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2 Pediatric Upper Airway Obstruction • Appreciated radiographically as a “steeple sign”

(Definition, Etiopathogenesis, Clinical manifestations, Diagnosis, due to subglottic narrowing
Management) • Management is non specific and the goal is to
prevent further airway obstruction.
ü Definition • Oxygen supplementation is given to those with
1. Upper airway obstruction is an impedance of airflow from moderate to severe croup.
the level of the upper nares to the distant end of the • Mist vaporizer moistens airways and decreases
trachea. The most commonly affected sites are the viscosity of airway secretions, making it easier for
pharynx, larynx or trachea. the patient to expectorate.
• Nebulized racemic epinephrine is a topical alpha
ü Etiopathogenesis adrenergic stimulant which decreases airway
1. As air is forced through a narrow tube, it undergoes a edema by mucosal vasoconstriction in the
decrease in pressure. This, in Physiology, is known as the subglottic region (0.5-2.0 mL of 2.25% solution)
Venturi effect. • Corticosteroids reduce duration and severity of
2. The decrease in lateral pressure causes the airway walls symptoms (Oral Dexamethasone 0.6 mg/kg PO,
to collapse and vibrate, generating stridor. single dose)
3. Airway resistance is inversely proportional to the 4th 2. Epiglottitis
power of the airway radius; that even 1mm of edema in • It is the acute inflammation of the epiglottis that
the normal pediatric subglottis reduces its cross-sectional may progress rapidly to life threatening airway
area by >50% obstruction.
4. Causes of acute upper airway obstruction may be • It is most commonly due to an infection by the
infectious or non-infectious. bacteria Haemophilus influenzae serotype B,
v Infectious Causes: however, nation wide vaccination decreased its
1. Laryngotracheobronchitis/ Croup incidence.
• It is an inflammation of the upper airway which • Occasionally, Streptococcus pneumoniae and
leads to severe swelling in the glottic area. Staphylococcus aureus act as etiologic agents.
• It is mainly due to an infection from Parainfluenza • It is most commonly seen among children between
virus types 1 & 3 or occasionally Respiratory 2 and 7 years of age.
Syncitial Virus (RSV) • Clinical manifestations include fever, “drooling”,
• Clinical manifestations include coryza (sneezing, sore throat, stridor, respiratory distress, absence
nasal congestion, rhinorrhea), brassy cough/ “seal of cough.
bark”, hoarseness, occasional dysphagia, • The symptoms worsen when the patient is supine
inspiratory and expiratory stridor and the patient prefers an erect, chin forward or
• The age of onset is between 6 months and 2 years. sniffing position
• Symptoms are not affected by patient’s position.

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• Diagnosis is clinical, however a throat swab culture • Xray findings, though unnecessary, include (+)
and sensitivity may be needed when one is irregular tracheal margins.
suspecting another etiology. • Management is the same as with epiglottitis.
• Radiologic appearance includes a swollen • Bronchoscopy assists in removal of purulent
epiglottis in a lateral neck xray pseudomembranes which may improve tracheal
• Management involves keeping the patient seated, toilette and may lessen airway obstruction.
provide supplemental oxygen, administer • Some patients may require intubation and
nebulized racemic epinephrine to decrease airway ventilatory support.
edema, always be ready to perform emergency • Antibiotics used are Ampicillin-Sulbactam or 3rd
endotracheal intubation. Generation Cephalosporin + Clindamycin to cover
• Give 2nd or 3rd Gen Cephalosporin to ensure anaerobes.
adequate coverage of the most common • Vancomycin is used if suspecting MRSA.
infectious pathogens 4. Retropharyngeal or Peritonsillar Abscess
• Cefuroxime or Ceftriaxone 50mg/kg IV • It is secondary to suppuration of the lymph node
• Add Vancomycin 10mg/kg IV when suspecting in these areas.
resistant strains. • Etiologic agent may be due to oral anaerobes, S.
• Antibiotics are continued for 7-10 days. aureus, S. pyogenes, or polymicrobial.
• Oral Dexamethasone 0.6 mg/kg PO is used to • Clinical manifestations include neck pain, severe
decrease mucosal edema. dysphagia, excessive drooling, ipsilateral ear pain,
3. Bacterial tracheitis/ Bacterial Croup neck swelling, stiffness with torticollis and
• Is an uncommon infection which may also cause hyperextension.
life threatening upper airway obstruction. • There is bulging of the posterior oropharynx
• It usually develops secondarily after a viral URTI. (retropharyngeal abscess) and a characteristic
• Mucosal damage impairs mucociliary clearance of “hot potato voice” (muffled), (+) contralateral
the thick, purulent secretions which leads to deviation of the uvula.
obstruction. • Diagnosis is clinical. On xray, peritonsillar abscess
• Etiologic agents include S. aureus, S. pneumoniae, appear as enlarged tonsillar soft tissue and
S. pyogenes, and M. catarrhalis retropharyngeal abscess appear as a thickened,
• Clinical manifestations include a history of URTI bulging retropharyngeal soft tissue.
with sudden worsening, accompanied by high • Management involves monitoring and
fever, stridor, and mucopurulent cough. There stabilization of the airway. Secure an intravenous
may also be sore throat, tenderness on palpation access for fluids and antibiotics.
of the trachea, raspy voice with no dysphagia. • Localized abscess may be treated with antibiotics
• Diagnosis is clinical. But CBC and Gram stain and alone: Ampicillin-Sulbactam + Clindamycin; 2nd or
culture may help document the disease.

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3rd Gen Cephalosporin + Clindamycin; all the rest o check-valve obstruction that results in
must have incision and drainage. hyperinflation of the affected side and
• Corticosteroids administered once may reduce mediastinal shift to the opposite side.
inflammation. o Perform Postero-Anterior and Lateral views to
v Non infectious causes of Acute Upper Airway Obstruction increase diagnostic sensitivity.
1. Angioedema (recall notes from Anaphylaxis/ Anaphylactoid ü Management
lecture) v Perform Basic Life Support (BLS) if complete obstruction
2. Airway Foreign Body leads to cardio-pulmonary arrest
• Occur in children between 1 and 3 years old as a result v Perform direct laryngoscopy for foreign body extraction
of oral exploration and uncoordinated swallowing- v Emergency tracheostomy if with failed ET intubation
breathing. v Bronchoscopic removal of foreign body under general
• Objects that are aspirated are usually food or toys. anesthesia
• There must be a high index of suspicion for diagnosis. A
sudden history of coughing or choking is the most
predictive of all signs and symptoms.
• Clinical manifestation
o The location of the aspirated foreign body plays a
role in determining the signs and symptoms on
presentation, though there may occasionally be an
overlap.
o Laryngotracheal obstruction presents with stridor
and/or hoarseness.
o Bronchial obstruction presents with unilateral
wheezing and/or decreased breath sounds. 80% of
foreign body obstruction are found in the bronchi.
• Diagnosis
o Plain radiographs may be helpful to confirm the
diagnosis but should not be used to exclude the
diagnosis because xray films are normal in >50% of
tracheal foreign body and 25% of bronchial foreign
body.
o 75% of foreign body in the pediatric population are
radiolucent. Indirect radiologic signs include:
o unilateral obstructive emphysema
o atelectasis
o consolidation

GAFIR UST-FMS 2017