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Paeds: Respiratory > Stridor > Flashcards

Stridor Flashcards

1
Q

What is stridor?

A

harsh, musical sound due to partial obstruction of the lower portion of the upper airway, including the upper trachea and larynx

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2
Q

What is the most common cause of stridor? How serious is this?

A

Laryngeal and tracheal infection, most commonly in the form of viral laryngotracheobronchitis aka croup

mucosal inflammation and swelling can rapidly cause life-threatening obstruction of the airway in young children

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3
Q

In addition to croup, what are 12 rarer causes of stridor?

A
  1. Epiglottitis
  2. Bacterial tracheitis
  3. Laryngeal or oesophageal foreign body
  4. Allergic laryngeal angioedema (anaphylaxis and recurrent croup)
  5. Inhalation of smoke and hot fumes in fires
  6. Trauma to the throat
  7. Retropharyngeal abscess
  8. Hypocalcaemia
  9. Severe lymph node swelling (TB, infectious mononucleosis, malignancy)
  10. Measles
  11. Diphtheria
  12. Psychological - vocal cord dysfunction
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4
Q

What are 2 causes of allergic laryngeal angioedema?

A
  1. Anaphylaxis
  2. Recurrent croup
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5
Q

What are 3 causes of severe lymph node swelling that can cause stridor?

A
  1. Tuberculosis
  2. Infectious mononucleosis
  3. Malignancy
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6
Q

How can the severity of upper airways obstruction be best assessed clinically? 2 ways

A
  1. Characteristics of stridor: none, only on crying, at rest, biphasic
  2. Degree of chest retraction: none, only on crying, at rest
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7
Q

In addition to stridor characteristics and chest retraction, what are 4 additional features that can be seen in severe upper airways obstruction?

A
  1. Increasing respiratory rate
  2. Heart rate increase
  3. Agitation
  4. Central cyanosis, drooling, reduced consciousness: impending complete obstruction
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8
Q

What are 3 features that suggest impending complete airway obstruction in stridor?

A
  1. Central cyanosis
  2. Drooling
  3. Reduced level of consciousness
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9
Q

What is the most reliable objective measure of hypoxaemia and how useful is this in upper airways obstruction?

A

Oxygen sats from pulse oximetry - but is a late feature of upper airways obstruction (unlike lung disease)

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10
Q

Why should you avoid looking at the throat of a child with upper airways obstruction unless full resuscitation equipment and personnel are at hand?

A

Total obstruction of the upper airway may be precipitated by exmaination of the throat using a spatula

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11
Q

What proportion of laryngotracheal infections are caused by viral croup?

A

95%

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12
Q

What is the most common cause of croup?

A

Parainfluenza viruses

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13
Q

What are 4 types of viruses which can cause croup?

A
  1. Parainfluenza viruses (most common)
  2. Rhinovirus
  3. RSV
  4. Influenza
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14
Q

Between which ages does croup typically occur? When is the peak?

A

6 months to 6 years of age; peak in second year of life (1-2yrs)

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15
Q

In what season is croup most common?

A

autumn

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16
Q

What are 6 clinical features of croup?

A
  1. Coryza and fever followed by:
  2. hoarseness due to inflammation of the vocal cords
  3. barking cough, like a sea lion
  4. harsh stridor
  5. variable degree of difficulty breathing with chest retraction
  6. symptoms start, and are worse, at night
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17
Q

What causes the characteristic barking cough of croup?

A

Tracheal oedema and collapse

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18
Q

What is likely to be the nature of the clinical signs of croup if it is mild?

A

stridor and chest recession disappear at rest

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19
Q

When can croup be managed at home? What are 6 additional features that influence the decision?

A

when upper airway obstruction is mild - stridor and chest recession disappear when child at rest

  1. time of day
  2. ease of access to hospital
  3. inadequate fluid intake
  4. child’s age - low threshold for admission if <12 months due to narrow airway calibre, all children <3mths
  5. Parental understanding and confidence about the disorder
  6. underlying conditions: immunodeficient, neuromuscular disorders, CLD, congenital heart disease
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20
Q

What are 4 aspects of management of croup at home?

A
  1. Tell parents to observe child closely for signs of increasing severity
  2. Steroids: oral dexamethasone, oral prednisolone or nebulised steroids (budesonide) - for EVERY patient
  3. Paracetamol and ibuprofen for fever and pain
  4. [Inhalation of warm moist air - not been shown to be beneficial]
21
Q

What is the benefit of prescribing steroids (oral or nebulised) for croup managed at home?

A

reduces severity and duration of group, first line for croup causing chest recession at rest

reduce need for hospitalisation

22
Q

What are 4 features of the management of severe upper airways obstruction?

A
  1. Oral dex/ pred or nebulised budesonide - first line for croup causing chest recession at rest
  2. Nebulised epinephrine (adrenaline) with oxygen by face mask
  3. Observe closely for 2-3 hours after administration as effects wear off
  4. Intubation - rare for viral croup due to introduction of steroid therapy
23
Q

What should guide the decision between oral and nebulised steroids to treat croup? What are the doses?

A

single dose of oral dexamethasone (0.15mg per kg) unless too unwell for oral medication, then give inhaled budesonide (2mg nebulised as single dose) OR IM dexamethasone (0.6mg/kg single dose)

24
Q

Over what time period does croup usually resolve?

A

usually within 48 hours

25
Q

What is acute epiglottitis?

A

intense swelling of epiglottis and surrounding tissues associated with sepsis - life-threatening emergency

26
Q

What are the effects of using nebulised epinephrine (adrenaline) to treat severe croup in hospital?

A

rapid but transient improvement, need to be monitored for 2-3 hours afterwards as effects wear off

27
Q

What may be the cause of a pattern of recurrent croup?

A

atopy

28
Q

Why is acute epiglottitis a life-threatening emergency?

A

high risk of respiratory obstruction

29
Q

What is the cause of acute epiglottitis?

A

H. influenzae type b

30
Q

Why has there been a >99% reduction in the incidence of epiglottitis in the UK?

A

due to universal Hib immunisation in infancy

31
Q

In what age group is epiglottitis most common?

A

children aged 1-6 years but affects all age groups

32
Q

Why is it important to distinguish between epiglottitis and croup as causes of stridor?

A

require very different treatment

33
Q

What are 9 differences in the clinical features between epiglottitis and croup?

A
  1. Onset: croup over days, epiglottitis over hours
  2. Preceding coryza: in croup not epiglottitis
  3. Cough: severe + barking vs absent or slight
  4. Able to drink: croup yes, epiglottitis no
  5. Drooling saliva: no in croup, yes in epiglottitis
  6. Appearance: unwell in croup but toxic/very ill in epiglottitis
  7. Fever: <38.5 in croup, >38.5 in epiglottitis
  8. Stridor: harsh and rasping in croup, soft and whispering in epiglottitis
  9. Voice/cry: hoarse in stridor, muffled/reluctant to speak in epiglottitis
34
Q

What are 7 features of the presentation of epiglottitis?

A
  1. High fever
  2. Very ill, toxic-looking child
  3. Intensely painful throat that prevents speaking or swallowing
  4. Saliva drools down chin (can’t swallow)
  5. Soft inspiratory stridor
  6. Rapidly increasing respiratory difficulty over hours
  7. Child sitting immobile, upright, with open mouth to optimise airway
35
Q

Is cough present in epiglottitis?

A

minimal or absent (unlike viral croup - barking cough)

36
Q

What are 3 important things not to do in a child with epiglottitis and why?

A
  1. lie child down
  2. examine throat with spatula
  3. perform lateral neck x-ray to identify swollen epiglottis/surrounding tissues

can precipitate total airway obstruction and death

37
Q

What is the management of suspected acute epiglottitis? 6 key steps

A
  1. Senior anaesthetist, paediatrician, ENT surgeon - summoned
  2. Transfer directly to ICU or anaesthetic room, accompanied by senior medical staff in case of respiratory obstruction
  3. Intubation with GA
  4. If intubation not possible, urgent tracheostomy
  5. After securing airway: blood taken for culture, IV antibiotics e.g. cefuroxime started. Give abx for 3-5 days
  6. Rifampicin offered to close hosuehold contacts
38
Q

How long should a tracheal tube usually be in for acute epiglottitis?

A

can usually be removed after 24 hours

39
Q

How long are antibiotics usually given for in acute epiglottitis and how long does recovery usually take?

A

given for 3-5 days

complete recovery usualy within 2-3 days

40
Q

What prophylaxis is offered to household contacts of children admitted with acute epiglottitis?

A

rifampicin as prophylaxis, as with other serious H. influenzae infections

41
Q

What is another name for bacterial tracheitis?

A

pseudomembranous croup

42
Q

What is the clinical appearance of bacterial tracheitis? 4 key features

A
  1. High fever
  2. Appear very ill
  3. Rapidly progressive airways obstruction
  4. Copious thick airway secretions
43
Q

What is the typical cause of bacterial tracheitis?

A

Staphylococcus aureus

44
Q

What is the management of bacterial tracheitis?

A

IV antibiotics and intubation, and ventilation if required

45
Q

What are 2 causes of stridor to consider if a child presents with an abrupt onset stridor without apparent infection?

A

anaphylaxis or inhaled foreign body

46
Q

What are 2 causes of chronic stridor?

A
  1. Intrinsic narrowing or collapse of laryngotracheal airway
  2. External compression
47
Q

What are 2 examples of narrowing or collapse of the laryngotracheal airway that can cause chronic stridor?

A
  1. Subglottic stenosis
  2. Laryngomalacia (floppy larynx)
48
Q

What are 3 examples of causes of external compression that can cause chronic stridor?

A
  1. Vascular ring
  2. Lymph nodes
  3. Tumours
49
Q

What is the speed of onset of oral or nebulised or IV steroids used for croup?

A

90-120 minutes

Paeds: Respiratory (7 decks)

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