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Stridor In Vocal Cord Palsy
- 1. EN Joanna Abellera EN Jade Ann Pen
- 2. MADAM YCL A case of 72 years old Chinese, Female Uncommunicative, bed bound ADL Dependent On long term NGT Admitted to VF on 06.06.2016
- 4. CURRENT ISSUES 21.03.2017 0900HR - noisy breathing in respiratory distress, non-cyanotic drowsy, drooling of saliva No fever, nocough and no vomiting Parameters: BP-152/85mmHg PR-105/min RR-28/min T-36.6C Sp02 95-97% on room air Chest findings: wheezes vs stridor Management: Nebulization: Ventolin 1ml : NSS 2mls O2 inhalation at 2LPM via NP 1126HR - Transferred to KTPH A&E Still with noisy breathing
- 5. PAST MEDICAL HISTORY 2016 Vascular Dementia Parkinson's Disease Vitamin B 12 Deficiency Recurrent UTI Severe Oropharyngeal Dysphagia
- 6. DRUG HISTORY 1. Amlodipine 5 mg OM 2. Cyproheptadine 4 mg OM 3. Domperidone 10 mg TDS 4. Famotidine 20 mg TDS 5. Folic Acid 5mg OM 6. Senna 15 mg ON 7. Lactulose 10 mls BD 8. Paracetamol 1 gm BD 9. Madopar 62.5 mg TDS
- 7. SOCIAL HISTORY Resident is a Widow and has 2 sons X Main contact person
- 8. PHYSICAL EXAMINATION General Survey: Drowsy, in respiratory distress Bedbound, on NGT, Upper Limb contractures Vital Signs: BP-152/85mmHg PR-105/min RR-28/min T-36.6C Sp02 95-97% on room air Chest findings: Nasal flaring, use of accessory muscles, wheezes vs stridor
- 9. 1. Monitor vital signs 2. Initial management: Nebulization 3. Recognize stridor as a medical emergency 4. Refer immediately to A&E. NURSING INTERVENTIONS
- 10. Hospital Management Diagnosis: Bilateral Vocal Cord Palsy likely secondary to progressive vascular dementia and Parkinsonism Noted stridor and referred to ENT Dexamethasone given IV Augmentin given
- 11. What is Stridor?
- 12. STRIDOR A high-pitched breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is a physical sign which is caused by a narrowed or obstructed airway. It is a symptom, not a diagnosis or a disease, and the underlying cause must be determined.
- 14. ETIOLOGY Foreign bodies Infections Airway oedema due to allergic reactions Vocal Cord Palsy Neurological disorders like Parkinson’s Disease
- 15. VOCAL CORD PALSY Occurs when the nerve impulses to your voice box (larynx) are disrupted, this results in paralysis of the vocal cord muscles. Can affect your ability to speak and even breathe. Recurrent episodes of unexplained stridor is often with hoarseness, throat tightness, a choking sensation, and/or cough.
- 16. Wheezing vs Stridor Wheezing and stridor are symptoms of airflow obstruction caused by the vibration of the walls of pathologically narrow airways. Wheezing is a musical sound produced primarily during expiration by airways of any size. Stridor is a single pitch, inspiratory sound that is produced by large airways with severe narrowing; it may be caused by severe obstruction of any proximal airway
- 18. WHEEZING
- 19. STRIDOR (SOUND)
- 20. STRIDOR Stridor is a sign of impending airway obstruction and should be considered an emergency.
- 21. Signs and Symptom Drooling and agitation Tripod position which indicates respiratory distress Cyanosis or hypoxemia on pulse oximetry Decreased level of consciousness
- 22. Nursing Management Emergency management is essentially about maintenance of the airway. 1. Resident should be kept nil by mouth. 2. Prop resident in upright position. 3. If there are any signs of airway obstruction from suspected foreign body try a single sweep manoeuvre 4. Administer oxygen 5. To do suctioning if necessary. 6. Reassure the residents
- 23. Nursing Management Long term recurrent stridor for frail residents should: 1. Close clinical follow up especially with residents with neurological problems to follow disease progression. 2. Update the family of the residents’ current status 3. Explore end of life care in view of residents’ premorbid status.
- 24. Questions?
Editor's Notes
- Good afternoon everyone, I am EN Joanna and I am EN Jade of Villa Francis Nursing Home. We will be sharing to you stridor in vocal cord palsy, We chose this topic because as we all know stridor usually happens To children and it is not a common scenario in the elderly. We would also like to encourage the other nursing homes to share their experience If they had one. Presenting to you the case of Madam YCl
- Functional Status assessment done and all ADL dependent both pre morbid and current status
- At 9 am we noted there was a sudden noisy breathing , noted resident was in respiratory distress,non- cyanotic She was drowsy, noted there was drooling of saliva, no fever, no cough, no vomiting. The noisy breathing sounded like these. Initial vital signs was BP- 152/85, PR- 105bpm, RR 28 cpm. T 36.6, SpO2 95-97percent Chest findings: We heard both wheezing and stridor We managed her by giving nebulization 1:2 Ventolin and normal saline Given o2 inhalation at 2 LPM via nasal prong. But apparently, there was no improvement and still have noisy breathing. We decided to transfer to the hospital
- Dexamethasone is used to treat inflammatory conditions and breathing disoders. Is there any questions so far?? If there are no questions the next part of our presentation will be presented by my colleague.
- Any one of you has experience managing a resident who is having stridor? (If none) Yes. As what my colleague have said, Stridor is rare in the elderly, but once it happens. It is very fatal. The nurses in the nursing homes should not overlooked this breathing abnormalities. Their potential comorbidities will alert us to determine the most effective nursing management.
- The larynx that we often called the voice box, is one of the organs that helps us speak. The bronchial tree that consist of trachea, bronchi and further down is the alveolar ducts and alvioli. Narrowed or constricted airway. In the case that we reported, the underlying cause is vocal cord palsy due to parkinsons dse. What we do in VF is we are following the progression of the disease thru timely geriatrician review of her medications. As her acute stridor is responsive to madopar (a parkinsonism drug)
- Pathophysiology. Stridor partially obstructed segment of the extrathoracic upper airway. Involved areas include the pharynx, epiglottis, larynx, and the extrathoracic trachea. Thus the resident will manifest a stridor.
- What are the causes of Stridor: Infectiions like epiglottitis (onset of high fever, sore throat. drooling and often respiratory distress) Haemophilus Influenzae type B. Airway eodema due to severe allergic reaction (sudden onset after exposure to allergens sometimes accompanied by itching and wheezing) Vocal cord palsy and various neurodegenerative disorders like parkinsonism that our resident has since 2016.
- PHOTO: This is a normal voice box that when the vocal folds are apart one is moving air in and out of the lungs. When the vocal cords are together, they vibrate very quickly creating a voice. A paralyzed vocal cord is when one of the vocal cords does not move resulting in a gap bet the vocal cords. Thus a high pitch sound can be heard upon inspiration. That we call a stridor.
- The differentiation of wheezing and stridor is crucial in determining what appropriate nursing intervention is needed. Wheezing is a musical sound that produced during expiration and is audible thru a stethoscope. But in other instances for severe wheezing we can even hear it without stet. While Stridor is heard even without a stetoscope during inspiratory. Proximal Airway: Like
- I will let you listen to various breath sounds. And can you differentiate the dif breath sounds. Sit straight. Close your eyes. Be calm. Hear your breathing. Breath in Breath out. Breath in. Breath out. . . . . And what sound did you hear? If your breathing is spontaneous and it is the free and easy respiration when at rest. You have Normal Breath Sounds It is a passage of air into and out of your lungs.
- While this sound is a sign that a person may be having breathing problems. The sound of wheezing is most obvious when breathing out. What respiratory disease is common to have wheezing? ASTHMA Nursing intervention? Bronchodilator as prescribed.
- It is heard when breathing in. That impedes the flow of air through the lungs. Which is fatal. Life threatening
- That makes the stridor to be an emergency case. SEND TO A&E.
- These are the associated symptoms that we need to note for us to refer the resident for transfer. 1. Drooling is what we initially noted on MDM YCL. And eventually 2. She is in distress as per laboured breathing and tachypneic at 28BPM 3. She may not have the cyanosis. YET. Or desaturation. 4. But she already has dec level of consciousness as she is already noted as drowsy, not her usual state.
- I already called up the AMBULANCE. As a nurse inn the nursing home what should I do. First is to maintain airway by: Or a back tap if not contraindicated.
- Mutlidisciplinary team like our geriatrician, GPs, speech therapist, dietician and even the OTs and the PTs has a vital role to serve. As some strategies like medication titrations, simple infection management, Speech therapy and even exercise should be considered an option because it may be beneficial in relieving both the stridor and other underlying causes in preventing further respiratory failures We reported a case of Mdm YCL and is discharged from the hospital with a diagnosis of bilateral vocal cord palsy secondary to progression of vascular dementia and parkinsons dse. We are following the disease process by timely referral to GPs for simple infection management, geriatrician for medication titration and dietitian for her fluid regime. OT/PTs her rehab. We also explore end of life in view of Mdm YCL premorbid status. ACP is introduced We also explained to the family that stridor will be long term, may havr risk of apnea, oxygen and possibly death. WE in the nursing home is the first defense of assessing our residents,.We have to be knowledgeable of even the simple physical assessments,so that proper acknowledgment of the needs of our aging populations is attained and accurate management is being utilize. WE HOPE YOU HAVE LEARNED SOMETHING FROM OUR PRESENTATION. THIS IS VILLA FRANCIS. Thank you very much.
- Are there any questions? If don’t have we have some questions for you just to recap and to make sure you had understand our topic. Mdm YCL stridor is due to vocal cordpalsy secondary to parkinsonism. Wheezing is heard during expiration. While Stridor is a high pitch sound during inspiration YES, because it is a sign of impending obstruction of the airway which is fatal. Nursing management: Vocal cord palsy is a The most common cause of stridor in the elderly is abscess or swelling of the upper airway, tumors and paralysis and malfunction of the vocal cords.