1. Done by : Dr.Juhaina Al Musawi Mentor : Dr.Salma Al Mawali Upper airway obstruction

4. Anatomy of the upper airway

6. The difference between peds and adult airway? Prpominent occiput Tounge large in relation to mouth Larynx is higher in neck Narrowest portion at cricoid ring Larynx

9. Causes of Stridor: Anatomic Location, Sound, and Etiology Croup Bacterial tracheitis Subglottic stenosis Foreign body Papillomas Foreign body Adenopathy Tonsillar hypertrophy Foreign body Pharyngeal abscess Epiglottitis Acquired Subglottic stenosis Tracheomalacia Tracheal stenosis Vascular ring Hemangioma cyst Laryngomalacia Vocal cord paralysis Laryngeal web Laryngocele Micrognathia ,Pierre Robin Macroglossia, Down syndrome Storage disease Choanal atresia Lingual thyroid Thyroglossal cyst Congenital Subglottic trachea Larynx Vocal cords Nose / Pharynx / Epiglottis Structures High-pitched stridor Inspiratory stridor Biphasic stridor Sonorous, gurgling Coarse, expiratory stridor, Sound Subglottic Trachea Glottic Supraglottic

10. Evaluation of acute upper airway obstruction in children

11. Observation History O/E Investigations Management

16. Management of complete airway obstruction in children

17. Management of severe upper airway obstruction in children

23. Epiglottitis : Lateral neck radiograph Epiglottic width > 8 mm Aryepiglottic width > 7 mm

27. Rapid overview : Epiglottitis ( supraglottitis ) in children Secure airway before diagnostic evaluation if respiratory distress is severe. Communicate early with otolaryngologist, anesthesiologist, and intensivist. Keep the patient in a setting where the airway can be rapidly managed if necessary ( eg, the emergency department, operating room, or intensive care unit) Evaluation Febrile, toxic - appearing children with rapid onset and progression of dysphagia, drooling, and respiratory distress Consider epiglottitis in : Respiratory distress : stridor, tachypnea, anxiety, refusal to lie down, " sniffing " or " tripod " posture . Sore throat, dysphagia, drooling, anterior neck pain ( at the level of the hyoid). Muffled " hot potato " voice Marked retractions and labored breathing indicate impending respiratory failure . Signs and symptoms that may indicate epiglottitis

28. Stridor, drooling, suprasternal and subcostal retractions Swollen, erythematous epiglottis, inflammation of the supraglottic structures Look for signs of extra-epiglottic infection (eg, pneumonia) Findings: Defer examination of the pharynx in children with signs of moderate/severe respiratory distress Examine the patient in the upright position Attempt to visualize the epiglottis (with aid of tongue depressor, direct or indirect laryngoscopy) only in patients with mild distress and not in those with more severe distress Maintain the child in a position of comfort with parent present Avoid invasive procedures Examination :

29. If abrupt obstruction: Attempt bag-valve mask ventilation first During laryngoscopy, pressure on the chest by an assistant may produce bubbling and help indicate the location of the glottis Perform needle cricothyrotomy (<8 years of age) or surgical cricothyrotomy (>8 years of age) if unable to ventilate or intubate Secure the airway, if time allows, in the operating room by anesthesia or otolaryngologist (artificially or surgically if necessary) Airway Management : Enlarged epiglottis (&quot;thumb&quot; sign), loss of vallecular air space, thickened aryepiglottic folds, distended hypopharynx, loss of cervical lordosis Findings : Soft-tissue radiograph of the lateral neck (portable if possible) when the clinical diagnosis is in doubt Defer imaging in patients with severe respiratory distress or in whom it will delay definitive visualization of the epiglottis Imaging :

30. Uptodate 2010 patient in the intensive care unit Monitor Cefotaxime OR ceftriaxone PLUS Clindamycin OR vancomycin Administer empiric antimicrobial therapy: Antimicrobial therapy Epiglottal cultures after establishment of artificial airway Blood cultures after the airway is secured Laboratory studies :

32. Diagnosis …. ? Retropharyngeal abscess

48. Croup / steepling of the subglottic trachea

53. THANK YOU

55. Child with classic presentation of acute epiglottitis Tripod posture (toxic appearance)