1. Tricia Falgiani, MD
Assistant Professor
University of Florida
Pediatric Emergency Medicine

2. Objectives
 Identify unique characteristics of the pediatric airway
 Identify upper and lower airway diseases
 Distinguish between airway urgencies and
emergencies

3. The Pediatric Airway
 Passive flexion due to a large occiput
 Relatively large tongue
 Mass of adenoidal tissue
 U-shaped and floppy epiglottis
 Larynx is more anterior

4. The Pediatric Airway
 Cricoid ring is the smallest diameter
 Narrow tracheal diameter and short distance between
the tracheal rings
 Airway cartilage is softer and more flexible
 Short tracheal length
 Large airways are more narrow

5. The Pediatric Airway

6. Airway Assessment
 History
 Acute or gradual onset?
 Fever?
 Drooling?
 Voice changes?
 Difficulty swallowing?
 URI symptoms?
 Significant past medical history?

7. Airway Assessment
 Physical Exam
 Appearance
 Alertness
 Muscle tone
 Ability to cry or speak
 Work of breathing
 Circulation
 Pallor
 Cyanosis
 Mottling
 Skin temperature

8. First Impressions….
 http://youtu.be/Ksl7Z3iwyL8
 http://youtu.be/-4OhWQ8Ppko

9. Respiratory Status
 Bradypnea is more concerning than tachypnea
 Normal rate/min
 Newborn 30-60
 6 months 25-35
 1-3 years 20-30
 4-6 years 18-26
 Adolescent 12-18

10. Signs of Respiratory Distress
 Increased work of breathing
 Retractions
 Nasal flaring
 Grunting
 Head bobbing

11. Signs of Respiratory Distress
 Altered mental status
 Agitation
 Irritability
 Lethargy
 Coma

12. Signs of Respiratory Distress
 Color
 Cyanosis
 Pallor
 Position
 Sniffing position
 Tripod position

13. Signs of Respiratory Distress
 Auscultation
 Snoring
 Grunting
 Stridor
 Wheezing
 Rales (crackles)
 Rhonchi

14. Practical Points
 Children have unique airway anatomy
 Airway assessment begins with a good history
 First impressions give us a lot of information
 Signs of respiratory distress
 Increased work of breathing
 Altered mental status
 Color
 Position
 Auscultation findings

15. Common Pediatric Airway Diseases
Upper Airway Diseases Lower Airway Diseases
 Croup
 Foreign Body
 Epiglottitis
 Bacterial tracheitis
 Asthma
 Bronchiolitis
 Pneumonia
 Foreign Body

16. Laryngotracheobronchitis
 Croup!
 Upper airway disease
 Viral infection of larynx, trachea and bronchi
 Parainfluenza (75%)
 Influenza
 RSV
 Adenovirus
 Age 6months-3 years
 Male > female
 Winter months

17. Clinical Presentation
 Fever
 Rhinorrhea
 Nasal congestion
 Barking cough
 Inspiratory stridor
 Respiratory distress
 Worse at night

18. Clinical Presentation
 Gradual onset of URI symptoms (days)
 Mild fever, hoarseness, barking cough
 Sudden stridor and retractions
 Dyspnea and tachypnea

19. Westley Scoring System
0 1 2 3
Stridor None Only with
agitation
Mild at rest Severe at rest
Retraction None Mild Moderate Severe
Air entry Normal Mild decrease Moderate
decrease
Marked
decrease
Color Normal N/A N/A Cyanotic
Level of
consciousness
Normal Restless when
disturbed
Restless when
undisturbed
Lethargic

20. Westley Scoring System
Score Degree Management
0-2 Mild Mist therapy
3-7 Moderate Racemic epi, steroids
>8 Severe Racemic epi, steroids,
admit

21. Treatment
 Labs and x-ray unnecessary
 Mist therapy
 Racemic epinephrine
 Dexamethasone
 0.6mg/kg

22.  https://www.youtube.com/watch?v=Z1_uKqmPyLA&f
eature=player_detailpage
 https://www.youtube.com/watch?v=Qbn1Zw5CTbA&f
eature=player_detailpage

23. Foreign Body
 Basics:
 Airway emergency?
 The airway is a funnel
 Typically under 3 years of age
 Impaired mentation
 Candy and food
 High index of suspicion

24. Clinical Presentation
 Sudden coughing or choking
 Dyspnea
 Stridor (upper)
 Wheezing, rhonchi or rales (lower)
 Unequal breath sounds (lower)

25. Treatment
 Maintain suspicion
 Keep child calm with parent
 Blow by oxygen if tolerated
 Don’t agitate patient
 Advanced airway maneuvers as indicated

26. Epiglottitis

27. Epiglottitis
 Upper airway disease
 Airway emergency
 Life threatening bacterial infection of epiglottis and
surrounding structures
 Rare
 Age 3-7 years
 Winter months
 Pathophysiology
 H. Influenzae
 S. Pneumoniae
 Group A streptococcus
 Staph aureus

28. Clinical Presentation
 Abrupt onset (hours)
 Toxic appearing
 Fever
 Stridor
 Drooling
 Inability to swallow
 Sore throat
 Respiratory distress
 Tripod position
 Sudden obstruction

29. Treatment
 Secure airway
 Don’t agitate child
 Antibiotics
 Ceftriaxone
 Cefotaxime
 Meropenem
 Clindamycin/vanc ?

30. Bacterial Tracheitis

31. Bacterial Tracheitis
 Rare (0.1 cases per 100,000 children per year)
 Invasive exudative bacterial infection of the trachea
 Male > Female
 Age 3 weeks- 16 years
 Pathophysiology
 Staph aureus (MRSA)
 Strep pyogenes
 Strep pneumoniae
 Moraxella catarrhalis
 H. influenza type B (unvaccinated)

32. Clinical Presentation
 Similar to croup
 URI prodrome
 Fever
 Stridor
 Barky cough
 Hoarseness
 Sore throat
 No drooling
 Respiratory distress

33. Treatment
 Secure airway
 Antibiotics
 Ceftriaxone
 Meropenem
 Clinda or vanc

34. Epiglottitis vs. Croup vs. Bacterial tracheitis
Epiglottitis Croup Bacterial
Tracheitis
Anatomy Supraglottic Subglottic Tracheal lumen
Etiology Bacterial Viral Bacterial
Age Range 3-7 years, adults 6months-3 years 3weeks-16 yrs
Onset 6-24 hours 2-3 days 1-3 days
Toxicity Marked Mild to moderate Mild- marked
Drooling Frequent Absent Absent
Cough Unusual Frequent Frequent
Hoarseness Unusual Frequent Frequent
WBC Leukocytosis Normal Leukocytosis

35. Causes of Stridor
 Spasmodic croup
 Retropharyngeal abscess
 Peritonsillar abscess
 Subglottic stenosis
 Allergic reaction
 Foreign body
 Tracheomalacia
 Laryngeal web
 Laryngeal papillomatosis
 Laryngeal hemangioma
 Trachea fracture
 Vocal cord paralysis
 Inhalation injury
 Uvulitis
 Vascular ring
 Double aortic arch
 Aberrant subclavian artery
 Pulmonary artery sling
 Epiglottitis
 Bacterial tracheitis
 Diphtheria
 Croup

36. Asthma
 Lower airway disease
 Airway urgency/emergency
 Chronic and recurrent
 Bronchospasm
 Airway inflammation
 Ventilation problem with air trapping

37. Assessment
 Respiratory rate
 Work of breathing
 Oxygen saturation
 Expiratory time
 Mental status

38. Clinical Presentation
 Dyspnea
 Retractions
 Tachypnea
 Nasal flaring
 Inability to speak
 Wheezing
 Prolonged expiratory phase
 Beware of the quiet chest

39. Treatment
 ABCs
 Give oxygen
 Nebulized albuterol
 Steroids
 Upright position
 Severe attacks
 Epinephrine
 Magnesium sulfate

40. Treatment
 Secure airway
 Surgical drainage
 Antibiotics
 Unasyn
 Clindamycin
 Vancomycin
 Augmentin

41. Asthma Caveats
 Many patients/parents do not take this disease
seriously
 Parents may not have an asthma action plan at home
 Albuterol is a short acting drug
 If patient is requiring multiple albuterol treatments at
home, they should be evaluated immediately

42. Bronchiolitis
 Lower airway disease
 Airway urgency
 2 months- 2 years
 Chronically ill are at higher risk
 Premature
 Congenital heart disease
 Less than 1 month old
 Inflammation, edema and mucous in the lower
airways
 Viral etiology

43. Clinical Presentation
 Dyspnea
 Tachypnea
 Retractions
 Nasal flaring
 Wheezing
 Long expiratory phase
 Rales
 Rhonchi
 Decreased air movement

44. Treatment
 SUPPORTIVE!!!
 Oxygen
 Suctioning
 Upright position
 ?nebulized albuterol
 ?nebulized hypertonic saline

45. Pneumonia
 Lower airway disease
 Airway urgency
 All ages
 Younger patients can be very ill
 Chronically ill at higher risk
 Bacterial or viral etiology

46. Clinical Presentation
 Rales (may be localized)
 Rhonchi
 Tachypnea
 Variable fever
 +/- Respiratory distress
 Hypoxemia

47. Treatment
 Oxygen
 Fluids
 Upright position
 Antibiotic therapy

48. Practical Points
 Upper vs. Lower airway diseases- listen for the
diagnosis!
 Airway urgencies can quickly progress to airway
emergencies
 Beware of the neonate!
 Trust the parents
 Look for visual cues
 Try not to agitate the patient

49. Questions?