A Stridulous Child

1. A Stridulous Child Mais Al-Hity Paediatrics April 2013

2. Aims • What is Stridor? • Common presentations • Rare presentations • Cases • Summary

3. Background • Stridor is an inspiratory noise usually associated with respiratory distress • Erratic air currents forcing their way through narrowed breathing passages • Obstruction usually in trachea or larynx • Play

4. Baby Gucci • 8 month old girl • Term baby, normal delivery • Previously fit and well • Abrupt onset of barking cough 2/7 • Stridor; worse at night • Few days hx of cold, snuffly nose • Temp measured by mum 37.9 • Feeding well, no other concerns

5. Common: Laryngotracheitis (Croup) • Play • 6 m - 5 yrs • Mild stridor • Assessment: ABC • Mild recession, chest clear • No other investigations • PAWS chart and Westley Croup Score

6. Westley Croup Score Score: 0 – 3 mild croup 4 – 7 moderate croup >7 severe croup

7. Management I • Minimal handling • Do not examine throat • Manage as per clinical presentation and Westley score • Antibiotics if secondary bacterial infection (bacterial tracheitis)

8. Humidified Oxygen(flow by) if hypoxic Oral dexamethasone(150 micrograms/kg); repeat in 12 hours if symptoms persist Nebulised budesonide (2mg) if not tolerating PO dexamethasone If child is this sick then Consultant anaesthetist and Consultant paediatrician should be present Nebulised adrenaline (400micrograms/kg i.e. 0.4ml/kg of 1 in 1000) with Oxygen Potential transfer to theatre Management II

9. Baby Gucci • Baby Gucci stayed overnight with mum • Improved with humidified oxygen and one dose oral dexamethasone • Fed well this morning • Mum wondering if she can go home?

10. Discharge criteria • No stridor at rest • Normal SATs • Normal colour • Normal conscious level • Able to tolerate oral fluids • 24 hour open access to ward; carers aware of what to look out for if no better (info sheet) • Further dose dexamethasone TTO can be given

11. Dolce and Gabbana • Term, identical twin babies • Now aged 4 • Mum in the kitchen • Playing with lego… • Mum heard loud coughing • Sudden onset breathing difficulty and stridor • Rang 999

12. Uncommon: Foreign body • History of playing with small objects – strongly suggestive history • Airway compromise • Needle cricothyroidotomy can be life saving when there is complete upper airway obstruction

13. Rare: Bacterial tracheitis • Can complicate croup/ occur independently • Usually in older children • Staphlococcus aureus, streptococci or Haemophilus influenzae (check imms) • Appear toxic; high grade fever; history of deterioration • require intubation and intravenous antibiotics • Call Consultant Paediatrician immediately if suspected

14. Baby Armani • Rushed to A&E by dad who gives hx: • Sat in his baby chair; sudden onset respiratory difficulty • Started drooling • Jutting head forward • Temperature 40 degrees • Hib was due 2/52 ago but had viral gastroenteritis

15. Rare: Epiglottitis • You did not examine throat or lay her down • Suspected epiglottitis • Oncall anaesthetist, paeds and ENT called • Play • Paediatric emergency

16. Baby Mulberry • Presented with a 4 day history of fever • A&E: HR 181 RR26 T 39.7 Sats 97% • Noted to have stridor • Pyrexia resistant to anti-pyretics • Widespread maculopapular rash • Stridor improved with budesonide neb • Koplik spots; petechial rash ? trauma • Treated as sepsis; thought to have measles

17. Investigations • CRP 101 • WCC 10.6 • Na 133 • ALT 178 • INR 1.4 • Reactive lymphocytes • ASOT: 99 (normal) • CXR: normal heart and lungs

18. Working diagnosis: Measles • Noted bilateral conjuctivitis and sore mouth • Ongoing spiking of fevers • Awaiting IgM measles serology • Contacted Health Protection Agency • Intermittent stridor; requiring further bedesonide and dexamethasone • Day 5 now of fever • Slight clinical improvement

19. Kawasaki’s disease I • Working diagnosis now: Kawasaki’s • Discussed with paediatric rheumatologist at LGI • Advised treating with Immunoglobulins • Treated with high dose aspirin • CT head and neck – ruled out retropharyngeal abscess; noted numerous small lymph nodes are demonstrated in both cervical chains (thought to be reactive) • Booked for urgent echo

20. Kawasaki’s disease II • Stridor settled by day 4 • Developed some erythema of the peripheries a strawberry tongue • Desquamation of skin – mucous membranes and fingers • Blood cultures negative after 5 days • ECG – normal • Urgent echo performed in clinic – normal coronary vessels

21. Kawasaki’s disease III • Acute febrile illness affecting infants and young children • Causing vasculitis of the small and medium size arteries • Aetiology unknown • Coronary aneurysms • Criteria for diagnosis available

22. Kawasaki: Criteria for diagnosis http://emedicine.medscape.com/article/965367-clinical

23. Stridor in Kawasaki’s • Very rare • Case 1: 8 y old with retropharyngeal abscess is a rare presentation of Kawasaki disease1 • Case 2: 6m old with croup from enlarged retropharyngeal lymph node2 • In this case; cause for stridor unknown 1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908875/ 2http://www.clinicsandpractice.org/index.php/cp/article/view/cp.2011.e23/html

24. Summary • Consider congenital abnormalities in <6months with stridor • All causes of stridor can and do cause severe life threatening airway obstruction • Never examine throat/ upset a child with stridor • Consider underlying diagnosis

25. Thank you

26. Summary