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Acute Stridor in Children Dr James Peerless January 2015.

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1 Acute Stridor in Children Dr James Peerless January 2015

2 Objectives Anatomy and Physiology Assessment Common Causes – Viral croup – Epiglottitis – Bacterial tracheitis – Retropharyngeal or tonsillar abscess – Foreign body Management

3 RCoA Syllabus Annex B PA_BK_08 Describes the management of acute airway obstruction including croup, epiglottitis and inhaled foreign body AN_BK_01 Mouth, nose, pharynx, larynx, trachea, main bronchi, segmental bronchi, structure of the bronchial tree; age-related changes from the neonate to the adult Annex C PA_IK_15 Explains the principles of stabilisation and safe transport of critically ill children and babies EN_IK_17 Recalls/explains the principles underlying the use of helium EN_IK_11 Explains the principles of the recognition and appropriate management of acute ENT emergencies, including bleeding tonsils, epiglottis, croup, and inhaled foreign body

4 Anatomy & Physiology of the Normal Airway in Children

5 Stridor “Stridor is the harsh, vibratory sound produced when the airway becomes partially obstructed.” StridorLevel of Obstruction InspiratoryAbove cords/extrathoracic; croup, epiglottitis ExpiratoryBelow cords/intrathoracic; FB BiphasicAt or below cords; FB, bact. tracheitis

6 The Infant Airway Upper and lower airways are small Prone to occlusion – Secretions – Oedema H-P equation – Laminar flow rate most affected by changes to vessel callibre – Reduced callibre  reduced flow, increased WoB


8 The Infant Airway Upper and lower airways are small Prone to occlusion – Secretions – Oedema H-P equation – Laminar flow rate most affected by changes to vessel callibre – Reduced callibre  reduced flow, increased WoB

9 The Infant Airway Thoracic cavity underdeveloped and compliant – Cartilaginous ribs – Perpendicular to vertebrae – Immature intercostal/accessory muscles – Diaphragm-dependent Higher ratio of fatigable muscle fibres Increased WoB  recession

10 The Infant Airway High metabolic rate Increased O 2 demand Smaller FRC All these factors predisposes the infant to rapid deterioration

11 Assessment Disturb as little as possible – Crying and agitation  increased effort – Don’t examine the airway – Don’t cannulate Allow to adopt comfortable position Assess degree of compromise – Inspection – Gentle examination – SpO 2 – Lab. tests and radiology

12 Increased Work of Breathing Ventilatory frequency Infant >50 Child >30 Effort Infant: head-bobbing, nasal flaring Child: see-saw chest and abdomen, recession (subcostal, intercostal, sternal, tracheal tug), nasal flaring Posture Infant: Arching backwards Child: Tripod Noise Grunting (to generate auto-PEEP) Wheezing Stridor Ineffective breathing Hypoxia & hypercarbia  tachcardia, sweating, agitation, confusion, pallor Impending respiratory arrest Reduced GCS Apnoeic epsiodes Silent chest Bradycardia

13 Assessment Mobilise help early – Senior anaesthetist – ENT – Theatre staff

14 Viral Croup

15 Laryngotracheobronchitis 80% of stridor cases (2% admitted) Parainfluenza virus – Also: ’Flu A+B, RSV, rhinovirus 6m – 3y (peak 2y)

16 Viral Croup Symptoms – 2-3 of URTI symptoms – Barking cough – Low-grade pyrexia – Inspiratory stridor Assessed by Croup score

17 Croup Score Score012 Breath soundsNormalHarsh, wheezeDelayed StridorNoneInspiratoryBiphasic CoughNoneHoarse cryBark RecessionNoneFlaring, suprasternal Flaring, suprasternal and intercostal CyanosisNoneIn airIn O 2 40%

18 Croup Score Mild – 0-3 Moderate – 4-6 (requires HDU) Severe – 7+ (requires intubation)

19 Anaesthetic Management Plan Remember ABC… Assessment and resuscitation Help and mobilisation of services Serial assessments Treatment – Humidified gases – Steroids – Adr. Nebs. ( -1 1:1000, max. 5mL) – Heliox

20 Anaesthetic Management Plan AIRWAY – Assess obstruction; is intubation warranted immediately? BREATHING – Assess degree of respiratory distress – O 2, SpO 2 CIRCULATION Avoid upsetting child Transfer to theatres Inhalational induction with child sat upright O 2 and sevoflurane Low-level CPAP can aid obstruction

21 Anaesthetic Management Plan Slow induction time (alveolar ventilation is restricted) Ensure adequate depth of anaesthesia prior to IV access and airway manipulation ENT team on standby for emergency tracheostomy Swap ETT for nasal tube if possible (PICU transfer) Once stable: – CXR – NG – Sedate and IPPV – IV fluids – Blood and laryngeal cultures, and antibiotics.

22 Epiglottitis

23 Life-threatening emergency H. influenzae (type B) – now rare due to Hib vaccine (1992) 2-6y (peak at 3y) Fulminant onset and toxic appearance of child Rapid and high fever, dysphagia and stridor, drooling. Child will often lean forward with jaw and tongue hanging down.

24 Epiglottitis Inhalational induction, as per croup ENT surgeon on standby Sitting position Follow the bubbles 1.0mm ID smaller ETT

25 Epiglottitis

26 Bacterial Tracheitis

27 Tracheitis S. aureus, H. influenzae, streptococci, Neisseria Mild 2-3d URTI, followed by rapid deterioration – high fever and respiratory distress Copious tracheal secretions Hoarse voice, and stridor Obstruction can occur secondary to oedema or due to debris

28 Tracheitis Similar assessment and management to epiglottitis. Bronchoscopy often required to remove debris from airway.

29 Abscess

30 Abscesses Retropharyngeal – Form in space between post. pharyngeal wall and pre- vertebral fascia Tonsillar Organisms – Staphylococci and streptococci. Unwell child; limited neck movements, drooling, trismus Oedema and swelling  upper airway obstruction Care must be taken to avoid rupture and subsequent pus aspiration during intubation.

31 Foreign Body

32 Commonest between ages 1-2y Often of sudden onset with choking, but unwitnessed events can mimic asthma Partial obstruction of lower airways can cause ball and valve effect  pneumothorax and surgical emphysema.


34 Foreign Body Timing weighing up urgency against fasting. Rigid bronchoscopy Dexamethasone and Adr. nebs will help reduce post-op. swelling

35 MCQs 1.Which of the following have been shown to be effective in the treatment of moderate to severe viral croup in children? a)Nebulised adrenaline 1:1000. b)Oral dexamethasone. c)Nebulised dexamethasone. d)Nebulised budesonide. e)Inhaled Heliox.

36 MCQs 2.The presentation of bacterial tracheitis differs from epiglottis in that: a)Stridor is inspiratory. b)There is dysphagia and drooling. c)The patient can lie flat. d)There is an antecedent history of an upper respiratory tract infection. e)Paroxysms of coughing produce copious tenacious secretions.

37 MCQs 3.In the management of a child with epiglottitis: a)A lateral X-ray of the neck is needed to confirm the diagnosis. b)Direct inspection of the epiglottitis using a tongue depressor will show a swollen, red epiglottis. c)The child should be anaesthetised with a rapid sequence induction. d)Nebulised adrenaline will help ease respiratory distress. e)Peak incidence is at 3 years of age.

38 MCQs 4.When securing the airway of a child with upper airway obstruction: a)Inhalational induction of anaesthesia is rapid. b)Anaesthesia should be induced with a volatile agent in an oxygen-nitrous oxide mixture. c)Sevoflurane may be used safely. d)It is best to exclude parents to avoid distress. e)It essential to have intravenous access before induction.

39 SAQs You are called to assess a 2-year-old girl in the ED whose mother describes a 4-day history of malaise, low-grade pyrexia and worsening cough. She has now developed stidor and is becoming increasingly agitated. (a)List the differential diagnoses of acute stridor in this child (20%) (b)What would be the indications for airway intervention in this child? (10%) (c)Following diagnosis, describe your management plan for this child. (70%)

40 Reference Maloney E, Meakin G. Acute Stridor in Children, CEACCP. 2007 7(6) 183-6 Maloney E, Meakin G. Acute Stridor in Children - MCQs, CEACCP. 2007 7(6) 215 Shorthouse J, Barker G, Waldmann. SAQs for the Final FRCA, 2011 Oxford University Press, Oxford.

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