- Admit, Intensive care
- Nebulized Epinephrine 0.5 ml/kg (5 ml), 1:1000 diluted NS, q2-6 hrs
- Dexamethasone IM/Oral 0.15-0.6 mg/kg stat
- Aerosolized Budesonide 2-4 mg
- Heliox (mixture of Helium + Oxygen)
- Intubation RARELY needed.
Do not rush for:
- Immediate X-rays, blood counts in typical cases of viral croup
- Antibiotics, in typical case
- Cough mixtures, expectorants
- Sedation
2) ACUTE EPIGLOTTIS
- 3-7 years age, Rapidly progressive, Severe, Quiet stridor
- Aphonic, muffled voice
- High fever, Toxic agitated*
- Airway obstruction with Drooling of saliva
Treatment
- Avoid procedures unless confirmed
- Examination under controlled setting by most experienced personal (ENT, anesthetists, Intensivist)
- Most will need intubation
- I.V. antibiotics (Cefotaxime/Ceftriaxone/Amoxy-clav)
- Supportive care
3) RETROPHARYNGEAL ABSCESS
Pus in the potential space between the posterior pharyngeal wall and the pre-vertebral fascia.
Etiology
Complication of bacterial pharyngitis, Cx. Lymphadenopathy, extension from vertebral osteomyelitis, penetrating injury to posterior pharynx.
Presentation:
Preschool-school going age, URTI, fever, stridor, neck swelling, torticollis*, dysphagia*, refusal to feed, severe distress*, drooling*.
Findings:
Febrile, toxic, edematous anterior bulge in posterior pharyngeal wall, neck stiffness.
Treatment:
- Antibiotics
- (Polymicrobic, Staph, Strept, H. Influ, Pneumo, Anaerobes):
- Penicillin + Metrogyl or Cefoxitin;
- Clinda or Ticarcillin/Clavulanate or Piperacillin/Tazobactum or Ampi/Sulbactam
- Intubation in 1/3 rd
- Surgery I & D under GA in OT.
4) UPPER AIRWAY FOREIGN BODY
Typical presentation
-
A toddler presented with a history of sudden onset bouts of coughing and respiratory distress since 3 hours.
The first step in diagnosis of a foreign body is to think of it
..
Extra thoracic Foreign Bodies
- Laryngeal, tracheal, upper esophageal
Presentation
- Croupy cough, stridor, RD, cyanosis
Diagnosis by
- History, X-ray neck for radio-opaque FB (AP, Lat)
- For complete airway obstruction-PALS protocol (Heimlich's Maneuver)
- For non urgent case ENT surgeon's help.
Other causes of upper airway obstruction are Relatively Uncommon
..
