Stridor Flashcards by Sumaya L

TirWhat is stridor?

A high-pitched monophonic wheeze best heard over the anterior neck, signifying large airway obstruction

May require emergency intervention.

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Common causes of stridor in infants include:

Laryngomalacia
Laryngotracheobronchitis
Foreign body

Laryngomalacia is the most common cause.

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For children aged 1-5 years, what is the most common cause of stridor?

Croup
Other common causes in this age include foreign bodies, laryngomalacia and laryngeal papilloma.

80% of children presenting with stridor and cough will have croup.

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What are the common causes of stridor in older children (>5 years)?

Retropharyngeal abscess
Foreign bodies
Croup

These remain the most prevalent causes.

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What are the symptoms of croup?

Barking cough worse at night
Hoarseness
Fever
Coryzal symptoms
History of preceding URI

Commonly caused by parainfluenza virus.

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What does a CXR show in cases of croup?

Classic steeple sign

Management includes dexamethasone and adrenaline for severe symptoms.

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What is the aetiology of croup?

It is commonly caused by parainfluenza virus, but may also be caused by RSV, rhinovirus and influenza

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What are the symptoms of epiglottitis?

Sudden onset high fever
Muffled voice
Dysphagia
Drooling saliva
tripod position due to respiratory distress

It is caused by haemophilius influenza type B

Caused by Haemophilus influenzae type B.

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What is the management of croup?

Adrenaline should be given immediately for warning signs like cyanosis, stridor at rest, agitation

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What does a CXR show in cases of epiglottitis?

Thumbprint sign

Treatment includes immediate endotracheal intubation and antibiotics.

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What is the treatment of epiglottis?

Treatment is immediate endotracheal intubation due to high risk of airway compromise and antibiotic ceftriaxone and vancomycin combination for influenza

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What prophylaxis can be given for Epiglottitis?

rifampicin

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What causes coughing and stridor in infants under 1 years old?

Vasucalr ring: Abnormal vascular development causing airway and esophagus compression

Key differential is that stridor improves with neck extension.

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How to differentiate Epiglottitis from vascular ring?

A key differential is the stridor will improve with neck extension.

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What is laryngomalacia?

Congenital anomaly of omega shaped epiglottis causing inspiratory stridor in infants In the first few days of life from collapse of the supraglottic structures during inspiration.

Characterized by an omega-shaped epiglottis.

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What are the types of laryngomalacia?

Type 1: Tightening of the aryepiglottic folds
Type 2: Redundant tissue in the supraglottic region
Type 3: Associated with other disorders Like NM weakness or

Stridor peaks in intensity at 4-8 months.

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What is the feature of stridor in Laryngomalacia?

This stridor peaks in intensity at 4-8 months: The stridor worsens when supine/eating and improves when baby is upright and crying

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What are the features of stridor in Laryngomalacia?

This stridor peaks in intensity at 4-8 months: The stridor worsens when supine/eating and improves when baby is upright and crying

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What relieves stridor in Laryngomalacia?

Symptomatic relief may be provided by hyperextending the neck during episodes of stridor

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What is used to investigate Laryngomalacia?

A key investigation aside from clincial history is visualisation of the epiglottis with fibre optic laryngoscope

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What is the management of larnygomalacia?

observation if infant has normal weight gain.

For infants with GERD, cyanosis or apnea, endoscopy and surgery is required. Surgery includes tracheostomy, laryngoplasty, excision of redundant mucosa, laser epiglottopexy or laser division of the l folds

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What is the management for infants with GERD and stridor?

Endoscopy and surgery

Surgery may include tracheostomy, laryngoplasty, or laser procedures.

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What is a retropharyngeal abscess?

Abscess in children under 6 years with fever, dysphagia, and muffled voice

Linked to underlying sinusitis or previous infections.

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What is the cause of Retropharyngeal abscess?

pathophysiology is related to underlying sinusitis, previous upper respiratory resp infection, acute otitis media or sinusitis.

As an abscess, it is linked to causative organisms like Group A strep, staph aureus and anaerobes.

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How do patients with Retropharyngeal abscess present?

They will have difficulty extending neck or opening mouth and have tender anterior cervical lymphadenoapthy

What is the first line investigation of Retropharyngeal abscess?

Lateral X-ray is first line and will show widened pre-vertebral space.

What is the gold standard investigation of Retropharyngeal abscess?

CT w/ abscess

What is the gold standard investigation for a **retropharyngeal abscess**?

CT with contrast ## Footnote Management depends on patient stability.

How to manage Retropharyngeal abscess?

based on patient stability. If unstable, or abscess is over 2.5cm, intubate and surgical drainage. For stable patients, empiric antibiotics and then repeat CT with contrast.

What are the symptoms of **foreign body aspiration**?

* Sudden onset respiratory distress * Biphasic stridor * Unilateral wheezing ## Footnote CXR shows mediastinal shift towards the unaffected side.

What will imaging show for foreign body aspiration?

CXR will show mediastinal shift towards the unaffected side.

How to differentiate foreign boy aspiration and tension pneumothorax?

To distinguish it from tension pneumothorax, there will be hyperinflation of the affected side. Unless aspirated objects are metal, they will not be visualised on CXR.

What is the management of foreign boy aspiration?

rigid bronchoscopy

When does bacterial tracheitis?

Occurs following a viral URI, where there is superinfection with staphylococcus aureus. There will be croup-like cough with tracheal narrowing on CXR.

What is a late sign of bacterial tracheitis?

In severe cases of upper airway obstruction, the stridor may become softer or silent. This may be a late sign in bacterial tracheitis

What is the management for **bacterial tracheitis**?

Antibiotics and supportive care ## Footnote Occurs following a viral URI with superinfection.

What should be suspected in children with stridor from developing countries or no vaccination history?

Diphtheria: Oral exminaion will show grey or off-white tonisllar pseudomembrane.; ## Footnote Oral examination shows grey or off-white tonsillar pseudomembrane.

What are the two areas of **extrathoracic stridor**?

* Supraglottic area * Glottis and subglottic area ## Footnote These areas affect different structures in the airway.

Which areas are affected in the supraglottic area?

affecting nasopharyngeal, epiglottis, larynx and false vocal cords

Which structures are affectied in the glottis and subglottic area?

extends from vocal cords to extra thoracic trachea

What causes intrathoracic stridor?

caused by structures like vascular rings, foreign body or compression from a tumour

What causes **inspiratory stridor**?

Extrathoracic obstruction from decreased airway pressure ## Footnote Occurs in conditions like epiglottitis and croup.

Which conditions cause Inspiratory stridor?

*Epiglottitis *Croup *Laryngomalacia *Retropharyngeal abscess *Foreign body *Craniofacial abnormalities

What causes **expiratory stridor**?

Intrathoracic obstruction from an intrathoracic obstruction such as: * Vascular rings * Foreign body * Tumour ## Footnote Examples include vascular rings and tumors.

What is **biphasic stridor** associated with?

Fixed obstruction such as: *vocal cord paralysis typically after neck surgery, thyroid procedures or intubation *Subglottic stenosis, which is either congenital or from intubation *Laryngeal patholgoy such as webs, cyst or tumour *Tracheal pathology like tracheomalacia or trachea stenosis ## Footnote Can occur after neck surgery or intubation.

What causes stridor that does not imrpove with neck extension?

laryngomalacia and Epiglottitis

What causes stridor that does imrpove with neck extension?

vascular ring

What are the investigations of stridor?

identifying and managing serious causes. * If the child is comfortable, observations can be taken (ie oxygen saturation, respiratory rate, temperature, pulse) * It is important to avoid upsetting the child and potentially compromising the airway * Avoid inspecting the throat, attempting bloods or x-rays or pressing an oxygen mask to the child's face.

What are the investigations for choking in children?

CXR Bronchoscopy

What is the key management for **stridor**?

* Keep the child comfortable * Call for urgent help if severe for paediatric and anaesthetic registrars for consideration of intubation. * Treat underlying cause ## Footnote Avoid upsetting the child to prevent airway compromise.

What is the management for choking in children if the object can be seen in the mouth?

Attempt to remove it ## Footnote If conscious and can cough, encourage coughing to dislodge the obstruction.

If a child is unconscious due to choking, what should be done first?

Start with 5 rescue breaths Then immediately commence CPR ## Footnote Then immediately commence CPR.

If a child is conscious but cannot cough due to choking, what should be done first?

Give 5 back blows followed by 5 chest (infant)/abdominal (child) thrusts.

If child is conscious and can cough, what should be done?

Encourage the child to continue coughing to help dislodge the obstruction.

What causes drooling and child in tripod position?

Likely acute Epiglottitis

What to do for infant with suspected bronchiolitisand low oxygen saturation?

Admit for observation and consideration of airway suction and supportive therapy

What causes initial croup-like symptoms that failed to respond to steroids?

Bacterial tracheitis

What is the classic presentation of acute Epiglottitis?

drooling, reluctance to lie flat, and a "hot potato" voice

What are some common **objects** that may be ingested?

* Coins * Toys * Jewelry * Batteries * Food items ## Footnote The list of potentially ingestible items is virtually limitless and varies based on cultural, environmental, and individual factors.

Name **high-risk objects** that may cause complications if ingested.

* Batteries * Large objects that may become trapped at the pylorus * Absorbent materials that may cause obstruction * Magnets swallowed with metal objects * Lead-based objects * Objects containing toxins ## Footnote These objects pose a greater risk for serious complications.

What are some **symptoms** of foreign body ingestion?

* Drooling * Difficulty swallowing or painful swallowing * Refusal to eat * Chest, throat, or abdominal pain * Vomiting * Blood in the stool ## Footnote The onset and type of symptoms can be influenced by the size, shape, location, and nature of the foreign body.

True or false: **Investigations** are necessary in an asymptomatic child with low-risk ingestion.

FALSE ## Footnote Investigations are unnecessary in asymptomatic children with low-risk ingestion.

What **investigations** may be conducted for symptomatic patients or those who have ingested high-risk objects?

* Plain radiography * Computed Tomography (CT) * Direct visualization with endoscopy ## Footnote These methods help in detecting foreign bodies based on their properties.

The majority of foreign bodies that are swallowed can be managed conservatively, including _______ and symptomatic treatment.

observation ## Footnote High-risk objects may require endoscopic or surgical removal.

What should clinicians provide to patients regarding foreign body ingestion?

Clear discharge instructions regarding potential complications and when to seek immediate medical attention ## Footnote This is crucial for ensuring patient safety after ingestion.

What causes a halo sign on chest radiograph?

Battery -> Urgent removal under general anaesthetic (rigid bronchoscopy

What is a dangerous object for children to swallow?b

battery which can react with bodily fluids such as saliva, which allows the battery to leak a strong alkaline fluid which can burn through the tissue

What to do for Asymptomatic patients without evidence of obstruction?

Observe the patient for spontaneous passage of the foreign body and arrange for follow-up

Which objects require monitoring?

Sharp or toxic foreign objects or child with symptoms like abdominal pain, vomiting or fialure to pass the object

What causes stridor worse in infants on feeding, causing fialure to thrive?

Laryngomalacia, which is the most common cause of stridor in infants.

What is the cause of Laryngomalacia?

It is a congenital abnormality which occurs due to a floppy epiglottis which folds into the airway on inspiration. This is normally a self-limiting condition, but if the stridor becomes severe with signs of respiratory distress, or if there is failure to thrive (due to poor feeding), then surgery is recommended to improve the airway.

What is the most common cause of pneumoina in children?

Streptococcus pneumonia

What is the first line antibiotic for paediatric pneumonia?

Streptococcus pneumonia

What is second line for paediatric pneumonia?

Macrolide

What antibiotic agent should be changed for paediatric pneumoina?

Use macrolide if mycoplasma or chlamydia is suspected

What antibiotc to use in pnuoeina associated with influenza?

Co-amoxiclav

What sign is an indication for admission for croup?

Audible stridor at rest

What is the NICE guidance for croup admission?

moderate or severe croup < 3 months of age known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome) uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)

What differentiates moderate and severe croup?

Severe croup has respiratory distress

What are the antibiotics for croup in infant loss than 3 months

When are macrolide prescribed?

Whooping cough caused by bordatella pertussis

What causes widespread crackles in an infant with respiratory distress?

Bronchiolitis

Which condition always requires steroids as part of management?

Croup

What cases acute onset of fever and sore throat in a child same day with foraward lean?

Epiglottitis, marked by tripod position

What causes stridor when infant lies on back or during feeding?

Laryngomalacia

What causes coryzal symptoms, cough, fever and bilateral crackles?

Bronchiolitis which should be managed with supportive

What to prescribe for child with pneumonia suspected in mycoplasma?

Macrolide antibiotic

When is throat examination contraindicated?

Throat examination is contraindicated in croup due to risk of airway obstruction. The risk is even greater in acute epiglottitis

When do NICE clarify to consider as pneumonia?

Consider a diagnosis of pneumonia if the child has: high fever (over 39°C) and/or persistently focal crackles

Management of stridor vs croup

Croup = Corticosteroids Bronchiolitis = Bugger all (supportive management

What should be suspected in an otherwise well infant with noisy breathing?

Laryngomalacia which can present in the first weeks of life, caused by a congenital softening of the cartilage of the larynx, causing collapse during inspiration

What to suspect in child with wheeze after viral illness?

Bronchiolitis

What makes bronchiolitis unlikely?

Absenc of wheeze

What causes paroxysmal cough in a Pyrexia infant with clear chest?

Early pertussis

What is a febrile pneumoina syndrome?

Chlamydia trachomatis pneumonia: typically presents at 1-3 months of age with a staccato cough and no fever. Additionally, there would be a history of conjunctivitis from birth which was not mentioned in the scenario.

What is the most common cause of stridor in infants?

Laryngomalacia

What causes apnoea and cyanosis with coughing fit?

Whooping cough caused by bordatella pertussis

What causes persistent cough with vomiting!

Whooping cough do manage with macrolide antibiotics in first 21 days of presentation

What confirms diagnosis of Epiglottitis?

direct visualisation of inflamed tissue from a senior anaesthetist in theatre -> x ray is for investigation

What causes Inspiratory stridor?

Supraglottitis

What causes expiratory stridor?

Infraglottitis

What is a key principle for managing glottitis?

For stable patients, treatment with nebulised adrenaline and IV dexamethasone to reduce mucosal oedema and then secure airway support.

What is essential first in Epiglottitis?

Referral to ENT/anaesthetics rather than immediate medical management

What causes stridor and pushing tongue out?

Epiglottitis suspicion as tongue out is an attempts to increase airway space so urgently call ENT

What medical treatment to give for Epiglottitis?

IV cefuroxime to treat the underlying bacterial infection, typically caused by Haemophilus influenzae type B

Stridor Flashcards

(106 cards)