Stridor, Stertor, and Snoring: Pediatric Upper Airway

Obstruction Nathan Page, MD

Pediatrics in the Red Rocks

June ?

• I have no disclosures

• I do not plan to discuss unapproved or off label use of products

Outline • Pediatric airway anatomy

• Airway examination and key airway sounds

• What constitutes an airway emergency?

• Airway management tools

• Common pediatric airway emergencies

Laryngeal Anatomy

Pediatric Larynx Adult Larynx

Pediatric vs Adult Larynx

• Location

• Consistency

• Size

• Shape

• Configuration

Pediatric vs Adult Larynx

•Location • Consistency

• Size

• Shape

• Configuration

Location

- More rostral

(i.e. higher)

- Cricoid reaches:

C4 at birth

C5 at 2yo

C6-7 at 15yo

Pediatric vs Adult Larynx

• Location

•Consistency • Size

• Shape

• Configuration

Consistency

• Softer, more pliable tissues

• Submucosal tissue is looser, less fibrous

• Stenosis more likely with internal injury to larynx

Pediatric vs Adult Larynx

• Location

• Consistency

•Size • Shape

• Configuration

Size

- Newborn larynx 1/3 adult size

- Greater cartilagenous portion of vocal cords (1/2 in infant, ¼-1/3 in adult), leads to greater injury potential

Pediatric vs Adult Larynx

• Location

• Consistency

• Size

•Shape • Configuration

Shape

Cylinder Funnel

Adult Infant

• Narrowest portion of the pediatric larynx is the cricoid cartilage

• Narrowest portion of the adult larynx is the glottis (vocal cords)

Pediatric vs Adult Larynx

• Location

• Consistency

• Size

• Shape

•Configuration

Configuration • Epiglottis is narrow, omega-

shaped (Ω)

• Cricoid slightly tilted backward

• Vocal cords at sharper angle

Configuration Thyroid cartilage more obtuse angle

Pediatric Larynx

Airway sounds

• Wheezing – intrathoracic obstruction (expiratory)

• Stertor –nasal/oropharyngeal obstruction (snoring – inspiratory)

• Stridor – laryngeal obstruction (inspiratory or biphasic)

Inspiration Expiration

Inspiration Expiration

Wheezing : Etiologies

• Asthma

• Bronchiolitis

• Structural obstruction of trachea or bronchi • Foreign body

• Tumor

• Compression

Stertor : Etiologies

• Nasopharyngeal obstruction • URI

• Adenoid hypertrophy

• Retropharyngeal abscess

• Craniofacial abnormalities

• Oropharyngeal obstruction • Tonsillar hypertrophy

• Enlarged tongue

• Craniofacial abnormalities

Stridor • Harsh sound caused by turbulent airflow

• Implies partial airway obstruction

• Laryngeal stridor – inspiratory or biphasic

Stridor : Etiologies • Laryngomalacia-different types

• Vocal Cord Paralysis

• Foreign Bodies

• Infectious • “Croup”, Epiglottitis

• Croup (Laryngotracheitis) Masquerade • Subglottic Hemangioma • Recurrent Respiratory Papillomatosis • Post Intubation Glottic and Subglottic Lesions • Congenital Glottic and Subglottic Stenosis • Extra-Esophageal (Gastroesophageal) Reflux Disease/Eosinophilic

Esophagitis

• Laryngeal Clefts

• Trauma

Assessment Strategies

•Guide to diagnosis and intervention • Age • Congenital vs. Acquired • Characteristics of stridor • Clinical picture

Clinical Picture: History

• Onset: acute, chronic, progression

• Prior respiratory problems

• Ex-preemie (NICU stay)

• Prior intubation

• GERD symptoms

• Wheezing episodes

• Feeding problems: • FTT, weight gain

• Choking episodes

• Acute events

Clinical Picture: Associated signs & symptoms

• Acute Disease

• Fever • Drooling (new onset) • Change in cry • Decrease in oral intake • Body position

Physical Examination

• Auscultation of bilateral lungs AND neck

- Asymmetric or unilateral wheezing

- Transmitted airway sounds

- Inspiratory vs expiratory vs biphasic stridor

• “Headless” stethoscope

What constitutes an airway emergency?

Assess Urgency

• Nasal flaring

• Tachypnea

• Retractions

• Drooling

• Cyanosis

• Desaturation is a very late sign!!!

• If the above are present – immediate action!

Severe Respiratory Distress

• 1.Evidence of supraclavicular, sternal, or intercostal, retractions

• 2.Nasal flaring (<2 yr)

• 3.Grunting respirations

• 4.Tripod position

• 5.Stridor at rest

• 6.Marked Wheezing

• 7. Pulse oximetry < 95%

From The Red Book page 5-5.

Croup (laryngotracheobronchitis)

• Fever, upper respiratory symptoms

• “Barky” cough

• Inspiratory stridor

• Starts after 6 months of age

• Hospitalized pt: IV steroids, mist tent, hydration, O2 sat monitor

Laryngomalacia

Laryngomalacia

• Most common cause of stridor in infants

• Strong association with reflux

• Inspiratory stridor

• Resolves by 12-18 months in most cases

• Minority need surgery – 1-10%

Breaker videos

Tracheomalacia

• More common in preterm infants

• Expiratory stridor and cough

• May be aggravated by bronchodilators

• Reflux treatment can benefit

• Typically resolves with time

• Primary vs secondary

Secondary tracheomalacia

• Innominate artery compression

• Vascular rings and slings

Complete tracheal rings

Subglottic hemangioma

• “Croupy” symptoms begin at 6-8 weeks

• Mean age at diagnosis is 4 mos

• Grows until one year old, then slowly regresses

Subglottic stenosis

• Barky cough and inspiratory stridor

Risk factors:

• Prematurity

• Prior intubation

• GERD

• Can develop at any age

Retropharyngeal abscess

• Infection of lymph nodes in the retropharyngeal space

• Fever

• Drooling

• Neck stiffness

Average age 2-3 yo

Frequently requires operative drainage

Epiglottitis

• Infection of the epiglottis caused by Haemophilus influenzae type B

• Upright posture

• Drooling

• Fever

• Stridor

• Muffled voice

DO NOT AGITATE CHILD.

DO NOT EXAMINE THROAT.

TRANSPORT UPRIGHT IMMEDIATELY!

Epiglottitis

Neoplasm

Aerodigestive Tract Foreign Bodies • The Usual Suspects-you name it

Airway Foreign Bodies

• The usual suspects: • Food -2/3 of Airway FB

• Non Food items • Pen caps

• Tacks

• Pins

• Toys

• Insects

Airway Foreign Bodies-Food

• Frequency: • Peanut (26%)

• Seeds (7%)

• Meat (7%)

• Popcorn (5%)

• Carrot (5%)

• Hot Dog

• Chicken

• Fish bone

• Apple

• Candy

• Fatalities: • Hot dog (16%)

• Candy (10%)

• Grape (8%)

• Meat (7%)

• Peanut (7%)

• Carrot (6%)

• Cookie (6%)

• Apple (5%)

• Popcorn (5%)

• Bread (4%)

Altkorn et al: Fatal and non fatal food injuries among children Intl J Ped Otorhinolaryngol (2008) 72, 1041-1046

Airway Foreign Bodies-Food

• Children < 3 y.o. increased risk • 69% of injuries (peanuts, seeds, popcorn, apples, carrots)

• 79% of deaths (Hot dogs, apples, bread, carrots, cookies, grapes)

• Incomplete dentition

• Immature swallowing coordination

• Easily distracted

Altkorn et al: Fatal and non fatal food injuries among children Intl J Ped Otorhinolaryngol (2008) 72, 1041-1046

Airway Foreign Bodies • History is key to diagnosis

• Witnessed choking event in 32-51%; subsequent coughing spell generates concern

• Symptoms are mild or absent by time of evaluation in 60%--transient wheeze • Asymptomatic interval- FB becomes lodged and reflexes fatigue. False sense of

security

• Complications- Erosion/ Obstruction/ Infection

Airway Foreign Bodies • Physical Examination:

• Cough (69%), • Decreased Breath Sounds (52%), • Intermittent/ Unilateral Wheeze (45%), • Intermittent Dyspnea