This lecture will discuss Approach to Acute infective upper airway obstruction (infective stridor) in children and paediatric age group. Topics:- Stridor Stridor croup, Epiglottitis laryngitis, bacterial tracheitis Retropharyngeal abscess Spasmodic Croup

1. Approach to Acute infective
upper airway obstruction
(infective stridor) in children
Jwan Ali AlSofi

2. Contents:-
•Stridor
•croup,
•Epiglottitis
•laryngitis,
•bacterial tracheitis
•Retropharyngeal abscess
•Spasmodic Croup
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3. Stridor:-
• It's a harsh noisy inspiratory breathing due to
partially obstructed extrathoracic airways.
• Types:
1. Inspiratory (Supra-glottic)
2. Biphasic (Sub-glottic/glottic to tracheal ring)
3. Expiratory (Tracheo-bronchial)

5. Differential Diagnosis of Acute
stridor:-

7. Indications for imaging and direct laryngoscopy:-
1. Stridor in infants younger than 4 months of age,
2. positional stridor,
3. persistence of symptoms for longer than 1 week

8. Croup (Viral Laryngiotrachiobronchitis)
• Heterogeneous group of acute and infectious processes
characterized by
1. barking or brassy cough
2. hoarseness,
3. inspiratory stridor
4. respiratory distress.
• Is the most common infection of the middle respiratory
tract.

9. Pathology:-
•Laryngotracheal airway inflammation
disproportionately affects children
because a small decrease in diameter
secondary to mucosal edema and
inflammation exponentially increases
airway resistance and the work of
breathing.
•During inspiration, the walls of the
subglottic space are drawn together,
aggravating the obstruction and
producing the stridor characteristic
of croup.

12. Anatomy

13. Etiology:-
• Parainfluenza viruses (types 1, 2, 3) are responsible for about 80% of croup
cases.
• Other infectious causes of croup-like illnesses include the following:
─Adenovirus
─Respiratory syncytial virus (RSV)
─Enterovirus
─Human bocavirus
─Coronavirus
─Rhinovirus
─Echovirus
─Reovirus
─Metapneumovirus
─Influenza A and B

14. Prevalence:-
• Gender
The male-to-female ratio for croup is approximately 1.4:1.
• Age
- Primarily a disease of infants and toddlers.
- Croup has a peak incidence in patients from age 6 months to 3 years.
- In adolescents, it manifests as laryngitis.

15. Natural history of croup:-
1. Most patients have an URTI with some combination of rhinorrhea, pharyngitis, mild cough,
and low-grade fever for 1-3 days before the signs and symptoms of upper airway
obstruction become apparent.
2. The child then develops the characteristic barking cough, hoarseness, and inspiratory
stridor.
• Symptoms are characteristically worse at night .
• Most ED visits occurring between 10 pm and 4 am.
• Other family members might have mild respiratory illnesses with laryngitis.
• Symptoms typically resolve completely within 3-7 days but can last as long as 2 weeks..

16. Clinical Features- History:-
• Coryza.
• Stridor
▫ is a harsh, high-pitched respiratory sound produced by turbulent airflow.
▫ It is usually inspiratory, but it may be biphasic
▫ is a sign of upper airway obstruction.
• Harsh cough described as barking or brassy,
• Fever:-
▫ The low-grade fever can persist.
▫ Some children are afebrile.
• Hoarseness
• Symptoms are characteristically worse at night .
• Agitation and crying greatly aggravate the symptoms and signs.
• The child may prefer to sit up in bed or be held upright.

17. Clinical Features- Physical examination:-
1. Normal to moderately inflamed pharynx.
2. Slightly increased respiratory rate.
3. Wheezing may be present if there is associated lower airway involvement.
• Rarely, the upper airway obstruction progresses and is accompanied by:-
- labored breathing
-cyanosis
-an increasing respiratory rate;
-nasal flaring;
-suprasternal, infrasternal, and intercostal retractions;
-continuous stridor.
• Croup is a disease of the upper airway, and alveolar gas exchange is usually normal 
Hypoxia and low oxygen saturation are seen only when complete airway
obstruction is imminent.
• The child who is hypoxic, cyanotic, pale, or obtunded needs immediate airway
management.

19. LABORATORY Findings:-
 Routine laboratory studies are not useful in establishing the diagnosis.
 Leukocytosis is uncommon and suggests epiglottitis or bacterial tracheitis.
 Many rapid tests (using [PCR]) are available for parainfluenza viruses, RSV, and other less
common viral causes of croup, such as influenza and adenoviruses.

20. Radiological Findings:-
 Croup is a clinical diagnosis and does not require a radiograph of the neck.
 Radiographs are considered only after airway stabilization in:-
1. Distinguishing between severe laryngotracheobronchitis and epiglottitis,
2. Children who have an atypical presentation or clinical course.
 The radiographs do not correlate well with disease severity.
 Lateral radiograph of the upper airway (Anteroposterior radiographs of the neck)
shows:
─ Normal epiglottis
─ Narrowing of the subglottic region
─ Steeple sign in a patient with croup
 Steeple sign:-
-may be absent in patients with croup,
-may be present in patients without croup as a normal variant,
-May rarely be present in patients with epiglottitis.

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23. DIFFERENTIAL DIAGNOSIS:-
•The infectious differential diagnosis includes
1. epiglottitis,
2. bacterial tracheitis
3. parapharyngeal abscess.
•Noninfectious causes of stridor include
▫ mechanical and anatomical causes (foreign body aspiration, laryngomalacia,
subglottic stenosis, hemangioma, vascular ring, vocal cord paralysis).

24. Treatment of Croup:-
1) General Measures
• Children with mild symptoms can be treated with
-humidity,
-antipyretics,
-oral hydration at home.
• Short, acute episodes of stridor can be treated with
-cool mist administered by face mask,
-a bathroom filled with steam from a shower
-cold night air.
• If the stridor persists, worsens or occurs at rest, the child should be seen in the emergency room.
▫ It is important to try to keep the child calm to minimize forceful inspiration as agitation or
anxiety can worsen symptoms and increase work of breathing.

25. 2) Medications
• Corticosteroids and nebulized racemic epinephrine are the first-line treatments for croup.
1. Oral or intramuscular dexamethasone
 Reduces symptoms and the need for hospitalization, and shortens hospital stays.
 Dexamethasone (0.6-1 mg/kg) may be given once intramuscularly or orally.
 Alternatively, prednisolone (2 mg/kg/day) may be given orally in two to three divided doses.
2. Aerosolized racemic (D- and L-)epinephrine
 Reduces subglottic edema by adrenergic vasoconstriction, temporarily producing marked clinical
improvement.
 The peak effect is within 10-30 minutes and fades within 60-90 minutes.
 A rebound effect may occur, with worsening of symptoms as the effect of the drug dissipates.
 Aerosol treatment may need to be repeated every 20 minutes (for no more than 1-2 hours) in severe cases.
 Dose: 0.5 mL of 2.25% solution (D- and L-isomers) in 2.5 mL normal saline delivered via nebulizer as needed.
 L-epinephrine: If racemic epinephrine is not available, 5 mL of L-epinephrine 1:10,000 delivered via nebulizer is
effective.

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27. COMPLICATIONS AND PROGNOSIS:-
1. The most common complication of croup is viral pneumonia, which occurs in 1-2%
of children.
Parainfluenza virus pneumonia and secondary bacterial pneumonia are more common in
immunocompromised patients.
2. Bacterial tracheitis may also be a complication of croup.
• The prognosis for croup is excellent.
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29. • Epiglottitis is a medical emergency because of the risk of sudden airway obstruction
• Is a potentially lethal condition characterized by acute rapidly progressive and potentially
fulminating course of high fever, sore throat, dyspnea, and rapidly progressive
respiratory obstruction and distress (variable).
• Often, the otherwise healthy child suddenly develops a sore throat and fever.
• Within hours, the patient:-
-Appears toxic
-Difficult swallowing,
-Drooling
-Labored breathing.
-Neck is hyperextended in an attempt to maintain the airway.
Acute Epiglottitis (Supraglottitis)

30. Etiology
1. Non-typeable H. influenzae,
2. H. influence type b – in unimmunized patients
3. Staphylococcus aureus
4. Group A streptococcus
• Epiglottitis used to occur among 2-4 yr old children (range from 1 to 7 yr).

31. Clinical Features:-
• Very limited or no prodrome of mild (URI).
• Abrupt onset of high fever (39–40◦C), sore throat, and dysphagia.
• “Hot potato” voice.
• Rapid onset of toxicity and respiratory distress.
• No Cough– and if it occurs it is usually late symptoms.
• Usually no other family members are ill with acute respiratory symptoms.
• Time from onset of symptoms to presentation with progressive respiratory distress is generally <12
hours.
• Child’s preferred way of sitting or positioning himself or herself (i.e. sitting upright, leaning forward
with chin hyperextended).
 Immunization against H. influenzae type B.
 Exposure to cats.

32. Physical Exam:-
• Extremely anxious, may appear distressed and toxic appearance.
• The child prefers to remain sitting up.
• The child often sitting “tripod” position / “sniffing position”:-
▫ sitting upright and leaning forward
▫ the chin up, mouth open and the jaw thrust forward
▫ bracing on the arms to maintain airway in a.
• Slow and labored respiratory effort.
• Drooling is seen as a manifestation of dysphagia.
• Inspiratory stridor, retractions, and late cyanosis
• Stridor is a late finding and suggests near-complete airway obstruction.
• Complete obstruction of the airway and death can ensue unless adequate treatment is provided.
• Diagnosis can be suspected on history and observation of child’s appearance alone.
• Do not attempt to examine the throat if epiglottitis is a serious consideration.

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34. Diagnosis:-
• The diagnosis requires direct visualization
under controlled circumstances by
laryngoscopy showing:-
▫ inflamed and swollen supraglottic structures
▫ a large, cherry red, swollen epiglottis.
• Classic radiographs of a child who has
epiglottitis show the thumb sign.
• Anxiety-provoking interventions such as
phlebotomy, intravenous line placement,
placing the child supine, or direct inspection
of the oral cavity should be avoided until the
airway is secure.
• Cultures of blood, epiglottic surface, and, in
selected cases, cerebrospinal fluid should be
collected after the airway is stabilized.

35. Treatment of Epiglottitis:-
• Initial Stabilization.
• Airway management:
-Maintain child upright, never supine.
-<2 years old: allow the child to assume his or her most comfortable position (usually in the mother’s
arms/lap).
-Personnel experienced in airway management should accompany the child at all times, including
during transport and in radiology.
-Establishing an airway by endotracheal or nasotracheal intubation or, less often, by tracheostomy is
indicated in patients with epiglottitis, regardless of the degree of apparent respiratory
distress, because as many as 6% of children with epiglottitis without an artificial airway die,
compared with <1% of those with an artificial airway.
• Oxygen by mask or blown by face.
-All patients should receive oxygen en route unless the mask causes excessive agitation.
• Transport to operating room as soon as possible for anesthesia and intubation, followed by positive
pressure ventilation as necessary.

36. Medications
First Line
▫ Empiric antibiotic coverage to include gram-positive cocci and β-lactamase producing H. influenzae
type B: Cefuroxime: 150 mg/kg/d divided q8h
▫ Staphylococcal disease (14–21 days): switch may be made to oral medication after extubation and
resumption of feeding.
Second Line
▫ Cefotaxime, ceftriaxone, or meropenem should be given parenterally, pending culture and
susceptibility reports, because 10-40% of H. influenzae type B cases are resistant to ampicillin.
▫ Treatment is continued for at least 10 days.
*** Racemic epinephrine and corticosteroids are ineffective.

37. Differential Diagnosis
• Viral laryngotracheobronchitis (croup) with or without secondary bacterial tracheitis.
• Severe parainfluenza or influenza infection.
• Uvulitis
• Peritonsillar, retropharyngeal, or lingual abscess.
• Foreign body aspiration in a child with URI.
• URI, including croup, in a child with a congenital or acquired airway problem (e.g.
premature infant with subglottic stenosis, laryngeal web, vascular ring, tracheal stenosis).
• Hereditary angioedema (deficiency of complement C1 esterase inhibitor) can present with
edema of the airway including the epiglottis.

38. Is superinfection of the trachea that may follow viral croup
is a rare
serious
is most commonly caused by S. aureus.
Patients may be toxic appearing
intubation may be required.
Bacterial tracheitis

39. Clinical features of croup (viral laryngotracheitis)
and bacterial tracheitis/epiglottitis:-
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40. RETROPHARYNGEAL ABSCESS
•Retropharyngeal
abscesses are deep
neck space infections
that can pose an
immediate life-
threatening
emergency, with
potential for airway
compromise and other
catastrophic
complications.
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41. •The retropharyngeal space can become infected in two ways :
1. Infection spreads from a contiguous area
2. Penetrating trauma (can directly inoculate the space)
•Once Infected, the nodes may progress through 3 stages:
1. cellulitis,
2. Phlegmon
3. Abscess.
•The "classic" retropharyngeal abscess observed in pediatric
patients occurs when an upper respiratory tract infection (URTI)
spreads to retropharyngeal lymph nodes, forming chains in the
retropharyngeal space on either side of the superior constrictor
muscle.
•Retropharyngeal nodes involute at 5 years of age….so the abscess
doesn’t occur after 5 years of age.
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42. Clinical Presentation:-
• Sore throat
• Fever
• Neck pain
• Neck stiffness (torticollis)
• Jaw stiffness (trismus)
• Stridor
• Drooling of saliva
• Muffled voice
• Sensation of lump in the throat
• Breathing difficulties
• Sometimes an upper respiratory illness can precede symptoms by weeks.
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43. Investigation:-
1. Laboratory Studies (Non-
specific)
- WBC counts can be elevated
- Culture and sensitivity test (Gram stain can
help direct with empiric antibiotic
treatment).
2. Imaging Studies (Lateral plain
X-ray)
- Perform the study during inspiration
with the neck held in normal extension
- May also demonstrate gas or a foreign
body in the retropharyngeal space.
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44. •CT scan
1. It can be useful in identifying rertropharyngeal, parapharyngeal or lateral pharyngeal
abscess.
2. Deep neck infections can be easily identified.
3. With contrast, it can reveal central lucency or scalloping of the walls of lymph node, which
is thought to predict abscess formation
•
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45. Management:-
• ABC - Determining airway stability remains a top priority.
• Allow patients to remain in a position of comfort, which is usually supine with their necks
extended. Neck flexion or forcing a child to sit up can occlude the airway.
• Remember that sedatives and paralytics can cause relaxation of airway muscles with
subsequent complete occlusion!
• Start empiric antibiotic therapy without delay (After obtaining blood culture results) Broad-
spectrum coverage is indicated.
• A 3rd generation cephalosporin combined with ampicillin-sulbactum or
clindamycin is effective.
• CT scanning or ultrasonography may be used to help guide the aspiration.
• Drainage is necessary in patients with respiratory distress or failure to improve with IV
antibiotics.
• Some authors advocate the use of antibiotics alone for small abscesses. These patients need to
be closely monitored for improvement.
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46. • Laryngitis is a common illness.
• Viruses cause most cases; diphtheria is an exception but is extremely rare in
industrialized countries .
• The onset is usually characterized by an upper respiratory tract infection during which
sore throat, cough, and hoarseness appear.
• The illness is generally mild.
• Respiratory distress is unusual except in the young infant.
• Hoarseness and loss of voice may be out of proportion to systemic signs and symptoms.
• The physical examination is usually not remarkable except for evidence of pharyngeal
inflammation.
• Inflammatory edema of the vocal cords and subglottic tissue may be demonstrated
laryngoscopically.
• The principal site of obstruction is usually the subglottic area.
Acute Infectious Laryngitis

47. •Is sudden onset of croup symptoms, usually at night, but
without a significant upper respiratory tract prodrome.
•These episodes may be recurrent and severe but usually are
of short duration.
•Spasmodic croup has a milder course than viral croup and
responds to relatively simple therapies, such as exposure to
cool or humidified air.
•The etiology is not well understood and may be allergic.
Spasmodic Croup

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Common Causes of Acute Upper Airway Obstruction

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50. Mother brought her 18-month-old infant to ER with history of URTI for the
last 2 days with mild respiratory distress. This evening the infant starts to
have a hard barking cough with respiratory distress. O/E: T 38C, RR 40/min,
associated with nasal flaring, suprasternal & intercostal recessions.
Auscultation to the chest shows equal air entry bilaterally, prolonged
expiratory phase, and crackles.
What is the most likely diagnosis?
a) Gastroesophageal reflux
b) Laryngotracheobronchitis
c) Viral Pneumonia
d) Bronchiolitis
e) Bacterial Pneumonia
Answer: b

51. Regarding the treatment of CROUP, choose the line of treatment needed:
a) Sedatives
b) IV fluid
c) Racemic epinephrine
d) Humidified oxygen
e) Corticosteroid
Answer: d