SUBJECT SEMINAR

ON
APPROACH TO STRIDOR

28.6.2010
STRUCTURES OF THE UPPER
AIRWAY

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 DEFINITION

 Stridor, a harsh, medium-pitched,

inspiratory sound associated with
obstruction of the laryngeal area
or the extrathoracic trachea,
often accompanied by a croupy
cough and hoarse voice

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 Turbulent air flow through partially obstructed / narrowed airway.

 Stridor is a symptom, not a diagnosis or disease, and the underlying cause

must be determined.

 Stridor may be inspiratory, expiratory, or biphasic

-Inspiratory stridor = extrathoracic lesion (eg, laryngeal, nasal,

pharyngeal).
-Expiratory stridor = intrathoracic lesion (eg, tracheal,
bronchial).
-Biphasic stridor suggests a subglottic or glottic anomaly

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 PATHOPHYSIOLOGY
 During normal inspiration extrathoracic intraluminal airway
pressure is negative relative to atmospheric pressure, leading to
collapse of supraglottic structures.

 In contrast, stridor caused by intrathoracic obstructions tends to

be more prominent on expiration. On expiration, intrathoracic
pressure is positive and tends to collapse the airway.

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DISEASES ASSOCIATED WITH ACUTE
 Acute laryngotracheitis. STRIDOR
 Acute laryngotracheobronchitis.
 Acute epiglottitis.
 Bacterial tracheitis.
 Foreign body.

Uncommon
 Peritonsillar abscess.
 Retropharyngeal abscess.
 Diphtheria

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 SIGNS OF  WORK OF
BREATHING
 Tachypnoea
 Chest retractions (SC / IC / SS )
 Stridor / Wheeze / Grunt
 Flaring of Ala nasi
 Head bobbing
 Abdominal breathing
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 Respiratory distress – Clinical pearls

Supra-sternal indrawing
(Use of accessory muscles, Upper airway
involvement)

Intercostal indrawing
(Decreased Parenchymal Compliance)

Subcostal indrawing
(Increased work of diaphragm)
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SOUNDS DURING RESPIRATORY
CYCLE
Stridor
(Extra thoracic airway structures)
Wheeze
(Intra thoracic airway structures)
Grunt
(Parenchymal lesions)

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 RESPIRATORY NOISES

Noises Phase of Respiration Localisation

 Snoring Insp. / Exp. Oro-pharynx

 Stridor Inspiration Larynx

 Wheeze Expiration Small AW

 Grunt Expiration Alveoli

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5 DIFFERENCES BETWEEN PEDIATRIC AND ADULT
AIRWAY

 Relatively larger tongue

 Angled vocal cords

 More anterior and cephalax larynx

 Funneled shaped larynx-narrowest part of pediatric airway is
cricoid cartilage
 Differently shaped epiglottis

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 PHYSIOLOGY: EFFECT OF
EDEMA
Poiseuille’s law
R = 8nl/ πr4

12 If radius is halved, resistance increases 16 x

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
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 ANATOMIC
CLASSIFICATION
BROAD SPECTRUM OF NEONATAL AIRWAY ABNORMALITIES
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 VIRAL CROUP

 Common respiratory illness in young children.

 Anglo-Saxon word Kropan; cry aloud.

 Hoarse voice; dry barking cough; inspiratory

stridor; and variable amount of respiratory distress
that develops over a brief period of time.

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 CROUP SYNDROME

 Group of diseases that varies in anatomic

involvement and etiologic agents.

 Laryngotracheitis.
 Spasmodic croup.
 Bacterial tracheitis.
 Laryngotracheobronchitis.
 Laryngotracheobronchopneumonitis.

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 CROUP
ACUTE LARYNGOTRACHEITIS

Disease of viral origin causing subglottic & tracheal

swelling.

The narrowed airway is responsible for the

hallmark of clinical picture.

The cricoid ring in the upper trachea which is

subglottic, has a narrow diameter which renders
children vulnerable to inflammation.

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 VIRAL CROUP
( ACUTE LARYNGOTRACHEITIS)

Etiology:

Respiratory viruses e.g. parainfluenza viruses

1,2,and 3, RSV, Influenza viruses A & B.

Clinical picture:

Age 6mths- 3 years, M>F, Fall & winter.

Gradual onset of low grade fever,URTI, barking
cough, inspiratory stridor & respiratory distress.
Hoarseness & aphonia may occur.

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 CROUP, DIAGNOSIS &
TREATMENT

Clinically

Lateral neck X-ray ( steeple sign).

Fluid intake

Cool mist/ hot steamy bathroom.

Aerosolized adrenaline.

Steroids( controversial)

Endotracheal intubation.

Helium-Oxygen Mixture.

Antibiotics

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 ACUTE EPIGLOTTITIS,
ETIOLOGY
 Bacterial infection of the supraglottic structures (epiglottis, aryepiglottic
folds & arytenoids soft tissues) causing rapid airway obstruction.

 Haemophilus Influenza type B in prevaccination era.

 Bacteria associated with epiglottitis in the Hib vaccine era include: HiA, Str.
Pn, Staph aureus, ß-hemolytic streptococci Gps A,B,C,and F

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ACUTE EPIGLOTTITIS, CLINICAL
PICTURE

 Age usually 2- 7 years.

 Sudden onset.

 High fever.

 Apprehensive, sitting forward, drooling saliva, hyperextended

neck & protruded chin.

 Stridor, dysphagia.

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 ACUTE EPIGLOTTITIS, DIAGNOSIS &
TREATMENT

 Direct visualization.

 Blood cultures.

 Latex agglutination of serum or urine.

 Treatment is a medical emergency.

 Ventilatory support, intubation.

 IV antibiotics, 2nd or 3rd generation

cephalosporin's or chloramphenicol till cultures
& sensitivity are known.

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25
ASSESSMENT- DOWNE’S SCORE
0 1 2
Stridor None Inspiratory Inspiratory +
expiratory
Cough None Hoarse Barking

Retractions None Suprasternal Flaring +

max.retractions
Cyanosis None In air In 40% oxygen
Breath Normal Harsh,wheeze/ + delayed
sounds rhonchi
Characteristic Epiglottitis Croup
Age Any age 6months-
12yrs
Onset Sudden Gradual
Location Supraglottic Subglottic
Temperature High fever Low-grade
fever
Dysphagia Severe Mild or
absent
Dyspnea 26
Present Present
 ETIOLOGY
Laryngotracheobronchitis (croup)
 Parainfluenza virus
 Adenovirus
 Echovirus
 Influenza viruses
 Respiratory Syncytial viruses
 Mycoplasma
 Epiglotitis
 H.influezae
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 CLINICAL FEATURES
Epiglotitis- acute onset, fever, sore throat, hoarseness, and
noisy breathing. Retraction of the suprasternal &
infrasternal chest.

Look for the 4 Ds

 Dysphagia
 Dysphonia (Hot potato voice)
 Drooling
 Distress
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 EPIGLOTITIS

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 EPIGLOTITIS

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 CLINICAL FEATURES

LARYNGITIS
 Barking cough , fever
 Tachypnea, dyspnea,subglottic
obstruction, inspiratory stridor
 Retraction of the suprasternal notch
and supraclavicular retractions

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 CLINICAL FEATURES

Laryngotracheobronchitis

 Also called viral croup or just croup

 Fever is higher, restlessness & air hunger
 Demonstrate substernal & intercostal retractions in
addition to suprasternal notch & supraclavicular
retraction.
 A barky cough, bronchitic inspiratory rales &
expiratory wheezes are heard

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 CROUP
USUALLY INVOLVES LARYNX TRACHEA, AND VARIABLE PART OF BRONCHI.

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 DIAGNOSIS
 Etiology should be determined
 Look for hoarseness, barking cough, inspiratory
stridor and retractions
 Throat swabs & smears are cultured and
examined
 Other airway obstructions should be considered
 Serological tests

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 X-RAY

 A positive thumb sign on lateral X-

ray of neck is diagnostic of
epiglottitis.

 The "steeple sign" in an

anteroposterior neck X-ray is
characteristic of viral croup (acute
laryngotracheobronchitis).

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 X-RAY
CROUP

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Croup

This radiograph shows

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a long area of narrowing extending below the
Normally narrowed area at the level of the vocal cords.
 EPIGLOTTITIS

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 THERAPY

Two fold
 Maintenance of an adequate airway
 Control of infection
 H. influenzae - ampicillin or
chloramphenicol.
 C. diphtheriae - antitoxin &
erythromycin or penicillin G.

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 DRUGS IN MANAGEMENT

GLUCOCORTICOIDS
 Dexamethasone - most potent, long acting &
can be given orally or parenterally.
 Budesonide - lower systemic bioavailability,
provides greater benefit as it is deposited in
upper airway
 Epinephrine - short term benefit by reducing
secretions & mucosal edema. effective in
severe cases.

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41
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 MIST THERAPY

 Blow-by or nebulisation method

 Humidified air
 Benefits- soothes inflamed airway, decreases airway
obstruction by reducing viscosity of secretions,
improves respiratory flow pattern.

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 MANAGEMENT - MILD
CROUP

 Minimal interference
 Continue oral feeds
 Steroids-budesonide 2mg in 4ml NS
 Improvement  discharge
 No improvement  treat as moderate croup

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 MANAGEMENT -
MODERATE CROUP

 Oxygen if spo2<95%
 Nebulised adrenaline1:1000.1st dose 1ml in
3ml NS.2nd dose 0.5ml/kg(max 4 dose)
 NPO. IV Fluids.
 Steroids - Dexamethasone 1mg/kg IV
stat,then q 8hr for 2-3 days.
 Budesonide nebulisation 2 mg in 4 ml NS
single dose.
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 MANAGEMENT - SEVERE
CROUP
 Oxygen.
 Iv fluids.
 Nebulised adrenaline.
 Steroids -IV dexamethasone + budesonide neb.
 Artificial airway .
ET tube – one size smaller than recommended
Quickly by experienced person
preferably under halothane anesthesia.

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 LARYNGOMALACIA
LARYNGEAL CONDITIONS

 Inspiratory collapse of arytenoids, aryepiglottic folds and epiglottis

 Anatomic, neurologic and inflammatory factors

 Symptoms:
 stridor, respiratory distress
 possible feeding difficulties
 weak cry
 vary with position and activity

 Onset usually delayed several weeks

 LARYNGOMALACIA
LARYNGEAL CONDITIONS

 Treatment
 Supportive
 Monitor symptoms, weight and feeding
 Role of antireflux medications (PPI, H2RA)
 Aryepiglottiplasty
 division of the short aryepiglottic folds
VOCAL CORD PARALYSIS
LARYNGEAL CONDITIONS

 2nd most common neonatal laryngeal anomaly

 Causes about 10% of congenital airway
obstruction
 Etiology
 increased ICP
 injury to vagus nerve
 injury to left recurrent laryngeal nerve
 20% result from traumatic birth
 VOCAL CORD PARALYSIS
LARYNGEAL CONDITIONS
 Clinical Findings
 Inspiratory stridor

 Cyanosis, apneas (bilateral)

 Weak/hoarse cry, aphonia (unilateral)

 Feeding difficulties (unilateral)

 Diagnosis
 direct laryngoscopy

 Treatment
 expectant

 reduce ICP (if present)

 Tracheostomy (bilateral)
 LARYNGEAL WEB
LARYNGEAL CONDITIONS

 Etiology- failure of laryngeal recanalization

 complete occlusion by mucosal and submucosal tissue
 partial occlusion by a thin membranous web
 Incidence- 1/10,000 births
 Clinical findings
 stridor
 weak or absent cry
 not positional
 Treatment
 Perforation, excision, dilation,
Cryotherapy, CO2 laser
 SUBGLOTTIC
HEMANGIOMA
 Relatively rare
 50% are associated
with cutaneous
hemangiomas
 Symptomatic within
first 2 months, and
present before 6
months
 Present with
inspiratory stridor
 SUBGLOTTIC STENOSIS
LARYNGEAL CONDITIONS

 Narrowing of the subglottic

airway
 housed in the cricoid
cartilage
 narrowest area of airway
 Congenital and acquired
 Most common abnormality
requiring trach in children <1yr
 ACQUIRED SUBGLOTTIC
STENOSIS
FACTORS IMPLICATED IN ITS DEVELOPMENT

 ETT size relative to child’s larynx

 Duration of intubation
 Motion of the tube
 Repeated intubations
 Factors affecting wound healing
 Laryngotracheal reflux
 Infection (historically tuberculosis and diphtheria)
 DO`S & DON`TS IN SEVERE
CROUP
DO`S DONT’S
 Treat on priority basis  Do not panic.

 Relieve anxiety  Don`t disturb sleep.

 Humidified oxygen  comfort the child,Avoid crying.

 Portable x-ray neck  Don`t send to x-ray room.

 If pus-antibiotics & send  Don’t neglect child till x-ray.

investigation  No IVF or venepuncture until
 Consult ENT surgeon or airway is secured
anaesthetist  Do not wait for culture for
antibiotics
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 IMPORTANT POINTS

Symptomatic child with increased work of

breathing should be treated with glucocorticoids
 Rx may be with dexamethasone or nebulised
budesonide
 Use L/ Epinephrine for moderate or severe croup
 Glucocorticoids reduce hospitalisation
 Injectable dexamethasone provides more benefit
than nebulised budesonide

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 EPIGLOTTITIS

 Stabilize airway under controlled

situation.
 Antibiotics – ampicillin and
chloramphenicol or 3rd generation
cephalosporins.
 Bacterial tracheitis - Use appropriate
antibiotics.
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 PROGNOSIS

 Depends on severity of illness

 Complications -obstruction of the airway,
atelectasis, pneumothorax, obstructive
mediastinal emphysema, and
bronchopneumonia
 morbidity and mortality of epiglottitis can be
very high with bacteremia often resulting in
meningitis, septic arthritis or osteomyelitis .

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 RECURRENT
  Allergic (spasmodic) croup 

  Respiratory infections in a child with otherwise

asymptomatic anatomic narrowing of the
large airways 

  Laryngomalacia
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 PERSISTENT STRID
- CAU
 Laryngeal obstruction 

 Laryngomalacia 
 Papillomas, other tumors 
 Cysts and laryngoceles 
 Laryngeal webs 
 Bilateral abductor paralysis of the cords
 Foreign body 
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 TRACHEOBRONCHIAL
DISEASE

 Tracheomalacia 
 Subglottic tracheal webs
 Endotracheal, endobronchial
tumors 
 Subglottic tracheal stenosis
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 EXTRINSIC MASSES

  Mediastinal masses 
 Vascular ring 
 Lobar emphysema 
 Bronchogenic cysts 
 Thyroid enlargement 
 Esophageal foreign body
 Tracheoesophageal fistulas
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 OTHER

 Gastroesophageal reflux
 Macroglossia, Pierre Robin syndrome
 Cri-du-chat syndrome
 Hysterical stridor
 Hypocalcemia
 Vocal cord paralysis
 Chiari crisis
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 SYMPTOMS OF
LARYNGOMALACIA

 Onset typically days to weeks after birth

 Most commonly within the first 2 weeks of life
 Inspiratory stridor
 Low pitch with a fluttering quality
 secondary to circumferential rimming of the supraglottic airway and
aryepiglottic folds

 More prominent when child is

 Supine
 Agitated
 Louder quality with more forceable inspiration
 Often associated with general noisy respiration

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 DIAGNOSIS OF
LARYNGOMALACIA

 Clinical assessment
 Suspect laryngomalacia in a neonate with
auscultation of inspiratory stridor
 Confirm suspicion with flexible laryngoscopy

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 FLEXIBLE
LARYNGOSCOPY
FINDINGS WITH
LARYNGOMALACIA
 Cyclical collapse of supraglottic larynx with inspiration
 Short aryepiglottic folds
 Draw the cuneiform and corniculate cartilages forward over the
laryngeal inlet resulting in prolapse during inspiration

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 LARYNGOMALACIA SEEN BY
FLEXIBLE LARYNGOSCOPY

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THANK YOU

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