Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Milindu Wickramarachchi STRIDORCONTENTS WHAT IS STRIDOR? HOW TO SPLIT THE DIFFERENTIAL HISTORY TAKING EXAMINATION INVESTIGATIONS QUIZ NO. 1 DDx 1: Epiglottitis DDx 2: Croup DDx 3: Laryngomalacia QUIZ NO. 2STRIDOR? - Stridor is an externally audible, high-pitched sound caused by turbulent airflow due to obstruction of the upper respiratory tract (pharynx, larynx or trachea). Classification: ● Inspiratory: obstruction above or at the level of the vocal cords (glottis or supraglottic) ● Biphasic: obstruction below the vocal cords (subglottic) ● Expiratory: obstruction of the trachea or larger bronchi HOW TO SPLIT THE DIFFERENTIAL NEWBORN: - Laryngomalacia ADULT: - Tracheomalacia - Subglottic stenosis - Supra/epiglottitis - Bacterial tracheitis CHILD: - Deep neck space infections - Croup - Epiglottitis - Tumour - Trauma - Quinsy - Deep neck space infections - Post-extubation - Bacterial tracheitis - Burns - Allergic/immune (ACEi) - Foreign Body - GORD - Anaphylaxis - Psychogenic - BurnsHISTORY T AKING HISTORY OF PRESENTING COMPLAINT PAST MEDICAL HISTORY DRUG HISTORY FAMILY HISTORY SOCIAL HISTORY (ICE!)HPC - Is the onset acute/chronic? - Associated features e.g. fever, cough, drooling - Is there a history of choking/foreign body ingestion? - Exacerbating factors? e.g. laryngomalacia and stridorPMH If child, important to do screening about birth - any stay in NICU/PICU? intubations etc. Preterm infants have smaller airways, more prone to respiratory distress. If adult, important to screen for co-morbidities and other cardiorespiratory illnesses which may put them at higher risk, e.g. COPD/asthma.DHX - ACEi such as ramipril, lisindopril -> risk of drug-induced angioedema - Common drugs that people are allergic to -> penicillins, NSAIDs -> ANAPHYLAXIS - CHECK THE DRUG CHARTSHx - Recent travel history -> diphtheria causing croup - Smoking - laryngeal tumours causing chronic airway obstruction and stridor - Neglected child -> foreign body ingestionFHX - Family history of any allergiesRED FLAGS - Preceding URTI/tonsillitis - Barking cough - Unclear vaccination history - Respiratory distress - Suspicion of FBI (not the police!)EXAMINA TION - Basic observations (temp, BP , sats etc.) - Assess for signs of respiratory distress - Auscultate chest for signs (AE, crackles) to exclude Basic A to E assessment If child is Distressed, Foreign body, unusually Drooling DON’T INSPECT AIRWAY - Don’t Freaking DisturbINVESTIGA TIONS BLOODS: IMAGING: - FBC, U+Es, CRP - Flexible Nasendoscopy - ABG - CT Neck: not acuteCONTENTS 1. JAUNDICE AND BILIRUBIN 2. DIFFERENTIAL DIAGNOSIS 3. HISTORY AND EXAMINATION 4. INVESTIGATIONS 5. QUIZ NUMBER 1 6. CONDITIONS CAUSING JAUNDICE a. Pre-hepatic b. Hepatic c. Post-hepatic 7. QUIZ NUMBER 2Question 1: What is stridor? 1. externally audible, high-pitched sound caused by turbulent airflow due to obstruction of the upper respiratory tract (pharynx, larynx or trachea). 2. a low pitched sound, generally produced from obstruction of the nares or nasopharynx 3. high-pitched, musical, adventitious lung sound produced by airflow through an abnormally narrowed or compressed airway 4. shorter, higher-pitched non-musical discontinuous sounds best heard on mid-to-late inspiration, unaffected by cough 5. longer, lower-pitched non-musical discontinuous sounds best heard on mid-to-late inspiration, unaffected by coughQuestion 2: Which of these is a cause of chronic stridor? 1. Epiglottitis 2. Laryngomalacia 3. Quinsy 4. Inhaled foreign body 5. Inhalation burnsQuestion 3: Which of these should you not do when examining someone with stridor? 1. Attempt to visualise the airway 2. Call for help 3. Conduct a basic A to E assessment 4. Conduct basic observations 5. Assess for signs of respiratory distressEPIGLOTTITISWHA T IS EPIGLOTTITIS? - Can completely obscure the airway within hours of onset, hence a MEDICAL EMERGENCYCAUSES/ RISK FACTORS - History of lack of vaccinations (not vaccinated against HiB) - Preceding URTISYMPTOMS AND SIGNS - Pyrexial, sore throat - Stridor - Unwell child, fatigued (NICE traffic light system)INVESTIGA TIONS - Bedside investigations SHOULD NOT BE performed due to risk of further airway obstruction - do not actively look for a foreign body to exclude as a cause of stridor - bodiesl neck x-ray ‘thumb’ sign, and also to exclude foreignTREA TMENT - Keep them CALM, and ensure airway is secure - Preparations for intubation and possible tracheostomy if needed, w/ possible transfer to HDU (keep a set nearby) - ESCALATE TO SENIORS (paeds + anaesthetics) - Once A secure, IV antibiotics (ceftriaxone) and steroids (e.g. dexamethasone)COMPLICA TIONS - Epiglottic abscess - Respiratory failure - SepsisCROUPWHA T IS CROUP? - and bronchi, including the vocalhea cords - A form of URTI - Usually self-limitingCAUSES/ RISK FACTORS - Infant aged 6 month to 2 years - Autumn/winter months - Preceded by a viral infection, typically parainfluenza virus - Previously, diphtheria, although now uncommon due to vaccineSYMPTOMS AND SIGNS - Stridor - Increased work of breathing (think - Dyspnoea recessions, use of accessory - Characteristic ‘barking cough’ muscles) (worse at night) - Hoarse voice - Pyrexia, low grade - Coryzal symptomsINVESTIGA TIONS - Typically diagnosed clinically - If a CXR is done in severe cases: sub-glottic narrowing (steeple sign)TREA TMENT Community: supportive management, postural changes, infection control In critical cases: - High-flow O2 Hospital: stat oral dose of - Neb. budesonide prednisolone, repeated after 12 hours - Neb. adrenaline prn - Intubation and ventilationCOMPLICA TIONS - Generally uncommon - Bacterial tracheitis - Pneumonia - Pulmonary oedema - DeathLARYNGOMALACIAWHA T IS LARYNGOMALACIA? - Part of the supraglottic larynx is structured such that it causes partial airway obstruction - Anafolds leading to the ‘omega sign’epiglotticCAUSES/ RISK FACTORS - Exact cause unknown Many theories: - Neurologic dysfunction - ?GORD - Imbalance of demand-supply on inhalation in infantsSYMPTOMS AND SIGNS - No associated respiratory distress (what signs?)INVESTIGA TIONS - Flexible laryngoscopy - Modified barium swallow to assess swallowing - Polysomnogram to assess obstructive sleep apnoeaTREA TMENT - Conservative management (in majority) - Supraglottoplasty - Tracheostomy if necessaryCOMPLICA TIONS -Concomitant reflux disease, treated with PPIsQuestion 4: Which of these is indicated in the management of croup? 1. Dexamethasone 0.15mcg/kg 2. Dexamethasone 0.1mcg/kg 3. IV Tazocin 4. Hydrocortisone 0.15mg/kg 5. Vitamin B12 injectionsQuestion 5: Which of these is not indicated in the treatment of laryngomalacia? 1. Supraglottoplasty 2. Conservative management 3. Tracheostomy 4. Needle aspiration 2nd intercostal space mid-clavicular line 5. High-flow O2Question 6: A concerned mother brings her baby into the GP having waited on the phone for half an hour. O/E: mottled skin, reduced skin turgor, BP 90/60. Signs of respiratory distress. Hard to rouse. What do you do? 1. Call for help, and an ambulance to A and E 2. Self-referral to A and E 3. Administer dexamethasone 0.15mcg/kg 4. Call 2222 5. Post about it on MedTwitterSUMMARY HOW TO SPLIT THE DIFFERENTIAL HISTORY TAKING EXAMINATION INVESTIGATIONS QUIZ NO. 1 DDx 1: Epiglottitis DDx 2: Croup DDx 3: Laryngomalacia QUIZ NO. 2THANK YOU!REFERENCES https://www.ncbi.nlm.nih.gov/books/NBK544266/ https://zerotofinals.com/paediatrics/respiratory/croup/ https://zerotofinals.com/paediatrics/respiratory/epiglottitis/ https://www.passmedicine.com/v7/menu.php Epiglottitis - StatPearls - NCBI Bookshelf (nih.gov) 💬1 - Stridor | Assessment & Management | Geeky Medics https://www.ncbi.nlm.nih.gov/books/NBK544266/