Upper airway obstruction (UAO)

Size: px

Start display at page:

Download "Upper airway obstruction (UAO)"

Arron Holland
5 years ago
Views:

1 Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm Children s Acute Transprt Service Clinical Guidelines Upper airway bstructin (UAO) Dcument Cntrl Infrmatin Authr L.Chigaru Authr Psitin CATS Cnsultant Dcument Owner E. Plke Dcument Owner Psitin Service Crdinatr Dcument Versin Versin 4 Replaces Versin January 2016 First Intrduced Review Schedule 2 Yearly Active Date January 2018 Next Review January 2020 CATS Dcument Number Applicable t All CATS emplyees Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 1 f 5

2 Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm Assessment The mst pertinent clinical sign is stridr, which is usually an inspiratry nise, but smetimes can be bth inspiratry and expiratry. Nt t be cnfused with: Key message Wheeze: a sign f lwer airway bstructin and narrwing. Stertr: signifies upper airway cllapse in children with decreased cnscius state, pharyngeal hyptnia r swallwing prblems. Identify and treat serius upper airway bstructin. Once the airway is secure, time can be spent n identifying the specific cause fr UAO. Specific pints in assessment Is this a first presentatin? Is there histry f previus intubatins r previus difficulty with intubatin? Is the airway stable? Prevalence in UK Diagnsis Key Features COMMON Viral laryngtrachebrnchitis (crup) Peak incidence in secnd year f life Barking cugh, stridr, lw-grade fever, harse vice Symptms ften at night UNCOMMON Epiglttitis Peak incidence 1-3yrs Acute presentatin High fever, sft stridr, drling, pen muth Txic Bacterial tracheitis Laryngeal freign bdy Inhalatinal Injury Anaphylaxis Average age 4-6yrs Preceding URTI Stridr, harse vice, high fever, respiratry distress Txic Peak incidence age 1-2yrs Acute nset Cughing, chking, stridr Respiratry distress Histry f expsure t smke Carbnaceus depsits arund muth, sputum Acute nset Expsure t triggers Itching, urticaria, facial swelling Cardivascular cmprmise Severe bilateral tnsillar enlargement Neck pain and swelling Dysphagia RARE Angineurtic edema Acute nset Lcalised angiedema Can affect any part f bdy Diptheria Retrpharyngeal abscess Recent travel Lw grade fever Neck pain and swelling Greyish adherent pseud membrane Neck pain and swelling, dysphagia, trismus Inspiratry stridr, fever Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 2 f 5

3 Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm Initial management Irrespective f the cause fr UAO, sme general management guidelines apply: General management: AVOID UPSETTING THE CHILD Leave child with parent in a cmfrtable psitin DO NOT insert tngue depressr DO NOT attempt IV access r bld tests DO NOT ask fr a Chest r lateral neck X-ray DO NOT frce an xygen mask ver face. Adrenaline nebulisers may temprarily relieve severe airway bstructin. Dse is 0.5 ml/kg f 1:1000 slutin, up t a maximum f 5 ml. The effect f adrenaline is temprary. Pulse ximetry is a pr guide t severity when xygen is delivered Specific management f selected cnditins Viral crup: summarized in flw chart. Mild Crup Scre = 0-1 Nrmal RR N recessin Nrmal pulse rate Nrmal O 2 sats Nrmal cnscius level Mderate Crup Scre = 2-7 Nrmal r raised RR Mild recessin AE decreased but easily audible Increased pulse rate O 2 sats > 93% Nrmal cnscius level Severe Crup Scre =/> 8 Increased RR Mderate/marked recessin Decreased AE and nt easily audible Increased pulse rate O 2 sats > 93% Altered cnscius level Reassure Fllw lcal guideline fr discharge Cnsider dexamethasne 0.15mg/kg p Dexamethasne 0.6 mg/kg iv/p (max 8 mg) single dse r nebulised budesnide 2 mg if p nt pssible Observatin fr 2-3 hurs CALL FOR SENIOR HELP Senir Paediatrician Senir Anaesthetist Senir ENT If n imprvement r wrsening, re-scre and act accrdingly Westley Crup Scre Stridr 0 = nne 1 = at rest, audible with stethscpe 2 = at rest, audible withut stethscpe Recessin 0 = nne 1 = mild recessin 2 = mderate recessin 3 = severe recessin Cyansis (O2 sats < 92% in air) 0 = nne 4 = with agitatin 5 = at rest Level f cnsciusness 0 = nrmal 5 = altered mental state Stay with child Give nebulised adrenaline 0.5ml/kg f 1:1000 slutin up t maximum f 5mls. This dse can be repeated Child might require urgent intubatin and transfer t PICU. Call CATS Crup scre 0-1: Mild crup Crup scre 2-7: Mderate crup Crup scre >/=8: Severe crup Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 3 f 5

4 Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm Epiglttitis DO Call fr senir help Paediatric SpR/Cnsultant Anaesthetic SpR/Cnsultant ENT SpR/Cnsultant Allw the child t remain in its favured psitin The child shuld be cnstantly supervised by smene skilled in intubatin Give humidified xygen as tlerated DO NOT Attempt rpharyngeal examinatin, since this may precipitate cmplete bstructin Attempt insertin f an iv cannula r take bld Send the child fr neck x-ray r ther x-ray Upset the child e.g. remving parents Administer IV antibitics when airway secured Leave the child unsupervised Rely nly n pulse ximetry Freign bdy bstructin: Bacterial tracheitis Inhalatinal injury The management depends n the site and severity f airway bstructin. Intubatin may result in further impactin f the freign bdy, and shuld be cnsidered ONLY when there is impending/actual cardi-respiratry arrest. The anaesthetist will then try t visualize/clear the bject under direct laryngscpy. Otherwise, examinatin under anaesthetic with rigid brnchscpy by the ENT team is the best ptin. Stridr may be sft r absent even in severe airway bstructin. Cnsider early intubatin by anaesthetist. After intubatin the ET may becme blcked with secretins. Administer IV antibitics nce the airway has been secured Alng with the histry, ther pinters may include st in sputum, singed nasal hair, st arund muth and face, and facial burns invlving muth and nse. The airway must be secured at the earliest pprtunity. Delay can lead t prgressive airway bstructin due t edema and a situatin where intubatin becmes impssible. Call anaesthetic team and intubate early. Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 4 f 5

5 Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm Indicatins fr intubatin Suspected epiglttitis Inhalatinal injury Fall in cnscius level Increasing respiratry failure Rising pco 2 Exhaustin Hypxia (SpO 2 <92% despite high-flw O 2 by mask >5 L/min) Management at Intubatin Mst experienced anaesthetist must be present at the intubatin. Mst anaesthetists wuld favur a gas inductin. Anticipate a difficult airway. (Refer t the difficult airway guidance frm APA/DAS) Ensure a back-up xygenatin strategy is prepared. Anticipate a smaller ETT than indicated by age (btain crup tubes if available) Management fllwing intubatin Once the airway bstructin is bypassed, mst children are easy t ventilate. Exceptins might be in case f bacterial tracheitis (pulmnary invlvement), inhalatinal injury (ARDS), r anaphylaxis (brnchcnstrictin). Ensure that the ETT is securely taped. Use sedatin and paralysis t ensure safety f ETT. Fllwing a difficult intubatin, an ETT shuld nly be changed if there is a clear clinical reasn which justifies this risk. Start adjunctive treatments such as iv dexamethasne (0.15 mg/kg QDS) in case f crup; r ceftriaxne (80 mg/kg) in case f epiglttitis r tracheitis. Bld cultures must be taken in suspected cases f infectin. In case f inhalatin injury and burns, start fluid replacement as per burns guidance. Patients with bacterial tracheitis may require fluid resuscitatin and intrpic supprt. Transprt cnsideratins Children with an unstable airway shuld nt be transprted withut detailed discussin with the CATS cnsultant. ETCO2 mnitring is mandatry during transfer t ensure cntinuus crrect ETT placement. Use cntinuus muscle relaxatin during retrieval t ensure safety f ETT. If transprting an un-intubated child with suspected freign bdy bstructin, avid unnecessary delay and transfer immediately t ENT centre (directly t theatres if necessary). The team must have a strategy t manage unexpected bstructin r hypxia. Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 5 f 5

Printed copies of this document may not be up to date, obtain the most recent version from Author Position

Printed copies of this document may not be up to date, obtain the most recent version from Author Position Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm www.cats.nhs.uk Children s Acute Transprt Service Clinical Guidelines Diabetic Ketacidsis Dcument Cntrl Infrmatin Authr