Respiratory emergencies

Airway obstruction is the primary mechanical emergency of the respiratory system in pediatric patients with malignancy. Obstruction can occur at the level of the larynx, trachea, or bronchi. Airway obstruction is the most common complication in pediatric patients presenting with a mediastinal mass, and it is reported in 60% of patients. Leukemia, lymphoma, Hodgkin disease, rhabdomyosarcoma, and neuroblastoma are the most common diagnoses in these patients. Laryngeal obstruction is uncommon in pediatric patients with cancer; it is most likely to occur in patients with vocal cord paralysis. Airway compromise in the absence of mediastinal mass or adenopathy is reported in pediatric patients presenting with hemangioma, lymphangioma, cervical and mediastinal teratoma, respiratory papillomatosis, thymoma, and various head and neck tumors. Clinical symptoms depend on the level of obstruction. Stridor is associated with extrathoracic obstruction, and a hoarse voice suggests unilateral vocal cord paralysis. Increased obstruction of the trachea or mainstem bronchi may manifest as wheezing, dyspnea, orthopnea, or increased effort of breathing. Rapid CT scanning is the preferred imaging study in children. Tracheal crosssectional area, as measured on CT scans, decrease by 35-93% in more than 30% of symptomatic patients. Although uncommon, symptomatic airway obstruction may be encountered either as a presenting feature or as a complication of refractory disease. Prompt diagnosis by using tissue samples is paramount in patients who initially present with airway compromise, and the institution of appropriate antitumoral therapy is the optimal strategy. Local radiation therapy may be used, but it can induce inflammation that worsens symptoms transiently. Primary airway support is usually sufficient until definitive therapy is started. Symptomatic relief is the primary objective for patients with airway obstruction as a terminal medical complication. A multimodality approach with radiation therapy, surgery, and pharmacotherapy may be required.