1 / 24

Morning Report

Morning Report. 08/21/2009 Ali F. Ahrabi, MD. Stridor. Harsh, high-pitched, musical sound produced by turbulent airflow through a partially obstructed airway May be inspiratory, expiratory, or biphasic depending on its timing in the respiratory cycle

Download Presentation

Morning Report

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Morning Report 08/21/2009 Ali F. Ahrabi, MD

  2. Stridor • Harsh, high-pitched, musical sound produced by turbulent airflow through a partially obstructed airway • May be inspiratory, expiratory, or biphasic depending on its timing in the respiratory cycle • Inspiratory stridor suggests an extrathoracic lesion (eg, laryngeal, nasal, pharyngeal) • Expiratory stridor implies an intrathoracic lesion (eg, tracheal, bronchial)

  3. History

  4. History • Age of onset, duration, severity, and progression; precipitating events (eg, crying, feeding); positioning (eg, prone, supine, sitting); quality and nature of crying; presence of aphonia; and other associated symptoms (eg, paroxysms of cough, aspiration, difficulty feeding, drooling, sleep disordered breathing). • Perinatal history is especially important and should include direct questioning regarding maternal condylomata, endotracheal intubation use and duration, and presence of congenital anomalies • Feeding and growth history, developmental history

  5. Physical Exam

  6. PE • Heart and respiratory rates, cyanosis, use of accessory muscles of respiration, nasal flaring, level of consciousness, and responsiveness • Physical examination of a patient with suspected acute epiglottitis is contraindicated • Note the presence of infection in the oral cavity; crepitations or masses in the soft tissues of the face, neck, or chest; and deviation of the trachea • Use care when examining (especially palpating) the oral cavity or pharynx because sudden dislodgement of a foreign body or rupture of an abscess can cause further airway compromise

  7. PE • Drooling from the mouth suggests poor handling of secretions, Dysphagia • Observe the character of the cough, cry, and voice • The presence of fever and toxicity generally implies serious bacterial infections • Careful auscultation of the nose, oropharynx, neck, and chest helps to discern the location of the stridor • special attention to craniofacial morphology, patency of the nares, and cutaneous hemangiomas

  8. Differential Diagnosis

  9. Differential – Acute onset • Laryngotracheobronchitis (croup) • the most common cause of acute stridor in children • 6 months to 2 years • barking cough that is worst at night • low-grade fever • Aspiration of foreign body • 1-2 years • food such as nuts, hot dogs, popcorn, and hard candy • history of coughing and choking that precedes development of respiratory symptoms • Bacterial tracheitis • uncommon • younger than 3 years • secondary infection (most commonly due to Staphylococcus aureus) following a viral process (commonly croup or influenza)

  10. Differential – Acute onset • Retropharyngeal abscess • complication of bacterial pharyngitis • younger than 6 years • abrupt onset of high fevers, difficulty swallowing, refusal to feed, sore throat, hyperextension of the neck, and respiratory distress • Peritonsillar abscess • infection in the potential space between the superior constrictor muscles and the tonsil • common in adolescents and preadolescents. • patient develops severe throat pain and trouble swallowing or speaking

  11. Differential – Acute onset • Spasmodic croup (acute spasmodic laryngitis) • most commonly in children aged 1-3 years • presentation may be identical to croup • Allergic reaction (ie, anaphylaxis) • hoarseness and inspiratory stridor may be accompanied by symptoms (eg, dysphagia, nasal congestion, itching eyes, sneezing, wheezing) that indicate the involvement of other organs • Epiglottitis • medical emergency • most commonly in children aged 2-7 years • Clinically, the patient experiences an abrupt onset of high-grade fever, sore throat, dysphagia, and drooling

  12. Differential - Chronic • Laryngomalacia • the most common cause of inspiratory stridor in the neonatal period and early infancy • accounts for up to 75% of all cases of stridor • Stridor may be exacerbated by crying or feeding • Placing the patient in a prone position with the head up improves the stridor • supine position worsens the stridor • usually benign and self-limiting and improves as the child reaches age 1 year

  13. Differential - Chronic • Subglottic stenosis • inspiratory or biphasic stridor • congenital subglottic stenosis occurs when an incomplete canalization of the subglottis and cricoid rings causes a narrowing of the subglottic lumen. • acquired stenosis is most commonly caused by prolonged intubation • Vocal cord dysfunction • second most common cause of stridor in infants • unilateral vocal cord paralysis can be congenital or secondary to trauma at birth or time of cardiac or intrathoracic surgery • bilateral vocal cord paralysis • Pt present with aphonia and a high-pitched stridor that may progress to severe respiratory distress. • It is usually associated with CNS abnormalities, such as Arnold-Chiari malformation or increased intracranial pressure

  14. Differential - Chronic • Laryngeal dyskinesia, exercise-induced laryngomalacia, and paradoxical vocal fold motion are other neuromuscular disorders • Laryngeal webs are caused by an incomplete recanalization of the laryngeal lumen during embryogenesis • Laryngeal cysts • Laryngeal hemangiomas (glottic or subglottic) • half of them are accompanied by cutaneous hemangiomas in the head and neck • Patients usually present with inspiratory or biphasic stridor that may worsen as the hemangioma enlarges • usually regress by age 12-18 months

  15. Differential - Chronic • Laryngeal papillomas • secondary to vertical transmission of the human papilloma virus in maternal condylomata or infected vaginal cells to the pharynx or larynx of the infant during the birth • Tracheomalacia • most common cause of expiratory stridor • Tracheal stenosis secondary to extrinsic compression

  16. Lab • ABG to evaluate oxygenation • Other labs as dictated by the clinical situation • Generally, no investigations are required for mild stridor

  17. Imaging • Anteroposterior (AP) and lateral radiographs of the neck and chest • Barium esophagram may be performed if vascular compression, tracheoesophageal fistula, GER, or neurological dysfunction is suspected • Contrast-enhanced CT scanning can demonstrate mediastinal masses or aberrant vessels • An MRI may be helpful in delineating lesions of the upper airway and vascular anomalies • Direct laryngoscopy and bronchoscopy is the criterion standard for making a diagnosis in infants and children with stridor

  18. Treatment • As per severity of the presentation and underlying diagnosis • Ensure airway is adequate • O2 as required • Comfortable positioning • If airway compromised or child in severe distress or hypoxia: Anesthesia/ENT and intensive care

  19. Treatment • Croup (infectious or spasmodic)

  20. Inspiratory stridor None - 0 points Upon agitation - 1 point At rest - 2 points Retractions Mild - 1 point Moderate - 2 points Severe - 3 points Air entry Normal - 0 points Mild decrease - 1 point Marked decrease - 2 points Cyanosis None - 0 points Upon agitation - 4 points At rest - 5 points Level of consciousness Normal - 0 points Depressed - 5 points Croup Severity

  21. Croup Treatment • The first rule of management is to keep the child as comfortable as possible • monitoring of the heart rate, respiratory rate, respiratory mechanics, and pulse oxymetry • Cool mist  • Randomized studies of children with moderate-to-severe croup revealed no difference in outcome between those who received cool mist and those who did not • The use of hot steam should be avoided because scalding has been reported • Mist tents can disperse fungus and molds if not properly cleaned and separates the child from the parent

  22. Croup Treatment • Corticosteroids (decrease hospitalization rates by 86%) • single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup if administered within the first 4-24 hours after onset of illness • The long half-life of dexamethasone (54 h)  • Dexamethasone (0.15 mg/kg) is as effective as 0.3 mg/kg or 0.6 mg/kg in relieving symptoms of mild-to-moderate croup • same efficacy if administered intravenously, intramuscularly, or orally. • A single oral dose of prednisolone (2 mg/kg) resulted in more return visits than a single oral dose of dexamethasone (0.6 mg/kg) • Inhaled budesonide has also proven to be effective but is more expensive

  23. Croup Treatment • Nebulized racemic epinephrine • is typically reserved for patients in moderate-to-severe distress • works by adrenergic stimulation • constriction of the precapillary arterioles, thereby decreasing capillary hydrostatic pressure fluid resorption from the interstitium and improvement in the laryngeal mucosal edema • beta-2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation • Can cause rebound effect • A child who is symptomatic enough to receive epinephrine may be discharged after at least 3 hours of observation

  24. Croup Treatment • Heliox • is a metabolically inert, nontoxic gas that is combined with oxygen.  • It has low viscosity and low specific gravity, which allows for greater laminar airflow through the respiratory tract • Helium decreases the force necessary to move the gas through the airways and decreases the mechanical work of respiratory muscles, which is clinically seen as less respiratory distress  • It has been shown to improve symptoms in very severe croup that failed to improve with racemic epinephrine

More Related