stridor talk for peds residents1-august 2008

How to Approach and Manage StridorLawrence M. Simon, M.D.Departmental of Lecture Series

Childrens Hospital of New OrleansLouisiana State University Health Sciences Center, New Orleans

Harsh sound caused by turbulent airflowImplies partial airway obstruction

Laryngeal stridor-inspiratory, biphasicStridor

Congenital Laryngeal AnomaliesLaryngomalacia-different typesTracheomalaciaVocal Cord ParalysisLaryngeal CleftsVascular Rings and SlingsInfectiousCroup (Laryngotracheitis)EpiglottitisTracheitisTraumaCroup MasqueradeSubglottic HemangiomaRecurrent Respiratory PapillomatosisPost Intubation Glottic and Subglottic LesionsCongenital Glottic and Subglottic StenosisExtra-Esophageal (Gastroesophageal) Reflux Disease/Eosinophilic EsophagitisForeign BodyTrachealEsophagealLaryngeal Stridor: Etiology

Guide to diagnosis and interventionAgeCongenital vs. AcquiredCharacteristics of stridorClinical pictureAssessment Strategies

Onset: acute, chronic, progressivePrior respiratory problemsEx-premie (NICU stay)Prior intubationGERD symptomsWheezing episodesFeeding problems:FTT, weight gainChoking episodesAcute eventsClinical Picture: History

Acute DiseaseFeverDrooling (new onset)Change in cry or voice Decrease in oral intakeBody positionClinical Picture: Associated signs & symptoms

Assess urgencyIs there acute distress?Nasal flaringTachypneaCyanosisRetractionsTripod positionImmediate action !Initial Evaluation

Let parent hold childPhysical Examination

Let parent hold childMirror for nasal airflow (stertor vs stridor)

Physical Examination

Let parent hold childMirror for nasal airflowHeadless stethoscopePhysical Examination

Let parent hold childMirror for nasal airflowHeadless stethoscopePositional changesPhysical Examination

Gold standard of office evaluationDynamic assessmentEasy to doMinimal morbidityWell tolerated

Pediatric Flexible Nasolaryngoscopy

Magit/Pransky: AAO Stridor 2007

DisadvantagesVC mobility often difficult to assessEspecially neonatesExcess secretionsPoor view of subglottisEasily misinterpretedInterpretation of erythema difficultOverhanging epiglottisMust be careful with local anesthesia in neurologically impaired child Pediatric Flexible Nasolaryngoscopy

IndicationsTo establish diagnosis or evaluate for synchronous lesionsSevere or progressive stridorCyanosis or apnea concernsRadiologic abnormalitiesParental or physician anxiety

AnesthesiologistCritical to success of operative evaluationComfort zone with sharing of the airwaySpontaneous ventilationOperative Endoscopy

Endoscopy Technique

Concerns in Airway EndoscopyPostoperative edema, infection

Long term treatment with steroids

Extended hospitalizations, intensive care

Complications: subglottic stenosis, glottic webs

Voice abnormalities

Most common cause of stridor in infantsVarying severity & varying typesPresentationStaccato inspiratory stridorWorse with exertion, feeding, cryingNoisy breathing generally begins at about 2-4 weeks of ageOffice evaluationCharacter of stridorPositional changes / Mandibular thrustFlexible nasopharyngolaryngoscopy

Laryngomalacia

Endoscopic appearanceOmega epiglottisForeshortenend aryepiglottic foldsCuneiform prolapseLaryngomalacia

Vast majority are mildDo these really need operative endoscopy?Parental reassurance & educationTransient worsening, gradual improvementWeight gain issuesGERD issues- Consider GERD treatment if there is evidence on endoscopyLaryngomalacia

Respiratory difficultyFeeding difficultyFailure to thriveGERDCNS abnormalities Severe Laryngomalacia

TreatmentAryepiglottic fold division (Aryepiglottoplasty)Cold, Laser, MicrodebriderTreat presumed GERD Severe Laryngomalacia

Absence of classical laryngomalacia findingsProlapse of pharyngeal tissuesNeurologic abnormalitiesOften older infantsTreatment Options:Trial Bi-papTracheostomyAryepiglottic fold division may make airway obstruction worse

Dyscoordinate Pharyngolaryngomalacia

Symptoms/ Signs:Tracheal wheezeBrassy coughFailure to thriveIncreasing respiratory distress with growthDiagnosis:Endoscopy location, extentMay not be idiopathic- look for contributing factorsTreatment:BiPAP / CPAPTracheotomy variable tube lengthStenting if no other choice

Tracheomalacia

Begins about 6 months of age !Croup before 6 months is not croupHigh KV AP of neck: symmetric subglottic narrowing (steeple sign)Endoscopically: 2 sets of vocal cordsHospitalized Patient: IV steroids, cold mist tent, hydration, O2 sat monitorCroup (Laryngotracheobronchitis)


Traditionally caused by H. influenza bSuden onset, rapidly progressive course80-90% decreased incidence since HIB vaccine introduced (1991)Majority of cases seen now are caused by StaphConsider immunocompromiseTreatment: Immediate intubation in OR with ENT presentSend CulturesAppropriate antibioticsEpiglottitis


Acute lower airway infectionTypically develops as bacterial super-infection after viral croupAcute airway obstruction, high fever, elevated WBC develop 2-3 days after onset viral illnessTreatment:Monitor, Humidified O2Bronchoscopy for suctioning of purulent secretions and cultureAntibiotics:Consider Staph aureus (MRSA), H. flu, B-hemolytic strep, pneumococcusTreat for 7-10 daysTracheotomy in severe casesTracheitis


Pediatric Airway Lesions Managed Endoscopically or with Open Surgical RepairSubglottic hemangiomaGlottic and Subglottic stenosis, websVocal Fold ImmobilityLaryngeal CleftsSaccular Cysts


Subglottic HemangiomaClassic scenarioCroup symptoms generally begin 6-8 weeks of ageNo fever, good cryRespiratory distress/stridor: often treated as outpatient with oral steroids or inpatient with IV steroids with improvement Croup recurs several weeks later

Mean age of diagnosis is 4 monthsDelay due to misdiagnosis of symptoms

Proliferative phase then involutional phase


Subglottic HemangiomaAssessmentEndoscope entire airwayBiopsy not essential (but can be done)CT/MRI--r/o extraluminal extension


Subglottic HemangiomaClassic Endoscopic appearanceSmooth submucosal massPosterolateral: left>rightBilateral lesions mistaken as soft subglottic stenosis


Traditional Management Options for Airway HemangiomaMedical Steroids GERD therapy (Interferon-spastic diplegia concerns) (Vincristine-life threatening cases, neurotoxicity)

SurgicalTracheostomy Open surgical excision +/- expansion LTR Endoscopic ExcisionCO2 / KTP laser Ablation Intralesional steroid injection


New Management Options for Airway HemangiomaPropanolol!

Laut-Labrze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, TaebA.Propranolol for severe hemangiomas of infancy. N Engl J Med. 2008 Jun12;358(24):2649-51.


HistoryIntubation--even transientNICU GraduateStridor with URIHistory of recurrent or prolonged croup or asthmaPoor response to standard therapyPost Intubation Injuries


Anterior commissure webWeak, hoarse cryMild-moderate respiratory distressTreatment:Endoscopic divisionLaryngeal keelShort term post-op intubationMitomycin (?)Post Intubation Injuries

Posterior glottic injury: Progressive changesGranulationUlcerationFurrowInterarytenoid ScarPost Intubation Injuries


Post Intubation InjuriesInterarytenoid webDifficult problemMistaken for vocal cord paralysisAssess with MSL using 2 handed distraction techniqueRepair: endoscopic division alone rarely successfulMitomicin CMucosal flap interpositionPosterior cricoid expansion


Subglottic StenosisAssess entire airwaySize & grade stenosisGrade I (0-50%)Grade II (50-70%)Grade III (70-99%)Grade IV (No visible lumen)TreatmentObservation (Grade I-II)Dilatation (Grade II-III)Laryngotracheal reconstruction (Grade III-IV)Treat for GERDPost Intubation Injuries

Subglottic CystsOften multipleRemovalForcepsLaser (CO2 / KTP)Microdebrider

Post Intubation Injuries

Physical: On examination, the baby is usually happy and appropriately interactive.Mild tachypnea may be present.Other vital signs are normal, and oxygen saturation is usually normal.One can usually detect nasal airflow. The noise may be increased if the baby is placed supine.The cry is normal. Hearing the baby's cry during the examination is important.The noise is purely inspiratory.The rest of the examination findings are unremarkable.

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stridor talk for peds residents1-august 2008

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