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بسم الله الرحمن الرحيم. Acute Stridor. By Yehia Abo Arida Ward 7. 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 . .

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acute stridor

Acute Stridor

By

Yehia Abo Arida

Ward7

stridor
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 .
causes of acute stridor
Causes of acute stridor
  • Laryngotracheobronchitis ( croup) .
  • Epiglottitis .
  • Bacterial tracheitis .
  • Foreig body
  • Angioedema .
  • Hypocalcemic tetany .
  • Edema after endotracheal intubation .
assessment of severity of stridor
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 .
worrying signs in children with stridor
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 .
croup
Croup

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

viral croup altb
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 .
slide10
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. . .
slide11
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 .
assessment evaluation
Assessment & evaluation
  • Mild:
    • well , active child .
    • barking cough .
    • stridor with agitation
    • minimal sings of increased WOB .
slide13
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 .
acute spasmodic croup
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 .
radiographs
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 .
treatment
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 .
slide19
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 .
slide20
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 .
therapies may be effective
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 .
slide22
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 .
slide23
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 .
slide24
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 .
slide25
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 .
mild croup
Mild croup
  • Reassurance .
  • May worse by night ( advice to return ) .
  • Dexamethazone PO (0.3- 0.6 mg\kg \ dose).
moderate croup
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 .
severe croup
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 .
bacterial traheitis
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 .
clinical manifestations
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 .
diagnosis
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 .
treatment1
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 .
complications
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 .
prognosis
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 .
epiglottitis
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 .
diagnosis1
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 ) .
intial management of suspected epiglottitis
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 .
slide41
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 .
treatment2
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 .
chemoprophylaxis
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 .
prognosis1
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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