PaediatricsAcute and chronic airway obstruction in children
Section snippets
Aetiology
Some of the causes of acute and chronic airway obstruction are outlined in Table 1.
Mechanics of airway obstruction
Upper and lower airway obstruction (Figure 1) produce different pictures because of the different pressures inside and outside the thoracic cavity during the breathing cycle. Anatomically, the thorax is separated from the neck at the thoracic inlet, or superior thoracic aperture, formed by the first thoracic vertebra, the first pair of ribs and the manubrium sterni. Anatomically, the upper airway is divided from the lower airway at the level of the subglottis. Physiologically, the upper airways
Recognizing airway obstruction in the spontaneously breathing child
In the spontaneously breathing child, extrathoracic airway obstruction produces inspiratory or biphasic stridor, which is usually monophonic. Increased effort is seen with accessory muscle use. Tracheal tug, sternal, subcostal and intercostal recession are exaggerated because of the high negative intrapleural pressures generated by the child in an attempt to overcome the obstruction. This is obvious in younger children with compliant, cartilaginous thoracic walls when even moderate upper airway
Recognizing airway obstruction in the ventilated or anaesthetized child
The ventilatory responses which generate the signs of airway obstruction outlined above are blunted in the anaesthetized child and absent in the paralysed child. The anaesthetist needs to remain alert to changes in tidal volumes or airway pressures as well as hypercarbia and hypoxaemia. Monitoring of tidal volumes, end-tidal carbon dioxide and oxygen saturations are vital. The only clinical signs may be reduced chest expansion and diminished breath sounds. The ‘feel’ during hand ventilation
Nose and nasopharynx
Bilateral choanal atresia usually presents within hours of birth with breathing difficulties, apnoea or cyanotic episodes often associated with feeding. Unilateral choanal atresia can present later in childhood with persistent unilateral rhinorrhoea. Adenoidal and tonsillar hypertrophy are the commonest cause of chronic upper airway obstruction in pre-school children, manifest usually by disordered breathing in sleep or breathing difficulties during upper respiratory tract infections. A
Larynx and upper trachea
Laryngomalacia is the commonest laryngeal cause of upper airway obstruction in young children and is characterized by inspiratory stridor of variable degree developing usually days to weeks after birth and improving as the child grows.1 In laryngomalacia the negative airway pressure normally generated during inspiration drags the epiglottis or aryepiglottic folds into the laryngeal inlet obstructing the airway. The problem is usually less marked if positive airway pressure is applied. The
Bronchospasm
Asthma remains the commonest chronic illness in childhood and the commonest cause of lower airway obstruction. Children can have hyper-reactive airways without satisfying the other criteria of classic atopic asthma. Pre-school children can have severe and recurrent wheeze in response to viral infections without symptoms in the intervening period (known as viral-associated wheeze or wheezy bronchitis). Other children may have an idiosyncratic reaction to anaesthetic gases, or an allergic
References (7)
The upper airway: congenital malformations
Paediatr Respir Rev
(2006)Acquired upper airway obstruction
Paediatr Respir Rev
(2004)- et al.
Croup
Lancet
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Cited by (5)
Acute upper airway obstruction in children and adults
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2017, Allergy: European Journal of Allergy and Clinical ImmunologyPaediatric hereditary angioedema: A survey of UK service provision and patient experience
2014, Clinical and Experimental Immunology