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Good Morning!!! Morning Report Tuesday, November 8 th, 2011.

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Presentation on theme: "Good Morning!!! Morning Report Tuesday, November 8 th, 2011."— Presentation transcript:

1 Good Morning!!! Morning Report Tuesday, November 8 th, 2011

2 What is Stridor? Monophonic, high-pitched sound usually caused by upper airway narrowing and partial obstruction Can be: Inspiratory Expiratory Biphasic

3 The Anatomy of Stridor Inspiratory stridor is caused by extrathoracic obstruction Extrathoracic region Supraglottic area Nasopharynx, epiglottis, larynx, aryepiglottic folds, false vocal cords Glottic and subglottic area Vocal cords to the extrathoracic segment of the trachea

4 The Anatomy of Stridor

5 Expiratory stridor (wheezing) is caused by intrathoracic obstruction Includes portion of the trachea that lies within the thoracic cavity and the mainstem bronchi Biphasic stridor is caused by critical and fixed airwary obstruction at any level

6 Pathophysiology ExtrathoracicIntrathoracic

7 Anatomic Differential Diagnosis Inspiratory Stridor Immobile cords Noid (adenoid) and tonsil enlargement Soft cartilage (laryngomalacia) Pharyngeal and hypopharyngeal masses Expiratory Stridor Tracheomalacia Bronchomalacia Vascular ring/ sling

8 Anatomic Differential Diagnosis Biphasic Stridor Subglottic stenosis Critical fixed airway obstruction Vocal cord lesions* Croup*

9 Historical Pearls Age: Laryngomalacia, subglottic stenosis, tracheomalacia: congenital disorders Foreign body aspiration: >6mos Croup: 6-36mos Retropharyngeal abscess: <4 yo Peritonsillar abscess: >10 yo

10 Historical Pearls Acuity of onset: Abrupt FB aspiration Allergic reactions Infectious processes (epiglottitis, tracheitis, etc…) Insidious Viral croup Delayed airway burns Recurrent FB Subglottic stenosis Vascular ring Tumor

11 Historical Pearls PMHx/ Birth Hx Prenatal/ perinatal complications? Intubations? Length? Surgical history? Exposure to allergens?

12 Physical Exam Gen: **Quickly identify any patients with impending airway obstruction** HEENT: Size of tongue and mandible, ?craniofacial malformations Neck: scars, edema Lungs: WOB, location of stridor* Ext: clubbing Lymphatics: peripheral LAD Skin: hemangiomas, café-au-lait spots

13 Imaging Plain neck films Non-specific May reveal changes associated with Retropharyngeal abscess Epiglottitis Croup Foreign body

14 Plain Neck Films Croup Retropharyngeal abscess

15 Imaging CXR Important when an intrathoracic problem is suspected Mediastinal LAD or mass R aortic arch (vascular ring) Foreign body Airway fluoroscopy Tracheomalacia CT/MRI Retropharyngeal cellulitis/ abscess Tumors/ LAD Abnormal vasculature

16 Other Diagnostic Modalities Spirometry Difficult to perform in small children

17 Other Diagnostic Modalities Airway visualization Emergent, flexible or rigid laryngoscopy: Epiglottitis Tracheitis Non-urgent, nasopharyngoscopy: Laryngomalacia Anatomic defects b/t nose and pharynx Non-urgent, flexible or rigid laryngoscopy: Thorough evaluation needed for diagnosis Foreign body

18 Case #1 4 yo M with a 2 day history of fever to Today, Mom noticed that his breathing was noisy and he was refusing to eat and drink. In the office, he is leaning forward, drooling with stridor…

19 Questions…Case #1 Diagnosis? Epiglottitis Inspiratory or expiratory stridor? Inspiratory Associated symptoms? Drooling Dysphagia Distress Leans forward (refuses to lie down)

20 Case #2 A mother brings in her 2 week old ex 37 wga F with c/o noisy breathing. She describes it as an inspiratory noise that seems to worsen when she cries and when she is lying down. The infant is growing and gaining weight appropriately.

21 Questions…Case #2 Diagnosis? Laryngomalacia Inspiratory or expiratory stridor? Inspiratory Associated symptoms Can have retractions Stridor worse with agitation and supine position Stridor improves with expiration Symptoms improve with time

22 Case #3 When you walk into an exam room to see your 2 month old WCC, you appreciate a loud wheeze. You notice the infant is feeding and ask Mom if this noise is a common occurrence with feeds. She says that it is and that the infant also seems to have difficulty getting down the formula…

23 Questions…Case#3 Diagnosis? Vascular ring Inspiratory or expiratory stridor? Expiratory Associated symptoms Stridor worse with feeds Feeding difficulty

24 Case #4 3 mo M with Trisomy 21 presents to the ED with noisy/ difficult breathing. Per Mom, she saw her PCP yesterday for the noisy breathing. He said it was wheezing from a cold and gave her Albuterol nebs to give q4. Since the meds, the infants respiratory distress has worsened…

25 Questions…Case #4 Diagnosis? Tracheomalacia Inspiratory or expiratory stridor? Expiratory Associations Confused with asthma Asthma: wheeze high-pitched, diffuse and musical; improves with beta-agonists Tracheomalacia: wheeze low-pitched, central and homophonous; worsens with beta-agonists Associated with Trisomy 21, TEF s/p repair, mechanical ventilation, and BPD

26 Noon Conference: VLBW Infant, Dr. Rivera


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