Pediatric Airway

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Pediatric Airway
2011-02-16 21:52:03
nasal obstruction airway anomalies etc

Pediatric Airway
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  1. Neonatal respiratory distress can be caused by obstruction at any of the following locations
    • Nasal vestibule, piriform aperature, choanae
    • Oral cavity (macroglossia, glossoptosis)
    • Oropharynx (lingual thyroid, dermoid, vallecular cyst, hemangioma, lymphangioma)
    • Larynx (supraglottic, glottic, subglottic abnormalities)
    • Tracheobroncheal anomalies
  2. Infant larynx is different from adults by:
    • High position in the neck (tip of epiglottis is at C2/3)
    • Larynx is more anterior
    • Subglottis/cricoid is narrowest portion of airway
    • Membranous portion of VC is 2/3 of true cord
    • Epiglottis is omega shaped
    • Pharyngeal structures are closer together
  3. Anatomic dimensions of pediatric airway
    • Vocal cords are 6 to 8 mm long
    • Vocal processes of the arytenoid cartilage extend 3 - 4 mm
    • Posterior glottis has a transverse length of 4 mm
    • Subglottis has a diameter of 5 to 7 mm
    • Trachea is 4 cm long; diameter of 3.6 mm
    • Ratio of cartilaginous to membranous trachea is 4.5 to 1
  4. 1mm reduction in diameter of the pediatric airway will cause how much obstruction?
  5. Phases of swallowing:
    • Preparatory
    • Oral
    • Pharyngeal
    • Esophageal

    Swallowing reflex is regulated by the brainstem in the newborn
  6. Features of pediatric swallowing
    • Infant swallowing undergoes orderly maturation process
    • Prior to 34th week of gestation, poor coordination and insufficient suckling response
    • Neuromuscular maturation thereafter allows full-term infants to suckle at birth
  7. Differences in swallowing structures
    • Hard palate is closer to the skull base
    • Larynx is higher
    • Adenoid pad, tonsils and tongue are relatively larger
    • Nasopharyngeal closure requires less angulation of the soft palate
    • Tonsils and tongue assist in oropharyngeal propulsion
  8. Airway protection during swallowing is maintained by:
    • 1. Oropharyngeal swallow mechanisms (e.g. nasopharyngeal closure, palatopharyngeal strucutures direct the food into the hypopharynx; pharynx and larynx elevate
    • 2. Laryngeal "sphincter": epiglottis, aryepiglottic olds, and arytenoid cartilages, false folds, true vocal folds
    • 3. Mucociliary clearance and cough reflex
  9. History for pediatric airway concerns should include:
    • SPECS-R
    • severity, progression, eating difficulties (swallowing, GER, aspiration), cyanosis +/- ALTE, sleep disturbances/SDB, radiologic findings
  10. Laryngeal findings of GERD/LPR
    • posterior glottic edema
    • arytenoid edema
    • enlargement of the lingual tonsils
    • granular exudate on TVC surface
    • Irregular contact edges
    • Deep shelf of posterior laryngeal tissue/induration
    • Posterior interarytenoid rugae
  11. Clinical Features of Laryngomalacia
    • Most common cause of stridor during infancy
    • Symptoms present weeks to months after birth
    • Resolve by 12 to 1 months of age
    • Stridor is usually low-pitched with a fluttering quality
  12. Classification of Laryngomalacia
    Type I - aryepiglottic folds are tightened or foreshortened

    Type II - redundant soft tissue in any area of the supraglottic region

    Type III - associated with NMD or GER
  13. Laryngomalacia affects
    • The epiglottis, arytenoid cartilages or both
    • If epiglottis - elongated, walls fold in on themselves; omega-shaped
  14. Recurrent Respiratory Laryngeal Papillomatosis is cause by which HPV subtypes
    HPV 6, 11, 16, 18
  15. Risk factors for RRP
    • First born, male
    • Maternal or paternal genital condylomata
    • Lower socioeconomic class
    • Multiple sexual partners
    • Younger maternal age
  16. RRP is categorized into...
    Juvenile onset (JORPP) <12 yrs of age

    Adult onset (AORPP) >12 yrs of age
  17. Incidence of RRP
    0.24 to 1.11 per 100,000
  18. Transmission of RRP
    • Vertical transmission from anogenital tract afected with condylomata (active or inactive)
    • Active = Risk of 231 x
    • Long labour increases risk 2x
    • Other factors: patient immunity, volume of viral exposure, lenght of exposure, local traumas
  19. Primary Ciliary Dyskinesia presents...
    • Ages 4 months to 41 years
    • Chronic sputum production
    • Nasal symptoms
    • Cough
    • Sinusitis
    • Otitis media
  20. Newborn presentation of PCD
    • Newborn rhinitis
    • Dextrocardia
    • Situs inversus
    • Esophageal atresia
    • Biliary atresia
    • Hydrocephalus
    • Positive family history
  21. Presentation of PCD in older children
    • Atypical asthma
    • Severe GERD
    • Rhinosinusitis +/- polyps
    • Bronchiectasis
    • Chronic and severe secretory otitis media
    • Chronic otorrhea with tympanostomy tubes
  22. Adult presentation of PCD
    • Infertility
    • Immotile sperm
  23. Investigations for Primary Ciliary Dyskinesia
    • CXR
    • CT-Chest
    • Sweat test
    • IgG, IgE
    • RF, ANA,
    • Alpha-1 antitrypsin levels
    • Esophageal monitoring
    • Fiberoptic bronchoscopy
  24. The Saccharin test
    • Screening for PCD
    • Measure of mucociliary clearance
    • Saccharin is placed on inferior turbinate
    • If time to tasting is >60 minutes, positive