TABLE 47-6 SIGNS AND SYMPTOMS SPECIFICALLY EXAMINED IN PATIENTS WITH STRIDOR

Breathing rate

Heart rate

Wheezing

Cyanosis

Chest retractions

Nasal flaring

Level of consciousness

b. Laryngomalacia caused by a long epiglottis that prolapses posteriorly is the most common cause of stridor in infants.

2. Signs and Symptoms (Table 47-6)

B. Bronchoscopy

1. Goals of anesthesia include a quiet surgical field (coughing or straining during instrumentation with a rigid bronchoscope may result in damage to the patient’s airway), use of an antisialagogue to decrease secretions that may obscure the view through the bronchoscope, and rapid return to consciousness with intact upper airway reflexes.

2. In children, an inhalation induction of anesthesia is common, but IV drugs are usually administered to adults. Maintenance of anesthesia often includes a volatile anesthetic and muscle relaxant.

a. Because ventilation of the lungs may be intermittent, it is recommended that 100% oxygen be used as the carrier gas during bronchoscopic examination.

b. If a rigid bronchoscope is used, ventilation of the lungs is accomplished through a side port (manual vs. Sander’s jet ventilation).

c. At the conclusion of rigid bronchoscopy, an endotracheal tube is usually placed to control the patient’s airway during recovery of anesthesia.

IV. PEDIATRIC AIRWAY EMERGENCIES

A. Epiglottitis is an infectious disease (caused by Haemophilus influenzae) of children (usually 2–7 years of age) and adults that can progress rapidly from a sore throat to total upper airway obstruction.

1. Characteristic signs and symptoms include sudden onset of fever, dysphagia, and preference for the sitting position.

2. Direct visualization of the epiglottis and sedation outside the operating room should not be attempted because total upper airway obstruction may result.

3. If the clinical situation allows, oxygen should be administered by mask, and lateral radiographs of the soft tissues in the neck may be obtained.

4. Children with severe airway compromise should proceed from the emergency department to the operating room accompanied by the anesthesiologist and surgeon.

5. In all cases of epiglottitis, an artificial airway is established by means of tracheal intubation (Table 47-7).

B. Laryngotracheobronchitis (LTB; Croup)

1. LTB is usually a viral illness that occurs most often in children age 6 months to 6 years.

2. The onset of LTB is more insidious than the onset of epiglottitis, with the child presenting with a low-grade fever, inspiratory stridor, and a barking cough.

3. Treatment includes a cool, humid mist and oxygen, and in severe cases, nebulized racemic epinephrine and a short course of steroids.

C. Foreign Body Aspiration

1. This diagnosis should be suspected in any patient who presents with wheezing and a history of coughing or choking while eating.

TABLE 47-7 ESTABLISHMENT OF AN ARTIFICIAL AIRWAY IN THE PRESENCE OF EPIGLOTTITIS

Bring the patient to the operating room. (The child may be accompanied by a parent.)

Place monitors. (The child may remain seated.)

Induce anesthesia by mask (sevoflurane in oxygen).

IV access may be accomplished after loss of consciousness.

Place an orotracheal tube with use of muscle relaxants. (Select a tube size at least one size smaller than normal.)

Replace the orotracheal tube with a nasotracheal tube after the surgeon has examined the larynx.

Extubation of the trachea is usually possible after 48–72 hrs (leak develops around the tracheal tube).

IV = intravenous.