PD
Pediatrics

Upper Airway Obstruction

November 21, 2013.
Steven M. Selbst, MD,

Educational Objectives

The goal of this program is to improve the management of upper airway obstruction in children. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate among the various infectious causes of upper airway obstruction.

2. Recognize cases of upper airway obstruction that require admission to the hospital or intensive care unit.

Summary

Introduction: stridor (inspiratory noise) hallmark; emergent action needed regardless of etiology

Noninfectious Etiology

Allergic reaction: to, eg, shellfish, peanuts; usually afebrile; urticaria (absent in 10%-20% of patients), facial swelling, swelling of lips and tongue, and respiratory distress; pale watery edema in pharynx

Management: epinephrine — epinephrine autoinjector (Auvi-Q, EpiPen, Twinject) used in children weighing >25 kg, and EpiPen Jr in smaller children; rapid administration crucial; recent survey by American Academy of Allergy and Immunology found that physicians often fail to respond with epinephrine as expeditiously as required; delayed administration major cause of death in patients with serious allergic reactions; only treatment shown effective; antihistamines — given after administration of epinephrine; along with steroids, considered adjunctive therapy, although no strong evidence of significant efficacy established; all patients treated with antihistamines for few days, plus 3- to 5-day course of steroids; patients observed for 6 to 8 hr because ≤20% of patients have biphasic reaction (recurrence of allergic symptoms); consider overnight admission or placing patient in observation unit

Spasmodic croup: subglottic allergic edema; cause unknown; often presents as severe distress in middle of night in child reported to be well during day; frequently resolves with exposure to cool air

Caustic ingestions and thermal injuries: symptoms similar to infectious epiglottitis; occurs soon after ingestion of, eg, liquid drain cleaner, which causes severe pain and burning of entire oropharynx; can lead to airway obstruction as edema and inflammation develop

Congenital disorders: laryngomalacia — causes chronic stridor in young infants; upper respiratory infection worsens stridor (patients may present with respiratory distress); others — congenital webs; hemangiomas; abnormally large tongue in Beckwith-Wiedemann syndrome; Pierre Robin syndrome (tongue relatively large, compared to small mandible)

Foreign body aspiration: major cause of death in children (usually toddlers); dangerous items include hotdogs, balloons (one of most common causes), and toys; clinical manifestations — upper airway obstruction, with acute distress and inability to vocalize; afebrile; history often unreliable; management — if obstruction partial and child coughing, do not remove; obtain (portable) x-ray; bring to operating room if aspiration significant; with complete obstruction, apply back blows and chest thrusts for young children and Heimlich maneuver for older children; in children <1 yr of age, blind finger sweep not recommended if unable to visualize foreign body; otherwise, perform 5 back blows between scapula, then roll child over and apply 5 chest thrusts; Heimlich maneuver contraindicated in young children (<1 yr) due to risk for laceration of liver and splenic injury

Infectious Etiology

Infectious mononucleosis: cause of airway obstruction in young children (<2 yr of age); heterophile antibody (Monospot) test not reliable in children; diagnosis made clinically; young child may present with exudative pharyngitis, large tonsils, significant lymphadenopathy, and splenomegaly; Epstein-Barr virus titers helpful in making diagnosis (but not helpful in first few hours); x-ray possibly helpful; management — admission to hospital; treatment with steroids if airway obstruction present; careful monitoring

Retropharyngeal abscess: study showed that airway obstruction develops in only 5% of cases (usually occurs in younger children); presents with fever, toxic appearance, and stiff neck (child able to flex neck, but unable to perform lateral movement); fullness usually palpable on one side of neck; etiology is group A β-hemolytic Streptococcus and Staphylococcus aureus; portable x-ray shows widened retropharyngeal space; management — referral to otolaryngologist; <50% of patients require surgery; intravenous (IV) antibiotics (clindamycin); computed tomography (CT) should be obtained, but requires caution

Bacterial tracheitis: more common than epiglottitis; previously called membranous laryngotracheobronchitis; involves pseudomembranes; similar to croup; most often caused by S aureus; epidemiology — occurs across wide age range, but most often in young children; winter peak season; pathophysiology — purulent tracheal secretions most important (not laboratory diagnosis); epiglottis normal; in 25% to 50% of cases, bacterial pneumonia also present; clinical manifestations — gradual onset; severe respiratory distress; high fever; barking cough; patients prefer supine position; laboratory findings — elevated white blood cell count; blood culture usually negative; in most cases, culture of tracheal secretions reveals S aureus; x-ray may show “scalping” or irregularity of trachea (key feature); management — admission to ICU; tracheal intubation almost always indicated; IV antibiotics (vancomycin)

Epiglottitis: incidence reduced due to advent of Haemophilus influenzae vaccine; other causative agents include group A Streptococcus; occasionally seen in immunocompromised host; seen most often in young infants and teenagers; occurs year round; signs and symptoms in young children — respiratory distress; fever; stridor (present in two-thirds of cases); cough; drooling (late finding; seen in ≈20% of cases); patient usually quiet and in sniffing position; x-ray (portable lateral view) beneficial if diagnosis unsure (hyoid bone landmark, above which “thumb” sign seen; widening of hypopharynx nonspecific); intubation difficult; older children present with severe sore throat and dysphagia; management — admission to ICU; IV antibiotics; intubation of younger children as soon as diagnosis made; for older children, observation in ICU to determine whether intubation needed

Croup: etiology — viral infection (due to, eg, parainfluenza, influenza, respiratory syncytial virus [RSV]); upper airway obstruction, barking cough, and wheezing usually seen in RSV infection); common illness; occurs more often in cold weather; most common in young children, but seen in all ages; clinical manifestations — gradual onset; patients do not appear toxic; barking “croupy” cough; stridor and dyspnea; restlessness and agitation; low-grade fever; x-ray usually not indicated; management — minimize anxiety; O2 (admit if hypoxic); hydration; mist not beneficial; racemic epinephrine indicated if significant respiratory distress present, but effects last only 2 hr; monitor patient for 2 to 3 hr after epinephrine wears off (if patient doing well, discharge); corticosteroids beneficial, even for mild cases (in ED, single dose of parenteral dexamethasone administered; 2- to 3-day course of oral prednisolone as effective as dexamethasone); criteria for hospitalization — inability to drink; cyanosis; stridor at rest after dose of racemic epinephrine; concern about parents’ ability to recognize need for hospitalization or obtain transportation back to hospital

Acknowledgements

Dr. Heinle was recorded at Pediatric Infections and Pulmonary Diseases: Perspectives 2012, held September 7-9, 2012, in Rehoboth Beach, DE, and sponsored by Nemours/Alfred I. DuPont Hospital for Children. Dr. Selbst was recorded at the 34th Annual Las Vegas Seminars — Pediatric Update, held November 15-18, 2012, in Las Vegas, NV, and sponsored by the American Academy of Pediatrics California District, Chapters 1, 2, 3, and 4. For future CME activities by these sponsors, please visit www.nemourseducation.org and www.aap-ca.org. The Audio-Digest Foundation thanks Drs. Heinle and Selbst, and the meeting sponsors, for their cooperation in the production of this program.

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Selbst was recorded at the 34th Annual Las Vegas Seminars — Pediatric Update, held November 15-18, 2012, in Las Vegas, NV, and sponsored by the American Academy of Pediatrics California District, Chapters 1, 2, 3, and 4. For future CME activities by this sponsor, please www.aap-ca.org. The Audio-Digest Foundation thanks Dr. Selbst, and the meeting 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:

PD594302

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.

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