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Seminar 2 - Acute stridor, causes, features and management
- 1. 1. Describe thecauses and pathogenesis of acute stridor. 2. Describe the common causal organisms of ALTB- Croups & Epiglottitis
- 2. What is Acutestridor? - harsh, high-pitch sound produced when the airway becomes partially obstructed,which can result in turbulent airflow - Present in both inspiration & expiration but more prominent during inhalation - It is a sign of children having underlying pathological problem - Commonly seen in infants (age <1 yr) and young children - Aetiology differ depending whether patient is child or adult
- 3. Types of stridor& Pathophysiology 1. Inspiratory stridor = Extrathoracic obstruction - any obstruction which occurs above the vocal cord 2. Expiratory stridor = Intrathoracic obstruction - any obstruction which occurs below the vocal cord ❏ Depending on the anatomic location involved and also what type of pathological cause involved - extrathoracic region = nose, larynx & trachea - intrathoracic region = distal trachea & bronchi ❏ Concerning part = Subglottic area - lower part of the larynx (below the vocal cord) - cause narrowing result in minimal airway flow
- 4. Causes of stridor Congenitalcauses - Nasal deformities E.g. choanal atresia, septum deformities - Laryngeal anomalies E.g. laryngomalacia, laryngeal webs, laryngeal cysts - Craniofacial anomalies E.g. Pierre Robin or Apert syndromes Acquired causes - Croup (Laryngotracheobronchitis) - Epiglottitis - Foreign body inhalation - Diphtheria - Adenoid hypertrophy - Tonsil hypertrophy - Pierre Robin Syndrome / Macroglossia - Anaphylaxis
- 5. Pierre Robin syndrome Choanalatresia Septum deformities Airway burns Croup Tonsil hypertrophy
- 6. What is diphtheria? ❏Serious bacterial infection that affects the mucous membrane of nose & throat ❏ Very rare due to widespread vaccine (DTaP and Tdap) ❏ Causal organism: Corynebacterium diphtheriae ❏ MOT : 1) Airborne droplets 2) Contaminated items ❏ Common symptoms are: - sore throat - stridor - difficulty breathing or rapid breathing - nasal discharge
- 7. ❏ People whoare risk: - childrens & adults who don’t have up-to-date vaccinations - people who lives in unsanitary area - past history of travelling to diphtheria infections areas ❏ What are the complications experience? - breathing problems (produces a toxin) - heart damage (toxin can spread) - nerve damage
- 8. Foreign body inhalation ❏Things which are not suppose to enter into the trachea or the larynx ❏ Potentially life-threatening ❏ Very common in young children (<4 years old) ❏ Most inhaled foreign bodies will be located in the bronchi ❏ E.g. nuts, popcorn, coins, pieces of toys
- 10. Croup (Laryngotracheobronchitis) ❏ Self-limitingupper airway viral infection ❏ Results in inflammation of the larynx and trachea leads to obstruction of airway (edema of the subglottic area) ❏ Result in severe narrowing of the airway (trachea) ❏ Common in children = 6 months - 3 years old ❏ Boys > Girls ❏ Common cause = virus (95%) - Parainfluenza virus 1 & 2 - Respiratory syncytial virus (RSV) - Human metapneumovirus - Influenza virus
- 12. Bacterial tracheitis (pseudomembranouscroup) ❏ Rare but dangerous condition ❏ Similar to viral croup but slight difference in the symptoms - rapid progressive airway obstruction (thick secretion) ❏ Common cause: Staphylococcus aureus ❏ Can be treated with intravenous antibiotics or intubation if necessary
- 13. Epiglottitis - Inflammation &swelling of the epiglottis - life - threatening condition because blocks the flow of the air - Common in children aged 1-6 years - Causes: 1) Group A Streptococcus 2) Haemophilus influenzae type B (Hib) 3) Trauma from foreign objects 4) Chemical burns - Surrounding area will also be affected
- 14. Why common inchild than adults? - Epiglottitis
- 15. Describe the clinicalfeatures of ALTB- Croups & Epiglottitis Describe the relevant investigations and findings of ALTB & Epiglottitis
- 16. Clinical Features Acute Laryngotracheobrontis(ALTB) / Croup Viral croup accounts for over 95% of laryngotracheal infections - Low grade fever and coryza (12-72 hours) - Barking cough and hoarseness - Stridor (when excited/ at rest/ both) - Varying degree of respiratory distress with chest retraction
- 17. Clinical Features Epiglottitis Life threateningemergency due to high risk of respiratory obstruction - Onset is usually very acute - High fever - Intensely painful throat → can’t speak or swallow (drooling saliva) - Soft inspiratory stridor - Rapidly increasing respiratory difficulty - Child is sitting upright with an open mouth
- 19. Investigations and Findings AcuteLaryngotracheobrontis (ALTB) / Croup ➢ Clinical Diagnosis ➢ Usually no investigations needed as it may cause distress to child and worsen the symptoms ➢ Chest and neck x-ray can be done for assisting in diagnosis ○ Steeple sign ○ Distension of hypopharynx
- 20. Investigations and Findings Steeplesign - Narrowing of subglottic airway Distended hypopharynx - due to the patient's attempt at decreasing airway resistance
- 21. Investigations and Findings AcuteLaryngotracheobrontis (ALTB) / Croup
- 22. Investigations and Findings Epiglottitis ➢Primarily clinical diagnosis ○ Ensure patient is able to breathe! ○ Avoid invasive procedures ➢ Tests to be done only when patient is stable and airway is secured ○ Blood culture ○ Lateral neck X-ray (only in some cases) ■ Thumb sign
- 23. Investigations and Findings Lateralx-ray of the neck with an arrow pointing to the enlarged epiglottis
- 24. Describe the complicationsof ALTB & Epiglottitis. Describe the principle of management of ALTB & Epiglottitis
- 25. Complications Acute Laryngotracheobrontis(ALTB) Complications are rare but can occur in some cases. They include: ● Secondary bacterial infection ● Pneumothorax ● Otitis media ● Dehydration ● Lymphadenitis
- 26. Complications of Epiglottitis. Complicationsof epiglottitis include the following: ● Cellulitis ● Cervical adenitis ● Empyema ● Epiglottic abscess ● Meningitis ● Pneumonia ● Pulmonary edema ● Respiratory failure ● Septic shock ● Hypoxia ● Prolonged ventilation ● Tracheostomy
- 27. Basic management ofacute upper airways obstruction • Do not examine the throat! • Reduce anxiety by being calm, confident and well organised. • Observe carefully for signs of hypoxia or deterioration. • If severe, administer nebulised epinephrine (adrenaline) and contact an anaesthetist. • If respiratory failure develops from increasing airways obstruction, exhaustion or secretions blocking the airway, urgent tracheal intubation is required.
- 29. Management of Acute Laryngotracheobronchitis (ALTB) ●Treatment depends on the severity based on the Westley croup score. ● mild croup (Westley croup score <2) ● moderate to severe croup (Westley croup score >3) Management of Acute Laryngotracheobronchitis (ALTB) ● Treatment depends on the severity based on the Westley croup score. ● mild croup (Westley croup score <2) ● moderate to severe croup (Westley croup score >3)
- 31. Management of Epiglottitis Oncethe patient is admitted, the following care is necessary: ● Do not agitate the patient ● Administer humidified oxygen ● Allow the patient to choose the position which is most comfortable ● Avoid the use of inhalers and sedatives ● Be prepared for a sudden worsening of the clinical condition ● Always have a tracheostomy cut down set at the bedside ● With appropriate treatment, most patients improve within 48-72 hours but antibiotics are still required for 7 days. Only afebrile patients should be discharged home.
- 32. Management of Epiglottitis ●Epiglottitis is a medical emergency and need immediate treatment with an artificial airway placed under controlled conditions, either in an operating room or intensive care unit. ● All patients should receive oxygen en route unless the mask causes excessive agitation. ● Cultures of blood, epiglottic surface, and, in selected cases, cerebrospinal fluid should be collected after the airway is stabilized. ● Ceftriaxone, cefotaxime, or meropenem should be given parenterally, ● After insertion of the artificial airway, the patient should improve immediately, and respiratory distress and cyanosis should disappear. ● Epiglottitis resolves after a few days of antibiotics, and the patient may be extubated; antibiotics should be continued for 7-10 days.
- 33. Reference ● Lissauer, T.(2017). Illustrated textbook of paediatrics (5th ed.). Elsevier Science. ● Nelson textbook of pediatrics (2016) - ELSEVIER - Philadelphia, PA ● https://www.ncbi.nlm.nih.gov/books/NBK431070/#:~:text=Laryngotracheitis%2C%20laryngotracheo bronchitis%2C%20and%20laryngotracheobronchopneumonitis%20are,edema%2C%20and%20rare ly%2C%20death. ● https://www.ncbi.nlm.nih.gov/books/NBK430960/#:~:text=Complications%20of%20epiglottitis%20in clude%20the,Death ● https://www.grepmed.com/images/5127/peds-diagnosis-score-severity-pediatrics ● Hussain, I., Ng, PH., & Thomas, T. (eds). (2012). Paediatric Protocols for Malaysian Hospitals. 3rd Edition, Kementerian Kesihatan Malaysia. ● https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/ ● https://www.urmc.rochester.edu/encyclopedia/content.aspx? contenttypeid=90&contentid=P02944#:~:text=What%20is%20epiglottitis%20in%20children,and %20inflamed%2C%20it's%20called%20epiglottitis.
- 34. Reference cont. ● https://academic.oup.com/bjaed/article/7/6/183/508301 ●https://www.ncbi.nlm.nih.gov/books/NBK525995/#:~:text=The%20cause%20of%20stridor%20can,o n%20congenital%20versus%20noncongenital%20causes.&text=Acute%3A%20Foreign%20body% 20aspiration%2C%20airway,%3A%20Peritonsillar%20abscess%2C%20retropharyngeal%20absces s ● https://www.youtube.com/watch?v=t3DLxpD3neg ● https://www.youtube.com/watch?v=8TBKMn0I9Tk ● https://www.youtube.com/watch?v=EAWjRXNBudY ● https://www.rch.org.au/clinicalguide/guideline_index/Foreign_bodies_inhaled/ ● https://radiopaedia.org/articles/croup ● https://radiopaedia.org/articles/epiglottitis
Editor's Notes
- #2 OSCE: stridor on mannequin
- #3 Subglottic area = lower part of the larynx / area below the vocal cord and above the trachea Inspiratory stridor = During inspiration, the intratracheal pressure falls below the atmospheric pressure, causing a collapse of the airway Expiratory stridor = During expiration, the increased pleural pressure compresses the airway causing a decrease in the airway size at the site of the intrathoracic obstruction
- #4 congenital narrowing of the back of the nasal cavity that causes difficulty breathing = Choanal atresia congenital softening of the tissues of the larynx (voice box) above the vocal cords = laryngomalacia rare congenital birth defect characterized by an underdeveloped jaw, backward displacement of the tongue and upper airway obstruction = Pierre Robin syndrome
- #5 Pierre Robine syndrome or Macroglossia
- #6 non - spore forming gram positive bacili This toxin damages tissue in the area of infection (nose & throat). Those infection site produces tough, gray membrane made up of dead cells.Thus this can obstruct breathing
- #7 This toxin damages tissue in the area of infection (nose & throat). Those infection site produces tough, gray membrane made up of dead cells.Thus this can obstruct breathing Spread through bloodstream and damage other tissues. E.g. heart muscle which can lead to inflammation of the heart muscle or myocarditis Damage nerve especially in the throat area, thus poor nerve conduction can cause difficulty in swallowing. Also causes muscle weakness of the upper and lower extremities
- #8 As aspirated solid or semisolid object may lodge in the larynx or trachea If object is large enough, it can cause complete obstruction
- #9 The right main bronchus has a predilection for foreign body impaction because it is wider than the left and the right main bronchus has more direct extension of the trachea than the left main bronchus
- #13 Found base of the tongue and above the larynx (small cartilage lid) Made of fibroelastic cartilage It works as a protective mechanism closing the pathway into the lungs to avoid food, liquid or foreign objects from entering in the lungs
- #14 In children, Epiglottis located anteriorly and more superiorly than adults Oesophagus is floppy while in adults it is rigid This anatomical conditions are the reasons why epiglottis is more serious in children than in adults
- #16 Croup typically occurs from 6 months to 6 years of age but the peak incidence is in the 2nd year of life. Coryza → catarrhal inflammation of the mucous membrane in the nose, caused especially by a cold or by hay fever.
- #17 an intensely painful throat that prevents the child from speaking or swallowing; saliva drools down the chin
- #19 No investigations are needed in croup (including nasopharyngeal aspirate, X-rays and blood tests) and they may cause distress to the child and worsening of symptoms Visual examination of the throat may reveal redness in the upper airway and/or epiglottis Cxr - xcluding other potential causes of similar symptoms such as foreign body aspiration. X-rays of affected pediatric patients with croup often show a tapering or narrowing of the airway below the vocal cords. This pattern is known as the steeple sign because its inverted V shape is reminiscent of a church steeple.
- #20 Chest X ray AP / lateral, including neck
- #21 In severe croup, it is advisable to examine the pharynx under controlled conditions, i.e. in the ICU or Operation Theatre *Loudness of stridor is not a good indicator of severity of obstruction. Soft stridor in the presence of worsening clinical picture may be a sign of imminent airway obstruction
- #22 Attempts to lie the child down or examine the throat with a spatula or perform a lateral neck X-ray to identify a swollen epiglottis and surrounding tissues must not be undertaken as they can precipitate total airway obstruction and death. No action should be taken that could stimulate a child with suspected epiglottitis, including examination of the oral cavity, starting intravenous lines, blood draws, or even separation from a parent Diagnosis is made on clinical grounds and laboratory or other interventions should not preclude or delay timely control of the airway if epiglottitis is suspected.
- #25 Pneumothorax- abnormal collection of air in the pleural space Otitis media is inflammation or infection located in the middle ear.
- #26 Cellulitis is a common, potentially serious bacterial skin infection. Empyema is a collection of pus in the pleural space. A hole that surgeons make through the front of the neck and into the windpipe (trachea).A tracheostomy tube is placed into the hole to keep it open for breathing.