Approach to Stridor : Approach to Stridor By Obay Al-Rawi What is Stridor? : What is Stridor? Stridor is a harsh sound produced usually at or near the larynx by the vibration of upper airway structure, and is predominantly inspiratory. Less commonly, stridor may be present on expiration, especially in lesions involving the trachea. Causes of acute Stridor : Causes of acute Stridor Croup.
Acute bacterial tracheitis.
Secondary to mediastinal tumor. Causes of persistent Stridor : Causes of persistent Stridor Laryngomalacia.
Vocal cord paralysis.
Vascular ring. Angioneurotic Edema : Angioneurotic Edema Diphtheria : Diphtheria Peritonsillar Abscess : Peritonsillar Abscess Retropharyngeal Abscess : Retropharyngeal Abscess Retropharyngeal Abscess : Retropharyngeal Abscess Foreign Body : Foreign Body Secondary to mediastinal tumor : Secondary to mediastinal tumor Laryngomalacia : Laryngomalacia Laryngeal papilloma : Laryngeal papilloma Sub-glottic hemangioma : Sub-glottic hemangioma Vascular Ring : Vascular Ring Vocal cord paralysis : Vocal cord paralysis Croup (Laryngotracheobronchitis) : Croup (Laryngotracheobronchitis) Viral infection causing subglottic and tracheal swelling.
Most common cause of stridor in children.
Parainfluenza virus (I) recovered in 50%. Additional causes: Parainfluenza (II & III), influenza, RSV, adenovirus, measles.
More common in fall and winter.
Usual age 6 months - 3 years (mean = 18 months). Pathophysiology : Pathophysiology Virus invades epithelium of the nasopharynx with local spread to larynx and trachea.
Epithelial damage causes mucous production and loss of ciliary function.
Edema of the subglottic larynx. A small amount of edema within the ring of the cricoid cartilage leads to a large decrease in air flow.
Fibrinous exudate partially occludes the lumen of the trachea. Clinical Manifestations : Clinical Manifestations Subglottic obstruction.
Insidious onset of fever, coryza, cough and sore throat.
Stridor and barking cough develop on day 2-3.
May be unable to maintain PO intake.
Majority appear mildly to moderately ill.
Fever is quite variable(37.7 to 40.5 °C).
Minimal to severe respiratory distress, suprasternal and intercostal retractions, and an increased respiratory rate. Lab/X-ray : Lab/X-ray Rarely abnormal or of diagnostic value.
WBC mildly elevated with predominance of PMN’s.
The "Steeple sign", a manifestation of subglottic narrowing, seen on X-ray of the neck, is neither sensitive nor specific. Croup : Croup Croup : Croup Management : Management Make the patient comfortable. Avoid unnecessary procedures that will increase anxiety and worsen respiratory status.
Rehydration. Account for ongoing losses such as tachypnea and fever. Medical managementMist therapy : Medical managementMist therapy Water droplets moisten mucosa and decrease viscosity of secretions.
Temperature is not important (although cold mist may provoke bronchospasm in patient with RAD).
Administer with O2 in hypoxic patient. Slide 30: Racemic Epinephrine
Vasoconstrictive effects decrease mucosal edema.
Hold for HR > 180 (unless tachycardia from respiratory failure).
Potential rebound phenomenon: initial improvement followed by deterioration over the next 1-2 hours can occur and should be anticipated. The deterioration is usually not to a worse state than the child’s pre-racemic epinephrine baseline.
Contraindications: subvalvular aortic stenosis, pulmonary stenosis, Tetralogy of Fallot Racemic versus L-epinephrine : Racemic versus L-epinephrine Racemic epinephrine 2.25% is a 1:1 mixture of the D- and L- epinephrine isomers; it contains 1.125% L- epinephrine, versus 1:1000 (0.1%) available L- epinephrine.
Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25 % solution diluted to 3 mL total volume with normal saline. It is given via nebulizer over 15 minutes.
L-epinephrine is administered as 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution. It is given via nebulizer over 15 minutes. Slide 33: Corticosteroids
Edema decreased by suppressing local inflammatory reaction, decreasing lymphoid swelling and decreasing capillary permeability.
Dexamethasone (Decadron) 0.6 mg/kg IV, IM or PO as a single dose.
Nebulized budesonide (2mg/4cc) has proved as effective as adrenaline nebulizer (4mg/4cc).
Antibiotics are not indicated.
Sedation is contraindicated. Endotracheal Intubation : Endotracheal Intubation Intubation in respiratory failure (< 5% of hospitalized patients).
Preferably done in OT under controlled conditions.
If needed, may sedate or paralyze and use mechanical ventilation.
Extubation best done when significant air leak develops (2-6 days after intubation).
Dexamethasone has been used to help decrease edema; 0.25 - 0.5 mg/kg IV q 6-12 hours, prior to the extubation attempt and may be given again at extubation then prn. Indications for admission : Indications for admission > 85% can be managed as outpatients
Significant respiratory compromise (cyanosis, drowsiness, stridor at rest).
Recurrent Emergency Department or clinic visits in 24 hours.
Other situations which may require admission:
Patient < 1 year old.
Patient lives a long distance from the hospital or has inadequate transportation.
Inadequate observation or follow up is likely.
Significant parental anxiety exists. Epiglottitis (supraglottitis) : Epiglottitis (supraglottitis) Epiglottitis is an acute, life-threatening bacterial infection consisting of cellulitis and edema of the epiglottis, aryepiglottic folds, arytenoids and hypopharynx, resulting in narrowing of the glottic opening.
Causative agents: Haemophilus influenzae b and a, Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes and Moraxella catarrhalis. Epiglottitis (supraglottitis) : Epiglottitis (supraglottitis) Incidence of epiglottitis has been reduced by 90% since the introduction of the conjugate Hib vaccine.
Age: 2-6 years.
Affects males and females equally
Supraglottic obstruction. Clinical manifestations : Clinical manifestations Sore throat, odynophagia, and dysphagia.
High grade fever.
Signs of toxicity (poor or absent eye contact, failure to recognize parents, cyanosis, irritability, anxiety).
Dyspnea, tachypnea, and soft inspiratory stridor.
Tripod position: The child will sit upright, lean forward, and hyperextend the neck with the jaw thrust forward and mouth open in an effort to enhance air exchange. Epiglottitis : Epiglottitis Epiglottitis : Epiglottitis Epiglottitis : Epiglottitis Treatment (A Medical Emergency) : Treatment (A Medical Emergency) Children should be allowed to assume the most comfortable position
Oxygen is supplied by mask or is blown by the face
Establishing an airway by nasotracheal intubation or, less often, by tracheostomy.
Antibiotics (Ceftriaxone 50-75 mg/kg/day for 7-10 days).
Extubation is usually done within 60 hours. Bacterial Tracheitis : Bacterial Tracheitis Infection of the trachea associated with airway inflammation and obstruction.
Staphylococcus aureus is the most commonly isolated pathogen. Moraxella catarrhalis, non-typable H. influenzae, and anaerobic organisms have also been implicated.
Age: 3-10 years.
Affects males and females equally Clinical manifestations : Clinical manifestations Typically, the child has a brassy cough, apparently as part of a viral laryngotracheobronchitis. High fever and “toxicity” with respiratory distress may occur immediately or after a few days of apparent improvement.
The patient can lie flat, does not drool, and does not have the dysphagia associated with epiglottitis. Bacterial Tracheitis : Bacterial Tracheitis Treatment : Treatment Appropriate antimicrobial therapy, which usually includes antistaphylococcal agents, should be instituted in any patient whose course suggests bacterial tracheitis.
An artificial airway should be strongly considered.
Supplemental oxygen may be necessary. Examination of the oropharynx for the following signs: : Examination of the oropharynx for the following signs: Cherry red, swollen epiglottis, suggestive of epiglottitis.
Pharyngitis, typically minimal in laryngotracheitis, may be more pronounced in epiglottitis or laryngitis.
Excessive salivation, suggestive of acute epiglottitis, peritonsillar abscess, or retropharyngeal abscess
Tonsillar asymmetry or deviation of the uvula suggestive of peritonsillar abscess.
Midline or unilateral swelling of the posterior pharyngeal wall suggestive of retropharyngeal abscess. Concerns have been raised about safety of examining the pharynx in children with upper airway obstruction and possible epiglottitis since such efforts have been reported to precipitate cardiorespiratory arrest. However, in two series, each including more than 200 patients with epiglottitis or viral croup, direct examination of the oropharynx was not associated with sudden clinical deterioration. : Concerns have been raised about safety of examining the pharynx in children with upper airway obstruction and possible epiglottitis since such efforts have been reported to precipitate cardiorespiratory arrest. However, in two series, each including more than 200 patients with epiglottitis or viral croup, direct examination of the oropharynx was not associated with sudden clinical deterioration. Thank You : Thank You