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Acute Upper Airway Obstruction

Most children who present to the hospital with acute upper airway obstruction have croup (acute laryngo- tracheobronchitis) or epiglottitis. Other differential diagnoses include bacterial tracheitis, inhaled foreign body and angioneurotic oedema.

On presentation, assess severity by examining for:

  • constitutional state (toxicity, fever, pulse rate)
  • stridor
  • drooling
  • cough
  • speech
  • tachypnoea
  • tracheal tug on inspiration
  • intercostal and subcostal indrawing on inspiration
  • asynchrony of chest and abdominal wall movement
  • cyanosis in air

Guidelines For The Diagnosis Of Croup And Epiglottitis

Characteristic Epiglottitis Croup
Appearance toxic and unwell well looking
Onset abrupt onset viral prodrome, slower onset
Fever high fever (>38.5oC) moderate fever
Stridor usually moderate-severe usually mild-moderate
Cough minimal or absent barking, seal-like quality
Speech unable to speak hoarse voice
Secretions unable to swallow, drooling of saliva able to swallow

Note: Each of these clinical signs in isolation is a poor discriminator however, considered together, they usually allow the correct diagnosis to be made.

Important Notes

  1. All children with stridor must be reviewed by the paediatric admitting officer before discharge home or admission to the ward.
  2. If the child is cyanosed he is likely to die very quickly -notify paediatric ICU immediately. The aim is to transfer severely obstructed children to ICU before intubation becomes imperative, as it is preferable to intubate them in ICU.
  3. as a child becomes physically exhausted the stridor, indrawing and air entry may decrease.


Management Of Severe Upper Airway Obstruction

  1. Notify Paediatric ICU Consultant to arrange transfer to ICU.
  2. Give oxygen and an adrenaline nebuliser (0.5 ml/kg of 1:1,000 solution; maximum dose 5 ml) for 10 minutes.
  3. Do not :
    • inspect the oropharynx
    • send the patient to radiology for a lateral neck or chest X-Ray
    • insert an IV
    • take blood gases

Management Of Croup

  • Mild - Barking cough and inspiratory stridor only when upset or minimal stridor at rest.

    Watch fluid intake. Hourly pulse and respiratory rate.

  • Moderate - Suprasternal and sternal retraction at rest. Child not particularly distressed or anxious looking and drinking reasonably well.

    Watch fluid intake. Quarter hourly pulse and respiratory rate. If a child's condition deteriorates with rising pulse, rising respiratory rate and the appearance of restlessness then nebulised adrenaline (0.5 ml/kg of 1:1000 solution; maximum dose 5 ml) or intubation is becoming urgent.

    Note :The administration of oxygen is only for the management of hypoxia while admission to Paediatric ICU and intubation is being arranged. Oxygen therapy is not a substitute for the relief of the child's upper airway obstruction.

  • Severe - Inspiratory and expiratory stridor at rest. Sternal and suprasternal retraction. Give oxygen and an adrenaline nebuliser (0.5 ml/kg of 1:1000 solution; maximum dose 5 ml) and notify Paediatric ICU to arrange transfer.

The decision to give nebulised adrenaline is to be made by the Registrar on duty in conjunction with Paediatric ICU. Children requiring adrenaline nebulisers should be transferred to Paediatric ICU however, a single dose may be given if the transfer cannot be effected safely without it. A member of the medical staff and a senior nurse must accompany the child to ICU. A doctor should always be in attendance when a child is receiving nebulised adrenaline.

Use Of Steroids In Croup

The literature supports the use of a single dose of steroids in the inpatient management of acute viral croup. There is no evidence to support its use in children with mild croup not requiring admission to hospital.

A few children with severe persisting croup may require further doses of steroids in a lower dose (0.5 mg/kg/dose). Further doses should be considered in children with moderate to severe croup, particularly those who need inhaled adrenaline or referral to ICU.

Administration of Steroids

Children admitted with a diagnosis of croup should be given a SINGLE DOSE of steroids in the emergency room either as IM dexamethasone or oral prednisolone.

  • Dexamethasone IM
    Child's weight Dose Preparation
    5-10 kg 5 mg 5 mg/ml
    11-20 kg 8 mg 8 mg/2 ml
    21-30 kg 10 mg 5 mg/ml


  • Oral prednisolone suspension
    Child's weight Dose Preparation (5mg/ml)
    5-10 kg 25 mg 5 ml
    11-20 kg 50 mg 10 ml
    21-30 kg 75 mg 15 ml

Investigations for croup

The only investigation performed routinely is a NPA for viral identification. Other investigations will usually be ordered after discussion with the consultant - e.g. a lateral neck x-ray if the pattern of the stridor is unusual.

Discharge

Children are normally discharged after they have had a relatively symptom free night. For most children this generally means 2 nights in hospital.

Follow-up

Most children with croup are not followed up. Those who are include: all intubated patients, prolonged stridor (> one week), multiple episodes (>6), children under 6 months of age.

Epiglottitis - A Medical Emergency

Important Notes:

  1. Most children with suspected epiglottitis are admitted directly to Paediatric ICU as approximately 80-90% of patients will require intubation.
  2. Occasionally a child will reach the ward, usually with the diagnosis not suspected. If the admitting doctor thinks epiglottitis is possible, he should immediately contact the unit Registrar. If the Registrar is concerned, the Paediatric ICU consultant should be contacted. Deaths have occurred when the RMO thought that a child admitted with croup had epiglottitis but was not sure, and decided to review the child in a short time before calling a Registrar. The children died before the resident had the opportunity to review the patient.
  3. The administration of oxygen is for the management of hypoxia while admission to Paediatric ICU and intubation are being arranged. Oxygen therapy is not a substitute for the relief of the child's upper airway obstruction.
  4. Transfer back from ICU: Most children will be transferred out of ICU shortly after extubation. They should continue intravenous antibiotics until they are drinking well.

Discharge

Children are usually discharged 24 hours after extubation, providing they are drinking well and able to take oral antibiotics. The antibiotics are continued to complete a 5 day course.

Follow-up

All patients who are admitted with epiglottitis should be followed up by the referring Paediatrician.

Inhaled Foreign Body

  1. Acute Presentation
    Children are admitted if the history is suggestive of foreign body inhalation (eg abrupt onset of respiratory symptoms in a previously well child who was playing with peanuts), the physical examination reveals asymmetry of the physical signs in two hemithoraces and/or a CXR demonstrates air trapping in one hemithorax during expiration.
  2. Late Presentation
    A missed foreign body may present with recurrent or persistent collapse or consolidation (pneumonia) of a lobe, usually a lower lobe of the lung.

Management

  1. Arrange good inspiratory and expiratory chest x-rays if they are not already available. If there are only outside films these should be repeated or copied for our records.
  2. Nil orally until a decision is made about the need and timing of bronchoscopy by the appropriate surgical endoscopist.
  3. Physiotherapy is contraindicated in suspected inhaled foreign body.

Prevention

Children less than 2 years of age should not be offered foods such as popcorn, raw carrot sticks or apples. Toys with small component parts should also be avoided in this age group. Peanuts should not be offered to children less than 4 years of age.