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PubMed2002

Vincristine-induced vocal cord paralysis in an infant.

We report the development of stridor and dysphagia in a 5-month-old-infant with acute lymphoblastic leukaemia after the administration of four weekly doses of vincristine during induction therapy. Because direct laryngoscopy revealed bilateral vocal cord paralysis, the patient underwent elective intubation. Extubation was performed 7 days later, after direct laryngoscopy confirmed recovery of vocal cord mobility. Vincristine-induced bilateral recurrent laryngeal nerve paralysis is a rare but potentially life-threatening complication. Therefore, it should be suspected when stridor is present, and clinicians should consider visualization of the airway to establish the cause of upper airway compromise in infants receiving vincristine.

Antineoplastic Agents, Phytogenic↗
PubMedDate not supplied

Adult laryngomalacia: an uncommon clinical entity.

A 27-year-old female presented with a several-day history of acute onset inspiratory stridor and shortness of breath that worsened with phonation and minimal exertion. Flexible fiberoptic direct laryngoscopy revealed prolapse of the mucosa overlying the arytenoid cartilages bilaterally, consistent with type 1 laryngomalacia. These symptoms persisted with only minimal improvement despite administration of short-term corticosteroids, several weeks of antireflux medications, and other conservative measures. The patient underwent a supraglottoplasty and exhibited a marked improvement in her symptoms. The literature describes several cases of exercise-induced laryngomalacia in both pediatric and adult populations in which symptoms of inspiratory stridor and shortness of breath are induced by exercise but resolve upon its discontinuation. Adult laryngomalacia appears to be a clinical entity distinct from exercise-induced laryngomalacia because symptoms fail to resolve after several weeks of medical therapy and discontinuation of exertional activity. This case suggests that adult laryngomalacia, unlike pediatric and exercise-induced laryngomalacia, is less likely to resolve over time with conservative management and may require surgical intervention with supraglottoplasty necessary to alleviate symptoms.

Adult↗
PubMed2000

[Transoral treatment of severe laryngomalacia. Review and presentation of a modified surgical technique].

BACKGROUND: Laryngomalacia is the most common cause of stridor in children. So far various authors have described surgical techniques in a sense of a supraglottoplasty or an epiglottoplasty to handle the severe form of this disease. We present a modified technique of the so called epiglottopexy. METHODS: Under the different types of laryngomalacia this study focuses on the treatment of three patients (5 to 10 months) with a posterior displacement of the epiglottis during inspiration. The first step of our technique was to denude a small portion of the base of the tongue from mucosa. A corresponding lesion was created on the lingual surface of the epiglottis. The vaporisation of the mucosa was performed with the CO2 laser at a power setting of 1 Watt and a 0.25 mm spot size. The epiglottis was then fixed transorally to the base of the tongue with 2 single stitch sutures and 1 inverse mattress suture, using a resorbable material. RESULTS: No intra- or postoperative complications were observed. All three patients demonstrated a significant airway improvement without stridor. CONCLUSION: The presented technique of transoral laser surgical epiglottopexy seems to be a method suitable for the treatment of laryngomalacia caused by posterior displacement of the epiglottis.

Age Factors↗
PubMed2004

[Impact of endoscopic ultrasonography in the diagnosis of aberrant right subclavian artery: a case report].

Aberrant right subclavian artery (ARSA) is the most common anomaly of the aortic arch. We present the successful use of endoscopic ultrasonography (EUS) in the diagnosis of ARSA. A 65-year-old woman was admitted because of dyspnoea and inspiratory stridor. Bronchoscopy revealed a subglottic tracheal stenosis. To exclude an underlying malignancy, endoscopy was performed showing an oesophageal impression, which subsequently was identified as ARSA by EUS. Computed tomography excluded neoplasm and confirmed the diagnosis of ARSA. After laser resection of subglottic tissue the stridor resolved and could therefore not be attributed to the co-existence of ARSA. In most cases the ARSA crosses between the oesophagus and the spine from the descending aortic arch to the right and may seldom cause dysphagia due to oesophageal compression. Diagnosis is usually based upon computed tomography or magnetic resonance imaging, whereas angiography is only rarely needed. Endoscopic ultrasonography offers a convenient alternative diagnostic tool and can be performed even as a bedside examination. The diagnosis can be easily assessed in all patients referred for EUS of the upper gastrointestinal tract for any reason. Especially in patients undergoing invasive procedures in the upper thorax or neck, knowledge of an abnormal course of the great vessels is important. Arteria lusoria is often found by chance. EUS is a simple and excellent tool for assessing the diagnosis and usually does not require confirmation through other investigation methods.

Aged↗
PubMed1996

[Interdisciplinary therapeutic concept in severe bacterial infections of the central respiratory tract in childhood].

BACKGROUND: Apart from all advances made in the management of central airway infections, Acute Epiglottitis (AE) and Bacterial Tracheitis (BT) continue to be causes of life-threatening airway obstruction in children. The aim of this retrospective study was to evaluate deficiencies in the diagnostical protocol, to clarify the role of airway endoscopy in acute childhood stridor, and to identify current reasons for fatalities in these diseases. MATERIAL: In the observation period between 1980-92, we found 12 patients suffering from BT and 21 from AE managed in close cooperation of the involved disciplines at the pediatric intensive care unit of the University of Cologne. RESULTS: Laryngoscopy with fiberoptic or small rigid endoscopes allowed in awake cooperative children accurate diagnose of AE, and the exclusion of supraglottic inflammation in BT without complications. Furthermore, additional endoscopic information of the degree of inflammation was helpful in the next critical decision, whether artificial airway or rigid tracheobronchoscopy was required. Nasotracheal intubation was necessary in 76% of our patients, in one child tracheostomy was performed (5%). Premature extubation necessitating reintubation occurred in 33% of the children suffering from BT. In these patients, our method of advancing a flexible endoscope for tracheoscopy through the respiration tube failed because of a low tube diameter. Another remarkable finding was the high mortality in AE (14%). Affected children were admitted in poor post-hypoxia conditions following outdoor cardiorespiratory arrest. CONCLUSION: In the analysis of the clinical course we found three decisive turning points in managing the disorder; First, the confirmation of the correct admission diagnosis; second, the decision, as to whether an artificial airway should be established; and third, the proper time of extubation. The most decisive factor in decreasing mortality seems to be timely, appropriate presentation at referral centers if AE or BT is suspected. Clinically, progressive management of childhood stridor requires close cooperation between the Pediatric, Anesthesiologic, and ENT Departments. Fiberoptic endoscopy as a guide to current airway management is a major step forward and should be a part of every established protocol.

Airway Obstruction↗
PubMed1986

Anaesthesia in the dyspneic canine or feline patient.

The different aspects of the anaesthetic approach of dyspneic patients are outlined, and the various possibilities for sedation, anaesthetic induction and maintenance, and facilitating recovery are discussed. More specific anaesthetic approaches are presented for each of the different types of stridoric dyspnea i.e. dyspnea associated with nasal, pharyngeal, laryngeal, or tracheal stridor.

Anesthesia, General↗
PubMed2004

Congenital subglottic stenosis in two unrelated pairs of siblings.

UNLABELLED: Subglottic stenosis in infants is mostly acquired (secondary) and caused by granulation tissue or submucosal mucous gland hyperplasia after prolonged endotracheal intubation. Subglottic stenosis may also be congenital (primary), and it usually occurs sporadically. There are some reports of its association with inherited anomalies, but there are no previous reports of its familial occurrence in otherwise healthy children. This report describes two pairs of siblings referred for acute inspiratory stridor in whom subglottic stenosis was diagnosed by endoscopy. They were all born at term, and their parents were unrelated. One child had an anteriorly located anus but no other abnormalities. CONCLUSION: Without any surgical intervention all had normal breathing at rest, but inspiratory stridor during respiratory infections and upon physical exercise at follow-up 4-9 y later.

Female↗
PubMed2001

Effect of common airway manoeuvres on upper airway dimensions and clinical signs in anaesthetized, spontaneously breathing children.

Chin lift, jaw thrust and these manoeuvres combined with continuous positive airway pressure (CPAP) can be used to improve the patency of the upper airway during general anaesthesia. We used video endoscopy and measurement of stridor to compare the efficacy of these manoeuvres in 24 children (3-10 yr) with adenotonsillar hyperplasia. A bronchofibrescope was passed via the nose while the children were breathing spontaneously, to identify (i) the shortest transverse distance between the tonsils during inspiration and during expiration and (ii) the distance from the tip of the epiglottis to the posterior pharyngeal wall. Chin lift or jaw thrust lifted the epiglottis and, when combined with CPAP (10 cm H2O), there was a significant lateral displacement of the tonsils. Both chin lift plus CPAP and jaw thrust plus CPAP reduced stridor significantly compared with the unsupported condition. In conclusion, in spontaneously breathing children with large tonsils, chin lift plus CPAP is recommended, whereas jaw thrust plus CPAP is no better and may cause post-operative discomfort.

Adenoidectomy↗
PubMed1981

Laryngeal abductor paralysis in multiple system atrophy. A report on three necropsied cases, with observations on the laryngeal muscles and the nuclei ambigui.

Clinical and pathological findings are reported in three cases of Shy-Drager syndrome with laryngeal stridor severe enough to require tracheostomy. Indirect laryngoscopy in all three cases revealed a failure to abduct the vocal cords properly with a resulting narrowing of the glottic airway. Histological studies showed a marked atrophy of the posterior crico-arytenoid muscles and little atrophy of the other laryngeal muscles. The posterior crico-arytenoid muscles have the sole responsibility of abducting the vocal cords, so it is concluded that the patient's stridor was caused by the selective paralysis of these muscles. Histological studies of the posterior crico-arytenoid muscles were suggestive of denervation but despite this finding, no clear evidence of any motor cell loss in the nuclei ambigui was obtained. Other possible causes of the selective posterior crico-arytenoid atrophy are discussed.

Autonomic Nervous System Diseases↗
PubMed1998

Jet ventilation in upper airway obstruction: description and model lung testing of a new jetting device.

UNLABELLED: Patients with critical upper airway stenosis require a tracheotomy for corrective surgery. We describe a new transtracheal device that permits safe ventilation of these patients without tracheotomy. It is based on a coaxial bicannular design that allows "push-pull" ventilation by jetting gas through the inner cannula and applying suction through the outer cannula. It further allows monitoring of airway pressure, tidal volume, and end-tidal CO2. The device was placed in the "trachea" of an artificial lung, and the preparation was made airtight by sealing the proximal end of the trachea. Tidal volumes and their associated pressures were measured simultaneously at different parts of the airway at several lung compliances and airway resistance settings while varying the jet and suction pressures. A large range of tidal volumes was achieved at safe airway pressures using clinically relevant airway resistance and lung compliance settings. Airway pressures measured through the device correlated well with pressures measured directly in the airways at the same time. Tidal volumes, measured through a Wright respirometer in the suction line, exceeded actual values at high suction settings and decreased below actual values at low suction settings. This new form of jet ventilation allowed efficient ventilation of the artificial lung with a totally occluded upper airway. IMPLICATIONS: Tracheotomy is required for surgery to relieve stridor because gas forced into the trachea at high pressures through a percutaneously placed needle (jetting) cannot be exhaled quickly enough for respiration. We describe a device that allows jetting in the stridorous patient by actively assisting expiration, thereby eliminating the tracheotomy requirement.

Airway Resistance↗
PubMed1983

Surgical management of vascular ring.

Between 1968 and 1980, 51 children had an operation for various forms of vascular ring. Additional cardiac malformations were present in five patients, and six had noncardiac congenital anomalies. Although symptoms started within the first month of life in 39 infants, only 16 came to operation under three months of age, and a delay of more than six months occurred in 15. Stridor, often life-threatening, and recurrent infections were the most common symptoms, but dysphagia was also important. The reasons for delay in diagnosis are discussed. Barium swallow provided the diagnosis in 44 patients and suggested it in a further four patients. Innominate artery compression of the trachea was not diagnosed by barium swallow. Operations of various types were performed. Accuracy in diagnosis is important because not all patients could be treated through the classic left thoracotomy. Severe tracheomalacia was responsible for the only two deaths in the series; one of these had tracheostomy performed in the referring hospital, the second child also had Fallot's tetralogy. The large majority of the patients have done well, 76% being asymptomatic at follow-up. Minimal to moderate stridor persists among the remainder to the present time.

Aorta, Thoracic↗
PubMed1987

Airway obstruction by vascular anomalies. Importance of telescopic bronchoscopy.

This review of 28 cases of airway obstruction by vascular anomalies in the past 6 years emphasizes the importance of these anomalies as causes of obstruction, stridor, and apnea in infants as well as the important contribution of telescopic bronchoscopy to the recognition of these lesions, especially compression of the trachea by the innominate artery. There were 20 patients with compression by the innominate artery; four were surgically corrected. Seven vascular ring anomalies were all corrected by operation as was an enlarged left atrium and malformed mitral valve in one patient. Vascular anomalies caused 26% of the obstructive airway lesions in a series of infants who had bronchoscopy for obstruction, stridor, or apnea. Failure to diagnose and treat these entities may result in progressive respiratory embarrassment and even death. Barium esophagogram and aortic arch arteriogram, the traditional modalities for diagnosing vascular rings, may fail to identify tracheal compression by enlarged cardiac chambers or the more common "anomalous" innominate artery. Telescopic bronchoscopy will identify tracheal compression by the innominate artery; furthermore, it will identify the area of compression by the vascular ring. Observation of the compressed area during corrective surgery ensures that the operative manipulations are appropriate and successful in relieving the obstruction. This observation can be facilitated by televised monitoring and videotaping.

Airway Obstruction↗
PubMed1992

Complications of endotracheal intubation and mechanical ventilation in infants and children.

OBJECTIVE: To assess the frequency of complications of endotracheal intubation and mechanical ventilation. DESIGN: Prospective cohort study. SETTING: Pediatric tertiary multidisciplinary ICU. PATIENTS: Eight hundred sixty-nine serial patients, of whom 500 were endotracheally intubated and 431 were mechanically ventilated. INTERVENTIONS: Daily clinical observation. MAIN OUTCOME MEASURES: Age, diagnosis, endotracheal tube size, type of ventilator and humidification, duration of intubation and mechanical ventilation, ventilatory settings, and complications (accidental extubation, tissue damage, endobronchial intubation, postintubation stridor, endotracheal tube blockage, pulmonary airleak, bronchopulmonary dysplasia, pulmonary atelectasis) were recorded. RESULTS: The median patient age was 10 months (25th and 75th quartiles: 1 month and 15 yrs). The median duration of endotracheal intubation and mechanical ventilation was 4 days and 2 days, respectively. A total of 186 complications were recorded in 119 (24%) patients. No deaths were due to intubation or ventilation. The overall frequency of accidental extubation was 3.2% of patients at a rate of 1.26 extubations/100 intubation days. In nonventilated, unsedated patients with croup or epiglottitis, the frequency of accidental extubation was 23% at a rate of 11.83 extubations/100 intubation days. Lung atelectasis occurred in 7.8%, airleak in 6.8%, and infection in 2.3% of patients. Other complications included tissue damage (3.4%), endobronchial intubation (2.4%), postintubation stridor (2.4%), bronchopulmonary dysplasia (2.3%), and endobronchial tube blockage (0.8%). CONCLUSIONS: Complications were related to the duration of intubation and mechanical ventilation.

Adolescent↗
PubMed1996

Dexamethasone for the prevention of postextubation airway obstruction: a prospective, randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To determine whether dexamethasone prevents postextubation airway obstruction in young children. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: Pediatric intensive care unit of a university teaching hospital. PATIENTS: Sixty-six children, < 5 yrs of age, intubated and mechanically ventilated for > 48 hrs. INTERVENTIONS: Patients were randomized to receive intravenous dexamethasone (0.5 mg/kg, maximum dose 10 mg) or saline, every 6 hrs for six doses, beginning 6 to 12 hrs before elective extubation. MEASUREMENTS AND MAIN RESULTS: Dependent variables included the presence of stridor, Croup Score, and pulsus paradoxus at 10 mins, 6, 12, and 24 hrs after extubation; need for aerosolized racemic epinephrine and reintubation. The dexamethasone and placebo groups were similar in age (median 3 months [range 1 to 57] vs. 4 months [range 1 to 59], p = .6), frequency of underlying airway anomalies (3/33 vs. 3/33, p = 1.0), and duration of mechanical ventilation (median 3.3 days [range 2.1 to 39] vs. 3.5 days [range 2.1 to 15], p = .7). The dexamethasone group had a lower frequency of stridor, Croup Score, and pulsus paradoxus measurement at 10 mins and at 6 and 12 hrs after extubation. Fewer dexamethasone-treated patients required epinephrine aerosol (4/31 vs. 22/32, p < .0001) and reintubation (0/31 vs. 7/32, p < .01). Three patients exited the study early-one patient in the dexamethasone group had occult gastrointestinal hemorrhage and one patient in each group had hypertension. CONCLUSION: Pretreatment with dexamethasone decreases the frequency of postextubation airway obstruction in children.

Airway Obstruction↗
PubMed1999

Paroxysmal laryngospasm after laryngeal nerve injury.

OBJECTIVE: Describe a clinical syndrome of laryngeal hypersensitivity following laryngeal nerve injury. STUDY DESIGN: Retrospective review of six patients with laryngeal paralysis sustained during neck surgery who presented with paroxysms of coughing and stridor, progressing to brief episodes of complete airway occlusion. METHODS: Chart review. RESULTS: Superior laryngeal nerve blockade temporarily improved symptoms in four of five patients. Botulinum toxin relieved spasm in two of three patients and reduced symptoms in the third. Symptoms gradually diminished or resolved in four patients from 1 to 2.5 years later. One patient underwent arytenoidectomy and one patient has a tracheostomy. CONCLUSIONS: Patients with laryngeal injury may present with stridor and acute airway obstruction secondary to paroxysmal laryngospasm. The authors have found that superior laryngeal nerve blockade or botulinum toxin may be effective in temporary relief of symptoms.

Adult↗
PubMed2000

Down syndrome: analysis of airway size and a guide for appropriate intubation.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to prospectively evaluate the airway size of children with Down syndrome (DS). Previous studies have observed an increase in postintubation stridor in children with DS. Anesthetic literature suggests using a smaller endotracheal tube in children with DS, but more specific recommendations are not offered. With this study, recommendations are presented for the appropriate endotracheal tube size to use in children with DS undergoing intubation. STUDY DESIGN: A prospective, nonrandomized study was performed on a cohort of 42 children with DS and 32 control subjects. Sizing of the airway was assessed through measurement of an air leak around the endotracheal tube at intubation. The size of the airway was also evaluated through measurements of the tracheal diameter at the "tracheotomy point" on magnetic resonance imagine (MRI) studies of the head and neck which were performed on a group of children with DS. These were compared with normative values of the tracheal diameter in children. METHODS: The proper size of endotracheal tube in a population of children with DS and in a group of normal controls was determined. The "proper size" of an endotracheal tube was defined as that size of tube which allowed an audible air leak around the tube between 10 and 30 cm of H2O pressure. Anesthetic technique was controlled and identical for all study subjects. Participants had no previous history of airway compromise, stridor, or previous intubation. Weight and age were recorded and evaluated for their influence on the results. A retrospective evaluation was made of MRI studies of the neck that were performed on children with DS. Using measurement techniques described by Reed et al., the tracheal diameters at the "tracheostomy point" were compared with normative values for children. Measurements were both obtained by the author and confirmed by a pediatric radiologist. RESULTS: Using this prescribed method to determine the proper size of endotracheal tube, the control group used endotracheal tubes that were predicted from established anesthesia charts and formulas. However, children with DS required endotracheal tubes at least two sizes smaller. Age was found to be a more reliable factor in predicting the endotracheal tube size. A table of endotracheal tube sizes for intubation in children with DS is presented. Evaluation of the tracheal diameter at the tracheotomy point revealed that children with DS have a smaller trachea when compared with control children. It is not only the subglottis that is smaller; the tracheal diameter as well must be assumed to be of a smaller diameter in children with DS. CONCLUSIONS: Children with DS have smaller airways than other children. This is because of an overall decrease in the diameter of the tracheal lumens. Initial intubation of a child with DS should be performed with an endotracheal tube at least two sizes smaller than would be used in a child of the same age without DS, to avert potential trauma to the airway.

Adolescent↗
PubMed1988

Childhood AIDS: an unusual presentation.

We have reported the case of a child with AIDS manifested by an acute episode of stridor associated with candidal esophagitis. Stridor is uncommon in candidal esophagitis, and we believe this is the first report of it as a presenting symptom in childhood AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed2004

Mechanical ventilation in children with acute respiratory failure.

PURPOSE OF REVIEW: Acute respiratory failure requiring mechanical ventilation continues to contribute to mortality and affect long-term functional outcomes in patients admitted to the pediatric intensive care unit (ICU). Studies in adults with acute respiratory distress syndrome (ARDS) far outnumber those conducted in the pediatric age group, and pediatric intensivists are left with the task of carefully selecting and critically appraising relevant adult data and extrapolating results to their domain of practice. RECENT FINDINGS: The recent ARDSNet study reinforces the use of low tidal volumes. Administration of surfactant is safe, but once again its beneficial effect was not sustained in a randomized trial. Surfactant proteins A and D have been shown to be of prognostic value in cases of acute lung injury. The effect of inhaled nitric oxide (NO) in patients with ARDS can be enhanced by aggressive lung recruitment strategies such as can be achieved using high-frequency oscillatory ventilation (HFOV). A recent adult trial shows good response rates but no significant long-term outcome benefit from prone positioning in patients with ARDS. Routine scheduled assessments of readiness for weaning and extubation may be more important than specific weaning modes and weaning criteria for children. A recent meta-analysis suggests that prophylactic dexamethasone use may decrease postextubation stridor and possibly reduce the need for reintubation in selected patients. Outcome data in children requiring mechanical support is encouraging, especially for high-risk groups such as bone marrow transplant (BMT) recipients, and may guide ethically challenging decision-making for these patients. SUMMARY: Mechanical ventilation strategies aiming for optimal alveolar recruitment with the judicious use of positive end-expiratory pressure (PEEP) and low tidal volumes will remain the mainstay for managing respiratory failure in children. Dexamethasone may prevent postextubation stridor. Prone positioning, surfactant therapy, HFOV, and inhaled NO are used sporadically and need to be evaluated for their effect on mortality and duration of ventilation.

Child↗