Stridor, Stertor, and Snoring: Pediatric Upper Airway Obstruction Nathan Page, MD Pediatrics in the Red Rocks June?
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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 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)
Pediatric vs Adult Larynx Location Consistency Size Shape Configuration
Configuration Epiglottis is narrow, omegashaped (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 Ped Otorhinolaryngol (2008) 72, 1041-1046 Intl J
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