On Call Guide to Stridor
Definitions
Stertor – noisy breathing caused by partial obstruction of the respiratory tract above the level of the larynx. A bit like snoring, gurgling.
Stridor - noisy breathing caused by partial obstruction of the respiratory tract at or just below the level of the larynx.
Wheeze – noisy breathing caused by partial obstruction of small intra-thoracic airways. Like in asthma
It is sometimes quite difficult to differentiate between these three, so don’t get worry too much about it. Management of your patient is more important than carefully thought out definitions.
Aetiology
Some of these are actually stertor or wheeze – but you should try and keep everything in mind when treating these patients.
Naso-oropharyngeal
- Congenital
- Oral synechiae / persistent buccopharyngeal membrane
- Choanal atresia / Stenosis
- Oral masses
- Ranula (+/- infection)
- Dermoid (+/- infection)
- Thyroglossal cyst (+/- infection)
- Craniofacial
- Pierre Robin syndrome
- Micrognathia
- Treacher Collins Syndrome
- Inflammatory
- Adenotonsillar hypertrophy
- Quinsy
- Neck abscesses
- Ludwigs angina
- Retro/Parapharyngeal collections
- Nasal polyps
- Diphtheria
- Allergic rhinitis / anaphylaxis
- Neoplastic
- Sinonasal malignancy
- Oropharyngeal malignancy (SCC mainly)
- Nasopharyngeal angiofibroma
- Trauma
- Foreign body
- Septal haematoma
- Burns
- Post operative oedema
- Facial fractures
Laryngeal
- Congenital
- Laryngomalacia
- Vocal cord palsy / dysfunction
- Glottic / subglottic webs
- Cystic hygroma
- Vascular slings
- Laryngeal cysts
- Inflammatory
- Allergic reaction / anaphylaxis
- Epiglottitis
- Laryngitis
- Laryngotracheitis (croup)
- Neck abscesses (including TB)
- Neoplastic
- SCC
- Recurrent Respiratory Papillomatosis
- Haemangioma
- Lymphomas
- External compression by other masses (e.g thyroid)
- Trauma
- Foreign body
- Stenosis post intubation injury / Post operative oedema
- Vocal cord paralysis (after thyroid or cardiac surgery)
- Inhalation burn injuries
- Laryngeal fracture
Management
Whilst resuscitating, attempt to work out where the obstruction is:
- Stertor is a typically gurgly, snoring type nose
- Supraglottic stridor tends to be a high pitch inspiratory stridor
- Glottic (level of vocal cords) and extra-thoracic trachea tends to be a bi-phasic stridor (inspiratory and expiratory)
- The intra-thoracic stridors tend to be expiratory in nature as the negative pressures hold the airways open
A good history will also give clues:
- Recent trauma / foreign body inhalation / burns etc.
- Operations (laryngeal / thyroid / cardiac (especially PDA surgery for the left recurrent laryngeal nerve)
- Infections
- Anaphylactic reactions
- Neoplasia symptoms – loss of weight, night sweats, loss of energy etc.
- Congenital problems
Treatment
Much of the management depends upon the pathology causing the stridor, but a reasonable treatment strategy would include:
- Oxygen – some give humidified oxygen although there isn’t any evidence for it.
- Adrenaline - 5mls of 1:1000 adrenaline nebulised
- Steroids
- Dexamethosone 0.6mg/kg up to 8mg
- or if not that bad – oral prednisolone 1mg/kg
- or if not that bad – 2mg nebulised budesonide
- Of course you can give combinations.
- Antibiotics – dependent on the cause but generally not a bad thing IV as long as they aren’t allergic to it.
- Consider Heliox as a holding measure. 30% oxygen and 70% helium – this mixture is easier to breath and can buy you a few more moments before surgery etc.
- Intubate – get an anaesthetist
- If they can’t secure the airway then proceed to a Needle Cricothyroidotomy and ask your anaesthetic team to start intermittent jet insufflation. Use a 12 gauge (brown) cannula and push it through the gap between the thyroid and the cricoid (first tracheal ring), at 45 degrees. Officially you only have 45minutes to get a proper airway, as there is inadequate ventilation of the lungs with this technique.
- If you still can’t get a secure airway you will need to move on to a tracheostomy.
Remember that you won’t ever be faced with something like this by yourself. There are loads of very experienced doctors in hospitals even at night. Call everybody and work as a team. Its amazing how your confidence springs back when your seniors and an anaesthetic team arrive! Just stay calm and think as clearly as you can. You’ll be fine!
Further Reading
eMedicine - Stridor - by Brian Benson MD
Disclaimer
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