Paediatric

Respiratory Emergencies

Dr. Hemraj Soni

DCH DNB
SDM Hospital Jaipur
 Respiratory Emergencies
• #1 cause of
– Pediatric hospital admissions as emergency
– Death during first year of life except for
congenital abnormalities
Respiratory Emergencies

Most pediatric cardiac arrest

begins as respiratory failure or
respiratory arrest
Pediatric Respiratory System
• Large head, small
mandible, small
neck
• Large, posteriorly-
placed tongue
• High glottic opening
• Small airways
• Presence of tonsils,
adenoids
 Pediatric Respiratory System
• Poor accessory muscle development
• Less rigid thoracic cage
• Horizontal ribs, primarily diaphragm
breathers
• Increased metabolic rate, increased O2
consumption
Pediatric Respiratory System

Decrease respiratory reserve +

Increased O2 demand =
Increased respiratory failure risk
Respiratory Distress
 Respiratory Distress
• Tachycardia (May be bradycardia in neonate)
• Head bobbing, stridor, prolonged expiration
• Abdominal breathing
• Grunting--creates CPAP
 Respiratory Emergencies
Medical Emergencies Surgical emergencies
• Choanal atresia
• Croup
• CDH
• Epiglottitis • TEF
• Foreign body aspiration
• Asthma
• Air leak syndrome
• Bronchiolitis • Neck Masses
– Cystic Hygromas
• Bronchopulmonary – Tracheal anomalies
dysplasia • Thoracic masses/pulmonary lesions
– Congenital lobar emphysema
• Pneumonia – Congenital cystic adenomatous
• ARDS malformation
– Pulmonary agenesis
Choanal Atresia
 INTRODUCTION
• Complete nasal obstruction in a newborn may
cause death from asphyxia, if appropriate
treatments are not available.
• if the infant cries and takes a breath through the
mouth, the airway obstruction is momentarily
relieved.
• Then the crying stops, the mouth closes, and the
cycle of obstruction is repeated.
 History of the Procedure
• In 1755, Roederer first described congenital
choanal atresia.
• In 1854, Emmert reported the first successful
surgical procedure using a curved trocar
transnasally.
• Over the years, the necessity of serial dilatations
to maintain patency of the choanae has clearly
been recognized.
 Epidemiology
• The average rate is 0.82 cases per 10,000
individuals.
• Unilateral atresia occurs more frequently on the
right side.
• ratio of unilateral to bilateral cases is 2:1.
• A slightly increased risk exists in twins.
• Maternal age or parity does not increase the
frequency of occurrence.
• Chromosomal anomalies are found in 6% of
infants.
• Five percent of patients have monogenic
syndromes or conditions.
 Epidemiology

• Race: Choanal atresia occurs with equal

frequency in people of all races.

• Sex: More studies report significantly more

females than males affected.

 Aetiology
• The nasal cavities extend posteriorly
during development under the influence of
the posteriorly directed fusion of the
palatal processes.
• Thinning of the membrane occurs, which
separates the nasal cavities from the oral
cavity.
• Failure of the 2-layer membrane consisting
of nasal and oral epithelia to rupture by the
38th day of development results in
choanal atresia.
 Aetiology
• Failure of the 2-layer
membrane
consisting of nasal
and oral epithelia to
rupture by the 38th
day of development
results in choanal
atresia
 Pathophysiology
• Theories proposed to explain the
occurrence of choanal atresia can be
summarized as follows:

• Persistence of the buccopharyngeal

membrane
• Failure of the bucconasal membrane of
Hochstetter to rupture
• Medial outgrowth of vertical and horizontal
processes of the palatine bone
• Abnormal mesodermal adhesions forming
in the choanal area
• Misdirection of mesodermal flow due to
local factors
 Clinical Evaluation
• complete physical examination to assess for other
congenital anomalies.
• complete nasal and nasopharyngeal examination.
• A high level of suspicion is required to diagnose bilateral
choanal atresia.
• Symptoms of severe airway obstruction and cyclical
cyanosis are the classic signs of bilateral atresia.
• When crying alleviates respiratory distress in an obligate
nasal breather, there is probability of bilateral choanal
atresia.
• Unilateral atresia may not be detected for years, and
patients may present with unilateral rhinorrhea or
congestion.
 Clinical Evaluation
• Many patients have an associated:
– Coloboma of the iris, choroid, and/or microphthalmia
– Heart defect such as atrial septal defect (ASD) and/or
conotruncal lesion
– Atresia of choanae
– Retarded growth and development
– Genitourinary abnormalities such as cryptorchidism,
microphallus, and/or hydronephrosis
– Ear defects with associated deafness (The external,
middle, and/or inner ear may be involved. Only a small
proportion of infants with choanal atresia and related
components probably represent this entity.)
 Clinical Evaluation
• The percentages of the different anomalies
in CHARGE syndrome association are as
follows:
– Coloboma - 80%
– Heart defect - 58%
– Atresia of choanae - 100%
– Mental retardation - 94%
– Growth deficiency - 87%
– Genital hypoplasia in males - 75%
– Ear anomalies - 88%
 Differential diagnosis
• Deviated nasal septum
• Dislocated nasal septum
• Septal hematoma
• Mucosal swelling
• Turbinate hypertrophy
• Encephalocele
• Nasal dermoid
• Hamartoma
• Chordoma
• Teratoma
 Investigations
• Imaging Studies:
– Rhinography is a procedure that involves the
administration of radiopaque dye into the nasal
cavity
– CT scanning is the radiographic procedure of
choice in the evaluation
• purpose is outlined as follows:
– Confirm the diagnosis of choanal atresia
(unilateral or bilateral).
– Evaluate choanal atresia (vomer bone width and
choanal airspace distance).
– Exclude other possible nasal sites of obstruction.
– Determine the degree of bony, membranous, or
mixed atresia.
– Delineate abnormalities in the nasal cavity and
nasopharynx.
 Investigations
• Choanal atresia.
Rhinogram
demonstrating
blockage of
radiopaque dye at
the posterior
choanae.
• From T.L. Tewfik and V.M. Der
Kaloustian, with permission.
 Investigations
• CT scan showing
membranous and
bony choanal
atresia. From T.L.
Tewfik and V.M. Der
Kaloustian, with
permission.
 Investigations
• Axial view of CT scan
nose/paranasal sinus
showing bony choanal
atresia
 Diagnostic Procedures
• Failure to pass an 8F catheter through the nasal cavity
more than 5.5 cm from the alar rim
• The lack of movement of a thin wisp of cotton under the
nostrils while the mouth is closed
• The absence of fog on a mirror when it is placed under
the nostrils
• Acoustic rhinometry
• Listening for breath sounds with either a stethoscope or
a Toynbee auscultation tube
• Gently blowing air into each nasal cavity with a Politzer
bag
• Administering into the nose a colored solution that is
visible in the pharynx
 TREATMENT
• Surgical therapy: divided into emergent
and elective definitive categories
• Bilateral choanal atresia in a neonate is an
emergency that is best initially treated by inserting
an oral airway to break the seal formed by the
tongue against the palate. This oral airway can be
well tolerated for several weeks.
• McGovern nipple, and intubation are viable
options.
• Tracheostomy
 Procedures
• Principles:
– restores the normal nasal passage,
– prevents damage to growing structures important in
facial development,
– is technically safe,
– requires short operative time, and
– provides short hospitalization and convalescence.
 Procedures
• Type of Approaches:
– Transnasal puncture, with or without a
microscope
– Transseptal
– Transpalatal repair
– Endoscopic technique (nasal or retropalatal),
with or without powered instrumentation
– Carbon dioxide and potassium titanyl
phosphate (KTP) lasers
• Diagram illustrating
the transpalatal
correction of
choanal atresia.
Endoscopic View
 Postoperative details
• Infants with documented (GERD) require
prolonged stenting and dilatations for choanal
restenosis and removal of granulation tissue.
• Stenting is usually performed using an
endotracheal tube or Foley catheter.
– use of stents in the management of patients with
choanal atresia is a controversial
• the use of stents following repair requires the
use of prophylactic antibiotic and antireflux
medications.
 Follow-up care
• Patients may require operative
debridement or periodic dilatations.
• This can sometimes be performed as an
outpatient procedure with:
– local decongestant and
– topical anesthesia
– using urethral sounds.
 Esophageal Atresia and
Tracheoesophageal Fistula
 Successive stages in the development of the
tracheoesophageal septum during embryologic
development.

• (A) The laryngotracheal

diverticulum forms as a ventral
outpouching from the caudal part
of the primitive pharynx.
• (B) Longitudinal
tracheoesophageal folds begin to
fuse toward the midline to
eventually form the
tracheoesophageal septum.
• (C) The tracheoesophageal
septum has completely formed.
• (D) If the tracheoesophageal
septum deviates posteriorly,
esophageal atresia with a
tracheoesophageal fistula
develops
 Esophageal atresia is a congenital
abnormality in which the midportion of
the esophagus is absent.

• Incidence is between 1 in 3,570 and

1 in 4,500.
Anatomic Variations

• 85%
 
• Most common

 
• VOGTtype3(b)
 
• GROSS type C
 
Anatomic Variations

6%
Atresia alone, 
alone,
• no fistula 
fistula
• Small stomach, 
stomach,
gasless abdomen 
abdomen
• Usually has a long 
long
gap between the 
the
esophagealends 
esophagealends
• VOGT types 1 and 2  2
• GROSS type A
Anatomic Variations
• 2% 
2%
• Proximal tracheo- 
tracheo-
esophageal fistula 
fistula
• No distal fistula 
fistula
Small stomach, 
stomach,
• gasless abdomen 
abdomen
• Often has a long 
long
gap between the 
the
Esophageal ends 
ends
• VOGT type 3(a) 
3(a)
• GROSS type B
Anatomic Variations

• l%
• Proximal and 
and
distal fistulas 
fistulas
• ("double fistula")

• VOGT type 3(c) 

3(c)
• GROSS type D  
Anatomic Variations
• 6%
• No atresia of
the esophagus
•  Congenital
tracheoesophageal 
tracheoesophageal
fistula
"H" or "N" fistula 
fistula
• GROSS type E  E
Physiologic effects of distal tracheoesophageal
fistula
• (A)1. Hyaline membrane disease
may necessitate higher ventilator
pressures, which encourage air to
pass through the distal fistula.
• 2. A distended abdomen elevates
and "splints" the diaphragm.
• 3. Gastric distension may result in
gastric rupture and
pneumoperitoneum.
• 4. Passage of air through a distal
tracheoesophageal fistula diminishes
the effective tidal volume.
• . (B) 1. Aspiration of gastric juices
leads to soiling of the lungs and
pneumonia
• 2. Gastroesophageal reflux
• 3. Direction of gastric fluid
proximally through distal fistula.
• 4. Overflow of secretions or
inadvertent feeding may contribute
to aspiration and contamination of
the airway. .
 Associated Abnormalities

Incidence of Associated Anomalies in Esophageal Atresia.

Anomaly Frequency (%)
• Congenital heart disease 25
• Urinary tract 22
• Orthopaedic (mostly vertebral and radial) 15
• Gastrointestinal (e.g., duodenal
• atresia,imperforate anus) 22

• Chromosomal (usually trisomy 18 or 21) 7

• Total with one or more associated 58
anomalies
 Associated Congenital Anomalies Reported in Patients with
Esophageal Atresia
System affected Potential anomalies
Musculoskeletal Hemivertebrae, radial dysplasia or
amelia, polydactyly, syndactyly, rib
malformations, scoliosis, lower limb
defects

Imperforate anus, duodenal atresia,

Gastrointestinal malrotation, intestinal
malformations, Meckel's
diverticulum, annular pancreas

Cardiac Ventricular septal defect, patent

ductus arteriosus, tetralogy of
Fallot, atrial septal defect, single
umbilical artery, right-sided aortic
arch
Genitourinary. Renal agenesis or dysplasia,
horseshoe kidney, polycystic kidney,
ureteral and urethral malformations,
hypospadias
 DIAGNOSIS OF
ESOPHAGEAL ATRESIA
• Antenatal Diagnosis (maternal
polyhydramnios, a small stomach, a
distended upper esophageal pouch, or
abnormal swallowing)
• Diagnostic suspicion is increased when
abnormalities known to be associated with
esophageal atresia are identified.
Fetal MRI

• This 32 week
fetus had
esophageal
atresia and an
absent stomach,
resulting in
marked
polyhydramnios
 Clinical Diagnosis

• Prematurity
• Any excessively drooling (copious, fine,
white, frothy bubbles of mucus in the
mouth and, sometimes, the nose).
Clinical Diagnosis
• . (A) Diagnosis of
esophageal atresia is
confirmed when a 10-
gauge (French)
catheter cannot be
passed beyond 10
cm from the gums.
(B) A smaller-caliber
tube is not used
because it may curl
up in the upper
esophageal segment,
giving a false
impression of
esophageal
continuity.
The chest radiograph
• A plain radiograph will
confirm the tube has
not reached the
stomach
The Gasless Abdomen
• Absence of gas in the
abdomen suggests
that the patient has
either atresia without
a fistula or atresia
with a proximal fistula
only
Contrast studies
• should be performed by
an experienced pediatric
radiologist, or after
transfer to the tertiary
institution, and with the
use of a small amount
(0.5 to 1 mL) of water-
soluble contrast. Care
must be taken to avoid
aspiration.
 Management
• Measures should be taken to reduce the risk of
aspiration(continuous suctioning of the upper
pouch, the infant's head should be elevated).
• In infants with respiratory failure, endotracheal
intubation should be performed.
• Transfer to a major tertiary pediatric institution is
best not delayed .
 Summary of Preoperative
Investigations
• A plain radiograph
• Renal ultrasonography and echocardiography
are routine preoperative investigations
• Endoscopy or a careful midesophageal contrast
study performed in a tertiary center. In some
centers, bronchoscopy is performed routinely in
all infants with esophageal atresia.
 Operative Repair of Esophageal
Atresia
• Surgical repair is delayed (1-2days) in
infants with low birth weight, pneumonia or
other major anomalies.
Operative Repair of Esophageal
Atresia
Operative Repair of Esophageal
Atresia
Tracheoesophageal fistula
without atresia (type E)

•  Respiratory difficulty
after feedings in a 3-day-
old boy. Barium
esophagogram clearly
shows an H-shaped
fistula between the
trachea and the middle
segment of the
esophagus (arrowhead).
Barium is filling the
bronchi of the right lower
lobe (arrows).
Tracheoesophageal fistula without
atresia (type E).
• Esophagogram
shows a fistula
(arrow) arising from
the anterior portion of
the esophagus (e)
and passing cephalad
to the posterior
portion of the trachea
(t).
Tracheoesophageal fistula without
atresia (type E).

• Endoscopic diagnosis
 Congenital
tracheoesophageal 
tracheoesophageal
fistula
Congenital diaphragmatic
hernia
 Incidence
• 1 : 2000-5000 live birth
• 8 % of all major congenital anomalies
• mortality rate nearing 70 percent
• CDH accounts > 1% of total infant
mortality in USA
 Causes
• The cause of CDH is largely unknown
• CDH can occur as part of a multiple
malformation syndrome in up to 40% of
infants (cardiovascular, genitourinary, and
gastrointestinal malformations)
• Karyotype abnormalities have been
reported in 4% of infants with CDH, and
CDH may be found in a variety of
chromosomal anomalies including trisomy
13, trisomy 18, and tetrasomy 12p
mosaicism
 Prenatal Diagnosis
• ultrasonography diagnosis (as early as the second
trimester)

Mediastinal shift
   Viscera herniation (stomach, intestines, liver*, kidneys, spleen and
gall bladder)             
   Abnormal position of certain viscera inside the abdomen
   Stomach visualization out of its usual position
   Intrauterine growth retardation*
   Polyhydramnios*
   Fetal hydrops*

* bad prognosis
Fetal diafragmatic hernia:
Ultrasound diagnosis
Prenatal MR Imaging - single-shot turbo spin-echo
(HASTE)- of congenital diaphragmatic hernia
Prenatal MR Imaging of congenital
diaphragmatic hernia
Pulmonary hypoplasia
Anatomopathology show of
CDH
 Prenatal Counseling
multidisciplinary team
• patient's obstetrician
• perinatologist
• geneticist
• surgeon
• social worker
 Prenatal management

• Glucocorticoids
• Thyrotropin-releasing hormone
• Fetal surgical therapy (Antenatal surgical intervention,
In utero tracheal occlusion )
 Delivery Room Management
• affected infants should be delivered in a center that has experienced
personnel and available therapies.
• the team in the delivery room consist of personnel experienced in the
immediate resuscitation and stabilization of critically ill neonates
• affected patients in any respiratory distress require positive pressure
ventilation in the delivery room.
• To prevent distension of the gastrointestinal tract and further
compression of the pulmonary parenchyma, a double-lumen
nasogastric or orogastric tube of large caliber is placed to act as a
vent.
• Early intubation is preferable ( bag-mask ventilation is
contraindicated) to continuous positive airway pressure via mask or
nasal prongs
 Postnanal Diagnosis
• Respiratory distress
• Scaphoid abdomen
• Auscultation of the lungs reveals poor air
entry
• Shift of the heart to the side opposite
 Lab Studies
• Arterial blood gas
– Obtain frequent arterial blood gas (ABG) measurements to assess
for pH, PaCO2, and PaO2.
– Note the sampling site because persistent pulmonary hypertension
(PPHN) with right-to-left ductal shunting often complicates CDH.
The PaO2 may be higher from a preductal (right-hand) sampling
site.
• Chromosome studies
– Obtain chromosome studies because of the frequent association
with chromosomal anomalies.
– In rare cases, chromosomal disorders that can only be diagnosed
by skin biopsy may be present. If dysmorphic features are observed
on examination, a consultation with a geneticist is often helpful.
• Serum electrolytes: Monitor serum electrolytes, ionized calcium,
and glucose levels initially and frequently. Maintenance of reference
range glucose levels and calcium homeostasis is particularly important
 Imaging Studies
• Cardiac ultrasonography
– Perform ultrasonographic studies to rule out congenital heart diseases.
– Because the incidence of associated cardiac anomalies is high (up to
25%), cardiac ultrasonography is needed to evaluate for associated
cardiac anomalies.

• Renal ultrasonography: A renal ultrasonographic examination

may be needed to rule out genitourinary anomalies.

• Cranial ultrasonography
– Perform cranial sonography if the infant is being considered for
extracorporeal support.
– Ultrasonographic examination should focus on evaluation of
intraventricular bleeding and peripheral areas of hemorrhage or infarct
or intracranial anomalies.
 Other Tests
Pulse oximetry
– Continuous pulse oximetry is valuable in the
diagnosis and management of PPHN.
– Place oximeter probes at preductal (right-
hand) and postductal (either foot) sites to
assess for a right-to-left shunt at the level of
the ductus arteriosus
 Postnanal Diagnosis left-sided CDH

• Radiograph in a male neonate shows the tip

(large arrow) of the nasogastric tube
positioned in the left hemithorax. Note the
marked apex leftward angulation of the
umbilical venous catheter (small arrow).
 Right congenital diaphragmatic
hernia

• Radiograph in a male neonate shows that the

nasogastric tube (arrow) deviates to the left of
the thoracic vertebral bodies as it passes
through the inferior portion of the thorax
 Procedures
• Intubation and mechanical ventilation
– Endotracheal intubation and mechanical ventilation are required
for all infants with severe CDH who present in the first hours of
life.
– Avoid bag-and-mask ventilation in the delivery room because
the stomach and intestines become distended with air and
further compromise pulmonary function.
– Avoid high peak inspiratory pressures and overdistension.
Consider high-frequency ventilation if high peak inspiratory
pressures are required.
• Arterial catheter placement: Place an indwelling catheter
in the umbilical artery or in a peripheral artery (radial,
posterior tibial) for frequent ABG monitoring.
• Central venous catheter placement
– Place a venous catheter via the umbilical or femoral vein to allow
for administration of inotropic agents and hypertonic solutions
such as calcium gluconate
 Postnatal management
• Mechanical ventilation
• Nitric Oxide
• Surfactant
• ECMO
• surgery
Operative approach
The defect in the diaphragm
Patch repair of a large defect
 Further Inpatient Care
• Pulmonary care
– Some severely affected infants have chronic lung disease. These
infants may require prolonged therapy with supplemental oxygen and
diuretics, an approach similar to that for bronchopulmonary dysplasia.
– The use of steroids, particularly high doses for prolonged periods, is
controversial and may actually hinder appropriate lung and brain
development.
• Neurologic evaluation
– Following recovery, a neurologist or developmental pediatrician should
examine the patient, including an evaluation for CNS injury by head
CT scanning.
– Because the incidence of hearing loss is high, perform an automated
hearing test prior to discharge.
• Feeding: Incidence of significant gastroesophageal reflux is very high.
While most infants can be managed medically, surgical intervention with
Nissen or Thal procedures is sometimes required.
 Further Outpatient Care
• Growth: Failure to thrive is common in a significant
percentage of survivors and is most common in severely
affected infants. Possible causes include increased caloric
requirements because of chronic lung disease, poor oral
feeding because of neurologic delays, and
gastroesophageal reflux.
• Developmental follow-up
– Because of the risk for CNS insult and sensorineural
hearing loss, infants should be closely monitored for
the first 3 years of life, preferably in a specialty follow-
up clinic.
– Reassess hearing at 6 months of life (and later if
indicated) because late sensorineural hearing loss
occurs in a high percentage of patients.
– Evaluate the patient prior to entering school to
determine if any subtle deficits may predispose the
patient to learning disabilities.
 Prognosis
• Pulmonary recovery: When all resources,
including ECMO, are provided, survival rates
range from 40-69%.
• Long-term morbidity: Significant long-term
morbidity, including
• chronic lung disease,
• growth failure,
• gastroesophageal reflux,
• neurodevelopmental delay, may occur in
survivors.
Foreign Body Aspiration
 Epidemiology
• Major cause of accidental death
• 17,000 ER visits (aspiration + ingestion) in
2000
• 1,500 die each year due to FB aspiration
• Majority < age 3
• Male > Female
 Aspiration in young children
• Lack of molar teeth
• Poorer mastication
• Tendency to put things in mouth
• Playing with things in mouth
• Immature protective laryngeal reflexes
Foreign body
 Symptoms and Physical
findings
• Cough
• Dyspnea
• Wheezing
• Stridor
• Cyanosis
• Decreased breath sounds
• Tachypnea
• Rhonchi
• Somnolence
Age Difference
 Distribution of FB in airway
• 70% Right main bronchus in adolescent &
adult
• Higher variability in young children
– Head/ body position
– Supine/ Prone position
• Carina usually positioned left of midline ;
Right of midline in 34 % children (Tahir N 2008)
Tahir N et al. 2009.
 Complications
• Mortality after bronchoscopy < 1%
• Bronchiectasis
• Pneumonia / bronchitis
• Subcutaneous Emphysema
• Pneumothorax / pneumomediastinum
• Granulation tissue and hemorrhage
• Cartilage destruction
• Airway compromise
• Death
 Diagnosis

• History
• Physical Exam
• Radiography
 History of choking

• Highly sensitive (> 90%) for aspiration

• Specificity: 45 – 76%
• Classic history:
– Choking episode followed by coughing spells
 Physical Exam
• Sensitivity: 24-86 %
• Specificity: 12-64 %
• Decreased unilateral breath sound
• Unilateral Wheezing
• Stridor
 Chest x-ray
• Normal in 20- 40 % of cases
• Most are radiolucent (food origin)
• Inspiratory/ expiratory film
• Air-trapping on expiration
• Atelectasis
• Infiltration
• Consolidation
Hyperinflation of Right lung
 Fluoroscopy
• Normal in 53 % of FB patients (Even L 2005)
• Sensitivity: 47%
• Specificity: 95%
• Mediastinal shift
• Paradoxical movement of the diaphragm
CT scan

• Hong SJ 2007
• Retrospective
• 42 patients
• Can visualize
radiolucent FBs
Hong SJ et al. 2008
 Rule of thumb
• Perform bronchoscopy if another one of
the following is positive:
– History
– PE
– Radiography
• Bronchoscopic evaluation is warranted on
the basis of a positive history alone
Digoy GP et al. 2008
 Medical management
• The role of beta-2 agonist remains unclear
• Alleviation of discomfort
• Expelling foreign body could be life
threatening
• Not a replacement for bronchoscopy
Age-appropriate Bronchoscope
Bronchoscopes
Optical forceps
 Anesthesia
• Availability of experienced Pediatric
anesthesiology team
• Daytime vs. night team
• If unstable, securing airway always a priority
over fasting guidelines
• Pulse oximetry
• Spray cords with 2% topical lidocaine to avoid
laryngeal spasm
• Ventilation via bronchoscope
 Fiberoptic bronchoscopy
• Useful when FB migrates to distal bronchi
• Introduced via endotracheal tube or LMA
 Role of Tracheotomy
• Incidence 0.5 -3 %
• Large FB in subglottic or proximal trachea
• Concomitent tracheotomy could be
performed if FB too big or sharp to pass
through glottic area
• Significant laryngeal edema
 Postoperative Care
• Admission / observation
• Clear liquid diet
• Chest x-ray
• Chest physiotherapy
• Antibiotics
– In cases of delayed diagnosis
 Summary
• A positive history of choking event followed by
coughing is an indication for bronchoscopic
evaluation
• Radiographic evaluation is helpful in localization
and identification of foreign body.
• Knowledge of age-appropriate instrument and
communication with surgical team are
paramount in the management of foreign body
aspiration
 Errors to Avoid in Suspected
Foreign Body Cases
• Do not reach for the foreign body with the
fingers.
 Errors to Avoid in Suspected
Foreign Body Cases
• Do not hold up the patient by the heels.
 Errors to Avoid in Suspected
Foreign Body Cases
• Do not fail to have a roentgenogram
made.
 Errors to Avoid in Suspected
Foreign Body Cases
• Do not fail to search endoscopically for a
foreign body in all cases of doubt.
 Errors to Avoid in Suspected
Foreign Body Cases
• Do not pass blindly an esophageal bougie
or other instrument.
 Errors to Avoid in Suspected
Foreign Body Cases
• Do not tell the patient he has no foreign
body until after X-Ray examination,
physical examination, indirect examination
and endoscopy have all proven negative.
 The following aphorisms afford
food for thought.
• Educate your eye and your fingers.
 The following aphorisms afford
food for thought.
• Be sure you are right, but not too sure.
 The following aphorisms afford
food for thought.
• Follow your judgment, never your impulse.
 The following aphorisms afford
food for thought.
• Cry over spilled milk enough to memorize
how you spilled it.
 The following aphorisms afford
food for thought.
• Let your left hand know what your right
hand does and how to do it.
 The following aphorisms afford
food for thought.
• Nature helps but she is no more interested
in the survival of your patient than in the
survival of the attacking pathogenic
bacteria.
Pulmonary air leak
syndrome
 Pulmonary air leak syndrome
When air escapes from the lung into extra alveolar
spaces where it is not normally present
Most common in newborn period.
-Iatrogenic pulmonary condition of the premature infant
with immature lungs (mechanical ventilation)
 Pulmonary air leak syndrome
Pulmonary Interstitial Emphysema
Pneumothorax
Pneumomediastinum
Pneumopericardium
Pneumoperitoneum
Subcutaneous Emphysema
 Pulmonary Interstitial Emphysema
• Collection of gases
outside the normal air
passages
• Escape of air into
pulmonary interstitium,
lymphatic and venous
circulation.
• Secondary to rupture
(usually junction of the
bronchiole and alveolar
duct)
 Pulmonary interstitial
emphysema Risk Factors
• Prematurity (< 32 weeks
GA)
• VLBW (< 1,000 g) •RDS
• Meconium aspiration
• Low Apgar score (< 5 )
syndrome
and need of resuscitation
•Amniotic fluid aspiration
• Positive pressure Infection
ventilation • Neonatal sepsis
• Use of ↑ ↑vT) Peak •Pneumonia
inspiratory pressure (PIP), • Pulmonary hypoplasia
Tidal volume ( vT ) & ↑
Inspiratory time (Ti)
 Pulmonary interstitial
emphysema Classification
Usually in the first 72 hrs of life :

• Acute ( less 7 days) or persistent

• Localized or diffused
• Unilateral or bilateral
 Pulmonary interstitial
emphysema Frequency

• Currently is uncommon because of post

natal surfactant, gentle ventilation and
high frequency ventilation.
Pulmonary interstitial emphysema
Pathophysiology
Mechanical ventilation with large tidal volume increases the
number of neutrophils and cytokines in the lungs and also the
permeability of the capillary membrane, leading to pulmonary
edema
 Pulmonary interstitial
emphysema Pathophysiology
 Recent studies have demonstrated
presence of free elastase and alpha 1
1-elastase-1- proteinase inhibitor as well
as elastase alpha 1 proteinase inhibitor in
tracheal aspirate of neonates with severe
RDS
 PIE infants appear to have free elastase
activity in tracheal aspirate fluid
Pulmonary interstitial emphysema
Diagnosis
• Mainly a radiographic and pathologic diagnosis
• Blood gas show
↑ PCO2 and ↓ PO2
• Increased respiratory support demand
• Increased lung volumes
 AP C-Xray :
• linear, oval or spherical cystic air-containing spaces (1
mm to1 cm)
• Pneumothorax
• Heart tends to get smaller
• ↑ intrathoracic pressure ….↑ lung volume
 Pulmonary interstitial
emphysema Differential Dx
 Bronchopulmonary dysplasia (BPD)
(lucency is less linear)
 Respiratory distress syndrome
 Congenital cystic adenomatoid
malformation (CCAM)
 Pulmonary interstitial
emphysema Complications
 Loss of pulmonary compliance
 Epitheliazation of the interstitial air
pockets
 Air embolus in pulmonary venous
circulation
 Rupture of subpleural lymphatic blebs
(pneumothorax)
 Pulmonary interstitial
emphysema Complications
BPD
 Rupture of bronchial connections and release of
air into the interstitium promotes edema and
oxidant injury Cochran et al, B J Radiol 1994.
 Highest risk for VLBW infant, low GA and PIE in
first 24 hrs of life. Gaylord et al, Pediatrics, 1985

 Increased risk for IVH in pneumothorax. Hill et al,

Pediatrics, 1982.
 Pulmonary interstitial
emphysema Treatment
 Localized
 Conservative management
 Decubitus position with affected side down
 Selective intubation of the main bronchus on the
uninvolved side (10 days O’Donovan Donovan 2001, 5 days
Khashu 2005)
 Lobectomy
 High frequency oscillatory ventilation (low
volumes of gas and low pressure) Nelle et al, Intensive
care med 1998.
Pulmonary air leak syndrome
• Pulmonary Interstitial Emphysema
• Pneumothorax
• Pneumomediastinum
• Pneumopericardium
• Pneumoperitoneum
• Subcutaneous Emphysema
 Pneumothorax
 Pneumothorax refers to the presence of
air or gas in the pleural cavity between the
visceral and parietal pleura, which results
in violation of the pleural space.

 There is a loss of intrapleural negative

pressure causing lung collapse.
 Pneumothorax
Pathophysiology
• The main physiologic consequences of a
pneumothorax are a decrease in vital
capacity and a decrease in PaO2

• In a simple pneumothorax, air in the pleural

space does not build up significant pressure
but allows the lung to collapse 10
30% without further expansion of the
pneumothorax.
Pneumothorax Pathophysiology
A complicated pneumothorax is progressive
and consists of continued air leakage into
the pleural space and progressive lung
collapse.
Tension pneumothorax is a life threatening
emergency It is caused when air enters
the pleural space during inspiration but
cannot exit during exhalation.
Pneumothorax Pathophysiology
• The positive pressure results in collapse of
the involved lung and a shift of the
mediastinal structures to the contralateral
side. This causes a decrease in cardiac
output as a consequence of decreased
venous return and leads to rapidly
progressive shock and death if not treated
 Pneumothorax Signs &
symptoms
• Increasing respiratory distress, including rapid
breathing, grunting, nostril flaring, and chest
wall retractions
• Difficulty hearing breath sounds when
listening with a stethoscope
• Change in the location of heart or lung sounds
when the organs are moved by the presence
of air
• Changes in arterial blood gas levels
(respiratory acidosis)
 Pneumothorax Dx diff
• Bronchogenic cyst
• Congenital lung malformation
• Cystic adenomatoid malformation
• Hemothorax
• Pleural effusion
 Pneumothorax Diagnosis
• A tension pneumothorax should always be
a clinical diagnosis since death can occur
before the radiograph is taken or
developed
 Pneumothorax Diagnosis
• When an infant is suspected of having a
pneumothorax, anterior posterior
radiographs are taken in the supine position.
Small pneumothoraces can be better
visualized with lateral decubitus film with the
affected side up.

• Transillumination of the chest may help to

establish the diagnosis in the newborn infant.
Pneumothorax
 Pneumothorax Treatment
• No specific management for asymptomatic
pneumothorax

• Infants with lung disease, the presence of

pneumothorax accentuates the respiratory
difficulty and requires intervention

• Full term with no mechanical ventilation: FIO2

100% in oxyhood up to 50 percent may
improve the resolution of small uncomplicated
pneumothorax
 Thoracentesis (needle aspiration)
Emergent treatment of a symptomatic
pneumothorax
• Localize site: 2nd -3rd intercostal space along
midclavicular line
• Cleanse the area
• 22/24 g angio attached to 20 ml syringe with a
stopcock
• Palpable 3rd rd rib at midclavicular line and insert
needle above the rib
• Advance needle till air is withdrawn in syringe
 Pneumothorax : chest tube
• Tension pneumothorax and pneumothorax
that develops in a mechanically ventilated
infant usually need chest tube placement
for definitive drainage.
 Equipment:
• Chest tube set up
• Sterile field
• < 2 Kg use 10 Fr catheter
• >2 Kg Use 12 Fr catheter
 Pneumothorax: chest tube
 Procedure
• Anterior placement (2nd -3rd intercostal space,
midclavicular line)
• Posterior placement (4th, 5th, 6th intercostal
space, anterior axillary line)
• NIPPLE LINE IS 4TH INTERCOSTAL
1. Position patient
2. Select site
3. Cleanse area / sterile field
4. Infiltrate area with 0.5%-1% lidocaine
 Pneumothorax: chest tube
5. Make small incision 1.5 cm in the skin over the
rib just below the intercostal space where tube is
to be inserted
6. Dissect tissue with hemostat.
7. Using tip of hemostat, puncture pleura just
above the rib
8. Insert chest tube through open hemostat
9. Attach to suction
10. Secure with sutures
11. Apply Vaseline
12. CXR
Pulmonary air leak syndrome
• Pulmonary Interstitial Emphysema
• Pneumothorax
• Pneumomediastinum
• Pneumopericardium
• Pneumoperitoneum
• Subcutaneous Emphysema
 Pneumomediastinum
• Pneumomediastinum consists of air in the
mediastinal space
• Most cases are asymptomatic.
• Large collections of air may result in tachypnea and
cyanosis
• Suspected on the routine newborn examination
when the heart sounds are distant.
• The diagnosis is made on a chest radiograph
• Usually resolves spontaneously, and requires no
specific treatment
• The patient should be observed closely for other air
leaks, especially pneumothorax.
Pneumomediastinum
Pulmonary air leak syndrome
• Pulmonary Interstitial Emphysema
• Pneumothorax
• Pneumomediastinum
• Pneumopericardium
• Pneumoperitoneum
• Subcutaneous Emphys
 Pneumopericardium
• Rare condition caused by air in the pericardial
space
• It can cause cardiac tamponade that is life
threatening.

• Typically occurs in a mechanically ventilated

preterm infant with severe RDS who also has
pneumothorax and/or PIE

• Rare in an infant who does not require mechanical

ventilation
 Pneumopericardium
Clinically:
• Abrupt onset of hemodynamic compromise due to
cardiac tamponade
• Tachycardia and a narrowed pulse pressure
• Follow by bradycardia, hypotension, increased
respiratory distress, and cyanosis
• The heart sounds may be muffled or distant
• The electrocardiogram may show low voltages with
a small QRS complex.
 Pneumopericardium
• Diagnosis is confirmed by chest radiograph
( gas shadow does not extend beyond the
reflection of the aorta and pulmonary artery)

• In life-threatening situations in which the

diagnosis is strongly suspected, the
diagnosis is made by a therapeutic
pericardiocentesis
Pneumopericardium
 Pneumopericardium
Management:
• Infants who are asymptomatic may not need
intervention (close monitoring)
• Ventilator pressures should be minimized
Pericardial drainage :
Symptomatic infants
This procedure is both diagnostic and
therapeutic
Pulmonary air leak syndrome
• Pulmonary Interstitial Emphysema
• Pneumothorax
• Pneumomediastinum
• Pneumopericardium
• Pneumoperitoneum
• Subcutaneous Emphysema
 Pneumoperitoneum
• Pneumoperitoneum and subcutaneous
emphysema are uncommon types of air leak
• Pneumoperitoneum may occur when
extrapulmonary air decompresses into the
peritoneal cavity
• The diagnosis is made on an abdominal
radiograph and usually has little clinical
significance
• It must be differentiated from intraperitoneal
air due to a perforated viscus
 Subcutaneous Emphysema
• Subcutaneous emphysema typically occurs
in the face, neck, or supraclavicular region. It
typically presents as crepitus detected by
palpation. It usually has no clinical
significance, although large air collections in
the neck may cause tracheal compromise
Airway/Respiratory
• Neck Masses
– Cystic Hygromas
– Tracheal anomalies
• Thoracic masses/pulmonary lesions
– Congenital lobar emphysema
• Overdistension of one or more lobes
– Congenital cystic adenomatous
malformation(CCAM)
• Multicystic mass of lung tissue, proliferation of
bronchial structures at the expense of alveoli
– Pulmonary agenesis
• Absence of lung
 Cystic Hygroma
• Multiloculated cystic spaces lined by
endothelial cells
– Separated by fine walls containing numerous smooth
muscle cells
– Result of maldevelopment of lymphatic spaces
• Incidence about 1 in 12,000 births
– 50-65% appear at birth, 85-90% appear by age 2
– Neck-75%, Axilla 20%; can be seen in mediastinum,
retroperitoneum, pelvis, groin
– Nuchal/post cervical CH’s have been associated with
chromosomal abnormalities—high mortality rate
Cystic Hygroma
 Cystic Hygroma
• Complications
– Respiratory—large hygromas can extend into oropharynx
and trachea
– Inflammation/Infection
– Hemorrhage
• Treatment
– Dependent on size, location, symptoms/complications
– Some pts require emergent surgery due to airway
compromise
– Best treatment is complete excision
– Aspiration typically not effective due to rapid refilling of fluid
– Sclerotherapy—Bleomycin, OK-432 (no longer available in
US), doxycycline, fibrin glue
Cystic Hygroma
 Congenital Lobar Emphysema
• Postnatal overdistension of one or more
lobes of histologically normal lung
– Probably due to cartilaginous deficiency in the
tracheobronchial tree
– Obstruction causing the overdistension may be due to
• 1—chondromalacia of bronchi
• 2—extrinsic pressure on bronchus by anomalous pulmonary
vein or abnormally large PDA
• 3—idiopathic
• Location
– LUL 47%, RML 28%, RUL 20%; lower lobes <5%; Bilat
rare
Congenital Lobar Emphysema
 Congenital Lobar Emphysema
• Diagnosis
– Usually can be made by plain CXR; Chest CT and
V/P scans may be helpful
• Treatment
– May require urgent surgical decompression with
lobectomy
– Selective bronchial intubation
– Sometimes see spontaneous resolution—need close
observation
 Congenital Cystic Adenomatous
Malformation (CCAM)
• Mass of cysts lined by ciliated cuboidal or columnar
pseudostratified epithelium
• Three types
– I—few large cysts >2cm; thick walls, normal alveoli
between the cysts; ciliated pseudostratified columnar
epithelium
– II—numerous small cysts <1cm, thin muscular coat, large
alveolar-like structures between the cysts; ciliated cuboidal
to columnar epithelium; assoc w/other congenital anomalies
– III—bulky firm masses of folded ciliated and non-ciliated
cuboidal epithelium and thick layer of smooth muscle; often
occupy the entire lobe or lobes of lung
 Congenital Cystic Adenomatous
Malformation (CCAM)
• More common on the left side, 2% bilateral
• Diagnosis
– CT scan allows differentiation of types
– Some can be diagnosed on prenatal US

• Treatment
– Surgical excision, typically anatomical lobe resection,
due to risk of infection, malignant transformation
– Some are performing fetal aspiration
Congenital Cystic Adenomatous
Malformation (CCAM)
Thanks…….