بسم الله الرحمن الرحيم
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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 .


  • 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. . .


  • 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 .


  • 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 subglottic narrowing .

  • 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 .




Therapies may be effective
Therapies may be effective receive clear instructions when to return :

  • 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 .


  • Humidification : receive clear instructions when to return :

    • 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 .


  • Adrenaline ( epinephrine ) : receive clear instructions when to return :

    • 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 .


  • Steroids : receive clear instructions when to return :

    • 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 .


  • Intubation : receive clear instructions when to return :

    • 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 receive clear instructions when to return :

  • Reassurance .

  • May worse by night ( advice to return ) .

  • Dexamethazone PO (0.3- 0.6 mg\kg \ dose).


Moderate croup
Moderate croup receive clear instructions when to return :

  • 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 receive clear instructions when to return :

  • 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 receive clear instructions when to return :

  • 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 receive clear instructions when to return :

  • 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 receive clear instructions when to return :

  • 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 tracheitis \ diphtheria )

  • 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 tracheitis \ diphtheria )

  • 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 tracheitis \ diphtheria )

  • 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 tracheitis \ diphtheria )

  • 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 tracheitis \ diphtheria )

  • 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 as thumb sign or thumb print .

  • 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 .


  • Do : as thumb sign or thumb print .

    • 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 as thumb sign or thumb print .

  • 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 as thumb sign or thumb print .

  • 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 as thumb sign or thumb print .

  • 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 .


Your Text Here as thumb sign or thumb print .

thank you


الحمد لله as thumb sign or thumb print .


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