NEEDING AIR
| Upper Airway Obstruction in Children —Steven M. Selbst, MD, Professor of Pediatrics and Vice-Chair
for Education, Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia; Alfred
I. duPont Hospital for Children, Wilmington, Delaware
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| Stridor: hallmark for upper airway obstruction; inspiratory sound heard without stethoscope (unlike wheezing and
rales from lower airway); requires rapid assessment
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Noninfectious Causes
| Allergic edema: presents with sudden onset of facial swelling, urticaria, and respiratory distress; patient afebrile; intramuscular
(IM) epinephrine indicated (works faster than subcutaneous form); give antihistamines, oral steroids,
and admit to hospital for overnight stay or keep in emergency department (ED) for 10 to 12 hr (swelling may recur)
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| Spasmodic croup (subglottic allergic edema): previously well child awakens during night with significant respiratory
distress and stridor; sometimes better by time patient presents to ED; resolves with cool air or mist
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| Caustic ingestion or thermal injury: usually have history of drinking hot liquid or caustic substance; have burning of
posterior pharynx and swelling of epiglottis; can present same as child with infectious epiglottitis; probably need
intubation to manage airway
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| Congenital disorders: laryngomalacia common and usually resolves on its own (children do fine until upper respiratory
infection); polyps or hemangiomas in airway; tongue relatively large compared to small mandible (Pierre-
Robin syndrome); suspect internal hemangioma obstructing airway if child with stridor has external hemangioma
on head, neck, or upper chest
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| Foreign body aspiration: particular problem for toddlers; hotdogs and balloons most common (may cause death);
small toys; child presents suddenly with acute respiratory distress and inability to vocalize; afebrile; history usually
helpful (absent in 25% of cases)
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| Partial airway obstruction: do not do anything dramatic (might convert to full obstruction); get child to ear, nose,
and throat (ENT) specialist or operating room (OR) where obstruction can be cleared under controlled circumstances;
lateral neck x-ray often helpful (use portable machine to avoid irritating child or forcing him or her to
change positions); do not let patient out of sight
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| Complete airway obstruction: initiate 5 back blows followed by 5 chest thrusts in children <1 yr of age; perform Heimlich
maneuver if child >1 yr of age
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Infectious Causes
| Infectious mononucleosis: enlarged adenoids and tonsils can obstruct airway in children <2 yr of age; airway obstruction
unlikely in children >2 yr of age because of larger airway; suspect diagnosis if child has fever, significant
adenopathy, and splenomegaly; Monospot test negative in children <8 yr of age; Epstein-Barr virus (EBV) titers
helpful but not during immediate management; admit to hospital if airway partially obstructed; steroids indicated
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| Retropharyngeal abscess: due to group A β-hemolytic streptococci or Staphylococcus aureus; present with fever, ill
appearance, and stiff neck (may be confused with meningitis); can usually feel mass, fullness, or tenderness on one
side of neck; child can flex neck slightly but does not want to move neck laterally; lateral neck x-ray shows widened
retropharyngeal space (should be ≈7 mm at C2 or half width of vertebral body at C2); consult ENT; obtain
computed tomography (CT; be careful moving patient and escort patient with airway equipment); admit patient and
treat with penicillin and clindamycin; <50% of cases need surgical management
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| Peritonsillar abscess: occurs in teenagers; does not cause upper airway obstruction
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| Bacterial tracheitis: not common but can be deadly; thought to be viral croup that becomes secondarily infected with
bacteria; affects wide age group, although usually involves young children; can occur during any season but peaks
during fall and winter; tracheal narrowing in subglottic area; adherent pseudomembranes; purulent tracheal pus key
to diagnosis; if epiglottis normal, >50% of cases have associated bacterial pneumonia; patients sick for few days
and gradually get worse; present with severe respiratory distress, high fever, stridor, barking cough; laboratory tests
show high white blood cell count with left shift, negative blood culture, but positive tracheal culture; intubate and
admit to intensive care unit (ICU); treat Staphylococcus with vancomycin, ceftriaxone, or cefuroxime; steroids and
racemic epinephrine ineffective; protecting airway key to management
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| Epiglottitis: uncommon in practice but still common on board examinations; caused by Haemophilus influenzae type
b (Hib), group A β-hemolytic streptococci; cases reported in children with chickenpox or altered immunity; incidence
has dramatically decreased since Hib vaccine; now more common in teenagers and adults
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 | Young children: almost 100% have fever and respiratory distress; two thirds also have stridor; some have mild
cough or cold; 20% have drooling (late finding); child toxic appearing, quiet, prefers sniffing position, and does
not want to be disturbed; lateral neck film (portable machine) helpful
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| Teenagers and adults: more likely to present with sore throat and dysphagia; less likely to have airway obstruction;
suspect if patient has severe sore throat
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| Treatment: admit to hospital and start IV antibiotics; observe in ICU, looking for development of airway obstruction;
young children should be intubated prophylactically
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| Croup: most common infectious cause of upper airway obstruction; viral infection caused by parainfluenza, influenza,
and respiratory syncytial virus (RSV); occurs in spring and fall, but can be seen throughout year; usually
occurs in children <2 yr of age; gradual onset; do not look toxic; have characteristic barky, seal-like, croupy
cough, stridor, and dyspnea; restless, agitated, and cannot get comfortable; often have low-grade fever; x-ray really
not needed but shows classic steeple sign (seen best on posteroanterior [PA] view); management goal to
minimize anxiety; avoid obtaining blood gases (rarely needed; manage with pulse oximetry); patients who need
oxygen have more serious disease and need close attention; some need IV hydration; humidity (mist) shown to
be no better than placebo
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| Racemic epinephrine: works, but used for more ill patients, eg, patient with retractions, significant respiratory distress,
or those with stridor at rest; clearly beneficial for disease but not cure (lasts only 90-120 min); can send
home if no recurrence after 3 to 4 hr of observation in ED
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| Steroids: effective for croup; reduce need for hospital admission; decrease croup score and severity of symptoms; result
in shorter ED stay if started early, less need for ICU admission and intubation; shorten hospital stay;
dexamethasone—treatment of choice (0.6 mg/kg; 0.3 mg/kg shown to work just as well; parenteral form [4 mg/
mL] well tolerated when mixed with cherry syrup and easy to administer); nebulized budesonide—works as well
as dexamethasone but more expensive and time consuming to administer; mild croup—benefits of steroids include
fewer return visits, less loss of parent’s sleep, faster resolution of symptoms, less parental stress
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| Hospital admission criteria: patients who cannot drink; patients who are cyanotic; stridor at rest despite racemic epinephrine
treatment; need for second racemic epinephrine treatment; physician suspects parents will not recognize
child getting worse; family lives too far from hospital
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| Near Drowning —John R. Richards, MD, Associate Professor of Emergency Medicine, University of California,
Davis, School of Medicine, Sacramento
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| Drowning process: something goes wrong, victim starts swallowing water, becomes fatigued, panics, loses buoyancy,
becomes exhausted, has cardiac arrest; hyperventilating before free diving can cause diver to lose consciousness;
victim more interested in breathing than calling for help; may appear to be playing when in distress (children can
struggle for only 10 sec before succumbing, adults ≈60 sec)
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| Sequence of events: laryngeal spasm determines wet drowning (water in lungs) or dry drowning (larynx closes; 10%-
20% of cases dry); lose consciousness within 3 min of swallowing water; brain death occurs within 3 min; secondary
drowning— patient has signs of life in ED and develops acute respiratory distress syndrome (ARDS), pneumonias,
pneumonitis, and electrolyte disturbances; immersion syndrome—when victim jumps into cold water causing profound
parasympathetic discharge, massive release of epinephrine, ventricular fibrillation and asystole (splashing water
onto face before immersion effective in preventing this)
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| Sea water vs fresh water: both equally damaging (remove surfactant); destruction of surfactant results in loss of alveolar
stability, collapsing of areas of lung, decreased compliance, stiffer lung (more difficult to take deep breath),
ventilation/perfusion (V/Q) mismatch; protein fills lungs, leading to basement membrane damage;, hypoxia occurs
due to vasoconstriction of pulmonary arteries and veins; may have occlusion of bronchi from aspirated foreign
body
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| Acute respiratory distress syndrome: 50% to 80% mortality; most feared complication of near drowning; can have
cardiac ischemia from hypoxia, cardiogenic shock, any type of arrhythmia, and acidosis; brain dies after 2 to 3 min
with no oxygen; if victim survives, cerebral edema becomes big problem (portion of skull removed to relieve pressure
on brain); reperfusion injury; 35% of immersion episodes in children fatal, 33% result in neurologic impairment
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| Spinal injury: suspect if full story not known, eg, patient found floating or patient heavily intoxicated
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| Initial presentation: asymptomatic—speaker recommends they come to ED because sequelae may develop over several
hours; symptomatic—altered vital signs, respiratory distress, neurologic deficits; do not give up if patient presents
with CPR in progress; limit interventions if patient normothermic and asystolic, or obviously dead (eg, rigor
mortis)
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| Poor prognostic factors: age ≤3 yr; submersion for >5 min; no attempts at resuscitation for 10 min; patient comatose
on presentation; acidosis; if ≤2 of these factors present patient has 90% chance of recovery, ≥3 factors, 5% chance
of recovery; long transport time; resuscitation >25 min; asystole on arrival at hospital
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| Other factors: water temperature; duration and degree of hypothermia; diving reflex; victim’s age; success of resuscitation
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| Resuscitation: Heimlich maneuver used to clear obstruction, not for near drowning; intubate all patients in respiratory
distress or who have altered level of consciousness (LOC)
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| Treatment in ED: intubation; hyperventilation; positive end-expiratory pressure (PEEP); β-agonists; steroids; prophylactic
antibiotics; warming; rehydration; nasogastric (NG) tube to remove water from gastrointestinal tract;
spine films; head CT
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| Treatment in ICU: surfactant replacement; albumin replacement; inhaled nitric oxide; furosemide (Lasix) diuresis;
barbituarte coma; induction of hypothermia; ventilation on high-frequency oscillator; extracorporeal membrane
oxygenation (ECMO)
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| Hyperventilation: in theory decreases intracranial pressure (ICP) by decreasing cerebral blood flow, but works only
for short-term
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| β-Agonists: in theory, cause bronchodilation, reduce neutrophil sequestration, accelerate alveolar fluid clearance,
enhance surfactant secretion, and modulate inflammation; do no harm and may help
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| PEEP: in theory recruits and stabilizes alveoli and increases oxygen delivery; in reality, works but must worry
about barotrauma and decreased venous return; recommended to keep tidal volumes to moderate or minimal
level (eg, 6 mL/kg)
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| Surfactant replacement: in theory, reestablishes surface tension; in reality, improvement short-term and outcome
not improved for patients with ARDS; availability limited; popular in pediatric intensive care units (PICUs)
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| Nitric oxide: in theory, results in pulmonary vasodilation; may help (no studies)
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| Diuresis: theory that it draws fluid from injured lung via oncotic gradient; may have some benefit
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| Hypothermia: in theory, decreases ICP, cerebral blood flow, and free radical damage; in reality, no benefit shown
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| Steroids: theory that they reduce inflammatory response; reality, may have some benefit in ARDS, unknown for
drowning
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| Barbiturate coma: theory that it helps decrease ICP from cerebral edema; in reality, studies show no change in survival
rate; may make patient more comfortable
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| ECMO: oxygenates blood while bypassing lungs; works but very expensive (costs ≈$50,000/day) and has very
limited availability
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Educational Objectives
| The goal of this program is to educate the listener about airway emergencies. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Name the noninfectious and infectious causes of stridor.
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| 2. List the congenital disorders that can cause upper airway obstruction in children.
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| 3. Describe the diagnosis and management of bacterial tracheitis.
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| 4. Discuss the use and efficacy of steroids for the treatment of croup.
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| 5. Review prognostic factors associated with near drowning.
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Discussed on This Program
Budesonide (many trade names)
Ceftriaxone sodium [Rocephin]
Cefuroxime [Ceftin, Kefurox, Zinacef]
Clindamycin (many trade names)
Dexamethasone (many trade names)
Haemophilus b conjugate vaccine [ActHIB, HibTITER, Liquid PedvaxHIB]
Penicillin (many trade names and formulations)
Racepinephrine (racemic epinephrine) [microNefrin, Nephron, S2]
Vancomycin [Vancocin, Vancoled]
Programs of Related Interest
Birnbaumer DM: Tough airways. Audio-Digest Emergency Medicine 21:10(May 21), 2004; Fishman G, Dauer EH:
Problems in the pediatric airway. Audio-Digest Otolaryngology 38:05(Mar 7), 2005; Hagan JB, Stollman N: The compromised
airway. Audio-Digest Otolaryngology 38:21(Nov 7), 2005; Kirse D, Wei JL: Approaching the pediatric airway.
Audio-Digest Otolaryngology 38:13(Jul 7), 2005; Setzen M et al: The airway and beyond. Audio-Digest
Otolaryngology 38:20(Oct 21), 2005.
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Baines PB et al: Upper airway obstruction. Hosp Med 65:108, 2004; Bjornson CL et al: A randomized trial of a single
dose of oral dexamethasone for mild croup. N Engl J Med 351:1306, 2004; Brook I: Aerobic and anaerobic microbiology
of bacterial tracheitis in children. Pediatr Emerg Care 13:16, 1997; Burford AE et al: Drowning and
near-drowning in children and adolescents: a succinct review for emergency physicians and nurses. Pediatr Emerg
Care 21:610, 2005; Craig FW et al: Retropharyngeal abscess in children: clinical presentation, utility of imaging,
and current management. Pediatrics 111:1394, 2003; Dykes J: Managing children with croup in emergency departments.
Emerg Nurse 13:14, 2005; Falk JL et al: Submersion injuries in children and adults. Semin Respir Crit Care
Med 23:47, 2002; Fitzgerald DA et al: Croup: assessment and evidence-based management. Med J Aust 179:372,
2003; Gulliver P et al: Usual water-related behaviour and ‘near-drowning’ incidents in young adults. Aust N Z J Public
Health 29:238, 2005; Leung AK et al: Viral croup: a current perspective. J Pediatr Health Care 18:297, 2004;
Ross JL: Summer injuries: near drowning. RN 68:36, 2005; Savoy NB: Differentiating stridor in children at triage:
it’s not always croup. J Emerg Nurs 31:503, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported no conflict.
Dr. Selbst was recorded March 30, 2005, in Lake Buena Vista, Florida, at Pediatric Emergency Medicine 2005: Advances
and Controversies for the Clinician, sponsored by The Nemours Children’s Clinic; Dr. Richards, October 21,
2005, in San Francisco, at Rural, Remote, and Wilderness Medicine, sponsored by the University of California,
Davis, Health System, Department of Emergency Medicine, and Continuing Medical Education. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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