Upper Airway Obstruction In Children Research Articles

The Comparison of Oral and IM Dexamethasone Efficacy in Croup Treatment

Background: Croup, or acute laryngotracheobronchitis, is the most common cause of upper airway obstruction in children. Objectives: In this study, the efficacies of intramuscular and oral dexamethasone administration are compared for treatment of croup. Patients and Methods: This is a single-blind randomized trial involving 68 children divided into two groups, the first group received 0.6 mg/kg intramuscular dexamethasone and the second group received 0.6 mg/kg oral dexamethasone. The clinical score, respiratory rate, heart rate, O2 saturation and clinical response were assessed before and then hourly for four hours after treatment. Results: The respiratory rate of two groups was significantly different at the first hour of treatment (P = 0.02), but it did not vary between study groups at the second, third, and fourth hour of treatment. There was no statistical difference among clinical score, heart rate, O2 saturation and clinical response in any of the measurement times. Conclusions: Oral and intramuscular administrations have the same effectiveness for treatment of croup and oral dexamethasone was proposed because this is a non-invasive procedure.

Upper Airway Obstruction in Children: Prevalence, Diagnosis, Repercussions, and Comorbidities

Objectives: Investigate the prevalence, diagnosis, and repercussions of upper airway obstruction in children under 5 years-old and their impact in public health. Methods: A cross-sectional study was conducted with 197 children under 5, randomly selected from a population of 1500, from November 2011 to December 2012. Parents answered to anamnesis about respiratory problems, upper airway infections, perinatal history, and feeding habits. They answered validated questionnaires about sleep disordered breathing and allergies. All subjects underwent a physical examination, and those who complained of respiratory problems also had nasal fiberendoscopy. Results: 197 subjects (2.33 ± 1.09 y.o.), 107 boys. Prevalence of mouth breathing was 19.2%, nasal obstruction 18.2%, snoring 22.8%, rhinorrhea and sneezing 36.5%, and sleep disordered breathing (SDB) 7.1%. Diagnosis: adenoid enlargement (A) 8.6%, tonsil enlargement (T) 0.5%, tonsil and adenoid enlargement (T&A) 10.7%, rhinitis 21.9%, allergic rhinitis 7.6% (totalizing 49.6%). Fifty-five point seven percent of children were exclusively breast fed for at least 6 months, and no correlation was found with nasal obstruction. Sleep disordered breathing symptoms were found in 7.1 % and were associated only with T&A (64.2%). Children with upper airway obstruction were prone to upper airway infections and visits to the emergency room. Conclusions: Upper airway obstruction is prevalent in about 20% of children. Breast feeding was not correlated to mouth breathing. Rhinitis is a common diagnosis. T&A is associated with SDB and infections, consuming high resources. Doctors must investigate and refer young children with upper airway problems to treatment in order to minimize large consumption of health resources.

Management of acute severe upper airway obstruction in children

There are many causes of acute severe upper airway obstruction (UAO) in children. The timing of symptom onset and the presence of fever will help to distinguish infectious from non-infectious conditions. Signs and symptoms from congenital malformations often present at birth but may also develop over time. The most common cause of UAO in children is croup. Choking on a foreign body also occurs relatively frequently. Evaluation of the child with UAO starts with a detailed history followed by a thorough physical examination, including an assessment of severity. Severe airway obstruction will result in respiratory failure. This situation requires an immediate response. A child with partial airway obstruction may initially have an adequate airway. However, this situation can deteriorate rapidly. Therefore, providing supportive care and mobilizing resources for definitive airway management may be the most appropriate interventions.

Work of breathing as a tool to diagnose severe fixed upper airway obstruction

A 4-year-old girl with bilateral vocal fold palsy was successfully decannulated from tracheotomy after seven laryngeal procedures. But an important stridor and dyspnea recurred 13 months after decannulation. Nocturnal gas exchange was normal but her daytime work of breathing was increased by fourfold, without any beneficial effect of nasal noninvasive continuous positive airway pressure ventilation (CPAP), reflecting a severe fixed airway obstruction. Endoscopic examination confirmed the work of breathing findings showing glottic and supraglottic stenosis. This upper airway obstruction was successfully treated with a recannulation. In conclusion, the major message of this case report is that measurement of the work of breathing was able to document the "fixed" nature of the airway obstruction, by showing no improvement even with highest tolerated levels of nasal CPAP. As such, the work of breathing may be proposed as a screening tool to quantify and assess the reversibility of severe upper airway obstruction in children.

Allergic rhinitis as a possible risk factor for malocclusion: a case–control study in children

Prolonged oral respiration is known to cause postural alterations, which can lead to dental malocclusions. Allergic rhinitis, a common cause of upper airway obstruction in children, must therefore be seen as a possible risk factor in the development of malocclusions. Aim of this study was to investigate the association between allergic rhinitis and malocclusions in primary and early-mixed dentition. A case-control study was carried out involving 275 Italian children aged 5-9. The case group and the control group were composed of 125 individuals affected by malocclusions and by 150 healthy patients, respectively. Through a questionnaire, we assessed the presence of professionally diagnosed allergic rhinitis. Data were analysed to identify associations between these variables and the presence of malocclusions. Children with a history of allergic rhinitis had a threefold increased risk to develop one or more dento-skeletal alterations [OR = 3.16; 95% CI (1.79-5.58), P < 0.001]. Statistically significant associations were found between allergic rhinitis and the development of posterior crossbite and increased overjet. No significant association was found for anterior openbite. Allergic rhinitis is a significant risk factor for the development of malocclusions in general and is associated with the development of posterior crossbite and increased overjet.

Bacterial Tracheitis: A Case Report

Bacterial tracheitis is an uncommon, but severe cause of acute infective upper-airway obstruction in children. Patients may present with croup-like symptoms, such as barking cough, stridor, and fever; however, patients with bacterial tracheitis do not respond to standard croup therapy and may experience acute respiratory decompensation. Herein, we describe a case of bacterial tracheitis in a 9-month-old girl who presented with acute respiratory failure after four days of upper respiratory tract infections. Such patients should be monitored in a pediatric intensive care unit and flexible bronchoscopy should be used to diagnose and guide specific therapy to decrease morbidity and mortality. (J Pediatr Resp Dis 2012;8:59-63)

A 10 year retrospective review on the management of upper airway obstruction in children with pierre robin sequence: the success of the nasopharyngeal airway

Introduction Pierre Robin Sequence (PRS) is a congenital anomaly presenting with micrognathia, glossoptosis and a cleft palate. Although significant upper airway obstruction is common, especially during sleep, there isn9t a general consensus about its management. In most centres, mandibular distraction surgery or insertion of tracheostomy is the recommended management for children with PRS not responding to conservative management such as positioning. The objective of this study was to present our experience with the use of nasopharyngeal airway in these patients as a possible alternative to surgery by retrospectively reviewing its use in our department over the last 10 years. Methods This study was conducted jointly between the respiratory and otolaryngology departments. Only the children with all three characteristics of this condition have been included. The data collected included the method of airway management and oximetry data pre and post intervention. Results Data was collected on 104 Pierre Robin patients referred to us from 2000 to 2010. Most of patients (64/104) were less than 4 weeks of age at referral. In this referred group, the airway symptoms were managed conservatively in 27 (25.9%), with nasopharyngeal airway (NPA) in 63 (60.6%) and tracheostomy in 14 (13.4%) patients. The duration of NPA use varied from 3 weeks to 27 months, the average being 7.9 months. There was an objective improvement on oximetry in all 63 patients with NPA. NPA did not improve symptoms subjectively or objectively in 14 patients who underwent a tracheostomy. There were no NPA related complications in this study. In this study 86.5% (90/104) PRS patients were successfully managed either conservatively or with the help of nasopharyngeal airway for few months. Conclusion In majority of children (86.5%), the airway obstruction can be managed by conservative measures or nasopharyngeal airway for few months. A small number of children need to be managed with a tracheostomy. Although oximetry studies are not the most accurate tool to diagnose obstruction in itself, they were accurate enough to show objective improvement post insertion of NPA.

Congenital Causes of Upper Airway Obstruction in Pediatric Patients: Updated Imaging Techniques and Review of Imaging Findings

Upper airway obstruction is a common and potentially serious condition in the pediatric age-group. Neonates and young children are particularly susceptible because their immatureairwaysaresmallinsizeandmuchmorecompliant than those of adults. 1 Children with upper airway obstructionusuallypresentwithstridororapnea,buttheycouldalso manifest with chronic problems, such as recurrent lung infections or obstructive sleep apnea, that can lead to growth retardation, chronic respiratory failure, cor pulmonale, and even death.2 Common causes of upper airway obstruction in children include congenital abnormalities, infectious or inflammatory processes, neoplasms, foreign body aspiration, and even trauma. Congenital abnormalities involving the structures of the pharynx and larynx are not uncommon and can cause upper airway obstruction in children. Such abnormalities may present at birth or can manifest after an inciting event. Although the clinical symptoms and physical examination are important in establishing the diagnosis, it is not always easytoclinicallylocalizetheabnormality.Therefore,imaging evaluation is helpful in establishing the diagnosis, defining the anatomic localization, and assessing the extent of the abnormality. Radiographs and fluoroscopy have long been used in the evaluation of the upper airway in pediatric patients, but cross-sectional imaging studies can provide more detailed and accurate demonstration of upper airway abnormalities. 3 The overarching goals of this article are to discuss updated imaging techniques and review characteristic imaging appearance of congenital causes of upper airway obstruction in pediatric population.

Outcome of Adenotonsillectomy for Sleep and Breathing Difficulties in Nigerian Children with Obstructive Adenotonsillar Enlargement

The aim of this study was to examine improvements or otherwise, in sleep disturbance and breathing difficulties after adenotonsillectomy (AT) for chronic upper airway obstruction in children. In a prospective clinical study and tertiary referral center setting, the study population included consecutive children aged 1.5 through 12years who underwent AT for chronic upper airway obstruction due to adenotonsillar enlargement, without any history of previous AT. The validated "Symptomatology score" (SS) parameters were used to grade the symptoms before and after AT. The extent of improvement of the symptoms after surgery were estimated by a standardized response mean (SRM). The study included 59 children, 40 of whom were males (68%). Their ages ranged from 1.5 to 12years with a mean of 3.3years and 63% were <4years. The results showed that tonsillar size was correlated significantly with a high preoperative SS (P≤0.001). The mean preoperative SS for the study population was 7.2, whereas the mean postoperative SS was 1.7. This change was highly significant (P<0.001). The symptom domain with the greatest change in mean score was snoring, which improved by 2 points with SRM of 2.2. The changes in total score and in the scores for each symptom domain were highly significant (P<0.002). We concluded that adenotonsillectomy is associated with remarkable improvement in breathing difficulties and sleep disturbances in children with obstructive adenotonsillar hypertrophy regardless of the condition whether it is mild or severe.

The effect of adenotonsillectomy on right ventricle function and pulmonary artery pressure in children with adenotonsillar hypertrophy

Objectives Adenotonsillar hypertrophy (ATH) is the most common cause of upper airway obstruction in children. Severe upper airway obstruction may have an effect on chronic alveolar hypoventilation, which consequently may lead to right ventricle (RV) dysfunction induced by hypoxemic pulmonary vasoconstriction. The investigators aimed to study RV function and mean pulmonary artery pressure (mPAP) in patients with ATH who were undergoing adenotonsillectomy by using tissue Doppler echocardiography (TDE). Methods The study examined 27 children with ATH who had a mean age of 8 ± 2 years. The subjects were comprised 17 (63%) males and 10 (37%) females. Hypertrophy of the tonsils was graded according to the Brodsky scale. Children having either grade 3 or 4 hypertrophied adenotonsils were recruited for the study. Adenotonsillectomy was performed on all subjects in the study group and echocardiographic examination was repeated 3 months postoperatively. Results Tricuspid Em significantly increased after adenotonsillectomy (17.7 ± 3.6 vs. 19.1 ± 5.5, p = 0.04). The RV myocardial performance index (MPI) and mPAP significantly decreased after adenotonsillectomy (RV MPI: 0.57 ± 0.13 vs. 0.40 ± 0.12, p < 0.001 and mPAP (mm Hg): 31 ± 9 vs. 25 ± 7, p = 0.001). Conclusion The results of this study, evaluated with the results of previous studies, demonstrated that adenotonsillectomy improved RV performance and reduced mPAP in children with ATH.

Antihypertensive drug-induced angioedema causing upper airway obstruction in children

Objective Angioedema is a well-described complication arising from the use of antihypertensive agents in the adult population. However, its occurrence and potential for upper airway compromise in pediatrics has only been sporadically reported in the literature. Our objective is to report and review the occurrence of antihypertensive-induced angioedema in the pediatric population and the potential for airway compromise. Methods Charts of 42 patients admitted to Cincinnati Children's Hospital Medical Center with the discharge diagnosis of angioedema (ICD-9 code 995.1) from January 2000 to January 2010 were reviewed. Of the 42 charts, 3 cases had angioedema induced by antihypertensive drugs and all 3 resulted in upper airway obstruction. Summary and findings of the data collected from the medical chart review included demographics, chief complaint(s), past medical history, hospital course, antihypertensive drugs used, diagnostic test(s), medical treatment, and time from onset of symptoms to resolution. In addition, a PubMed literature search using the terms angioedema and antihypertensive drugs was performed to review its occurrence in pediatrics. The previous literature case reports were compared to our cases to further characterize and emphasize the clinical features of this occurrence in children and adolescents. Results Despite the well-known occurrence of antihypertensive drug-induced angioedema causing airway obstruction in adults, only 4 case reports have been previously published in children. At our institution, we describe 3 children who developed acute angioedema with upper airway obstruction after the chronic use of antihypertensive medications [2 drugs in the ACE inhibitor class (enalapril and lisinopril), and 1 drug in the calcium channel blocker class (CCB; amlodipine)]. In all 3 cases, the symptoms resolved within 1 week after the antihypertensive agent was discontinued. Conclusion Upper airway obstruction can occur at any age when taking antihypertensive drugs. Particular caution should be applied to ACE inhibitors and CCBs in this regard. With the increasing use of antihypertensive agents in the pediatric population, clinicians should be alert to the possibility of angioedema with upper airway obstruction as a potential lethal adverse effect.

WITHDRAWN: Humidified air inhalation for treating croup.

Croup (laryngotracheobronchitis) is a common cause of upper airway obstruction in children with a peak incidence of 60 per 1000 child years in those aged between one and two years. It is characterised by hoarseness, a barking cough, and inspiratory stridor. These symptoms are thought to occur as a result of oedema of the larynx and trachea, which have been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. Severe cases are admitted to hospital and steroid treatment is established to reduce disease severity. Treatment with humidified air was previously widely used and is still commonly recommended as home treatment. To assess the efficacy of humidified air in the treatment of croup. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005), MEDLINE (1966 to January 2006) and EMBASE (1990 to January 2006). Randomised controlled trials (RCTs) involving children suffering from croup treated with humidified air. Two authors independently identified potentially relevant abstracts identified from the search and then assessed the full papers for inclusion and methodological quality. Outcome measures included mortality, ventilation, admission to hospital, re-contact with medical services, number of days off school and relief of symptoms; these were separately analysed for the week following treatment. Data extraction was performed by the two authors then entered by one and checked by the second author. Missing data were obtained from trial authors where possible. Data were analysed using Review Manager version 4.2. Sensitivity and sub-group analysis were not possible due to the paucity of trials. Three studies in emergency settings provided data on 135 patients with moderate croup for the main outcome (croup score). The combined results from 20 to 60 minutes in the three studies marginally favoured the treatment group with a weighted standardised mean difference of -0.14 (95% confidence interval (CI) -0.75 to 0.47). No other outcomes were significantly different between the groups. The croup score of children managed in an emergency setting with mild to moderate croup probably does not improve greatly with inhalation of humidified air. Further research is needed in primary care settings, using a wider range of more sensitive outcome measures.

Altered cardio-respiratory response to spontaneous cortical arousals in children with upper airway obstruction

Objective Upper airway obstruction (UAO) during childhood is associated with cardiovascular morbidity. The aim of this study was to investigate the cardio-respiratory response to cortical arousal during sleep in children with UAO. Methods Standard paediatric overnight polysomnography (PSG) was conducted in 40 children with UAO (25 M, 7.5 ± 2.7 yrs) prior to and 6 months following adenotonsillectomy. For comparison a control group of 40 normal, sex and age matched children (21 M, 7.5 ± 2.6 yrs) underwent two PSGs without intervention at the same time points. Results Heart rate and respiratory rate were measured during spontaneous and respiratory arousals in stage 2 and REM sleep 15 s prior to and 15 s immediately following cortical arousal onset. Cortical arousal was associated with a significant increase in heart and respiratory rate in both groups of children. UAO children, however, showed a significantly higher heart rate response in stage 2 sleep (−17.5 ± 6.0 vs. −14.4 ± 4.8%; p < 0.05), a lower pre-arousal baseline respiratory rate (stage 2: 17.1 ± 1.4 vs. 18.2 ± 1.7 BPM; p < 0.01) and a prolonged increase in respiratory rate compared to control children. Cardiac and respiratory arousal responses were not significantly different from controls following adenotonsillectomy in the UAO children. Conclusions UAO in children is associated with an altered cardiorespiratory response to spontaneous arousal from sleep, which may indicate early signs of autonomic dysfunction. Surgical treatment of UAO appears to reverse these outcomes.

Auriscopy in the diagnosis of adenoid hypertrophy in children

Objective To explore the application of auriscopic nose- nasopharyngeal examina tion in the diagnosis and treatment of adenoid hypertrophy in children. Methods Auriscopic nose-na sopharyngeal examination was performed in 412 children with the symptoms of upper airway obstruction to explore the relationship between the degree of adenoid enlargement and upper airway obstruction. Results The procedure was successfully performed in 395 of 412 children. Of the 395 children, 358 had adenoid hypertrophy, 14 had choanal polyp, 16 has allergic rhinitis, and the remaining 7 had chronic rhinitis. Accord ing to the degree of rear nasal passage blockage, in 358 children with adenoid hypertrophy, 43 (12%) was grade Ⅰ, 97 (27%) was Ⅱ, 103 (28.8%) was Ⅲ, and 115 (32.2%) was Ⅳ. Conclusions Auriscopic nose nasopharyngeal examination is an ideal procedure for nasopharyngeal adenoid hypertrophy in children. It is directly visual, accurate, and safe. Grade Ⅳ adenoids is the main etiology of upper airway obstruction in children, which is the indication of surgical treatment. Key words: Auriscopy; Children; Adenoidal hypertrophy; Treatment

Distraction osteogenesis of the mandible for airway obstruction in children: Long-term results

Objective To determine the long-term results of distraction osteogenesis of the mandible for upper airway obstruction in children with micrognathia. Study Design Case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods The records of a pediatric otolaryngology practice and tertiary children's hospital were searched for patients treated with bilateral mandibular distraction osteogenesis for upper airway obstruction. Patients were selected if greater than three years of follow-up data were available. Data were analyzed for airway and feeding outcomes, and long-term surgical complications were identified. Results Thirty-two patients met study criteria. Of the 11 patients who had tracheotomy prior to distraction, seven were decannulated after the procedure. Seventeen patients needed perioperative gastrostomy. Seven are now able to feed orally. Fifteen patients treated with mandibular distraction were able to avoid gastrostomy tube placement altogether. The complication of open bite deformity was experienced by nine patients (28%). Five of 32 patients (16%) had tooth malformation, tooth loss, or dentigerous cyst formation while an additional three patients (9%) had long-term facial nerve injury. Nineteen patients (59%) were under three months old at the time of their distraction. Only one of these patients (5.2%) required an additional distraction procedure. Conclusion Long-term follow-up data on patients treated with mandibular distraction for upper airway obstruction show sustained airway improvement. Additionally, micrognathic children treated with distraction have improved outcomes in oral feeding with a relatively low rate of long-term complications. It remains important to follow these patients to monitor the need for secondary reconstructive procedures.

MP-12.05: Enuresis in Children Before and After Adenotonsillectomy

Enuresis originally meant incontinence of urine, but usage has caused the term to be restricted to bedwetting after 3 years. Enuresis could be one of the symptoms of severe upper airway obstruction in children, which leads to abnormal ADH secretion due to abnormality in REM sleep. Relative upper airway obstruction could change sleep patterns and affect normal ventilation in sleep. Adenotonsillar hyperthrophy is one of the most common causes of upper airway obstruction in children. Prevalence of enuresis is about 4% -47% among children with adenotonsillar hypertrophy, which has been reported to decrease after adenotonsilectomy, especially in secondary type enuresis.

Upper airway obstruction in children

Upper airway obstruction in children

Effect of maxillary protrusion on upper airway obstruction in children by fluid-mechanical simulation

Effect of maxillary protrusion on upper airway obstruction in children by fluid-mechanical simulation

Pediatric sleep apnea: Early onset of the ‘syndrome’?

Obstructive sleep apnea is a common disorder in childhood, particularly in the last decade when an increased prevalence of obesity has been documented. The neurocognitive and behavioral problems associated with this disorder have been known for a long time. However, the increased knowledge of cardiovascular and metabolic complications in adults with sleep apnea has been followed by a better understanding of the systemic effects of upper airway obstruction in children. Obstructive sleep apnea (OSA) has been shown to induce autonomic imbalance in children and to affect blood pressure, cerebral blood flow and cardiac function in an early phase. OSA may also induce chronic systemic inflammation and may contribute to the development of metabolic syndrome in obese children. Very recent research indicates that in children primary snoring, the mildest form of the sleep-disordered breathing spectrum, may also be associated with morbidity. It is, therefore, likely that these respiratory sleep disorders do not simply influence children's' performance in private and social life, but may more seriously affect children's' health. The aim of this review is to outline early systemic complications of obstructive sleep apnea and primary snoring in infants and children.

Arytenoid Prolapse following Laryngotracheoplasty

Objective Dynamic arytenoid prolapse (AP) is a potential and often late source of upper airway obstruction in children following laryngotrachoplasty (LTP). Reasons for this occurrence remain unclear. We examined the incidence and clinical features of AP in patients following LTP to explore the etiology and optimal surgical approach to this problem. Methods Retrospective database and chart review of children diagnosed with AP after LTP at a pediatric tertiary care institution from 1981–2007. Results 120 patients with no history of AP were diagnosed with AP following LTP (incidence 7.3% = 120/1634). 63 patients had unilateral prolapse, while 57 had bilateral AP. Average time from LTP to presentation was 44 months. Common symptoms were dyspnea on exertion, tracheostomy-dependence, and sleep-disordered breathing. Posterior cricoid interventions and revision LTP were most frequently associated with postoperative AP. 64% (n=77) of patients required surgical intervention. Endoscopic arytenoid reduction (AR) was performed in 54 patients, while 13 underwent AR during revision LTP. 2 patients underwent AR with cordotomy. Tracheostomy was performed with AR in another 2 patients. 28 patients required a second procedure for persistent prolapse. 36%(n=42) of patients did not require surgery. Airway complaints were relieved, or tracheostomy decannulation was achieved, in all patients after AR in which AP was the source of obstruction (avg. f/u=34.4mos). Conclusions Dynamic AP is a notable cause of airway obstruction following LTP. Subtle airway complaints and decannulation failures are common clinical features. Both endoscopic and open AR procedures are successful in relieving AP. Potential etiology for AP after LTP is discussed.