INFECTIOUS CROUP, FOREIGN BODY ASPIRATION, & ACUTE EPIGLOTTITIS
Croup is obstruction of the airway
characterized by a barking cough. One type of croup, postintubation croup, has
already been discussed. Another type is due to viral infection. Infectious croup usually fol-lows a viral URI in children aged 3 months to 3 years. The
airway below the epiglottis is
involved (laryn-gotracheobronchitis). Infectious croup progresses slowly and
rarely requires intubation. Foreign body aspiration is typically encountered in
children aged 6 months to 5 years. Commonly aspirated objects include peanuts,
coins, screws, nails, tacks, and small pieces of toys. Onset is typically acute
and the obstruction may be supraglottic, glottic, or subglot-tic. Stridor is
prominent with the first two, whereas wheezing is more common with the latter.
A clear history of an aspiration may be absent. Acute epi-glottitis is
a bacterial infection (most commonlyHaemophilus
influenzae type B) classically affect-ing 2- to 6-year-old children but
also occasionally appearing in older children and adults. It rapidly progresses
from a sore throat to dysphagia and com-plete airway obstruction. The term supraglottitis has been suggested
because the inflammation typically involves all supraglottic structures.
Endotracheal intubation and antibiotic therapy can be lifesaving. Epiglottitis
has increasingly become a disease of adults because of the widespread use of H influenza vaccines in children.
Patients with croup are managed conservatively with oxygen and mist
therapy. Nebulized racemic epinephrine (0.5 mL of a 2.25% solution in 2.5 mL
normal saline) and intravenous dexamethasone (0.25–0.5 mg/kg) are used.
Indications for intuba-tion include progressive intercostal retractions,
obvious respiratory fatigue, and central cyanosis.
Anesthetic management of a foreign body aspiration is challenging,
particularly with supra-glottic and glottic obstruction. Minor manipula-tion of
the airway can convert partial into complete obstruction. Experts recommend
careful inhala-tional induction for a supraglottic object and gen-tle upper
airway endoscopy to remove the object, secure the airway, or both. When the
object is subglottic, a rapid-sequence or inhalational induc-tion is usually
followed by rigid bronchoscopy by the surgeon or endotracheal intubation and
flex-ible bronchoscopy. Surgical preferences may vary according to the size of
the patient and the nature and location of the foreign body. Close coopera-tion
between the surgeon and anesthesiologist is essential.
Children with impending airway obstruction
from epiglottitis present in the operating room for definitive diagnosis by
laryngoscopy followed by intubation. A preoperative lateral neck radiograph may
show a characteristic thumblike epiglottic shadow, which is very specific but
often absent. The radiograph is also helpful in revealing other causes of
obstruction, such as foreign bodies. Stridor, drooling, hoarseness, rapid onset
and progression, tachypnea, chest retractions, and a preference for the upright
position are predictive of airway obstruc-tion. Total obstruction can occur at
any moment, and adequate preparations for a possible tracheos-tomy must be made
prior to induction of general anesthesia. Laryngoscopy should not be performed
before induction of anesthesia because of the possi-bility of laryngospasm. In
most cases, an inhalational induction is performed with the patient in the
sit-ting position, using a volatile anesthetic and oxygen. Oral intubation with
an endotracheal tube one half to one size smaller than usual is attempted as
soon as an adequate depth of anesthesia is established. The oral tube may be
replaced with a well-secured nasal endotracheal tube at the end of the
procedure, as the latter is better tolerated in the postoperative period. If
intubation is impossible, rigid bronchoscopy or emergency tracheostomy must be
performed.
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