Dr. Ramesh ParajuliChitwan Medical College Teaching Hospital Bharatpur-

10,Chitwan, Nepal

Stridor & management of obstructed airway

Stridor: Noisy breathing due to partial obstruction of upper airway eg. in oropharynx, hypopharynx, larynx, trachea or bronchi

Stertor: Noisy breathing due to rattling or rumbling of secretions in the pharynx

Rales & Crepitus: Distal portion of bronchial tree & alevoli

(Lower respiratory tract)Hoarseness: Alteration in quality of voice Aphonia vs Dysphonia

Causes of hoarseness

1.Inflammatory: laryngitis, Tuberculosis2. Neoplasms 3. Non-neoplastic (tumour like masses): Vocal

nodule/polyp3. Trauma: Laryngeal trauma, intubation4. Neurological: Recurrent laryngeal nerve palsy6. Congenital: Laryngeal web, cyst7. Systemic: hypothyroidism 8. Psychogenic: functional aphonia, puberophonia,

Dysphonia plica ventricularis9.Habitual dysphonia: vocal nodule, vocal edema,

contact ulcers

Congenital Acquired

1. Laryngomalacia 1. Inflammatory: Acute epiglottitis,

2. Vocal cord palsy croup, laryngeal edema, RRP,TB,

3. Subglottic stenosis Retropharyngeal abscess

4. Subglottic hemangioma 2. Trauma

5. Laryngeal web & atresia

6. Laryngeal cyst 3. Malignancy

4. Foreign body

5. B/L vocal cord palsy

Causes of stridor

Laryngomalacia

Most common congenital laryngeal anomaly of larynxExcessive flaccidity of cartilaginous structuresManifests at birth or soon after, usually disappears by

2 years of age.Characteristic features (Seen on Flexible NPL):

Elongated epiglottis(Omega shaped), floopy aryepiglottic(AE) fold & prominent arytenoids(Sucked in during inspiration)

Inspiratory stridor:

Increased on supine position

Relieved by prone position Phonation & cry are normal.

Management:

Conservative: Reassurance

Tracheostomy: for severe respiratory obstruction

Epigllotoplasty: Laser assisted

Stridor may be:

1. Inspiratory stridor Glottis or supraglottis

2. Biphasic stridor Subglottis or trachea

3. Expiratory stridor obstruction at the level of alveoli

(commonly referred to as wheeze and is not true stridor)

History1.Time of onset: Congenital or acquired2. Mode of onset:

Sudden onset Foreign body, Trauma, Infection Gradual(insidious) onset + progressive Laryngomalacia,

Stenosis, Respiratory papillomatosis, Neoplasms3. Relation to feeding Aspiration due to laryngeal

paralysis, esophageal obstruction4. Relation to sleep and body position: Present only during sleep Stertor Disappears in prone position Laryngomalacia

Physical examination: Stridor is always associated with respiratory

distress. Signs of airway resistance: Nasal flaring,

intercostal/ subcostal / supraclavicular recession, cyanosis

Investigations

1. X-Ray soft tissue neck: Epiglottitis, Stenosis

2. X-Ray chest: Mediastinal lesion3. Flexible Nasopharyngolaryngoscopy

(NPL)4. Direct laryngoscopy & Bronchoscopy 5. Imaging (CT/MRI) of neck & chest

Nasopharyngolaryngoscopy(NPL): B/L abductor palsy

1. Heimlich manoeuvre2. Oropharyngeal or nasal airway3. Intubation 4. Wide bore needle 5. Cricothyroidotomy6. Tracheostomy

Management of obstructed airway

Acute life threatening respiratory obstruction Vs Gradual onset respiratory obstruction

Acute life threatening resp. obstruction: FB, inhalation of food bolus, trauma, infection, late presentation of large neoplasms of larynx/hypopharynx (esp.in Nepal)

Gradual onset resp. obstruction: Neoplasms of larynx/hypopharynx, subglottic/tracheal stenosis, infection, blunt laryngeal trauma

Signs of worsening (increasing stridor) in gradual onset respiratory obstruction

Stridor at restRestlessPatient can’t lie flat in bedRising pulse ratePatient using accessory muscles of respiration:

intercostal recession

Intubation or Tracheostomy

Heimlich manoeuvre

Acute respiratory obstruction due to food bolus or foreign body

Residual air in the lungs to expel the FB.

Pressure exerted by rapid squeezing motion applied against the xiphoid region of the sternum

Oropharyngeal or nasal airway

When the obstruction lies in the oral cavity, oropharynx or base of tongue

Guedell / Oropharyngeal airway Nasopharyngeal airway

Wide bore cannula

To provide temporary relief until either intubation or tracheostomy can be performed

Endotracheal (ET) tube for Intubation

Appropriate instruments, trained personnel and adequate facilities are available

Cricothyroidotomy

Cricothyroid membrane is superficial,relatively avascular, easily identifiable landmark

Cricothyroid membrane incised endotracheal tube or tracheostomy tube

Tracheostomy done as soon as possible

Cricothyroidotomy should never be done as a substitute for tracheostomy bcoz of high possibility of subglottic stenosis

Needle cricothyroidotomy

Tracheostomy

Tracheostomy Intubation

More time to perform Less time to perform

Invasive Non-invasive

Complications are more Less

Can be kept for long duration Should not be kept for > 2 weeks(Subglottic stenosis)

Patient can speak Can’t speak

Tracheo-bronchial toilet is easy Difficult

Decannulation esp. in children is difficult--subglottic

edema,granulations,psychological dependence on tracheostomy tube

Preferred over tracheostomy in children – Resp. obstruction due to

airway infection usu. Resolve within 72 hrs

Thank you