Audio recording courtesy of David W. Cugell, M.D.

Stridor is a shrill, predominantly inspiratory noise. It is most commonly associated with acute cases of foreign body, but can also result from more chronic diseases such as tracheomalacia. Inspiratory stridor at Krupp. var player panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘player..’); ko.applyBindings ({MediaUrl ‘/-/media/manual/professional/sounds/stridor_de.mp3?la=de&thn=0&mw=350’, Mime Type: ‘audio / wav’}, playerPanel.get (0)); Stridor audio recording courtesy of David W. Cugell, M.D. Pathophysiology stridor is generated by the rapid turbulent flow of air through a narrowed or partially occluded segment of the extrathoracic upper respiratory tract. Involved include pharynx, epiglottis, larynx and extrathoracic trachea etiology Most causes manifest acutely, but some patients also have chronic or recurring symptoms (see table: causes of stridor). Acute causes are up for foreign objects and allergies contagious generally. Chronic causes are usually congenital or acquired structural abnormalities of the upper airway. Temporary or intermittent wheezing can occur from acute laryngospasm or vocal cord dysfunction due to aspiration. Children The most common causes of acute stridor in children In the past, epiglottitis was a common cause of stridor in children Krupp foreign body, but their frequency has decreased since the introduction of the vaccine against Haemophilus influenzae type b (Hib). Various congenital respiratory diseases can go to common causes in adults include as recurrent stridor in newborns and infants manifestieren.Erwachsene vocal cord dysfunction (also called paradoxical vocal cord movement disorder called Laryngeal edema after invasive ventilation Stimmbandödem or-paralysis laryngeal tumors Allergic reactions A vocal cord dysfunction often mimics asthma, therefore falsely given many patients with vocal cord dysfunction medicines for asthma, but are not. an act epiglottitis can occur more frequently in adults, but it is less likely in adults as a stridor in children. causes of stridor cause Suspicious findings diagnostic approach stridor Acute Allergic reaction (severe) Sudden onset of exposure to allergens usually accompanied by wheezing and sometimes orofacial edema; No itching fever or sore throat; rarely cough Clinical evaluation Krupp age 6-36 months barking cough that verscxhlimmert in the night, symptoms of infections of the upper respiratory tract, no swallowing, mild fever Clinical evaluation Sometimes shows an anteroposterior radiograph of the neck a subglottic narrowing ( “steeple sign”) epiglottitis Mainly adults as well as children without Hib vaccination sudden high fever, sore throat, salivation and often breathlessness and severe anxiety Toxic appearance Lateral radiograph of the neck when the patient is stable examination in the operating room on Anze cozy Sudden of mental stress foreign body occurrence in an infant or child, having no symptoms of infections of the upper respiratory tract or constitutional symptoms. In adults, foreign bodies are typical in the upper respiratory tract in history. Direct or indirect laryngoscopy or bronchoscopy injury by inhalation (eg., By cleaners or smoke inhalation) Clinically obvious recent tear gas inhalation Clinical evaluation Sometimes bronchoscopy complications after invasive ventilation (z. B. laryngeal edema, laryngospasm, “arytenoid” dislocation) Recent intubation and respiratory distress Clinical review Sometimes direct laryngoscopy retropharyngeal especially in children <4-year high fever, severe sore throat, salivation, Difficulty swallowing, shortness of breath sometimes swelling that may be visible in the pharynx. Lateral radiographs of the neck Sometimes CT of the neck with contrast bacterial tracheitis (rare) barking cough that worsens at night, high fever and shortness of breath Toxic appearance radiographs of the neck Sometimes direct or indirect laryngoscopy showing and culture purulent tracheal secretions laryngospasm Recurrent episodes accompanied by gastroesophageal reflux or recent drug use or occurrence after endotracheal intubation Direct or indirect laryngoscopy vocal cord dysfunction Recurrent episodes of unexplained stridor often with hoarseness, throat tightness, choking and / or cough. Direct laryngoscopy Chronic stridor Congenital malformations (numerous; laryngomalacia most common) Normally, in newborns or infants Sometimes other congenital anomalies CT occur sometimes problems with feeding or sleeping sometimes worse in infections of the upper respiratory tract of the neck and thorax direct laryngoscopy spirometry with "flow-volume curves" external compression Positive history for head and neck tumors or obvious mass, night sweats and weight loss X-ray of the neck and Thoracic CT of the neck and thorax Direct or indirect laryngoscopy larynx tumors (eg. As squamous, hemangiomas, small cell carcinomas) inspiratory or biphasic stridor, which can worsen with magnifying tumor Direct or indirect laryngoscopy spirometry with "flow-volume curves" Congenital tracheomalacia Chronic symptoms can stridor or barking cough during coughing, crying or feeding in the supine position deteriorate CT or MRI spirometry with "flow-volume curves" Sometimes bronchoscopy Bilateral vocal cord paralysis or dysfunction Recent trauma (eg., during childbirth, thyroid and other throat surgery, intubation od He "deep airway suctioning") Various neurodegenerative or neuromuscular disorders Good speech, but limited intensity Direct or indirect laryngoscopy Hib = Haemophilus influenzae type B. Clarification history In the history of the present illness should first find out whether the symptoms acute or chronic and transient are or intermittent. If these acute symptoms of all infections of the upper respiratory tract (runny nose, fever, sore throat) or allergy (itching, sneezing, facial swelling, rash, potential exposure to allergen) are noted. Recent intubation or neck surgery should be clinically evident. If the symptoms are chronic, age are at onset (eg. As since birth, since childhood, only in adulthood) whether the symptoms are limited hours and, continuously or intermittently, and the duration. In intermittent symptoms (able to allergen exposure, cold, scared, Feeding, crying z. B.) searches for triggering or reinforcing factors. Important associated symptoms in all cases are cough, pain, drooling, dyspnea, cyanosis, and difficulty in feeding. In examining the body systems should be looked for symptoms that indicate the causative disorders such as heartburn or other reflux symptoms (laryngospasm); Night sweats, weight loss and fatigue (cancer); Change of voice, difficulty swallowing, and recurrent aspiration (neurological disorders) The history of children should include the perinatal past, particular in respect of endotracheal intubation, known congenital anomalies and the vaccination history (especially Hib). In adults past intubation, tracheotomy should recurrent respiratory infections as well as tobacco and alcohol consumption asked werden.Körperliche investigation The first step is to determine the presence and degree of breathlessness by evaluating vital signs (including pulse oximetry) and a quick check. Among the signs of severe distress include cyanosis, altered mental status, low oxygen saturation (z. B., <90%), air hunger, using the respiratory muscles and difficulty speaking. Children with epiglottitis may sit upright, with the arms to the legs or the examination table supported, bent forward with hyperextended neck, vorgeschobenem jaw and open mouth and wrestle hard for air (Dreifußzeichen-sitting position) A moderate respiratory distress is tachypnea, use of the respiratory muscles and collect the intercostal muscles appear. In severe respiratory distress further investigation is moved to equipment and personnel for emergency treatment are available. The oropharyngeal examination of a patient (particularly a child) with epiglottitis can trigger anxiety, which leads to functional disability and loss of the respiratory tract. Thus, if a epiglottitis is suspected, neither a spatula yet another instrument should be kept in the mouth. There is little suspicion and do not suffer from respiratory distress, patients, imaging can be performed. Other patients should be sent for a direct laryngoscopy in the operating room, which should be performed by an otolaryngologist under anesthesia. If the vital signs and respiratory tract of the patient are stable and no acute epiglottitis is suspected, the oral cavity should be thoroughly examined for pooled secretions, hypertrophic tonsils, induration, redness, or foreign bodies. The neck is scanned on masses and Trachealabweichungen. A careful auscultation of the nose, oropharynx, neck and thorax can help the position of stridor be seen. Infants should with particular attention to craniofacial morphology (looking for signs of congenital malformations) patency of the nostrils, and cutaneous abnormalities studied werden.Warnzeichen The following results are of particular importance: salivation and agitation Dreifußzeichen-sitting posture cyanosis or hypoxia on pulse oximetry consciousness clouding interpretation of results The distinction between acute and chronic stridor is important. Other findings are also often helpful (see table: causes of stridor). Acute symptoms rather reflect an immediately life-threatening disease. In these diseases, fever indicates an infection. Fever plus. Barking cough points to Krupp toward or, very rarely, in tracheitis. Patients with Krupp generally have more prominent symptoms of infections of the upper respiratory tract and fewer symptoms of a toxic appearance. Fever without cough, especially when accompanied by a toxic appearance, sore throat, difficulty swallowing, or shortness of breath, can on epiglottitis and in young children, close to the less frequent retropharyngeal. Salivation and Dreifußzeichen-sitting posture indicate a epiglottitis, while a retropharyngeal can manifest to lengthen the neck with neck stiffness and inability. Patients without fever or symptoms of infections of the upper respiratory tract may be of acute allergic reaction, or aspirated foreign bodies. An acute allergic reaction, which is strong enough to cause a stridor, includes other manifestations of Atemwegödemen (eg., Oral or facial edema, wheezing), or anaphylaxis (itching, urticaria) as a rule. A foreign body obstruction of the upper airways that causes wheezing, is always acute, but can occult in infants be (older children and adults can communicate the incident, unless there is an almost complete obstruction of the airways from which manifests itself as such, not as stridor). Coughing is common with foreign bodies, but rarely in allergic reactions. Chronic stridor, which begins early in childhood and without a clear precipitating factor, suggests a congenital anomaly or a tumor of the upper respiratory tract. In adults, excessive smoking and alcohol consumption should increase the suspicion of laryngeal cancer. A vocal cord paralysis has generally brought a unique triggers such as surgery or intubation or with other neurological findings, such as muscle weakness related. Patients with tracheomalacia often have sputum-producing cough and past recurrent Atemwegsinfektionen.Tests The tests should include pulse oximetry. In patients with minimal respiratory distress soft shots of the neck can help. An enlarged epiglottis or retropharyngeal space can be seen on the side view, and the subepiglottische narrowing of Krupp (steeple sign) can be seen on the anteroposterior view. Foreign bodies in the cervical and thoracic area can be represented radiologically. In other cases, a direct laryngoscopy vocal cord abnormalities, structural abnormalities and tumors can recognize. A CT of the neck and the breast should be performed when concern about a structural abnormality, such as a tumor of the upper airways or tracheomalacia exists. "Flow-volume curves" may be useful to show an obstruction of the upper airway in chronic and intermittent stridor. Result of flow volume curves that deviate from the norm, generally require a follow-up with CT or laryngoscopy. Therapy to definitive therapy of stridor include treatment of the underlying cause. As a bridging measure in patients with severe shortness of breath, a mixture of helium and oxygen (heliox) improves airflow and reduces wheezing in diseases of the large airways, such as laryngeal edema after invasive ventilation, Krupp and laryngeal tumors. The mechanism of action appears to be in a reduced flow turbulence due to lower density of helium in comparison with oxygen and nitrogen. Nebulised epinephrine (0.5-0.75 ml of 2.25% sodium epinephrine racemate is added to 2.5-3 ml of physiological saline), and dexamethasone (10 mg iv, then 4 mg IV every 6 h) can in patients be useful with Atemwegsödem as the cause. Endotracheal Intubationsollte be done to secure the airways of patients with advanced respiratory distress, respiratory impending losses or consciousness. Significant edema may complicate endotracheal intubation and require surgical emergency airway (eg. As coniotomy, tracheotomy). Conclusion inspiratory stridor often constitutes a medical emergency. The first step is to assess the vital signs and the degree of difficulty in breathing. In some cases, the airway may be necessary before or during the physical examination. Acute epiglottitis is rare in children who have received a Hib vaccine.

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