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PubMed1991

Helium-oxygen mixture in the treatment of postextubation stridor in pediatric trauma patients.

OBJECTIVE: To assess the effectiveness of a helium-oxygen mixture in reducing post-extubation stridor in children hospitalized for burns or trauma. DESIGN: Randomized, controlled crossover trial. SETTING: Harborview Medical Center's Burn and Trauma ICUs from March to September 1989. PATIENTS: Children less than 15 yr old who were electively extubated and had symptoms of postextubation stridor, but required less than or equal to 35% oxygen. INTERVENTION: Each treatment (helium-oxygen and oxygen-supplemented room air) was given in random order for 15 min after extubation. MEASUREMENTS: Respiratory distress was assessed by a physician blinded to treatment order using a standard stridor score and clinical judgment. RESULTS: There were 13 children with 15 extubations; seven (47%) of 15 patients required subsequent treatment with racemic epinephrine or reintubation. Stridor scores were lower with helium-oxygen than with oxygen-supplemented room air (2.8 vs. 3.7, p less than .005), and helium-oxygen was preferred in eight of nine trials in which one treatment was clearly favored by the physician. CONCLUSION: Because helium-oxygen therapy can reduce stridor scores and is clinically preferred by physicians caring for stridorous children, it may be a useful adjunctive therapy in pediatric trauma patients with postextubation stridor.

Adolescent↗

PubMed2002

The "air leak" test around the endotracheal tube, as a predictor of postextubation stridor, is age dependent in children.

OBJECTIVES: The airleak test is measured with a manometer as the pressure necessary to generate an audible airleak around the endotracheal tube. Our objectives were to determine whether the airleak test predicts postextubation stridor in children and if age affects its sensitivity and specificity. DESIGN: A retrospective study. SETTING: Pediatric intensive care unit. PATIENTS: We studied all intubated patients admitted to our pediatric intensive care unit between July 1998 and December 1999. Patients were excluded if they had acute viral croup, tracheal surgery, hypotonic airway, or vocal cord paralysis or if they died before extubation. INTERVENTIONS: Medical records were reviewed for patient demographics, presence of an airleak on the day of extubation, airleak values, presence of postextubation stridor, and extubation failure secondary to upper airway obstruction. MEASUREMENTS AND MAIN RESULTS: One hundred and five patients met our inclusion criteria and had an airleak test at the time of extubation. In children <7 yrs of age, the incidence of postextubation stridor was similar in patients with or without an airleak at >20 mm Hg (50% vs. 67.7%; >.05) with a sensitivity of 65.6% (95% confidence interval, 46.9-80.8). In children >or=7 yrs of age, the incidence of postextubation stridor was greater in patients with an airleak at >20 mm Hg (55.5% vs. 5.8%; p=.01) with a sensitivity of 83.3% (95% confidence interval, 36.8-99) in predicting postextubation stridor. CONCLUSIONS: Our study suggests that the airleak test has a low sensitivity when used as a screening test to predict postextubation stridor in young children (<7 yrs old), whereas in older children (>or=7 yrs old) the airleak test may predict postextubation stridor.

Adolescent↗

PubMed1996

Association between reduced cuff leak volume and postextubation stridor.

STUDY OBJECTIVE: Laryngotracheal injury or edema in the setting of intubation may narrow the upper airway and predispose toward postextubation stridor. The presence or absence of an audible airleak when the sealing balloon cuff of the endotracheal tube is deflated has been demonstrated to be a marker of laryngotracheal edema in high-risk patients. We hypothesized that (1) the volume of the cuff leak can be quantified in a general medical ICU population, and (2) the cuff leak volume can be correlated with likelihood of postextubation stridor. METHODS: Within 24 h of both the initiation and termination of mechanical ventilation, the cuff leak volume, defined as the difference between the inspiratory tidal volume and the averaged expiratory tidal volume while the cuff around the endotracheal tube was deflated, was recorded. RESULTS: In 100 consecutive intubations, the preextubation cuff leak volume was 349 +/- 163 mL [mean +/- SD]). Overall, 6% of extubations were accompanied by postextubation stridor. The mean cuff leak volume measured within 24 h of planned extubation was significantly lower in those who subsequently developed stridor in comparison to those who did not (180 +/- 157 mL vs 360 +/- 157 mL; p = 0.012). The positive predictive value for postextubation stridor in the setting of a cuff leak less than 110 mL was 0.80, the predictive value for absence of postextubation stridor with a cuff leak volume greater than 110 mL was 0.98, and the specificity of the test was 0.99. No other demographic factors or indexes related to mechanical ventilation were significantly different between the two groups. CONCLUSIONS: A reduced cuff leak volume prior to extubation identifies a population at increased risk for postextubation stridor.

Aged↗

PubMed1999

Diagnosis of stridor in children.

Stridor is a sign of upper airway obstruction. In children, laryngomalacia is the most common cause of chronic stridor, while croup is the most common cause of acute stridor. Generally, an inspiratory stridor suggests airway obstruction above the glottis while an expiratory stridor is indicative of obstruction in the lower trachea. A biphasic stridor suggests a glottic or subglottic lesion. Laryngeal lesions often result in voice changes. A child with extrinsic airway obstruction usually hyperextends the neck. The airway should be established immediately in children with severe respiratory distress. Treatment of stridor should be directed at the underlying cause.

Algorithms↗

PubMed2005

Management of stridor in neonates and infants.

Stridor is the sound caused by abnormal air passage into the lungs and can exist in different degrees and be caused by obstruction located anywhere in the extra-thoracic (nose, pharynx, larynx, trachea) or intra-thoracic airway (tracheobronchial tree). Stridor may be congenital or acquired, acute, intermittent or chronic. Laryngotracheal inflammation (croup) is the most common cause of acute stridor. Laryngotracheomalacia is the most common cause of congenital, chronic stridor. Stridor is a clinical sign and not a diagnosis. The golden standard in the workup of stridor is an upper and lower airway endoscopy under general anaesthesia. Endoscopic examination under general anaesthesia requires a multidisciplinary approach and close cooperation between anaesthesiologist, paediatrician, ENT surgeon and nursing staff. Following this procedure, a place in the intensive care unit should be available for those cases presenting with stridor in which a definite diagnosis could not yet be established. Although important, pre-endoscopy assessment including history, physical examination and radiological examination, is only a guide to the type and degree of pathology found during endoscopy. About 1 out of 10 infants are found to have lesions in more than one anatomical site of the upper aerodigestive tract.

Airway Obstruction↗

PubMed1992

Functional stridor diagnosed by the anaesthetist.

While stridor is an ominous sign implying severe airway stenosis, not all stridor has an organic aetiology. We present two cases of functional stridor in which the diagnosis was made by the anaesthetist. As experts in the management of difficult airways, anaesthetists should be aware of this clinical entity. Recurrent episodes present as aphonia, dysphonia, dyspnoea, apnoea or unconsciousness. Stridor is usually inspiratory. Flow volume loops show a pattern of variable extrathoracic obstruction with diminished peak inspiratory flow. Awake fibreoptic laryngobronchoscopy reveals normal airway anatomy, intense adduction of false and true vocal cords during inspiration and normal vocal cord motion on expiration. Treatment of functional stridor is supportive. The diagnosis of functional stridor demands exclusion of life-threatening airway stenosis of organic aetiology. A high index of suspicion for this clinical entity will reduce the incidence of unnecessary interventions such as tracheal intubation and tracheostomy.

Adult↗

PubMed2002

Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test.

OBJECTIVE: To evaluate the incidence and identify factors associated with the occurrence of post-extubation stridor and to evaluate the performance of the cuff-leak test in detecting this complication. DESIGN: Prospective, clinical investigation. SETTING: Intensive care unit of a university hospital. PATIENTS: Hundred twelve extubations were analyzed in 112 patients during a 14-month period. INTERVENTION: A cuff-leak test before each extubation. MEASUREMENTS AND RESULTS: The incidence of stridor was 12%. When we chose the thresholds of 130 ml and 12% to quantify the cuff-leak volume, the sensitivity and the specificity of the test were, respectively, 85% and 95%. The patients who developed stridor had a cuff leak significantly lower than the others, expressed in absolute values (372+/-170 vs 59+/-92 ml, p<0.001) or in relative values (56+/-20 vs 9+/-13%, p<0.001). Stridor was associated with an elevated Simplified Acute Physiology Score (SAPS II), a medical reason for admission, a traumatic or difficult intubation, a history of self-extubation, an over-inflated balloon cuff at admission to ICU and a prolonged period of intubation. These results provide a framework with which to identify patients at risk of developing a stridor after extubation. CONCLUSION: A low cuff-leak volume (<130 ml or 12%) around the endotracheal tube prior to extubation is useful in identifying patients at risk for post-extubation stridor.

Airway Obstruction↗

PubMed2006

Dexamethasone reduces reintubation rate due to postextubation stridor in a high-risk paediatric population.

OBJECTIVE: To study the effect of dexamethasone on postextubation stridor (PS) incidence and reintubation rate due to PS in a high-risk paediatric intensive care population. PATIENTS AND METHODS: All children aged between 4 wk and 6 y, who were intubated for at least 24 h and extubated between August 1999 and May 2002, were retrospectively included (n=60). Medical records of the included patients were studied; records of patients treated with dexamethasone prior to and following extubation (n=23) were compared with control patients who had not received prophylactic medication (n=37). RESULTS: Nine patients in the control group developed significant postextubation stridor, necessitating nebulized epinephrine or glucocorticosteroids. In six of these children, reintubation as a result of postextubation stridor was indicated. None of the patients treated with dexamethasone developed severe postextubation stridor or required reintubation. CONCLUSIONS: The risk of postextubation stridor is relatively high in the group of children aged between 4 wk and 6 y with intubation exceeding 24 h. We found dexamethasone to be effective in preventing reintubation due to postextubation stridor in this paediatric high-risk group.

Anti-Inflammatory Agents↗

PubMed1991

Predictors of postextubation stridor in pediatric trauma patients.

OBJECTIVE: To determine which factors are the best predictors of postextubation stridor in pediatric trauma patients. DESIGN: Prospective cohort study. SETTING: The Burn and Trauma ICUs at Harborview Medical Center from March to September 1989. PATIENTS: Children were eligible for the study if they were less than 15 yr old, were intubated for greater than 12 hr, and did not have underlying cardiopulmonary disease. The study included 25 patients with 30 extubations. RISK FACTORS ASSESSED: Age, type of injury (burn vs. trauma), location of intubation ("field" vs. hospital), endotracheal tube size, length of intubation, and presence of an airleak around the tube at the time of extubation at 30 cm H2O pressure. MAIN OUTCOME MEASURE: Moderate to severe postextubation stridor requiring treatment with racemic epinephrine, helium-oxygen, reintubation, or tracheostomy. RESULTS: Treatment for postextubation stridor was required after 11 (37%) of 30 extubations, with five reintubations and one tracheostomy. The best predictor of postextubation stridor was absence of an airleak at the time of extubation (sensitivity 100%, positive predictive value 79%, p less than .001), followed by type of injury (facial burn vs. all others; sensitivity 64%, positive predictive value 88%, p less than .001). After controlling for these two factors, no other factor studied was a significant predictor of postextubation stridor. CONCLUSION: In pediatric trauma patients, mechanism of injury (facial burn vs. other) and absence of an airleak at the time of extubation are the strongest factors predicting postextubation stridor. Patients with one or both risk factors require special attention to airway management.

Adolescent↗

PubMedDate not supplied

Etiology of stridor in the neonate, infant and child.

Of 219 patients whose primary presenting symptom was stridor, 150 were males, 69 were females. All were under 2 1/2 years of age; more than half were four months of age or younger. Congenital anomalies caused stridor in 191 (87.2%). Congenital laryngeal anomalies accounted for the stridor in 132 (60.3%); there were 35 (16.0%) patients with congenital tracheal anomalies, 11 (5.0%) with congenital bronchial anomalies, 12 (5.5%) with infectious conditions, 12 (5.5%) with internal laryngeal trauma and 15 (6.8%) patients with other conditions. The cause of stridor was undetermined in two patients. Sixteen vascular anomalies were diagnosed and classified according to the part of the tracheobronchial tree which was involved. Twenty-six patients required tracheotomy. Fifty-eight (26.5%) were referred with an erroneous presumptive diagnosis for which they were being treated. The mean length of time from onset of symptoms to determination of the correct diagnosis by endoscopy was four months; it varied from one day to 16 months. The importance of early endoscopy for the diagnosis of conditions causing stridor cannot be overemphasized. The occurrence of more than 1 anomaly in 99 (45.2%) of the 219 patients demonstrates the importance of complete endoscopic examination of all patients with stridor.

Bronchi↗

PubMed1989

[Stridor in children].

Stridor is the presenting symptom of abnormalities of larynx and trachea in children. The anatomical differences in size and consistency of the larynx play a crucial role in stridor in children as compared with adults. From 1983 to 1988, 81 children (65 males, 16 females) with severe or prolonged stridor were admitted to our hospital. Thorough examination, including endoscopy of larynx and trachea and radiology revealed various congenital abnormalities and acquired conditions as the cause of stridor. Congenital laryngeal anomalies accounted for stridor in 26 children, there were 12 children with congenital tracheal or vascular anomalies, 28 with infectious diseases and 15 with other diseases. Intubation and (or) tracheotomy were performed in one-third of the patients: 5 of them died of severe complications. For proper treatment of children with stridor it is essential to investigate its aetiology carefully.

Child↗

PubMed1995

Congenital stridor.

Fifty-two infants and children with stridor were examined. The median age was 5 months and the boy/girl ratio was 2:1. Fiberoptic bronchoscopy was performed when other diagnostic methods had failed to establish the origin of stridor. The most common cause of stridor was laryngomalacia, which was found in 34 children (65%). The most common form of laryngomalacia was due to large, floppy arytenoid cartilages; this was observed twice as often as other forms of laryngomalacia and boys suffered from this abnormality more than twice as often as girls. Children with laryngomalacia had significant weight (24%) and height (8%) deficits in comparison with the normal healthy population (P < 0.001). In all but four patients with laryngomalacia, blood gases were within normal limits. In 18 children (35%) stridor was not caused by laryngomalacia. This group showed significant etiologic heterogeneity. However, identification of the cause of stridor in these patients is important because specific treatment can be offered and prognosis depends on the type and cause of the anatomical and functional abnormality present.

Bronchoscopy↗

PubMed1991

Dexamethasone in the prevention of postextubation stridor in children.

To assess whether there is any advantage in the use of corticosteroid to prevent postextubation stridor in children, we conducted a prospective, randomized, double-blind trial of dexamethasone versus saline solution. The patients were evaluated and then randomly selected to receive either dexamethasone or saline solution according to a stratification based on risk factors for postextubation stridor: age, duration of intubation, upper airway trauma, circulatory compromise, and tracheitis. Dexamethasone, 0.5 mg/kg, was given every 6 hours for a total of six doses beginning 6 to 12 hours before and continuing after endotracheal extubation in a pediatric intensive care setting. There was no statistical difference in incidence of postextubation stridor in the two groups; 23 of 77 children in the placebo group and 16 of 76 in the dexamethasone group had stridor requiring therapy (p = 0.21). We conclude that the routine use of corticosteroids for the prevention of postextubation stridor during uncomplicated pediatric intensive care airway management is unwarranted.

Child↗

PubMed1996

Stridor in neonates.

Stridor in neonates and infants is a symptom that indicates partial obstruction of the large diameter airways. Its presence should prompt a thorough examination and workup. Steps in evaluating stridor include a careful history and physical examination and rapid assessment of the severity of the clinical situation. Infants with respiratory distress and severe stridor should be safely and urgently transported to a tertiary care center, and colleagues from the departments of otolaryngology and anesthesia-critical care should be alerted. An essential component of the physical examination is auscultation. The phase of respiration in which the stridor is heard best provides important clues to help localize its cause. Radiographs, including plain films, dynamic fluoroscopic airway films, contrast esophagography, CT, and MR imaging are useful in specific clinical situations, based on the likely differential diagnosis. The anatomic causes for stridor in infants and neonates are vast. Successful management depends on expert consultation, proper equipment, and a staff that is experienced in the management of pediatric airway problems. The trend over the past decade has been to significantly decrease morbidity and mortality and also to decrease the number of tracheotomies necessary to stabilize pediatric airways. The best treatment outcomes result when there is good cooperation and communication among pediatricians, otolaryngologists, pulmonologists, and anesthesiologists.

Airway Obstruction↗

PubMed2000

The role of fibreoptic laryngoscopy in infants with stridor.

Stridor in infants may be potentially serious and would require further investigations in all cases. Laryngomalacia is the most common cause of congenital stridor. This is a self-limiting condition with a good prognosis but other causes of stridor should be excluded to enable the surgeon to plan further intervention if needed. Traditionally microlaryngoscopy and bronchoscopy under a general anaesthetic is performed to evaluate the airway. We have investigated the use of the flexible fibreoptic laryngoscope under local anaesthetics in infants with inspiratory stridor. The procedure was performed in the day surgery unit on a non-fasting, non-sedated child. A retrospective analysis of procedures performed between January 1998 and August 1999 was carried out. Of the 43 patients studied, laryngomalacia was diagnosed in 35, vocal cord palsies in six and two infants had a normal larynx. There were no complications during the procedure and only one child required further intervention. The results showed that the combination of fibreoptic laryngoscopy under local anaesthetic with follow-up is a safe, effective and cost effective method of assessing stridor in this group of patients.

Ambulatory Care↗

PubMed1999

An unusual case of stridor due to osteophytes of the cervical spine: (Forestier's disease).

Stridor is a noisy breathing caused by compromised airway in the larynx and trachea. The causes can either be due to intrinsic or extrinsic compression. Stridor resulting from extrinsic compression due to anterior cervical osteophytes is rare. We report an unusual case of acute stridor due to an osteophytic mass in the cervical vertebrae resulting in a mechanical upper airway obstruction. The underlying pathology was Forestier's disease or diffuse idiopathic skeletal hyperostosis (DISH). Stridor is a rare manifestation of DISH and it certainly represents the most life-threatening one. Only a few cases have been reported in the English literature and are mainly secondary to impaired function of the vocal folds, or postcricoid ulceration and oedema. We present such a case, in that stridor was the result of direct airway obstruction by the osteophytic mass and an emergency tracheostomy had to be performed to establish an airway.

Aged↗

PubMed2001

Bloodletting acupuncture for the prevention of stridor in children after tracheal extubation: a randomised, controlled study.

Bloodletting acupuncture has been used for the treatment of a variety of upper respiratory tract problems, especially those of laryngeal origin. This study assesses its efficacy in reducing the incidence of stridor after tracheal extubation in children undergoing general anaesthesia with halothane. Sixty children were randomly allocated to an acupuncture group and a control group. In the acupuncture group, bloodletting acupuncture was performed before extubation. A blinded observer determined the presence and severity of postextubation stridor. The incidence of stridor in the acupuncture group was significantly higher than in the control group. In addition, the severity of stridor was significantly greater in the acupuncture group. It is concluded that in children undergoing halothane anaesthesia, the incidence of postextubation stridor cannot be reduced by bloodletting acupuncture.

Acupuncture Therapy↗

PubMedDate not supplied

The use of dexamethasone in the prevention of postextubation stridor in pediatric patients in PICU/NICU settings: an analytical review.

ISSUES AND PURPOSE: Dexamethasone has been used to prevent postextubation stridor in children, but its use is controversial. Five randomized, controlled clinical trials were reviewed to analyze the effectiveness of prophylactic dexamethasone on postextubation stridor in pediatric patients. CONCLUSIONS: Previous studies had inconsistent results. Several factors may contribute to postextubation stridor in pediatric patients. Postextubation stridor and extubation failure do not always result from airway edema. PRACTICE IMPLICATIONS: In addition to prophylactic dexamethasone, other approaches should be used to prevent postextubation stridor, such as preparing the patient, following established guidelines, and providing appropriate postextubation care.

Anti-Inflammatory Agents↗