Paediatric Airway Assessment and Management

69 Paediatric Airway Assessment and Management


69.1 Paediatric Larynx


• Functions:


figure Protection of tracheobronchial tree on swallowing


figure Coughing


figure Phonation


figure Straining


• Differences from adult larynx:


figure More anterior


figure Higher: C3 to C4 (C6 in adults)


figure Larger epiglottis+ omega-shaped


figure Cricoid cartilage narrowest part of airway 4 to 5 mm (adult is glottis 7 × 4 mm)


69.1.1 Child with Stridor Features


• Biphasic (high in trachea)


figure Subglottic stenosis


figure Subglottic haemangioma


figure Croup


• Expiratory


figure Asthma


figure FB


• Inspiratory (level of larynx)


figure Web


figure VF palsy


figure Papilloma


figure Haemangioma


figure Inflammatory, e.g., epiglottitis


• Stertor


figure Choanal atresia


figure Ads


figure Macroglossia, e.g., Down syndrome


figure Micrognathia, e.g., Pierre Robin sequence


figure Muscular incoordination, e.g., cerebral palsy


Timing of Onset

• Birth


figure Subglottic stenosis


figure Web


figure VF palsy (hydrocephalus—Arnold–Chiari)


• 1st few weeks


figure Laryngomalacia


• 2–6/12


figure Subglottic haemangioma


figure Vascular ring


• 1 year


figure Papilloma


• Iatrogenic


figure Subglottic stenosis


Specific Points from History

• Difficulty feeding


• Poor wt gain (growth curves), i.e., failure to thrive


• Any cyanosis: lung/cardiac problems


• Voice/cry normal: papillomas


• Worse supine: laryngomalacia


• Previous intubations, PICU, SCBU, prem—subglottic stenosis


• Cardiac surgery—VF palsy, subglottic stenosis


• Respiratory symptoms—lung disease


• GORD


Examination

• Respiratory—tracheal tug, intercostal recession, respiratory rate, cyanosis


• Cutaneous haemangioma—50% with subglottic haemangioma have a cutaneous one


• Nasal airway


• Micrognathia


• Syndromal


• Oropharynx—tonsil size


All children with stridor need direct laryngoscopy!


Differentiating between Epiglottitis and Croup

• See Table 69.1


69.1.2 How to Examine Paediatric Larynx


• See Table 69.2


Order of Frequency of Endoscopies for Airway Problem

1. Subglottic stenosis


2. Laryngomalacia


3. VF palsy


4. Tracheomalacia


Table 69.1 Differentiating between epiglottitis and croup




















































  Epiglottitis Croup
Cause Haemophilus type B Parainfluenza
Age 2–5 yrs 6/12–2 yrs
Onset Fast (hours) Slow
Fever High Low grade
Dysphagia Marked None
Drooling Yes Minimal
Cough No Barking
Voice Muffled Hoarse
Stridor Inspiratory Initially inspiratory then biphasic
Treatment

• Do not distress child


• Secure airway in theatre with senior anaesthesiologist


• IV access


• Swab


• BCs


• ABx 3rd-generation cephalosporin (Ceftriaxone) or chloramphenicol

• Humidification


• Oxygen


• Nebulized adrenaline (1 mL of 1 in 1000 over 30 min)


• ABx (cephalosporin)


• Dex (0.25 mg/kg)


Table 69.2 How to examine a paediatric larynx
















  Pros Cons
1. Awake flexinasendoscopy <18/12—child that tolerates

• Laryngomalacia


• VF palsy

• View trachea

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Jul 4, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Paediatric Airway Assessment and Management

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