Clinical features important to dx of upper airway obstruction 1. onset and duration2. assoc sx3. progression with age4. exacerbating factors (ie pos

URI crying)5. Feeding abnorm or dysphagia6. Prior airway procedure - ie intub neonate7. Choking episode8. BL noises cry quality and voice

regardless of the patient’s age. At C6 this distance

162. Ped Upper Airway Obs, Infxn Flashcards by Tegan Turner

What anatomical/physiologic things make children more predisposed to resp failure? -increased airway R due to small compressible airway - low FRC - high O2 metabolism –> quicker fatigue

shorter safe apnea time

with precipitous hypoxia

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Upper airway obstruction - main 3 categories 1. Infxn 2. Congenital anomaly 3. FB - esoph/airway

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Clinical features important to dx of upper airway obstruction 1. onset and duration 2. assoc sx 3. progression with age 4. exacerbating factors (ie pos

URI

crying) 5. Feeding abnorm or dysphagia 6. Prior airway procedure - ie intub neonate 7. Choking episode 8. BL noises

cry quality and voice

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Upper airway obstruction: key PE -vitals - WOB -character/timing of stridor -breath sounds

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Key components of resp failure extreme distress with hyper or hypoventilation

AMS

pale/mottled/cyanotic skins color

hypotonia

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Upper airway obstruction: stridor defn harsh

vibratory sound caused by partial obstruction or collapse

result of turbulent airflow through some portion nose to trachea - timing in inspir vs expir both - coarse vs high pitched

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Inspiratory stridor: where is the lesion? above glottis

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Expiratory stridor: where is the lesion? intrathoracic obstruction

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Biphasic stridor indicates a __ or … critical or fixed obstruction at any level

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Snoring/stertor: defn low pitched inspiratory noise caused by nasal/nasopharyngeal obstruction

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Stridor from pharynx: what does this classically sound like? “ex PTA: sonorous

gurgling

coarse "”hot potato voice”””

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Laryngomalacia and croup have what kind of inspiratory stridor? high pitched inspiratory indicating supraglottic/immed subglotic trachea -hoarse/weak voice but can be N

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A biphasic stridor indicates a fixed lesion - examples of this? laryngeal webs vocal cord paralysis

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Examples of stridor from lower part of trachea: (diseases x2) FB bact tracheitis

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How to take an XR when considering epiglotitis/RPA etc? neck in ext film in inspiration

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“<img src=”“Screen Shot 2024-07-06 at 8.17.52 PM.png””>”

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Supraglottic airway - where is this? nose pharynx epiglottis surrounding structures

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Diseases of the pharynx/nose: symptoms? noisy congested breathing and resp distress

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Congenital lesions of supraglottic airway disease: choanal atresia macroglossia micrognathia thyroglossal duct cyst lingual thyroid

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Acquired cuases of supraglottic disease: nasal polyps nasal FB hypertrophic tonsils and adenoids epiglottis RPA PTA pharyngitis mono Upper airway FB

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What is the most common congenital abnormality of the nose? choanal atresia

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“<img src=”“Screen Shot 2024-07-06 at 8.20.32 PM.png””>”

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What is choanal atresia? persistence of bucconasal membrane or bony septum in posterior nairs so that posterior tip extends to contact epiglottis

What kind of choanal atresia is a life thr emergency? bilateral

How to manage choanal atresia (unilateral) with a compounding URTI? suction
urgent referral to surgical repair

What 3 conditions have macroglossia? 1. DS
2. Glycogen storage disorder
3. Congenital hypothyroidism

How to manage macroglossia with a compounding URTI? nasal suction with good head positioning to relieve obstruction

Micrnognathia is an abnormally small _ mandible

causing posterior displacement of a N size tongue (ie Pierre Robin ## Footnote Treacher Collins syndrome)
*obstrxn worsens when supine

What is the most common cause of sore throat in children? infection - viruses

Coxsackie A causes ? sx HFM disease or herpangina

HSV commonly causes __itis stomatitis

MC bacterial cause of pharyngitis GAS

Diptheria sx thick exudate on tonsillar membrane

What is sufficient/recommended tx for most causes of pharyngitis? tyl/ibu

PTA: MC deep neck infection - young or older adol? adol

Common sx PTA: drooling
muffled hot potato voice
trismus
bulging asym tonsil
deviation of avula away from abscess

Throat pain in a PTA may radiate... to the pt ear

PTA: tx abx
drainage/needle aspirate

PTA bacteria? "

Predominant bacterial species are

S. pyogenes (group A streptococcus)

Staphylococcus aureus (including

Methicillin-resistant S. aureus [MRSA])

and respiratory anaerobes.

Imaging PTA options "

Posterior pharynx ultrasonography can confirm the diagnosis and

guide treatment.

128 ## Footnote 172);"">2 3 A CT scan may be indicated if extension of infec-

tion is suspected.

If you try to aspirate a PTA

what has to be avoided? carotid a

Where is the carotid a compared to tonsillar pillar in a kid >12y 25mm posterolateral to tonsillar pillar

What is the rate of recurrence of PTA? 10-20%

Mono - caused by which virus? ebv

Mono - how does this cause upper airway obstruction? mucosal edema and exudate pharyngitis
uncommon but massive airway enlargement secondary to enlarged tonsil can cause

What is the preferred antibody in a child <4y to test for mono? EBV IgM

What is the preferred antibody in a child >4y to test for mono? heterophile antibody 50% pt first week illness

60% 2nd week ## Footnote 3rd week 90%

Children with sore throat MAY have a dx of which r/o? leukemia

Why avoid steroids in kids who have yet to be dx with leukemia? delays dx
incr risk TLS
complicates risk stratification

If I want to give steroids to a kid with sore throat

what can they NOT have (ie what might actually be signs of malignancy)? 1. lymphadenopathy
2. hepatosplenomegaly
3. rash
4. abn bl count

RPA: where is this? potential space between posterior pharyngeal wall and prevertebral fascia extending base of skull to T2

How can an RPA form? abscess from trauma to mouth penetrating soft tissue
suppration LN
contiguous spread of infection
hematogenous seeding

Why is RPA usually a disease in younger kids? lymphatic chains prominent in young; atrophy pre puberty

RPA: bacteria? "

commonly polymicrobial

with Streptococcus and anaerobes being the

most commonly isolated organisms. MRSA is increasing

RPA with MRSA - what two complication/further disease can you worry about? 1. jugular venous thrombosis
2. mediastinal extension

RPA: common symptoms

" may start as cellulitis*
fever
sore throat
neck stiffness/nuchal rigidity
torticollis
trismus
neck swelling
drooling
stridor
muffled voice

RPA: limitations in what movement? cannot extend neck or look side to side

Complications of RPA (5): jugular venous thrombosis
mediastinal extension
mediastinitis
pneumonia
empyema

RPA: testing "

in the normal patient

the width of the

retropharyngeal space should not exceed the diameter of the adjacent

vertebral body (

128 ## Footnote 172);"">Fig. 162.4). The soft tissue width should not be larger

94

than 7 mm at C2

regardless of the patient’s age. At C6 ## Footnote this distance

should not exceed 14 mm in children younger than 15 years and 22 mm

in adults

"RPA: Most patients will demonstrate ? on the lateral neck radiograp" retropharyngeal thickening

How to manage RPA: 1. safety first ABC - can they even lie down?
2. ENT involved early
3. IV abx for some small
4. surgery for other

What features indicate need for RPA abscess for surgical drainage? 1. imaging findings of scalloping on abscess walls
2. rim enhancement
3. lesions >2cm

What abx for tx RPA? clinda
ceftriaxone/third gen
+ vanco/linezolid if suspect MRSA

Ludwig angina/Submandibular space infection - what is this? rapidly progressive brawny cellulitis of the sublingual

submandibular and submaxillar spaces with potential for airway obs

Ludwig angina - spread? direct
not LN

Ludwig angina- MC source of infection? dental

Ludwig angina- hallmarks enlargement and elevation of tongue above lower teeth
tender woody induration of sublingual space
trismus
odynophagia

Ludwig angina- imaging ct for extent but MRI for better delineation ST involvement

Ludwig angina- tx broad spec IV abx with anaerobic coverage
airway support
adm
consult ent/anesth if emergent airway

Epiglottitis: what vaccination has decreased this disease? Hinflu B

Epiglottitis: what is this? invasive bacterial disease causing inflamm adn edema epiglottis

aryepiglottic folds ## Footnote arytenoids surrounding supraglottic tissues

Epiglottitis: causes (bugs) hinflu B despite vaccine/younger
H influ A

F non typeable
streptococci
s aureus
N. meningidits

Epiglottitis: noninfectious causes thermal injury from hot liquids
steam inhalation
caustic injury
allergic rxn
FB
irritant
Lymphoprolif disorders

Epiglottitis: clinical features acute onset with high fever

intense sore throat ## Footnote toxic appear rapid progression where tripod/sniff jaw forward DROOLING

Epiglottitis: common MISdx? croup

Epiglottitis: older pt key signs/symptoms sore throat out of proportion to exam
tender anterior neck to palpation

Epiglottitis: immunocompromised can get what subset of this? NEcrotizing

Epiglottitis: dx test lateral neck radiograph for enalrge epiglottis - thumbprint sign

thick aryepiglottic fold ## Footnote lack air vallecula dilated hypopharynx BUT 70% can be N

Epiglottitis: management stable pt - don't bug them --> OR
unstable: BMV until intub of successfel. if neither success --> needle crich or trach
if time to call for help: anes

ENT ## Footnote gen surg

Epiglottitis: unstable pt gets intubated

how long do they stay this way for?
what abx? 3-5d for abx therapy to decrease swelling *second or third gen cephalosporin

Epiglottitis - burns can mimic this - what would tx be? intubation/secured airway early due to laryngeal edema
bronchodil bronchospasm
NO steroids

Allergic reaction causing upper airway obs:
who has highest rte mortality? allergy to __ peanuts and tree nuts with atopy and asthma

Allergic reaction causing upper airway obs: tx anaphylaxis IM epi 2mg/ml at 0.01mg/kg up to 0.5mg per dose

Allergic reaction causing upper airway obs: refractory epi infusion dose for anaphylaxis? (shock dose) IV epi 0.1mg/mL solution at 0.001mg/kg bolus then 0.1-1mcg/kg/min up to 10mcg/min

Allergic reaction causing upper airway obs: epi R bronchospasm - tx? racemic epi

Allergic reaction causing upper airway obs: autoinjector dose for child <30kg vs >/=30 0.15
0.3

Congenital lesions causing stridor: what is laryngomalacia? MC congenital cause stridor
incomplete devleopment of support cartilage of larynx

Laryngomalacia physiology: inspire - long floppy epiglottis

arytenoids ## Footnote aryepiglottic folds drawn into larynx to create an obs

Laryngomalacia: baseline stridor starts at what age? worsens with what? several weeks post birth
lying down

neck flex ## Footnote increased resp effort of crying or URI

Laryngomalacia: if they have resp distress

feeding diff or failure to thrive is this common? nope

Laryngomalacia: when do pt get most resolution of sx? 2y

Laryngomalacia: confirmation of dx fiberoptic bronch for coexisting anomalies as most tx conservatelively

Laryngomalacia: when to consider surgical tx? 1. apneic event >20 seconds
2. resp compromise
3. pulmonary hypertension
4. failure to thrive

Second MC cause chronic stridor in infants? VC paralysis

VC paralysis kids: bilateral = sign resp distress - what is a certain CNS abnormality you can see with this (named disease) Arnold Chiari malformation

VC paralysis kids: Unilateral VC paralysis causes - which side N effected? left

VC paralysis kids: Unilateral VC paralysis causes - 1. traction L recurrent laryngeal n at birth
2. compression mediastinal structure

VC paralysis kids: symptoms? hoarse weak cry
feeding diff
aspiration

VC paralysis kids: PE to test to side? worsens with distress and IS better when effected side is down

VC paralysis kids: tx mostly ? speech therapy

Laryngeal web: what is this? failure of complete canalization of airway

Laryngeal web: where are most webs? between cords and as partial anterior fusion

Laryngeal web: small web sx hoarse weak cry
stridor mild

Laryngeal web: larger/more complete web sx aphonia
severe resp distress

Congenital laryngotracheal/subglottic stenosis: what is this? result of defect in canalization of subglottic trachea

with usually seen deformity of cricoid ring

Congenital laryngotracheal/subglottic stenosis: severe stenosis at birth have what sx stridor

Congenital laryngotracheal/subglottic stenosis: Mild lesions may not be seen until? infection/inflammation of area

Congenital laryngotracheal/subglottic stenosis: how can this be acquired? prolonged intubation
blunt trauma to neck

Subglottic hemangioma: less common cause of stridor but how does it present? asymp birth
biph stridor and cough within first few wks to mo of life
sx peak at 6mo due to infant growth and hemangioma during first few mo

Subglottic hemangioma: when does stridor worsen? resp sx

agitation

Subglottic hemangioma: what other hemangioma can also be seen with this? cutaneous - often beard distribution about 50% of time

Subglottic hemangioma: what is dx? endoscopy

Acquired peds lesions causing stridor (2): laryngeal papilloma
subglottic tracheal disease

Acquired peds lesions causing stridor: laryngeal papilloma: benign neoplasm

laryngeal papilloma: sx hoarseness
inspir stridor
abn cry by 3-4y
resp distress if large

What is the mosst common benign laryngeal neoplasm in children and second most common cause of hoarseness? laryngeal papilloma:

laryngeal papilloma: caused by ? virus from vertical transmission from mum HPV

"Sublottic tracheal stenosis: can be caused from what basic ""VINDICATE"" causes?" congenital
inflamm from infection
trauma - prolonged intubation

Croup official name laryngotracheobronchitis

Croup - what is this? MC infectious cause of upper airwau distress and obstruction

What accounts for more than 90% of stridor in children croup

When does croup usually occur? (age group) 6-36mo

Croup: causes Parainfluenza 50-75%
other - RSV

Infl A and B ## Footnote rhinovirus

What other disease in unvaccinated children can cause croup? measles

Croup: what virus causes a more severe picture of croup than with parainfluenza cause? influ A

Croup: infllamation

exudates and edema of loosely adherent mucosal and submucosal tissue in the __ space
expands where? subglottic
up into airway lumen because the cricoid cartilage forms a complete and nonexpanding ring in that part of the trachea

Croup: clinically diagnosed; sx 1-3d prodrome of fever

URI
barky cough ## Footnote hoarse voice high pitched inspiratoy stridor

Croup: yo children vs older children MC sounds barky cough
hoarse

Croup: how long does cough last? whole thing? 3d
4-7days

What is the definition of mild croup? intermittent barky cough
stridor with agitation but not rest
mild tachypnea
tachycardia
minimal distress

well hydrated ## Footnote N mental status

Moderate croup defintion audible stridor at rest

worsening with agitation
barky cough
increased wob - retraction ## Footnote tachypnea tachycardia
fussy but alert interactive and comforted by parents
HYPOXIA rare

Lab tests for croup? nope

Management of croup (in general) 1. GC - oral dex 0.6mg/kg max 10-16mg - improves sx within 2 hours
IV if severe - same dose
2. Stridor at rest or sign resp distress: nebulizedc L epi at 1:1000 solution 0.5ml/kg max 5L OR racemic epi 2.25% solution 1.125mg/kg max 11.25mg/dose --> either diluted 2-3ml NS and given via nebulizer

How long to watch kids after L epi administration from croup in ED? 2-3 hours
d/c if no recurrence stridor

resp distress

Mod to severe croup - in add to dex/L epi

what can you give kids? heliox to help gas flow and decrease wob
but really only benefits first hour ## Footnote not beyond

Moderate croup: factors in decision to adm vs home 1. severity of initial sx
2. persistence rep distress
3. hx airway disease or recurrent croup
4. <6mo of age
5. diff with feeds
6. poor social supports

Severe croup is <1% - what will you see? fatigue
hypoxia
hypercapnia
AMS
extreme resp distress

Severe croup - intubate with what tube? half size smaller than expected given inflamm

Atypical croup defn numerous recurrent episodes or croup outside expected age group
often seen with allergy

atopy ## Footnote airway hyperreactivity asthma GERD
r/ airway lesions like subglottic stenosis contribution

Congenital lesions of the trachea: what is tracheomalacia? abnormally soft

underdeveloped supporting cartilage of tracheal rings

When is tracheomalacia seen (ie what infants/diseases)? -normal healthy term newborns
DS
Digeorge

Tracheomalacia: what hx supports this dx? stridor increasing first few weeks of life

worsens w/ agitation ## Footnote supine positioning infection

Tracheomalacia: what dx testing to get? fluoroscopy may be helpful as is dynamic

Tracheal stenosis: what is this? congenital anomaly resulting from complete tracheal rings

Tracheal stenosis: sx persistent stridor

resp distress
symptoms worsen with agitation and age as tracheal diameter is fixed

What might cause external tracheal compression? vascular anomalies
mediastinal lesions - vascular ring ex

Examples of vascular rings double Aortic arch
right aortic arch with persistent L ligamentum arteriosum
anomalus innominate artery
anomalous L CCA
L PA
aberrant R subclavian A

Kids with vascular rings may also have other ? anomalies cardiovascular

How do kids with vascular rings typically present? peristent unexplained resp and feeding problems

Vascular ring dx testing? CXR - abnormal RS aortic arch
barium esophagram traditionally most important if complete

Bacterial tracheitis: what immunization has decreased this? Hinflu

Bacterial tracheitis: pathophys sev inflamm tracheal epithelium and production of thick mucopurulent secretions
mucosa becomes necrotic and sloughs in the lumen so microabscesses possible in trachea

What organism (bacteria) is mc cause for bacterial tracheitis? mrsa

Bacterial tracheitis: clinical presentation toxic child
high fever
rapidly worsening stridor
fails to improve with racemic epi

Bacterial tracheitis: features suggesting this? viral prodrome

then acute decompensation
sx atypical for croup (high fever/cyanosis/severe distress)
poor response to neb epi
inspire and expiratory stridor

Bacterial tracheitis: xray findings (though this may not be helpful) lat and AP: subglottic narrowing

ragged edge of usually smooth tracheal column ## Footnote hazy density within lumen

Bacterial tracheitis: management if severe immed intub

suction in ED
serial endoscopy for secretions
vanco or clinda + ceftr

Bacterial tracheitis: if penicillin allergic vanco or clinda + cipro if concern pseudomonas or levo if strep pneumoniae

Bacterial tracheitis: abx length 7-10d

Bacterial tracheitis: complications TSS
septic shock
renal failure
post intubation pulmonary edema
acute resp distress syndrome with need for reintubation

FB usually end up which bronchus? R mainstem

FB clinical features complete = poor air exchange

inability to speak ## Footnote ineff cough sever distress cyanosis

FB stable pt: dx testing portable lateal neck radiograph

chest radiograph
00> helpful for radioopaque materials ## Footnote mediastinal shift emphysema atelectasis

If signficant concern for FB

what test/procdure? diagnostic flexible bronchoscopy

FB management BLS
choking <1y: 5 back blocks then 5 chest thrusts head below trunk
heimlech >1y w/ chest compression to unconscious child

FB - pt oxygenatd

moving air: how to manage? preferred pos
cont cough to clear obstruction
breath spont until op management arranged
AVOID RSI

Can't intubate can't ventilage FB: management surgical crich >8y
needle crich <8: 14 angiocath into a 3ml syringe and with 7.5mm ETT adaptor
BVM

Angio cath needle crich set up for kids needing crich? "

A 14- to 18-gauge angiocatheter (the size of the

catheter does not affect the rate of turbulent gas flow) is inserted in

the cricothyroid membrane and connected to a 3-mL syringe (with-

out the plunger) to a 7.5-mm ETT adaptor (or a 3.0-mm ETT con-

nector directly to the angiocatheter). These homemade kits are rigid

and may easily become dislodged. Alternative setups include using

IV tubing—attaching IV tubing to the angiocatheter

cutting the tub-

ing

and attaching a 2.5-mm ETT connector—or directly connect-

ing oxygen tubing to the catheter with a Y connector or three-way

stopcock. Bag-mask ventilation (recommended in children <5 years)

can be performed through the ETT adaptor at 10 to 12 breaths/min

to minimize barotrauma by allowing for passive exhalation. Percu-

taneous transtracheal ventilation (in children ≥5 years) is given at

an oxygen flow rate of 1 L/min/year of age with a 1:4 inspiration-

to-expiration ratio (I:E). Adults should receive oxygen from the wall

source at 15 L/min (50 to 58 psi) and children at a rate of 10 to 12 L/

min (25 to 35 psi).

1. Which of the following is the most common cause of upper respira- tory obstruction in childhood?
a. Airwayforeignbody
b. Bacterial tracheitis

c. Croup
d. Epiglottitis

" c

2. A 3-year-old girl presents at 2 am with complaints of a barky

cough, which started abruptly overnight. Vital signs are heart rate, 140 beats/min, respiratory rate, 40 breaths/min, and temperature, 100.1°F (38°C). She has no history of asthma or wheezing. She appears to be in moderate distress and has audible stridor. Indica- tions for admission include which of the following?

" d

A 5-year-old immunized boy presents with severe stridor at rest, low-grade fever, and nasal congestion. His family reports a barky- sounding cough. After initiating vaporized epinephrine, he appears well and is in no distress. The parents are asking about discharge. Which of the following would be the most appropriate next step in management?

a. Administer dexamethasone, observe the patient for 2 to 3 hours,

and discharge if well.
b. Admit the patient for overnight observation.
c. Allow the patient to go home.

d. Allow the patient to go home with a prescription of steroids.

" a

. What is the ideal head position to assess a pediatric soft tissue radiograph of the neck for upper airway pathology?
a. Extensionduringinspiration
b. Flexion

c. Flexionduringinspiration
d. Neutral

" A

5. Which of the following factors is least consistent with the diagnosis

of peritonsillar abscess?
a. Muffled, hot potato voice b. Pain radiating to the ear c. Patient 3 years of age
d. Patient 13 years old
e. Trismus

" C

6. A 3-year-old immunized girl presents after a brief viral illness with progressive dyspnea, ill appearance, and high fever. The child is relatively still, appearing as if she is trying not to cough. Stridor is heard, and she does not respond to croup therapy. You notify the operating room, where the patient undergoes bronchoscopy, with suctioning and airway placement. Culture results are most likely to grow which of the following organ- isms?

a. Bacteroides fragilis
b. Candida albicans

c. Parainfluenza
d. Staphylococcus aureus
e. Streptococcus pneumoniae

" D

162. Ped Upper Airway Obs, Infxn Flashcards

(242 cards)