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Upper Airway Obstruction

Upper airway obstruction is a potentially lethal condition, in both children and adults and requires prompt diagnosis and management. The degree of emergency with which it needs to be addressed depends on the severity of the obstruction since complete obstruction leads to rapid respiratory and subsequent circulatory failure.


Presentation

Clinical presentation of the patient depends on the extent of the upper airway obstruction and symptoms include panic, choking, confusion, dyspnea, hoarseness, gasping, wheezing, stridor, tachypnea, tachycardia, hypertension, and pulsus paradoxus. Cyanosis sets in rather late, as the hypoxemia becomes severe.

Increased work of breathing indicates respiratory distress but does not necessarily signify airway obstruction [1] [2].

Clinical signs such as increased use of accessory respiratory muscles, seen as suprasternal, supraclavicular, subclavicular, intercostal and subcostal retractions or even paradoxical chest and abdomen movement can be observed. As oxygenated hemoglobin level decreases, the patient becomes agitated, develops altered sensorium, then becomes unconscious and finally lapses into a coma. Several symptoms are suggestive of a specific cause of the obstruction e.g. fever and barking cough imply croup; low pitched expiratory stridor may be encountered in epiglottitis; choking and aphonia with sudden onset could mean foreign object aspiration; urticaria and facial swelling are seen in anaphylaxis. If the obstruction is mild, the patient will be able to speak in full sentences, whereas more severe obstruction leads to fractioned words.

If the onset of the condition is gradual, exertional dyspnea is the first complaint, with no hypoxemia or hypercapnia symptoms at rest [3]. As the obstruction grows more severe, dyspnea and stridor occur at rest [4] due to hypoventilation [5] [6].

Enuresis
  • Participants were separated into monosymptomatic nocturnal enuresis (MNE) (group 1) and without MNE (group 2) groups.[ncbi.nlm.nih.gov]
Hemophilia A
  • Abstract We report a rare case of acute upper airway obstruction caused by spontaneous retropharyngeal hemorrhage as a result of hemophilia A in a 16-year-old pediatric patient who routinely received factor VIII replacement.[ncbi.nlm.nih.gov]
Malocclusion
  • Abstract Upper airway obstruction is associated with many dental and skeletal malocclusions. Recognizing and removing the problems at an early age is encouraged.[ncbi.nlm.nih.gov]
  • Abstract 13-year old boy with spastic quadriplegia cerebral palsy visited dental clinic with chief complaints of mouth breathing and malocclusion.[ncbi.nlm.nih.gov]
Joint Tenderness
  • There is a fairly consistent picture of brief symptoms, which include weakness or fatique, bleeding or bruising, and bone or joint tenderness. Acute or subacute fever also is a common symptom.[ncbi.nlm.nih.gov]
Spastic Quadriplegia
  • Abstract 13-year old boy with spastic quadriplegia cerebral palsy visited dental clinic with chief complaints of mouth breathing and malocclusion.[ncbi.nlm.nih.gov]
Nocturnal Enuresis
  • Participants were separated into monosymptomatic nocturnal enuresis (MNE) (group 1) and without MNE (group 2) groups.[ncbi.nlm.nih.gov]

Workup

On auscultation, an absence of breath sounds should raise suspicion of complete obstruction while foreign sounds mean partial obstruction. Stridor is found during inspiration if the location of the obstruction is laryngeal or during expiration if the obstruction is located lower in the respiratory system.

The clinician should also observe or inquire about the presence of other diseases, such as cardiac malformations, burns, bleeding that might obstruct the airway, anaphylaxis and periodically reassess patient status.

Arterial blood gas readings show respiratory acidosis and high carbon dioxide pressure, reflecting the hypoxemia and hypercapnia. Hypoxemia is easily evaluated with pulse oximetry.

Spirometry and flow-volume loops are applicable in partial obstruction cases and offer valuable parameters like forced expiratory volume per second (FEV1), peak expiratory flow rate (PEFR), maximal voluntary ventilation (MVV), maximal mid-expiratory flow (MEF50) and maximal mid-inspiratory flow (MIF50) [7] [8] [9], that may also indicate if the obstruction is fixed or variable. For instance, the MEF50/MIF50 ratio is increased in variable extrathoracic lesions and decreased in variable intrathoracic lesions [10]. The FEV1/MEF ratio is useful, for instance, in patients with vocal cord paralysis [11] [12].

Obstructive sleep apnea, a frequent cause of chronic upper airway obstruction in adults, as well as neuromuscular diseases, Parkinson's disease, and episodic laryngeal dyskinesia, have a particular "sawtooth" appearance on the flow volume curves [13]. It is important to remember during interpretation of the results that posture and activity influence the flow volume curves [14] [15].

Additional imaging techniques include spiral computer tomography and optic fiber bronchoscopy; these are especially useful in adult patients, especially those suspected of having a malignancy obstructing the upper respiratory system, but also in children suspected to have tracheomalacia. Another cause of upper respiratory obstruction in children may be lingual thyroglossal duct cysts, [16] [17] and symptomatic patients should be evaluated with magnetic resonance imaging [18].

Treatment

  • Other treatments for managing paediatric SDB include nasal continuous airway pressure, the administration of nasal steroids, dentofacial orthopaedic treatment and surgery.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Sialoendoscopy has gained popularity and is an accepted method for diagnosis and treatment of most inflammatory conditions of the major salivary glands.[ncbi.nlm.nih.gov]
  • We also discussed the effect of needle aspiration in the emergency treatment of external laryngopyocele.[ncbi.nlm.nih.gov]
  • This systematic review was conducted to determine the effectiveness of MDO in the treatment of airway obstruction. The databases searched included PubMed, Embase, Scopus, and grey literature sources.[ncbi.nlm.nih.gov]
  • The aim of the study was to carry out surgical resection and reconstruction with locoregional flap and free bone graft in the neonatal and early infantile period for definitive management of head and neck masses and treatment of potential airway obstruction[ncbi.nlm.nih.gov]

Prognosis

  • The prognosis is poor with squamous cell carcinoma of the trachea, which carries a 5-year survival of approximately 40% when resectable and 7% when unresectable.[clinicaladvisor.com]
  • […] especially when being prepared for children Consume food slowly and fully chew food before swallowing, which is an effective preventative method Closely watch very young children while they play with toys and small play items (toy parts) What is the Prognosis[dovemed.com]
  • Overall prognosis is considered considered generally poor 6 . tracheal atresia Promoted articles (advertising)[radiopaedia.org]
  • Progressing neurological deficit secondary to acute ischemic stroke: a study on predictability, pathogenesis, and prognosis. Arch Neurol . 1995; 52 : 670–675.[ahajournals.org]

Etiology

  • Tonsil hypertrophy, adenoid vegetation, septal deviation, turbinate hypertrophy, allergic rhinitis, upper airway obstruction, and snoring etiology were assessed.[ncbi.nlm.nih.gov]
  • Its etiology is not well known but probably caused by congenital and acquired causes. It is uncommon and usually asymptomatic. It may be seen at any age but is most commonly presented at fifth and sixth decades.[ncbi.nlm.nih.gov]
  • Cephalometric measurements of the MB group differed according to the etiology of upper airway obstruction.[ncbi.nlm.nih.gov]
  • The etiologies vary widely throughout the age groups and according to the mode of presentation.[ncbi.nlm.nih.gov]
  • .  Common etiologies of upper airway obstruction in adults include infection, inflammatory disorders, trauma, and extrinsic compression related to pathology of adjacent structures.  Definitive management depends on the underlying etiology and may include[slideshare.net]

Epidemiology

  • This report highlights the epidemiology, presentation, complication and management of laryngoceles.[ncbi.nlm.nih.gov]
  • Germany. 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Tuebingen, Germany. 3 Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Tuebingen, Tuebingen, Germany. 4 Institute for Clinical Epidemiology[journals.lww.com]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • "Acute epiglotitis: epidemiology, clinical presentation, management and outcome". J Laryngol Otol . vol. 122. 2008. pp. 818-23.[clinicaladvisor.com]
Sex distribution
Age distribution

Pathophysiology

  • The clinical and pathophysiologic manifestations can be ameliorated by establishing an airway. In one patient symptoms were abolished by permanent tracheostomy.[annals.org]
  • See Figure 2 for a comparison of what 1 mm of circumferential edema does in terms of airway resistance to an infant and an adult Pathophysiology Upper airway obstruction can occur for a variety of causes, but fundamentally, leads to increased airway resistance[learnpicu.com]
  • Prevalence and pathophysiology The consensus view is that OSAS affects about 3% of children, with 8%–12% snoring most nights. 1, 2 The peak prevalence occurs between the ages of 2 and 8 years, when lymphoid enlargement relative to upper-airway size is[mja.com.au]
  • Palliative interventions for patients with chronic upper airway obstruction include: balloon dilatation airway stenting laser therapy electrocautery and argon plasma coagulation cryotherapy nocturnal, noninvasive, positive-pressure ventilation Pathophysiology[clinicaladvisor.com]

Prevention

  • Abstract The safety of high pressure source ventilation (jet ventilation) is dependent upon upper airway patency to facilitate adequate passive expiration and prevent increasing intrathoracic pressure and its associated deleterious sequelae.[ncbi.nlm.nih.gov]
  • Primary MDO for the relief of upper airway obstruction was found to be successful at preventing tracheostomy in 95% of cases. Syndromic patients were found to have a four times greater odds of failure compared to those with isolated PRS.[ncbi.nlm.nih.gov]
  • RATIONALE: Subglottic edema is the most common cause of pediatric extubation failure, but few studies have confirmed risk factors or prevention strategies.[ncbi.nlm.nih.gov]
  • Prompt evaluation and management of suspected UAO may prevent subsequent complications including cardiac arrest, anoxic brain injury, and negative pressure pulmonary edema.[accessmedicine.mhmedical.com]
  • […] sleepiness or reports of "waking up tired", especially if snores heavy; perform complete health assessment; Sleep Apnea - Intervention Nonsurgical management: change in sleeping position or weight loss may reduce mild apnea, position-fixing devices may prevent[quizlet.com]

References

Article

  1. Warren JB, Anderson JM. Newborn respiratory disorders. Pediatr Rev. 2010;31(12):487–495.
  2. Nitu ME, Eigen H. Respiratory failure. Pediatr Rev. 2009;30(12):470–477.
  3. Courey MS. Airway obstruction: the problem and its causes. Otolaryngol Clin North Am. 1995;28:673-684.
  4. Braman SS, Gaissert HA. Upper airway obstruction. In: Fishman AP, Elias JA, Fishman JA, et al, eds. Fishman’s Pulmonary Diseases and Disorders. 3rd ed. New York: McGraw-Hill; 1998:783-801.
  5. Al-Bazzaz F, Grillo H, Kazemi H. Response to exercise in upper airway obstruction. Am Rev Respir Dis. 1975;111:631.
  6. Aboussouan LS, Stoller JK. Diagnosis and management of upper airway obstruction. Clin Chest Med. 1994;1:35-53.
  7. Miller RD, Hyatt RE. Obstructing lesions of the larynx and trachea: clinical and physiologic characteristics. Mayo Clin Proc. 1969;44:145-161.
  8. Miller RD, Hyatt RE. Evaluation of obstructing lesions of the trachea and larynx by flow-volume loops. Am Rev Respir Dis. 1973;108:475-481.
  9. Gamsu G, Borson DB, Webb WR, Cunnigham JH. Structure and function in tracheal stenosis. Am Rev Respir Dis. 1980;121:519-531.
  10. Lunn WW, Sheller JR. Flow volume loops in the evaluation of upper airway obstruction. Otolaryngol Clin North Am. 1995;28:721-729.
  11. Cantarella G, Fasano V, Bucchioni E, Domenichini E, Cesana BM. Spirometric and plethysmographic assessment of upper airway obstruction in laryngeal hemiplegia. Ann Otol Rhinol Laryngol 2003; 112(12):1014-1020.
  12. Kashima HK. Documentation of upper airway obstruction in unilateral vocal cord paralysis: flow-volume loop studies in 43 subjects. Laryngoscope 1984;94(7):923-937.
  13. Krieger J, Weitzenblum E, Vandevenne A, Stierle JL, Kurtz D. Flow-volume curve abnormalities and obstructive sleep apnea syndrome. Chest. 1985;87:163-167.
  14. Meysman M, Vincken W. Effect of body posture on spirometric values and upper airway obstruction indices derived from the flow-volume loop in young nonobese subjects. Chest. 1998;114:1042-1047.
  15. Melissant CF, Lammers JWJ, Demedts M. Relationship between external resistances, lung function changes and maximal exercise capacity. Eur Respir J. 1998;11:1369-1375.
  16. Byard RW, Bourne AJ, Silver MM. The association of lingual thyroglossal duct remnants with sudden death in infancy. Int J Pediatr Otorhinolaryngol. 1990;20(2):107–112.
  17. Kanawaku Sudden Infant Death: lingual thyroglossal duct cyst versus environmental factors. Forensic Science Int. 2006;156(2-3):158–160.
  18. Sameer KS, Mohanty S, Correa MM, Das K. Lingual thyroglossal duct cysts--a review. Int J Pediatr Otorhinolaryngol. 2012;76(2):165–168.

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Last updated: 2018-06-21 22:18