Respiratory emergency

PaediatricRespiratory Emergencies

Dr. Hemraj Soni DCH DNB

SDM Hospital Jaipur

Respiratory Emergencies

• #1 cause of – Pediatric hospital admissions as emergency– Death during first year of life except for

congenital abnormalities

Respiratory Emergencies

Most pediatric cardiac arrest begins as respiratory failure or

respiratory arrest

Pediatric Respiratory System

• Large head, small mandible, small neck

• Large, posteriorly-placed tongue

• High glottic opening• Small airways• Presence of tonsils,

adenoids

Pediatric Respiratory System

• Poor accessory muscle development

• Less rigid thoracic cage

• Horizontal ribs, primarily diaphragm breathers

• Increased metabolic rate, increased O2 consumption

Pediatric Respiratory System

Decrease respiratory reserve + Increased O2 demand =

Increased respiratory failure risk

Respiratory Distress

Respiratory Distress

• Tachycardia (May be bradycardia in neonate)• Head bobbing, stridor, prolonged expiration• Abdominal breathing• Grunting--creates CPAP

Respiratory EmergenciesMedical Emergencies• Croup• Epiglottitis• Asthma• Bronchiolitis• Bronchopulmonary

dysplasia• Pneumonia• ARDS

Surgical emergencies• Choanal atresia• CDH• TEF• Foreign body aspiration• Air leak syndrome• Neck Masses

– Cystic Hygromas– Tracheal anomalies

• Thoracic masses/pulmonary lesions– Congenital lobar emphysema– Congenital cystic adenomatous

malformation– Pulmonary agenesis

Choanal AtresiaChoanal Atresia

INTRODUCTIONINTRODUCTION

• Complete nasal obstruction in a newborn may cause death from asphyxia, if appropriate treatments are not available.

• if the infant cries and takes a breath through the mouth, the airway obstruction is momentarily relieved.

• Then the crying stops, the mouth closes, and the cycle of obstruction is repeated.

History of the ProcedureHistory of the Procedure

• In 1755, Roederer first described congenital

choanal atresia.

• In 1854, Emmert reported the first successful

surgical procedure using a curved trocar

transnasally.

• Over the years, the necessity of serial dilatations

to maintain patency of the choanae has clearly

been recognized.

EpidemiologyEpidemiology• The average rate is 0.82 cases per 10,000

individuals.• Unilateral atresia occurs more frequently on the

right side.• ratio of unilateral to bilateral cases is 2:1.• A slightly increased risk exists in twins.• Maternal age or parity does not increase the

frequency of occurrence.• Chromosomal anomalies are found in 6% of

infants.• Five percent of patients have monogenic

syndromes or conditions.

EpidemiologyEpidemiology

• Race: Choanal atresia occurs with equal

frequency in people of all races.

• Sex: More studies report significantly more

females than males affected.

AetiologyAetiology

• The nasal cavities extend posteriorly during development under the influence of the posteriorly directed fusion of the palatal processes.

• Thinning of the membrane occurs, which separates the nasal cavities from the oral cavity.

• Failure of the 2-layer membrane consisting of nasal and oral epithelia to rupture by the 38th day of development results in choanal atresia.

AetiologyAetiology

• Failure of the 2-layer membrane consisting of nasal and oral epithelia to rupture by the 38th day of development results in choanal atresia

PathophysiologyPathophysiology • Theories proposed to explain the

occurrence of choanal atresia can be summarized as follows:

• Persistence of the buccopharyngeal membrane

• Failure of the bucconasal membrane of Hochstetter to rupture

• Medial outgrowth of vertical and horizontal processes of the palatine bone

• Abnormal mesodermal adhesions forming in the choanal area

• Misdirection of mesodermal flow due to local factors

ClinicalClinical EvaluationEvaluation• complete physical examination to assess for other

congenital anomalies.• complete nasal and nasopharyngeal examination.• A high level of suspicion is required to diagnose bilateral

choanal atresia.• Symptoms of severe airway obstruction and cyclical

cyanosis are the classic signs of bilateral atresia. • When crying alleviates respiratory distress in an obligate

nasal breather, there is probability of bilateral choanal atresia.

• Unilateral atresia may not be detected for years, and patients may present with unilateral rhinorrhea or congestion.

ClinicalClinical EvaluationEvaluation• Many patients have an associated:

– Coloboma of the iris, choroid, and/or microphthalmia

– Heart defect such as atrial septal defect (ASD) and/or conotruncal lesion

– Atresia of choanae

– Retarded growth and development

– Genitourinary abnormalities such as cryptorchidism, microphallus, and/or hydronephrosis

– Ear defects with associated deafness (The external, middle, and/or inner ear may be involved. Only a small proportion of infants with choanal atresia and related components probably represent this entity.)

ClinicalClinical EvaluationEvaluation

• The percentages of the different anomalies in CHARGE syndrome association are as follows:– Coloboma - 80%– Heart defect - 58%– Atresia of choanae - 100%– Mental retardation - 94%– Growth deficiency - 87%– Genital hypoplasia in males - 75%– Ear anomalies - 88%

Differential diagnosisDifferential diagnosis • Deviated nasal septumDeviated nasal septum• Dislocated nasal septumDislocated nasal septum• Septal hematomaSeptal hematoma• Mucosal swellingMucosal swelling• Turbinate hypertrophyTurbinate hypertrophy• EncephaloceleEncephalocele• Nasal dermoidNasal dermoid• HamartomaHamartoma• ChordomaChordoma• TeratomaTeratoma

InvestigationsInvestigations• Imaging Studies:

– Rhinography is a procedure that involves the administration of radiopaque dye into the nasal cavity

– CT scanning is the radiographic procedure of choice in the evaluation• purpose is outlined as follows:

– Confirm the diagnosis of choanal atresia (unilateral or bilateral).

– Evaluate choanal atresia (vomer bone width and choanal airspace distance).

– Exclude other possible nasal sites of obstruction.

– Determine the degree of bony, membranous, or mixed atresia.

– Delineate abnormalities in the nasal cavity and nasopharynx.

InvestigationsInvestigations

• Choanal atresia. Rhinogram demonstrating blockage of radiopaque dye at the posterior choanae.

• From T.L. Tewfik and V.M. Der Kaloustian, with permission.

InvestigationsInvestigations

• CT scan showing membranous and bony choanal atresia.. From T.L. Tewfik and V.M. Der Kaloustian, with permission.

InvestigationsInvestigations

• Axial view of CT scan nose/paranasal sinus showing bony choanal atresia

Diagnostic ProceduresDiagnostic Procedures

• Failure to pass an 8F catheter through the nasal cavity more than 5.5 cm from the alar rim

• The lack of movement of a thin wisp of cotton under the nostrils while the mouth is closed

• The absence of fog on a mirror when it is placed under the nostrils

• Acoustic rhinometry• Listening for breath sounds with either a stethoscope or

a Toynbee auscultation tube• Gently blowing air into each nasal cavity with a Politzer

bag• Administering into the nose a colored solution that is

visible in the pharynx

TREATMENTTREATMENT

• Surgical therapy: divided into emergent and elective definitive categories

• Bilateral choanal atresia in a neonate is an emergency that is best initially treated by inserting an oral airway to break the seal formed by the tongue against the palate. This oral airway can be well tolerated for several weeks.

• McGovern nipple, and intubation are viable options.

• Tracheostomy

ProceduresProcedures

• Principles:

– restores the normal nasal passage,

– prevents damage to growing structures important in

facial development,

– is technically safe,

– requires short operative time, and

– provides short hospitalization and convalescence.

ProceduresProcedures

• Type of Approaches:– Transnasal puncture, with or without a

microscope– Transseptal– Transpalatal repair– Endoscopic technique (nasal or retropalatal),

with or without powered instrumentation– Carbon dioxide and potassium titanyl

phosphate (KTP) lasers

• Diagram illustrating the transpalatal correction of choanal atresia.

Endoscopic ViewEndoscopic View

Postoperative detailsPostoperative details

• Infants with documented (GERD) require prolonged stenting and dilatations for choanal restenosis and removal of granulation tissue.

• Stenting is usually performed using an endotracheal tube or Foley catheter. – use of stents in the management of patients with

choanal atresia is a controversial

• the use of stents following repair requires the use of prophylactic antibiotic and antireflux medications.

Follow-up careFollow-up care

• Patients may require operative debridement or periodic dilatations.

• This can sometimes be performed as an outpatient procedure with: – local decongestant and – topical anesthesia – using urethral sounds.

Esophageal Atresia and Tracheoesophageal Fistula

Successive stages in the development of the tracheoesophageal septum during embryologic

development.

• (A) The laryngotracheal diverticulum forms as a ventral outpouching from the caudal part of the primitive pharynx.

• (B) Longitudinal tracheoesophageal folds begin to fuse toward the midline to eventually form the tracheoesophageal septum.

• (C) The tracheoesophageal septum has completely formed.

• (D) If the tracheoesophageal septum deviates posteriorly, esophageal atresia with a tracheoesophageal fistula develops

Esophageal atresia is a congenital abnormality in which the midportion of

the esophagus is absent.

• Incidence is between 1 in 3,570 and

1 in 4,500.

Anatomic Variations

• 85%85%

 • Most commonMost common

 • VOGTtype3(b)VOGTtype3(b)

 • GROSS type CGROSS type C

Anatomic Variations

6%6%Atresia alone,Atresia alone, • no fistulano fistula • Small stomach,Small stomach,  gasless abdomengasless abdomen • Usually has a longUsually has a long  gap between thegap between the  esophagealendsesophagealends • VOGT types 1 and 2VOGT types 1 and 2 • GROSS type AGROSS type A

Anatomic Variations

• 2%2% • Proximal tracheo-Proximal tracheo- 

esophageal fistulaesophageal fistula • No distal fistulaNo distal fistula 

Small stomach,Small stomach, • gasless abdomengasless abdomen • Often has a longOften has a long 

gap between thegap between the 

Esophageal endsEsophageal ends • VOGT type 3(a)VOGT type 3(a) • GROSS type BGROSS type B

Anatomic Variations

• l%l%• Proximal andProximal and 

distal fistulasdistal fistulas • ("double fistula") ("double fistula")

• VOGT type 3(c)VOGT type 3(c) • GROSS type D GROSS type D  

Anatomic Variations

• 6%6%• No atresia ofNo atresia of

the esophagusthe esophagus•  CongenitalCongenital

tracheoesophagealtracheoesophageal 

fistulafistula

"H" or "N" fistula"H" or "N" fistula • GROSS type EGROSS type E 

Physiologic effects of distal tracheoesophageal

fistula • (A)1. Hyaline membrane disease

may necessitate higher ventilator pressures, which encourage air to pass through the distal fistula.

• 2. A distended abdomen elevates and "splints" the diaphragm.

• 3. Gastric distension may result in gastric rupture and pneumoperitoneum.

• 4. Passage of air through a distal tracheoesophageal fistula diminishes the effective tidal volume.

• . (B) 1. Aspiration of gastric juices leads to soiling of the lungs and pneumonia

• 2. Gastroesophageal reflux• 3. Direction of gastric fluid

proximally through distal fistula.• 4. Overflow of secretions or

inadvertent feeding may contribute to aspiration and contamination of the airway. .

Associated Abnormalities

Incidence of Associated Anomalies in Esophageal Atresia. Anomaly Frequency (%) • Congenital heart disease 25 • Urinary tract 22 • Orthopaedic (mostly vertebral and radial) 15• Gastrointestinal (e.g., duodenal• atresia,imperforate anus) 22

• Chromosomal (usually trisomy 18 or 21) 7 • Total with one or more associated 58 anomalies

Associated Congenital Anomalies Reported in Patients with Esophageal Atresia

System affectedSystem affected

MusculoskeletaMusculoskeletall

Gastrointestinal Gastrointestinal

CardiacCardiac

Genitourinary. Genitourinary.

Potential anomalies Potential anomalies

Hemivertebrae, radial dysplasia Hemivertebrae, radial dysplasia or amelia, polydactyly, or amelia, polydactyly, syndactyly, rib malformations, syndactyly, rib malformations, scoliosis, lower limb defectsscoliosis, lower limb defects

Imperforate anus, duodenal Imperforate anus, duodenal atresia, malrotation, intestinal atresia, malrotation, intestinal mmalformations, Meckel's alformations, Meckel's diverticulum, annular pancreasdiverticulum, annular pancreas

Ventricular septal defect, Ventricular septal defect, patent ductus arteriosus, patent ductus arteriosus, tetralogy of Fallot, atrial septal tetralogy of Fallot, atrial septal defect, single umbilical artery, defect, single umbilical artery, right-sided aortic archright-sided aortic arch

Renal agenesis or dysplasia, Renal agenesis or dysplasia, horseshoe kidney, polycystic horseshoe kidney, polycystic kidney, ureteral and urethral kidney, ureteral and urethral malformations, hypospadiasmalformations, hypospadias

DIAGNOSIS OF ESOPHAGEAL ATRESIA

• Antenatal Diagnosis (maternal polyhydramnios, a small stomach, a distended upper esophageal pouch, or abnormal swallowing)

• Diagnostic suspicion is increased when abnormalities known to be associated with esophageal atresia are identified.

Fetal MRI

• This 32 week fetus had esophageal atresia and an absent stomach, resulting in marked polyhydramnios

Clinical Diagnosis

• Prematurity

• Any excessively drooling (copious, fine, white, frothy bubbles of mucus in the mouth and, sometimes, the nose).

Clinical Diagnosis• . (A) Diagnosis of

esophageal atresia is confirmed when a 10-gauge (French) catheter cannot be passed beyond 10 cm from the gums. (B) A smaller-caliber tube is not used because it may curl up in the upper esophageal segment, giving a false impression of esophageal continuity.

The chest radiograph

• A plain radiograph will confirm the tube has not reached the stomach

The Gasless Abdomen

• Absence of gas in the abdomen suggests that the patient has either atresia without a fistula or atresia with a proximal fistula only

Contrast studies

• should be performed by an experienced pediatric radiologist, or after transfer to the tertiary institution, and with the use of a small amount (0.5 to 1 mL) of water-soluble contrast. Care must be taken to avoid aspiration.

Management

• Measures should be taken to reduce the risk of aspiration(continuous suctioning of the upper pouch, the infant's head should be elevated).

• In infants with respiratory failure, endotracheal intubation should be performed.

• Transfer to a major tertiary pediatric institution is best not delayed .

Summary of Preoperative Investigations

• A plain radiograph • Renal ultrasonography and echocardiography

are routine preoperative investigations• Endoscopy or a careful midesophageal contrast

study performed in a tertiary center. In some centers, bronchoscopy is performed routinely in all infants with esophageal atresia.

Operative Repair of Esophageal Atresia

• Surgical repair is delayed (1-2days) in infants with low birth weight, pneumonia or other major anomalies.

Operative Repair of Esophageal Atresia

Operative Repair of Esophageal Atresia

•  Respiratory difficulty after feedings in a 3-day-old boy. Barium esophagogram clearly shows an H-shaped fistula between the trachea and the middle segment of the esophagus (arrowhead). Barium is filling the bronchi of the right lower lobe (arrows).

Tracheoesophageal fistulawithout atresia (type E)

Tracheoesophageal fistula without atresia (type E).

• Esophagogram shows a fistula (arrow) arising from the anterior portion of the esophagus (e) and passing cephalad to the posterior portion of the trachea (t).

Tracheoesophageal fistula without atresia (type E).

• Endoscopic diagnosis

CongenitalCongenital tracheoesophageal tracheoesophageal 

fistula fistula

Congenital diaphragmatic hernia

Incidence

• 1 : 2000-5000 live birth

• 8 % of all major congenital anomalies

• mortality rate nearing 70 percent

• CDH accounts > 1% of total infant mortality in USA

Causes

• The cause of CDH is largely unknown • CDH can occur as part of a multiple

malformation syndrome in up to 40% of infants (cardiovascular, genitourinary, and gastrointestinal malformations)

• Karyotype abnormalities have been reported in 4% of infants with CDH, and CDH may be found in a variety of chromosomal anomalies including trisomy 13, trisomy 18, and tetrasomy 12p mosaicism

Prenatal Diagnosis

• ultrasonography diagnosis (as early as the second trimester)

Mediastinal shMediastinal shififtt

      Viscera herniation (stomach, intestines, Viscera herniation (stomach, intestines, liver*,liver*, kidneys, kidneys, spleen and gall bladder)              spleen and gall bladder)             

      Abnormal position of certain viscera inside the abdomenAbnormal position of certain viscera inside the abdomen

      Stomach visualization out of its usual positionStomach visualization out of its usual position

      Intrauterine growth retardation*Intrauterine growth retardation*

      Polyhydramnios*Polyhydramnios*

      Fetal hydrops*Fetal hydrops*

* bad prognosis* bad prognosis

Fetal diafragmatic hernia: Ultrasound diagnosis

Prenatal MR Imaging - single-shot turbo spin-echo (HASTE)- of congenital diaphragmatic hernia

Prenatal MR Imaging of congenital diaphragmatic hernia

Pulmonary hypoplasia

Anatomopathology show of CDH

Prenatal Counseling multidisciplinary team

• patient's obstetrician

• perinatologist

• geneticist

• surgeon

• social worker

Prenatal management

• Glucocorticoids

• Thyrotropin-releasing hormone

• Fetal surgical therapy (Antenatal surgical intervention,

In utero tracheal occlusion )

Delivery Room Management • affected infants should be delivered in a center that has experienced

personnel and available therapies. • the team in the delivery room consist of personnel experienced in the

immediate resuscitation and stabilization of critically ill neonates • affected patients in any respiratory distress require positive pressure

ventilation in the delivery room. • To prevent distension of the gastrointestinal tract and further

compression of the pulmonary parenchyma, a double-lumen nasogastric or orogastric tube of large caliber is placed to act as a vent.

• Early intubation is preferable ( bag-mask ventilation is contraindicated) to continuous positive airway pressure via mask or nasal prongs

Postnanal Diagnosis

• Respiratory distress

• Scaphoid abdomen

• Auscultation of the lungs reveals poor air entry

• Shift of the heart to the side opposite

Lab Studies • Arterial blood gas

– Obtain frequent arterial blood gas (ABG) measurements to assess for pH, PaCO2, and PaO2.

– Note the sampling site because persistent pulmonary hypertension (PPHN) with right-to-left ductal shunting often complicates CDH. The PaO2 may be higher from a preductal (right-hand) sampling site.

• Chromosome studies– Obtain chromosome studies because of the frequent association

with chromosomal anomalies.– In rare cases, chromosomal disorders that can only be diagnosed

by skin biopsy may be present. If dysmorphic features are observed on examination, a consultation with a geneticist is often helpful.

• Serum electrolytes: Monitor serum electrolytes, ionized calcium, and glucose levels initially and frequently. Maintenance of reference range glucose levels and calcium homeostasis is particularly important

Imaging Studies • Cardiac ultrasonography

– Perform ultrasonographic studies to rule out congenital heart diseases.

– Because the incidence of associated cardiac anomalies is high (up to 25%), cardiac ultrasonography is needed to evaluate for associated cardiac anomalies.

• Renal ultrasonography: A renal ultrasonographic examination may be needed to rule out genitourinary anomalies.

• Cranial ultrasonography– Perform cranial sonography if the infant is being considered for

extracorporeal support.– Ultrasonographic examination should focus on evaluation of

intraventricular bleeding and peripheral areas of hemorrhage or infarct or intracranial anomalies.

Other Tests

Pulse oximetry– Continuous pulse oximetry is valuable in the

diagnosis and management of PPHN.– Place oximeter probes at preductal (right-

hand) and postductal (either foot) sites to assess for a right-to-left shunt at the level of the ductus arteriosus

Postnanal Diagnosis left-sided CDH

• Radiograph in a male neonate shows the tip (large arrow) of the nasogastric tube positioned in the left hemithorax. Note the marked apex leftward angulation of the umbilical venous catheter (small arrow).

Right congenital diaphragmatic hernia

• Radiograph in a male neonate shows that the nasogastric tube (arrow) deviates to the left of the thoracic vertebral bodies as it passes through the inferior portion of the thorax

Procedures

• Intubation and mechanical ventilation– Endotracheal intubation and mechanical ventilation are required

for all infants with severe CDH who present in the first hours of life.

– Avoid bag-and-mask ventilation in the delivery room because the stomach and intestines become distended with air and further compromise pulmonary function.

– Avoid high peak inspiratory pressures and overdistension. Consider high-frequency ventilation if high peak inspiratory pressures are required.

• Arterial catheter placement: Place an indwelling catheter in the umbilical artery or in a peripheral artery (radial, posterior tibial) for frequent ABG monitoring.

• Central venous catheter placement– Place a venous catheter via the umbilical or femoral vein to allow

for administration of inotropic agents and hypertonic solutions such as calcium gluconate

Postnatal management

• Mechanical ventilation

• Nitric Oxide

• Surfactant

• ECMO

• surgery

Operative approach

TThe defect in the diaphragm he defect in the diaphragm

Patch repair of a large defect

Further Inpatient Care

• Pulmonary care– Some severely affected infants have chronic lung disease. These

infants may require prolonged therapy with supplemental oxygen and diuretics, an approach similar to that for bronchopulmonary dysplasia.

– The use of steroids, particularly high doses for prolonged periods, is controversial and may actually hinder appropriate lung and brain development.

• Neurologic evaluation– Following recovery, a neurologist or developmental pediatrician

should examine the patient, including an evaluation for CNS injury by head CT scanning.

– Because the incidence of hearing loss is high, perform an automated hearing test prior to discharge.

• Feeding: Incidence of significant gastroesophageal reflux is very high. While most infants can be managed medically, surgical intervention with Nissen or Thal procedures is sometimes required.

Further Outpatient Care

• Growth: Failure to thrive is common in a significant percentage of survivors and is most common in severely affected infants. Possible causes include increased caloric requirements because of chronic lung disease, poor oral feeding because of neurologic delays, and gastroesophageal reflux.

• Developmental follow-up– Because of the risk for CNS insult and sensorineural

hearing loss, infants should be closely monitored for the first 3 years of life, preferably in a specialty follow-up clinic.

– Reassess hearing at 6 months of life (and later if indicated) because late sensorineural hearing loss occurs in a high percentage of patients.

– Evaluate the patient prior to entering school to determine if any subtle deficits may predispose the patient to learning disabilities.

Prognosis

• Pulmonary recovery: When all resources, including ECMO, are provided, survival rates range from 40-69%.

• Long-term morbidity: Significant long-term morbidity, including

• chronic lung disease,• growth failure,• gastroesophageal reflux,• neurodevelopmental delay, may occur in

survivors.

Foreign Body Aspiration

Epidemiology

• Major cause of accidental death

• 17,000 ER visits (aspiration + ingestion) in 2000

• 1,500 die each year due to FB aspiration

• Majority < age 3

• Male > Female

Aspiration in young children

• Lack of molar teeth

• Poorer mastication

• Tendency to put things in mouth

• Playing with things in mouth

• Immature protective laryngeal reflexes

Foreign body

Symptoms and Physical findings

• Cough• Dyspnea• Wheezing • Stridor• Cyanosis• Decreased breath sounds• Tachypnea• Rhonchi• Somnolence

Age Difference

Distribution of FB in airway

• 70% Right main bronchus in adolescent & adult

• Higher variability in young children– Head/ body position– Supine/ Prone position

• Carina usually positioned left of midline ; Right of midline in 34 % children (Tahir N 2008)

Tahir N et al. 2009.

Complications

• Mortality after bronchoscopy < 1%• Bronchiectasis• Pneumonia / bronchitis• Subcutaneous Emphysema• Pneumothorax / pneumomediastinum• Granulation tissue and hemorrhage• Cartilage destruction• Airway compromise• Death

Diagnosis

• History

• Physical Exam

• Radiography

History of choking

• Highly sensitive (> 90%) for aspiration

• Specificity: 45 – 76%

• Classic history:– Choking episode followed by coughing spells

Physical Exam

• Sensitivity: 24-86 %

• Specificity: 12-64 %

• Decreased unilateral breath sound

• Unilateral Wheezing

• Stridor

Chest x-ray

• Normal in 20- 40 % of cases

• Most are radiolucent (food origin)

• Inspiratory/ expiratory film

• Air-trapping on expiration

• Atelectasis

• Infiltration

• Consolidation

Hyperinflation of Right lung

Fluoroscopy

• Normal in 53 % of FB patients (Even L 2005)

• Sensitivity: 47%

• Specificity: 95%

• Mediastinal shift

• Paradoxical movement of the diaphragm

CT scan

• Hong SJ 2007

• Retrospective

• 42 patients

• Can visualize radiolucent FBs

Hong SJ et al. 2008

Rule of thumb

• Perform bronchoscopy if another one of the following is positive:– History– PE– Radiography

• Bronchoscopic evaluation is warranted on the basis of a positive history alone

Digoy GP et al. 2008

Medical management

• The role of beta-2 agonist remains unclear

• Alleviation of discomfort

• Expelling foreign body could be life threatening

• Not a replacement for bronchoscopy

Age-appropriate Bronchoscope

Bronchoscopes

Optical forceps

Anesthesia

• Availability of experienced Pediatric anesthesiology team

• Daytime vs. night team• If unstable, securing airway always a priority

over fasting guidelines• Pulse oximetry• Spray cords with 2% topical lidocaine to avoid

laryngeal spasm• Ventilation via bronchoscope

Fiberoptic bronchoscopy

• Useful when FB migrates to distal bronchi

• Introduced via endotracheal tube or LMA

Role of Tracheotomy

• Incidence 0.5 -3 %

• Large FB in subglottic or proximal trachea

• Concomitent tracheotomy could be performed if FB too big or sharp to pass through glottic area

• Significant laryngeal edema

Postoperative Care

• Admission / observation

• Clear liquid diet

• Chest x-ray

• Chest physiotherapy

• Antibiotics – In cases of delayed diagnosis

Summary• A positive history of choking event followed by

coughing is an indication for bronchoscopic evaluation

• Radiographic evaluation is helpful in localization and identification of foreign body.

• Knowledge of age-appropriate instrument and communication with surgical team are paramount in the management of foreign body aspiration

Errors to Avoid in Suspected Foreign Body Cases

• Do not reach for the foreign body with the fingers.

Errors to Avoid in Suspected Foreign Body Cases

• Do not hold up the patient by the heels.

Errors to Avoid in Suspected Foreign Body Cases

• Do not fail to have a roentgenogram made.

Errors to Avoid in Suspected Foreign Body Cases

• Do not fail to search endoscopically for a foreign body in all cases of doubt.

Errors to Avoid in Suspected Foreign Body Cases

• Do not pass blindly an esophageal bougie or other instrument.

Errors to Avoid in Suspected Foreign Body Cases

• Do not tell the patient he has no foreign body until after X-Ray examination, physical examination, indirect examination and endoscopy have all proven negative.

The following aphorisms afford food for thought.

• Educate your eye and your fingers.

The following aphorisms afford food for thought.

• Be sure you are right, but not too sure.

The following aphorisms afford food for thought.

• Follow your judgment, never your impulse.

The following aphorisms afford food for thought.

• Cry over spilled milk enough to memorize how you spilled it.

The following aphorisms afford food for thought.

• Let your left hand know what your right hand does and how to do it.

The following aphorisms afford food for thought.

• Nature helps but she is no more interested in the survival of your patient than in the survival of the attacking pathogenic bacteria.

Pulmonary air leak syndrome

Pulmonary air leak syndrome When air escapes from the lung into extra alveolar

spaces where it is not normally present Most common in newborn period.

-Iatrogenic pulmonary condition of the premature infant with immature lungs (mechanical ventilation)

Pulmonary air leak syndrome

Pulmonary Interstitial Emphysema Pneumothorax Pneumomediastinum Pneumopericardium Pneumoperitoneum Subcutaneous Emphysema

Pulmonary Interstitial Emphysema• Collection of gases

outside the normal air passages

• Escape of air into pulmonary interstitium, lymphatic and venous circulation.

• Secondary to rupture (usually junction of the bronchiole and alveolar duct)

Pulmonary interstitial emphysema Risk Factors

• Prematurity (< 32 weeks GA)

• VLBW (< 1,000 g) • Low Apgar score (< 5 )

and need of resuscitation • Positive pressure

ventilation • Use of ↑ ↑vT) Peak

inspiratory pressure (PIP), Tidal volume ( vT ) & ↑ Inspiratory time (Ti)

•RDS • Meconium aspiration syndrome •Amniotic fluid aspiration Infection • Neonatal sepsis •Pneumonia • Pulmonary hypoplasia

Pulmonary interstitial emphysema Classification

Usually in the first 72 hrs of life :

• Acute ( less 7 days) or persistent

• Localized or diffused

• Unilateral or bilateral

Pulmonary interstitial emphysema Frequency

• Currently is uncommon because of post natal surfactant, gentle ventilation and high frequency ventilation.

Pulmonary interstitial emphysema Pathophysiology

Mechanical ventilation with large tidal volume increases the number of neutrophils and cytokines in the lungs and also the permeability of the capillary membrane, leading to pulmonary edema

Pulmonary interstitial emphysema Pathophysiology Recent studies have demonstrated

presence of free elastase and alpha 1

1-elastase-1- proteinase inhibitor as well as elastase alpha 1 proteinase inhibitor in tracheal aspirate of neonates with severe RDS

PIE infants appear to have free elastase activity in tracheal aspirate fluid

Pulmonary interstitial emphysema Diagnosis

• Mainly a radiographic and pathologic diagnosis• Blood gas show

↑ PCO2 and ↓ PO2• Increased respiratory support demand• Increased lung volumes

AP C-Xray :• linear, oval or spherical cystic air-containing spaces (1

mm to1 cm)• Pneumothorax• Heart tends to get smaller• ↑ intrathoracic pressure ….↑ lung volume

Pulmonary interstitial emphysema Differential Dx

Bronchopulmonary dysplasia (BPD) (lucency is less linear)

Respiratory distress syndrome Congenital cystic adenomatoid

malformation (CCAM)

Pulmonary interstitial emphysema Complications

Loss of pulmonary compliance Epitheliazation of the interstitial air

pockets Air embolus in pulmonary venous

circulation Rupture of subpleural lymphatic blebs

(pneumothorax)

Pulmonary interstitial emphysema Complications

BPD Rupture of bronchial connections and release of

air into the interstitium promotes edema and oxidant injury Cochran et al, B J Radiol 1994.

Highest risk for VLBW infant, low GA and PIE in first 24 hrs of life. Gaylord et al, Pediatrics, 1985

Increased risk for IVH in pneumothorax. Hill et al, Pediatrics, 1982.

Pulmonary interstitial emphysema Treatment

Localized Conservative management Decubitus position with affected side down Selective intubation of the main bronchus on the

uninvolved side (10 days O’Donovan Donovan 2001, 5 days Khashu 2005)

Lobectomy High frequency oscillatory ventilation (low

volumes of gas and low pressure) Nelle et al, Intensive care med 1998.

Pulmonary air leak syndrome

• Pulmonary Interstitial Emphysema

• Pneumothorax

• Pneumomediastinum

• Pneumopericardium

• Pneumoperitoneum

• Subcutaneous Emphysema

Pneumothorax Pneumothorax refers to the presence of

air or gas in the pleural cavity between the visceral and parietal pleura, which results in violation of the pleural space.

There is a loss of intrapleural negative pressure causing lung collapse.

Pneumothorax Pathophysiology

• The main physiologic consequences of a pneumothorax are a decrease in vital capacity and a decrease in PaO2

• In a simple pneumothorax, air in the pleural space does not build up significant pressure but allows the lung to collapse 10

30% without further expansion of the pneumothorax.

Pneumothorax Pathophysiology

A complicated pneumothorax is progressive

and consists of continued air leakage into the pleural space and progressive lung collapse.

Tension pneumothorax is a life threatening emergency It is caused when air enters the pleural space during inspiration but cannot exit during exhalation.

Pneumothorax Pathophysiology

• The positive pressure results in collapse of the involved lung and a shift of the mediastinal structures to the contralateral side. This causes a decrease in cardiac output as a consequence of decreased venous return and leads to rapidly progressive shock and death if not treated

Pneumothorax Signs & symptoms

• Increasing respiratory distress, including rapid breathing, grunting, nostril flaring, and chest wall retractions

• Difficulty hearing breath sounds when listening with a stethoscope

• Change in the location of heart or lung sounds when the organs are moved by the presence of air

• Changes in arterial blood gas levels (respiratory acidosis)

Pneumothorax Dx diff• Bronchogenic cyst

• Congenital lung malformation

• Cystic adenomatoid malformation

• Hemothorax

• Pleural effusion

Pneumothorax Diagnosis

• A tension pneumothorax should always be a clinical diagnosis since death can occur before the radiograph is taken or developed

Pneumothorax Diagnosis

• When an infant is suspected of having a pneumothorax, anterior posterior radiographs are taken in the supine position. Small pneumothoraces can be better visualized with lateral decubitus film with the affected side up.

• Transillumination of the chest may help to establish the diagnosis in the newborn infant.

Pneumothorax

Pneumothorax Treatment• No specific management for asymptomatic

pneumothorax

• Infants with lung disease, the presence of pneumothorax accentuates the respiratory difficulty and requires intervention

• Full term with no mechanical ventilation: FIO2 100% in oxyhood up to 50 percent may improve the resolution of small uncomplicated pneumothorax

Thoracentesis (needle aspiration)Emergent treatment of a symptomatic

pneumothorax• Localize site: 2nd -3rd intercostal space along

midclavicular line

• Cleanse the area

• 22/24 g angio attached to 20 ml syringe with a

stopcock

• Palpable 3rd rd rib at midclavicular line and insert needle above the rib

• Advance needle till air is withdrawn in syringe

Pneumothorax : chest tube

• Tension pneumothorax and pneumothorax that develops in a mechanically ventilated infant usually need chest tube placement for definitive drainage.

Equipment: • Chest tube set up

• Sterile field • < 2 Kg use 10 Fr catheter • >2 Kg Use 12 Fr catheter

Pneumothorax: chest tubeProcedure• Anterior placement (2nd -3rd intercostal space,

midclavicular line)• Posterior placement (4th, 5th, 6th intercostal

space, anterior axillary line)• NIPPLE LINE IS 4TH INTERCOSTAL

1. Position patient

2. Select site

3. Cleanse area / sterile field

4. Infiltrate area with 0.5%-1% lidocaine

Pneumothorax: chest tube5. Make small incision 1.5 cm in the skin over the

rib just below the intercostal space where tube is to be inserted

6. Dissect tissue with hemostat.

7. Using tip of hemostat, puncture pleura just above the rib

8. Insert chest tube through open hemostat

9. Attach to suction

10. Secure with sutures

11. Apply Vaseline

12. CXR

Pulmonary air leak syndrome

• Pulmonary Interstitial Emphysema

• Pneumothorax

• Pneumomediastinum

• Pneumopericardium

• Pneumoperitoneum

• Subcutaneous Emphysema

Pneumomediastinum• Pneumomediastinum consists of air in the

mediastinal space • Most cases are asymptomatic. • Large collections of air may result in tachypnea

and cyanosis • Suspected on the routine newborn examination

when the heart sounds are distant. • The diagnosis is made on a chest radiograph • Usually resolves spontaneously, and requires no

specific treatment

• The patient should be observed closely for other air leaks, especially pneumothorax.

Pneumomediastinum

Pulmonary air leak syndrome

• Pulmonary Interstitial Emphysema

• Pneumothorax

• Pneumomediastinum

• Pneumopericardium

• Pneumoperitoneum

• Subcutaneous Emphys

Pneumopericardium

• Rare condition caused by air in the pericardial space

• It can cause cardiac tamponade that is life threatening.

• Typically occurs in a mechanically ventilated

preterm infant with severe RDS who also has pneumothorax and/or PIE

• Rare in an infant who does not require mechanical ventilation

Pneumopericardium

Clinically: • Abrupt onset of hemodynamic compromise due to

cardiac tamponade • Tachycardia and a narrowed pulse pressure • Follow by bradycardia, hypotension, increased

respiratory distress, and cyanosis • The heart sounds may be muffled or distant • The electrocardiogram may show low voltages with

a small QRS complex.

Pneumopericardium

• Diagnosis is confirmed by chest radiograph ( gas shadow does not extend beyond the reflection of the aorta and pulmonary artery)

• In life-threatening situations in which the diagnosis is strongly suspected, the diagnosis is made by a therapeutic pericardiocentesis

Pneumopericardium

Pneumopericardium

Management: • Infants who are asymptomatic may not need

intervention (close monitoring) • Ventilator pressures should be minimized

Pericardial drainage : Symptomatic infants

This procedure is both diagnostic and therapeutic

Pulmonary air leak syndrome

• Pulmonary Interstitial Emphysema

• Pneumothorax

• Pneumomediastinum

• Pneumopericardium

• Pneumoperitoneum

• Subcutaneous Emphysema

Pneumoperitoneum • Pneumoperitoneum and subcutaneous

emphysema are uncommon types of air leak

• Pneumoperitoneum may occur when extrapulmonary air decompresses into the peritoneal cavity

• The diagnosis is made on an abdominal radiograph and usually has little clinical significance

• It must be differentiated from intraperitoneal air due to a perforated viscus

Subcutaneous Emphysema

• Subcutaneous emphysema typically occurs in the face, neck, or supraclavicular region. It typically presents as crepitus detected by palpation. It usually has no clinical significance, although large air collections in the neck may cause tracheal compromise

Airway/Respiratory• Neck Masses

– Cystic Hygromas– Tracheal anomalies

• Thoracic masses/pulmonary lesions– Congenital lobar emphysema

• Overdistension of one or more lobes

– Congenital cystic adenomatous malformation(CCAM)

• Multicystic mass of lung tissue, proliferation of bronchial structures at the expense of alveoli

– Pulmonary agenesis• Absence of lung

Cystic Hygroma• Multiloculated cystic spaces lined by

endothelial cells– Separated by fine walls containing numerous smooth

muscle cells– Result of maldevelopment of lymphatic spaces

• Incidence about 1 in 12,000 births– 50-65% appear at birth, 85-90% appear by age 2– Neck-75%, Axilla 20%; can be seen in mediastinum,

retroperitoneum, pelvis, groin– Nuchal/post cervical CH’s have been associated with

chromosomal abnormalities—high mortality rate

Cystic Hygroma

Cystic Hygroma• Complications

– Respiratory—large hygromas can extend into oropharynx and trachea

– Inflammation/Infection– Hemorrhage

• Treatment– Dependent on size, location, symptoms/complications– Some pts require emergent surgery due to airway

compromise– Best treatment is complete excision– Aspiration typically not effective due to rapid refilling of fluid– Sclerotherapy—Bleomycin, OK-432 (no longer available in

US), doxycycline, fibrin glue

Cystic Hygroma

• Postnatal overdistension of one or more lobes of histologically normal lung– Probably due to cartilaginous deficiency in the

tracheobronchial tree– Obstruction causing the overdistension may be due to

• 1—chondromalacia of bronchi• 2—extrinsic pressure on bronchus by anomalous pulmonary

vein or abnormally large PDA• 3—idiopathic

• Location– LUL 47%, RML 28%, RUL 20%; lower lobes <5%; Bilat

rare

Congenital Lobar Emphysema

Congenital Lobar Emphysema

Congenital Lobar Emphysema

• Diagnosis– Usually can be made by plain CXR; Chest CT and

V/P scans may be helpful

• Treatment– May require urgent surgical decompression with

lobectomy– Selective bronchial intubation– Sometimes see spontaneous resolution—need close

observation

Congenital Cystic Adenomatous Malformation (CCAM)

• Mass of cysts lined by ciliated cuboidal or columnar pseudostratified epithelium

• Three types– I—few large cysts >2cm; thick walls, normal alveoli

between the cysts; ciliated pseudostratified columnar epithelium

– II—numerous small cysts <1cm, thin muscular coat, large alveolar-like structures between the cysts; ciliated cuboidal to columnar epithelium; assoc w/other congenital anomalies

– III—bulky firm masses of folded ciliated and non-ciliated cuboidal epithelium and thick layer of smooth muscle; often occupy the entire lobe or lobes of lung

Congenital Cystic Adenomatous Malformation (CCAM)

• More common on the left side, 2% bilateral

• Diagnosis– CT scan allows differentiation of types– Some can be diagnosed on prenatal US

• Treatment– Surgical excision, typically anatomical lobe resection,

due to risk of infection, malignant transformation– Some are performing fetal aspiration

Congenital Cystic Adenomatous Malformation (CCAM)

Thanks…….