Stridor, Stertor, and Snoring: Pediatric Upper Airway Obstruction. Nathan Page, MD Pediatrics in the Red Rocks June?
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1 Stridor, Stertor, and Snoring: Pediatric Upper Airway Obstruction Nathan Page, MD Pediatrics in the Red Rocks June?
2 I have no disclosures I do not plan to discuss unapproved or off label use of products
3 Outline Pediatric airway anatomy Airway examination and key airway sounds What constitutes an airway emergency? Airway management tools Common pediatric airway emergencies
4 Laryngeal Anatomy
5 Pediatric Larynx Adult Larynx
6 Pediatric vs Adult Larynx Location Consistency Size Shape Configuration
7 Pediatric vs Adult Larynx Location Consistency Size Shape Configuration
8 Location - More rostral (i.e. higher) - Cricoid reaches: C4 at birth C5 at 2yo C6-7 at 15yo
9 Pediatric vs Adult Larynx Location Consistency Size Shape Configuration
10 Consistency Softer, more pliable tissues Submucosal tissue is looser, less fibrous Stenosis more likely with internal injury to larynx
11 Pediatric vs Adult Larynx Location Consistency Size Shape Configuration
12 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
13 Pediatric vs Adult Larynx Location Consistency Size Shape Configuration
14 Shape Adult Infant Cylinder Funnel Narrowest portion of the pediatric larynx is the cricoid cartilage Narrowest portion of the adult larynx is the glottis (vocal cords)
15 Pediatric vs Adult Larynx Location Consistency Size Shape Configuration
16 Configuration Epiglottis is narrow, omegashaped (Ω) Cricoid slightly tilted backward Vocal cords at sharper angle
17 Configuration Thyroid cartilage more obtuse angle
18 Pediatric Larynx
19 Airway sounds Wheezing intrathoracic obstruction (expiratory) Stertor nasal/oropharyngeal obstruction (snoring inspiratory) Stridor laryngeal obstruction (inspiratory or biphasic)
20 Inspiration Expiration
21 Inspiration Expiration
22
23 Wheezing : Etiologies Asthma Bronchiolitis Structural obstruction of trachea or bronchi Foreign body Tumor Compression
24 Stertor : Etiologies Nasopharyngeal obstruction URI Adenoid hypertrophy Retropharyngeal abscess Craniofacial abnormalities Oropharyngeal obstruction Tonsillar hypertrophy Enlarged tongue Craniofacial abnormalities
25 Stridor Harsh sound caused by turbulent airflow Implies partial airway obstruction Laryngeal stridor inspiratory or biphasic
26 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
27 Assessment Strategies Guide to diagnosis and intervention Age Congenital vs. Acquired Characteristics of stridor Clinical picture
28 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
29 Clinical Picture: Associated signs & symptoms Acute Disease Fever Drooling (new onset) Change in cry Decrease in oral intake Body position
30 Physical Examination Auscultation of bilateral lungs AND neck - Asymmetric or unilateral wheezing - Transmitted airway sounds - Inspiratory vs expiratory vs biphasic stridor Headless stethoscope
31 What constitutes an airway emergency?
32 Assess Urgency Nasal flaring Tachypnea Retractions Drooling Cyanosis Desaturation is a very late sign!!! If the above are present immediate action!
33 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.
34 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
35 Laryngomalacia
36 Laryngomalacia Most common cause of stridor in infants Strong association with reflux Inspiratory stridor Resolves by months in most cases Minority need surgery 1-10%
37
38 Breaker videos
39 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
40 Secondary tracheomalacia Innominate artery compression Vascular rings and slings
41 Complete tracheal rings
42 Subglottic hemangioma Croupy symptoms begin at 6-8 weeks Mean age at diagnosis is 4 mos Grows until one year old, then slowly regresses
43 Subglottic stenosis Barky cough and inspiratory stridor Risk factors: Prematurity Prior intubation GERD Can develop at any age
44
45
46 Retropharyngeal abscess Infection of lymph nodes in the retropharyngeal space Fever Drooling Neck stiffness Average age 2-3 yo Frequently requires operative drainage
47 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!
48 Epiglottitis
49 Neoplasm
50 Aerodigestive Tract Foreign Bodies The Usual Suspects-you name it
51 Airway Foreign Bodies The usual suspects: Food -2/3 of Airway FB Non Food items Pen caps Tacks Pins Toys Insects
52
53 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 Ped Otorhinolaryngol (2008) 72, Intl J
54 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,
55 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
56 Airway Foreign Bodies Physical Examination: Cough (69%), Decreased Breath Sounds (52%), Intermittent/ Unilateral Wheeze (45%), Intermittent Dyspnea
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