4- stridor + sleep apnoea

Question 1

what is stridor?

Answer 1

predominantly inspiratory wheeze due to large airways obstruction (larynx/trachea/major bronchi)

Question 2

what is wheeze?

Answer 2

expiratory polyphonic wheeze due to narrowing of airways

Question 3

what are infections that can cause stridor in children?

Answer 3

• croup (inflammation/swelling of upper airway, common in very young kids, goes away by itself)
• epiglottitis (much more serious, risk of complete block)
• pseudomembranous croup (pseudomembrane in upper airway - thick, fibris, inflammatory membrane)
• retropharyngeal abscess (bacterial growth in lymph nodes behind throat
• diphtheria (unusual in Uk due to vaccine)
• infectious mononucleosis (glandular fever) = common in teenagers

Question 4

what are causes of stridor in children?

Answer 4

• infections
• foreign body e.g. peanut, lego
• anaphylaxis
• other e.g. trauma, burns

Question 5

what are causes of stridor in adults?

Answer 5

• neoplasms = larynx, trachea, bronchi
• goitre (large thyroid extending retrosternally)
• foreign body (more for elderly)
• trauma
• other e.g. recurrent laryngeal nerve, bilateral local cord palsy, rheumatoid arthritis (by either artritis of articulation of cartilage or destruction of cartilage)

acutely = anaphylaxis

Question 6

what is tracheomalacia?

Answer 6

→damaging of trachea (rheumatoid and other thing can damage it)

malacia= abnormal softening (mostly for cartilage)

Question 7

what investigations can be done for acute stridor?

Answer 7

• laryngoscopy (beware in acute epiglottitis, only 1 shot)
• bronchoscopy
• flow volume loop (like lines drawn on graph - would just show less air breathed out in expiration - has both inspiration & expiration)
• chest x-ray
• other imaging (CT; thyroid scan)

Question 8

what is cricothyroidotomy?

Answer 8

surgical procedure used to establish an emergency airway when traditional methods of intubation or ventilation are not feasible or have failed. It involves making an incision through the skin and cricothyroid membrane in the neck to create a temporary opening directly into the trachea

Question 9

what is heimlich manoeuvre?

Answer 9

• foreign body inhalation treatment

= rapid upward thrust in epigastrium forces upward movement of diaphragm and forced expiration

Question 10

what are treatment of malignant airway obstruction?

Answer 10

• Tumour removal:
• laser; photodynamic therapy (drug sensitive to light); cryotherapy (freeze tumour); diathermy; surgical resection
• Tumour compression: intraluminal stent
• Radiotherapy (external beam; brachytherapy)
• (Chemotherapy; Corticosteroids)

Question 11

what is anaphylaxis?

Answer 11

Type 1 hypersensitivity (triggered by IgE = immediate effect). often systemic reaction (effects all over body)

Question 12

what is the main symptom of anaphylaxis that causes problems?

Answer 12

angioneurotic oedema (lips, tongue→face, larynx, bronchi) = most dangerous part

Question 13

what are presenting symptoms of anaphylaxis?

Answer 13

• angioneurotic oedema
• hypotension (vasodilatation and plasma exudation) →circulatory collapse (shock)
• Stridor, wheeze and respiratory failure

Question 14

what are causes of anaphylaxis?

Answer 14

• foods e.g. nuts, shellfish
• insect venom e.g. bee, wasp
• drugs e.g. penicillin, aspirin, anaesthetics
• other e.g. latex

Question 15

what is treatment of anaphylaxis?

Answer 15

• if mild →oral anti-histamine
• if severe →epipen (1 shot of adrenaline). 2nd dose if no improvement after 5-10 mins
• supportive care e.g. if hypoxic = oxygen, if asthmatic reaction = nebulised bronchodilators like salbutamol

Question 16

what is management of anaphylaxis?

Answer 16

• identify allergy and avoid allergen (when possible)
• attempt immunotherapy (desensitization) by administering in small doses
• self-administered epinephrine

Question 17

what is obstructive sleep apnoea?

Answer 17

intermittent upper airway collapse in sleep

Question 18

what happens in obstructive sleep apnoea?

Answer 18

= when sleep, pharyngeal dilator muscle relax (along with all other muscles) and throat becomes floppy so you can’t breathe cause airways close (your ribcage and abdomen still trying to breathe) and then you get woken up (mostly not consciously) when you might gasp, reactivate muscles etc

Question 19

what are risk factors for obstructive sleep apnoea?

Answer 19

• enlarged tonsils
• overweight (biggest risk factor)
• retrognathia (ste back jaw making all crowded at back of throat)
• acromegaly, hyperthyroidism (hormones messing up stuff it hink)
• oropharyngeal deformity = congenital
• neurological e.g. stroke, MS, myasthenia gravis
• drugs e.g. benzodiazepines, opiated, alcohol
• post-op period after anaesthesia

Question 20

what is consequences of obstructive sleep apnoea?

Answer 20

profound sleep fragmentation (they wake up 100s of times throughout night so actually barely any sleep meaning sleepy/grumpy/cognitive impairment etc) = can’t drive if untreated

• bad for your health - each time you get told to wake you get adrenaline release which means high blood pressure, very activates sympathetic system
• raised CRP
• impaired endothelial dysfunction so more at risk to other conditions
• impaired glucose tolerance

= all improved by CPAP

Question 21

what is important treatment for obstructive sleep apnoea?

Answer 21

• CPAP = continuous positive airway pressure (very common and most effective)= puts air from environment into airways to keep them open (not supplying O2 just delivering it in effective way to keep airways open)
  
  • SIM card inbuilt technology to help monitor compliance, airleak and allow remote titration of pressures = this can be shown to DVLA to be allowed to drive
• remove underlying cause if possible

*also mouthguards for mild sleep apnoea

Question 22

what is mild and severe sleep apnoea numbers?

Answer 22

5-15 = mild

above 30 = severe

Question 23

what test can be done to help diagnose obstructive sleep apnoea?

Answer 23

• snoring + EPS
• overnight sleep study - given something to take home