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Upper Respiratory Emergencies. Chapter 133 Tintinalli May 4, 2006 Dee Mortensen. STRIDOR. Common physical sign of upper respiratory tract obstruction Inspiratory and expiratory stridor Associated with supraglottic, glottic, and subglottic obstruction

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Upper respiratory emergencies l.jpg

Upper Respiratory Emergencies

Chapter 133 Tintinalli

May 4, 2006

Dee Mortensen


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STRIDOR

  • Common physical sign of upper respiratory tract obstruction

  • Inspiratory and expiratory stridor

    • Associated with supraglottic, glottic, and subglottic obstruction

    • Supraglottic obstruction-marked inspiratory stridor with mild expiratory stridor, whereas in the other causes, inspiratory/expiratory are of less magnitude

    • Stridor may also be seen with tracheal or primary bronchial obstruction


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STRIDOR

  • Until proven otherwise, patients with marked variation in pattern of stridor have a foreign body obstruction

  • Quality of pitch not clinically useful for diagnosis

  • Age of patient will narrow the differential diagnosis


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Common Causes of Stridor Table 133-1

  • Children < 6 months of age

    • Laryngotracheomalacia: chronic, resolves by age 2

    • Vocal cord paresis or paralysis

    • Arnold-Chiari malformation

  • Children > 6 months of age: acute

    • Viral Croup-- Retropharyngeal abscess

    • Epiglottitis-- Foreign Body aspiration


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LARYNGOMALACIA

  • 60 % of all neonatal laryngeal problems

    • 2° to developmentally weak larynx

  • Each inspiration collapses epiglottis, aryepiglottic folds and arytenoids

    • Worse with crying and agitation

    • May be exacerbated by URI

    • Improves with neck ext. and prone position


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LARYNGOMALACIA

  • Rarely a/w respiratory distress, apnea or feeding problem

  • Tracheotomy or epiglottoplasty rarely needed

  • Definitive dx-fiberoptic laryngoscopy

  • Self limited disorder-90% of cases resolved by age 2.


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Vocal Cord Paralysis or Paresis

  • 2nd most common etiol. of neonatal stridor

  • Most with h/o birth trauma, shoulder dystocia, macrosomia, forceps delivery, abnormal cry or other intrathoracic anomaly

  • Dx-fiberoptic laryngoscopy during speech or crying


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Vocal Cord Paralysis or Paresis

  • Intubation during respiratory failure difficult if b/l vocal cords paralyzed

    • Try placing bevel of ETT parallel to glottic opening then rotating ¼ turn while applying gentle pressure- Never force it

  • Needle cricothyroidotomy and tracheotomy may be needed


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Arnold Chiari Malformation

  • Brain and cerebellum during development partially herniate thru foremen magnum

  • Compression of cerebellar tonsils, pons, medulla, and upper cervical spinal cord leads to various neurologic abnormalities

  • Consider it in patient with stridor and:

    • Child with trisomy 21

    • Myelomeningocele

    • Hydrocephalus

    • Sacral dimple or sacral epidermal abnormality


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Arnold Chiari Malformation

  • If intubation required, inline stabilization is imperative to prevent further compression of CNS structures

  • Obtain urgent neurosurgical consultation, decompression likely required for tx


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Stridor in Children > 6 months old

  • Usually present with short duration of symptoms (hours to days)

  • Common causes (see Table 133-2)

    • Epiglottitis

    • Croup

    • Bacterial Tracheitis

    • Foreign Body Aspiration

    • Peritonsillar abscess

    • Retropharyngeal abscess


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EPIGLOTTITIS

  • Causative Organisms

    • H. influenza < 25% secondary to vaccinations

    • Strep pyogenes and pneumoniae

    • Staph aureus

  • Immunocompromised patients

    • Herpes simplex, candida, varicella

  • Prior to H. Flu vaccination median age was 3 years—currently age 7


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EPIGLOTTITIS

  • Classic symptoms- abrupt onset of high fever, sore throat, stridor, dysphagia, and drooling, +/- stridor. Usually no cough

    • Some cases may develop over days

  • P.E.- toxic-appearing, apprehensive, often sits in tripod or “sniffing” position, voice may be muffled, marked tenderness with palpation of hyoid


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EPIGLOTTITIS

  • Dx- lateral XR unnecessary for classic sxs

    • If uncertain dx – lateral XR of soft tissues w/ neck extended during inspiration

      • False (+) if XR with head flexed or in expiration

      • If False (-) direct visualization needed to r/o dx

  • XRays- epiglottis is swollen “thumbprint” at the base of the hypopharynx

    • Commonly vallecular space obscured

    • Supraglottic ballooning


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EPIGLOTTITIS

  • Airway Management- Try not to disturb the patient!!

    • Urgently consult ENT and Anesthesia

    • Oxygen as needed

    • Nebulized racemic epinephrine- decreases airway edema

    • ACLS-for difficult airway mgt or respiratory failure

      • Use ETT one size smaller than usual

      • Correct tube size will have small air leak on end inspiration


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EPIGLOTTITIS

  • Rx Management

    • 2nd or 3rd cephalosporin +/- vancomycin

    • Oral ATBX for 7-10 days after extubation

    • Steroids remain controversial


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Viral Croup (laryngotracheobronchitis)

  • Most common cause of stridor after neonatal period

  • Most affected are children 6 mo.- 3 y.o

  • Peak incidence b/t 1-2 yrs of age

    • Narrowest part of airway is at cricoid cartilage and in children 1 mm of airway edema may ↓ cross-sectional area 50-60%

  • Most cases occur late fall or early winter


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SPASMODIC CROUP

  • Thought to be on continuum with acute viral croup

  • Seen more commonly in atopic children

  • No seasonal variation

  • Usually resolves within 6 hours of onset

  • Often recurrent and not associated with fever


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VIRAL CROUP

  • Etiology-mostly viral

    • Parainfluenza virus type I,II,III

    • Incubation 2-6 days, virus shed for about 2 weeks

  • Others

    • Influenza A or B, RSV, rhinovirus, and measles

    • Adenovirus- also a/w hemorrhagic cystitis, and conjunctivitis

    • Mycoplasma pneumoniae may present with croup like syndrome


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    VIRAL CROUP

    • Signs & Symptoms

      • 1-5 day prodrome of cough, coryza, +/- low grade fever and URI type symptoms

      • Followed by 3-4 days of barking cough, worse in late evening and night

      • +/- biphasic stridor: inspiratory component greater than expiratory. Unaffected by position, worsened by agitation or crying

      • Duration 3-7 days regardless of tx, usually 3rd and 4th days are worst, followed by improvement


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    VIRAL CROUP

    • Diagnosis- made clinically

    • X-rays: If other causes being considered or in atypical or prolonged cases

      • Obtain lateral neck films and PA CXR

      • PA CXR in croup “steeple sign”


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    VIRAL CROUP-Treatment

    • Pulse ox, and humidified O2

      • Often improvement after child has been in cold night air or moist air from shower

    • Antipyretics if fever present

    • Antibiotics not indicated

    • IV fluid hydration only if necessary

    • Nebulized Albuterol

    • Stridor only with agitation- doesn’t need epinephrine

    • Stridor at rest or child in respiratory distress-tx with epinephrine and steroids

    • Intubation if respiratory failure or pending (use ETT 0.5 to 1.0 mm smaller than typically used)


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    Treatment Continued

    • Racemic Epinephrine

      • Positive affects seen w/in 10 min

      • Maximal affect seen in ~ 1 hr

      • Therapeutic affects gone w/in 2 hrs

      • Acts by vasoconstriction of mucosal vessels

    • L-epinephrine 1:1,000 concentration may also be used

    • Recommended to watch patient for 3 hrs before considering discharge


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    Treatment Continued

    • Dexamethasone

      • Steroids-used with moderate to severe episodes of croup

      • Mild episodes controversial to tx with steroids

      • Effects may be seen in ½ to 2 hrs with persistent effects over next 1 to 2 weeks

      • 0.3-0.6 mg/kg IM or PO x 1, equal efficacy

      • Complete steroid list/dosages Table 133-6


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    Treatment Continued

    • Heliox

      • Replacing nitrogen w/ helium decreases airway resistance and improves ventilation

      • Helium is therapeutic only when concentration is 60-80% of inspired gas. (Thus can’t use if patient requires > 30-40 % O2)

      • Indications still controversial


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    Viral Croup-Discharge Criteria

    • ≥ 3 hrs since last epinephrine

    • Nontoxic appearance, able to tolerate PO

    • Not clinically dehydrated

    • Room air pulse ox > 90 %

    • Age > 6-12 months- controversial

    • Caregiver able to recognize change in clinical status and relatively short transit from hosp.

    • Weather conditions allow rapid return to ED


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    BACTERIAL TRACHEITIS

    • Often caused by bacterial superinfection of antecedent viral upper respiratory infection

    • Most common in children <3 yrs

    • Signs & Symptoms

      • 2-7 days of crouplike syndrome

      • Then worsening symptoms & toxic appearance

      • Severe inspiratory & expiratory stridor

      • Cough w/ occasional thick sputum

      • Raspy / hoarse voice, no dysphagia

      • May complain of gnawing/ burning substernal chest discomfort


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    BACTERIAL TRACHEITIS

    • Diagnosis

      • Most w/ ↑ WBC and left shift

      • XR- subglottic narrowing of trachea +/- irregular densities w/in trachea, borders appear ragged/indistinct

    • Management - Similar to epiglottitis- 85 % require intubation

    • Treatment- Vancomycin and 3rd generation cephalosporin


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    FOREIGN-BODY (FB) ASPIRATION

    • Peak incidence age 1 to 3 years

      • 90% of cases under age 4

    • Most commonly foods or toys

      • Foods- peanuts, raisins, grapes, and hot dogs

      • Vegetable matter can cause intense pneumonitis and subsequent pneumonia

      • Toys/objects- typically small, smooth, and round


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    FOREIGN-BODY ASPIRATION

    • Signs & Symptoms

      • Majority with abrupt onset of stridor or respiratory distress or failure

      • Classically, but not always, laryngotracheal FB cause stridor and bronchial FB cause wheeze

      • Some may be asymptomatic and normal P.E.

      • FB should be suspected in unilateral wheeze


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    FOREIGN-BODY ASPIRATION

    • Other Signs & Symptoms

      • History of choking episode

      • Chronic cough

      • History of persistent or recurrent pneumonia

      • Persistent croup or asthma after adequate tx

      • Pharyngeal pain


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    FOREIGN-BODY ASPIRATION

    • Diagnosis

      • Maintain high index of suspicion

      • Up to 1/3 of FB aspirations may have normal XR as most FB are not radiopaque

      • CT may be helpful

      • If clinical suspicion is high may need laryngoscopy and rigid bronchoscopy


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    FB Diagnosis continued

    • Complete obstruction-may see segmental atelectasis on XR

    • Partial obstruction-ball valve effect, may cause obstructive emphysema

      • B/l decubitus PA XR obstructed side remains inflated and diaphragm inferiorly displaced when involved side is down

    • Esophageal FB vs Tracheal FB

      • Narrow flat FB in esophagus usually orients in coronal plane, vs sagittal plane if in the trachea


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    Where is the FB located?


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    FOREIGN-BODY ASPIRATION

    • Treatment

      • ACLS-obstructed airway management, or follow predetermined ED protocols if available

      • Obtain appropriate consults, ENT, Anesthesia or Pulmonary

      • Removal by trained personal or transport to appropriate facility


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    PERITONSILLAR ABSCESS (PTA)

    • Most common in adolescents w/ antecedent sore throat, improvement prior to worsening sxs

    • Signs & Symptoms

      • Appear acutely ill

      • Fevers

      • Dysphagia

      • Trismus

      • Drooling

      • Muffled “hot potato” voice

      • Ipsilateral ear pain and torticollis


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    PERITONSILLAR ABSCESS

    • Peritonsillar space – superior aspect of tonsil & area lateral to adenoids and to the area of pyriform sinus

    • If patient unable to cooperate or if extension into deep tissues of the neck suspected, CT of oropharyngeal and cervical soft tissues may be needed

    • On exam

      • May note bilateral tonsillar erythema & exudate

      • Uvula may be displace away from affected tonsil

      • Involved tonsil is anteriorly & medially displaced

      • Cervical adenopathy often present


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    PERITONSILLAR ABSCESS


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    PERITONSILLAR ABSCESS

    • Confident diagnosis w/out imaging study can be made with

      • Uvular deviation

      • Marked soft palate displacement

      • Severe trismus

      • Airway compromise

      • Localized areas of fluctuance


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    PERITONSILLAR ABSCESS

    • Treatment

      • If patient is nontoxic-appearing, has findings most consistent with peritonsillar cellulitis and has good follow up with PCP or ENT then may tx as outpatient with penicillin, a macrolide, or clindamycin

      • Definitive tx for PTA is either I&D in OR or needle aspiration in E.D. or ENT office

        • Continue as above with ATBX and pain control


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    RETROPHARNGEAL ABSCESS

    • Relatively rare, but peak incidence in infants-range from 6 months to 4 years

    • Rare after 4 yr of age b/c repeated URIs have obliterated retropharyngeal lymph nodes

    • Evolve over days after minor URI or after localized trauma to posterior pharyngeal wall. i.e. fall with stick or object in mouth.


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    RETROPHARNGEAL ABSCESS

    • Anatomy

      • Retropharyngeal space b/t buccopharygeal fascia and prevertebral fascia

      • Extends from skull base to level of T1 or T2

      • Two major cervical chains that drain nasopharynx, adenoids and posterior paranasal sinuses enter into this potential space


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    RETROPHARNGEAL ABSCESS

    • Etiologic organisms-usually mixed flora

      • S. aureus, s. pyogenes, S. viridans, and Klebsiella,

      • Anaerobes-Peptostreptococcus, Fusobacterium, and Bacteroides.

    • Signs & Symptoms

      • High fever--Dysphagia

      • Meningismus--Muffled voice

      • ↓ Oral intake--Persistently hyperext. neck

      • Stridor--Possible resp. distress


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    RETROPHARNGEAL ABSCESS

    • Diagnosis

      • Lateral neck XR-neck extended during inspiration

        • Normal prevertebral soft tissue should be no wider than diameter of vertebral body at same level

        • Controversial to use specific values as criteria for retropharyngeal abscess as values seem dependent on age and position of patient.

      • Definitive dx-based on CT scan when possible


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    RETROPHARNGEAL ABSCESS

    • Treatment

      • Intubation if acute respiratory distress

      • Retropharyngeal cellulitis and very small abscess may be tx’d with ATBX alone

      • Large abscess will need I&D by ENT

      • Consult ENT for definitive TX options

      • ATBX choices

        • Single Agent-Unasyn

        • Clindamycin with 3rd generation cephalosporin


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    Questions

    • In viral croup which virus is associated with hemorrhagic cystitis and conjunctivitis?

      • A. Parainfluenza

      • B. RSV

      • C. Rhinovirus

      • D. Adenovirus


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    Questions

    2. In epiglottis, what is the appropriate lateral soft tissue radiograph to obtain?

    • A. Neck extended during expiration

    • B. Neck flexed during inspiration

    • C. Neck extended during inspiration

    • D. Neck flexed during expiration


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    Questions

    3. During pediatric intubation what is the appropriate ETT size, if the patient has croup?

    • A. Same as for other illnesses

    • B. 0.5 to 1.0 mm smaller than typically used

    • C. 0.5 to 1.0 mm larger than typically used

    • D. 2 mm larger than typically used


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    Questions

    • Typically a foreign body in the trachea will be oriented in the coronal plane (T/F)

    • Most common cause of croup is Parainfluenza virus (T/F)


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    Answers

    • D

    • C

    • B

    • F-usually in the sagittal plane

    • T


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