TECHNIQUES FOR MANAGING THE PEDIATRIC AIRWAY
From Pediatric Otolaryngology Update presented by Stanford University School of Medicine and Lucile Packard
Children’s Hospital
| LARYNGOMALACIA ----- Peter Koltai, MD, Professor of Otolaryngology and Pediatrics, and Chief, Division
of Pediatric Otolaryngology, Stanford University School of Medicine, Palo Alto, CA
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| Introduction: condition formerly known as congenital laryngeal stridor; anatomic abnormality in which loose tissue
above vocal cords folds into airway during inspiration, causing partial obstruction; in response, infant increases inspiratory
effort, which exacerbates obstruction; obstruction clears only after child relaxes; most common cause of
noisy breathing in infants; most common laryngeal anomaly in infants; specific etiology unknown; reduced neuromuscular
tone of airway, possibly due to underdevelopment, impairs normal dilatory mechanism
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| Diagnosis: typical history—intermittent noisy breathing; characteristic rising, high-pitched whistle on inspiration;
worsens with agitation, crying, and feeding; symptoms also may worsen while sleeping because of reduced neuromuscular
tone; symptoms become apparent at ≈10 days of age, worsen during first few months, then generally resolve
by 12 to 18 mo of age; symptoms of concern—poor weight gain; difficulty feeding (infant cannot coordinate
suck and swallow); choking and aspiration; retractions, especially when sitting upright or trying to feed; sleep apnea;
cyanosis (uncommon); reflux; growth chart—children fall off growth curve early and stay below curve; key
component of diagnosis; fiberoptic laryngoscopy—findings include omega-shaped epiglottis, short aryepiglottic
folds, and hooded larynx; laryngeal introitus obscured; nap polysomnography—daytime sleep study may help assess
severity
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| Classification: mild—noisy breathing without complications; folded epiglottis; shortened aryepiglottic folds; excess
mucosa over corniculate and cuneiform cartilages, but vocal cords visible; narrowed laryngeal introitus;
moderate—frequent noisy breathing while asleep and awake; child has difficulty feeding but gains weight; reflux
symptoms; respiratory distress leads to emergency department (ED) visits; nap polysomnography and pH probe (to
assess reflux) useful; omega-shaped epiglottis; significantly shortened aryepiglottic folds; excess mucosa over cartilages
more prominent, causing markedly reduced laryngeal introitus; severe—frequent noisy breathing; periods
of apnea; occasional cyanosis; chronic retractions and prominent pectus excavatum; failure to thrive; supplemental
oxygen may be required; if untreated, pulmonary hypertension and cor pulmonale may develop (consider echocardiography
and consult pediatric cardiologist); soft larynx collapses easily; Narcy test (suction at laryngeal introitus
under suspension laryngoscopy) causes larynx to collapse
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| Treatment: observation—collaborate with pediatrician; chart growth; assess feeding and breathing; positioning—
symptoms exacerbated in supine position; prone, lateral, or lateral-upright positions lesson frequency of stridor;
feeding strategies—thickening breast milk or formula with rice cereal reduces pace and improves success of
feeding; reflux—resulting edema of laryngeal tissues may exacerbate prolapse into airway; increased work of
breathing increases intrathoracic and intraabdominal pressures, worsening reflux; proton pump inhibitor or H2 -
blocker may help; surgery—tracheotomy reserved for severe cases; supraglottoplasty standard treatment
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 | Supraglottoplasty: CO2 laser procedure—divide aryepiglottic fold; apply suction; denude mucosa from aryepiglottic
fold, exposing corniculate and cuneiform cartilages; remove eschar (induces inflammation); caveat—
disturbing interarytenoid mucosa will cause scarring and supraglottic stenosis; anesthesia—suspension laryngoscopy
requires precise control by experienced anesthesiologist
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| DIAGNOSING AIRWAY FOREIGN BODIES ----- Frederick S. Rosen, MD, Adjunct Clinical Professor, Stanford
University Medical Center, and Physician, Children’s Hospital, Oakland, CA
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| Prevalence: airway foreign bodies (AFBs) most common in toddlers (put everything in mouths; have sparse dentition
and immature neuromuscular system; prone to distraction while eating); fourth most common cause of
death in toddlers
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| History: most important element of diagnosis; larynx—episode of choking or gagging followed by coughing; exposure
to small food items (eg, peanuts, seeds, beans); large, conforming objects (eg, balloons, latex gloves)
may completely obstruct larynx; smaller objects may lodge in glottis or piriform sinuses, resulting in cough, inspiratory
stridor, hoarseness, or odynophagia; distal airway—associated with intermittent paroxysmal cough;
≈33% have delayed presentation with fever and purulent cough; misdiagnosis common (eg, chronic cough, atypical
asthma); witnessed aspiration and choking present in ≈75% of cases
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| Physical examination: symptoms depend on location of AFB and degree of obstruction; because severity may
progress, serial evaluations of respiratory status may be helpful; small AFBs may not cause stridor; when stridor
occurs, phase gives clues to location of AFB; classic triad of symptoms (unilateral wheeze, cough, and focally
decreased breath sounds) present in <50% of cases; nasopharyngoscopy recommended if inspiratory stridor present
(but laryngeal AFBs easy to miss)
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| Radiographs: ≈80% of AFBs radiolucent; ≈25% of chest radiographs have no abnormal findings; radiograph should
include neck to check for laryngeal AFBs; anteroposterior (AP) and lateral chest radiographs—findings include
obliterated tracheobronchial air column, emphysema (most common finding), and atelectasis; findings often subtle;
inspiratory and expiratory radiographs—classic diagnostic modality, but difficult to obtain in toddlers; lateral decubitus
radiographs acceptable alternative; findings—expiratory (dependent) hyperinflation; inspiratory (nondependent)
hypoinflation; lobar or segmental atelectasis suggests prolonged presence of AFB; atelectasis typically
predictive of presence of granulation tissue
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| Other diagnostic modalities: fluoroscopy involves significant exposure to radiation, with high rate of false-negative
results (11%-45%); spiral computed tomography (CT) and flexible bronchoscopy useful in difficult cases or
when delayed presentation suspected
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| Rigid bronchoscopy and direct laryngoscopy: gold standard for diagnosis and treatment; advent of rod-lens telescope
associated with decrease in mortality rate from ≈50% to ≈1%; laryngeal obstruction or presence of organic
AFB warrants expeditious use (otherwise, wait for empty stomach and experienced staff); multiple AFBs—
present in 5% to 19% of cases; complications—arrhythmia most common; negative results—≈33% of patients
with AFBs have false-negative results, but pus, mucus plug, or mucosal edema or hyperemia noted on endoscopy
in one third of these; false-negative results more common in children <1 yr of age
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| Delayed diagnosis: granulation tissue noted in ≈66% of children who undergo endoscopy \>72 hr after event and in
10% of children if endoscopy <72 hr after event; ≈20% of children receive treatment based on misdiagnosis
(asthma and chronic cough most common); prolonged bronchiectasis may necessitate lobectomy
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| Special problems: neurologically impaired children—dyscoordinate swallowing associated with increased risk;
history may be less reliable, complicating diagnosis; children typically older and have more complications; laryngeal
AFBs—children have complex of croup-like symptoms; incidence probably underestimated, because some
children dead on arrival (eg, those with large or conforming AFBs); small AFBs easy to miss
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| PEDIATRIC TRACHEOTOMY ----- Dr. Koltai
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| Indications: fixed airway lesions (eg, subglottic or tracheal stenosis); neurologic impairment requiring ventilatory
support or frequent pulmonary toilet; chronic pulmonary disease (rarely); prolonged intubation in critically ill children;
prolonged intubation—few studies in children; no consensus on maximum duration; case review of 59 children
intubated for ≥1 wk found 14% required tracheotomies; duration of intubation did not significantly differ
between patients who received tracheotomies and those who remained on ventilators; need for tracheotomy not
predicted by duration of intubation, number of times intubation occurred, or age of child; need for continued pulmonary
toilet or long-term ventilatory support more significant indicators of need for tracheotomy than length of
intubation; study suggests children tolerate prolonged intubation well (behave more like neonates than like adults);
intubation ≥30 days safe in children; tracheotomy indicated when ventilatory independence unlikely within 30 to
60 days
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| Standard technique: make horizontal incision in skin; identify strap muscles; divide thyroid (if in field); make vertical
incision through 3 to 4 tracheal rings; place retention sutures; place tube; indications—tracheotomy expected
to be in place for <3 to 6 mo; all ages
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| Starplasty technique: based on 3-dimensional Z-plasty; procedure—make x-shaped incision ≈1 cm above sternal
notch; inject area with lidocaine-epinephrine mixture; circumferentially undermine skin and remove subcutaneous
fat; expose strap muscles, divide along midline, and retract laterally; make plus-shaped incision in trachea
(tracheal flaps offset 45° from skin flaps); use 5.0 Vicryl to make 8 mattress sutures, creating continuous mucocutaneous
suture line; review of results—of 68 children who underwent starplasty procedure, 33 had airway-related
etiology and 35 had neurologic etiology; successful decannulation more likely in children with airway-
related etiology; complications—persistent tracheocutaneous fistula, but anterior tracheal wall does not collapse,
and incidence of suprastomal granuloma reduced; advantages—promotes healing; creates lined tract for
easy recannulation; reduces risk for pneumothorax; facilitates care of stoma
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| Surgical closure of fistula: make elliptical incision around fistula; follow tract to trachea; amputate tract, leaving
small cuff of tissue above tracheal lumen; close with 5.0 Vicryl suture; reapproximate strap muscles; close
skin
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| HOME MANAGEMENT OF PEDIATRIC TRACHEOTOMY: TRAINING THE CAREGIVERS ----- Ginny
Curtin, RN, MS, Pediatric Nurse Practitioner, Department of Otolaryngology-Head and Neck Surgery, Lucile
Packard Children’s Hospital, Palo Alto, CA
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| Basic information: when possible, educate parents and caregivers before placement of tracheotomy; anatomy—
airway vs esophagus; purpose of tracheotomy—some families have unrealistic expectations (they think of tracheotomy
as cure); common reasons for tracheotomy include ventilator dependence, bilateral vocal cord paralysis,
subglottic stenosis, and micrognathia; restrictions—child may not swim; child must always be in care of someone
trained to perform emergency change of tracheotomy tube; complications—plugging; accidental decannulation;
3% to 5% mortality rate due to complications
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| Initial assessment: identify 2 primary caregivers and ≥1 backup caregiver; discuss need for home nursing care (8 hr
per 24-hr period for infants <1 yr of age; 16 hr per 24-hr period for ventilator-bound children); help caregivers prepare
home by providing information about sleeping arrangements, necessary machinery, and storage space; ensure
caregivers have telephone and reliable transportation; schedule ≥3 teaching sessions for primary caregivers and ≥1
session for backup caregivers
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| Lifestyle changes: constant monitoring by someone who knows how to take care of tracheotomy and can perform
emergency change of device; challenges related to presence of home care nurse (eg, loss of privacy); constant
availability of emergency equipment; normalization of activity (eg, school, play); accommodation of equipment
and supplies in home; maintenance of health insurance and relationships with primary care provider and specialists;
challenges related to day care and school
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| Maintenance: clean skin around stoma with soap and water or normal saline; avoid using hydrogen peroxide (impairs
wound healing and causes irritation); suction with normal saline, as needed, to loosen secretions; change
tracheotomy device (primary caregivers must perform ≥3 supervised changes before leaving hospital with child;
backup caregivers must perform ≥1 supervised change); learn to assess for respiratory distress; learn cardiopulmonary
resuscitation (CPR)
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| Plugged tracheotomy tube: recognition—use of accessory muscles for breathing; squeaky breathing; cyanosis;
intervention—suction; add normal saline and suction again; if tube remains plugged, cut ties, remove tube, and
extend neck; replace tube when plug clear; prevention—humidification of room air; drops of normal saline in
tube (especially when away from home); suction when cough insufficient to remove mucus from tube
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| Accidental decannulation: secure tracheotomy ties essential; Velcro unsuitable for young children; other options
include 10-French suction catheter or small chain
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| Emergency equipment: portable suction machine and catheter; scissors (for cutting ties); extra tracheotomy tubes
(same size and one size smaller); shoulder roll (eg, rolled-up baby blanket); obturator from current tracheotomy
tube; normal saline; important—this equipment must always accompany child
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| Artificial nose: device traps humidified expired air; for use during waking hours; device must be kept dry
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| Speech: because tracheotomy bypasses vocal cords, special valve (Passy-Muir speaking valve) necessary for phonation;
children with complete subglottic stenosis cannot use; air inspired normally; device directs expired air over vocal
cords
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Suggested Reading
Aydogan LB et al: Rigid bronchoscopy for the suspicion of foreign body in the airway. Int J Pediatr Otorhinolaryngol
70:823, 2006; Bent J: Pediatric laryngotracheal obstruction: current perspectives on stridor. Laryngoscope
116:1059, 2006; Bittencourt PF et al: Foreign body aspiration: clinical, radiological findings and factors associated
with its late removal. Int J Pediatr Otorhinolaryngol 70:879, 2006; Despres N et al: 3-year impact of a provincial
choking prevention program. J Otolaryngol 35:216, 2006; Goldson E et al: Guidelines for the care of the child with
special health care needs. Adv Pediatr 53:165, 2006; Hitchings A et al: A variant of laryngomalacia in the neurologically
normal older child. Int J Pediatr Otorhinolaryngol, 2007 [epub ahead of print]; Karakoc F et al: Late diagnosis
of foreign body aspiration in children with chronic respiratory symptoms. Int J Pediatr Otorhinolaryngol 71:241,
2007; Kay DJ, Goldsmith AJ: Laryngomalacia: a classification system and surgical treatment strategy. Ear Nose
Throat J 85:328, 2006; Latifi X et al: Rigid tracheobronchoscopy in the management of airway foreign bodies: 10
years experience in Kosovo. Int J Pediatr Otorhinolaryngol 70:2055, 2006; Lee W et al: Indications for tracheotomy
in the pediatric intensive care unit population: a pilot study. Arch Otolaryngol Head Neck Surg 128:1249, 2002; Lewarski
JS: Long-term care of the patient with a tracheostomy. Respir Care 50:534, 2005; Sautter NB et al: Closure of
persistent tracheocutaneous fistula following “starplasty” tracheostomy in children. Int J Pediatr Otorhinolaryngol
70:99, 2006; Silvan Y et al: Diagnosis of laryngomalacia by fiberoptic endoscopy: awake compared with anesthesia-
aided technique. Chest 130:1412, 2006; Valera FC et al: Evaluation of the efficacy of supraglottoplasty in obstructive
sleep apnea syndrome associated with severe laryngomalacia. Arch Otolaryngo Head Neck Surg 132:489, 2006.
Educational Objectives
| The goal of this program is to improve the clinical management of the pediatric airway. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Diagnose and treat the infant with laryngomalacia.
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| 2. Recognize the clinical and radiographic findings typical of foreign bodies in the proximal and distal airway.
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| 3. List the indications for tracheotomy in children.
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| 4. Compare the standard and starplasty tracheotomy techniques.
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| 5. Educate primary caregivers about caring for children with tracheotomies.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members 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 reported nothing to disclose.
Acknowledgements
Drs. Koltai and Rosen and Ms. Curtin were recorded at Pediatric Otolaryngology Update, presented by Stanford University
School of Medicine and Lucile Packard Children’s Hospital, and held October 27-28, 2006, in Palo Alto, CA.
The Audio-Digest Foundation thanks the speakers, Stanford University School of Medicine, and Lucile Packard Children’s
Hospital for their cooperation in the production of this program.
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