Pediatric Upper Airway

Emergencies
Sangeeta Schroeder, MD
Resident Noon Conference

Usual Suspects
Infectious

Other Infectious

Croup
Bacterial Tracheitis
Epiglottitis

Infectious Mono
Neck Abscess
Retropharyngeal
Paratonsillar

Pediatric Upper Airway Emergencies

 Anatomic/Congenital
Malacia
Laryngo; Tracheo; Broncho

Vascular Rings/Slings
Laryngeal Webs
Subglottic Stenosis
Subglottic Hemangioma

Other
Anaphylaxis
Foreign Body
Pediatric Upper Airway Emergencies

Extrathoracic/Supraglottic
Lacks cartilaginous
support
Composed mostly of
soft tissue and muscle

Glottic/Subglottic
Smallest part of the
pediatric airway
Some cartilaginous
support

Intrathoracic
Tracheo-Bronchial Tree

Pediatric Upper Airway Emergencies

Epiglottitis
Laryngomalacia
Croup
Subglottic Stenosis
Subglottic Hemangioma
Laryngeal Webs
Bacterial Tracheitis
Tracheomalacia
Vascular Rings/Slings
Bronchomalacia

Pediatric Upper Airway Emergencies

Clinical Presentation:
Infectious
History
Fever
High fevers with sudden onset: bacterial infections

URI symptoms
Acute onset of symptoms
Acute worsening of insidious symptoms
Incomplete Hib immunization: Epiglottitis
Associated Varicella infection: Epiglottitis
Pediatric Upper Airway Emergencies

Clinical Presentation
Exam
Anxious appearing child; tripod positioning:
epigottitis, bacterial tracheitis
Gurgling sounds without stridor: epiglottitis
Severe respiratory distress: bacterial tracheitis,
severe croup
Nasal congestion: croup

Pediatric Upper Airway Emergencies

Bacterial Causes
Epiglottitis

Bacterial Tracheitis

Acute process of edema and

inflammation
Two age groups: <3 and 6-7
Strep pneumo, Strep
pyogenes, Staph aureus
Tripod positioning
Anxious appearing out of
proportion to their signs of
respiratory distress
Upper airway gurgling sounds
without stridor or retractions

Pseudomembrane formation
from direct bacterial invasion
Mucous, bacteria,
inflammatory products

Can be a complication of croup

Usually less than 6 yrs
Staph aureus, Strep pyogenes
Tripod positioning
Anxious and toxic appearing
with cough, stridor and severe
retractions

Pediatric Upper Airway Emergencies

Laryngotracheitis (Croup)
Inflammation and mucous production in the subglottis
Parainfluenza (1,2,3), Influenza (A,B), RSV, Adenovirus
Mild nasal congestion that progresses to a barking
cough and/or stridor
Categorized into Mild, Moderate or Severe
Mild: no stridor at rest; can have stridor with activity
Moderate: stridor and retractions at rest
Severe: stridor and severe retractions at rest associated
with behavioral changes (extreme agitation or lethargy)

Pediatric Upper Airway Emergencies

Diagnostics
Croup: Steeple Sign on AP view
Epiglottitis: Thumb Sign on Lateral view
NOT WARRANTED

X-Ray only if you suspect a foreign body

Bacterial Tracheitis: Laryngoscopy

Pediatric Upper Airway Emergencies

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Endoscopic Visualization
Epiglottitis

Bacterial Tracheitis

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Treatment: Croup
Humidified Air and Cool Mist are not effective treatments
0.6mg/kg Decadron PO/IM for ALL croup
Do not need to repeat dose

Racemic epi nebs for moderate and severe croup

If there is stridor at rest: use racemic epi

Continuous to Q4 PRN
Observe for 2-3 hrs after treatment for epi to wear off
Rebound Effect: likely not real

Admission Criteria:
2 or more racemic epi treatments
Poor PO intake or inadequate follow-up
Admit to PICU if on continuous racemic nebs
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Treatment:
Bacterial Tracheitis
Airway Management
Bronchoscopy to suction purulent and necrotic
debris
Continued suctioning while intubated

IV Antibiotics
Vancomycin + 3rd Generation Cephalosporin

PICU admission

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Treatment: Epiglottitis
Do all kids with epiglottitis need intubation?
Prospective study done in Germany in 1996
International Journal of Pediatric Otorhinolaryngology

Fiberoptic visualization of airway

Assess degree of inflammation and airway involvement

Kids managed without intubation increased from 8% to 45%

Mean age of child intubated: 3.4
Mean age of child not intubated: 6.1

Regardless, current practice is to still intubate all kids with

epiglottitis in a controlled environment
IV Antibiotics and PICU Admission
Vancomycin + 3rd Generation Cephalosporin

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Clinical Presentation:
Anatomic/Congenital
History Overview
Insidious and/or intermittent symptoms
Past history of prolonged intubation or severe GERD:
subglottic stenosis
Trisomy 21: congenital subglottic stenosis
DiGeorge Syndrome: laryngeal webs
Congenital Cardiac Lesions: laryngeal webs, vascular
rings
Underlying neuromuscular disorder/hypotonia:
tracheo/bronchomalacia
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Clinical Presentation
Exam Overview
Hypotonia: Malacia
Skin Hemangiomas: Subglottic hemangioma
Biphasic Stridor: Subglottic hemangioma
Surgical Scars: Subglottic stenosis
Abnormal Facies: Laryngeal webs
Caf au lait spots: Neurofibromas of the airway

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Congenital Causes Clinical

Presentations
Laryngomalacia
Intermittent episodes of stridor without fever
Usually Mild without evidence of respiratory
distress
Worsens with activity/URIs
Worse in the supine position
Most self-resolve by 1 year
Male predilection
Associated GERD (more severe)
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Laryngomalacia
Epiglottis
-Tall and Narrow
Aryepiglotic Folds
-Thin, Flacid
Arytenoids

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Congenital Causes Clinical

Presentations
Tracheo/Bronchomalacia
Symptoms are more persistent and severe than
laryngomalacia
Significant distress with mild URIs and basic
activities (coughing/feeding/stooling)
Underlying hypotonia

Pediatric Upper Airway Emergencies

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Congenital Causes:
Subglottic Stenosis
Acquired V congenital
If no hx of intubation, considered to be congenital

Males >> Females

Two forms
Mucosal: Submucosal hypertrophy (more common)
Cartilaginous: Narrow cricoid cartilage (more severe)

Usually presents with biphasic stridor during

URIs
Recurrent Croup
Acquired is usually more severe
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Congenital Causes:
Subglottic Hemangioma

Females >> Males

Insidious presentation of biphasic stridor without fever
Recurrent Croup
Rapidly enlarges from 2 months to 1 year of age
Resolve by 2-5 yrs of life
Most need surgical management prior to 2 years
50% will have a face/neck hemangioma
Enlarging hemangioma: sudden upper airway
obstruction and distress
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Congenital Causes:
Laryngeal Webs
Weak cry, horseness
Varying degress of resp distress
Type 1 (<35% webbing) Type 4 (>75% webbing)
Caused by failure of normal embryonic tissue
regression
Type 4 usually diagnosed at birth with respiratory
failure
1/3 associated with other anomalies of the airway

Subglottic stenosis (most common)

Recurrent croup
Pediatric Upper Airway Emergencies

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Congenital Causes:
Vascular Rings/Slings
Tracheo-esophageal compression
Caused by the abnormal persistence of embryonic
tissue that comprises the aortic arch
Double aortic arch (50-60%)
Right aortic arch with an aberrant left subclavian (12-25%)
Pulmonary artery sling

Wheezing (from the ring/sling) and stridor (from

ass. GERD)
Often diagnosed as recurrent bronchiolitis
Can present with sudden apneic and cyanotic spells
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Diagnostics

Laryngomalacia: Usually not warranted

Tracheo/bronchomalacia: Bronchoscopy
Subglottic Stenosis: Rigid Bronchoscopy
Subglottic Hemangioma: MRI
Airway endoscopy to rule out other causes

Laryngeal Webs: Laryngoscopy, Lateral neck films

Sail sign: persistent tissue from the glottis to the
subglottis

Vascular Rings: Barium Swallow, MRI

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Treatment: Malacia
Laryngomalacia
Self-resolves by 1 year as the larynx travels into the
neck
Treat concurrent GERD
Surgical correction is rare: Supraglottoplasty

Tracheomalacia/Bronchomalacia
Self resolve by 1-2 years
If pt has underlying hypotonia, can be persistent

Treatment focused on concurrent infections

Often will need Positive Pressure ventilation until the
airways grow in size (CPAP, BiPAP)
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Treatment
Subglottic Stenosis
More than self resolve by
2 years of age
Surgical Interventions:
Stenting
Tracheostomy
Usually can de-cannulate by
3-4 yrs of age

Reconstruction
(Laryngotracheoplasty)
Reserved for severe cases

Subglottic Hemangioma
Regress completely by 5
years of age
Most require intervention
Small/Medium hemangiomas:
Steroid Injections, Endoscopic
Laser Ablation
If a circumferential area is
ablated at one treatment:
subglottic stenosis

Large hemangiomas:
resection, tracheostomy

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Treatment:
Webs and Rings
Laryngeal Webs

Child is observed until they are 3-4 yrs of age if able

Types I-II: knife or laser ablation
Types III-IV: early larygo-tracheal reconstruction
Complicated webs may require revision surgeries

Vascular Rings
Corrected early
Decrease the risk of malacia
Allow for normal growth of the tracheo-bronchial tree
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Key Points
Dexamethasone 0.6mg/kg IM or PO has become the mainstay
of treatment for croup, regardless of severity.
Bacterial Tracheitis is now the most common infectious cause
of pediatric upper respiratory emergencies, with the most
common bacterial agents being Staphylococcus aureus and
Streptococcus pyogenes.
Epiglottitis is no longer a disease of infants. Since
Haemophilus type B immunization, the most common causes
of epiglottitis are Streptococcus pneumonia and group A
strep. With this change in bacterial etiology, the average age
of children with epiglottitis is now 6-7 years.
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Key Points
Laryngomalacia is often seen in otherwise healthy infants who
present with intermittent stridor that is worse with activity. Almost
all infants present by the age of 6 weeks and resolve their
symptoms by the age of 1 year.
Tracheomalacia is often seen is infants with underlying diagnosis
that lend to truncal hypotonia. These children can decompensate
quickly in the face of an otherwise benign viral respiratory infection.
Stenosis/Webs/Rings are often misdiagnosed as croup and
bronchiolitis. If you are seeing a child with recurrent croup or
bronchiolitis, make sure to consider these diagnoses.
Subglottic hemangiomas should be considered in any child
presenting with progressively worsening stridor in late infancy who
also has other hemangiomas present, especially on the chin and
neck.

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References

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3Kussman BD, Geva R, McGowan F. Cardiovascular causes of airway compression. Pediatric
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New England
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of Medicine 2004; 351:1306-1313
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