بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Acute Stridor By Yehia Abo Arida Ward7

3. Stridor • It is a harsh, high-pitched respiratory sound, which is usually inspiratory but it can be biphasic and is produced by turbulent airflow; it is not a diagnosis but a sign of upper airway obstruction .

5. Causes of acute stridor • Laryngotracheobronchitis ( croup) . • Epiglottitis . • Bacterial tracheitis . • Foreig body • Angioedema . • Hypocalcemic tetany . • Edema after endotracheal intubation .

6. Assessment of severity of stridor • Timing : • The prominent phase of respiratory noise should be inspiratory • Expiratory stridor ----- more severe , or intrathoracic obstruction . • Work of breathing : • Increased RR . • Sternal ( supra – sub ) recession . • How effective is the breathing : • Chest expansion . • Breath sounds for air entery . • Is there adequate oxygenation : • Is HR increased . • Pallor , cyanosis . • O2 saturation . • Activity level .

7. Worrying signs in children with stridor • High fever or signs of toxicity • Rapid onset . • Drooling & dysphagia . • Muffled voice & quiet stridor . • Angioedema . • Age less than 4 mths . • Skin cavernous hemangioma . • Previous ventilation as a neonate .

8. Croup Is derived from an oldscottish word , roup , whichmeans to cry out in a hoarse voice .

9. Viral croup ( ALTB ) • Viral croupis the most common cause of acute stridor in children . • Most patients withcroupare between ages of 3 mths and 5 yrs , with the peak around 1-2 yrs . • Common pathogens include parainfluenza viruses ( 1,2 & 3 ) account for 75% of cases; others include influenza ( A&B ) , RSV & measles V . • Mycoplasma pneumoniae has rarely been isolated from children with croup .

10. The term laryngotracheobronchitis refers to viral infection of the glottic and subglottic regions . Some clinicians use the termlaryngotracheitisfor the most common & most typical form of croup and reserve the term LTB for more severe form . • Inflammation & partial obstruction of the upper airways result in a barkelike or brassy cough& inspiratory stridor & may be associated with hoarseness & RD . • Small children are at higher risk because of the relative small size of their upper airways. . .

11. Unlike relatively rare conditions as epiglottitis & bacterial tracheitis , croup has : • a more insidious onset over a few days . • systemic toxicity & fever are considerably less . • have typical barking cough , often associated with hoarse voice , stridor & low grade fever . • As in many respiratory conditions , symptoms are often worse at night .

12. Assessment & evaluation • Mild: • well , active child . • barking cough . • stridor with agitation • minimal sings of increased WOB .

13. MODERATE : • stridor at rest . • some signs of increased WOB . • SEVERE : • stridor at rest + expiratory component . • marked increased WOB . • increased RR & HR • agitation & pallor . • as AW obstruction became very serious stridor became quieter . • agitation turn to exhaustion .

14. Acute spasmodic croup • Some children develop recurrent short lived episodes of croup without preceding coryzal prodrome that is seen in classical viralcroup. • children are afebrile & awake suddenly with acute stridor during night . • recurrence occurs on subsequent 2-3 nights . • it occurs in children of the same age group , during same season & sometimes same virus can isolated . • children with recurrentspasmodic croupoften havea strong atopic or asthmatic family background .

15. Radiographs • Croupis a clinical diagnosis and does not require a radiograph of the neck . • It may show the typical subglottic narrowing or ( steeple sign ) on AP view , which may be present as a normal variation or in epiglottitis & may be absent in patient with croup . • Should be considered in patient with atypical presentation . • May be helpful to distinguish severe LTB & epiglottitis , but airway management should always take priority .

16. Steeple sign (croup \ normal \ epiglottitis ) due to subglottic narrowing .

18. Treatment • Majority of cases will have a mild illness that can be managed at home . • Those with significant RD and stridor at rest will require treatment & reassessment . • Those showed significant improvement following treatment may be considered for discharge home .

19. There should be a low threshold for admission in : • children under age of 12 mths . • all children with marked RD . • those with oxygen requirement on presentation. • those with parents remain anxious about discharge .

20. Parents of children not requiring admission should receive clear instructions when to return : • chest wall recession . • tachypnoea . • color changes . • inability to feed . • decreased level of consciousness .

21. Therapies may be effective • Simple measures : • in all cases it is very important to keep the child and parents calm . • direct inspection of the throat can be dangerous and result in complete obstruction of the airway. • neck x ray is no longer useful and carry the risk of further upset and deterioration .

22. Humidification : • steam inhalation forcroupis widely used but oflittle proven benefits . • the percieved benefits ( placebo effect ) may be due to presence in a warm calming environment . • a steamy bathroom with hot water tap running and plug opened is accepted , but use of kettle and boilers should discouraged , because it carry the risk of scalding .

23. Adrenaline ( epinephrine ) : • nebulizedadrenalineis very effective in severecroup . • duration of action between 20 minutes and 3 hours . • it is used in most cases whenintubationis considered. • weaning effect of adrenaline result in return to pretreatment baseline rather than a true rebound . • for children with severe croup , the period of improvement on adrenaline is long enough to allow the steroid to start working .

24. Steroids : • Corticosteroids improve clinical parametrs . • Decrease the admission rate . • decrease duration of hospital stay . • Decrease the need for repeated nebulized adrenaline in children with croup . • nebulized budesonideor oraldexamethazoneshowed equal effect in treating children with croup . • approximately 1-5 % of croup cases require ETT before introduction of steroid therapy .

25. Intubation : • a small numbers of children will still require ET for severe croup . • The decision to intubate should be based on worsening airway obstruction , signs of exhaustion or impending respiratory failure . • Children with epiglottitis and bacterial tracheitis require specialist care , with input from senior ENT & anethetic stuff . • IV antibiotics & intubation are often required . • steroid & adrenaline have minimal effect on these condition .

26. Mild croup • Reassurance . • May worse by night ( advice to return ) . • Dexamethazone PO (0.3- 0.6 mg\kg \ dose).

27. Moderate croup • Cardio respiratory monitor • Dexamethazone PO&\or nebulized budesonide (pulmicort) 2 mg stat . • Reassess in 2 hours • If improved ------- discharge . • If no improvement : • Consider nebulized adrenaline 1: 1000 • 2.5 ml for those younger than 1 year . • 2.5 - 5 ml for older than 1 year . • If improved -----observe for 4 hrs & discharge .

28. Severe croup • Cardio respiratory monitor . • Oxygen to maintain O2 sat ( 92% or more ) . • Nebulized adrenaline ( 1\1000) Q 1-4 hrs . • IV dexamethazone ( 0.3-0.6 mg\kg\dose ) . Or • Nebulized budesonide ( pulmicort ) 2mg . • IF no improvement consider BGA , ICU . • Intubation & ventillation may be required .

29. Bacterial traheitis • Bacterial infection of upper airway , does not involve the epiglottis but, like epiglottitis and croup , is capable of causing life-threatening airway obstruction . • Staph aureus is the most commonly isolated organism . • Most patients were below 3 yrs , but in recent case series the mean age has been between 5-7 yrs . • I t may be considered as bacterial complication of disease , rather than a primary bacterial illness .

30. Clinical manifestations • Typically child has a brassy cough , apparently asa part ofLTB . • High fever and toxicity with RD immediately or after few days of apparent improvement . • Patient can lie flat , does not drool , and does not have dysphagia associated with epiglottitis . • the usual treatment for croup is ineffective , intubation or tracheostomy may be necessary . • The major pathologic feature is mucosal swelling at level of ciricoid cartilage , complicated by copious thick purulent secretions sometimes causing pseudomembrane .

31. Diagnosis • Diagnosis is based on evidence of bacterial upper airway disease (high fever – purulent airway secretions & absent classic finding of epiglottitis ) . • XR not needed , but may show classic findings (pseudomembrane detachment in the trachea ) . • Purulent material is noted below the cords during ET intubation .

32. Black arrow points tracheal pseudomemerane (bacterial tracheitis \ diphtheria )

34. Treatment • Antimicrobial therapy , which usually includes antistaph agents , should be instituted in any patient whose course suggest bacterial traheitis . • When diagnosed by direct laryngoscopy , or suspected on clinical background , an artificial airway should be strongly considered . • Supplemental oxygen may be necessary .

35. Complications • CXR showed : • Patchy infiltrates & show focal densities. • Subglottic narrowing . • Cardio respiratoryarrest can occur if airway management is not optimal . • Toxic shock syndromehas beenassociated with staphtracheitis .

36. Prognosis • oxygen therapy continued . For most of patients is excellent . • Patient become afebrile within 2-3 days of institution of antimicrobial therapy , but prolonged hospitalization may be necessary. • After extubation the patient should be observed carefully while antibiotics and O2 continued .

37. Epiglottitis • Dramatic potentially lethal condition characterized by an acute , potentially fulminating course of high fever , sore throat , dyspnea & rapidly progressing respiratory obstruction . • Degree of RD at presentation is variable. • Often the otherwise healthy child develops sore throat and fever within a matter of 4-6 hrs .Child appear toxic ,swallowing is difficult and saliva drooling . • He sitting upright and assume tripod position( leaning forward ,chin up, bracing on the arm ) . • A brief period of air hunger with restlessness may be followed by cyanosis and coma . • Stridor is a late and suggest near complete airway obstruction. • If no treatment provided complete obstruction of airway and death . • barking cough typical of croup is rare .

38. Diagnosis • laryngoscopy : • Showed large( cherry red) , swollen epiglottis • Other supraglottic structures especially aryepiglottic fold , occasionally more involved . • It should be performed in a controlled environment as OR or ICU . • Lateral radiograph of upper airway : • Showed the classical ( thumb sign ) .

39. Red arrow points ( normal & swollen epiglottis) known as thumb sign or thumb print .

40. Intial management of suspected epiglottitis • Do not : • Examine the throat . • Put the child flat . • Order a lateral XR of the neck . • Upset the child by trying to gain iv access or place an O2 mask .

41. Do : • Call airway team . • Stay with the child and parents . • Allow the child to sit on knee of his mother . • Measure O2 sat if possible . • Give O2 therapy if absolutely needed and well tolerated .

42. Treatment • Immediate treatment with artificial airway placed in OT orICU . • All cases should receive oxygen unless the mask causes excessive agitation . • Racemic epinephrine & corticosteroids are ineffective . • Blood & epiglottic surface C&S and in selected cases CSF should be collected after stabilization of airway. • Cefotriaxone, cefotaxime , orcombinationof ampicillin and salbactum should be given parenterally, pending C&S reports . • Antibiotics should be continued for 7-10 days .

43. Chemoprophylaxis • Not routine for household , child-care or nursery contacts of patient with invasive HIb infection , but observation & medical evaluation is mandatory when exposed child develop febrile illness . • Indication for rifampin prophylaxis : • Any contact less than 1y & incompletely immunized . • Any contacts less than 2 yrs of age who has not received the primary vaccination series . • An immunocompromised child in the household . • Dose : (20 mg \kg \d ) once , for 4 days , maximum dose is 600 mg \ day .

44. Prognosis • Length of hospitalization and mortality rate increase as infection spread to involve a greater portion of respiratory tract , except in epiglottitis in which local infection may prove to be fatal . • Causes of death in croup are : • Laryngeal obstruction . • Complications of tracheostomy . • rarely , fatal out-of-hospital arrest due to viral LTB have been reported . • Untreated epiglottitis has mortality rate of 6% but if treatment initiated the prognosis is excellent . • The outcome of LTB ,and spasmodic croup is also excellent .

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