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Stridor and management of obstructed airway
1. Dr. Ramesh Parajuli
Chitwan Medical College Teaching Hospital Bharatpur-
10,Chitwan, Nepal
Stridor & management of
obstructed airway
2. 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
5. Laryngomalacia
Most common congenital laryngeal anomaly of larynx
Excessive flaccidity of cartilaginous structures
Manifests 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)
8. 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)
9. History
1.Time of onset: Congenital or acquired
2. Mode of onset:
Sudden onset → Foreign body, Trauma, Infection
Gradual(insidious) onset + progressive → Laryngomalacia,
Stenosis, Respiratory papillomatosis, Neoplasms
3. Relation to feeding → Aspiration due to laryngeal paralysis,
esophageal obstruction
4. Relation to sleep and body position:
Present only during sleep Stertor
Disappears in prone position Laryngomalacia
10. Physical examination:
Stridor is always associated with respiratory distress.
Signs of airway resistance: Nasal flaring, intercostal/
subcostal / supraclavicular recession, cyanosis
14. 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
15. Signs of worsening (increasing stridor) in gradual
onset respiratory obstruction
Stridor at rest
Restless
Patient can’t lie flat in bed
Rising pulse rate
Patient using accessory muscles of respiration: intercostal
recession
Intubation or Tracheostomy
16. 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
17. Oropharyngeal or nasal airway
When the obstruction lies in the oral cavity, oropharynx or base
of tongue
Guedell / Oropharyngeal airway Nasopharyngeal airway
18. Wide bore cannula
To provide temporary relief until either
intubation or tracheostomy can be
performed
19. Endotracheal (ET) tube for Intubation
Appropriate instruments, trained personnel and adequate facilities
are available
20. 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
24. 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