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Upper airway obstruction in pediatric

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1 Upper airway obstruction in pediatric
patients from anesthesiologist vew Prof. Mirjana Shosholcheva University clinic of surgery “St. Naum Ohridski” Medical faculty-Skopje, Macedonia One of the most challenging clinical situations mandating nursing skills is assessment, rapid diagnosis and management of the acute airway obstruction in children. Although many airway disorders exist, obstruction of the upper airway is the most potentially life-threatening situation. The main goal is to prevent cardiac arrest or irreversible brain damage that occurs within minutes of complete airway obstruction. Good outcome can be ensured by appropriate management with implementation of preventive aspects of airway obstruction and training in basic life support techniques, as this situation requires an immediate, aggressive response.

2 Disclosures No financial disclosures No conflict of interest

3 Key points Causes of airway obstruction in children
Signs of airway obstruction Airway obstruction with foreign body Airway obstruction during emergence from anaesthesia Management of laryngospasm Securing the airway in a child with airway obstruction

4 Epidemiology and mortality
Upper airway obstruction accounts for up to 15% pediatric emergency* The major causes are: Viral croup (80%)** Epiglotitis (5%) Foreign body aspiration Failure to manage the airway is the leading cause of preventable pediatric deaths Infants and children decompensate more quickly compared to adults Narrowing of the upper respiratory tract has an exponential effect on airflow because linear airflow is a function of the fourth power of the radius (Hagen-Poisell equitation). Although UAO occurs at any level of the upper respiratory tract, laryngeal obstruction has a particular importance because larynx is the narrowest portion of the upper airway. The narrowest portion of the larynx is at the glottis in adults and the subglottis in infants * Loftis L. Emergent evaluation of acute upper airway obstruction in children. Reprint from Up to date ** Manno M. Pediatric respiratory emergencies: Upper airway obstruction and infections. In: Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice . 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 166

5 Important causes of airway obstruction in children
Life-threatening emergency Laryngospasm after tracheal extubation –major of UAO after surgery Depressed conscious level Congenital anomalies Post-extubation laryngospasm Anaphylactoid reactions Rapidly progressive Airway obstruction Infections Many of the infectious causes of upper airway obstruction have lost their threat today as a result of the progress made in preventing and treating these infections. Infections: Viral tracheobronchitis (croup); infectious mononucleosis | Bacterial: epiglottitis, tracheitis, tonsillitis, retropharyngeal, peritonsilar abscess Foreign bodies: airway foreign body, esophageal foreign body Trauma: blunt and penetrating injury Congenital anomalies: choanal atresia, micrognathia, macroglossia, hereditary angioedema Acute upper airway obstruction from any cause can be a life-threatening emergency in the pediatric patient and unless promptly diagnosed and appropriately managed, complete obstruction will result in respiratory failure followed by cardiac arrest in a matter of minutes. Thermal injury Airway foreign body Trauma *Morton NS. Large airway obstruction in children: causes, assessment and management. Update Anaesthesia 2004; 18 (article 13):1

6 Signs of airway obstruction in children
conscious patient unconscious or sedated patient marked respiratory distress altered voice dysphagia the hand-to-the-throat choking sign stridor, facial swelling prominence of neck veins absence of air entry into the chest tachycardia inability to ventilate with a bag-valve mask asphyxia progresses to cyanosis bradycardia hypotension irreversible cardiovascular collapse A quick evaluation considering age group, history, physical examination, and clinical circumstances helps determine the site and cause of obstruction, the severity of the obstruction, and the need to establish an airway urgently Stridor is heard during the entire respiratory cycle but typically intensifies during inspiration and is usually more prominent above the neck. The presence of stridor indicates severe airway obstruction, (airway passage <5 mm) but unfortunately does not help to specify its nature or location. Obstructive noise or stridor is specific for UAO

7 Specifics regarding signs of airway obstruction in children
Mild upper airway obstruction child recovering from anaesthesia tonsillar hypertrophy and obstructive sleep apnea Signs of partial upper airway obstruction include biphasic snoring and mild desaturation Severe, non-complete, progressive airway obstruction increased work of breathing respiratory failure Hypoxemia cardiac arrest Children with severe croup, tracheitis, epiglottitis, airway burns Trauma, depending on its severity and location, may produce immediate or progressive obstruction

8 Signs of increased work of breathing
Tachypnea Paradoxical respiration “See-saw” pattern of breathing (dyssynchrony between rib cage and abdomen) Suprasternal, intercostal, and subcostal retraction along with an increased use of accessory muscles of respiration auto CPAP Position: Infants may assume an opisthotonic position; the "tripod" or sniffing position is seen in the older child

9 Stridor Inspiratory stridor Expiratory stridor
airway compromise at the supraglotic or laryngeal level Stridor: inspiratory stridor indicates airway compromise at the supraglotic or laryngeal level, while expiratory stridor is indicative of intrathoracic obstruction. It is very important to be noticed that the magnitude or severity of stridor does not correlate with the severity of obstruction intrathoracic obstruction The magnitude or severity of stridor does not correlate with the severity of obstruction

10 Signs of ineffective breathing and respiratory failure:
Cyanosis Altered consciousness Bradypnea, apneic spelss Silent chest in spite of vigorous effort Post-extubation laryngospasm, angiooedema and anaphylactoid reactions Compleet airway obstruction Compleet airway obstruction is signaled by gagging, choking. absent breath sounds and aphonia in the case of large foreign bodu aspiration. this rapidly progresses to cyanosis, bardycardia and cardiac arrest. Complete airway obstruction in the abscense of foreign body aspiration is seen in post-extubation laryngospasm, angiooedema and anaphylactoid reactions Choking, absent breath sounds and aphonia This rapidly progresses to cyanosis, bardycardia and cardiac arrest

11 Airway obstruction with foreign body
Foreign-body aspiration is a relatively frequent accident and a leading cause of accidental death in children under 5 years of age Diagnosis of foreign body aspiration should be suspected in children who do not respond to appropriate intervention Laryngeal impaction is life-threatening (large or sharperdged foreign bodies may lodge in the larynx) Most foreign bodies pass the vocal cords and lodge in the lower airways (bronchi -80%) Symptoms can mimic other diseases such as croup or asthma

12 Airway obstruction with foreign body
Nasal foreign bodies unilateral rhinorrhea and stinking breath Oropharyngeal foreign bodies : mouth breathing Children with a history of choking and subsequent symptoms must be referred to immediate bronchoscopy! A diagnosis of foreign-body aspiration should also be considered whenever a child exhibits unexplained symptoms that are refractory to medical treatment and are consistent with airway obstruction What about the child who has stridor and wheezing? The causes of stridor and wheezing in older infants and children include foreign bodies in the airway and in the esophagus and combination of infectious causes

13 Management of airway obstruction with foreign body
*if the child can cough and verbalized it is placed in the position of comfort and oxygen is given IV line placement and other interventions which may agitate the child in this case are avoided X-ray evaluation for localization can be performed urgently in stable children The presence of asphyxia indicates the need for immediate resuscitation and securing the airway *Schmidt H., Manegold BC. Foreign body aspiration in children. Surg Endosc 2000; 14:644-8

14 1. Mild oedema of the respiratory mucosa
“Circulus viciosus” BLS maneuvers (Heimlich, Guidel ) Most patients can be discharged within 24 h direct laryngoscopy Magill forceps or suction Complications 1. Mild oedema of the respiratory mucosa 2. Tracheobronchitis 3. granulation tissue flexible bronchoscopy When BLS maneuvers are not successful, direct laryngoscopy should be performed. In some cases the foreign body may be removed with a Magill forceps or suction when it is above the vocal cords. Extraction with rigid bronchoscopy is usually performed in the most cases for suspected or confirmed obstruction with foreign body. Prior evaluation by flexible bronchoscopy might be justified in unclear cases but provisions should be made to provide immediate rigid bronchoscopic management. Complications after successful foreign-body removal are rare. Inflammatory responses, such as mild oedema of the respiratory mucosa, tracheobronchitis or granulation tissue resolve without sequelae. Routine use of steroids or antibiotics is not indicated. Most patients can be discharged within 24 h. Repeat bronchoscopy may be indicated if there is uncertainty about complete removal. A short course of corticosteroids may be helpful before repeat bronchoscopy in cases where mucosal swelling does not allow complete visualisation of the lower airways. Potential complications, such as bronchial stenosis, bronchiectasis, abscess formation or perforation are more likely to occur the longer the foreign body remains in the airways. short course of corticosteroids Repeat bronchoscopy rigid bronchoscopy

15 The foreign body is withdrawn by a forceps through the bronchoscope
Child is in respiratory distress! inhalational induction with 100% oxygen and sevoflurane After loosing the consciousness. i.v. cannula TIVA with propofol and fentanyl gentle assistance with inhalational technique cords are sprayed with local anaesthetic rigid bronchoscope with a ventilating side arm is inserted, facilitated by laryngoscopy When the child is in respiratory distress, inhalational induction with 100% oxygen and sevoflurane is given. After loosing the consciousness. i.v. cannula is introduced. TIVA using propofol and fentanyl is administrated: the child may become apneic after induction if the work of breathing was severely increased. Children may require gentle assistance even with inhalational technique. The cord are sprayed with local anaesthetic and a rigid bronchoscope with a ventilating side arm is inserted, facilitated by laryngoscopy. Desaturation may occur as “the clean” lung is excluded from ventilation and higher FiO2 may be required. High ventilating pressures are not recommended, as the foreign body, if partially mobile, might be displaced into a distal airway and than retrieval might be more difficult. Dexamethadone is administrated to reduce edema and stridor. The foreign body is withdrawn by a forceps through the bronchoscope. Laryngeal edema might be worsen after multiple insertions of the rigid bronchoscope, and post-procedure reintubation might be required. higher FiO2 The foreign body is withdrawn by a forceps through the bronchoscope Dexamethadone Laryngeal edema might be worsening after multiple insertions of the rigid bronchoscope, and post-procedure reintubation might be required

16 Securing the airway in a child with airway obstruction – General considerations
Laryngoscopy and intubation volatile anaesthetics Sevoflurane might be choice, but its use has some controversy, because lower potency of sevoflurane may not permit intubation The Jackson-Rees modification of Ayer,s “T piece” circuit - CPAP For the intubation, volatile anaesthetics are used. Sevoflurane might be choice, but its use has some controversy, because lower potency of sevoflurane may not permit intubation. In many centers halothan in 100 oxygen is still very frequent choice. The concentration is increased by 0.5% every 10 breaths, gradually increasing the concentration up to 5%. Attempts to assist ventilation against complete obstruction are usually futile! Alveolar ventilation in these children is severely compromised. Uptake of volatile agents is very slow and induction of anaesthesia may take more than 15 min

17 Any attempt at “asynchronous” assistance leads to complete obstruction, especially in large foreign bodies “Synchronized” assistance (analogous to triggered ventilation) is very helpful to maintain oxygenation

18 intubation is difficult or impossible
As the depth of anaesthesia increases, the child may be gradually lowered to the supine position flexible fiberoptic bronchoscopy intubation is difficult or impossible If the condition of the child deteriorates, cricothyrotomy and ventilation through a T piece circuit can be considered Jet ventilation is not appropriate as it may lead to barotrauma

19 The safest option is emergent tracheostomy under musk anaesthesia for most children who cannot be intubated in one or two attempts

20 Controversy associated with heliox therapy in UAO
Heliox has been used in several conditions: postextubation laryngeal edema, tracheal stenosis or extrinsic compression, status asthmaticus and angioedema To be effective, the helium–oxygen ratio must be at least 70:30 Although the work of breathing and dyspnea improves to some degree with the use of heliox, the mechanical obstruction is still in place The use of heliox in patients with severe UAO should only be used to provide temporary support pending definitive diagnosis and management

21 Algorithm for management of upper airway obstruction

22 Infective causes of airway obstruction
acute clinical syndrome of hoarse voice, barking cough and stridor Today many of the Infective causes of airway obstruction have lost their threat as a result of the progress made in preventing and treating these infections. Prompt recognition and appropriate management of the child presenting with upper airway obstruction due to the infective causes remains critical, because certain causes can progress rapidly from a mild to a potentially lifethreatening disease state Radiological presentation of subglottic oedema in viral croup (left) compared with a normal trachea (right) Endoscopic view of subglottic oedema in viral croup There is some controversy regarding treatment with epinephrine Usually affects children from 6 months to 4 years of age, with a peak incidence at 2 years of age

23 Epiglotitis Controversy! To look or not to look
Epiglottitis is a serious, life-threatening infection and an airway emergency. It is characterised by acute inflammatory oedema and hyperaemia involving the supraglottic structures, above the epiglottis itself and the aryepiglottic folds. Supraglottitis is a more appropriate description Also, controversy exists regarding management of the epiglottitis although the incidence of this disease has decreased dramatically. To look or not to look, visualization of the epiglottitis in a child with acute stridor and in whom the diagnosis of epiglottitis is not usually advocated. However the presence of anesthesiologist provides reliable approach in this case. Schematic (left) and endoscopic view (right) of epiglottitis. Lateral neck radiographs of a normal child (left) and a child with epiglottitis with the typical thumb sign (right). Conversely, epinephrine is not effective in the treatment of epiglottitis and may be deleterious. Controversy! To look or not to look

24 Airway burns Heat produces an immediate injury to the airway mucosa  edema Suspect for inhalation injury Exposure in an enclosed space Decreased level of consciousness, confusion Soot in mouth, nares Carbonaceous sputum Airway burns often progress rapidly to acute upper airway obstruction, but still allow time for the child to be intubated under anaesthesia. Swelling, ulceration of oral mucosa or tongue Dyspnoea Increased work of breathing Hoarseness Oxygen saturations <94% in air Caboxyhaemoglobin >5% on co-oximetry Stridor, wheeze, crepitations

25 Effect of deep face burns on airway maintenance are:
Airway obstruction by intraoral and laryngeal edema Anatomic distortion by face and neck edema, which increases the difficulty of endotracheal intubation Oral edema decreasing clearance of intraoral secretion Impaired protection of the airway from aspiration Maintaining an adequate airway! There is insufficient data to support a treatment standard or a treatment guideline for the diagnosis of inhalation injury. However, maintaining an adequate airway is essential for successful early management. There are four standard criteria (the four P’s) for the need for endotracheal intubation A judgment decision must be made in the initial assessment as to whether the airway can be managed safely without an endotracheal tube. When in doubt, it is safer to intubate, as airway burns often progress rapidly to acute upper airway obstruction, but still allow time for the child to be intubated under anaesthesia Maintain airway patency Protect against aspiration Pulmonary toilet to decrease mucous plugging and infection risks Need for positive-pressure When in doubt, it is safer to intubate!

26 Endotracheal tube complications
TRAUMATIC LESIONS Damage from endotracheal intubation and tracheotomy Even the dictum that ‘cuffed endotracheal tubes should not be used in children under the age of 8 years’ can no longer be maintained since the development of high-volume, low-pressure cuffs* Endotracheal tube complications incorrect size, traumatic or multiple intubations up and down movements of the endotracheal tube inadequate analgesia and sedation, whereby the infants struggle while intubated Complications and damage of the upper airway may occur during the endotracheal intubation as so as when longterm endotracheal intubation was introduced for pediatrics requiring prolonged ventilator support. Acquired subglottic stenosis is problem that can be resolved with experience of choosing appropriately sized tubes thus preventing tube trauma and particular care of the intubated patient *Newth CJL, Rachman B, Patel N, Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004; in press

27 Cuff vs Uncuffed Endotracheal Tube
Controversial issue Traditionally, uncuffed ETT recommended in children < 8 yrs old to avoid post-extubation stridor and subglottic stenosis Arguments against cuffed ETT: smaller size increases airway resistance, increase work of breathing, poorly designed for pediatric patients, need to keep cuff pressure < 25 cm H2O Arguments against uncuffed ETT: more tube changes for long-term intubation, leak of anesthetic agent into environment, require more fresh gas flow > 2L/min, higher risk for aspiration -

28 Concluding Recommendations
- For “short” cases when ETT size >4.0, choice of cuff vs uncuffed probably does not matter Cuffed ETT preferable in cases of: high risk of aspiration (ie. Bowel obstruction), low lung compliance (ie. ARDS, pneumoperitoneum, CO2 insufflation of the thorax, CABG), precise control of ventilation and pCO2 (ie. increased intracranial pressure, single ventricle physiology) Golden, S. “Cuffed vs. Uncuffed Endotracheal tubes in children: A review” Society for Pediatric Anesthesia. Winter 2005 edition.

29 Laryngeal Mask Airway – WHEN?
Supraglottic airway device Flexible bronchoscopy, radiotherapy, radiologic procedures, urologic, orthopedic, ENT and ophthalmologic cases are most common pediatric indications for LMA Useful in difficult airway situations, and as a conduit of drug administration (ie. Surfactant) Different types of LMAs: Classic LMA, Flexible LMA, ProSeal LMA, Intubating LMA Disadvantages: Laryngospasm, aspiration

30 Concern:light plane of anesthesia!
Airway obstruction during emergence from anaesthesia Postoperative laryngospasm - life-threatening complication aspiration, airway obstruction Tracheal extubation awake deep anesthesia Concern:light plane of anesthesia! Tracheal extubation can be performed while pediatric patients are awake or under deep anesthesia. Both techniques have their pros and cons. A small number of studies involving children show a greater incidence of upper airway complications with awake extubation as a result of increased airway reactivity. However, the endpoint for wakefulness in these studies was taken as swallowing; the incidence of respiratory complications dramatically decreased when extubation was performed when eyes were open, with spontaneous ventilation. Extubation under deep anaesthesia decreases cardiovascular stimulation and reduces the incidence of coughing and straining on the tube. Laryngospasm is most frequently caused by local irritation by blood or saliva and is likely to occur during light planes of anaesthesia, when the children are neither able to prevent this reflex nor generate an adequate cough. The incidence can be reduced if they are left undisturbed in the lateral recovery position until they wake up. local irritation by blood or saliva light planes of anaesthesia Child undisturbed - in the lateral recovery position Hypoventilation Hypoxemia Hypercarbia Cardiac dysrhythmias Cardiac arrest

31 Emergence and extubation: A systemic approach
Can this patient be extubated while deeply anesthetized? Yes No No rezidual NMB Easy musk ventilation Easily intubated Not at increased risk for regurgitation/aspiration - Normothermic Difficult musk ventilation Difficult intubation Residual NMB present Full stomach Can this patient be extubated immediately following surgery and emergence from general anesthesia?

32 Can this patient be extubated immediately following
surgery and emergence from general anesthesia? Yes No Awake Following commands Breathing spontaneuosly Wheel oxigenated Not excessively hyperbaric (PaCo2  50 mmHg Fully recovered from MR Sustained head lift Strong hand grip Strong tongue protrusion - Hypoxic (O2 saturation < 90 mmHg) - Excessively hyperbaric(Pa CO2 >50mm Hg - Hypothermic (< 34 C) - NMB present

33 complete laryngospasm
Partial laryngospasm complete laryngospasm inspiratory stridor absence of air movement Tracheal tug and paradoxical (“see-saw”) movement of the abdomen Increased airway problems children with a history of a recent upper respiratory tract infection former premature infants children with chronic, obstructive sleep apnea Anesthesiologists should anticipate increased airway problems in three groups of children:

34 Managament of laryngospasm
jaw thrust maneuver, neck extension and mouth opening mild biphasic snoring-noisy breathing placing the child in the “safe” position The presence of secretions in the oropharynx may be responsible for these complications. However, data have not shown that extubating the trachea when the patient is fully awake leads to decreased hypoxemia compared to tracheal extubation while deeply anesthetized oxygen by face mask positive pressure with a bag and face mask may be required along with a naso-pharyngeal airway If necessary a dose of succinylcholine followed by tracheal re-intubation (in children older than 2 years!!!)

35  Of particular concern have been the instances of life-threatening malignant hyperpyrexia and reports of rare, but often fatal, hyperkalaemic cardiac arrests in young boys with undiagnosed muscular dystrophy. As a result of these reports, in 1994, the US Food and Drug Administration (FDA) recommended that ‘the use of succinylcholine in children should be reserved for emergency intubation and instances where immediate securing of the airway is necessary, e.g. laryngospasm, difficult airway, full stomach, or for i.m. use when a suitable vein is inaccessible’. Since the publication of this recommendation, the use of succinylcholine in routine anaesthesia in children has been declined.

This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of the drug in healthy appearing children (usually, but not exclusively, males, and most frequently 8 years of age or younger). There have also been reports in adolescents.

37 Recent concerns about the elective use of succinylcholine in pediatric patients have focused on the occasional reports of hyperkalemic cardiac arrest, particularly in children with undiagnosed Duchenne muscular dystrophy. The incidence of Duchenne muscular dystrophy is only 1 in 3000 to 8000 male children. The revised labeling continues to permit the use of succinylcholine for emergency control of the airway and treatment of laryngospasm. Succinylcholine is the only neuromuscular blocking agent currently available that has been demonstrated to be effective after intramuscular (IM) administration when emergency control of the airway is required and there is no IV access. In this circumstance, the dosage must be increased to 4 to 5 mg/kg IM. Atropine is administered simultaneously. Following IM succinylcholine, onset of neuromuscular blockade takes approximately 2 to 5 minutes; the response in patients who are hypotensive or hypovolemic is unpredictable. 

38 In the Proposed Approach to the management of
laryngospasm first of all is to think of: Airway irritation/obstruction Blood/secretions Light anaesthesia Regurgitation

39 The main aim is to rapidly oxygenate child!
100% oxygen (warm, humidified, oxygen enriched air mixture in neonates) Visualize and clear pharynx/airway Jaw thrust with bilateral digital pressure behind temporomandibular joint, oral/nasal airway Deepen anaesthesia with propofol (20% induction dose) Succinylcholine 0.5 mg/kg to relieve laryngospasm ( mg/kg i.v. or 4.0 mg/kg i.m. for intubation Be aware of use in children < 2 years old!!! Intubate and ventilate

40 Airway obstruction in the postoperative period
post-intubation croup Laryngeal edema - in neonates and infants = inspiratory stridor within 6 h of extubation (Subglottic edema of 1 mm in neonates can reduce the laryngeal lumen by 35%) - Supraglottic oedema - Retroarytenoidal oedema - Subglottic oedema Associated risk factors The incidence seems to be decreasing as anesthesiologists have started to use smaller tracheal tubes and ensuring there is an air leak below cms water pressure However there are no enough evidences that cuffed tracheal tubes that have been used in small children increased incidence of croup. Perhaps the wider use of steroids during adeno-tonsillectomies, one of the pediatric operations with greater risk, may be a factor in the decrease in postintubation croup tight fitting tube trauma at intubation duration of intubation >1 h coughing on the tube change of head and neck position during surgery

41 Management of laryngeal edema
warm, humidified, oxygen enriched air mixture nebulized epinephrine 1:1000 (0.5 ml kg−1 up to 5 ml) dexamethasone 0.25 mg kg−1 followed by 0.1 mg kg−1 six hourly for 24 h reintubation with a smaller tube in severe cases

42 Conclusion ● Upper airway obstruction (UAO) is a life-threatening emergency that requires prompt diagnosis and treatment ● Severe UAO can be surprisingly asymptomatic at rest if it develops gradually. Sudden clinical deterioration is unpredictable ● Patients with possible UAO must never be sedated until the airway is secured. Minimal sedation may precipitate acute respiratory failure ● Achievement of airway patency in total airway obstruction and reestablishment of ventillatory airflow is the first and foremost goal of the anaesthesiologists

43 Conclusion ● Critical care physicians must be aware that pharmacologic interventions (epinephrine, steroids, and heliox) provide temporary support but cannot significantly improve mechanical UAO ● Bronchoscopy constitutes the most accurate diagnostic tool and frequently provides the best way to correct UAO ● Cricothyroidotomy is the surgical intervention of choice to reestablish airflow when medical interventions have failed

44 Conclusion If the anaesthesiologist is competent in the full range of airway access procedures and when appropriately management is performed, the possibility of incidence and consequences of acute airway obstruction in children will be very low

45 Thank you

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