Pathophysiology of the Airway and Bronchoscopy in the...

Pediatria d’Urgenza e

Terapia Intensiva Pediatrica

Policlinico Umberto I

Corrado Moretti

Pathophysiology of the Airway and Bronchoscopy

in the Neonate

When should we suspect a disease of the airway ?

When there is an alteration of its functions

Breathing (air is filtered, humidified and warmed)

Speaking/Crying

Swallowing

Protection from inhalation Upper airways perform many important functions and have no structural rigidity: they are made up of muscles connected to rigid supports

Airway diseases are very dangerous:

can rapidly cause a severe respiratory failure

Localization of the obstruction

- inspiratory-expiratory symptoms - noise: stridor - barking cough and alterations of the voice (weak, aphonic, husky) - opisthtonus (head arched back forward shift of the hyoid bone)

- difficulties to feed: cough, apnoea, cyanosis, inhalation

- inspiratory symptoms - noise: stertor (low-pitched) or stridor (high pitched) - dyspnoea, retractions, obstructive apnoeas - CXR: pulmonary oedema

- expiratory symptoms - prolonged expiration - noise: weezing - CXR: air trapping

- Upper airway (pressure around airways is 0)

- Larinx

- Lower airway (intrapleurical pressure squeezes the airway)

- All

Stridor

Obstructive apnoea

Unexplained cyanosis crisis

Recurrent aspiration

Unexplained respiratory distress

Persistent or recurrent atelectasis

Lobar enphisema

Unexplained pulmonary haemorrhage

Pulmonary malformation

Failure to extubate

Position of tracheal tube

Broncho Alveolar Lavage (BAL)

Neonatal symptoms and clinical conditions

which require Bronchoscopy

Upper obstruction: endo-thoracic

negative pressure

Lower obstruction: endo-abdominal

positive pressure

suctioning pushing

Gastro-oesophageal reflux

Neonatal Flexible Bronchoscopy

Epiglottis

Uvula

Arytenoids

Vocal cords

Monitoring - ECG - SpO2 %

eye piece

insertion tube

flexion-extension lever

suction control

2.8 – 3.5 mm

Aryepiglottic folds

Arytenoids

Pharyngoepiglottic folds

Epiglottis

Interarytenoid notch

Valerio

A loud stridor appeared immediately after birth and grew worse when the baby cried

quiet breathing during cry

Laryngomalacia

Tubular epigottis - whistle shaped

Stridor is produced by the rapid, turbulent flow of air through a narrowed segment of the respiratory tract

Pressure x Flow = K

Tight tubular epiglottis that curls on itself Redundant, prolapsing arytenoids Short aryepiglottic folds

Mild and/or intermittent stridor

- reassure parents, disease is usually self-limiting

- frequent evaluation of breathing, feeding and growth

- consider reflux precautions

Moderate to severe and persistent stridor and other symptoms as cough, weak cry, etc.

- flexible laryngoscopy

Giorgia

Noisy breathing and cough from birth

At one month of life progressive abdominal distension followed by a severe apnoea crisis

Transferred intubated to our PICU

Progressive closure of the glottis

Stronger efforts to breathe

Increasing distension of the bowels

Upward shift of the diaphragm

Cyst at the base of the tongue

APNOEA

Brian

Coughing during feeding followed by marked wheezing:

Tracheo-Esophageal Fistula?

Opaque feeding with barium

Laryngeal Cleft deficiency in the separation of

the larinx from the hypopharinx

in the midline posteriorly;

in severe cases it extends

into the cervical or thoracic trachea

Tracheo-Esophageal Fistula

Francesco

Severe RSV bronchiolitis at 20 days of age

Difficult intubation and mechanical ventilation for 3 days

Mild respiratory distress and inspiratory stridor 5 days after discharge from hospital

Laryngeal Web… the TT broke the membrane, but after a few days the membrane had closed again

Anna

Admitted to hospital at 3 weeks due to a severe apparent life-threatening event (ALTE)

Transferred intubated to our NICU with diagnosis of pharyngeal mass

Intermittent noisy breathing and cough from birth

Lateral neck X-ray

A peduncolted mass originating from the pharinx and descending as far as the larynx, obstructing the upper airways

Pharingeal opening of the auditory tube

Mass

Nasal septum

Palate

Mouth - the baby is supine - left palatine fossa

The surgeon tries to grasp the mass with forceps to stretch it out

in order to understand where it grows from

Congenital malformation of the first and second branchial arches growing from

the soft palate and containing hair follicles, and sebaceous and sweat glands

“Hairy Polyp”

Roberto

- Biphasic wheezing, barking cough, dysphagia

A barium swallow shows the impression of a double aortic arch on the esophagus

Flow-volume loops

Tracheal Injury

from Intubation

Alessio

Admitted to hospital at 2 month due to increasing breathing difficulties

for RSV pneumonia

progressive hyperinflation

of the right lung

FiO2

0.4 0.8

...before

…immediatly after lavage

…after few hours

Bronchiolitis

Bronchial lavage to remove a mucus plug

If in doubt……it’s always better to give a look!

Clara

Weight: 4000 gr Severe Pierre-Robin Syndrome waiting for surgery….

…severe apnoea crisis during the night due to a cold

Difficult Intubation

… slide the tt on the bronchoscope using it as a guide

GA: 33 weeks

BW: 1400 gr

Elena

Suspected tracheo-esophageal fistula

Coughing and cyanosis during feeding

Tracheo-esophogeal fistula

Marco

Transferred at 15 days due to ……………

GA: 30 weeks

BW: 1450 gr

Alligator scissors

...inhalation of a defective catheter which broke during suctioning

Valeria

Stridor, weak cry and opisthotonus

Laryngeal Emangioma

Stridor

Obstructive apnoea

Unexplained cyanosis crisis

Recurrent aspiration

Unexplained respiratory distress

Persistent or recurrent atelectasis

Lobar enphisema

Unexplained pulmonary haemorrhage

Pulmonary malformation

Failure to extubate

Position of tracheal tube

Broncho Alveolar Lavage (BAL)

Neonatal symptoms and clinical conditions

which require Fiberoptic Bronchoscopy (FOB)

- Radiology /Echo-scan

- Polisomnography

- Barium swallow

- MRI scan/TC

Investigations to perform beyond FOB

- Oesophageal pH-metry

Upper obstruction: endo-thoracic

negative pressure

Lower obstruction: endo-abdominal

positive pressure GER

suctioning pushing