Approach to upper airway obstruction (pediatrics): Clinical sciences

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Introduction0:00–0:28

Upper airway obstruction occurs when any part of the airway above the thoracic inlet is blocked based on the site of obstruction.
Upper airway obstruction can be subdivided into nasopharyngeal supraglottic glottic subglottic and tracheal. If your patient presents with a chief concern, suggesting upper airway obstruction, first perform an ABCD E assessment to determine if your patient is unstable or stable, if unstable, stabilize their airway breathing and circulation.

Unstable Patient0:28–1:06

In some cases, you might need to intubate your patient or even place a surgical airway emergently. Next, obtain IV access and put your patient on continuous vital sign monitoring, including respiratory rate, pulse oximetry and cardiac monitoring.
Finally, if needed, don't forget to provide supplemental oxygen. Once you stabilize the patient, obtain a focused history and physical exam to determine the underlying cause.

Epiglottitis1:06–2:14

First, let's start with epiglottitis. In this case, your patient's caregiver will usually report a rapid onset of high fever as well as difficulty breathing and swallowing with the drooling and the absence of a cough.
The physical exam typically reveals an anxious appearing child, sitting upright with their neck extended in a tripod position with the chin pushed forward.
Additionally, your patient may have a muffled voice, audible stridor with labored breathing and a cherry red epiglottis.
These findings are highly suggestive of epiglottitis. Here's a clinical pearl.
If the findings don't clearly point to epiglottitis, you can order a lateral neck X ray. If imaging reveals a thumb sign and swelling of the airy epiglottic folds, you can confirm the diagnosis of epiglottitis.
Next up is bacterial tracheitis. These patients might have a recent history of a viral upper respiratory infection with rapid onset of high fever, hoarseness, progressive stridor and respiratory distress.

Bacterial Tracheitis2:14–2:51

That's not responsive to nebulized racemic epinephrine. Additionally, physical exam reveals a toxic appearing child with a biphasic stridor.
These findings are highly suggestive of bacterial tracheitis. Finally, let's go over anaphylaxis.

Anaphylaxis2:51–3:29

In this case, your patient's caregiver will typically report a rapid onset of facial swelling and dyspnea without a fever.
They may also have a known allergy with exposure to a specific food or another allergen such as insect venom. Meanwhile, the physical exam may reveal hypotension as well as audible stridor and wheezing.
Additionally, you may notice facial edema and a diffuse urticarial rash. Based on these findings, you can diagnose anaphylaxis.
Now, let's return to the ABCDE assessment and discuss stable patients. First, obtain a focused history and physical examination.

Stable Patient3:29–4:01

Patients usually have a history of dyspnea with or without a cough while physical exam might reveal signs of respiratory distress like suprasternal intercostal and subcostal retractions.
Additionally, you might notice audible stern stridor or monophonic or localized wheezing. With these findings.
You should consider upper airway obstruction. Next, assess for signs and symptoms of nasopharyngeal obstruction, such as audible stern and visible tonsillar or pharyngeal swelling.

Nasopharyngeal Obstruction4:01–4:31

If these are present, consider nasopharyngeal causes of upper airway obstruction, including retropharyngeal abscess, peritonsillar, abscess, tonsillitis and adenotonsillar hypertrophy.
First, let's discuss retropharyngeal abscess, which is most commonly seen in preschool age. Children.

Retropharyngeal Abscess4:31–5:48

Patients typically have a preceding viral upper respiratory infection and subsequently develop neck pain and dysphasia. They may have poor oral intake due to dysphasia and some might even report chest pain and dyspnea on exam.
They are often anxious and ill appearing with a stiff neck and limited neck mobility. You may also detect a palpable neck mass drooling and respiratory distress.
These findings are highly suggestive of a retropharyngeal abscess. Here's a clinical pearl.
Another diagnosis to consider here is epiglottitis. Usually Children with epiglottitis, drool and lean forward in the tripod position.
While Children with retropharyngeal abscesses, drool and hyperextend their necks to diagnose retropharyngeal abscess. You may need to order an X ray of the neck which shows a widening of the retropharyngeal space or prevertebral soft tissue swelling.
Now, let's consider patients with peritonsillar abscess, which is most commonly seen in adolescents. These individuals often present with progressively worsening, sore throat, decreased oral intake and a classic hot potato voice.

Peritonsillar Abscess5:48–6:34

They might also report dysphasia and unilateral otalgia. The physical exam typically reveals unilateral tonsillar bulging with or without uvular deviation drooling or Christmas.
At this point, you can diagnose peritonsillar abscess, which is a clinical diagnosis and doesn't require confirmation with imaging.
Next up is tonsillitis. These patients may present with sore throat and constitutional symptoms like fever and fatigue.

Tonsillitis6:34–7:13

Physical exam. Demonstrates an erythematous pharynx and enlarged tonsils.
Often with exudates. You may detect cervical lymphadenopathy and in some cases splenomegaly.
These findings are consistent with tonsillitis which can be caused by bacteria like group a streptococcus or Neisseria, gonorrhea or by viruses like Epstein Barr virus.

Adenotonsillar Hypertrophy7:13–8:13

Finally, let's go over adenotonsillar hypertrophy. In this case, your patient's caregiver may report nighttime snoring, daytime, sleepiness and attention or behavioral problems.
Some patients might experience apnic episodes as well. A physical exam reveals mouth breathing and significantly enlarged tonsils.
Diagnose adenotonsillar hypertrophy. Here's a clinical pearl.
Some craniofacial malformations can cause upper airway obstruction shortly after birth. One example is bilateral choanal atresia which presents with neonatal respiratory distress that occurs during feeding and is relieved with crying.
Other important conditions include nasal deformities, seen in cleft lip and palate as well as micrognathia that occurs in association with the Pierre Robin sequence.

Nasopharyngeal Obstruction Absent8:13–8:41

Now, let's consider individuals with no signs or symptoms of nasopharyngeal obstruction. In this case, assess your patient for stridor or wheezing if you notice a stridor that is audible during inspiration, consider supraglottic or glottic causes of upper airway obstruction, such as croup, laryngomalacia and vocal cord dysfunction.

Croup8:41–9:44

Let's start with croup. Patients are usually between six months and three years old with a low grade fever and upper respiratory infection, symptoms like nasal congestion or rhinorrhea.
In addition, your patient's caregiver may describe hoarseness as well as rapid onset of a barking or seal like cough that's worse at night.
Additionally, physical exam typically reveals a child with tachypnea, normal oxygen saturation and possible suprasternal intercostal and subcostal retractions at this point.
You can clinically diagnose croup. Here's a clinical pearl if your suspicion for croup is high, but the patient's presentation isn't clear.
You can order a lateral neck, X ray. The presence of the steeple sign with subglottic narrowing supports the diagnosis of croup.

Laryngomalacia9:44–10:19

Next up is laryngomalacia, which is typically seen in infants between three and five months of age. In this case, the stridor is worse during feeding with activity and in a supine position and improves in the prone position.
The physical examination might reveal mild retractions. These findings are suggestive of laryngomalacia which is typically a benign cause of stridor that resolves on its own by 12 months of age.
Moving on to vocal cord dysfunction. History typically reveals an older child or adolescent with an acute onset of dyspnea that's triggered by physical activity or strong emotions.

Vocal Cord Dysfunction10:19–11:07

Additionally, physical exam reveals labored breathing with these findings, you should consider vocal cord dysfunction. So order a flexible fiber optic laryngoscopy.
If direct visualization shows an inappropriate adduction of the vocal cords during inspiration, diagnose vocal cord dysfunction.
This condition can often be confused with asthma. But remember that asthma presents with wheezing and improves with bronchodilators while vocal cord dysfunction doesn't.

Biphasic Stridor11:07–11:29

Now, let's go back and take a look at patients with biphasic stridor, meaning it's present during inspiration and expiration.
In this case, you should consider subglottic causes of airway obstruction such as vascular ring or sling and subglottic stenosis.

Pulmonary Sling11:29–12:08

First, let's focus on the pulmonary sling, which is due to an anomalous left pulmonary artery history typically reveals an infant with dyspnea and noisy breathing that appears to improve with neck extension and worsens with neck flexion.
Sometimes. In addition to a biphasic stridor, you might notice a monophonic wheeze with these findings, consider a pulmonary sling and order a barium swallow.
If imaging reveals an anterior indentation of the esophagus, specifically, you can diagnose a pulmonary sling, then there's subglottic stenosis.

Subglottic Stenosis12:08–12:36

Consider this if history reveals prolonged or recurrent intubation with a chronic barking cough and biphasic stridor that is louder with increased respiratory effort.
Next, order a diagnostic bronchoscopy. If you identify a narrowing of the airway below the vocal cords, you can diagnose subglottic stenosis.
Now that we're done with causes that present with stridor, let's discuss what to do if there's no stridor. But you identify wheezing in this case, consider tracheal causes of upper airway obstruction such as tracheomalacia and foreign body aspiration.

Wheezing12:36–12:57

First, let's discuss tracheomalacia, which commonly occurs in infants and typically resolves by age two. This is associated with cough and intermittent cyanotic episodes.

Tracheomalacia12:57–13:42

Symptoms tend to be worse after bronchodilator use and improve with prone positioning. Physical exam typically reveals a monophonic central expiratory wheeze.
And in some cases, you might hear audible biphasic stridor. With these findings consider tracheomalacia and order a diagnostic bronchoscopy.
If you see dynamic collapse of the tracheobronchial tree diagnose tracheomalacia, finally, let's go over foreign body aspiration.

Foreign Body Aspiration13:42–14:22

These patients might present with an abrupt onset of cough, possibly with a witnessed choking event. The exam will often reveal localized wheezing or the unilateral absence of breath sounds.
However, if there's a higher level of obstruction, you might detect stridor with these findings. Consider foreign body aspiration and consult the surgical team for bronchoscopy.
If bronchoscopy reveals a foreign body in the airway, you just confirm the diagnosis. All right, it's a quick recap unstable patients with upper airway obstruction, usually present with epiglottitis, bacterial tracheitis or anaphylaxis on the flip side.

Review14:22–15:09

In stable patients with signs and symptoms of nasopharyngeal obstruction. Consider nasopharyngeal causes such as retropharyngeal abscess, peritonsillar abscess, tonsillitis and adenotonsillar hypertrophy.
However, if there's no nasopharyngeal obstruction, assess if your patient is presenting with stridor or wheezing. Inspiratory stridor is associated with supraglottic or glottic causes.
While biphasic stridor should make you think of subglottic causes. Finally, if there's no stridor, but you identify wheezing, consider tracheal obstruction and conditions like tracheomalacia and foreign body