Acute Stridor 2

8/8/2019 Acute Stridor 2

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y a harsh, low-pitched, vibratory sound associated with obstruction of the laryngeal area or theextrathoracic trachea

y Produced by rapid, turbulent flow of air through anarrowed segment of the upper respiratory tract

y usually inspiratory but may be expiratory/biphasicy most commonly observed in children with croup;

foreign bodies and trauma can also cause acutestridor


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y Inspiratory stridor suggests an extrathoracic lesion(eg, laryngeal, nasal, pharyngeal)

y Expiratory stridor implies an intrathoracic lesion

(eg, tracheal)y Biphasic stridor suggests a subglottic or glottic

anomaly y The louder the stridor, the worse is the obstruction


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y STR IDO R y Inspiration phasey Prolong inspiration >

expirationy Extrathoracic airway obstruction

y WHEEZINGy Expiration phasey Prolong expiration >

inspirationy Intrathoracic airway obstruction

Extrathoracic -nose to midtrachea


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y STR IDO R y Variable phase: inspiratory

or expiratory / biphasicy air flow changes within the

larynx, trachea or bronchiy sound produced rangesfrom low pitched to highpitched frequencies

y S tridor is infact more oftenmusical in character.

y May associated withhoarseness of voice/barking cough

y STERTO R y Mostly in inspiratory

phasey obstruction of airway

above the level of thelarynxy It is low pitched snoring or

snuffly soundy produced by vibrations of

tissue of the naso pharynx,pharynx or soft palate

y Usually no hoarseness of voice/barking cough


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Nose and pharynx

y C hoanal atresiay thyroglossal cysty Macroglossiay Hypertrophic tonsils/adenoidsy Retropharyngeal abscessy peritonsillar abscess

Trachea

y Tracheomalacia

y Bacterialtracheitis

y Externalcompression

L arynx

Laryngomalacia Laryngeal web, cyst orlaryngoceleLaryngotracheobronchitis(viral croup) Acute Epiglottitis Vocal cord paralysis

Laryngotracheal stenosis C ystic hygroma Foreign body

Subglottic hemangioma Laryngeal papilloma


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STRIDOR

CONGENITAL ACQUIRED

APYREXIAL PYREXIAL

1.1. C. WebC. Web2.2. C. subglottic stenosisC. subglottic stenosis

3.3. Supraglottic Cyst Supraglottic Cyst 4.4. LaryngomalaciaLaryngomalacia5.5. V/C palsy V/C palsy6.6. Vascular anomaly Vascular anomaly7.7. MicrognathiaMicrognathia8.8. Cleft larynxCleft larynx

9.9. LymphangiomaLymphangioma10.10. HaemangiomaHaemangioma

1.1. A. subglottic stenosis A. subglottic stenosis2.2. FBFB3.3. TraumaTrauma4.4. Scald/ burnsScald/ burns

5.5. Recurrent resp papillomatosisRecurrent resp papillomatosis6.6. Enlarged tonsils, adenoidsEnlarged tonsils, adenoids

1.1. Acute Acuteepiglottitis epiglottitis

2.2. Acute laryngitis Acute laryngitis3.3. Acute Acute

laryngotracheolaryngotracheo-- bronchitis bronchitis (croup)(croup)

4.4. DiphteriaDiphteria5.5. RetropharyngealRetropharyngeal

abscessabscess


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SIG N EX TRATHORACIC I NTRATHORACIC-EX TRAPULMO N AR Y

I NTRAPULMO N ARY PAR ENCHYMA

TA C HYPN EA + + ++ ++++

RETRA C TION ++++ ++ ++ ++

STR IDO R ++++ ++ - -

WHEEZING +/- +++ ++++ +/-

G RUN TING +/- +/- ++ ++++


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y O nset: day / night / very acute onset: F oreign Body y D uration : chronicity y C haracteristic : stridor / snoring / wheezingy

S everity : sign of respiratory distressy Precipitating factor: feeding / crying / exercisey Preceding URT I sx? Yes: croup N o: epiglotitisy Associated symptoms:

y fever , cough , drooling of saliva , hoarsness of voice , choking,leaning forward

y Maternal history y HPV infection


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y Birth history y Any history of respiratory distress requires endotracheal

intubation : subglotic stenosisy

Feeding history y Poor feedingy History of choking

y Immunization history y

Hib vaccination


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y Family history y Any other sibling had similar symptom / chronic

respiratory problem


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y O nset over hoursy Toxic, very ill appearancey N o preceding coryzay High grade fever(>38.5 C )y Absent / slight coughy L eaning forwardy Soft stridory Muffled, reluctant to speaky C an t drink & drooling of saliva


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y G eneraly L evel of conciounessy C yanosisy S

ign of respiratory distressy Hydration statusy Vital signs

y Throat: injected / enlarged tonsily

O ral / nasal cavity


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y Respiratory systemy Peripheral sign: cyanosis, clubbing, bounding pulsesy N ose: nasal f laring, hypertrophied nasal turbinate, nasal

secretiony C entral cyanosis, hoarseness of voice, barking coughy Recession , chest deformity y Transmitted sound, rhonci, crepts


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y C V Sy Tachycardia

y C NSy

Agitated, drowsy, unconciousness


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Assessment of airway y Head tilt-chin lifty Intervention

y Removal of foreign body y O ral / nasal airway y Intubation:

y apneay

airway obstruction unrelieved by airway-opening maneuversy increased work of breathing that may lead to fatiguey need for positive end-expiratory pressure

y tracheostomy


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Assessment of breathingy L ook : chest rise/fally listen : mouth breathingy F

eel : air existing in airwaysy Intervention

y 2 rescue breathing over 1 sec: place mouth over infant smouth and nose


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y Removal of Foreign Body Airway obstructiony Perform 5 back blows and 5 chest thrust


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y C linical syndrome characterize by barking cough,inspiratory stridor, hoarseness of voice and respiratory distress of varying severity

y Viral Infection of larnyx, trachea and bronchiy Most common pathogen : Parainfluenza virus (74%)y S ymtoms:

y Rhinorrhea, pharyngitis, mild cough, low grade fever for 1-3days before sign and symptom of upper airway obstructionoccur

y Barking cough, hoarseness of voice and inspiratory stridory May worse at nighty Aggravated by agitation and cryingy C hild may prefer sit up in the bed / held upright


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y Mil d : stridor with excitement or at rest, no respiratory distress

y M oderate : stridor at rest with Intercostal, subcostaland sternal recession

y Severe : stridor at rest with marked recession, decreaseair entry and altered level of consciousness


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y Moderate-severe croupy Poor oral intakey L ive long distance from hospitaly L ess than 6 monthsy Toxic looking


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Indication for oxygen therapy y Severe viral croupy Percutaneous S ao2


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y It is an acute lif e threaten i ngillness (medical emergency)

y C ause by H. influenza type b . raresince Hib immunization.

y Mostly aged 1 -6 years


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y High fever, ill, tox i c l ook i ng childy An intensely pa i n f u l throat that prevents the child

from swallowing or speaking.y Typically prefer to sit upright breathing from the

mouth, constantly drooling of saliva.y So f t i nsp i ratory str i dory The diagnosis is based on the clinical history, the signs

of toxaemia and upper airway obstruction.


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Managementy Urgent hospital adm i ss i ony Tracheostomy or endotrachea l i ntubat i ony Intravenous ant i b i ot i c

eg; ceftriaxone / cefotaxime / unasyn for 7-10 daysy Mortality is high as the diagnosis is delayedy With appropiate treatment, most children recover

completely within 2-3 days.


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C roupy O nset over daysy Appearance unwelly

Preceding coryzay L ow grade fevery S evere, barking-like coughy Harsh stridory Hoarse voicey C an drink and no drooling

of saliva

Ep i gl ot i tt i sy O nset over hoursy Toxic,very ill appearancey N o preceding coryzay High grade fever(>38.5 C )y Absent @ slight cough

y S oft stridory Muffled, reluctant to speaky C an t drink & drooling of

saliva

Acute Stridor 2

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