Makindo Medical Notes

Related Subjects: |Acute Epiglottitis |Croup |Acute Tracheitis |Stridor

Stridor suggests an impending upper airways obstruction so airway management is key so fast bleep anaesthetic team and ENT. Never leave unattended.

About

• Stridor is an unusual, high pitched sound that indicates possible significant airway obstruction.
• Inspiratory stridor tends to suggest extra-thoracic pathology. Expiratory stridor suggests intra-thoracic pathology.
• Biphasic stridor is usually due to a fixed obstruction such as a foreign body

Causes

• Inspiratory Croup: Epiglottitis or Croup, Bacterial tracheitis, Retropharyngeal peritonsillar abscess, Laryngomalacia, Anaphylaxis, Vocal cord paralysis
• Expiratory stridor: Tracheal stenosis, Bacterial tracheitis, Anaphylaxis
• Biphasic: Foreign body, Haemangioma, Mass/Tumour, Subglottic stenosis

Clinical

• Signs of airway obstruction include stridor, tachypnoea, retractions, drooling, trismus, dysphagia, patient in tripod or “Sniffing" positions, altered phonation, altered mental status, or severe fatigue
• Stridor, fever, and rapidly progressing symptoms are most likely to be epiglottitis or bacterial tracheitis.
• In the afebrile patient with stridor and progressively worsening symptoms, consider foreign body, anaphylaxis, or thermal epiglottitis in the appropriate clinical setting. An older patient with cachexia and weight loss and slowly progressive symptoms may suggest tumour

Management

• ABC and 15 L/min O₂(humidified) continuous SaO₂/BP and cardiac monitor. If infectious or inflammatory then do not examine throat until airways management seniors present. Support, keep patient comfortable sitting upright.
• If acutely inhaled foreign body suspected and unable to cough e.g. food bolus during a meal then suspected then follow choking algorithm with 5 back blows and Heimlich manoeuvre and consider inspecting airway
• Consider Heliox 80:20 if available (helium-oxygen mix less viscous than air. Easier to inhale past obstruction).
• Adrenaline 0.5 mg IM if anaphylaxis which may be repeated (Do not give IV unless cardiac arrest)
• Adrenaline nebulizer: 1-5 ml of 1:1000 adrenaline
• In extremis or worsening Fast Bleed Anaesthetist: In extremis or about to lose airway get urgent anaesthetic help. Intubation could be challenging. A smaller ETT should be used due to expected airway oedema.
• Fast bleep ENT as if intubation not possible then “front of neck airway" needed. If stable can prepare for a fast track to the operating room for tracheostomy.
• If even this is not possible "can't intubate, can't oxygenate" then consider the standard FONA 'front of neck airway’ should be a scalpel-bougie cricothyroidotomy done by ENT.
• Consider Dexamethasone 8 mg IV if anaphylaxis or inflammatory or malignant aetiology
• Further management If stable then get CXR and Bloods
• Definitive treatment includes: If tumour -related then radiotherapy should be discussed with an on-call clinical oncologist Laser/stenting for tracheal obstruction - discuss with local Respiratory team. If no other treatment options then make the patient comfortable with sedation.

References