AIRWAY OBSTRUCTION

IN CHILDREN
PEDIATRIC RESPIROLOGY
CHILD HEALTH DEPT.
GADJAH MADA UNIVERSITY
 INTRODUCTION

• AIRWAY OBSTRUCTION :
* Upper Airway obstruction
* Lower Airway obstruction
Difference between peds &adult airways?

• The tongue:larger,easily displaced

>>> Cause of airway obstruction in child.

• The narrowest pediatric airway:

 subglottic pathology
more likely than adults.
• The most significant obstruction 
Small radius of the pediatric larynx.

• REMEMBER – 1mm of swelling in an

infant airway causes BIG problems!!!

 Moderate/Severe airway obstruction 

hypoxia, hypercapnia, and acidosis
progress rapidly  cardiac arrest.
• Stridor: rapid turbulent flow
through a narrowed airway.

• The sound: depends degree of constriction

& localization obstruction.

• Observation  the best clue to

localization, before stethoscope
• Supraglottic lesions: Epiglottitis
 inspiratory stridor,
 prolonged inspiratory phase
 muffled cry or voice.

• Glottic lesions:
 high-pitched inspiratory stridor
 weak or hoarse voice

• Subglottic lesions:
 expiratory stridor
 normal voice and a brassy cough
 Expiration: passive
 Active expiration
 Prolonged exp. Time
 Recruitment accessory muscles
 Wheezing

Significant severe lower airway obstruction.

Signs and symptoms of respiratory
distress………..
• Tachycardia
• Tachypnea
0-2 months RR P 60x/min
2-12 months RR P 50x/min
1-5 years RR P 40x/min
• Suprasternal retractions:
 more severe obstruction than
intercostal and subcostal retractions
WARNING SIGNS/Impending respiratory failure
include: - marked retractions,
- decr. or absent breath sounds,
- increasing tachycardia,
- decreasing respiratory effort or rate,
- decreasing stridor,
- a worried or unsettled appearance.

Ominous signs are:

- Decr. level of conc.
- Extreme pallor
- Decr. Heart rate.
• Cyanosis:  extremely late sign in
upper airway obstruction

A CHILD WHO DOES NOT CRY

 IS NOT BEING GOOD.
THE CHILD IS IN BIG TROUBLE
 ETIOLOGY
• Congenital :
 in young infants
 Tumors
 Edema secondary severe allergic reaction.

Acquired :
- infection,
- trauma,
- neoplasia,
- inhalation of foreign body
• Traumatic etiologies:
- Foreign bodies
- External trauma to the neck
- Burns
- Iatrogenia (ex. Postintubation)

• Upper airway obstruction is a common

cause of pediatric emergency (15%)
• Infectious etiologies: 90%
Viral croup: 80%.

• Epiglottis: 5% of severe cases.

• Other causes
- Other infections etiologies
(bacterial tracheitis, tonsillar pathology,
mononucleosis, and diphtheria)
Inspiratory obstruction = extrathorax

- Obstruction is heard during inspiration

- Usually monophonic
- High pitched
 In croup

Low to medium pitched:

Adenotonsillar hypertrophy.
 Congenital malformations
• Nasal, nasopharyngeal, and oropharyngeal
malformations
- Retrognathia (Pierre Robin syndrome)
- Nasal, choanal, or nasopharyngeal stenosis
- Tumor, mass Craniopharyngioma, Anterior
encephalocele, Teratoma
- Adenotonsillar hypertrophy
- Obesity or redundant pharyngeal tissue
- Hypotonia (e.g., Down syndrome)
- Oral cavity or pharyngeal tumor
- Lingual tumor : Lingual thyroid tumor, Hemangioma
- Neck masses : bronchial cleft cyst, Cystic hygroma
• Laryngeal or subglottic airway malformations
- Laryngomalacia
- Paralyzed vocal cords
- Laryngeal or arytenoid cysts
- Laryngocele
- Subglottic stenosis
- Subglottic hemangioma
• Infection
- Nasal, nasopharyngeal, and oropharyngeal infection.
Tonsillitis and peritonsillar abscess
Sublingual abscess (Ludwig’s angina)
Retropharyngeal abscess
• Allergy and asthma
- Anaphylactoid reaction to food or
inhalant
- Vocal cord dysfunction
• Metabolic problem
- Hypocalcemia or hypomagnesemia
• Acquired tumor (rare)
 Expiratory obstruction = intrathoracic
- Sound obstruction on expiration
- Focal or monophonic
- Low to medium pitch
- Diffuse or polyphonic medium to high pitch.

Congenital malformations
Tracheobronchial tree malformations
Tracheobronchomalacia
Primary (focal or diffuse) tracheobronchomalacia
Tracheobronchomalacia secondary to
compression by tumor (focal).
Congenital malformations
• Tracheostenosis
VATER (vertebral defects, imperforate anus, tracheo
esophangeal fistula, radial and renal dysplasia),
association
Complete tracheal rings
• Vascular compression (ring or sling)
- Aberrant subclavian vein
- Pulmonary artery sling ( aberrant left pulmonary artery)
- Right-sided thoracic aorta with left ductus arteriosus
- Left-sided thoracic aorta with right ductus arteriosus
- Double aortic arch.
• Dilated cardiac chamber or dilated pulmonary artery with
compression
• Infection
- Intrinsic airway narrowing
Bronchitis
Bronchiolitis
Laryngotracheobronchitis
Bacterial tracheitis
Bronchiectasis
Cystic fibrosis
Juvenile respiratory papillomatosis (late)
- Extrinsic airway compression
Mycobacterial or fungal infection with lymph node
enlargement.
Infection or congenital foregut malformations, cysts
Lung abscess.
• Foreign body or aspiration
- Gastroesophageal reflux with bronchitis
- Foreign body in airway
- Foreign body in esophagus
• Trauma
- Tracheobronchial burns or scalds
- Tracheobronchial injury (blunt or penetrating)
• Allergy and asthma
- Anaphylactoid reaction to food or inhalant
- Asthma with inflammation or bronchospasm
• Autoimmune disease
- Bronchiolitis obliterans after lung or bone
marrow transplant
- Idiopathic bronchiolitis obliterans
• Tumor
- Primary airway narrowing
> Hamartoma
> Benign tumors (e.g., lipoma, chondroma, myoblastoma)
> Malignant tumor
Bronchial adenoma
Bronchogenic carcinoma
Sarcoma
- Extrinsic airway compression
> Hodgkin’s lymphoma
> T cell lymphoproliferative disease with mediastinal mass

> Sarcoma
• Pulmonary edema
 Croup

• Laryngotracheobronchitis
• Most common cause of infectious
acute upper airway obstruction.
• 10% of children with croup require
admission,
• 1-5% require intubation,
Pathophysiology

• Entry  nose & nasopharynx

• Prodrome: few days of mild URI
nasal congestion, sore throat & cough

• Spreads distally  edema.

• Hoarse voice: bark like cough
• Stridor usually develops at night
• Viral etiologies:
- Parainfluenza virus type 1
- Influenza
- Respiratory syncytial virus (RSV)
- Rhinoviruses
- Measles.

• Mean age: 18 months

- Slight male predominance
- Seasonal increase: autumn & early winter.
Croup
• May have elevated temperature.
• May have mild expiratory wheezing
• Inspiratory stridor at rest with nasal
flaring, suprasternal and intercostal
retractions.
• Poor air entry
• Lethargy + agitation = HYPOXIA
• Dehydration
Treatment of Croup
• Humidified air or oxygen

• Steroids are controversial

• Albuterol treatment 2.5mg in 3ml NS

• Epinephrine  It has been shown to decrease

airway obstruction
 Epiglottitis
• Also known as supraglottitis

• First: in 1878
adults. “angina epiglottidea anterior”

• 60% male dominance

Epiglottitis
• Occurs in children 3-7 year
- Only 4% < 1 year

• Hemophilus influenzae (bacterial

infection)  common etiology

- Other: Viruses, allergic reactions,

physical and thermal injuries
Pathophysiology
• Epiglottis  followed by bacteremia.

• The epiglottis, aryepiglottic folds, false

vocal cords, and supraglottic structures
 inflamed & edematous
 Narrowed airway

• Inspiratory airway occlusion:

 Prior to total occlusion from
supraglottic edema.
Pathophysiology con’t….

• Ingesting hot liquids may develop of

epiglottitis.
• Scald burns to the face.
• Foreign bodies
• Inhalation injuries
• Exposure to crack cocaine
• Burns from a crack cocaine pipe
screen filter.
The evidence…..
• Swollen epiglottis (the thumb sign)
• Thickened epiglottic folds
• Obliteration of the vallecula
Signs and symptoms

• Very sudden , progresses rapidly

• Muffled voice or cry
• Minimal cough
• Sore throat, fever, hoarseness
• Difficulty swallowing saliva
• Intercostal muscle retractions
• Noisy, high-pitched, squeaky inhalations
• Purple skin and nails
 Why do children with epiglottitis
have airway obstruction?

• Fatigue
• Laryngospasm
• Progressive swelling of the
supraglottic structures
• Pooled secretions
Croup Epiglottitis
• Voice – hoarse • Voice – muffled
• Cough – barking • Cough – usually none
• Fever – yes • Fever – yes
• Saliva – minimal • Saliva – lots
• Neck swelling – little • Neck swelling – lots
• Begins – slowly • Begins – suddenly
• Season – autumn • Season – all year
• Time – • Time – all day
evening/night
Remember……………
• Failure to manage the airway is
the leading cause of
preventable deaths in children.
Treatment of epiglottitis
• DO NOT AGITATE THE CHILD IN
ANY WAY

• Airway management

• Administer high flow humidified

oxygen

• Position of comfort
Treatment con’t…..

• Advanced airway management, IV,

cardiac monitor, Pulse ox, etc

- Always have a smaller ET tube

readily available because of the
possibility of significant airway edema.

• Watch for aspiration

LOWER AIRWAY
OBSTRUCTION
ASTHMA
DEFINITION
• Chronic inflammatory disease of the air way

associated with - airway hyperresponsiveness

- air flow limitation
- respiratory symptoms
• Air way inflammation
* Acute bronchoconstriction
* Swelling of the air way
* Chronic mucous plug formation
* Air way remodelling
 ASTHMA
Allergen, viruses,
Chemical sensitiser,
emotions, weather
/seasonal changes, Inflammation
pollution? eosinophilic
bronchitis
Triggers

Symptoms Airway
cough,
wheeze,dispneu, hyper responsiveness
chest tightness
TRIGGERS
Classification of Asthma Severity (from GINA)
Symptoms Night-time PEF
symptoms
STEP 4 Continuous limited Frequent < 60% predicted
Severe physical activity variability >30%
persistent
STEP 3 Daily, use ß 2 > once a week > 60-80%
Moderate agonist daily, predicted,
persistent Attacks affect Variability >30%
activity
STEP 2 > Once a week, > twice a P80% predicted
Mild but < once a day month Variability 20-30%
persistent
STEP 1 < once a week O twice a P 80% predicted
Intermittent Asymptomatic, month Variability <20%
normal PEF
between attack
 ASTHMA MANAGEMENT

• Key components: assesment

management
• Assesment of asthma severity
- Severity of asthma attack
- The episode of asthma
(Classification of Asthma Severity )
 CLASSIFICATION OF ASTHMA ATTACK
Signs & Mild Moderate Severe Impending
symptoms Resp. failure
Activity walking Talking Rest
(infant) (loudly (weakly (can’t eat)
crying) crying)
Talking Sentence Phrase Word

Position Supine Sitting Tripot

position
Consciousness May be Usually Usually Confuse
agitation agitation agitation
Cyanosis No No +

Wheezy Moderate, Hihg pitch, Audible Difficult/ No

the end of exp. + without
expiration insp. stethoscope
Dyspneu Mild Moderate Severe
Accessories No Yes Yes Paradoxal
muscle
Retraction shallow, moderate, + Deep, + nasal Shallow or (-)
intercostals sup.stern ret. flare
ret.
RR Tachypnea Tachypnea Tachypnea Menurun

HR Normal Tachycardia Tachycardia Bradicardi

Paradoxal No Yes Yes No

pulse (<10 mmHg) 10-20 mmHg >20 mmHg (Muscle
weakness)
PEF / FEV1 (% predictive)
-pre b.dilat. >60% 40-60% <40%
-post b.dil >80% 60-80% <60%
SaO2 >95% 91-95% <90%

PaO2 Normal >60 mmHg <60 mmHg

PaCO2 <45 mmHg <45 mmHg >45 mmHg

 Goals of Treatment

The overall goal is control of asthma

- minimal chronic symptoms
- minimal episodes
- no emergency visits
- minimal need for using ß2 agonist
- no limitation on activities
- PEF variability < 20%
- (near) normal PEF
- minimal or no adverse effects from medicine
 DRUGS
• RELIEVER
- Asthma attack
- ß2 agonist orally or inhaler
• CONTROLLER
- To prevent asthma attack (frequent
episode)
- Inhalation Corticosteroid (ICS)