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Mahindra Kumar

Define stridor Describe mechanism of developing stridor List common causes of stridor in children Describe the clinical presentation, investigation, and outline of management of: Acute laryngo-tracheobronchitis Acute epiglottitis Foreign body inhalation Retropharyngeal abscess Describe the clinical presentation of laryngomalacia

a harsh, high-pitched respiratory sound such as the inspiratory sound often heard in acute laryngeal obstruction Key points: Harsh High pitch At inspiratory phase commonly

Begin as low-pitched high-pitched crowing as respirations become more vigorous. Depends on its timing in the respiratory cycle.
Inspiratory stridor: laryngeal obstruction

Expiratory stridor : tracheobronchial obstruction


Biphasic stridor : subglottic or glottic anomaly.

Duration
Chronic- congenital abnormality Acute- infection or obstruction

Inspiration: alveolar P<atmospheric P


Expiration: alveolar P >atmospheric P Pressure gradients across the airway wall & this tends to alter airway calibre.

The pressure around the extrathoracic airways =atmospheric, intrathoracic airways = pleural pressure.

During inspiration, there is a net force tending to narrow the extrathoracic airways and to dilate the intrathoracic airways.
During expiration, the direction of the forces is opposite, resulting in a tendency to narrow intrathoracic airways and dilate extrathoracic airways.

INSPIRATION

EXPIRATION

flow limitation fluttering of the walls

STRIDOR respiratory noise during inspiration

ACUTE
Croup/ ALTB Retropharyngeal

CHRONIC
Laryngomalacia Laryngeal anomalies-

abscess Epiglottitis Inhaled foreign body Bacterial tracheitis Angioneurotic oedema Diphtheria Peritonsillar abscess Allergic reaction

webs & cyst Vocal cord palsy Laryngeal Papilloma Subglottic stenosis Laryngeal hemangiomas Tracheomalacia Tracheal stenosis Choanal atresia

Parainfluenza viruses(75%), RSV ,influenza (A&B),Adenovirus, Measles,Mumps and Rhinovirus.


mucosal inflammation increased secretions affecting the larynx, trachea and bronchi

oedema of the subglottic area result in critical narrowing of the trachea


6 months to 6 years of age

low grade fever, cough and coryza for 12-72 hours increasingly bark-like cough and hoarseness stridor that may occur when excited, at rest or both respiratory distress of varying degree

Mild

Moderate

Severe

Stridor with excitement or at rest, with no respiratory distress Stridor at rest with intercostals, subcoastal or sternal recession. Stridor at rest with marked recession, decreased air entry and altered level of consciousness.

Nasopharyngeal secretion FBC Chest x-ray

seen on an AP neck X-ray of a child with croup

Indications for hospital admission


moderate and severe viral croup poor oral intake

family lives a long distance from hospital;

lacks reliable transport Toxic looking Age less than 6 months Unreliable caregiver.

H. influenzae type b.(HiB)


intense swelling of the epiglottis and surrounding tissues associated with septicaemia aged 1-6 years but affects all age groups

High fever with ill, toxic appearance Inability to swallow (dysphagia) or talk and drooling of saliva

Cough minimal/absent
Soft inspiratory stridor and rapidly increasing respiratory difficulty over hours

Children often lean forwards with an open airway to optimise airway.

FBC- counts with predominance of neutrophils suggests bacterial cause Examination of the throat with spatula is contraindicated as it may precipitate complete airway obstruction. CHERRY RED swollen epiglottis @ laryngoscopy confirms the diagnosis. thumb sign at Lateral radiographs of the upper airway

Thumb like impression (due to enlarged epiglottis) seen on X-ray lateral view neck in patients with acute epiglottitis

transfer child immediately to an operating theatre for nasotracheal intubation.


emergency tracheostomy may be needed. (occasionally) blood cultures can be taken and IV antibiotics(cefotaxime) given for 3-5 days.

Extubation is usually possible after 24 hours.


With appropriate treatment, most children recover completely within 2-3days.

5-year-old girl severe sore throat, drooling of saliva, a high fever increasing difficulty breathing over 8 hours. Dx: EPIGLOTITIS Management: her airway was guaranteed with a nasotracheal tube. Antibiotics were started immediately. She made a full recovery.

Infants and toddlers


Usually nuts , candy, toy parts etc May cause complete airway obstruction

Complete obstruction rapidly asphyxiates the child unless promptly relieved with the Heimlich maneuver. They lodge between the vocal cords in the sagittal plane, causing symptoms of croup, hoarseness, cough, stridor, and dyspnea.

Choking and aspiration in 90% of, stridor in 60%, and wheezing in 50%. Posteroanterior and lateral soft tissue neck radiographs (airway films) -abnormal in 92% of children
chest radiographs- abnormal in 58%.

Laryngoscopy is carried out promptly if there is history of eating nuts


Bronchoscopy is deferred only until the patient has been prepared by adequate hydration and emptyping of the stomach. Prompt endoscopic removal of FB with rigid instrucments. Usually removed the same day the diagnosis is first considered.

children <34 yr of age (m>F)


Can be due to penetrating trauma to the oropharynx, dental infection, and vertebral osteomyelitis

Common etiological agent: group A streptococcus , oropharyngeal anaerobic bacteria and Staphylococcus aureus.

Nonspecific: fever, irritability, decreased oral intake drooling. Neck stiffness and torticollis

(refusal to

move the neck.) sore throat Other signs: muffled voice, stridor, and respiratory distress.

Definitive Dx-Incision for drainage and culture of an abscessed node. CT scan


identify the presence of retropharyngeal abscess.
deep neck infections can be accurately identified

and localized.

Soft tissue neck films taken during inspiration with the neck extended : width or an airfluid level in the retropharyngeal space.

Intravenous antibiotics with or without surgical drainage. A 3rd-generation cephalosporin combined with ampicillin-sulbactam or clindamycin.

inspiratory stridor, but should have no evidence of significant expiratory obstruction. The stridor typically is loudest when the infant is crying,agitation and feeding. Viral infections may exacerbate laryngomalacia. Symptoms usually disappear by 18 to 24 months of age.

Establishing a definitive diagnosis is important for its appropriate management and to exclude other, more serious lesions.
Complete bronchoscopy provides information about the patency and collapse of the larynx and bronchi. diagnosis is confirmed by flexible laryngoscopy in the office work of breathing is moderate to severe - airway films and chest radiographs Dysphagia -contrast swallow study and esophagogram

observation
endoscopic supraglottoplasty can be used to avoid tracheotomy.

What should I do?


History? Immediate interventions?

DONT EXAMINE THE THROAT!!


ANXIETY

CONFIDENT, CALM & WELL ORGANISED


OBSERVE SIGNS FOR HYPOXIA or DETERIORATION NEBULISED EPINEPHINE URGENT TRACHEAL INTUBATION

1.
2. 3.

4.
5. 6.

7.

age of onset? Speed of onset of symptom? Progression of stridor? Effects on body position? Presents of expiratory components? Quality of voice? Other contributing medical condition ?

Croup
Mostly viral 6 mths- 6 yrs of age Harsh, loud stridor Coryza and mild fever, hoarse voice

Epiglottitis
Mostly aged 1-6 yrs Caused by HIB High fever, ill, toxic looking Painful throat, unable to swallow saliva which drools down the chin.

Inhaled foreign body


Choking on peanut/toy in mouth 1-2 yrs of age Sudden onset of cough/respiratory distress

R.Abscess
< 3-4 yrs of age Soft stridor Muffled voice with neck stiffness

Croup Onset Over days

Acute epiglottis Over hours No Absent/slight No Yes Toxic, very ill >38.5 Soft, whispering Muffled, reluctant to

FB inhalation Minutes No Paroxysm No No Anxious& depressed No Harsh Hoarse

R. abscess Hours to days No No Decrease oral intake Yes irritable Yes Soft Muffled, neck stiffness

Preceding coryza Yes Cough Able to drink Drolling saliva Appearance Fever ( c) Stridor Voice,cry Severe, barking Yes No Unwell <38.5 Harsh, rasping Hoarse

Practical Paediatric, 6th edition D.M Roberton Nelson Textbook of Paediatric 18th edition, Kliegman Behrman, Jenson Stanton. Illustrated Textbook of Paediatrics, 3rd Edition Tom Lissauer, Graham Clayden, Mosby Elsevier Paediatrics at a Glance, Lawrence Mall,Mary Rudolf, Malcolm Levene Paediatric protocols for Malaysian Hospitals 2nd edition Rudolph's Pediatrics 21st edition

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