Seminar 2 - Acute stridor, causes, features and management

Acute stridor

1. 1. Describe the causes and pathogenesis of acute stridor. 2. Describe the common causal organisms of ALTB- Croups & Epiglottitis

2. What is Acute stridor? harsh, high-pitch sound produced when the airway becomes partially obstructed,which can result in turbulent airflow Present in both inspiration & expiration but more prominent during inhalation It is a sign of children having underlying pathological problem Commonly seen in infants (age <1 yr) and young children Aetiology differ depending whether patient is child or adult

3. Types of stridor & Pathophysiology Inspiratory stridor = Extrathoracic obstruction - any obstruction which occurs above the vocal cord Expiratory stridor = Intrathoracic obstruction - any obstruction which occurs below the vocal cord Depending on the anatomic location involved and also what type of pathological cause involved - extrathoracic region = nose, larynx & trachea - intrathoracic region = distal trachea & bronchi Concerning part = Subglottic area - lower part of the larynx (below the vocal cord) - cause narrowing result in minimal airway flow - increase airway resistance

4. Causes of stridor Congenital causes Nasal deformities E.g. choanal atresia, septum deformities Laryngeal anomalies E.g. laryngomalacia, laryngeal webs, laryngeal cysts Craniofacial anomalies E.g. Pierre Robin or Apert syndromes Acquired causes Croup (Laryngotracheobronchitis) Epiglottitis Foreign body inhalation Diphtheria Adenoid hypertrophy Tonsil hypertrophy Pierre Robin Syndrome / Macroglossia Anaphylaxis

5. Pierre Robin syndrome Choanal atresia Septum deformities Airway burns Croup Tonsil hypertrophy

6. What is diphtheria? Serious bacterial infection that affects the mucous membrane of nose & throat Very rare due to widespread vaccine (DTaP and Tdap) Causal organism: Corynebacterium diphtheriae MOT : 1) Airborne droplets 2) Contaminated items Common symptoms are: - sore throat - stridor - difficulty breathing or rapid breathing - nasal discharge

7. People who are risk: - childrens & adults who don’t have up-to-date vaccinations - people who lives in unsanitary area - past history of travelling to diphtheria infections areas What are the complications experience? - breathing problems (produces a toxin) - heart damage (toxin can spread) - nerve damage

8. Foreign body inhalation Things which are not suppose to enter into the trachea or the larynx Potentially life-threatening Very common in young children (<4 years old) Most inhaled foreign bodies will be located in the bronchi E.g. nuts, popcorn, coins, pieces of toys

9. Croup (Laryngotracheobronchitis) Self-limiting upper airway viral infection Results in inflammation of the larynx and trachea leads to obstruction of airway (edema of the subglottic area) Result in severe narrowing of the airway (trachea) Common in children = 6 months - 3 years old Boys > Girls Common cause = virus (95%) - Parainfluenza virus 1 & 2 - Respiratory syncytial virus (RSV) - Human metapneumovirus - Influenza virus

10. Bacterial tracheitis (pseudomembranous croup) Rare but dangerous condition Similar to viral croup but slight difference in the symptoms - rapid progressive airway obstruction (thick secretion) Common cause: Staphylococcus aureus Can be treated with intravenous antibiotics or intubation if necessary

11. Epiglottitis Inflammation & swelling of the epiglottis life - threatening condition because blocks the flow of the air Common in children aged 1-6 years Causes: 1) Group A Streptococcus 2) Haemophilus influenzae type B (Hib) 3) Trauma from foreign objects 4) Chemical burns Surrounding area will also be affected

12. Why common in child than adults? - Epiglottitis

13. Describe the clinical features of ALTB- Croups & Epiglottitis Describe the relevant investigations and findings of ALTB & Epiglottitis

14. Clinical Features Acute Laryngotracheobrontis (ALTB) / Croup Viral croup accounts for over 95% of laryngotracheal infections Low grade fever and coryza (12-72 hours) Barking cough and hoarseness Stridor (when excited/ at rest/ both) Varying degree of respiratory distress with chest retraction

15. Clinical Features Epiglottitis Life threatening emergency due to high risk of respiratory obstruction Onset is usually very acute High fever Intensely painful throat → can’t speak or swallow (drooling saliva) Soft inspiratory stridor Rapidly increasing respiratory difficulty Child is sitting upright with an open mouth

16. Investigations and Findings Acute Laryngotracheobrontis (ALTB) / Croup Clinical Diagnosis Usually no investigations needed as it may cause distress to child and worsen the symptoms Chest and neck x-ray can be done for assisting in diagnosis Steeple sign Distension of hypopharynx

17. Investigations and Findings Steeple sign Narrowing of subglottic airway Distended hypopharynx due to the patient's attempt at decreasing airway resistance

18. Investigations and Findings Acute Laryngotracheobrontis (ALTB) / Croup

19. Investigations and Findings Epiglottitis Primarily clinical diagnosis Ensure patient is able to breathe! Avoid invasive procedures Tests to be done only when patient is stable and airway is secured Blood culture Lateral neck X-ray (only in some cases) Thumb sign

20. Investigations and Findings Lateral x-ray of the neck with an arrow pointing to the enlarged epiglottis

21. Describe the complications of ALTB & Epiglottitis. Describe the principle of management of ALTB & Epiglottitis

22. Complications Acute Laryngotracheobrontis (ALTB) Complications are rare but can occur in some cases. They include: Secondary bacterial infection Pneumothorax Otitis media Dehydration Lymphadenitis

23. Complications of Epiglottitis. Complications of epiglottitis include the following: Cellulitis Cervical adenitis Empyema Epiglottic abscess Meningitis Pneumonia Pulmonary edema Respiratory failure Septic shock Hypoxia Prolonged ventilation Tracheostomy

24. Basic management of acute upper airways obstruction • Do not examine the throat! • Reduce anxiety by being calm, confident and well organised. • Observe carefully for signs of hypoxia or deterioration. • If severe, administer nebulised epinephrine (adrenaline) and contact an anaesthetist. • If respiratory failure develops from increasing airways obstruction, exhaustion or secretions blocking the airway, urgent tracheal intubation is required.

25. Management of Acute Laryngotracheobronchitis (ALTB) Treatment depends on the severity based on the Westley croup score. mild croup (Westley croup score <2) moderate to severe croup (Westley croup score >3) Management of Acute Laryngotracheobronchitis (ALTB) Treatment depends on the severity based on the Westley croup score. mild croup (Westley croup score <2) moderate to severe croup (Westley croup score >3)

26. Management of Epiglottitis O nce the patient is admitted, the following care is necessary: Do not agitate the patient Administer humidified oxygen Allow the patient to choose the position which is most comfortable Avoid the use of inhalers and sedatives Be prepared for a sudden worsening of the clinical condition Always have a tracheostomy cut down set at the bedside With appropriate treatment, most patients improve within 48-72 hours but antibiotics are still required for 7 days. Only afebrile patients should be discharged home.

27. Management of Epiglottitis Epiglottitis is a medical emergency and need immediate treatment with an artificial airway placed under controlled conditions, either in an operating room or intensive care unit. All patients should receive oxygen en route unless the mask causes excessive agitation. Cultures of blood, epiglottic surface, and, in selected cases, cerebrospinal fluid should be collected after the airway is stabilized. Ceftriaxone, cefotaxime, or meropenem should be given parenterally, After insertion of the artificial airway, the patient should improve immediately, and respiratory distress and cyanosis should disappear. Epiglottitis resolves after a few days of antibiotics, and the patient may be extubated; antibiotics should be continued for 7-10 days.

28. Reference Lissauer, T. (2017). Illustrated textbook of paediatrics (5th ed.). Elsevier Science. Nelson textbook of pediatrics (2016) - ELSEVIER - Philadelphia, PA https://www.ncbi.nlm.nih.gov/books/NBK431070/#:~:text=Laryngotracheitis%2C%20laryngotracheobronchitis%2C%20and%20laryngotracheobronchopneumonitis%20are,edema%2C%20and%20rarely%2C%20death. https://www.ncbi.nlm.nih.gov/books/NBK430960/#:~:text=Complications%20of%20epiglottitis%20include%20the,Death https://www.grepmed.com/images/5127/peds-diagnosis-score-severity-pediatrics Hussain, I., Ng, PH., & Thomas, T. (eds). (2012). Paediatric Protocols for Malaysian Hospitals. 3 rd Edition, Kementerian Kesihatan Malaysia. https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/ https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=P02944#:~:text=What%20is%20epiglottitis%20in%20children,and%20inflamed%2C%20it's%20called%20epiglottitis.

29. Reference cont. https://academic.oup.com/bjaed/article/7/6/183/508301 https://www.ncbi.nlm.nih.gov/books/NBK525995/#:~:text=The%20cause%20of%20stridor%20can,on%20congenital%20versus%20noncongenital%20causes.&text=Acute%3A%20Foreign%20body%20aspiration%2C%20airway,%3A%20Peritonsillar%20abscess%2C%20retropharyngeal%20abscess https://www.youtube.com/watch?v=t3DLxpD3neg https://www.youtube.com/watch?v=8TBKMn0I9Tk https://www.youtube.com/watch?v=EAWjRXNBudY https://www.rch.org.au/clinicalguide/guideline_index/Foreign_bodies_inhaled/ https://radiopaedia.org/articles/croup https://radiopaedia.org/articles/epiglottitis