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Y4 Respiratory > Stridor, anaphylaxis & sleep apnoea > Flashcards

Stridor, anaphylaxis & sleep apnoea Flashcards

1
Q

Define what stridor is

A

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

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2
Q

List the main causes of stridor in children

A
  • Laryngomalacia
  • Inhaled foreign bodies
  • Infections - croup, epiglottitis, retropharyngeal abscess, siptheria, infectious mononucleosis (IM)
  • Anaphylaxis
  • Trauma e.g. burns
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3
Q

List the main causes of stridor in adults

A
  • Neoplasms - of the larynx, trachea or main bronchi
  • Anaphylaxis
  • Goitre (retrosternal)
  • Foreign body
  • Trauma (eg strangulation, burns, irritant gases)
  • Other (eg bilateral vocal cord palsy; Wegener’s granulomatosis; cricoarytenoid arthritis (RA); tracheopathia
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4
Q

What is the most common foreign body which gets stuck in the airways ?

A

Peanuts

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5
Q

What age of child is most at risk of airway obstruction from a foregin body ?

A

Children < 3

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6
Q

What are the clinical features of an inhaled foreign body ?

A

Acute onset accompanied by a chocking spell:

  • cough
  • stridor
  • dyspnoea
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7
Q

What investigations should be done in someone suspected of having inhaled a foreign body ?

A

CXR & airway films

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8
Q

Describe what laryngomalacia is

A

It is a congenital softening of the tissues of the larynx (voice box) above the vocal cords. This is the most common cause of noisy breathing in infancy.

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9
Q

How does laryngomalacia typically present and when?

A

Infants typical present at 4 weeks of age with stridor

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10
Q

Is laryngomalacia a serious condition ?

A
  • In most cases, laryngomalacia in infants is not a serious condition — they have noisy breathing, but are able to eat and grow.
  • It will resolve for these cases by about 18-20months old
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11
Q

What is a retropharyngeal abscess ?

A

It is an abscess located in the tissues in the back of the throat behind the posterior pharyngeal wall (the retropharyngeal space).

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12
Q

What are the signs/symptoms of a retropharyngeal abscess ?

A
  • Stiff neck (limited neck mobility or torticollis)
  • Some form of palpable neck pain (may be in “front of the neck” or around the Adam’s Apple)
  • Malaise
  • Difficulty swallowing
  • Fever
  • Stridor
  • Drooling
  • Croup-like cough
  • Enlarged cervical lymph nodes
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13
Q

What is the difference in ages groups that retropharyngeal abscesses occur compared to a peritonsillar abscess ?

A

Peritonsillar occur commonly in adolescents and young adults whereas retropharyngeal abscesses occur mainly in children < 5 years of age

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14
Q

How is a retropharyngeal abscess diagnosed ?

A
  • 1st line = lateral neck X-ray
  • 2nd line = CT
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15
Q

What is the treatment of a retropharyngeal abscess ?

A

IV antibiotics & surgical drainage

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16
Q

What investigations may be done in someone presenting with stridor ?

A
  • Laryngoscopy (beware in acute epiglottitis)
  • Bronchoscopy
  • Flow volume loop
  • Chest X ray
  • Other imaging (CT; thyroid scan)
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17
Q

What is the treatment of laryngeal obstruction ?

A
  • Treat underlying cause eg foreign body removal, anaphylaxis
  • Mask bag ventilation with high flow O2
  • Cricothyroidotomy
  • Tracheostomy
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18
Q

What manoeuvre is used to attempt to dislodge a inhaled foreign body ?

A

Heimlich manoeuvre - Rapid upward thrust in epigastrium forces upward movement of diaphragm and forced expiration

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19
Q

Define what anaphylaxis is

A
  • It is a severe, life-threatening, generalised or systemic hypersensitivity reaction.
  • Resulting in angioedema causing respiratroy compromise followed by cardiovascular collapse (shock). Often with urticaria
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20
Q

What type of hypersensitivity reaction is anaphylaxis ?

A

Type 1 (immediate) hypersensitivity (IgE)

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21
Q

List the different causes of anaphylaxis

A
  • Foods eg nuts; shellfish
  • Insect venom (bee, wasp)
  • Drugs (Antibiotics e.g. penicillin, aspirin, anaesthetics, contrast media etc)
  • Other eg latex
22
Q

What are the clinical features of anaphylaxis ?

A
  • Flushing, pruritus, urticaria,
  • Angioneurotic oedema (lips, tongueà face, larynx, bronchi)
  • GI symptoms - abdominal pain, vomiting, incontinence
  • Hypotension (vasodilatation and plasma exudation) ==> circulatory collapse (shock)
  • Stridor, wheeze and respiratory failure
23
Q

An anaphylactic reaction is highly likely when what 3 criteria is met ?

A
  1. Sudden onset and rapid progression of symptoms
  2. Life-threatening Airway and/or Breathing and/or Circulation problems
  3. Skin and/or mucosal changes (flushing, urticaria, angioedema)
24
Q

What also helps support the diagnosis of anaphylaxis ?

A

Exposure to a known allergen / trigger for the patient helps support the diagnosis

25
Q

What assessment is key to be done in someone presenting with a potential anaphylactic reaction ?

A

ABCDE

26
Q

Considering A of the ABCDE assessment, what airway problems suggest an anaphylactic reaction ?

A
  • Airway swelling e.g. throat and tongue swelling
  • Difficulty in breathing and swallowing
  • Sensation that throat is ‘closing up’
  • Hoarse voice
  • Stridor
27
Q

Considering B of the ABCDE assessment, what breathing problems suggest an anaphylactic reaction ?

A
  • Shortness of breath
  • Increased respiratory rate
  • Wheeze
  • Patient becoming tired
  • Confusion caused by hypoxia
  • Cyanosis (appears blue) – a late sign
  • Respiratory arrest
28
Q

Considering C of the ABCDE assessment, what circulatory problems suggest an anaphylactic reaction ?

A
  • Signs of shock – pale, clammy
  • Tachycardia
  • Hypotension
  • Myocardial ischaemia / angina
  • Cardiac arrest
29
Q

Considering D of the ABCDE assessment, what disability problems suggest an anaphylactic reaction ?

A
  • Sense of “impending doom”
  • Anxiety, panic
  • Decreased conscious level caused by airway, breathing or circulation problem
30
Q

Considering E of the ABCDE assessment, what disability problems suggest an anaphylactic reaction ?

A
  • Skin changes often the first feature
  • Present in over 80% of anaphylactic reactions
  • Skin, mucosal, or both skin and mucosal changes
  • Erythema – a patchy, or generalised, red rash
  • Urticaria (also called hives, nettle rash, weals or welts) anywhere on the body
  • Angioedema - similar to urticaria but involves swelling of deeper tissues e.g. eyelids and lips, sometimes in the mouth and throat
31
Q

List the differentials other than anaphylaxis for someone presenting with clinical features of anaphylaxis ?

A
  • Asthma
  • Septic shock
  • Vasovagal episode
  • Panic attack
  • Breath-holding episode in a child
  • Idiopathic (non-allergic) urticaria or angioedema
32
Q

What is the initial resucitation treatment of anaphyalxis ?

A
  • IM adrenaline (epinephrine) (dose can be repeated every 5 mins if necessary) + rapid IV fluid challenge (due to large volumes of fluid leaking from patients circulation during anaphylaxis reaction)
  • High flow O2
  • Consider further bronchodilator therapy with salbutamol (inhaled or IV), ipratropium (inhaled), aminophylline (IV) or magnesium (IV)
33
Q

What are the different dosages used of IV fluids, adrenaline, cholramphenamine and hydrocortisone used for treatment of anaphylaxis ?

A
34
Q

What is the treatment of an anaphylaxis reaction following the initial resucitation treatment ?

A

IM or IV Antihistamine (chlorphenamine) + IM or IV steroids (hydrocortisone)

35
Q

Sometimes it can be difficult to establish whether a patient had a true episode of anaphylaxis. What can be done to confirm if someone has a true anaphylactic reaction?

A

Measuring mast cell tryptase.

36
Q

Once someone is confirmed to have had an anaphylactic reaction what is prophylactic treatment is then provided ?

A
  • Allergen avoidance (where possible)
  • Desensitisation (immunotherapy) eg venom
  • Give a self-administered epinephrine (epipen)
37
Q

Anaphylaxis is one of the few times when you would not have time to look up the dose of a medication.

What are the doses of adrenaline you should give for the following age groups:

  • < 6 years
  • 6-12 years
  • > 12 years
A
  • <6 years - 150 micrograms
  • 6-12 years - 300 micrograms
  • > 12 years - 500 micrograms
38
Q

Anaphylaxis is one of the few times when you would not have time to look up the dose of a medication.

What are the doses of hydrocortisone you should give for the following age groups:

  • < 6 months
  • 6months - 6 years
  • 6-12 years
  • > 12 years
A
  • < 6 months - 25mg
  • 6months - 6 years - 50mg
  • 6-12 years - 100mg
  • > 12 years - 200mg
39
Q

Anaphylaxis is one of the few times when you would not have time to look up the dose of a medication.

What are the doses of Chlorphenamineyou should give for the following age groups:

  • < 6 months
  • 6months - 6 years
  • 6-12 years
  • > 12 years
A
  • < 6 months - 25 micrograms/kg
  • 6months - 6 years - 2.5mg
  • 6-12 years - 5mg
  • > 12 years - 10mg
40
Q

Where on the body should you give an IM injection of adrenaline ?

A

Anterolateral aspect of the middle third of the thigh.

41
Q

Define what snoring is and what causes it

A
  • It is a snorting or grunting sound when you sleep
  • Caused by relaxation of pharyngeal dilator muscles during sleep (esp. REM) resulting in upper airway narrowing, turbulent airflow and vibration of soft palate and tongue base
42
Q

Define what obstructive sleep apnoea (OSA) is

A
  • This is intermittent upper airway collapse in sleep resulting in apnoeas or hypopnoeas ± hypoxaemia (breathing stops for a bit then starts again)
  • This leads to recurrent arousals / sleep fragmentation
43
Q

What are the risk factors for developing OSA?

A
  • Enlarged tonsils, adenoids
  • Obesity
  • Retrognathia
  • Acromegaly, hypothyroidism
  • Oropharyngeal deformity
  • Neurological: stroke, MS, myesthenia gravis, myotonic dystrophy
  • Drugs: benzodiazepines, opiates, alcohol,
  • Post-operative period after anaesthesia
44
Q

What does the partner of someone with OSA often complain of ?

A

Excessive snoring and may report periods of apnoea.

45
Q

What are the consequences of OSA?

A
  • Excessive daytime sleepiness
  • Personality change
  • Cognitive / functional impairment
  • Major impact on daytime function
  • 7-fold increase in RTA – it is the equivalent to being twice legal limit for alcohol
  • Independent risk factor for hypertension
  • Activated sympathetic system
  • Raised CRP
  • Impaired endothelial function
  • Impaired glucose tolerance
  • (probable increased risk of stroke and cardiovascular events)
46
Q

How is OSA diagnosed ?

A

Assessment of sleepiness:

  • Epworth Sleepiness Scale - questionnaire completed by patient +/- partner (raised score suggestive)
  • Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)

Diagnostic test = Overnight Sleep studies (polysomnography)

47
Q

What is measured on an overnight sleep study ?

A
  • oximetry
  • Domicillary recording (airflow, oximetry, thoracic/abdominal movement)
  • Full polysomnography
48
Q

What is the treatment of OSA?

A

1st line = Remove underlying cause & weight loss + CPAP

49
Q

Who should be informed if someone has OSA causing excessive daytime sleepiness ?

A

DVLA

50
Q

What other treatment may be used instead of CPAP for OSA and when can it be used ?

A

Intra-oral devices (e.g. mandibular advancement) - may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness

Y4 Respiratory (27 decks)

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