Stridor and management of obstructed airway

for UG

1. Dr. Ramesh Parajuli
Chitwan Medical College Teaching Hospital Bharatpur-
10,Chitwan, Nepal
Stridor & management of
obstructed airway

2. Stridor: Noisy breathing due to partial obstruction of upper
airway eg. in oropharynx, hypopharynx, larynx, trachea or
bronchi
Stertor: Noisy breathing due to rattling or rumbling of
secretions in the pharynx
Rales & Crepitus: Distal portion of bronchial tree & alevoli
(Lower respiratory tract)
Hoarseness: Alteration in quality of voice
Aphonia vs Dysphonia

3. Causes of hoarseness
1.Inflammatory: laryngitis, Tuberculosis
2. Neoplasms
3. Non-neoplastic (tumour like masses): Vocal nodule/polyp
3. Trauma: Laryngeal trauma, intubation
4. Neurological: Recurrent laryngeal nerve palsy
6. Congenital: Laryngeal web, cyst
7. Systemic: hypothyroidism
8. Psychogenic: functional aphonia, puberophonia, Dysphonia
plica ventricularis
9.Habitual dysphonia: vocal nodule, vocal edema, contact
ulcers

4. Congenital Acquired
1.Laryngomalacia 1. Inflammatory: Acute epiglottitis,
2.Vocal cord palsy croup, laryngeal edema, RRP,TB,
3.Subglottic stenosis Retropharyngeal abscess

4.Subglottic hemangioma 2. Trauma
5.Laryngeal web & atresia
6.Laryngeal cyst 3. Malignancy
4. Foreign body
5. B/L vocal cord palsy
Causes of stridor

5. Laryngomalacia
Most common congenital laryngeal anomaly of larynx
Excessive flaccidity of cartilaginous structures
Manifests at birth or soon after, usually disappears by 2
years of age.
Characteristic features (Seen on Flexible NPL): Elongated
epiglottis(Omega shaped), floopy aryepiglottic(AE) fold &
prominent arytenoids(Sucked in during inspiration)

6. Inspiratory stridor:
Increased on supine position
Relieved by prone position
Phonation & cry are normal.

7. Management:
 Conservative: Reassurance
 Tracheostomy: for severe respiratory obstruction
 Epigllotoplasty: Laser assisted

8. Stridor may be:
1. Inspiratory stridor® Glottis or supraglottis
2. Biphasic stridor® Subglottis or trachea
3. Expiratory stridor® obstruction at the level of alveoli
(commonly referred to as wheeze and is not true stridor)

9. History
1.Time of onset: Congenital or acquired
2. Mode of onset:
Sudden onset ® Foreign body, Trauma, Infection
Gradual(insidious) onset + progressive ® Laryngomalacia,
Stenosis, Respiratory papillomatosis, Neoplasms
3. Relation to feeding ® Aspiration due to laryngeal paralysis,
esophageal obstruction
4. Relation to sleep and body position:
Present only during sleep Stertor
Disappears in prone position Laryngomalacia

10. Physical examination:
Stridor is always associated with respiratory distress.
Signs of airway resistance: Nasal flaring, intercostal/
subcostal / supraclavicular recession, cyanosis

11. Investigations
1.X-Ray soft tissue neck: Epiglottitis, Stenosis
2.X-Ray chest: Mediastinal lesion
3.Flexible Nasopharyngolaryngoscopy (NPL)
4.Direct laryngoscopy & Bronchoscopy
5.Imaging (CT/MRI) of neck & chest

12. Nasopharyngolaryngoscopy(NPL): B/L abductor
palsy

13. 1.Heimlich manoeuvre
2.Oropharyngeal or nasal airway
3.Intubation
4.Wide bore needle
5.Cricothyroidotomy
6.Tracheostomy
Management of obstructed airway

14. Acute life threatening respiratory obstruction
Vs
Gradual onset respiratory obstruction
Acute life threatening resp. obstruction: FB, inhalation of food
bolus, trauma, infection, late presentation of large neoplasms of
larynx/hypopharynx (esp.in Nepal)
Gradual onset resp. obstruction: Neoplasms of
larynx/hypopharynx, subglottic/tracheal stenosis, infection, blunt
laryngeal trauma

15. Signs of worsening (increasing stridor) in gradual
onset respiratory obstruction
Stridor at rest
Restless
Patient can’t lie flat in bed
Rising pulse rate
Patient using accessory muscles of respiration: intercostal
recession
Intubation or Tracheostomy

16. Heimlich manoeuvre
Acute respiratory obstruction due to
food bolus or foreign body
Residual air in the lungs to expel the
FB.
Pressure exerted by rapid squeezing
motion applied against the xiphoid
region of the sternum

17. Oropharyngeal or nasal airway
When the obstruction lies in the oral cavity, oropharynx or base
of tongue
Guedell / Oropharyngeal airwayNasopharyngeal airway

18. Wide bore cannula
To provide temporary relief until either
intubation or tracheostomy can be
performed

19. Endotracheal (ET) tube for Intubation
Appropriate instruments, trained personnel and adequate facilities
are available

20. Cricothyroidotomy
Cricothyroid membrane is superficial,relatively avascular,
easily identifiable landmark
Cricothyroid membrane incised endotracheal tube or
tracheostomy tube
Tracheostomy done as soon as possible
Cricothyroidotomy should never be done as a substitute for
tracheostomy bcoz of high possibility of subglottic stenosis

22. Needle cricothyroidotomy

23. Tracheostomy

24. Tracheostomy Intubation
More time to perform Less time to perform
Invasive Non-invasive
Complications are more Less
Can be kept for long durationShould not be kept for > 2 weeks
(Subglottic stenosis)
Patient can speak Can’t speak
Tracheo-bronchial toilet is easy Difficult
Decannulation esp. in children is
difficult--subglottic
edema,granulations,psychological
dependence on tracheostomy tube
Preferred over tracheostomy in
children – Resp. obstruction due to
airway infection usu. Resolve
within 72 hrs

25. Thank you