-------------------------------------------------------------------------------- TITLE: THE MANAGEMENT OF ACUTE UPPER AIRWAY OBSTRUCTION SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: July 12, 1994 FACULTY: RONALD W. DESKIN, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Infection in the Pediatric Airway A. Location 1. Supraglottic 2. Subglottic 3. Tracheitis B. Why Are Symptoms So Severe? 1. Size of the airway 2. Loose submucosa 3. Rigid subglottic i.e., 1mm of swelling equals 35% decrease in circumference II. History A. Onset 1. How presented? 2. Duration? 3. Progressive? 4. History of foreign body? B. Associated Illness 1. URI 2. Cough 3. Medications C. Allergy 1. Penicillin 2. Asthma 3. Other meds D. Associated Symptoms 1. Cough 2. Hoarseness, muffled voice 3. Sputum 4. Cyanosis 5. Vomiting 6. Drooling 7. Fever 8. Dysphagia, throat pain E. Time and Nature of Last Oral Intake F. Family History G. Other Conditions/Respiratory, Cardiovascular, Neurologic III. Physical Examination A. Cyanosis B. Position C. Anxiety D. Drooling E. Describe Stridor F. Retraction G. Voice of Cry H. Respiratory rate and depth I. Pulse and temperature J. Auscultation IV. Decide on Consultants and Call Them V. Physician Stays with Child A. Parent's lap B. Sitting on stretcher C. Do not lay down D. No upsetting procedure such as IV, ABG, Blood Culture, Throat Culture or Throat Exam E. Keep room traffic down VI. Initial Treatment A. Cool Mist B. Vaponefrin C. If arrest occurs - positive pressure with mask and oxygen VII. Triage Nurse A. Calls Consultants B. Notifies OR and ICU C. Hold Elevator D. Get emergency equipment ready in the emergency room E. Proper scopes F. ETT-appropriate size and two sizes smaller G. McGill forceps H. Tonsil Suction I. Succinyl Choline J. Monitor Child K. Act as parent if parents are upsetting child or cannot function VIII. Disposition A. Avoid unnecessary delay in ER B. Radiology? C. Portable X-ray? D. Operating room - set up and ready E. Direct laryngoscopes - intubating type F. Bronchoscope size 3 and 4 G. Tracheotomy set H. Foreign Body instruments IX. Transfer to OR A. Induction with mask - gentle B. IV after asleep C. Laryngoscopy D. Oral ETT - Change to nasal tube E. Size smaller than usual for age F. Throat culture, blood culture and LP? X. PICU A. Sedate and restrain B. Humidified oxygen with unencumbered ETT C. Frequent saline and suction D. NPO - NG tube E. Antibiotics for 10 days - 7 days IV F. If CSF positive - 10 to 14 days IV G. AMP/chlor or 3rd generation cephalosporin H. Extubate 48 hours I. Criteria/afebrile, improved condition overall, leak around ETT J. in PICU? in OR if above uncertain K. NPO and PICU X 8 hours L. Transfer to floor M. Prophylaxis for contacts - AAP common I.D. XI. Croup - LTB A. DL and NTT, if ( some prefer tracheotomy): -Severe stridor needing epi treatment increasingly frequent -cyanosis unrelieved by oxygen -pulse consistently greater than 180 steroids usually given before this point to try to avoid intubation (1mg per kg of decadron) B. PICU Care as with Epiglottis 1. Rare to be able to extubate sooner than 3 to 4 days 2. Decadron, 1 mg per kg 4 hours prior to extubation XII. Bacterial Tracheitis A. Croup Symptoms - but poor response to treatment B. Older Child C. 50% Staph Aureus D. X-ray - scalloping of tracheal walls E. Treatment 1. Bronchoscopy to remove crusts 2. IV Fluid 3. Humidification 4. Anti-Staph antibiotic 5. ETT, trach rarely ----------------------------------------------------------------------- BIBLIOGRAPHY 1. Apley, John: "The Infant with Stridor," Arch. Dis. Child. 28:423, 1953. 2. "Acute Epiglottitis in Children," New Eng. J. of Med. 258:870, 1958. 3. Holinger, Paul: "Pediatric Laryngology," Otolaryngologic Clinic of North America. 625-37, Oct. 1970. 4. Gross, Chas: "Treatment of Upper Airway Obstruction in Children," Otolaryngologic Clinics of North America. 157-65, Feb. 1977. 5. Bluestone & Stool: "Pediatric Otolaryngology," Vol. II. 1152-1156-1259, W.B. Saunders & Co., 1990. 6. Ashcraft, C. & Steele, Russell: "Epiglottitis - A Pediatric Emergency" J. of Resp. Disease. 48-60, July 1988. -----------------------------END------------------------------------------- Guidelines for the Care of Patients Suspected of Having Acute Epiglottitis at Brackenridge Hospital All patients who are seriously suspected to have acute epiglottitis, either on the basis of clinical history and physical examination alone or on the basis of radiographic findings, shall be evaluated jointly by a team consisting of three services: Pediatrics, ENT and Anesthesia. If the diagnosis is strongly suspected on the basis of clinical history and physical findings alone, especially if the patient does not appear stable, the team should be assembled as rapidly as possible. If the diagnosis is less certain and the patient's condition allows, a soft tissue lateral radiograph of the neck should be obtained. If the diagnosis is supported by radiographic findings, then the team should be assembled immediately. During the initial evaluation of any patient suspected of having epiglottitis who is having respiratory distress, several precautions are necessary: supplemental oxygen (preferably humidified) should be provided continuously, the patient should not be unnecessarily disturbed, and experienced personnel capable of cardiopulmonary resuscitation with appropriate airway equipment should remain with the patient at all times. As the physician team is being assembled, simultaneous arrangements should be made to go to the operating room with adequate O.R. staff. During transfer to the O.R., humidified oxygen therapy should continue, close monitoring with attendance by someone proficient in CPR should continue, and the child should not be disturbed. It is desirable to keep the child in his mother's arms. In the O.R. direct laryngoscopy should be done. Usually the procedure is done under general anesthesia. If the diagnosis of acute epiglottitis is confirmed, an artificial airway should be secured. Preferably, oral intubation should be performed quickly and then the oral tube should be replaced by a nasotracheal tube. If endotracheal intubation cannot be performed quickly and successfully, a surgeon must be prepared to perform a tracheostomy immediately. Throat culture, epiglottal culture, blood cultures, and other venipunctures should be deferred until an airway has been established. --------------------------------END---------------------------------------- After the airway is secure, the patient should be moved to Pediatric ICU. The patient will require careful nursing care with regular suctioning, chest physical therapy, humidified air and oxygen source, appropriate restraints, and continuous monitoring. The airway is kept in place generally 24-72 hours. Appropriate antibiotics should be ordered by Pediatrics once the airway is secure and once indicated cultures are obtained. --------------------------------END--------------------------------------