Transcript STRIDOR AND EPIGLOTTITIS

STRIDOR
- An ER Approach
Dr.R.Ashok. MD(A & E)
HEAD OF THE DEPT.
DEPT OF ACCIDENT & EMERGENCY MEDICINE
VMMC & H, KARAIKAL
Case Scenario
A 6 year old boy was well until he woke from
sleep at 3am with a high fever. His mother
brought him to the ED because he was unable
to lie down, had noisy respirations, and was
drooling saliva.
What is Stridor?
• Stridor is the sound produced by
turbulent flow of air through a narrowed
segment of the respiratory tract
• It typically originates from the larynx
(voice box) or trachea (windpipe)
What are the causes of
Stridor ?
• Congenital anomalies of the larynx, trachea,
and bronchial tree
• Foreign body aspiration
• Infectious conditions of the respiratory tract
• Vocal cord paralysis
• Trauma
• Neoplasms of the airway
• Allergic reaction
• Inhalation injury
• Prolonged intubation
• Diagnostic tests such as bronchoscopy or
laryngoscopy
How is stridor evaluated?
Historical information in the
Evaluation of Stridor in Children
Age of onset:
• Birth: Vocal cord paralysis, congenital
lesions such as choanal atresia, laryngeal
web and vascular ring
• 4 to 6 weeks: Laryngomalacia
• 1 to 4 years: Croup, epiglottitis, foreign
body aspiration
Chronicity:
• Acute onset:
Foreign body aspiration,
infections such as croup and epiglottitis
• Long duration: Structural lesion such as
laryngomalacia, laryngeal web or
larynogotracheal stenosis
Precipitating factors
• Worsening with straining or crying:
Laryngomalacia, Subglottic Hemangioma
• Worsening at night : Viral or spasmodic croup
• Worsening with feeding :
Tracheoesophageal fistula, Tracheomalacia,
Neurologic disorder, Vascular compression
• Antecedent upper respiratory tract
infection: Croup, bacterial tracheitis
• Choking: Foreign body aspiration,
Tracheoesophageal fistula
Associated symptoms
• Barking cough: Croup
• Brassy cough:
Tracheal lesion
• Drooling: Epiglottitis,
Foreign body in esophagus,
Retropharyngeal or
Peritonsillar abscess
• Weak cry: Laryngeal anomaly or
Neuromuscular disorder
• Muffled cry : Supraglottic lesion
• Hoarseness: Croup, vocal cord paralysis
• Snoring:
Adenoidal or
Tonsillar Hypertrophy
• Dysphagia:
Supraglottic lesion
Past Health
• Endotracheal Intubation
• Birth trauma, perinatal asphyxia,
• Cardiac problem
Psychosocial History
• Psychosocial stress - Psychogenic stridor
Physical Examination
General
• Cyanosis
- Cardiac disorder,
Hypoventilation with hypoxia
• Fever
- Underlying infection
• Toxicity
- Epiglottitis
• Tachycardia - Cardiac failure
• Bradycardia - Hypothyroidism
Quality of Stridor
• Inspiratory stridor - Obstruction above
glottis
• Expiratory stridor - Obstruction at or below
lower trachea
• Biphasic stridor - Glottic or subglottic
lesion12
Position of child
• Hyperextension of the neck –
Extrinsic obstruction at or above
larynx
• Leaning over, drooling –
Epiglottitis
• Lessening of stridor in prone
position - Laryngomalacia
Chest Finding
• Prolonged inspiratory phase –
Laryngeal obstruction
• Prolonged expiratory phase –
Tracheal obstruction
• Unilateral decreased air entry –
Foreign body in ipsilateral bronchus
Signs of Impending Respiratory
Failure
• Increased work of breathing with tiring
• Increasing tachypnea and tachycardia
• Abrupt onset of bradycardia
• Cyanosis
• Marked lethargy or unresponsiveness
Initial approach to a Stridorous child
• Avoid disturbing or upsetting the child
• Avoid tongue depressor or other oral
instruments
• Confirm the diagnosis by direct or
radiographic visualisation
Diagnosis
• History and Physical examination
• Chest and neck x-rays, bronchoscopy, CT-
scans, and / or MRIs may reveal structural
pathology
• Flexible fiberoptic bronchoscopy
Parents or caregivers may be asked..?
• Is the abnormal breathing a high-pitched sound?
• Did the breathing problem start suddenly?
• Could the child have put something in the mouth?
• Has the child been ill recently?
• Is the child's neck or face swollen?
Parents or caregivers may be asked..?
• Has the child been coughing or complaining of a
sore throat?
• What other symptoms does the child have? (For
example, nasal flaring or bluish color to the skin,
lips, or nails)
• Is the child using chest muscles to breathe
(intercostal retractions)?
How will you approach this in the ER?
• Tracheal intubation or Tracheostomy is
immediately necessary?
• Expectant management with full monitoring, oxygen
by face mask, and positioning the head of the bed
for optimum conditions (e.g., 45 - 90 degrees)
• Use of nebulized racemic adrenaline (0.5 to 0.75 ml
of 2.25% racemic adrenaline added to 2.5 to 3 ml of
normal saline) in cases where airway edema may be
the cause of the stridor
• Use of dexamethasone (Decadron) 4-8 mg IV q 8 12 h in cases where airway oedema may be the
cause of the stridor
• Use of inhaled Heliox (70% helium, 30% oxygen);
the effect is almost instantaneous. Helium, being a
less dense gas than nitrogen, reduces turbulent
flow through the airways
• Nebulized Cocaine in a dose not exceeding 3
mg/kg may also be used, but not together with
racemic adrenaline [because of the risk of
ventricular arrhythmias]
Remember :
• Stridor is a symptom and not a diagnosis
• History and physical are key in diagnosis
• Airway endoscopy is an important adjunct
• Proper management is possible only after a precise
diagnosis has been established