Upper airway diseases

EPIGLOTTITIS

J05.1

DESCRIPTION

Life-threatening upper airway obstruction at the level of the supraglottic structures (epiglottis and arytenoids).
The condition is rare since H. influenzae type b vaccination has been introduced.

DIAGNOSTIC CRITERIA

  • Acute onset, high fever, sore throat, dysphagia, refusal to eat or swallow, drooling and muffled voice.
  • Position of comfort to protect the upper airway: sitting upright, head forward, open mouth, neck in extension.

GENERAL AND SUPPORTIVE MEASURES

  • Do not interfere with the protective mechanism of the patient. Allow the child to remain sitting up.
  • Avoid all measures that could agitate the patient:
    • make no attempt to see the epiglottis,
    • do not routinely perform X-rays of neck and chest,
  • Secure airway before IV line insertion and blood sampling.
  • Monitor oxygen saturation (pulse oximeter).

Acute airway obstruction

Caution
Epiglottitis is an upper airway emergency.
Total upper airway obstruction is imminent by the time stridor appears.
Prepare equipment for bag-mask ventilation, endotracheal intubation, needle cricothyroidotomy and tracheostomy.

  • If airway obstructs completely or respiratory arrest occurs, attempt to establish an airway: ventilate with bag and mask.
  • If unable to ventilate: intubate.
  • If unable to intubate: perform needle or surgical cricothyroidotomy.

Total airway obstruction may occur suddenly and quite unpredictably; the patient should ideally be intubated before referral. Intubation should preferably be performed under general anaesthesia in an operating theatre.

If intubation prior to referral is not possible, transfer patient as an emergency advising transfer staff to avoid lying the child down. Inform the receiving hospital before departure.
During transport, if the child decompensates, attempt bag and mask ventilation.

After an open airway has been secured:

  • take blood for cultures,
  • swab epiglottis for microscopy, culture and sensitivity,
  • monitor heart rate, respiratory rate, blood pressure and SaO2 ,
  • ensure adequate nutrition and hydration.

MEDICINE TREATMENT

  • Oxygen, humidified, if needed.
  • Ceftriaxone, IV, 50 mg/kg/dose, once daily for 7 days.

REFERRAL

  • All, once airway is secured.

LARYNGOTRACHEOBRONCHITIS, ACUTE VIRAL (CROUP)

J05.0

DESCRIPTION

Potentially life-threatening airway obstruction in children and one of the most common causes of stridor in children aged between 6 months and 2 years.
The most important viruses causing laryngotracheobronchitis (LTB) include:

  • para-influenza virus (most common),
  • measles,
  • herpes simplex,
  • adenovirus.

DIAGNOSTIC CRITERIA

Clinical

  • a previously healthy child who, a day or two after the onset of an upper respiratory tract infection, develops progressive airway obstruction with a barking cough and stridor,
  • a mild fever may be present,
  • stridor becomes softer as airway obstruction becomes more severe.

The following features suggest a different diagnosis:

  • acute onset of obstruction without prodromal features (foreign body or angioneurotic oedema),
  • incomplete immunisation and a membrane in the upper airway (diphtheria),
  • high fever, dysphagia, drooling or sitting position (epiglottitis, retro-pharyngeal abscess, bacterial tracheitis),
  • recurrent upper airways obstruction (laryngeal papilloma).

Assessment of severity of airway obstruction in LTB

Severity Inspiratory
obstruction
(Stridor) 		Expiratory
Obstruction
(Stridor) 		Pulsus paradoxus
Grade 1 +
Grade 2 + +
passive expiration
Grade 3 + +
active expiration
using abdominal
muscles 		+
Grade 4 Cyanosis, apathy,
marked retractions,
impending apnoea 		Cyanosis, apathy,
marked retractions,
impending apnoea 		Cyanosis, apathy,
marked retractions,
impending apnoea

GENERAL AND SUPPORTIVE MEASURES

  • Monitor the nutritional status and fluid requirements.
  • Monitor oxygen saturation, heart rate and respiratory rate.
  • Avoid arterial blood gas estimations. Clinical criteria are more effective in determining severity.
  • Depending on severity, admit child to high care or intensive care ward.

MEDICINE TREATMENT

Grade 1 obstruction

  • Prednisone, oral, 2 mg/kg as a single dose.

OR

  • Dexamethasone, IV/IM, 0.5 mg/kg as a single dose.

Note:
Avoid steroids in patients with measles or herpes infection.

Grade 2 obstruction

As above
PLUS

  • Adrenaline (epinephrine), 1:1000, nebulise with oxygen, every 15–30 minutes until expiratory obstruction is abolished.
    • 1 mL adrenaline (epinephrine) 1:1 000 diluted in 1 mL sodium chloride 0.9%.

Grade 3 obstruction

As above:

  • if improvement, treat as in grade 2 but reduce frequency of adrenaline (epinephrine) nebulisations with time,
  • if no improvement within 1 hour, intubate, preferably under general anaesthetic,
  • Refer.

Grade 4 obstruction

As above and:

  • continue steroids,
  • continue with adrenaline (epinephrine) nebulisation with 100% warm humidified oxygen,
  • emergency intubation or intubation under general anaesthesia, if circumstances permit,
  • If unable to intubate, bag and mask ventilate and refer urgently.

For suspected herpes:

  • Aciclovir IV, 10–15 mg/kg/dose 8 hourly for 5–7 days.

For suspected bacterial infection in children < 20 kg:

  • Ampicillin, IV, 12.5–25 mg/kg/dose 6 hourly for 5–10 days.

For suspected bacterial infection in children > 20 kg:

  • Ampicillin, IV, 250–500 mg, 6 hourly for 7 days.

AND

If bacterial tracheitis is suspected:

  • Cloxacillin, IV, 50 mg/kg/dose 6 hourly for 7 days.

REFERRAL

  • Intubated children for ICU care. Intubate all children with grade 3 airway obstruction not responding to adrenaline nebulisations and all children with grade 4 airway obstruction before referral.
  • Children with an uncertain diagnosis.