Tuesday, December 26, 1995 23:36:55
               Factoids Item
       From:           Sylvia Feder,Medic One OnLine
       Subject:        Upper airway obstruction (notes)
       To:             Factoids
                       
       Cc:             
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TITLE: THE MANAGEMENT OF ACUTE UPPER AIRWAY OBSTRUCTION
SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: July 12, 1994
FACULTY: RONALD W. DESKIN, M.D.
DATABASE ADMINISTRATOR: Melinda McCracken, M.S.
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"This material was prepared for the Postgraduate Training
Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was
prepared for the purpose of stimulating group discussion in a conference
setting. No warranties, either express or implied, are made with respect
to its accuracy, completeness, or timeliness. The material does not
necessarily reflect the current or past opinions of members of the UTMB
faculty and should not be used for purposes of diagnosis or treatment
without consulting appropriate literature sources and informed professional
opinion."

I. Infection in the Pediatric Airway

A. Location

1. Supraglottic

2. Subglottic

3. Tracheitis

B. Why Are Symptoms So Severe?

1. Size of the airway

2. Loose submucosa

3. Rigid subglottic i.e., 1mm of swelling equals 35% decrease
in circumference

II. History

A. Onset

1. How presented?

2. Duration?

3. Progressive?

4. History of foreign body?

B. Associated Illness

1. URI

2. Cough

3. Medications

C. Allergy

1. Penicillin

2. Asthma

3. Other meds

D. Associated Symptoms

1. Cough

2. Hoarseness, muffled voice

3. Sputum

4. Cyanosis

5. Vomiting

6. Drooling

7. Fever

8. Dysphagia, throat pain

E. Time and Nature of Last Oral Intake

F. Family History

G. Other Conditions/Respiratory, Cardiovascular, Neurologic

III. Physical Examination

A. Cyanosis

B. Position

C. Anxiety

D. Drooling

E. Describe Stridor

F. Retraction

G. Voice of Cry

H. Respiratory rate and depth

I. Pulse and temperature

J. Auscultation

IV. Decide on Consultants and Call Them

V. Physician Stays with Child

A. Parent's lap

B. Sitting on stretcher

C. Do not lay down

D. No upsetting procedure such as IV, ABG, Blood Culture, Throat
Culture or Throat Exam

E. Keep room traffic down
VI. Initial Treatment

A. Cool Mist

B. Vaponefrin

C. If arrest occurs - positive pressure with mask and oxygen

VII. Triage Nurse

A. Calls Consultants

B. Notifies OR and ICU

C. Hold Elevator

D. Get emergency equipment ready in the emergency room

E. Proper scopes

F. ETT-appropriate size and two sizes smaller

G. McGill forceps

H. Tonsil Suction

I. Succinyl Choline

J. Monitor Child

K. Act as parent if parents are upsetting child or cannot function

VIII. Disposition

A. Avoid unnecessary delay in ER

B. Radiology?

C. Portable X-ray?

D. Operating room - set up and ready

E. Direct laryngoscopes - intubating type

F. Bronchoscope size 3 and 4

G. Tracheotomy set

H. Foreign Body instruments

IX. Transfer to OR

A. Induction with mask - gentle

B. IV after asleep

C. Laryngoscopy

D. Oral ETT - Change to nasal tube

E. Size smaller than usual for age

F. Throat culture, blood culture and LP?

X. PICU

A. Sedate and restrain

B. Humidified oxygen with unencumbered ETT

C. Frequent saline and suction

D. NPO - NG tube

E. Antibiotics for 10 days - 7 days IV

F. If CSF positive - 10 to 14 days IV

G. AMP/chlor or 3rd generation cephalosporin

H. Extubate 48 hours

I. Criteria/afebrile, improved condition overall, leak around ETT

J. in PICU? in OR if above uncertain

K. NPO and PICU X 8 hours

L. Transfer to floor

M. Prophylaxis for contacts - AAP common I.D.

XI. Croup - LTB

A. DL and NTT, if ( some prefer tracheotomy):

-Severe stridor needing epi treatment increasingly frequent

-cyanosis unrelieved by oxygen

-pulse consistently greater than 180
steroids usually given before this point to try to avoid
intubation (1mg per kg of decadron)

B. PICU Care as with Epiglottis

1. Rare to be able to extubate sooner than 3 to 4 days

2. Decadron, 1 mg per kg 4 hours prior to extubation

XII. Bacterial Tracheitis

A. Croup Symptoms - but poor response to treatment

B. Older Child

C. 50% Staph Aureus

D. X-ray - scalloping of tracheal walls

E. Treatment

1. Bronchoscopy to remove crusts

2. IV Fluid

3. Humidification

4. Anti-Staph antibiotic

5. ETT, trach rarely
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BIBLIOGRAPHY

1. Apley, John: "The Infant with Stridor," Arch. Dis. Child.
28:423, 1953.

2. "Acute Epiglottitis in Children," New Eng. J. of Med. 258:870,
1958.

3. Holinger, Paul: "Pediatric Laryngology," Otolaryngologic Clinic of
North America. 625-37, Oct. 1970.

4. Gross, Chas: "Treatment of Upper Airway Obstruction in Children,"
Otolaryngologic Clinics of North America. 157-65, Feb. 1977.

5. Bluestone & Stool: "Pediatric Otolaryngology," Vol. II. 1152-1156-1259,
W.B. Saunders & Co., 1990.

6. Ashcraft, C. & Steele, Russell: "Epiglottitis - A Pediatric Emergency"
J. of Resp. Disease. 48-60, July 1988.