soal stridor, aspiration,&cough

7/28/2019 Soal Stridor, Aspiration,&Cough

http://slidepdf.com/reader/full/soal-stridor-aspirationcough 1/36

STRIDOR, ASPIRATION AND

COUGH

SUBDIVISI LARING FARING

THT- KL RSMH



INTRODUCTION

• The complex structures of the upper airwayallow for coordination of both respirationand swallowing.

• The structural and physiologic relationshipsbetween the various structures change withgrowth from infancy through adulthood.

•

The structural and physiologic relationshipsbetween the various structures change withgrowth from infancy through adulthood.



STRIDOR

• The signs and symptoms of a child with respiratorydistress usually differ, depending on the location andseverity of obstruction.

• Airway obstruction at the level of the nasopharynx or

oropharynx produces the inspiratory low-pitchedsound called stertor or snoring.

• Dynamic supraglottic and glottic obstructions produce inspiratory stridor caused by collapse of thesestructures with negative inspiratory pressure.

• Intrathoracic airway lesions cause expiratory stridor.

• Stridor caused by fixed subglottic laryngeal &cervical tracheal lesions is most often biphasic.



STRIDOR

• Stridor is the audible noise produced by turbulentairflow through a partially obstructed airway.

• Obstructing lesions of the airways produce theturbulent airflow.

• With narrower columns of air, small partialobstructions are more likely to cause significantturbulence.

•This is why the infant with an upper respiratorytract infection may exhibit the signs of stridorand croup.



STRIDOR

• The infant larynx and trachea are much smaller thanthose of the adult.

• In the infant, the vocal cords are 6 to 8 mm long andthe vocal processes of the arytenoid cartilage extend

one half the length.

• The posterior glottis has a transverse length of 4 mm.

• The subglottis has a diameter of 5 to 7 mm.

• The trachea is 4 cm long and has a diameter of 3.6 mm.

• The ratio of cartilaginous : membranous trachea is4.5:1.



COUGH

• Cough is a complex reflex initiated by sensory

receptors in the respiratory epithelium.

• Receptors are concentrated in the larynx and

carina and at other airway bifurcations.

• No receptors lie beyond the terminal bronchioles.

• Other receptors are in the nose, nasopharynx,

external auditory canals, tympanic membranes,stomach, esophagus, pleura, pericardium, and

diaphragm.



COUGH

• Afferent pathways in the tenth and, to a lesserextent, the fifth and ninth cranial nerves carryimpulses to the cough center in the medulla.

• Cough can also voluntarily be initiated withoutstimulation from other afferent pathways.

• The efferent fibers of the cough reflex carry theirsignals from the cough center to the diaphragmand intercostal muscles through the phrenic and

spinal motor nerves, respectively.• The abdominal and pelvic muscles also

participate in the efferent limb.



COUGH

• The mechanics of a cough involve developing and then sustaining a high velocitycolumn of air.

• To do this, the cough begins with an initial inspiratory phase in which occurmaximal abduction of the vocal cords and an increase in the chest dimensions,filling the lungs with air to a high volume.

• The second phase follows with rapid closure of the larynx at the supraglottic and

glottic levels.• Expiratory muscle contraction forces a rise in airway pressure during this

compressive phase of coughing.

• It is the closure of the ventricular bands (false focal folds) that contributes thegreatest sphincteric effect in preventing the flow of air during the compressivephase.

• The third (expiratory) phase occurs as the glottis suddenly opens and rapid airflow

expectorates mucus and foreign material.• Maintenance of airflow velocity is assisted during expiration by continued

narrowing of the opened supraglottic larynx. Vibrations of the laryngeal mucosaalso assist in secretion clearance during the expiratory phase.



SWALLOWING

• Traditionally, the normal swallow is divided into four stages:preparatory, oral, pharyngeal, and esophageal.

• The first two are under voluntary control, except in the newbornperiod, when the swallowing reflex is regulated at the level of thebrainstem.

• The second two are reflex actions.• The afferent limb consists of sensory and proprioceptive fibers in

the glossopharyngeal, trigeminal, and superior laryngeal nervesthat supply the laryngeal and pharyngeal mucosa.

• Impulses are transmitted to the swallowing center in the floor of

the fourth ventricle. The efferent limb consists of general visceralefferent fibers that begin in the nucleus ambiguous and descendthrough the vagus nerve to supply the laryngeal and pharyngealmusculature.



SWALLOWING

• In the preparatory phase, food is taken in and prepared into a bolusheld between the hard palate and central anterior two thirds of thetongue.

• The apposition of the base of tongue and soft palate prevents foodfrom traveling posterior while chewing. During the oral phase, the

anterior tongue elevates and contacts the hard palate, the softpalate closes off the nasopharynx, and the food bolus is pushed intothe pharynx.

• Squeezing liquid from the nipple appears to be part of an infant'soral phase. The pharyngeal phase begins as the bolus passes thetonsillar pillars.

• The palatopharyngeal partition, made up of the apposingpharyngeal constrictors, palate, and palatopharyngeus, directs thefood into the hypopharynx, and the pharynx and larynx elevate.

• At the onset of the esophageal



SWALLOWING

• The swallowing reflex in children varies from that of adults and undergoesan orderly maturation as the child develops.

• Before the 34th week of gestation, the premature infant demonstrates apoorly coordinated and insufficient suckling response.

• Beyond the 34th week, neuromuscular maturation progresses and oralfeeding can usually be maintained, with the full-term infant able to suckleat birth. The anatomy of the swallowing mechanism also differs from thatof an adult.

• As mentioned, in children, the hard palate is closer to the skull base andthe larynx is higher in the neck, and the adenoid pad, tonsils, and tongueare relatively larger.

• Therefore, nasopharyngeal closure requires less angulation of the softpalate, whereas the tonsils and tongue assist in oropharyngeal propulsion.

• With age, the oral cavity and pharynx enlarge, the larynx descends in theneck, the relative size of the tongue decreases, and teeth erupt.



• Airway protection in the normal person is maintained bythree interlocking systems.

• The first system is the swallow mechanism, mentionedabove.

•

The second system is the three-tiered system of thelaryngeal â€œsphinctersâ€•: the epiglottis, aryepiglotticfolds, and arytenoid cartilages (first level); the false vocalfolds (second level); and the true vocal folds (third level).

• The third system is that of mucociliary clearance and the

cough reflex.• A breakdown in any of these systems can result in

aspiration.



Stridor Evaluation

History and Physical Examination

The extent and urgency with which the diagnosticevaluation of a stridorous patient is carried out isdetermined by the patient's degree of distress.

Assessment begins with a careful history, emphasizing the

birth history, the age at stridor onset, severity,progression, and fluctuation of respiratory symptoms.

Related symptoms, including hoarseness, eating orfeeding difficulties, and sleep-disordered breathing, are

also noted.The mnemonic SPECS-R (severity, progression, eatingdifficulties, cyanosis, sleep disturbances, and radiologicfindings) can be used to organize the history.



• The initial physical examination assesses the severity of respiratorydistress and the need for emergency airway management.

• Patients with severe respiratory distress, particularly children,require careful, noninvasive inspection to avoid exacerbating airwaycompromise.

• Respiratory rate and level of consciousness are the most importantindicators of severity.

• Tachypnea is often the first sign of respiratory distress in children.

• Relatively quiet shallow breathing characterizes late respiratoryfailure and exhaustion; a mental status assessment at this stage

reveals confusion or lethargy and suggests impending respiratoryarrest.

• Increased work of breathing with suprasternal, subcostal, andintercostal retractions in the stridorous patient indicates P.1099



1. Which condition is most likely to result in

clinical aspiration?

a. Posterior cricoarytenoid paralysis

b. Bilateral recurrent laryngeal nerve injury

(upper motor neuron)c. pharyngeal phase dysfunction

d. Bilateral recurrent laryngeal nerve injury

(lower motor neuron)



Answer : D



2. Which is the earliest sign of respiratory failure

a. Cyanosis

b. Biphasic stridor

c. tachypnea

d. Substernal retractions



• Answer : C



3. What is the best indicator of the anatomic

level of airway obstruction?

a. Posturing

b. Respiratory rate

c. respiratory phase during which stridoroccurs

d. Associated eating difficulties



• Answer: C



4. What is the best method to diagnose

laryngomalacia

a. Flexible laryngoscopy while the patient is

awake

b. Endolateral airway filmsc. rigid bronchoscopy

d. history



• Answer : A



5. Which of the following statements is false?

a. Multiple synchronous airway anomalies

occur in 20-40% of patients with congenital

stridor

b. Congenital stridor always presents at birthc. Congenital stridor most often is due to

laryngeal anomalies

d. Congenital stridor is more common than

acquired stridor in infants



• Answer: B



6. Reccurent croup is most likely

a. To respond to steroidsb. Due to bacterial infection

c. associated with immune deficiency

d. Due to underlying subglottic pathology



• Answer : D



7. Supraglottoplasty is indicated for severe

laryngomalacia associated with all of the

following except

a. Failure to thrive

b. Recurrent cyanosis

c. congenital subglottic stenosis

d. Cor pulmonale



• Answer : C



8. Which is the best method to diagnose an

anomalous innominate artery

a. Endoscopy

b. CT scan with contrast

c. barium esophagogramd. Arteriography



• Answer : A



9. The immediate response to a respiratory

arrest in a 2-year-old-child with croup is

a. Steroids and racemic epinephrine

b. Intubation with a 4,5 cm (internal diameter)

endotracheal tube

c. positive pressure ventilation by mask

d. cricothyrotomy



• Answer : C



10. Long term relief of severe aspiration due to

combined pharyngeal and laryngeal

swallowing dysfunction most likely to occur

after

a. Laryngotracheal separation

b. Vocal fold medialization

c. tracheotomy

d. Surgical closure of the glottis



• Answer : A



11. Cough variant asthma is associated with all

of the following except

a. Nonproductive cough

b. Bronchoconstriction

c. a normal chest radiogram

d. wheezing



• Answer : D

soal stridor, aspiration,&cough

Documents