Pediatric Airway Obstruction




UPPER AIRWAY OBSTRUCTION



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AIRWAY PHYSICS





  • Poiseuille’s law




    • Q=ΔPπr48ηl; r = Radius of airway



    • Flow (Q) is proportional to the radius to the fourth power; incremental changes in the radius cause exponential decreases in airflow




  • Bernoulli’s principle




    • Increased airflow results in a decrease in pressure



    • Narrowed airway → Increased airflow speed → Decreased intraluminal pressure (vacuum) → Further collapse of walls of lumen




  • Stridor – high-speed airflow through collapsed tissues causes vibration and a resonance, resulting in a sound




NOISY BREATHING





  • Physical obstruction of the airway is associated with noise on inspiration or expiration, depending on the site and nature of the lesion



  • Stridor is not only audible, but also visible




    • Examiner should be able to visualize site of obstruction while noise is being made



    • Requires adequate instrumentation techniques of the airway




  • Isolated tachypnea (i.e., without stridor) is not a sign of airway obstruction





SYMPTOMS BY SUBSITE SEE TABLE 20-1



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TABLE 20-1

Symptoms by Subsite






LESIONS AND TREATMENTS BY SUBSITE



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NASAL OBSTRUCTION





  • Piriform aperture stenosis




    • Bony narrowing of the anterior nasal vestibule in neonates; results in airway-related respiratory distress and feeding problems



    • Diagnosed by computerized tomography (CT) scan showing <8 mm patency between nasal processes of maxillary bone



    • Can be associated with holoprosencephaly (central incisor) or choanal atresia



    • Treatment: sublabial approach to nasal vestibule with high-powered drill reduction of nasal process of maxillary bone




  • Choanal atresia/stenosis




    • Incomplete or uncannulated opening from the nose to the nasopharynx in neonates; results in airway-related respiratory distress



    • CHARGE syndrome (coloboma, heart defects, atresia choanae, growth retardation, genital abnormalities, and ear abnormalities)



    • May go undiagnosed if unilateral



    • Treatment: transnasal or transpalatal resection of posterior obstructive tissues





PHARYNGEAL OBSTRUCTION





  • Adenotonsillar disease




    • Most common cause of obstructive sleep apnea (OSA) in children



    • Diagnosed by direct visualization on exam and attended nocturnal polysomnogram



    • Treatment: adenotonsillectomy adequately treats >80% of patients with pharyngeal airway obstruction




  • Pharyngomalacia




    • Poor pharyngeal muscle tone, results in collapse of tissues and obstruction with stertor



    • Treatment: noninvasive positive pressure ventilation (continuous or bilevel)




  • Glossoptosis/macroglossia (Figure 20-1)




    • Tongue and tongue base obstruction of the airway



    • Pierre-Robin’s sequence, Down’s syndrome, lingual tonsil hypertrophy, isolated micrognathia, Ludwig’s angina (anterior floor of mouth abscess)



    • Treatment: alleviate obstruction by resection, advancement, or bypass (i.e., tracheotomy)




  • Pharyngeal obstruction results primarily in sleep apnea symptoms





FIGURE 20-1


Glossoptosis causing upper airway obstruction. Note how the base of the tongue compresses the epiglottis against the posterior pharynx.


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Jan 14, 2019 | Posted by in PEDIATRICS | Comments Off on Pediatric Airway Obstruction
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