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Child with stridor


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Child with stridor

  1. 1. Stridor from the mouth Stridor from the neck Stridor is a high pitched, harsh, vibratory noise caused by partial upper airway obstruction & mainly inspiratory.
  2. 2. Is the musical soundIs the musical sound occurring mainly duringoccurring mainly during expiratory phase andexpiratory phase and indicates lower airwayindicates lower airway obstruction.obstruction. Wheeze:Wheeze:
  3. 3. Causes of the stridor: 1- Causes of acute stridor: Require an urgent evaluation and treatment. 2- Causes of chronic stridor: Most often caused by anatomic defects. Divided to supraglottic, glottic and subglottic. Can be divided to:
  4. 4. 1- causes of Acute stridor1- causes of Acute stridor “acquired”:“acquired”: The most common are:  laryngotracheobronchitis (Croup): is the number one cause of acute stridor.  Inhaled foreign body.  Bacterial tracheitis.  Acute epiglottitis.
  5. 5. Other causes of acute stridor:  metabolic hypocalcaemia.metabolic hypocalcaemia.  Tonsillitis.Tonsillitis.  Allergic edema “angioneurotic”Allergic edema “angioneurotic”  Diphtheria.Diphtheria.  Retro pharyngeal abscess.Retro pharyngeal abscess.  Lymphadenopathy.Lymphadenopathy.  Hot fumes.Hot fumes.
  6. 6. 1- Causes of chronic stridor: » Supraglottic causes: • Laryngomalacia*: (most common) • Cysts: aryepiglottic cyst & dermoid cyst. • Lingual thyroid. • Micrognathia. • Macroglossia.
  7. 7. 1- Causes of chronic stridor: •Laryngeal web* • Vascular ring*. • Haemangioma and lymphangioma. • Bilateral vocal cord paralysis (BVCP). • Polyps & papilloma. • Congenital subglottic stenosis. • Traumatic: post-intubation or after surgery. • Neoplastic: thyroid carcinoma, mediastinal tumor. » Glottic and subglottic causes:
  8. 8. Laryngotracheobronchitis or viralLaryngotracheobronchitis or viral croup: an infection of both thecroup: an infection of both the upper and lower respiratory tracts.upper and lower respiratory tracts. Cause:Cause: Parainfluenza virus type I.Parainfluenza virus type I. Sex:Sex: male-to-female ratio is 2:1.male-to-female ratio is 2:1. Age:Age: 6 months to 3 years. The6 months to 3 years. The mean age is 18 months.mean age is 18 months.
  9. 9. • Mild URTI with coryza,Mild URTI with coryza, • Nasal congestion,Nasal congestion, • Sore throat,Sore throat, • Insidious onset of fever (38-39°C).Insidious onset of fever (38-39°C). Hoarse voice and harsh, brassy, barklikeHoarse voice and harsh, brassy, barklike cough follow.cough follow. • Inspiratory stridor usually develops atInspiratory stridor usually develops at nightnight
  10. 10. Signs of RD.Signs of RD. Air entry may be poor.Air entry may be poor. Lethargy or agitation may be aLethargy or agitation may be a result of hypoxemia.result of hypoxemia. Tachypnea, tachycardia, pallor, andTachypnea, tachycardia, pallor, and hypotonia. Dehydration.hypotonia. Dehydration. Cyanosis is a late ominous sign.Cyanosis is a late ominous sign.
  11. 11. CBC: lymphocytosis and leukopeniaCBC: lymphocytosis and leukopenia Transcutaneous oximetry:Transcutaneous oximetry: ABGs: unnecessary unless sever.ABGs: unnecessary unless sever. Direct laryngoscopy: “not routinely”Direct laryngoscopy: “not routinely” if suspected bacterial infection.if suspected bacterial infection. Viral and bacterial cultures: if atypicalViral and bacterial cultures: if atypical presentations.presentations. Neck x-ray: steeple sign on AP viewNeck x-ray: steeple sign on AP view in 50-60% of 50-60% of cases.
  12. 12. Treatment may include:Treatment may include: Humidification: “hHumidification: “humidifiedumidified oxygen” increased humidityoxygen” increased humidity decreases the viscosity of thedecreases the viscosity of the secretions and facilitates clearance.secretions and facilitates clearance. Vasoconstrictors: “eVasoconstrictors: “epinephrine”pinephrine” To relieve edema & relax theTo relieve edema & relax the bronchial smooth muscles.bronchial smooth muscles.
  13. 13. Glucocorticoids:Glucocorticoids: ““Dexamethsone,Dexamethsone, PrednisonePrednisone” to” to decrease airway inflammationdecrease airway inflammation Intravenous fluid to correctIntravenous fluid to correct dehydrationdehydration
  14. 14. Sever airway obstruction.Sever airway obstruction. Pneumothorax andPneumothorax and pneumomediastinum.pneumomediastinum. Bacterial superinfectionBacterial superinfection Otitis media.Otitis media. Dehydration.Dehydration.
  15. 15. is an acute inflammation of the epiglottis with inflammation in the supraglottic region Sex: M:F ratio is about 3:1. Age: 3-7 years, although any age may be affected.
  16. 16. Cause: H. influenzae type B. Streptococcus pneumoniae, Staphylococcus aureus, and group A beta- hemolytic streptococci were occasionally found. Since the introduction of the HIB vaccine in the late 1980s, the overall incidence of epiglottitis in children has declined, and HIB is less commonly the cause.
  17. 17. Rapid onset and progression of symptoms. Sore throat (95%). Odynophagia/dysphagia (95%). Muffled voice (54%). Usually no prodromal (URTI).
  18. 18. Cervical adenopathy Respiratory distress Very tender larynx Toxic appearance. Tripod position Fever Drooling Stridor “late” Hypoxia Mild cough Irritability
  19. 19. Secure airways first. Don’t use the tongue depressor. lateral view x-ray of the neck is confirmatory & should be performed in the E.R. “The thumb sign”
  20. 20. The normal epiglottis in the image on the right is contrasted with the markedly thickened one on the left. A column of air can still be seen though the epiglottis is swollen.
  21. 21. Soft-tissue lateral neck x-ray reveals edema of epiglottis consistent with acute epiglottitis
  22. 22. A. Airway Management 1. immediate endotracheal intubation. based on clinical grounds. “extreme agitation and pronounced stridor with R.D. are indications for intubation. 2. If the child is cyanotic, bradycardic or sustains respiratory arrest, the child should be intubated immediately with the help of anesthetist.
  23. 23. B. Antibiotic Therapy: 1. 3rd generation cephalosporins are the antibiotics of choice for acute epiglottitis b/c of the high prevalence of ampicillin-resistant strains of Hib (1/3 of all Hib isolates). - Ceftriaxone -Cefuroxime -Cefotaxime
  24. 24. 2. Cephalosporins should be avoided in patients with a history of an allergic reaction to penicillin because of the 10% cross hypersensitivity between penicillin and cephalosporins. Chloramphenicol is an appropriate alternative in penicillin allergic patients.
  25. 25. C. On the ICU mildly sedation with midazolam. Humidification can be maintained by blow-by mist and oxygen. D. Intubation should be maintained for one to three days. The patient is extubated after the presence of a leak around the endotracheal tube is apparent. Dexamethasone is given after extubation to prevent the edema.
  26. 26. Pulmonary edema Epiglottic abscess Pneumonia Meningitis Cervical adenitis Septic arthritis Pericarditis Cellulitis Septic shock Vocal Granuloma Pneumothorax Pneumo- mediastinum (rare) Death (asphyxia) N.B.: close contacts should be treated with rifampin as prophylaxis
  27. 27. Prognosis: Most patients can be extubated within 1-2 days. Good prognosis with appropriate treatment
  28. 28. B. T. is diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. Sex: M:F ratio = 2:1 Age: 3weeks & up with mean age of 4y. Causes: »Staphylococcus aureus. »H. influenzae type B. »Streptococcus pyogenes.
  29. 29. Prodrome of URTI. Progression to higher fever. Cough. Inspiratory stridor.
  30. 30. ①Inspiratory stridor ②Barklike or brassy cough ③Hoarseness ④Variable degrees of R.D.: Nasal flaring, Retractions, Dyspnea, Cyanosis ⑤Sore throat. ⑥Odynophagia. ⑦Dysphonia.
  31. 31. Tracheal secretions & blood for culture. X-ray lateral view of the neck May reveal subglottic narrowing Laryngotracheobronchoscopy: Only definitive means of diagnosis May be therapeutic by performing tracheal toilet and stripping purulent membranes
  32. 32. Antibiotics is the main treatment of B. T. Bronchopneumonia. Exacerbation of COPD & may lead to respiratory failure. The main complications are:
  33. 33. The most common age group affected is b/w 6m & 5y. most commonly are lodged in the right main stem and lower lobe. Aspiration has been documented in all lobes including the upper lobes, though with less frequency.
  34. 34. Cough.Cough. Stridor.Stridor. Dyspnea.Dyspnea. Wheezing.Wheezing. Dysphagia.Dysphagia. Sudden choking after eatingSudden choking after eating
  35. 35. Inspiratory stridor or expiratory wheezing, with prolongation of the expiratory phase and medium-to-coarse rhonchi. Signs of R.D.
  36. 36. PA & lateral CXR are mandatory. Laryngoscopy if doubt diagnosis and to remove the foreign body.
  37. 37. Tooth (molar) was dislodged during intubation a lobar pneumonia from the tooth Aspirated foreign body lodged in the right main stem bronchus
  38. 38. ABC management. Laryngoscope. Dexamethasone after laryngoscopy.
  39. 39. laryngeal web is a congenital disorder due to partial canalisation of the epithelial lamina between the vestibulotracheal canal above, and the pharyngotracheal canal below. 75% are sited in the glottis, the remaining 25% in the supra- or sub-glottis.
  40. 40. Most are situated anteriorly, involving a variable length of the vocal cord. They are often thick and fibrotic, and may cause severe stridor and airway obstruction. Small laryngeal webs rarely require treatment. Larger, symptomatic ones may be removed by an endoscopic laser or knife.
  41. 41. Laryngomalacia is a congenital abnormality of the laryngeal cartilage. It is the most common cause of chronic inspiratory stridor in infants. It has a male-to-female ratio of approximately 2:1.
  42. 42. It is due to an intrinsic defect or delayed maturation of supporting structures of the larynx. The airway is partially obstructed during inspiration by the prolapse of the flaccid epiglottis, arytenoids and aryepiglottic folds. The inspiratory stridor is usually worse when the child is in a supine position, when crying or agitated, or when an upper respiratory tract infection occurs.
  43. 43. The classic history and endoscopic examination usually suffice to establish a diagnosis of laryngomalacia.
  44. 44. Most cases of laryngomalacia can be managed by observation, Surgical management is indicated in rare instances if respiratory complications develop.
  45. 45. Laryngomalacia generally is a self- resolving condition & have a good prognosis. Complications in rare cases include chest deformities, cyanotic attacks, obstructive apnea, pulmonary hypertension, right heart failure, and failure to thrive.
  46. 46. Tracheal compression may result from vascular anomalies such as double aortic arch, right aortic arch with left ligamentum arteriosum, anomalous innominate artery, anomalous left common carotid artery, anomalous left pulmonary artery or aberrant subclavian artery.
  47. 47. The child may prefer to keep the neck hyperextended. The stridor resulting from tracheal compression is often aggravated by feeding. The trachea may also be compressed by a mediastinal cyst, teratoma, lymphoma or lymphadenopathy.
  48. 48. Echo. Or Doppler U.S. Barium swallow. MRI also can be used in the diagnosis
  49. 49. 1- Causes of chronic stridor:
  50. 50. 1.Symptom complex, duration, acuity. 2.The age & the birth history. 3.History of URTI. 4.History of airway instrumentation (previous intubation) 5.Vaccination history ( H. influenza) 6.Foreign body- abrupt onset 7.Mother has history of HPV infection Key points for history taKing:
  51. 51. 1.Inspiratory vs. expiratory vs. biphasic stridor. 2.Fever. 3.Drooling or hyperextension of neck and unusual sitting position, change of symptoms with positioning. 4.Weak or muffled cry. 5.Prolonged inspiratory/expiratory phase. Key points in physical exam.:
  52. 52. 6.Presence of cyanosis. 7.Degree of distress. 8.Facial deformities. 9.Presence of Haemangioma elsewhere. 10.Neck masses. Key points in physical exam.:
  53. 53. Key points in physical exam. in child with stridor: A newborn infant with Pierre-Robin syndrome. Note the micrognathia.
  54. 54. Key points in physical exam. in child with stridor: A two-year-old child with a cystic hygroma on the left side of the neck.
  55. 55. 1.AP and endolateral radiographs of the neck can assess adenoidal size, epiglottis, and trachea. 2.AP and lateral CXR to look for foreign body or pulmonary disease. 3.Airway fluoroscopy. 4.If stridor is persistent, direct exam of airway via flexible bronchoscope to look at area below cords. 5.A.B.G. or pulse oximetry to assess hypoxia. Diagnostic studies:
  56. 56. Diagnostic studies: Severe laryngomalacia: The epiglottis is rolled in from side to side, and the arytenoid mucosa is pulled into the larynx during inspiration.