STRIDOR - An ER Approach

1
STRIDOR- An ER Approach

• Dr.R.Ashok. MD(A E)
• HEAD OF THE DEPT.
• DEPT OF ACCIDENT EMERGENCY MEDICINE
• VMMC H, KARAIKAL

2
Case Scenario

• A 6 year old boy was well until he woke from
  sleep at 3am with a high fever. His mother
  brought him to the ED because he was unable to
  lie down, had noisy respirations, and was
  drooling saliva.

3

• What is Stridor?

4
 

• Stridor is the sound produced by turbulent flow
  of air through a narrowed segment of the
  respiratory tract
• It typically originates from the larynx (voice
  box) or trachea (windpipe)

5

• What are the causes of Stridor ?

6
 

• Congenital anomalies of the larynx, trachea, and
  bronchial tree
• Foreign body aspiration
• Infectious conditions of the respiratory tract
• Vocal cord paralysis
• Trauma

7

• Neoplasms of the airway
• Allergic reaction
• Inhalation injury
• Prolonged intubation
• Diagnostic tests such as bronchoscopy or
  laryngoscopy

8

• How is stridor evaluated?

9
Historical information in the Evaluation of
Stridor in Children

• Age of onset 
• Birth Vocal cord paralysis, congenital lesions
  such as choanal atresia, laryngeal web and
  vascular ring
• 4 to 6 weeks Laryngomalacia
• 1 to 4 years Croup, epiglottitis, foreign
  body aspiration

10

• Chronicity 
• Acute onset Foreign body aspiration,
  infections such as croup and epiglottitis
• Long duration Structural lesion such as
  laryngomalacia, laryngeal web or larynogotracheal
  stenosis

11
Precipitating factors

• Worsening with straining or crying
• Laryngomalacia, Subglottic Hemangioma
• Worsening at night Viral or spasmodic croup
• Worsening with feeding
• Tracheoesophageal fistula, Tracheomalacia,
• Neurologic disorder, Vascular compression

12

• Antecedent upper respiratory tract
• infection Croup, bacterial tracheitis
• Choking Foreign body aspiration,
• Tracheoesophageal fistula

13
Associated symptoms

• Barking cough Croup
• Brassy cough Tracheal lesion
• Drooling Epiglottitis,
• Foreign body in
  esophagus,
• Retropharyngeal or
• Peritonsillar abscess
• Weak cry Laryngeal anomaly or
• Neuromuscular disorder

14

• Muffled cry Supraglottic lesion
• Hoarseness Croup, vocal cord paralysis
• Snoring Adenoidal or
• Tonsillar Hypertrophy
• Dysphagia Supraglottic lesion

15
Past Health

• Endotracheal Intubation
• Birth trauma, perinatal asphyxia,
• Cardiac problem
• Psychosocial History 
• Psychosocial stress - Psychogenic stridor

16
(No Transcript)
17
Physical Examination

• General
• Cyanosis - Cardiac disorder,
• Hypoventilation with
  hypoxia
• Fever - Underlying infection
• Toxicity - Epiglottitis
• Tachycardia - Cardiac failure
• Bradycardia - Hypothyroidism

18
Quality of Stridor

• Inspiratory stridor - Obstruction above glottis
• Expiratory stridor - Obstruction at or below
  lower trachea
• Biphasic stridor - Glottic or subglottic lesion12

19
Position of child

• Hyperextension of the neck
• Extrinsic obstruction at or above
• larynx
• Leaning over, drooling
• Epiglottitis
• Lessening of stridor in prone
• position - Laryngomalacia

20
Chest Finding

• Prolonged inspiratory phase
• Laryngeal obstruction
• Prolonged expiratory phase
• Tracheal obstruction
• Unilateral decreased air entry
• Foreign body in ipsilateral bronchus

21
Signs of Impending Respiratory Failure

• Increased work of breathing with tiring
• Increasing tachypnea and tachycardia
• Abrupt onset of bradycardia
• Cyanosis
• Marked lethargy or unresponsiveness

22
Initial approach to a Stridorous child

• Avoid disturbing or upsetting the child
• Avoid tongue depressor or other oral instruments
• Confirm the diagnosis by direct or radiographic
  visualisation

23
Diagnosis

• History and Physical examination
• Chest and neck x-rays, bronchoscopy, CT-scans,
  and / or MRIs may reveal structural pathology
• Flexible fiberoptic bronchoscopy

24
Parents or caregivers may be asked..?

• Is the abnormal breathing a high-pitched sound?
• Did the breathing problem start suddenly?
• Could the child have put something in the mouth?
• Has the child been ill recently?
• Is the child's neck or face swollen?

25
Parents or caregivers may be asked..?

• Has the child been coughing or complaining of a
  sore throat?
• What other symptoms does the child have? (For
  example, nasal flaring or bluish color to the
  skin, lips, or nails)
• Is the child using chest muscles to breathe
  (intercostal retractions)?

26

• How will you approach this in the ER?

27

• Tracheal intubation or Tracheostomy is
  immediately necessary?

28

• Expectant management with full monitoring, oxygen
  by face mask, and positioning the head of the bed
  for optimum conditions (e.g., 45 - 90 degrees)
• Use of nebulized racemic adrenaline (0.5 to 0.75
  ml of 2.25 racemic adrenaline added to 2.5 to 3
  ml of normal saline) in cases where airway edema
  may be the cause of the stridor

29

• Use of dexamethasone (Decadron) 4-8 mg IV q 8 -
  12 h in cases where airway oedema may be the
  cause of the stridor
• Use of inhaled Heliox (70 helium, 30 oxygen)
  the effect is almost instantaneous. Helium, being
  a less dense gas than nitrogen, reduces turbulent
  flow through the airways

30

• Nebulized Cocaine in a dose not exceeding 3 mg/kg
  may also be used, but not together with racemic
  adrenaline because of the risk of ventricular
  arrhythmias

31
Remember

• Stridor is a symptom and not a diagnosis
• History and physical are key in diagnosis
• Airway endoscopy is an important adjunct
• Proper management is possible only after a
  precise diagnosis has been established

32
Thank you