UPPER AIRWAY OBSTRUCTION

Generally indicate stridor ( highpitched,crowing noise typically heard on inspiration) Pattern of stridor helps to localize the lesion: Insp: at / above vocal cords & due to collapse of the soft tissues wth ve pressure during insp Exp: due to decrease airway caliber wth expiration & emanates frm intrathoracic trachea& bronchi Biphasic: on insp & exp,indicate unchanging airway caliber due to fixed lesion, related to edema &near cricoid cartilage tht encircles trachea

Causes of stridor:
Neonate: Coanal atresia Birth-related septal deviation Congenital nasopharyngeal tumour Mandibular hypoplasia Oropharyngeal web Thymic cyst Infants: Laryngomalacia Vocal cord paralysis Croup (acute laryngotracheobronchitis) Acute epiglotitis Acute spasmodic laryngitis Foreign body

Croup: 3mths-6yrs, peak incidence 1-2yrs Male>female 15% of pts hv a family hx Cause: parainfluenza (type1,2,3) virus (74%), RSV, influenza virus, adenovirus, enterovirus, measles, mumps and rhinoviruses Rarely: mycoplasma pneu & corynebacterium diptheria

Viral invasion of laryngeal, tracheal & bronchial mucosa leads to inflam hyperemia, edema, epithelial necrosis & shedding of ths region

Irritation (cough), airway obstruction due to subglottic narrowing (biphasic stridor), collapse supraglottic region (insp stridor) & resp distress

 CF: LG fever & prodrome cough &coryza for 12-72hrs-followed by increasing bark-like cough & hoarseness Stridor- whn excited, at rest / both Resp distress of varying degree Complication: otitis media, sec bac tracheitis, pneu, resp failure Dx: clinical dx, virus can b isolated frm nasopharyngeal secretions, neck x-ray-to xclude foreign body

Assessment of severity: Mild: excitement /at rest ,no resp distress Mod:at rest + IC,SC or sternal recession Severe:at rest + marked recession, decreased air entry &altered level of consciousness Indication for hosp admission: Mod & severe viral croup Toxic looking Poor oral intake Age<6mths Unreliable caregiver at home Family living far from hosp

 Mild outpt: Dexa: Oral 1st choice / parenteral 0.15kg/single dose Rpt 12-24hrs Prednisolone: 1-2mg/kg/stat / if vomiting Nebulised budesonide:2mg single dose Improve home Mod-inpt: Dexa:oral/parenteral 0.3-0.6mg/kg single dose & /or Nebulised budesonide:2mg stat & 1mg BD Improvement-home No improvement/deteriorate nebulised adrenaline If still no improvement/deteriorate-intubate&ventilate

Severe- inpt: nebulised adrenaline:0.5mg/kg 1:1000 & Dexa: parenteral 0.3-0.6mg/kg Nebulised budesonide: 0.2g stat, 1mg 12hrly & oxygen No improvement/deteriorate- intubate &ventilate Indication for O2 tx: severe viral croup, Percutaneous Sa O2 <93% a/b-not recommended unless bac super-infec/pts vry ill IVD not usually necessary xcept for those unable to drink

Acute epiglottitis
2-6yrs, male >female (3:2) Cause: haemophilus influenzae type b Presents as acute, rapidly progressive cellulitis of epiglottitis & hypopharynx + inflammatory swelling & risk of complete airway obstruction CF: acute onset, HG fever, painful throat-prevents child frm speaking /swallowing- drooling of saliva

 Soft insp stridor- rapidly increasing resp difficulty over hrs Sits immobile, upright (hyperextended neck) with an open mouth to optimise airway Cough-minimal / absent 5Ds- drooling- dysphagia- dysphoniadyspnea-distress Oral ex wth spatula/ lat neck x-ray/ procedures-minimized-can precipitate total airway obstruction & death Dx: direct laryngoscopy

 Mx: urgent hosp admission Prompt mx of airway- tracheostomy (can be removed after 24hrs) Blood taken for culture IV a/b- 2nd/3rd gen cephalosporin (ceftriaxone/cefotaxime)- given for 3-5days Usually recover wth tx within 2-3days Vaccination: Hib immunisation- decrease 99% of the incidence in UK

Laryngomalacia
due to insp collapse of laryngeal cartilage Males > females Appears in 1st month of life- usually resolves by 1-2 yrs of age CF: insp stridor, loudest whn feeding, quietly relaxing, supine / neck flexion position, Diminishes during sleeping / when child is crying Viral infection exacerbate laryngomalacia May be associated with tracheomalacia

 Dx : direct laryngoscopy MX: no tx unless hypoxia /growth failureresulting airway obstruction-require tracheostomy/ epiglottoplasty

Vocal cord paralysis:

Usually due to CNS lesions (eg: Arnold-Chiari malformation, raised IC pressure, other brainstem insults) Or traction on recurrent laryngeal nerve (often a birth complication) Small cricoid cartilage Acquired subglottic stenosis- complication of intubation Subglottic and laryngeal cysts Webs Tracheal rings Subglottic hemangioma

Acute spasmodic laryngitis Acute infectious laryngitis bac tracheitis Complication of airway obstruction consequent to recent viral infec Cause: staph aureus, moraxella catarrhalis, strep pneu, h.influ CF: stridor, barking cough, no fever, hoarseness

Foreign Body Whn symtoms do not resolve according to expectations X-ray: radiopaque object Mx: endoscopic removal