Nelsons Pediatrics (Respiratory System)

RESPIRATORY PATHOPHYSIOLOGY innervate the respiratory muscles

(Polyneuritis)
Respiratory system consists of:
- Pumping mechanism
o respiratory muscles, the chest
wall, and the conducting airways UPPER RESPIRATORY TRACT
- Membrane gas exchanger
o Interface between the air spaces
and the pulmonary circulation
- Central neural control
o connected to a network of
chemical and mechanical sensors
distributed throughout the
circulation and the components of
the respiratory system itself
Respiratory Distress and Respiratory Failure

Function of respiratory pump

- Regulated by a highly responsive
neuronal network that integrates
chemical signals from:
o Central chemoreceptors:
o located in the ventral
reticular nuclei of the
medulla
o sensitive to pH and Pco2
o Peripheral chemoreceptors
o carotid bodies
o sensitive to Po2
o Mechanoreceptors
o Located in the lungs to
influence the neural output
to the respiratory muscles
Nose
- provides initial warming and
humidification of inspired air
- Nasal passage
o contribute as much as 50% of the
total resistance of normal
breathing.
Anterior nasal cavity
- turbulent airflow and coarse hairs
enhance the deposition of large
particulate matter
Turbinate region

Anomaly in neural control of breathing
- development of arterial hypoxemia and
especially hypercapnia without increase
in the respiratory effort
- Due to:
o CNS injury
o Trauma
o intracranial haemorrhage
o Drug-induced inhibition of the
inspiratory neuronal network
(opioid intoxication)
o Dysfunction/injury of the spinal
motor neurons or nerve fibers that
- airflow becomes laminar and the air
stream is narrowed and directed
superiorly, enhancing particle deposition,
warming, and humidification
Nasal flaring
- a sign of respiratory distress
- reduces the resistance to inspiratory
airflow through the nose and may
improve ventilation.
Nasal mucosa
- more vascular, especially in the turbinate
region, than in the lower airways;
Nelsons Pediatrics (Respiratory System)
- however, the surface epithelium is
similar, with ciliated cells, goblet cells,
Treatment
submucosal glands, and a covering
blanket of mucus
- mucous glycoproteins: which provide
viscoelastic properties
Nasal secretions
- contain lysozyme and secretory IgA, both
of which have antimicrobial activity, and
IgG, IgE, albumin, histamine, bacteria,
lactoferrin, and cellular debris
Chapter 362
Acquired Disorders of Nose
Foreign body
Clinical features
- Initial symptoms
o local obstruction
o sneezing
o relatively mild discomfort
o rarely pain
- Irritation results in
o mucosal swelling
o some foreign bodies are
hygroscopic and increase in
size as water is absorbed,
signs of local obstruction and
discomfort may increase with
time.
- Infection usually follows
o gives rise to a purulent,
malodorous, or bloody
discharge
o may also present with a
generalized body odor known
as bromhidrosis
Diagnosis
- Unilateral nasal discharge and
obstruction
- Purulent secretions must often be
removed so that the foreign object
can actually be seen
- A lateral skull radiograph assists in
diagnosis if the foreign body is
metallic or radiopaque
- Performed with topical
anaesthesia, using either forceps
or nasal suction.
- If there is marked swelling,
bleeding, or tissue overgrowth,
general anaesthesia may be
needed to remove the object.
Epistaxis
- Kiesselbach plexus
o The most common site of
bleeding
o An area in the anterior
septum where vessels from
both the internal carotid and
external carotid converge.
o The thin mucosa in this area,
as well as the anterior
location, make it prone to
exposure to dry air and
trauma
Etiology
- Common causes of nosebleeds from
the anterior septum
o digital trauma
o foreign bodies
o dry air
o Inflammation
o Nasal steroid sprays
o Young infants with significant
GER into the nose
- Susceptibility is increased during
respiratory infections and in the
winter when dry air irritates the
nasal mucosa, resulting in formation
of fissures and crusting
- Severe bleeding may be
encountered with congenital
vascular abnormalities
Nelsons Pediatrics (Respiratory System)
Treatment
- The nares should be compressed
and the child kept as quiet as
possible, in an upright position with
the head tilted forward to avoid
blood trickling back into the throat
- Cold compresses applied to the nose
may also help.
- If these measures do not stop the
bleeding
o local application of a solution
of oxymetazoline (Afrin) or
Neo-Synephrine (0.25-1%)
Chapter 363
Nasal polyps
- benign pedunculated tumors formed
from edematous, usually chronically
inflamed nasal mucosa
- originate from the ethmoidal sinus and
present in the middle meatus
- they appear within the maxillary
antrum and can extend to the
nasopharynx (antrochoanal polyp)
Types
- Ethmoidal sinus polyp
o Smaller and multiple
- Antral choanal polyp
o Large and single
Etiology
- Cystic fibrosis
o most common childhood cause
of nasal polyposis and should be
suspected in any child younger
than age 12 yr with nasal polyps
- Nasal polyposis is also associated with
chronic sinusitis and allergic rhinitis
Clinical manifestation
- Obstruction of nasal passages is
prominent
- associated hyponasal speech and
mouth breathing
- Profuse mucoid or mucopurulent
rhinorrhea may also be present
- An examination of the nasal passages
shows
o glistening, gray, grapelike
masses squeezed between the
nasal turbinates and the septum
- Ethmoidal polyps
o can be readily distinguished
from the well-vascularized
turbinate tissue, which is pink or
red
- Antrochoanal polyps
o may have a more fleshy
appearance
Chapter 364
Common colds
- viral illness in which the symptoms
of rhinorrhoea and nasal
obstruction are prominent
- systemic symptoms and signs such
as myalgia and fever are absent or
mild
rhinitis but includes self-limited
involvement of the sinus mucosa
and is more correctly termed
rhinosinusitis
Etiology
- The most common pathogens
associated with the common cold
are the rhinoviruses but the
syndrome may be caused by many
different viruses
Pathogenesis
- Viruses spread by:
Nelsons Pediatrics (Respiratory System)
o Large-particle aerosols
o small-particle aerosols
influenza virus
o direct contact
an efficient mechanism
of transmission of these
viruses
- Rhinovirus and Adenovirus
o result in the development of
serotype-specific
protective immunity
- Influenza viruses
o have the ability to change
the antigens presented on
the surface of the virus and
behave as though there
were multiple virus
serotypes
- Coronavirus
o Its multiple distinct strains
are capable of inducing at
least short-term
protective immunity
- Parainfluenza viruses and RSV
o each have a small number
of distinct serotypes
o Re-infection with these
viruses occurs because
protective immunity to
these pathogens does not
develop after an infection
- Viral infection of the nasal
epithelium
o destruction of the epithelial
lining, as with influenza
viruses and adenoviruses
o no apparent histologic
damage, as with
rhinoviruses, RSV, and
coronavirus
o associated with an acute
inflammatory response
characterized by release of
a variety of inflammatory
cytokines and infiltration of
the mucosa by inflammatory
cells.
o This acute inflammatory
response appears to be
responsible at least in part
for many of the symptoms
associated with the common
cold.
Clinical Manifestations
- 1-3 days after viral infection:
o onset of common cold
symptom
o First symptom: sore or
scratchy throat followed by
nasal obstruction and
rhinorrhea
- 2nd or 3rd day of illness
o Sore throat resolves quickly
o Nasal symptoms
predominate
o Cough is associated with
approximately 30 % of colds
and begins after the onset
of nasal symptoms
- The usual cold persist about 1
week although 10 % last 2 weeks
Physical findings
- Limited to the upper respiratory
tract
- A change in the color or
consistency of the secretions is
common during the course of the
illness and is not indicative of
sinusitis or bacterial superinfection
Treatment
- The management of the common
cold consists primarily of
symptomatic
Chapter 365
Nelsons Pediatrics (Respiratory System)
Sinusitis
- is a common illness of childhood and
adolescence with significant morbidity
and the potential for serious
complications
Types
- Viral
o The common cold produces a
viral, self-limited rhinosinusitis
- Bacterial
o 2 % of viral URTI in children and
adolescents are complicated by
actue bacterial sinusitis
Anatomy
- Ethmoidal sinus
o Present at birth
o Pneumatised at birth
- Maxillary sinus
o Not pneumatised until 4 years
old
- Sphenoidal sinus
o Present by 5 years of age
- Frontal sinuses
o Begin development at age 7-8
yr nd completely developed until
adolescence
- Ostia draining the sinuses are narrow
(1-3 mm) and drain into the
ostiomeatal complex in the middle
meatus.
- The paranasal sinuses are normally
sterile, maintained by the mucociliary
clearance system
Etiology
- acute bacterial sinusitis in children and
adolescents include:
o Streptococcus pneumoniae
(30%)
o Haemophilus influenzae (20%)
o Moraxella catarrhalis (20%)
Pathogenesis
- Acute bacterial sinusitis
o follows a viral upper respiratory
tract infection
o Initially, the viral infection
produces a viral rhinosinusitis
o Nose blowing has been
demonstrated to generate
sufficient force to propel nasal
secretions into the sinus
cavities.
o Bacteria from the nasopharynx
that enter the sinuses are
normally cleared readily, but
during viral rhinosinusitis the
inflammation and edema may
block sinus drainage and impair
mucociliary clearance of
bacteria.
o The growth conditions are
favorable, and high titers of
bacteria are produced
Clinical Manifestations
- nasal congestion
- nasal discharge (unilateral or bilateral)
- fever, and cough
Physical examination
- may reveal mild erythema and
swelling of the nasal mucosa with
nasal discharge
- Sinus tenderness may be detectable
in adolescents and adults
Diagnosis
Nelsons Pediatrics (Respiratory System)
- clinical diagnosis of acute bacterial
sinusitis is based solely on history
- Complicating acute bacterial
sinusitis
o Persistent nasal discharge and
cough, for longer than 10-14
days without improvement
o Severe respiratory symptoms,
including temperature of at least
102F (39C) and purulent nasal
discharge for 3-4 consecutive
days
-Chronic sinusitis
o history of persistent respiratory
symptoms, including cough,
nasal discharge, or nasal
congestion, lasting more than 90
days
Sinus aspirate culture
- Only accurate method of diagnosis but
is not practical for routine use
Transillumination of the sinus cavities
- demonstrate the presence of fluid but
cannot reveal whether it is viral or
bacterial in origin
Chapter 367
Retropharyngeal abscess,
Parapharyngeal abscess and
Peritonsillar Abscess
Anatomy
- The neck consists of deeply located
lymph nodes that drain the mucosal
surfaces of the upper airway and
digestive tracts
o retropharyngeal nodes
o lateral pharyngeal nodes
- These nodes lie within the
o retropharyngeal space
located between the
pharynx and the cervical
vertebrae and extending
down into the superior
mediastinum)
o lateral pharyngeal space
bounded by the pharynx
medially, the carotid
sheath posteriorly, and the
muscles of the styloid
process laterally), which
are interconnected
Pathogenesis
- The lymph nodes in these deep neck
spaces communicate with each other,
allowing bacteria from either cellulitis
or node abscess to spread to other
nodes
- Infection of the nodes usually occurs
as a result of extension from a
localized infection of the oropharynx
Retropharyngeal abscess
- may result from penetrating trauma to
the oropharynx, dental infection, and
vertebral osteomyelitis
- result of suppuration of
retropharyngeal lymph node secondary
to infection in adenoids, nasopharynx,
paranasal sinus
- Once infected, the nodes may progress
through three stages:
Cellulitis
Phlegmon
Nelsons Pediatrics (Respiratory System)
Abscess
- Infection in the retropharyngeal and
lateral pharyngeal spaces may result
in airway compromise or posterior
mediastinitis, making timely diagnosis
important
Clinical manifestations
- include fever, irritability, decreased
oral intake, and drooling
- Neck stiffness, torticollis, and refusal
to move the neck may also be present
- The verbal child may complain of sore
throat and neck pain
- Other signs may include muffled voice,
stridor, and respiratory distress
Physical examination
- may reveal bulging of the posterior
pharyngeal wall, although this is
present in less than 50% of infants
with retropharyngeal abscess
- Cervical lymphadenopathy may also
be present. Lateral pharyngeal abscess
commonly presents as fever,
dysphagia, and a prominent bulge of
the lateral pharyngeal wall, sometimes
with medial displacement of the tonsil
Retropharyngeal and lateral pharyngeal
infections
- are most often polymicrobial
- the usual pathogens include group A
Streptococcus, oropharyngeal
anaerobic bacteria, and
Staphylococcus aureus
Treatment
- IV antibiotics with or without surgical
drainage.
- 3rd generation cephalosporin combined
with ampicillin-sulbactam or
clindamycin to provide anaerobic
coverage is effective
- Drainage is necessary in the patient
with respiratory distress or failure to
improve with intravenous antibiotic
treatment
Complications
- significant upper airway obstruction
- rupture leading to aspiration
pneumonia extension to the
mediastinum
- Thrombophlebitis of the internal
jugular vein and erosion of the carotid
artery sheath may also occur
Lemierre disease
- characteristic infection of the
parapharyngeal space
- infection from the oropharynx extends
to cause septic thrombophlebitis of the
internal jugular vein and metastatic
abscesses in the lungs
- The causative pathogen is
Fusobacterium necrophorum
Typical presentation
- is that of a previously healthy
adolescent or young adult with a
history of recent pharyngotonsillar
disease who becomes acutely ill with
fever and pulmonary symptoms
Diagnosis
- Chest radiography demonstrates
multiple cavitary nodules, often
bilateral, and often accompanied by
pleural effusion
- Blood culture may be positive
Treatment
- involves prolonged intravenous
antibiotic therapy with penicillin or
cefoxitin; surgical drainage of
extrapulmonary metastatic abscesses
may be necessary
Peritonsillar Abscess/ Cellulitis
- caused by bacterial invasion through
the capsule of the tonsil, leading to
cellulitis and/or abscess formation in
the surrounding tissues
- typical patient with a peritonsillar
Nelsons Pediatrics (Respiratory System)
abscess is an adolescent with a recent
history of acute pharyngotonsillitis
- collection of pus in the peritonsillar
space between capsule and superior
constrictor muscles
Etiology
- acute tonsillitis which arise de-novo
without previous history of sore throat
- chronic tonsillitis
Pathogenesis
- one of the tonsillar crypts usually
crypta magna gets infected and sealed
off-> leading to intra tonsillar abscess
when bursts through tonsillar capsule-
>peritonsilitis->peritonsillar abscess
Clinical manifestation
- sore throat, fever, trismus, and
dysphagia
Physical examination
- asymmetric tonsillar bulge with
displacement of the uvula.
- An asymmetric tonsillar bulge is
diagnostic, but it may be poorly
visualized because of trismus
Treatment
- surgical drainage and antibiotic
therapy effective against group A
Streptococcus and anaerobes
Lower Respiratory Tract
- disorder is mild and self-limited as often
occurs with viral bronchitis
Chapter 370
Chronic or Recurrent Respiratory Symptoms
Persistent cough
- reflex response of the lower respiratory
tract to stimulation of irritant or cough
receptors in the airways' mucosa
- The most common cause in children is
reactive airways (asthma)
- cough receptors also reside in the
pharynx, paranasal sinuses, stomach,
and external auditory canal
- Specific lower respiratory stimuli
include
o excessive secretions
o aspirated foreign material
o inhaled dust particles or noxious
gases
o an inflammatory response to
infectious agents or allergic
processes
Diagnosis
- Considerable information pertaining to
the cause of chronic cough can be
obtained during the physical
examination
Chronic upper airway disease (sinusitis)
- posterior pharyngeal drainage
combined with a nighttime cough
Asthma or cystic fibrosis
- overinflated chest suggests chronic
airway obstruction
- Expiratory wheeze w/ or w/o diminished
breath sounds
Bronchiectasis
- Coarse crackles
- Clubbing of digits
- Very purulent sputum
Foreign body aspiration or mediastinal mass
- Tracheal deviations
Nelsons Pediatrics (Respiratory System)
Persistent Wheeze
- troublesome manifestation of
obstructive lower respiratory tract
disease in children
- site of obstruction may be anywhere
from the intrathoracic trachea to the
small bronchi or large bronchioles
- sound is generated by turbulence in
larger airways that collapse with forced
expiration
- Children younger than 2-3 yr of age
prone to wheezing because
bronchospasm, mucosal edema, and
accumulation of excessive secretions
have a relatively greater obstructive
effect on their smaller airways.
- Most recurrent or persistent wheezing
in children is the result of reactive
airways disease. Nonspecific
environmental factors such as cigarette
smoke may be important contributors
Diagnosis
Congenital structural abnormalities involving
the lower respiratory tract/
tracheobronchomalacia
- recurring or persistent wheezing
starting at or soon after birth
Cystic fibrosis
- first year of life
Foreign body aspiration
- Sudden onset of severe wheezing in a
previously healthy child
Persistent stridor
- a harsh, medium-pitched, inspiratory
sound associated with obstruction of
the laryngeal area or the extrathoracic
trachea
- is often accompanied by a croupy
cough and hoarse voice.
- Stridor is most commonly observed in
children with croup; foreign bodies and
trauma may also cause acute stridor.
However, a small number of children
acquire recurrent stridor or have
persistent stridor from the first days or
weeks of life
Diagnosis
Congenital anomalies of large airways
- become symptomatic soon after birth.
Laryngomalacia or tracheomalacia
- increase of stridor when a child is
supine
Increase of stridor when a child is supine
Involvement of vocal cords
- An accompanying history of hoarseness
or aphonia
Persistent Lung Infiltrates
- resulting from acute pneumonia usually
resolve within 1-3 wk
- but a substantial number of children,
particularly infants, fail to completely
clear infiltrates within a 4-wk period.
They may be febrile or afebrile and may
display a wide range of respiratory
symptoms and signs
Diagnosis
Infection acquired in utero or during descent
through the birth canal
- Symptoms associated with chronic lung
infiltrates during the first several weeks
of life
Cystic fibrosis or congenital anomalies
(aspiration or airway obstruction)
- Early appearance of chronic infiltrates
Asthma
- A history of recurrent infiltrates,
wheezing, and cough
Pulmonary hemosiderosis
- related to cow's milk hypersensitivity
- appearing in the first year of life with
Nelsons Pediatrics (Respiratory System)
recurrent lung infiltrates
Bronchopulmonary dysplasia
- have episodes of respiratory distress
attended by wheezing and new lung
infiltrates
Cystic fibrosis or chronic asthma
- Overinflation and infiltrates
- history of paroxysmal coughing in an
infant
Alveolar proteinosis
- "silent chest" with infiltrates
Chapter 371
Acute Inflammatory Upper Airway
Obstruction
- minor reductions in cross-sectional
area (mucosal edema or other
inflammatory processes) cause an
exponential increase in airway
resistance and a significant increase in
the work of breathing
Anatomy
- Major cartilages of larynx (superior to
inferior)
o Epiglottic
o Arytenoid
o Thyroid
o Cricoid
encircles the airway just below
the vocal cords
defines the narrowest portion
of the upper airway in children
younger than 10 yr of age
Inflammation involving the vocal cords and
structures inferior to the cords
- laryngitis, laryngotracheitis,
laryngotracheobronchitis
Inflammation of the structures superior to the
cords
(arytenoids, aryepiglottic folds ["false cords"],
epiglottis)
- supraglottitis
Croup
- heterogeneous group of mainly acute
and infectious processes
- characterized by a barklike or brassy
cough and may be associated with
hoarseness, inspiratory stridor, and
respiratory distress
- infection leads to swelling inside the
throat, which interferes with normal
breathing and produces the classical
symptoms of a
"barking" cough, stridor,
and hoarseness
- usually affects to some degree the
larynx, trachea, and bronchi.
- When the involvement of the larynx is
sufficient to produce symptoms, they
dominate the clinical picture over the
tracheal and bronchial signs
- Types
o Spasmodic or recurrent croup
allergic component and
improves rapidly without
treatment
o Laryngotracheobronchitis
always associated with a
viral infection of the
respiratory tract
Stridor
- harsh, high-pitched respiratory sound
- usually inspiratory but may be
biphasic, produced by turbulent
airflow;
- it is not a diagnosis but a sign of
Nelsons Pediatrics (Respiratory System)
upper airway obstruction
Infectious Upper Airway Obstruction
Etiology
- Viral agents
o Account for most acute
infectious upper airway
obstruction
o Parainfluenza virus (75%)
o Influenza A
severe
laryngotracheobronchitis
o Influenza B
o RSV
o Measels
- Bacterial agents
o Diphtheria
o Bacterial tracheitis
o Epiglottitis
S pyogenes
S pneumoniae
S aureus
Laryngotracheobronchitis (Croup)
- Primarily viruses cause croup
- most common form of acute upper
respiratory obstruction
- viral infection of the glottic and
subglottic regions
Clinical Manifestation
- have URTI with some combination of
o rhinorrhea
o pharyngitis
o mild cough
o low-grade fever for 1 to 3 days
before the signs and symptoms
of upper airway obstruction
become apparent
- The child then develops the
characteristic "barking" cough,
hoarseness, and inspiratory
stridor. The low-grade fever may
persist, although temperatures may
reach 39-40C
- Symptoms are worse at night and
often recur with decreasing
intensity for several days and
resolve completely within a week
- Agitation and crying greatly
aggravate the symptoms and signs.
- The child may prefer to sit up in bed
or be held upright
Physical examination
- reveal a hoarse voice, coryza, normal
to moderately inflamed pharynx, and a
slightly increased respiratory rate.
- Patients may vary substantially in
their degree of respiratory distress.
- Croup is a disease of the upper airway,
and alveolar gas exchange is usually
normal.
- Hypoxia and low oxygen saturation are
seen only when complete airway
obstruction is imminent
- Occasionally, the pattern of severe
laryngotracheobronchitis may be
difficult to differentiate from epiglottitis
despite the usually more acute onset
and rapid course of the latter
Acute Epiglottitis/ Supraglottitis
- potentially lethal condition
- characterized by an acute fulminating
course of high fever, sore throat,
dyspnea, and rapidly progressing
respiratory obstruction
- initial lack of respiratory distress may
deceive the unwary clinician, although
respiratory distress may be the first
manifestation
- healthy child suddenly develops a sore
throat and fever. Within a matter of
hours, the patient appears toxic,
swallowing is difficult, and breathing is
labored
- Drooling is usually present and the
neck is hyperextended in an
attempt to maintain the airway.
- The child may assume the tripod
position sitting upright and leaning
Nelsons Pediatrics (Respiratory System)
forward with the chin up and mouth
open while bracing on the arms.
- A brief period of air hunger with
restlessness may be followed by
rapidly increasing cyanosis and
coma.
- Stridor is a late finding and suggests
near-complete airway obstruction.
- Complete obstruction of the
airway and death may ensue unless
adequate treatment is provided
Diagnosis
- "cherry-red" swollen epiglottis by
laryngoscopy
- Classic radiographs of a child who has
epiglottitis show the "thumb sign"
Treatment
- Establishing an airway by nasotracheal
intubation or, less often, by
tracheostomy is indicated in patients
with epiglottitis, regardless of the
degree of apparent respiratory
distress, because as many as 6% of
children with epiglottitis without an
artificial airway die, compared with
less than 1% of those with an artificial
airway
Summary (Epiglottitis)
Acute Infectious Laryngitis
- Commonly caused by virus
- onset is usually characterized by an
upper respiratory tract infection during
which sore throat, cough, and
hoarseness appear
- The illness is generally mild;
respiratory distress is unusual except
in the young infant
- Hoarseness and loss of voice may be
out of proportion to systemic signs and
symptoms.
- The physical examination is usually
not remarkable except for evidence of
pharyngeal inflammation.
- Inflammatory edema of the vocal
cords and subglottic tissue may be
demonstrated laryngoscopically.
- The principal site of obstruction is
usually the subglottic area
Spasmodic Croup
- most often in children 1-3 yr of age
and is clinically similar to acute
laryngotracheobronchitis
- history of a viral prodrome and fever
in the patient and family are frequently
absent.
- The cause is viral in some cases, but
allergic and psychological factors may
Nelsons Pediatrics (Respiratory System)
be important in others.
- Laryngoscopy reveals pale, watery
edema with preservation of the
epithelium (unlike the erythematous
edema and destruction of the
epithelium of acute infectious
laryngotracheobronchitis)
Progession of Disease
- Occurring most frequently in the
evening or night-time
- spasmodic croup begins with a sudden
onset that may be preceded by mild to
moderate coryza and hoarseness.
- The child awakens with a
characteristic barking, metallic cough,
noisy inspiration, and respiratory
distress and appears anxious and
frightened.
- severity of the symptoms diminishes
within several hours and, the following
day, the patient often appears well
except for slight hoarseness and
cough.
- Similar, but usually less severe,
attacks without extreme respiratory
distress may occur for another night or
two.
- Spasmodic croup may represent more
of an allergic reaction to viral antigens
than direct infection, although the
pathogenesis is unknown
TREATMENT FOR CHILDREN WITH CROUP
- AIRWAY MANAGEMENT
- most children with either acute
spasmodic croup or infectious croup
can be managed at home safely
- NEBULIZED EPINEPHRINE
o constriction of the precapillary
arterioles through the -
adrenergic receptors causing
fluid resorption from the
interstitial space and a decrease
in the laryngeal mucosal edema
o Indications: moderate to severe
stridor at rest
- INTUBATION
o respiratory distress, hypoxia,
and when stridor does not
respond to cool mist
- CORTICOSTEROIDS
o decrease the edema in the
laryngeal mucosa through their
anti-inflammatory action
Bacterial Tracheitis
- acute bacterial infection of the upper
airway,
- does not involve the epiglottitis but is
capable of causing life-threatening
airway obstruction
- often follows a viral respiratory
infection (especially laryngotracheitis)
so it may be considered a bacterial
complication of a viral disease, rather
than a primary bacterial illness
Etiology
- Staphylococcus aureus
- Moraxella catarrhalis
- H. influenzae
Clinical Manifestation
- brassy cough, apparently as part of a
viral laryngotracheobronchitis
- High fever and "toxicity" with
respiratory distress may occur
immediately or after a few days of
apparent improvement.
- The patient lie flat, does not drool,
and does not have the dysphagia
associated with epiglottitis.
- The usual treatment for croup (e.g.,
mist, racemic epinephrine) is
ineffective. Intubation or tracheostomy
may be necessary.
- The major pathologic feature appears
to be mucosal swelling at the level
of the cricoid cartilage, complicated
by copious thick, purulent secretions,
sometimes causing
pseudomembranes.
- Suctioning these secretions, although
Nelsons Pediatrics (Respiratory System)
occasionally affording temporary relief,
usually does not sufficiently obviate
the need for an artificial airway
Diagnosis
- based on evidence of bacterial upper
airway disease, which includes high
fever, purulent airway secretions, and
an absence of the classic findings of
epiglottitis
Treatment
- Appropriate antimicrobial therapy
should be instituted in any patient
whose course suggests bacterial
tracheitis.
- When bacterial tracheitis is diagnosed
by direct laryngoscopy or is strongly
suspected on clinical grounds, an
artificial airway is indicated
Complications
- Chest radiographs: show patchy
infiltrates and may show focal
densities
- Subglottic narrowing and a rough and
ragged tracheal air column can often
be demonstrated radiographically
- If airway management is not optimal,
cardiorespiratory arrest can occur.
- Toxic shock syndrome has been
associated with tracheitis
Chapter 372
Congenital Anomalies of Larynx
Anatomy and Physiology
- Functions of Larynx
o breathing passage
o a valve to protect the lungs
o primary organ of communication
- symptoms of laryngeal anomalies
o abnormalities of phonation
o difficulty feeding
o airway obstruction
Severity: determines the
necessity for diagnostic
procedures and surgical
intervention.
Obstructive symptoms vary
from mild stridor to severe
obstruction, with episodes of
apnea, cyanosis, suprasternal
(tracheal tugging) and
subcostal retractions, dyspnea,
and tachypnea
Chronic obstruction may cause
failure to thrive
Laryngomalacia
- most common congenital laryngeal
anomaly
- most frequent cause of stridor in
infants and children
- Of congenital laryngeal anomalies in
children with stridor, 60% are caused
by laryngomalacia.
Clinical Manifestation
- Inspiratory stridor, low pitched, and
exacerbated by any exertion (i.e.,
crying, agitation, feeding)
- Stridor results from the collapse of
supraglottic structures inward
during inspiration.
- Symptoms usually appear within the
first 2 wk of life and increase in
severity for up to 6 mo, although
gradual improvement may begin at
any time
- Laryngopharyngeal reflux is commonly
associated with laryngomalacia
Diagnosis
- confirmed by flexible laryngoscopy in
the office.
- Airway films and Chest
Radiographs
o When the work of breathing is
moderate to severe
Nelsons Pediatrics (Respiratory System)
- Contrast swallow study and
esophagogram
o With associated dysphagia
- Complete bronchoscopy
o Moderate to severe obstruction
Subglottic stenosis
- second most common cause of stridor
- Stridor is biphasic or primarily
inspiratory
- Recurrent or persistent croup is typical
- First symptoms often occur with a
respiratory tract infection as edema
and thickened secretions of a common
cold narrow an already compromised
airway
Diagnosis
- Airway radiographs is confirmed by
direct laryngoscopy.
- As with all cases of upper airway
obstruction, tracheostomy is avoided
when possible.
- Anterior laryngotracheal
decompression (cricoid split) or
laryngotracheal reconstruction with
cartilage grafting is usually effective in
avoiding tracheostomy
Vocal cord paralysis
- third most common congenital
laryngeal anomaly producing stridor in
infants and children
- Paralysis may occur as a result of
surgical correction of congenital
cardiac anomalies or
tracheoesophageal fistula
Bilateral vocal paralysis
- produces airway obstruction
manifested by high-pitched inspiratory
stridor: a phonatory sound or
inspiratory cry
Unilateral vocal paralysis
- causes aspiration, coughing, and
choking. The cry is weak and breathy,
but stridor and other symptoms of
airway obstruction are less common
Diagnosis
- awake flexible laryngoscopy
- Because of the association with other
congenital lesions, evaluation includes
neurology and cardiology consultations
as well as diagnostic endoscopy of the
larynx, trachea, and bronchi
Management
- Vocal cord paralysis in infants usually
resolves spontaneously within 6-12 mo
- Bilateral paralysis: Temporary
tracheotomy
- Unilateral paralysis with aspiration: the
paralyzed vocal cord is injected
laterally so that it touches the now
paralyzed cord medially, reducing
aspiration and related complications
Congenital Laryngeal Webs
- Most congenital laryngeal webs are
glottic with subglottic extension and
associated subglottic stenosis
- Diagnosis: direct laryngoscopy
- Treatment: may require only incision or
dilation. Webs with associated
subglottic stenosis are likely to require
cartilage augmentation of the cricoid
(laryngotracheal reconstruction)
Clinical manifestation
- The cry may be high pitched
- Airway obstruction is not always
present and may be related to the
subglottic stenosis
- Thick webs may be suspected in
lateral radiographs of the airway
Congenital Subglottic Hemangioma
- hemangioma are symptomatic within
the first 2 months of life, with almost
all presenting before 6 month of age.
- Stridor is biphasic but usually more
prominent during inspiration.
Nelsons Pediatrics (Respiratory System)
- The infant may be hoarse, have a
barking cough, and present with croup.
- Diagnosis is made by direct
laryngoscopy
- Medical management: systemic
steroids
Laryngoceles and Saccular Cysts
Laryngocele
- abnormal air-filled dilation of the
laryngeal saccule
- It communicates with the laryngeal
lumen and, when intermittently filled
with air, causes hoarseness and
dyspnea
Saccular cysts
- Congenital cyst of larynx
- distinguished from the laryngocele in
that its lumen is isolated from the
interior of the larynx and it contains
mucus, not air
- may be visible on radiography, but the
diagnosis is made by laryngoscopy
Diagnosis
- Needle aspiration of the cyst confirms
the diagnosis but rarely provides a
cure. Endoscopic CO2 laser excision
may suffice, but external excision is
often necessary
Chapter 373
Foreign Bodies of the Airways
- Most victims of foreign body aspiration
are older infants and toddlers
- Children younger than 3 yr of age
account for 73% of cases
Clinical Manifesations
- A positive history must never be
ignored
- A negative history may be misleading
- Choking or coughing episodes
accompanied by wheezing are highly
suggestive of an airway foreign body.
- Because nuts are the most common
bronchial foreign body, the physician
specifically questions the toddler's
parents about nuts.
- If there is any history of eating nuts,
bronchoscopy is carried out promptly
Complications
- The most serious complication of
foreign body aspiration is complete
obstruction of the airway.
- Globular food objects such as hot dogs,
grapes, nuts, and candies are the most
frequent offenders
- Complete airway obstruction is
recognized in the conscious child as
sudden respiratory distress followed by
inability to speak or cough
Three stages of symptoms result from
aspiration of an object into the airway:
- Initial Event
o Violent paroxysms of coughing,
choking, gagging, and possibly
airway obstruction occur
immediately when the foreign
body is aspirated
- Asymptomatic Interval:
o The foreign body becomes lodged,
reflexes fatigue, and the
immediate irritating symptoms
subside.
o This stage is most treacherous
and accounts for a large
percentage of delayed diagnoses
and overlooked foreign bodies.
o It is during this second stage that
the physician may minimize the
possibility of a foreign body
accident, being reassured by the
absence of symptoms that no
foreign body is present
- Complications:
o In this third stage, obstruction,
erosion, or infection develops to
again direct attention to the
presence of a foreign body
Nelsons Pediatrics (Respiratory System)

o Complications include fever, fluoroscopy may provide the same

cough, hemoptysis, pneumonia, information but are unnecessary
and atelectasis - History and physical examination
determine the indication for
Treatment bronchoscopy
- endoscopic removal with rigid
instruments
- Airway foreign bodies are usually
removed the same day the diagnosis is
first considered
Laryngeal Foreign Bodies
- Complete obstruction asphyxiates the
child unless promptly relieved with the
Heimlich maneuver
- Objects that are partially obstructive
are usually flat and thin.
- They lodge between the vocal cords in
the saggital plane, causing symptoms
of croup, hoarseness, cough, stridor,
and dyspnea

Tracheal Foreign Bodies

- 90 % Choking and aspiration
- 60 % Stridor in 60%
- 50 % Wheezing in 50%
- Posteroanterior and lateral soft tissue
neck radiographs (airway films) are
abnormal in 92% of children, whereas
chest radiographs are abnormal in only
58%

Bronchial Foreign Bodies

- Posteroanterior and lateral chest
radiographs: assessment of infants and
children suspected of having aspirated
a foreign object.
- During expiration the bronchial foreign
body obstructs the exit of air from the
obstructed lung, producing obstructive
emphysema (air trapping) with
persistent inflation of the obstructed
lung and shift of the mediastinum
toward the opposite side.
- Air trapping is an immediate
complication, in contrast to atelectasis,
which is a late finding.
- Lateral decubitus chest films or