stridor, stertor, and snoring: pediatric upper airway obstruction · altkorn et al: fatal and non...
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Stridor, Stertor, and Snoring: Pediatric Upper Airway
Obstruction Nathan Page, MD
Pediatrics in the Red Rocks
June ?
• I have no disclosures
• I do not plan to discuss unapproved or off label use of products
Outline • Pediatric airway anatomy
• Airway examination and key airway sounds
• What constitutes an airway emergency?
• Airway management tools
• Common pediatric airway emergencies
Laryngeal Anatomy
Pediatric Larynx Adult Larynx
Pediatric vs Adult Larynx
• Location
• Consistency
• Size
• Shape
• Configuration
Pediatric vs Adult Larynx
•Location • Consistency
• Size
• Shape
• Configuration
Location
- More rostral
(i.e. higher)
- Cricoid reaches:
C4 at birth
C5 at 2yo
C6-7 at 15yo
Pediatric vs Adult Larynx
• Location
•Consistency • Size
• Shape
• Configuration
Consistency
• Softer, more pliable tissues
• Submucosal tissue is looser, less fibrous
• Stenosis more likely with internal injury to larynx
Pediatric vs Adult Larynx
• Location
• Consistency
•Size • Shape
• Configuration
Size
- Newborn larynx 1/3 adult size
- Greater cartilagenous portion of vocal cords (1/2 in infant, ¼-1/3 in adult), leads to greater injury potential
Pediatric vs Adult Larynx
• Location
• Consistency
• Size
•Shape • Configuration
Shape
Cylinder Funnel
Adult Infant
• Narrowest portion of the pediatric larynx is the cricoid cartilage
• Narrowest portion of the adult larynx is the glottis (vocal cords)
Pediatric vs Adult Larynx
• Location
• Consistency
• Size
• Shape
•Configuration
Configuration • Epiglottis is narrow, omega-
shaped (Ω)
• Cricoid slightly tilted backward
• Vocal cords at sharper angle
Configuration Thyroid cartilage more obtuse angle
Pediatric Larynx
Airway sounds
• Wheezing – intrathoracic obstruction (expiratory)
• Stertor –nasal/oropharyngeal obstruction (snoring – inspiratory)
• Stridor – laryngeal obstruction (inspiratory or biphasic)
Inspiration Expiration
Inspiration Expiration
Wheezing : Etiologies
• Asthma
• Bronchiolitis
• Structural obstruction of trachea or bronchi • Foreign body
• Tumor
• Compression
Stertor : Etiologies
• Nasopharyngeal obstruction • URI
• Adenoid hypertrophy
• Retropharyngeal abscess
• Craniofacial abnormalities
• Oropharyngeal obstruction • Tonsillar hypertrophy
• Enlarged tongue
• Craniofacial abnormalities
Stridor • Harsh sound caused by turbulent airflow
• Implies partial airway obstruction
• Laryngeal stridor – inspiratory or biphasic
Stridor : Etiologies • Laryngomalacia-different types
• Vocal Cord Paralysis
• Foreign Bodies
• Infectious • “Croup”, Epiglottitis
• Croup (Laryngotracheitis) Masquerade • Subglottic Hemangioma • Recurrent Respiratory Papillomatosis • Post Intubation Glottic and Subglottic Lesions • Congenital Glottic and Subglottic Stenosis • Extra-Esophageal (Gastroesophageal) Reflux Disease/Eosinophilic
Esophagitis
• Laryngeal Clefts
• Trauma
Assessment Strategies
•Guide to diagnosis and intervention • Age • Congenital vs. Acquired • Characteristics of stridor • Clinical picture
Clinical Picture: History
• Onset: acute, chronic, progression
• Prior respiratory problems
• Ex-preemie (NICU stay)
• Prior intubation
• GERD symptoms
• Wheezing episodes
• Feeding problems: • FTT, weight gain
• Choking episodes
• Acute events
Clinical Picture: Associated signs & symptoms
• Acute Disease
• Fever • Drooling (new onset) • Change in cry • Decrease in oral intake • Body position
Physical Examination
• Auscultation of bilateral lungs AND neck
- Asymmetric or unilateral wheezing
- Transmitted airway sounds
- Inspiratory vs expiratory vs biphasic stridor
• “Headless” stethoscope
What constitutes an airway emergency?
Assess Urgency
• Nasal flaring
• Tachypnea
• Retractions
• Drooling
• Cyanosis
• Desaturation is a very late sign!!!
• If the above are present – immediate action!
Severe Respiratory Distress
• 1.Evidence of supraclavicular, sternal, or intercostal, retractions
• 2.Nasal flaring (<2 yr)
• 3.Grunting respirations
• 4.Tripod position
• 5.Stridor at rest
• 6.Marked Wheezing
• 7. Pulse oximetry < 95%
From The Red Book page 5-5.
Croup (laryngotracheobronchitis)
• Fever, upper respiratory symptoms
• “Barky” cough
• Inspiratory stridor
• Starts after 6 months of age
• Hospitalized pt: IV steroids, mist tent, hydration, O2 sat monitor
Laryngomalacia
Laryngomalacia
• Most common cause of stridor in infants
• Strong association with reflux
• Inspiratory stridor
• Resolves by 12-18 months in most cases
• Minority need surgery – 1-10%
Breaker videos
Tracheomalacia
• More common in preterm infants
• Expiratory stridor and cough
• May be aggravated by bronchodilators
• Reflux treatment can benefit
• Typically resolves with time
• Primary vs secondary
Secondary tracheomalacia
• Innominate artery compression
• Vascular rings and slings
Complete tracheal rings
Subglottic hemangioma
• “Croupy” symptoms begin at 6-8 weeks
• Mean age at diagnosis is 4 mos
• Grows until one year old, then slowly regresses
Subglottic stenosis
• Barky cough and inspiratory stridor
Risk factors:
• Prematurity
• Prior intubation
• GERD
• Can develop at any age
Retropharyngeal abscess
• Infection of lymph nodes in the retropharyngeal space
• Fever
• Drooling
• Neck stiffness
Average age 2-3 yo
Frequently requires operative drainage
Epiglottitis
• Infection of the epiglottis caused by Haemophilus influenzae type B
• Upright posture
• Drooling
• Fever
• Stridor
• Muffled voice
DO NOT AGITATE CHILD.
DO NOT EXAMINE THROAT.
TRANSPORT UPRIGHT IMMEDIATELY!
Epiglottitis
Neoplasm
Aerodigestive Tract Foreign Bodies • The Usual Suspects-you name it
Airway Foreign Bodies
• The usual suspects: • Food -2/3 of Airway FB
• Non Food items • Pen caps
• Tacks
• Pins
• Toys
• Insects
Airway Foreign Bodies-Food
• Frequency: • Peanut (26%)
• Seeds (7%)
• Meat (7%)
• Popcorn (5%)
• Carrot (5%)
• Hot Dog
• Chicken
• Fish bone
• Apple
• Candy
• Fatalities: • Hot dog (16%)
• Candy (10%)
• Grape (8%)
• Meat (7%)
• Peanut (7%)
• Carrot (6%)
• Cookie (6%)
• Apple (5%)
• Popcorn (5%)
• Bread (4%)
Altkorn et al: Fatal and non fatal food injuries among children Intl J Ped Otorhinolaryngol (2008) 72, 1041-1046
Airway Foreign Bodies-Food
• Children < 3 y.o. increased risk • 69% of injuries (peanuts, seeds, popcorn, apples, carrots)
• 79% of deaths (Hot dogs, apples, bread, carrots, cookies, grapes)
• Incomplete dentition
• Immature swallowing coordination
• Easily distracted
Altkorn et al: Fatal and non fatal food injuries among children Intl J Ped Otorhinolaryngol (2008) 72, 1041-1046
Airway Foreign Bodies • History is key to diagnosis
• Witnessed choking event in 32-51%; subsequent coughing spell generates concern
• Symptoms are mild or absent by time of evaluation in 60%--transient wheeze • Asymptomatic interval- FB becomes lodged and reflexes fatigue. False sense of
security
• Complications- Erosion/ Obstruction/ Infection
Airway Foreign Bodies • Physical Examination:
• Cough (69%), • Decreased Breath Sounds (52%), • Intermittent/ Unilateral Wheeze (45%), • Intermittent Dyspnea