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280 Paediatric Upper Airway Obstruction

injections and nasal airways, as they only upset the child
Observations and management of LTB are as follows:
• A slowing pulse and reduced respiration rate are good signs.
• Humidified air, or oxygen if necessary, is given via a mask held in
front of the child’s face.
• Oral fluid is given.
• Antibiotics are not necessary except for the more severe cases
when oral cephalexin (25mg/kg body weight, every 6 hours) or
chloramphenicol (2.5mg/kg body weight, every 6 hours) are given.
• Steroids (dexamethasone, 0.6mg/kg body weight) given orally
twice a day as necessary will help.
• Nebulised adrenaline (5 ml of 1 in 1000) given via a face mask is a
good way to reduce oedema in the more severe cases. This may need
repeating every 2 hours while the condition is monitored with a trans-
cutaneous oxygen probe and careful pulse and respiratory rates are
Figure 42.1: Technique for thumping child on the back in a prone position to recorded.
remove foreign body.
• Severe cases will need intubation or, occasionally, tracheostomy.
As children grow, the subglottic lumen increases oedema from LTB
has less effect on narrowing the airway, which is why this condition is
usually seen only in children under 2 years of age.
Acute Epiglottitis
Epiglottitis is a frightening emergency airway problem to deal with, but
if handled correctly will lead to a child rapidly restored to health from
a potentially fatal situation. It is an infection caused by Haemophilus
influenza in a nonimmunised child, usually around the age of 5 years. It
is very much rarer than LTB, especially in countries where H. influenza
vaccine immunisation is routinely given. Rapid diagnosis is essential
to ensure urgent life-saving treatment. It is safe to assume all children
will require a temporary alternative airway, usually intubation if the
skills are present to carry out what is a potentially difficult procedure;
otherwise, a tracheostomy is necessary.
The following points should be heeded in the management having
suspected the diagnosis based on the information in Table 42.1:
• Never examine the throat except in a facility where intubation can
be immediately carried out.
• Never do anything invasive or attempt to lie the child down. The
Figure 42.2: Heimlich maneouvre to remove foreign body. child is much safer sitting up, leaning forward, drooling, and in the
clothes in the child had been wearing.
X-rays for the diagnosis of acute epiglottitis are dangerous in that • Never carry out a lateral neck x-ray. The thumb sign seen in most
they distress the child and waste valuable time; if a retropharyngeal textbooks is not necessary to make the diagnosis, and the perfor-
abscess is suspected, however, a lateral neck film is useful. Cyanosis mance of moving and positioning a child for a neck x-ray may pre-
is a sign of imminent disaster and indicates the child needs an urgent cipitate a sudden airway crisis.
alternative airway. Increasing pulse and respiration rates are also good • Always reassure the child and the mother.
signs that the child’s condition is worsening.
Table 42.1 distinguishes among the various causes of acute • Always arrange urgent transfer to an anaesthetic room, having first
infective upper airway obstruction that can be determined from called an anaesthetist and ENT surgeon to be present so that an
the history and observation of a child. It particularly distinguishes alternative airway can be performed.
epiglottitis from other causes so that urgent action may be taken with • Always use humidified oxygen given by a face mask held close to
reasonable diagnostic certainty.
the child’s face while being transferred to a resuscitation room.
Laryngotracheobronchitis
Once the appropriate personnel are present, general anaesthesia
Laryngotracheobronchitis (LTB, or croup) is a viral condition and is the
is induced while the child is in the sitting position, and the child is
most common infection that causes stridor. Most cases occur at around
laid prone once asleep. The diagnosis is now made with an intubating
18months of age, and there is always a history of upper respiratory
laryngoscope when a “cherry red” epiglottis is seen. Intubation is carried
infection in the preceding week. There may be a history of previous
out at the same time. If this is impossible, a thump on the chest will often
attacks. Mild cases present with a barking seal-like cough with a hoarse
produce a bubble of air, indicating where the tube should be aimed. If the
cry and inspiratory stridor, which is worse if the child gets agitated
swelling is so great that a flexible tube will not pass, the ENT surgeon
when an expiratory component can also be heard.
should be able to pass a rigid bronchoscope through the obstruction. A
Rarely is there any need for intubation (less than 5%) and the
useful trick is to use a Magill nasal sucker, which has a blunt end and a
management is to calm the child and reassure the mother. Avoid
gentle curve, allowing easy intubation. If either of these rigid instruments