Morning Report

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