Pediatric Airway Disease Presentation, Evaluation, and Management

Educational Objectives

The goal of this program is to improve the management of stridor in infants. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate emergent from nonemergent stridor in infants.
2. List the phases of stridor and establish a differential diagnosis based on auscultation findings.

Summary

Presentation of stridor: common ailment seen in emergency department (ED); infants may present after parents have tried to manage stridor at home for weeks; parents often told stridor in young infants self-limited laryngomalacia; although often true, child should receive adequate evaluation to rule out pathologic stridor; misdiagnosis may lead to acute respiratory emergencies

Endoscopy and laryngoscopy: mainstay of diagnosis and management; many emergency medicine (EM) physicians now training in these procedures in order to learn how to rapidly exclude life-threatening pathology; understanding underlying anatomy and pathology paramount to evaluation and diagnosis

Common causes of pediatric stridor: laryngomalacia — inspiratory stridor; affects airway above glottis; subglottic stenosis — biphasic stridor heard consistently, at all times of day; tracheobronchomalacia — expiratory stridor, commonly confused with laryngomalacia; foreign body — also commonly seen in ED; other pathologic causes of stridor — vocal cord paralysis, saccular cyst, laryngocele, subglottic hemangioma, and webs; acquired stridor — history important, especially family history of papilloma, multiple episodes of croup, or recent illness

Phases and types of stridor: inspiratory stridor — negative intrathoracic pressure in chest creates gasping sound with inspiration; biphasic stridor — derives from pathology of glottic or subglottic areas; dynamic breathing not present, as anatomy fixed in these areas; expiratory stridor — dynamic; tracheal and bronchial pathology

Evaluation and auscultation: auscultate neck and chest; for inspiratory stridor, listen for collapse and stridor at inspiration; with biphasic stridor, listen to voice (evaluate if muffled, hoarse, or aphonic); tracheal lesion will reveal collapse with expiration

Pediatric vs adult airways: stridor may be more sinister in children than in adults; airway is smaller (4 mm in diameter); even 1 mm of constriction may result in significant compromise of airway; adult airways 8 mm in diameter (wide enough to accommodate 1-mm constriction)

Clinical history: 3 major functions of larynx — respiration, protection, and phonation; history-taking should focus on these; inquire about quality of breathing, including respiratory rate, difficulty breathing, ability to cough, any choking or gagging while feeding, ability to feed, and ability to clear secretions; assess phonation (presence of aphonia, hoarseness, gagging, or coughing)

Diagnostic studies: lateral radiographs — generally not optimal diagnostic tool; may show minor narrowing or retropharyngeal bulging; beneficial for epiglottitis; anterior-posterior and lateral views may be used to visualize subglottic narrowing; computed tomography and magnetic resonance imaging (MRI) — MRI requires intubation or sedation of children, which may be detrimental in setting of airway disease; for either study, supine position may further compromise airway; flexible fiberoptic laryngoscopy — gold standard; may be performed at bedside; may be performed for evaluation of nasal, nasopharyngeal, oropharyngeal, glottic, and laryngeal lesions; not helpful for evaluation of trachea or subglottic regions; magnified airway — performed if flexible fiber laryngoscopy yielded negative results, and patient stable; provides view of trachea and subglottis; test not diagnostic for supraglottic issues

Supraglottic lesions: infant has narrow supraglottis; expansion of chest on inspiration causes supraglottic tissues to collapse, resulting in inspiratory stridor and issues with feeding and airway protection; children may choke and gag during feeding because of difficulty in coordinating acts of swallowing and feeding

Laryngomalacia

Laryngomalacia: most common congenital anomaly and cause of stridor in infants; age of onset ranges from birth to 14 days; peaks at 6 to 12 months, then slowly improves; if children gaining weight and not suffering from apnea, clinician may watch and wait, with conservative surveillance; education of patients — laryngomalacia not caused by weakened cartilage; instead, caused by neurologic issue that leaves infant with insufficient strength to maintain open airway; patients with cerebral palsy and Down syndrome have higher risk; clinical presentation — inspiratory stridor; difficulty with feeding (eg, dysphagia, aspiration, slow feeding, regurgitation); gastroesophageal reflux (GERD) — caused by weak sensory motor function and high negative pressure with inspiration; aspiration of gastric contents may further irritate airways, resulting in edema and decreased airflow; proton pump inhibitor — may decrease reflux and airway swelling; should not be given to premature neonates because of risk for necrotizing enterocolitis

Classification and treatment of laryngomalacia: severe laryngomalacia — severe classification includes children who have stridor, apnea, cyanosis, significant retractions requiring medical attention, difficulty feeding, weight loss, failure to thrive, cor pulmonale or pectus excavatum (sternum bows in with breathing); treatment of mild cases — observation; treatment of moderate cases — acid suppression, feeding modifications (thickened formula); treatment for severe cases — maximized acid suppression plus surgical intervention with supraglottoplasty; Nissen fundoplication indicated if reflux uncontrolled; tracheostomy not indicated in healthy children; evaluation for classification — clinical and physical evaluation; assess comorbidities; evaluate parental quality of life; in-office evaluation by otolaryngologist involves laryngoscopy while child feeds

Intervention: 80% to 90% of patients treated conservatively; 10% to 20% require surgical intervention; presence of aspiration on evaluation places child at higher stage; quality of life experienced by child and parent affects decision to intervene

Supraglottoplasty: surgery of aryepiglottic folds; removes tissue overriding arytenoids; success rate ≈94%; does not increase rate of aspiration; does not affect voice; opens airways; short procedure

Other Causes of Stridor

Other supraglottic disorders: presentation similar to that of laryngomalacia; vallecular and saccular cysts; epiglottitis; papillomas

Disorders of glottis and subglottis: may present with inspiratory or biphasic stridor; audible turbulent flow; often related to diameter; vocal cord paralysis — if bilateral, consider Chiari malformation; if unilateral, may be secondary to cardiothoracic surgery

Recurrent croup: may be sign of underlying airway disease and chronic inflammation; causes of chronic inflammation — reflux, allergies, and eosinophilic esophagitis; treatment — warm or cold air; steroids; nebulized treatment; parental education; if exacerbations caused by allergy, clinician should begin treatment with fluticasone or ipratropium nasal spray (decreases postnasal drip); reflux medications may be administered if condition related to GERD

Readings

Dobbie AM et al: Laryngomalacia. Pediatr Clin North Am. 2013 Aug;60(4):893-902; Hanlon K et al: Subglottic Stenosis. Curr Probl Pediatr Adolesc Health Care. 2018 Apr;48(4):129-135; O’Connell Ferster AP et al: Diagnosis and treatment of paradoxical vocal fold motion in infants. Int J Pediatr Otorhinolaryngol. 2018 Apr; Epub ahead of print; Ribeiro J et al: Supraglottoplasty in children with laryngomalacia: A review and parents’ appraisal. Am J Otolaryngol. 2018 May; Epub ahead of print.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Thottam was recorded at the 44th Annual Michigan Emergency Medicine Assembly, held July 30 to August 2, 2017, in Mackinac Island, MI, and presented by the Michigan College of Emergency Physicians. For information about upcoming CME conferences from the Michigan College of Emergency Physicians, please visit https://www.mcep.org/. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM351801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.