Upper Airway Obstruction Evaluation of the Stridorous Patient

Initial Management (ABCs)

• Evaluate Airway: quickly determine severity and stability of airway (acute versus chronic, progression of stridor, dyspnea at rest versus with exercise)

• Establish Airway: see pp. 443-447 for complete protocol in establishing an airway

• Administer Oxygen: masked ventilation may adequately improve oxygenation until able to secure airway; after establishing a secure airway, ease of ventilation and maintenance of oxygenation should be evaluated

• Heliox: may be considered for short-term oxygenation for stable airway obstructions; 80% helium, 20% oxygen (may increase O2 concentration to 40%); helium has a lower molecular weight (decreased density) allowing passage past narrow obstruction

• consider humidification, corticosteroids, nebulized racemic epinephrine, and antibiotics

History and Physical Exam

• Character of Upper Airway Sounds: determine respiratory phase of stridor versus stertor (see below), onset and duration, constant versus intermittent

• Contributing Factors: complete perinatal history (maternal drug and alcohol abuse, venereal diseases, complicated delivery, neonatal intensive care unit stay); recent upper respiratory infection, fever, cough, sore throat, allergy; recent trauma, caustic ingestion, previous tracheotomy, intubations or airway manipulations, surgeries; medications (medicine allergies, ACE inhibitors); history of sarcoidosis, connective tissue disorders, granulomatous diseases (Wegener's, tuberculosis), asthma, cardiac and pulmonary problems

• Associated Symptoms: dysphagia, drooling, hoarseness, airway bleeding, weight loss, odynophagia, cough (barking cough), sleep pattern (snoring, daytime somnolence), choking (GERD, foreign body), feeding difficulties (regurgitation, worse with feeding)

• Nasopharyngoscopy/Indirect Mirror Exam: assess airway patency, vocal fold mobility, supraglottic structure, examine tracheal stoma (retroflex to access subglottis)

• Nasal Exam and Evaluation Nasopharyngeal Patency: may attempt to pass #6 catheter through both nares, nasal endoscopy, nasoseptal deformities, nasal masses, nasal congestion

• Complete Head and Neck Exam: oral cavity (macroglossia, tonsilar hypertrophy or infection), complete neurological exam (cranial nerves), evaluate for external compression (trachea midline, goiter, palpable laryngeal fractures), cutaneous lesions (hemangiomas)

• cardiac and pulmonary history and exam (wheezing, chest pain, retractions, cyanosis)

• Think "KITTENS" for differential diagnosis (see Table 3-2)

Description of Upper Airway Sound by Site ofObstruction

• Nasopharyngeal: stertor (snoring), no cough

• Oropharynx: gurgly

• Supraglottic: inspiratory stridor, throaty voice, feeding problems

• Glottic: inspiratory or biphasic stridor, hoarseness

• Subglottic: husky voice, biphasic stridor, barking cough

• Tracheobronchial: expiratory stridor, wheezing, suprasternal retraction indicate obstruction above thoracic inlet

Endoscopy

• Indications for Endoscopy: (SPECS-R) Severity of obstruction, Progression of shortness of breath, Eating difficulties, Cyanotic episodes, Sleep apnea, Radiologic findings

• Direct Laryngoscopy: allows evaluation and instrumentation of the glottis and supraglottis vo

TABLE 3-2. Differential Diagnosis of Upper Airway Obstruction: KITTENS Method

(K) Congenital

Infectious

Trauma

Neurologic

Systemic/ PSychiatric

Above larynx

Micrognathia Macroglossia Choanal atresia Lingual thyroid Nasoseptal deformity

Retropharyngeal abscess Peritonsillar abscess Mononucleosis Diphtheria

Juvenile nasopharyngeal angiofibromas Neurogenic nasal tumors

Facial fracture Retropharyngeal hematoma

Posteriorly displaced tongue Central sleep apnea

Allergic rhinitis

Wegener's

Obesity

(obstructive sleep apnea)

Supraglottis

Laryngomalacia

Epiglottitis

Tumor

Intubation trauma

Sarcoidosis

Glottic

Glottic web Laryngeal atresia Vocal fold paralysis

TB laryngitis Laryngeal diphtheria

Respiratory papillomatosis

Laryngeal fracture Foreign body

Vocal fold paralysis

Hereditary angioedema

(K) Congenital

Infectious

Tumor (Neoplasia)

Toxins & Trauma

Neurologic

Systemic/ PSychiatric

Subglottic

Vascular ring and aortic arch anomalies Tracheoesophageal fistula Subglottic stenosis

LTB (Croup)

Subglottic hemangioma

Subglottic stenosis Respiratory

Thyroid or neck muscle masses (extrinsic paralysis compression)

Wegener's Asthma

Tracheobronchial Tracheomalacia Tracheitis

Vascular rings Bronchitis

Mediastinal, tracheal, or bronchial tumors

Foreign body

External compression (goiter)

• Bronchoscopy: flexible bronchoscopy allows identification of severity and location of stenosis, rigid bronchoscopy allows for instrumentation and for management for an emergent airway crisis

Ancillary Tests

• Chest X-ray and Plain Neck Films: screening films for laryngotracheal structural defects, intrinsic lung and mediastinal disease

• CT/MRI of the Neck: indicated to evaluate the location, extent, or compression of the stenosis; also evaluates destruction of local laryngeal structures

• Modified Barium Swallow and Esophagram: examine esophageal pathology, gastroesophageal reflux, aspiration, and vascular abnormalities

• Pulmonary Function Tests and Flow Volume Loops: identifies level of obstruction and assess for intrinsic lung disease

• Magnified Airway (Fluoroscopy): dynamic evaluation of airway, assess vocal fold motion

• Arteriography: indicated if vascular abnormalities are suspected

• Labs: arterial blood gas, complete blood count, electrolyte panel

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