Pediatric Airway Disorders and Parenchymal Lung Disease

Upper and Lower airway obstruction

Pneumonia
Tuberculosis
Sickle cell disease
Recurrent aspiration syndrome

The Pediatric Airway

Airway disorders may cause severe and at times sudden threats to a child’s life.
Several factors that causes disorders in the airway stems:
Congenital abnormalities
Anatomical structure itself
Child behavior

Upper Airway Disorders

Structurally, the infant’s larynx is positioned higher in the neck (near C3-4) than
is an adult’s larynx (at C4-5). Because of this superior location, the tongue base
tends to “hide” the larynx from view during direct laryngoscopy.

Upper Airway Disorders

Supralaryngeal Obstruction
Choanal Atresia
Pierre Robin Syndrome
Deep Neck Infections
Tonsillar Enlargement
Peritonsillar Abscess
Retropharyngeal Abscess
Obstructive Apnea
Periglottic Obstruction
Epiglottitis
Laryngotracheobronchitis (traumatic and postoperative)

Supralaryngeal Obstruction
Common causes of obstruction above the larynx include congenital lesions, acute
inflammatory disorders, and disorders related to abnormal supralaryngeal tissue or
airway tone or both (e.g., obstructive apnea).

Choanal Atresia
A congenital disorder where back of the nasal passage (choanal) is
blocked/stenotic. Caused by developmental failure of the nasal cavity that fails to
connect with nasopharynx.
Typically occurs in immediate postnatal period.
Neonates presents severe respiratory distress that appears to lessen with crying.

Manifestations
Noisy labored breathing
Difficult to feed
Cyclic respiratory distress which relieved in crying
Nasal drainage
Breathing failure upon delivery that needs immediate artificial ventilation

Treatment/Prevention
Immediate surgery to remove obstruction as it is the only solution. Surgery may be
done through transnasal or transplatal.
Use of tracheostomy if there are plans to delay surgery.
Since atresia cannot really be avoided as doctors still do not have a clear
understanding about the cause of condition. The Physician would suggest to
avoid/reduce the possible risk factors during pregnancy and eat essential foods
during pregnancy.

Pierre Robin Syndrome

A congenital condition of facial abnormalities
3 main features are:
Cleft palate
Retrognathia (chin projects slightly backwards)
Glossoptosis (airway obstruction caused by backward displacement of the tongue
base)

Cleft Palate
Retrognathia
Glossoptosis

Etiology
Recent studies have indicated that genetic dysregulation of SOX9 gene prevents the
SOX9 protein from properly controlling the facial structure development.
Occurs between 7th week and 11th week of gestation.

Manifestations
Small lower jaw
Tongue which tends to ball up at the back of the mouth and fall back towards the
throat
Horseshoe-shaped cleft palate
Breathing and feeding difficulties

Management
For respiratory symptoms
Should be placed in side-lying or prone position
Oral airway placement (LMA or intubation)
Feeding difficulties
Upright feeding techniques, modification of the nipple for bottle feeding,
temporary use of NGT or consideration of gastrostomy insertion.
Surgery
Tracheostomy
Glossopexy (should be done before start of speech development)
Mandibular lengthening

Deep Neck Infections

Are feared complications of upper respiratory and gastrointestinal tract
infections.
Common causes are aerobic and anaerobic pathogens.
Can be rapidly severe causing airway obstruction and aspiration. Infections can
spread in nearby anatomical structures.

Neck affected compartments

Peritonsillar space
Submandibular space
Parapharyngeal space
Retropharyngeal space
Carotid space

Manifestations
Unusual bulging
Cellulitis
Necrotizing cellulitis
Associated with thrombophlebitis (in severe cases Lemierre’s syndrome)
Airway obstruction
Elevated tongue
Paucity of pus

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Management
Aspiration
Depends upon the site, if the area has too many abscess
Secure artificial airway (use of tracheostomy in severe neck enlargement)
Incision of dead tissues
Antibiotics

Tonsillar/Peritonsillar enlargement and Abscess

Acute illness characterized by fever and sore throat may develop swelling of
oropharyngeal tissues.
Tonsillitis or streptococcal pharyngitis presents as exudative pharyngitis and
cervical adenopathy.
If cough and nasal congestion is present it increases the likelihood that the
infection is viral.

This abscess commonly forms unilaterally around the tonsillar tissue that causes
unilateral swelling and protrusion of the affected tonsil.
Classical deviation of uvula to the unaffected side.
Patients commonly complain about difficulty opening of the mouth.
There are severe sore throat, muffled voice or hoarse voice and torticollis.
Management: should be treated by the use of antibiotics however, in severe cases it
should be surgically removed. If tonsillitis occurs more than 4-7x in a year the
Physician will suggest it to be removed as it will cause rheumatic heart disease.
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Obstructive Apnea
Children with a history of chronic noisy snoring and air flow loss, in spite of
active chest wall movement, are likely suffering from obstructive apnea.
Abnormally large adenoids or tonsils with or without abnormal positioning of the
airway tissues are likely causes of obstruction.
During sleep, the airway muscular tone is decreased, resulting in more severe
airway obstruction.

Management
Medications
Such as nasal steroids like fluticasone and budesonide as it might ease sleep apnea
symptoms for some children who have mild obstruction.
For allergic cause: montelukast with nasal steroids
Positive airway pressure therapy
Removal of adenoids or tonsils
Oral appliance like mouthpieces or some devices that help to expand the palate and
nasal passages or move the child’s bottom of the jaw and tongue forward to keep the
airway open.
Diet modification and exercise

Supraglottic Obstruction
Obstruction of the airway at or just below the level of the glottis typically
presents as high-pitched stridor.
This region is relatively fixed in diameter because the noncompliant cartilage
surrounding the glottis does not “balloon open” to allow air passage around the
obstruction.
Quickly leads to significant distress with both inspiratory and expiratory
compromise.
Cause: Infection
Management: supportive management, antibiotics, O2 therapy, positive pressure
therapy and intubation or tracheostomy in severe cases.

Epiglottitis
A life threatening infection that affects both children and adults.
It results from bacterial invasion of the soft tissues of the larynx causing
inflammation of supraglottic structures that further advanced in the epiglottis.
Most common organism causing epiglottis is Haemophilus influenzae type B.
High fever, severe sore throat, dysphagia with drooling and cough that progresses
to stridor that if left unmanaged will cause respiratory distress. “Thumb Sign” at
lateral neck X-ray
Management: supportive management, antibiotics, O2 therapy, positive pressure
therapy and intubation or tracheostomy in severe cases.

Laryngotracheobronchitis #(Croup Syndrome)

Is the most common cause of airway obstruction in children between 6 months and 6
years of age.
Typically it occurs in the fall and winter. Parainfluenza virus 1 is the most
common cause, resulting in biennial epidemics in the United States during October
through February of odd-numbered years.
Other much less common infectious causes include influenza viruses, RSV, herpes
simplex virus, and Mycoplasma pneumoniae.
Pathognomonic sign: Barking cough

Lateral neck X-ray shows “Steeple Sign” a sharply sloped, wedge-shaped, linear
narrowing of the trachea. This demonstrates the subglottic tracheal edema that
extends from the larynx to the thoracic trachea.
Treatment: mild cases of LTB is largely supportive— ensuring temperature control,
adequate hydration, and humidification of inspired air. Antibiotics, Racemic
Epinephrine, corticosteroids, positive airway pressure and artificial airway.

Lower Airway Obstruction

Obstruction of the Trachea and Major Bronchi
Tracheomalacia
Congenital Tracheal or Bronchial Stenosis
Intraluminal Obstruction
Foreign Body Aspiration
Atelectasis
Bronchiectasis
Acute Bronchiolitis

Tracheomalacia
Is a condition of dynamic tracheal collapse caused by abnormal shape and
flexibility of the tracheal cartilage rings.
The abnormality can affect either a small section or the entire length of the
trachea.
Management: Bronchodilators, calcium with Vit. D supplementation and supportive
treatment.
Treatment: Supportive care, surgery is rarely needed as children will just outgrow
this disorder.

Congenital Tracheal or Bronchial Stenosis

Like tracheomalacia, congenital tracheal or bronchial stenosis may involve
extensive or short lengths of the involved airway.
The severity of symptoms depends on the degree and length of the stenosis.
A common cause of stenosis in the newborn is the formation of a vascular ring.
Occurs in infants with congenital malformation of the great vessels of the heart,
usually a double aortic arch. With this malformation, the aorta wraps around both
the esophagus and trachea.
Management: Bronchodilators, artificial airway insertion, tracheobronchial plasty/
stenting surgery.

Intraluminal Obstruction
An acquired cause of airway narrowing is the development of intraluminal
obstruction. In the child, foreign body obstruction is encountered more commonly
than the adult problem of endobronchial tumor.
Infectious agents (e.g., Mycobacterium tuberculosis) or a neoplasm, classically
Hodgkin’s lymphoma, may cause lymphadenopathy that compresses the airway.
Other differential diagnosis to consider is cardiomegaly in patients with
congenital heart defects, which especially can compress the left main bronchus
because of its anatomical relation to the heart.

Foreign Body Aspiration

Leading cause of accidental death in the toddler is foreign body aspiration. Degree
of severity depends on the nature of material being aspirated.
They can range from unilateral wheezing or recurrent pneumonia, as when peanuts or
popcorn obstruct the smaller airways, to immediate occlusion of the upper airway
with complete absence of air movement and rapid death from suffocation, as seen in
hot dog or balloon aspiration fatalities.
Management: do heimlich’s maneuver or CPR in a worst case scenario.
Anteroposterior and lateral neck and chest radiographs are useful if the object is
radiopaque.

Atelectasis
Is collapsed lung parenchyma and is best compared to a wet sponge that fails to
reinflate after being compressed.
Internal or parenchymal disorders that are characterized by an inadequate tidal
volume, loss of lung compliance (e.g., acute respiratory distress syndrome), airway
obstruction (e.g., mucus plugging), and increased elastance of lung tissue can all
result in atelectasis.
Management: treat the underlying cause, lung expansion therapy, positive pressure
therapy, and mechanical ventilation.

Bronchiectasis
It is an irreversible dilation of the bronchial tree.
Typically the segmental and subsegmental bronchi become irregularly shaped and
dilated, leading to a loss of the typical funnel configuration that allows smooth
central flow of secretions.
May occur acutely after an infection or have a more insidious onset in patients
suffering from chronic pulmonary diseases such as CF or reflux and aspiration.
Management: pallative care, bronchial hygiene therapy, O2 therapy and
bronchodilators.

Acute Bronchiolitis
A condition in infants in which a viral respiratory tract infection results in
clinical symptoms of small airway obstruction.
Causative organism is RSV(most common)
RSV is a highly contagious virus and has its greatest impact on young infants.
Infants younger than 6 months of age are at particular risk of severe infection,
with the peak incidence for hospitalization occurring between 2 and 6 months of
age.
Bronchiolitis(smaller airway) vs. Bronchitis(bronchi/larger airway)
Management: supportive treatment and careful monitoring, O2 therapy,
hospitalization are not necessary if mild.
Pneumonia
Is an infection that inflames the air sacs in one or both lungs. The air sacs may
fill with fluid or pus (purulent material), causing cough with phlegm or pus,
fever, chills, and difficulty breathing. A variety of organisms, including
bacteria, viruses, protozoans and fungi, can cause pneumonia.

Causes
Bacterial
Streptococcus pneumonia
Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella pnumoniae
Legionella pneumophila
Mycoplasma pneumonia
Haemophilus influenza
Chlamydia pneumonia
Acinetobacter baumannii

Viral
Coronavirus
Adenovirus
Respiratory syncytial virus
Rhinovirus
Viruses that causes measles, rubella
Herpes simplex virus

Causes
Fungal
Histoplasmosis
Blastomycosis
Cryptococcosis
Sporotrichosis
Aspergillus
Candida
Coccidiodomycosis
Pneumocystis carinii

Protozoan
Toxoplasma gondii
Ascariasis
Hookworms
Amoeba

Basic pathophysiology

Types of Pneumonia
Community acquired pneumonia
Hospital acquired pneumonia
Health care acquired pneumonia
Aspiration pneumonia
Ventilator acquired pneumonia
Static pneumonia
Community acquired pneumonia
Acquired outside the hospital.
2 types
Typical- usually caused by bacteria
Atypical- usually caused by bacteria, viral, fungal and protozoa
Hospital acquired pneumonia
Pneumonia contracted by a patient in a hospital at least 48–72 hours after being
admitted.
Health Care Acquired Pneumonia
hospitalization in an acute care hospital for two or more days in the last 90 days
residence in a nursing home or long-term care facility in the last 30 days
receiving outpatient intravenous therapy (like antibiotics or chemotherapy) within
the past 30 days
receiving home wound care within the past 30 days
attending a hospital clinic or dialysis center in the last 30 days

Ventilator acquired pneumonia

Acquired due to prolong usage of the ventilator for more than 2 weeks.
Contaminated ventilator circuit (tubings, humidifier, bacterial filters)
Contaminated ventilator
Aspiration Pneumonia
Develops if you accidentally aspirate food, liquid or any gastric contents to your
lungs.
Static Pneumonia
Caused by being immobile.
Most common in patients who are unconscious

Signs and Symptoms

Fever
Chills
Cough mucopurulent secretion
Shortness of breath
Grunting
Nasal Flaring
Fatigue
Chest pain when breathing or coughing(severe cases)

Diagnostic Tests
Chest x-ray (to determine the extent and exact location)
Sputum culture (gold standard test)
Complete blood count (for RBC and WBC monitoring)
Skin test (to avoid drug induced allergies)
ABG (if DOB)

Stages of Pneumonia
Congestion- happens at first 24 hrs of inection, the lung is characterized
microscopically by vascular congestion and alveolar edema. Many bacteria and few
neutrophils are present.
Red hepatization- happens at 2-4 days of infection, so called because of similarity
to the consistency of liver, because of the presence of many erythrocytes,
neutrophils, desquamated epithelial cells, and fibrin within the alveoli.
Gray hepatization- 4-7 days of infection, the lung is gray-brown to yellow because
of fibrinopurulent exudate, disintegration of RBCs.
Resolution- over 3 weeks restoration and resorption of the pulmonary architecture.
Pneumonia Scaling
Mild- can be managed at home with antibiotics prescribed by the physician.
Moderate- needs to be hospitalized at the ward for close monitoring and to avoid
spreading of the disease. Sometimes needs to supplement a low flow oxygen for at
least 1-2LPM.
Severe- needs to be confined at the ICU due to sepsis, drug resistance and late
diagnosis. Most often needs to be intubated immediately.

Goals and Approach to Treatment

Adequacy of respiratory function
Humidified oxygen for hypoxemia
Bronchodilators (Salbutamol)
CPT with Postural Drainage
Adequate Hydration
Expectorants such as Guaifenesin
Chest pain (analgesics)
Use of Antibiotics

Preventive Measures
Smoking Cessation (of a family member)
Influenza Vaccine
Pneumococcal Vaccine
Chin down posture reduces the chance of aspiration both before and during the
swallow.
Follow up chest radiographs for smokers
Avoid crowded places

Tuberculosis/Primary Complex
It is an airborne contagious disease that is caused by Mycobacterium tubercle
bacilli bacteria.
Can also be ingested due to food and drink contamination.
Continuous productive cough for 2 or more weeks with low grade fever.
Hallmark sign: Hemoptysis

Bacterial Causes
Mycobacterium tubercle bacilli (Most common)
Mycobacterium africanum
Mycobacterium bovis

Sites Involved
Pulmonary tuberculosis (85% of all TB cases)
Extra-pulmonary TB (15% of all TB cases)
Bones
Brain
Lymph nodes
Intestine
Genitourinary
Skin

Signs and Symptoms

Central nervous system
Appetite loss
Fatigue and weakness
Low grade fever
Lungs
Chest pain
Hemoptysis
Prolonged cough
DOB
Skin
Night sweats
Pallor

Diagnostic test
Skin test/mantoux test- false positive
Chest X-ray- to determine the extent and exact location
Sputum culture- gold standard test (AFB detection)
CBC

TB drugs
Drugs
Specific Side Effects
RIFAMPICIN

Red Orange Discoloration of Body Fluids

ISONIAZID

Peripheral Neuritis
PYRAZINAMIDE

Hyperuricemia
ETHAMBUTOL

Color Blindness
STREPTOMYCIN

Ototoxicity

Management
Hydration
Patient and family education
Analgesics(PRN)
Oxygen (PRN)
COMPLIANCE of TB drug
Self-quarantine
Airborne precaution
Negative room pressure if possible

Sickle Cell Disease

Is an autosomal-recessive inherited disorder of the hemoglobin structure and is the
most common inherited disease of the African-American population.
Defective hemoglobin S converts from a soluble hemoglobin molecule contained in the
red cells to a gelatinous state in the presence of low oxygen, low pH, rapid
temperature changes, or hypernatremic dehydration.
Gelatinous state causes the red cells to “sickle,” resulting in a variety of
complications, including acute chest syndrome, cardiomegaly and left ventricular
failure, splenectomy, and renal disease.
Signs and Symptoms
Anemia
Pain episodes in some parts of the body
Edema
Stunted growth
Vision problems

Management
Supportive care
Frequent blood transfusions
Stem cell (optional due to its risks)

Recurrent Aspiration Syndrome

Neurologically impaired patients, those with abnormal anatomy of the
gastrointestinal tract or airways, and patients with gastroesophageal reflux are
often diagnosed with recurrent aspiration syndrome.
Diagnosis is based on clinical and radiographic findings. Barium swallow may reveal
a tracheoesophageal fistula or other malformation that requires surgical
intervention.
The cause and severity of the disease determine treatment.