Acute StridorAcute Stridor

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Yehia Abo Arida Yehia Abo Arida WardWard 77

StridorStridor

It is a harsh, high-pitched respiratory It is a harsh, high-pitched respiratory sound, which issound, which is usually inspiratory but usually inspiratory but it can be biphasic and is produced by it can be biphasic and is produced by turbulent airflow; it is not a diagnosis but turbulent airflow; it is not a diagnosis but a sign of upper airway obstruction .a sign of upper airway obstruction .

Causes of acute stridorCauses of acute stridor Laryngotracheobronchitis ( croup) .Laryngotracheobronchitis ( croup) . Epiglottitis .Epiglottitis . Bacterial tracheitis .Bacterial tracheitis . Foreig body Foreig body Angioedema .Angioedema . Hypocalcemic tetany .Hypocalcemic tetany . Edema after endotracheal intubation .Edema after endotracheal intubation .

Assessment of severity of stridorAssessment of severity of stridor Timing :Timing :

– The prominent phase of respiratory noise should be inspiratory The prominent phase of respiratory noise should be inspiratory – Expiratory stridor ----- more severe , or intrathoracic obstruction .Expiratory stridor ----- more severe , or intrathoracic obstruction .

Work of breathing :Work of breathing :– Increased RR . Increased RR . – Sternal ( supra – sub ) recession .Sternal ( supra – sub ) recession .

How effective is the breathing :How effective is the breathing :

– Chest expansion .Chest expansion .– Breath sounds for air entery .Breath sounds for air entery .

Is there adequate oxygenation :Is there adequate oxygenation :– Is HR increased .Is HR increased .– Pallor , cyanosis .Pallor , cyanosis .– O2 saturation .O2 saturation .– Activity level .Activity level .

Worrying signs in children with Worrying signs in children with stridorstridor

High fever or signs of toxicity High fever or signs of toxicity Rapid onset .Rapid onset . Drooling & dysphagia .Drooling & dysphagia . Muffled voice & quiet stridor .Muffled voice & quiet stridor . Angioedema .Angioedema . Age less than 4 mths .Age less than 4 mths . Skin cavernous hemangioma .Skin cavernous hemangioma . Previous ventilation as a neonate .Previous ventilation as a neonate .

CroupCroup

Is derived from an oldIs derived from an old scottish wordscottish word , , rouproup , , whichwhich means to cry means to cry out in a hoarse voiceout in a hoarse voice . .

Viral croup ( ALTB )Viral croup ( ALTB ) Viral croupViral croup is the most common cause of acute is the most common cause of acute

stridor in children .stridor in children . Most patients withMost patients with croupcroup are between ages of 3 are between ages of 3

mths and 5 yrs , with the peak around 1-2 yrs .mths and 5 yrs , with the peak around 1-2 yrs . Common pathogens include Common pathogens include parainfluenza parainfluenza

viruses ( 1,2 & 3 ) account for 75% of cases; viruses ( 1,2 & 3 ) account for 75% of cases; others include others include influenza influenza ( A&B ) , ( A&B ) , RSVRSV & & measlesmeasles V . V .

Mycoplasma Mycoplasma pneumoniae has rarely been pneumoniae has rarely been isolated from children with croup .isolated from children with croup .

The term The term laryngotracheobronchitis laryngotracheobronchitis refers to refers to viral infection of the glottic and subglottic viral infection of the glottic and subglottic regions . Some clinicians use the termregions . Some clinicians use the term laryngotracheitislaryngotracheitis for the most common & most for the most common & most typical form of croup and reserve the term typical form of croup and reserve the term LTBLTB for more severe formfor more severe form . .

Inflammation & partial obstruction of the upper Inflammation & partial obstruction of the upper airways result in a barkelike or brassy cough& airways result in a barkelike or brassy cough& inspiratory stridor & may be associated with inspiratory stridor & may be associated with hoarseness & RD .hoarseness & RD .

Small children are at higher risk because Small children are at higher risk because of the relative small size of their upper of the relative small size of their upper airways.airways. . . . .

Unlike relatively rare conditions asUnlike relatively rare conditions as epiglottitis epiglottitis & & bacterial tracheitisbacterial tracheitis , , croupcroup has : has : – a more insidious onset over a few days .a more insidious onset over a few days .– systemic toxicity & fever are considerably less .systemic toxicity & fever are considerably less .– have typical barking cough , often associated have typical barking cough , often associated

with hoarse voice , stridor & low grade fever .with hoarse voice , stridor & low grade fever .

As in many respiratory conditions , symptoms As in many respiratory conditions , symptoms are often are often worseworse at night . at night .

Assessment & evaluationAssessment & evaluation

Mild:Mild:– well , active child .well , active child .– barking cough .barking cough .– stridor with agitation stridor with agitation – minimal sings of increased WOB .minimal sings of increased WOB .

MODERATE :MODERATE :– stridor at rest .stridor at rest .– some signs of increased WOBsome signs of increased WOB . .

SEVERE :SEVERE :– stridor at rest + expiratory component .stridor at rest + expiratory component .– marked increased WOB .marked increased WOB .– increased RR & HR increased RR & HR – agitation & pallor .agitation & pallor .– as AW obstruction became very serious stridor as AW obstruction became very serious stridor

became quieter .became quieter .– agitation turn to exhaustion .agitation turn to exhaustion .

Acute spasmodic croupAcute spasmodic croup Some children develop recurrent short lived Some children develop recurrent short lived

episodes of croup without preceding coryzal episodes of croup without preceding coryzal prodrome that is seen in classical viralprodrome that is seen in classical viral croupcroup..

children are afebrile & awake suddenly with acute children are afebrile & awake suddenly with acute stridor during night .stridor during night .

recurrence occurs on subsequent 2-3 nightsrecurrence occurs on subsequent 2-3 nights . . it occurs in children of the same age group , during it occurs in children of the same age group , during

same season & sometimes same virus can isolated .same season & sometimes same virus can isolated . children with recurrentchildren with recurrent spasmodic croupspasmodic croup often haveoften have

a strong atopic or asthmatic family background .a strong atopic or asthmatic family background .

RadiographsRadiographs CroupCroup is a clinical diagnosis and does not require is a clinical diagnosis and does not require

a radiograph of the neck .a radiograph of the neck . It may show the typical subglottic narrowing or It may show the typical subglottic narrowing or

( steeple sign ) on AP view , which may be present ( steeple sign ) on AP view , which may be present as a normal variation or in as a normal variation or in epiglottitis epiglottitis & may be & may be absent in patient with absent in patient with croupcroup . .

Should be considered in patient with atypical Should be considered in patient with atypical presentation .presentation .

May be helpful to distinguish severeMay be helpful to distinguish severe LTB LTB & & epiglottitisepiglottitis , but airway management should , but airway management should always take priority . always take priority .

Steeple sign (croup \ normal \ epiglottitis ) due Steeple sign (croup \ normal \ epiglottitis ) due to subglottic narrowing . to subglottic narrowing .

TreatmentTreatment Majority of cases will have a mild illness that Majority of cases will have a mild illness that

can be managed at home .can be managed at home . Those with significant RD and stridor at rest Those with significant RD and stridor at rest

will require treatment & reassessment .will require treatment & reassessment . Those showed significant improvement Those showed significant improvement

following treatment may be considered for following treatment may be considered for discharge home .discharge home .

There should be a low threshold for There should be a low threshold for admission in :admission in :– children under age of 12 mths .children under age of 12 mths .– all children with marked RD . all children with marked RD . – those with oxygen requirement on presentation. those with oxygen requirement on presentation.

– those with parents remain anxious about those with parents remain anxious about

discharge .discharge .

Parents of children not requiring Parents of children not requiring admission should receive clear admission should receive clear instructions when to return :instructions when to return :

– chest wall recession .chest wall recession .

– tachypnoea . tachypnoea .

– color changes .color changes .

– inability to feed .inability to feed .

– decreased level of consciousness .decreased level of consciousness .

Therapies may be effectiveTherapies may be effective

Simple measuresSimple measures : :– in all cases it is very important to keep the child in all cases it is very important to keep the child

and parents calm .and parents calm .– direct inspection of the throat can be dangerous direct inspection of the throat can be dangerous

and result in complete obstruction of the airway. and result in complete obstruction of the airway.

– neck x ray is no longer useful and carry the risk neck x ray is no longer useful and carry the risk of further upset and deterioration . of further upset and deterioration .

Humidification :Humidification :– steam inhalation forsteam inhalation for croupcroup is widely used but ofis widely used but of

little proven benefits .little proven benefits .– the percieved benefits ( placebo effect ) may be the percieved benefits ( placebo effect ) may be

due to presence in a warm calming environment .due to presence in a warm calming environment .– a steamy bathroom with hot water tap running a steamy bathroom with hot water tap running

and plug opened is accepted , but use of kettle and plug opened is accepted , but use of kettle and boilers should discouraged , because it carry and boilers should discouraged , because it carry the risk of scalding .the risk of scalding .

Adrenaline ( epinephrine ) :Adrenaline ( epinephrine ) :– nebulizednebulized adrenalineadrenaline is very effective in severeis very effective in severe

croup .croup .– duration of action between 20 minutes and 3 duration of action between 20 minutes and 3

hours .hours .– it is used in most cases whenit is used in most cases when intubationintubation is is

considered.considered.– weaning effect of adrenaline result in return to weaning effect of adrenaline result in return to

pretreatment baseline rather than a true pretreatment baseline rather than a true rebound .rebound .

– for children with severe croup , the period of for children with severe croup , the period of improvement on adrenaline is long enough to improvement on adrenaline is long enough to allow the steroid to start working .allow the steroid to start working .

Steroids :Steroids :– Corticosteroids improve clinical parametrs .Corticosteroids improve clinical parametrs .– Decrease the admission rate .Decrease the admission rate .– decrease duration of hospital stay . decrease duration of hospital stay . – Decrease the need for repeated nebulizedDecrease the need for repeated nebulized

adrenaline adrenaline in children with in children with croup . croup . – nebulized nebulized budesonidebudesonide or oralor oral dexamethazonedexamethazone

showed equal effect in treating children with showed equal effect in treating children with croup . croup .

– approximately 1-5 % of croup cases require approximately 1-5 % of croup cases require ETT before introduction of steroid therapy .ETT before introduction of steroid therapy .

Intubation :Intubation :– a small numbers of children will still require ET a small numbers of children will still require ET

for severe for severe croupcroup . .– The decision to intubate should be based on The decision to intubate should be based on

worsening airway obstruction , signs of worsening airway obstruction , signs of exhaustion or impending respiratory failure .exhaustion or impending respiratory failure .

– Children with Children with epiglottitisepiglottitis and and bacterial tracheitisbacterial tracheitis require specialist care , with input from senior require specialist care , with input from senior ENT & anethetic stuff .ENT & anethetic stuff .

– IV antibiotics & intubation are often required .IV antibiotics & intubation are often required .– steroidsteroid & & adrenaline adrenaline have minimal effect on have minimal effect on

these condition . these condition .

Mild croupMild croup

Reassurance .Reassurance . May worse by night ( advice to return ) .May worse by night ( advice to return ) . DexamethazoneDexamethazone PO (0.3- 0.6 mg\kg \ dose). PO (0.3- 0.6 mg\kg \ dose).

Moderate croupModerate croup

Cardio respiratory monitor Cardio respiratory monitor DexamethazoneDexamethazone PO&\or nebulized PO&\or nebulized budesonidebudesonide

(pulmicort) 2 mg stat .(pulmicort) 2 mg stat . Reassess in 2 hoursReassess in 2 hours

– If improved ------- discharge . If improved ------- discharge . – If no improvement : If no improvement :

Consider nebulized Consider nebulized adrenalineadrenaline 1: 1000 1: 1000– 2.5 ml for those younger than 1 year .2.5 ml for those younger than 1 year .– 2.5 - 5 ml for older than 1 year .2.5 - 5 ml for older than 1 year .– If improved -----observe for 4 hrs & discharge .If improved -----observe for 4 hrs & discharge .

Severe croupSevere croup

Cardio respiratory monitor .Cardio respiratory monitor . OxygenOxygen to maintain O2 sat ( 92% or more ) . to maintain O2 sat ( 92% or more ) . Nebulized Nebulized adrenalineadrenaline ( 1\1000) Q 1-4 hrs . ( 1\1000) Q 1-4 hrs . IVIV dexamethazone dexamethazone ( 0.3-0.6 mg\kg\dose ) . Or ( 0.3-0.6 mg\kg\dose ) . Or Nebulized Nebulized budesonidebudesonide ( pulmicort ) 2mg . ( pulmicort ) 2mg . IF no improvement consider BGA , ICU .IF no improvement consider BGA , ICU . IntubationIntubation & & ventillationventillation may be required . may be required .

Bacterial traheitisBacterial traheitis Bacterial infection of upper airway , does not Bacterial infection of upper airway , does not

involve the epiglottis but, like involve the epiglottis but, like epiglottitis epiglottitis and and croupcroup , is capable of causing life-threatening , is capable of causing life-threatening airway obstruction . airway obstruction .

StaphStaph aureus is the most commonly aureus is the most commonly isolated organism .isolated organism .

Most patients were below 3 yrs , but in Most patients were below 3 yrs , but in recent case series the mean age has been recent case series the mean age has been between 5-7 yrs .between 5-7 yrs .

I t may be considered as bacterial I t may be considered as bacterial complication of disease , rather than a complication of disease , rather than a primary bacterial illness . primary bacterial illness .

Clinical manifestationsClinical manifestations Typically child has a brassy cough , apparently asTypically child has a brassy cough , apparently as

a part ofa part of LTBLTB . . High fever and toxicity with RD immediately or High fever and toxicity with RD immediately or

after few days of apparent improvementafter few days of apparent improvement . . Patient can lie flat , does not drool , and does not Patient can lie flat , does not drool , and does not

have dysphagia associated with have dysphagia associated with epiglottitisepiglottitis . . the usual treatment for croup is ineffective , the usual treatment for croup is ineffective ,

intubation or tracheostomy may be necessary .intubation or tracheostomy may be necessary . The major pathologic feature is mucosal swelling The major pathologic feature is mucosal swelling

at level of ciricoid cartilage , complicated by at level of ciricoid cartilage , complicated by copious thick purulent secretions sometimes copious thick purulent secretions sometimes causing pseudomembrane . causing pseudomembrane .

DiagnosisDiagnosis Diagnosis is based on evidence of bacterial Diagnosis is based on evidence of bacterial

upper airway disease (high fever – purulent upper airway disease (high fever – purulent airway secretions & absent classic finding of airway secretions & absent classic finding of epiglottitisepiglottitis ) . ) .

XR not needed , but may show classic XR not needed , but may show classic findings (pseudomembrane detachment in findings (pseudomembrane detachment in the trachea ) . the trachea ) .

Purulent material is noted below the cords Purulent material is noted below the cords during ET intubation .during ET intubation .

Black arrow points tracheal pseudomemerane Black arrow points tracheal pseudomemerane (bacterial tracheitis \ diphtheria ) (bacterial tracheitis \ diphtheria )

TreatmentTreatment Antimicrobial therapy , which usually Antimicrobial therapy , which usually

includes antistaph agents , should be includes antistaph agents , should be instituted in any patient whose course instituted in any patient whose course suggest suggest bacterial traheitisbacterial traheitis . .

When diagnosed by direct laryngoscopy , or When diagnosed by direct laryngoscopy , or suspected on clinical background , an suspected on clinical background , an artificial airway should be strongly artificial airway should be strongly considered .considered .

Supplemental oxygen may be necessary .Supplemental oxygen may be necessary .

ComplicationsComplications

CXR showedCXR showed : :– Patchy infiltrates & show focal densities.Patchy infiltrates & show focal densities.– Subglottic narrowing .Subglottic narrowing .

Cardio respiratoryCardio respiratory arrest can occur if arrest can occur if airway management is not optimalairway management is not optimal . .

Toxic shock syndromeToxic shock syndrome has beenhas been associated with staphassociated with staph tracheitis tracheitis . .

PrognosisPrognosis

oxygen therapy continued . For most of oxygen therapy continued . For most of patients is excellent .patients is excellent .

Patient become afebrile within 2-3 days of Patient become afebrile within 2-3 days of institution of antimicrobial therapy , but institution of antimicrobial therapy , but prolonged hospitalization may be necessary. prolonged hospitalization may be necessary.

After extubation the patient should be After extubation the patient should be observed carefully while antibiotics and O2 observed carefully while antibiotics and O2 continued .continued .

EpiglottitisEpiglottitis

Dramatic potentially lethal condition characterized by an acute , Dramatic potentially lethal condition characterized by an acute , potentially fulminating course of high fever , potentially fulminating course of high fever , sore sore throat , throat , dyspnea & rapidly progressing respiratory obstruction . dyspnea & rapidly progressing respiratory obstruction .

Degree of Degree of RDRD at presentation is variable. at presentation is variable. Often the otherwise healthy child develops sore throat and Often the otherwise healthy child develops sore throat and

fever within a matter of 4-6 hrs .Child appear toxic ,swallowing fever within a matter of 4-6 hrs .Child appear toxic ,swallowing is difficult and saliva is difficult and saliva drooling drooling ..

He sitting upright and assume He sitting upright and assume tripodtripod position( leaning position( leaning forward ,chin up, bracing on the arm ) . forward ,chin up, bracing on the arm ) .

A brief period of air hunger with restlessness may be followed A brief period of air hunger with restlessness may be followed by by cyanosis cyanosis and and coma coma ..

Stridor Stridor is a late and suggest near complete airway obstruction. is a late and suggest near complete airway obstruction. If no treatment provided complete obstruction of airway and If no treatment provided complete obstruction of airway and

death . death . barking cough typical of barking cough typical of croupcroup is rare . is rare .

DiagnosisDiagnosis

laryngoscopy :laryngoscopy :– Showed large( cherry red) , swollen epiglottis Showed large( cherry red) , swollen epiglottis – Other Other supraglotticsupraglottic structures especially structures especially

aryepiglotticaryepiglottic fold fold , occasionally more involved . , occasionally more involved .– It should be performed in a controlled It should be performed in a controlled

environment as environment as OROR or or ICU ICU ..

Lateral radiograph of upper airway :Lateral radiograph of upper airway :– Showed the classical ( Showed the classical ( thumb signthumb sign ) ) . .

Red arrow points ( normal & swollen epiglottis) Red arrow points ( normal & swollen epiglottis) known as thumb sign or thumb print . known as thumb sign or thumb print .

Intial management of suspected Intial management of suspected epiglottitisepiglottitis

Do not :Do not :– Examine the throat .Examine the throat .– Put the child flat . Put the child flat . – Order a lateral XR of the neck . Order a lateral XR of the neck . – Upset the child by trying to gain iv access or Upset the child by trying to gain iv access or

place an O2 mask . place an O2 mask .

Do :Do :– Call Call airway team .airway team .– StayStay with the child and parents . with the child and parents .– AllowAllow the child to sit on knee of his mother . the child to sit on knee of his mother .– MeasureMeasure O2 sat O2 sat if if possible .possible .– Give Give O2O2 therapy therapy ifif absolutely needed and well absolutely needed and well

tolerated . tolerated .

TreatmentTreatment Immediate treatment with artificial airway placed inImmediate treatment with artificial airway placed in OT OT

oror ICUICU . . All cases should receive All cases should receive oxygenoxygen unless the mask unless the mask

causes excessive agitation .causes excessive agitation . Racemic Racemic epinephrineepinephrine & & corticosteroidscorticosteroids are ineffective . are ineffective . Blood & epiglottic surface Blood & epiglottic surface C&S C&S and in selected casesand in selected cases

CSF should be collected after stabilization of airway.CSF should be collected after stabilization of airway. CefotriaxoneCefotriaxone,, cefotaxime cefotaxime , , oror combinationcombination of of

ampicillin and salbactum should be given parenterally, ampicillin and salbactum should be given parenterally, pending C&S reports .pending C&S reports .

Antibiotics should be continued forAntibiotics should be continued for 7-10 7-10 days . days .

ChemoprophylaxisChemoprophylaxis Not routine for household , child-care or nursery Not routine for household , child-care or nursery

contacts of patient with invasivecontacts of patient with invasive HIb HIb infection , but infection , but observation & medical evaluation is mandatory observation & medical evaluation is mandatory when exposed child develop febrile illness .when exposed child develop febrile illness .

Indication for Indication for rifampinrifampin prophylaxis : prophylaxis :– Any contact less than 1y & incompletely immunized . Any contact less than 1y & incompletely immunized . – Any contacts less than 2 yrs of age who has not Any contacts less than 2 yrs of age who has not

received the primary vaccination series .received the primary vaccination series .– An immunocompromised child in the household .An immunocompromised child in the household .– DoseDose : (20 mg \kg \d ) once , for 4 days , maximum dose : (20 mg \kg \d ) once , for 4 days , maximum dose

is 600 mg \ day .is 600 mg \ day .

PrognosisPrognosis Length of hospitalization and mortality rate Length of hospitalization and mortality rate

increase as infection spread to involve a greater increase as infection spread to involve a greater portion of respiratory tract , except in portion of respiratory tract , except in epiglottitisepiglottitis in in which local infection may prove to be fatal .which local infection may prove to be fatal .

Causes of death in Causes of death in croupcroup are : are :– Laryngeal obstruction . Laryngeal obstruction . – Complications of Complications of tracheostomy .tracheostomy . – rarely , fatal out-of-hospital arrest due to viral rarely , fatal out-of-hospital arrest due to viral LTBLTB have have

been reported .been reported . Untreated Untreated epiglottitis epiglottitis has mortality rate of 6% has mortality rate of 6%

but if treatment initiated the prognosis is but if treatment initiated the prognosis is excellent . excellent .

The outcome of The outcome of LTBLTB ,and spasmodic ,and spasmodic croupcroup is also is also excellent .excellent .