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STRIDOR - An ER Approach. Dr.R.Ashok. MD(A & E) HEAD OF THE DEPT. DEPT OF ACCIDENT & EMERGENCY MEDICINE VMMC & H, KARAIKAL. Case Scenario.
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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.
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)
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
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)?
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
Thank you