- Acute respiratory emergencies in the pediatric patient are common and may, if improperly treated, result in significant morbidity and mortality.
- The clinician must maintain an awareness of the unique anatomic and physiologic characteristics of the respiratory tract in the growing infant and child.
- Stridor may originate anywhere in the upper airway from the anterior nares to the subglottic region.
- The most common causes of acute upper airway obstruction are croup, epiglottitis, and foreign body obstruction. Additional processes include peritonsillar abscess, bacterial tracheitis, and retropharyngeal abscess.
Acute respiratory emergencies in the pediatric patient are common and may, if improperly treated, result in significant morbidity and mortality. Calm, decisive, and deliberate intervention is mandatory to ensure the most effective outcome. The clinician must maintain an awareness of the unique anatomic and physiologic characteristics of the respiratory tract in the growing infant and child. An expanded knowledge of the most frequent airway problems encountered in children will assist in arriving at the proper evaluation, treatment, and disposition of these patients. The ability to accurately assess the child in respiratory distress remains the most critical step in patient care.
Upper Airway Considerations
The small caliber of the upper airway in children makes it vulnerable to occlusion secondary to a variety of disease processes and also results in greater baseline airway resistance. Any process that further narrows the airway will cause an exponential rise in airway resistance and a secondary increase in the work of breathing. As the child perceives distress, an increase in respiratory effort will augment turbulence and increase resistance to a greater degree.
Since the young infant is primarily a nasal breather, any degree of obstruction of the nasopharynx may result in significant increase in work of breathing and present clinically as retractions. The large tongue of infants and small children can occlude the oropharynx. Any child who presents with altered mental status will be at risk for the development of upper airway obstruction secondary to a loss of muscle tone affecting the tongue. Occlusion of the oropharynx by this anatomic structure is quite common in this setting. Interventions that can correct this anatomic blockage include either tilting of the head or lifting of the chin. Insertion of an orotracheal or a nasotracheal airway may also assist in alleviating respiratory distress.
Older children will frequently present with enlarged tonsillar and adenoidal tissues. Although they rarely cause an upper airway catastrophe, these structures are vulnerable to trauma and bleeding during clinical interventions such as insertion of an oral or nasal airway. The pediatric trachea is easily compressible because of incomplete closure of the cartilaginous rings. Any maneuver that overextends the neck will contribute to compression of this structure and secondary upper airway obstruction. The cricoid ring represents the narrowest portion of the upper airway and is often the site of occlusion in foreign body aspiration.
Lower Airway Considerations