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Upper airway obstruction ‫قصي ناصر حسين‬0‫د‬ Upper air way obstruction classified clinically into :- 1-congenital 2-acquired Also classified into supra glottis or subglottis obstruction.. Main feature is strider which is whistled sound occurred during inspiration which reverse to...

Upper airway obstruction ‫قصي ناصر حسين‬0‫د‬ Upper air way obstruction classified clinically into :- 1-congenital 2-acquired Also classified into supra glottis or subglottis obstruction.. Main feature is strider which is whistled sound occurred during inspiration which reverse to wheezing that resulting from lower air way obstruction , occurred during expiration. Upper air way obstruction classified according to to causes and the age :- A-new born ( until one month of age ) :- 1-foreign material( meconium and amniotic fluid ) 2-bilateral cho-anal atresia 3-cong. Sub-glottic stenosis 4-micrognathia as in pierr Robin syndrome and Diagorgi syndrome. 5-macroglosia as in hypothyrodism &down syndrome 6-cong. Anomalies of the larynx , pharynx & trachea. 7-vocal cord paralysis 8-laryngospasm ( as in intubation and aspiration ) B-infancy ( 1—12 month of age ) 1-laryngomalacia ( commonest ) 2-sub-glotic stenosis 3-rhinitis 4-vascular ring 5-tongue tumor & ectopic thyroid C-Toddler ( 1—3 years ) 1-viral croup ( commonest ) 2-spasmodic croup 3-F.B inhalation. 4-bacteria trachitis 5-tonsil & adenoid hyperatrophy 6-retropharyngial abscess 7-diphteria ( rare ) D-above 3 years :- 1-epiglotitis 2-F.B 3-trauma 5-angio-edema 5-IMN ( infec. Mono nucleosis ) 6-anaphylaxasis 7-peritonsilar abscess in adolescent 8-diphtheria ( rare) Congenital Upper air way obstruction:- 1-Laryngomalacia 2-Congenital Subglottic Stenosis Laryngomalacia softening in laryngeal Cartilage benign condition laryn , , Omegas ce Surgical intervention 2 5. , Sever - / - benign Condition & Big CLINICAL MANIFESTATIONS Laryngomalacia accounts for 45% to 75% of congenital laryngeal anomalies in children with stridor. Stridor is inspiratory, low-pitched, and exacerbated by any exertion: crying, agitation, or feeding and quite by sleeping. The stridor is caused, in part, by decreased laryngeal tone leading to supraglottic collapse during inspiration. Symptoms usually appear within the 1st 2 wk and increase in severity for up to 6 mo, although gradual improvement can begin at any time. Gastroesophageal reflux disease, laryngo-pharyngeal reflux disease, and neurologic disease influence the severity of the disease and thereby the clinical course. DIAGNOSIS 1-The diagnosis is made primarily based on symptoms. The diagnosis is confirmed by outpatient flexible laryngoscopy. 2-When the work of breathing is moderate to severe, airway films and chest radiographs are indicated 3-When dysphagia is suspected, a contrast swallow study and/or a fiberoptic endoscopic evaluation of swallowing (FEES) may be considered. 4-Because 15–60% of infants with laryngomalacia have synchronous airway anomalies, complete bronchoscopy is undertaken for patients with moderate to severe obstruction. TREATMENT 1- Expectant observation is suitable for most infants because most symptoms resolve spontaneously as the child and airway grow. 2-Laryngopharyngeal reflux is managed aggressively with antireflux medications, inhibitors (PPIs). Risk:benefit ratio should be assessed in each patient 3-In 15–20% of patients, symptoms are severe enough to cause progressive respiratory distress, cyanosis, failure to thrive, or cor pulmonale. In these patients, surgical intervention via supraglottoplasty is considered. Supraglottoplasty is 90% successful in relieving upper airway obstruction caused by laryngomalacia..  Congenital Subglottic Stenosis intubation In↑ I5 - acquired ** ↳ prolonged intubation 11 d Es 3- 2 T Tracheostomy 251j) * CLINICAL MANIFESTATIONS Congenital subglottic stenosis is the second most common cause of stridor. The subglottis is the narrowest part of the upper airway in a child and is located in the space extending from the undersurface of the true vocal folds to the inferior margin of the cricoid cartilage. Subglottic stenosis is a narrowing of the subglottic larynx and manifests in the infant with respiratory distress and biphasic or primarily inspiratory stridor. Symptoms often occur with a respiratory tract infection as the edema and thickened secretions of a common cold narrow an already compromised airway leading to recurrent or persistent croup-like symptoms. Biphasic or primarily inspiratory stridor is the typical presenting symptom for congenital subglottic stenosis. The edema and thickened secretions of the common cold further narrow an already marginal airway that leads to croup-like symptoms. DIAGNOSIS The diagnosis made by airway radiographs is confirmed by direct laryngoscopy. During diagnostic laryngoscopy the subglottic larynx is visualized directly and sized objectively using endotracheal tubes. The percentage of stenosis is determined by comparing the size of the patients’ larynx to a standard of laryngeal dimensions based on age. Treatment Stenosis >50% is usually symptomatic and often requires treatment. As with all cases of upper airway obstruction, tracheostomy is avoided when possible. Subglottic stenosis is typically measured using the Myer-Cotton system, with grade I through grade IV subglottic stenosis indicating the severity of narrowing. Dilation and endoscopic laser surgery can be attempted in grade I and II, although they may not be effective because most congenital stenoses are cartilaginous. Anterior cricoid split or laryngotracheal reconstruction with cartilage graft augmentation is typically used in grade III and IV subglottic stenosis.  Acquired Upper air way obstruction:- 1-Foreign Body 4-epiglotitis 3-Croup 2-trachitis Foreign Bodies in the Airway EPIDEMIOLOGY AND ETIOLOGY Choking is a leading cause of morbidity and mortality among children, especially those younger than 4 yr of age. Most victims of foreign body aspiration are older infants and toddlers ; males have been found to be victims up to 1.7 times more likely than females. Studies show that children younger than 4 yr of age account for 61.7–70% of airway foreign body cases. The most common objects on which children choke are food items (59.5–81% of all choking cases). Nuts, seeds most frequently aspirated food items. Common inorganic objects on which children choke include coins, latex balloons, pins, jewelry, magnets, pen caps, and toys. Globular, compressible, or round objects such as hot dogs, grapes, nuts, balloons, marshmallows, meats, and candies are particularly hazardous due to their ability to completely occlude the airway. Why children more at risk to aspirate a foreign body? 1-because of their developmental vulnerabilities and their underdeveloped ability to swallow food 2- Infants and toddlers often use their mouths to explore their surroundings, and 3-children generally are more likely to be distracted, playing, or ambulatory while eating. >>>Young children are more likely to experience significant blockage by small foreign bodies due to their smaller airway diameter. Mucus and secretions may form a seal around the foreign body, making it more difficult to dislodge by forced air. In addition, the force of air generated by an infant or young child’s cough is less effective in dislodging an airway obstruction. It is recommended that children younger than 5 yr of age should avoid hard candy and chewing gum and that raw fruits and vegetables be cut into small pieces. Other factors, such as developmental delays or disorders causing neurologic or muscular issues, can also put children at higher risk for foreign body aspiration. CLINICAL MANIFESTATIONS – depending on the characteristics, duration, and location of the foreign body. The clinical manifestations range from an asymptomatic state to severe respiratory distress. The most serious complication of foreign body aspiration is complete obstruction of the airway, which may be recognized in the conscious child as sudden respiratory distress followed by an inability to speak or cough. There are typically three stages of symptoms that result from aspiration of an object into the airway: 1. Initial event: Paroxysms of coughing, choking, gagging, and possibly airway obstruction occur immediately after aspiration of the foreign body. The child is sometimes able to expel the foreign body during this stage. 2. Asymptomatic interval: The foreign body becomes lodged, reflexes fatigue, and the immediate irritating symptoms subside. The lack of symptoms can be particularly misleading to the provider when a child presents in this stage and accounts for a large percentage of delayed diagnoses and overlooked foreign bodies. A large meta-analysis of more than 30,000 patients showed that diagnosis is delayed more than 25 hr in almost 40% of airway foreign body cases. 3. Complications: Obstruction, erosion, or infection develops, which again directs attention to the presence of a foreign body. In this third stage, complications include fever, cough, hemoptysis, pneumonia, and atelectasis. Acute or chronic complications have been reported in almost 15% of cases of foreign bodies of the airway. DIAGNOSIS History is the most important factor in determining the need for bronchoscopy. A positive history must never be ignored, but a negative history can be misleading. Because nuts and seeds are the most common bronchial foreign bodies, the physician should specifically question the child’s parents about these items, and bronchoscopy essential, including examination of the nose, oral cavity, pharynx, neck, wheezing and asymmetric breath sounds are highly suggestive of foreign body in the airway. In addition to history and physical examination, radiology studies have an important role in diagnosing foreign bodies in the airway. Plain films are typically recommended first, although many foreign bodies are radiolucent (80–96%), and therefore providers often must rely on secondary findings (such as air trapping, asymmetric hyperinflation, obstructive emphysema, atelectasis, mediastinal shift, and consolidation) to indicate suspicion of a foreign body. Expiratory or lateral decubitus films can assist in revealing these suggestive secondary findings. The indication for computed tomography of the chest is currently being explored due to its high sensitivity and specificity, its ability to detect radiolucent objects, and its potential to eliminate the need for an anesthesia and procedure. However, the known risks of radiation must certainly be considered. If there is a high index of suspicion despite negative or inconclusive imaging, bronchoscopy should be performed. TREATMENT A conscious child suspected of having a partial foreign body obstruction should be permitted to cough spontaneously until coughing is no longer effective, respiratory distress and stridor increase, or the child becomes unconscious. If the child becomes unconscious, the child should be gently placed on the ground, supine. The provider should then open the airway with the head-tilt/chin-lift maneuver and attempt mouth-to-mouth ventilation. If ventilation is unsuccessful, the airway is repositioned and ventilation attempted again. If there is still no chest rise, attempts to remove a foreign body are indicated. In an infant