Transcript Extern conference An infant with stridor!!!

Extern conference
28 June 2007
What is the abnormal finding ?
Stridor
musical, monophonic, audible breath
sounds (noisy breathing)
caused by oscillations of narrowed large
extrathoracic airways
indicates a partial obstruction of the upper
airways, glottis, or trachea
History
CC : inspiratory stridor 1 day after birth
PI : Maternal Hx. : 24 yr. G1P0A0
Antenartal Hx : Adequate ANC
GA 40 wks by date
C/S due to CPD
 Term AGA female infant
 BW 3630 g (P75), HC 34 cm (P50), Lt 51 cm (P 50)
 Apgar 7 (color 2, RR1), 9 (RR1)
 O2 tubing 5 LPM and tactile stimulation
 After birth RR 48/min
 30 min after birth developed tachypnea and grunting
 Transfer to nursery
At nursery: physical examination
 V/S : T 37.6 C, P 163/min, BP 61/36 mmHg,
RR 52/min
 Sp O2 65% (RA)
 GA : Active, central and peripheral cyanosis,
no jaundice, no hemangioma at beard
and neck region
 HEENT : no midline defect, poor nasal air
flow Rt. > Lt.
At nursery: physical examination
 RS : Dyspnea, subcostal retraction,
no flaring of alar nasi, no grunting, normal
breath sounds, no adventitious sound,
no stridor
 CVS : Normal S1,S2, no murmur
 Abdomen : WNL
 NS : Normotonia, symmetrical movement,
grasping reflex +ve, rooting reflex +ve, Moro
reflex +ve
At nursery
 O2 tubing 10 LPM and Syringe ball suction with
NSS Nasal drop : improved
 Then continue O2 hood 5 LPM :
SpO2 99 %, FiO2 0.45 then wean off O2 in 6 hrs
later SpO2 98%
Cyanosis developed when she received
spoon feeding and spontaneously
recovered, then she was retained OG tube.
Cyanosis and inspiratory stridor related
with hoarse crying can be improved by
prone position.
Problem list
Problem list
1.
2.
3.
4.
C/S due to CPD
Term AGA female infant
Perinatal depression (Apgar 7,9)
Cyanosis and inspiratory stridor related
to feeding and crying
5. Hoarseness of voice
Approach to congenital stridor
Approach to congenital stridor
Stridor = upper airway obstruction
Anatomical
Supralaryngeal
Laryngeal
Tracheal
Approach to congenital stridor
•Laryngeal :
oLaryngomalacia
oVocal cord paralysis
oSubglottic stenosis
oLaryngeal abnormalities
(hemangiomas, webs, cysts, cleft)
Approach to congenital stridor
oSupralaryngeal
oVallecular cysts
oThyroglossal cysts
oTongue teratoma
Differential diagnosis
1. Laryngomalacia
2. Unilateral vocal cord paralysis
3. Laryngeal abnormalities
4. Supralaryngeal causes
Initial Investigation
Initial Investigation
CXR
Film lateral neck
Further Investigation
Bronchoscopy
Diagnosis
 Left Unilateral Vocal cord paralysis
Congenital Vocal cord paralysis
Unilateralstridor and retraction are not marked
weak & hoarse cry, aggravated by agitation
Feeding difficulties
Congenital Unilateral Vocal cord paralysis
Etiology
ousually idiopathic
osecondary to peripheral n. esp. recurrent laryngeal n.
-Lt.sided : common
perhaps from birth trauma
-Rt. Sided : complication of thoracic & neck surgery
oMay be lesions in the mediastinum
(tumors and vascular malformations)
Prognosis – uncertain due to etiologies
Congenital Vocal cord paralysis
Bilateral -much more serious condition
stridor at rest
near-normal phonation
progressive airway obstruction
poor prognosis due to underlying and
associated problems
Management in this patient
Specific
No specific treatment for vocal cord paralysis
Ix for underlying etiology
 Supportive
Observe respiratory: apnea, SpO2
Retain OG tube
Correct position
Position picture.
Lies on paralyzed side
Take home message
Upper airway obstruction can be cured as
conservative but when the patient develop
- cyanosis when feeding
- weak cry
- hoarseness of voice
- abnormal lat. neck film
- biphasic stridor
REFER
Members
 Ext. Assawin
Ruangmongkolleot
 Ext. Panrudee
Watanaprakornkul
 Ext. Nisarath
Soontrapa
 Ext. Prapa
Pattrapornpisut
 Ext. Patcharaporn
Chandraparnik