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

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 lesion 12

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. 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)? Parents or caregivers may be asked..?

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