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Stridor, Emergency Medicine

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Stridor, Emergency Medicine

Basics

Description

These tests are not helpful and thus avoidable; may upset a child even more.

Radiograph of lateral and posteroanterior neck and chest:

All cases of stridor that are not completely resolved during the ED course mandate admission of patient to hospital.

Stridor fully resolved or identified as a nonstridorous abnormal breathing sound.

Consultation with an otolaryngologist or a pediatric surgeon prior to airway visualization

  • High-pitched audible wheezing and vibratory harsh sounds mainly on inspiration.
  • Impedance of air movement through the upper airway.
  • It implies a laryngotracheal airway obstruction.

Etiology

  • Congenital:LaryngomalaciaLaryngeal webs/rings
  • Vocal cord dysfunction:CongenitalSurgical injuryPostintubation traumaThyroid malignancyMediastinal massNeural abnormalities (e.g., meningomyelocele, Arnold " “Chiari malformation)
  • Subglottic stenosis:Postoperative scarringAfter radiation therapyAfter prolonged endotracheal intubation
  • Subglottic hemangioma
  • Infection:Bacterial tracheitisEpiglottitisViral croupPeritonsillar abscessRetropharyngeal abscessSupraglottitisUvulitis (e.g., Quincke disease)Ludwig anginaDiphtheriaTetanus
  • Extrinsic compression:TraumaHematomaVascular anomalies (e.g., rings)
  • Intraluminal obstruction of the trachea:Foreign bodyTracheomalaciaCystInvasive tumorsSquamous cellLymphomasThyroid masses/carcinomasLaryngeal or tracheal papilloma
  • Angioedema
  • Laryngomalacia
  • Laryngeal webs/rings
  • Congenital
  • Surgical injury
  • Postintubation trauma
  • Thyroid malignancy
  • Mediastinal mass
  • Neural abnormalities (e.g., meningomyelocele, Arnold " “Chiari malformation)
  • Postoperative scarring
  • After radiation therapy
  • After prolonged endotracheal intubation
  • Bacterial tracheitis
  • Epiglottitis
  • Viral croup
  • Peritonsillar abscess
  • Retropharyngeal abscess
  • Supraglottitis
  • Uvulitis (e.g., Quincke disease)
  • Ludwig angina
  • Diphtheria
  • Tetanus
  • Trauma
  • Hematoma
  • Vascular anomalies (e.g., rings)
  • Foreign body
  • Tracheomalacia
  • Cyst
  • Invasive tumors
  • Squamous cell
  • Lymphomas
  • Thyroid masses/carcinomas
  • Laryngeal or tracheal papilloma

Diagnosis

Signs and Symptoms

  • Breathing difficulties
  • Audible stridor (worsens with feeds, crying, and on lying supine)
  • Muffled hoarseness "Hot potato "  voice in adults
  • Feeding difficulties in infants (amount of feeds and regurgitation with GERD)
  • Apneas and cyanotic attacks
  • Antenatal, perinatal, and birth events (e.g.. resuscitation at birth with intubation)
  • Anxiety
  • Cough
  • Drooling
  • Sore throat
  • Tachypnea
  • Dyspnea
  • Dysphagia
  • Fever
  • Respiratory distress, worse with agitation
  • Nasal flaring, intercostal retractions, subcostal indrawing
  • Paradoxic diaphragmatic movement (late finding)
  • Audible stridor (inspiratory/biphasic stridor)
  • Cyanosis
  • Trismus:Peritonsillar abscess, retropharyngeal abscess, Ludwig angina
  • Peritonsillar abscess, retropharyngeal abscess, Ludwig angina

Essential Considerations

  • Visualization of the upper airway:Radiographic if symptoms very mild; be careful!
  • Direct visualization in OR with a surgeon prepared to perform a cricothyrotomy or tracheostomy is the safest approach.
  • Radiographic if symptoms very mild; be careful!

Diagnosis Tests & Interpretation

  • Not essential
  • Only done in extremely mild cases or when there is suspicion of foreign body aspiration
  • Fiberoptic laryngoscopy:Should be performed with an intubating fiberoptic laryngoscope in a setting where a rapid surgical airway can be obtained
  • Direct laryngoscopy:Diagnostic study of choiceShould be performed in a setting where a rapid surgical airway can be obtained
  • Should be performed with an intubating fiberoptic laryngoscope in a setting where a rapid surgical airway can be obtained
  • Diagnostic study of choice
  • Should be performed in a setting where a rapid surgical airway can be obtained

Differential Diagnosis

  • Stertor:Pharyngeal obstruction while wheezing
  • Bronchospasm
  • Malingering (patient breathing against a closed glottis)
  • Pharyngeal obstruction while wheezing

Treatment

Pre-Hospital

  • Keep child calm, with mother if possible.
  • Supply blow-by oxygen.
  • Maintain adequate airway.
  • Use bag-valve-mask (BVM) if respiratory status deteriorates.
  • Intubate if BVM ineffective.
  • Provide rapid transport with ED notification.

Initial Stabilization/Therapy

  • In children: Avoid agitation. Supply blow-by oxygen.
  • Use 100% nonrebreathing-type face mask
  • Pulse oximetry to check oxygen saturation and monitoring of vitals.
  • Avoid agitating child.
  • Watch for rapid deterioration of respiratory status.

Ed Treatment/Procedures

  • Airway management:Stridor comprises a difficult airway passage:Be prepared to create an airway surgically before intubation.If time permits, perform intubation in OR with surgeon and pediatric anesthesiologist present.Intubate with tube 1 or 2 sizes smaller than would be normally used.
  • Oral awake intubation:Ketamine inductionPatient is sedated but continues to ventilate during procedure.
  • Avoid blind nasotracheal intubation.
  • Oral intubation is preferred initially. After oral intubation the oral tube is replaced by a nasal tube of the same size.
  • Provide surgical airway if intubation fails or sudden deterioration in respiratory status occurs.
  • Postintubation ceftriaxone in cases of infectious cause
  • Sedation/paralysis for duration of intubated status after airway is secured.
  • Extubation could be attempted when an air leak develops around the tracheal tube, which can take around 2 " “10 days.
  • Controversies:Heliox therapyRacemic epinephrine therapyEarly intubation
  • Stridor comprises a difficult airway passage:Be prepared to create an airway surgically before intubation.If time permits, perform intubation in OR with surgeon and pediatric anesthesiologist present.Intubate with tube 1 or 2 sizes smaller than would be normally used.
  • Be prepared to create an airway surgically before intubation.
  • If time permits, perform intubation in OR with surgeon and pediatric anesthesiologist present.
  • Intubate with tube 1 or 2 sizes smaller than would be normally used.
  • Ketamine induction
  • Patient is sedated but continues to ventilate during procedure.
  • Heliox therapy
  • Racemic epinephrine therapy
  • Early intubation

Medication

  • Atropine: 0.02 mg/kg IV
  • Ceftriaxone: 1 " “2 g IV
  • Diazepam: 2 " “10 mg IV (peds: 0.2 " “0.3 mg/kg)
  • Etomidate: 0.3 mg/kg IV
  • Fentanyl: 3 Ž Όg/kg IV
  • Ketamine: 1 " “2 mg/kg IV or 4 " “7 mg/kg IM
  • Lidocaine: 1.5 mg/kg IV
  • Midazolam: 1 " “5 mg IV (0.07 " “0.3 mg/kg for induction)
  • Vecuronium: 0.1 mg/kg IV
  • Nebulized epinephrine: 1 mL of 1:1,000 diluted to 5 mL with normal saline
  • Dexamethasone: 0.15 mg/kg oral/IV

Follow-Up

Disposition

Pearls and Pitfalls

  • Attempting visualization of the airway without the backup needed for an emergency tracheostomy is a pitfall.
  • Laryngoscopy findings determine the indications for other complementary exams such as barium swallow, polysomnography, echocardiography, CT, or magnetic resonance scans of neck and thorax.
  • Patients, especially children with stridor, often have associated abnormalities involving respiratory tract which mandates not only endoscopic exam of the larynx, but also the tracheobronchial system.

Additional Reading

  • Boudewyns ‚ A, Claes ‚ J, Van de Heyning ‚ P. Clinical practice: An approach to stridor in infants and children. Eur J Pediatr. 2010;169(2):135 " “141.
  • Daniel ‚ M, Cheng ‚ A. Neonatal stridor. Int J Pediatr. 2012;2012:859104.
  • Halpin ‚ LJ, Anderson ‚ CL, Corriette ‚ N. Stridor in children. BMJ. 2010;340:c2193.
  • Mellis ‚ C. Respiratory noises: How useful are they clinically? Pediatr Clin North Am. 2009;56(1):1 " “17, ix.
  • Walaschek ‚ C, Forster ‚ J, Echternach ‚ M. Vocal cord dysfunction without end? Klin Padiatr. 2010;222(2):84 " “85.

Codes

ICD9

  • 748.2 Web of larynx
  • 748.3 Other anomalies of larynx, trachea, and bronchus
  • 786.1 Stridor
  • 478.74 Stenosis of larynx
  • 464.10 Acute tracheitis without mention of obstruction
  • 464.11 Acute tracheitis with obstruction
  • 464.1 Acute tracheitis
  • 464.4 Croup

ICD10

  • Q31.0 Web of larynx
  • Q31.5 Congenital laryngomalacia
  • R06.1 Stridor
  • J38.6 Stenosis of larynx
  • J04.10 Acute tracheitis without obstruction
  • J04.11 Acute tracheitis with obstruction
  • J04.1 Acute tracheitis
  • J05.0 Acute obstructive laryngitis [croup]

SNOMED

  • 70407001 Stridor (finding)
  • 55490007 Congenital laryngeal stridor (disorder)
  • 297159008 Laryngeal web (disorder)
  • 22668006 Subglottic stenosis (disorder)
  • 58596002 inspiratory stridor (finding)
  • 62994001 Tracheitis (disorder)
  • 71186008 Croup (disorder)