Links To And Excerpts From “Airway Problems in Neonates—A Review of the Current Investigation and Management Strategies”

In this post, I link to and excerpt from Airway Problems in Neonates—A Review of the Current Investigation and Management Strategies [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Front Pediatr. 2017 Mar 30;5:60.

The key for the primary care physician is to promptly refer patients having the following symptoms:

To ensure that a diagnosis is made earlier it helps to have a high
index of suspicion. Consider the possibility of an airway problem and investigate if the following symptoms and signs are present:

• recurrent stridor or wheeze
• chronic cough
• recurrent cyanotic episodes
• life threatening events
• feeding difficulties with failure to thrive
• repeated failed extubation attempts
• associated congenital anomalies especially cardiac defects
• signs of dysmorphism
• recurrent aspiration pneumonia
• persistent atelectasis or lobar hyperinflation on chest Xray

In addition, the child may not present until a few months of age, when the obstruction is unmasked by their increased activity and the need for larger tidal volumes as the child grows. Occasionally, the airway problem only comes to light following a respiratory tract infection resulting in increased respiratory effort, or difficulty in intubation with an appropriate size endotracheal tube, or inabilityto extubate following general anesthesia for a planned surgical procedure. Late presentation at a few months of age does not exclude a congenital lesion.

All that follows is from the above resource.

Abstract

Airway problems in the neonatal population are often life threatening and raise challenging issues in diagnosis and management. The airway problems can result from congenital or acquired lesions and can be broadly classified into those causing obstruction or those due to an abnormal “communication” in the airway. Many different investigations are now available to identify the diagnosis and quantify the severity of the problem, and these tests can be simple or invasive. Bronchography and bronchoscopy are essential to determine the extent and severity of the airway problem and to plan treatment strategy. Further imaging techniques help to delineate other commonly associated abnormalities. Echocardiography is also important to confirm any associated cardiac abnormality. In this review, the merits and disadvantages of the various investigations now available to the clinician will be discussed. The current therapeutic strategies are discussed, and the review will focus on the most challenging conditions that cause the biggest management conundrums, specifically laryngotracheal cleft, congenital tracheal stenosis, and tracheobronchomalacia. Management of acquired stenosis secondary to airway injury from endotracheal intubation will also be discussed as this is a common problem. Slide tracheoplasty is the preferred surgical option for long-segment tracheal stenosis, and results have improved significantly. Stents are occasionally required for residual or recurrent stenosis following surgical repair. There is sufficient evidence that a multidisciplinary team approach for managing complex airway issues provides the best results for the patient. There is ongoing progress in the field with newer diagnostic tools as well as development of innovative management techniques, such as biodegradable stents and stem cell-based tracheal transplants, leading to a much better prognosis for these children in the future.

Keywords: airway, tracheal stenosis, tracheobronchomalacia, bronchography, bronchoscopy, tracheoplasty, internal airway stent
CAUSES OF AIRWAY PROBLEMS
Airway problems can be broadly classified into congenital or
acquired lesions and further divided into conditions causing
obstruction of the airway and those due to an abnormal communication between the airway and esophagus. Congenital
obstructive lesions can be from a simple intrinsic lesion in the
airway (e.g., hemangiomata, cysts, and webs) or from abnormal development of the airway (e.g., congenital tracheal stenosis). Extrinsic compression can also occur from lesions external to the airway (e.g., vascular rings or slings, lymphangiomatous lesions, mediastinal tumors).
PHYSIOLOGY
. . . patients with obstruction in the upper extra-thoracic
airway present with inspiratory stridor, while obstruction in the
intra-thoracic part of the airway causes biphasic or an expiratory noise or prolonged expiration on auscultation.
In addition, the child may not present until a few months of age, when the obstruction is unmasked by their increased activity and the need for larger tidal volumes as the child grows. Occasionally, the airway problem only comes to light following a respiratory tract infection resulting in increased respiratory effort, or difficulty in intubation with an appropriate size endotracheal tube, or inability to extubate following general anesthesia for a planned surgical .procedure.
Late presentation at a few months of age does not exclude a  congenital lesion.
DIAGNOSIS
To ensure that a diagnosis is made earlier it helps to have a high
index of suspicion. Consider the possibility of an airway problem and investigate if the following symptoms and signs are present:
• recurrent stridor or wheeze
• chronic cough
• recurrent cyanotic episodes
• life threatening events
• feeding difficulties with failure to thrive
• repeated failed extubation attempts
• associated congenital anomalies especially cardiac defects
• signs of dysmorphism
• recurrent aspiration pneumonia
• persistent atelectasis or lobar hyperinflation on chest Xray

 

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