STRIDOR

SLEEP APNOEA

Dr Robin SmithDr Robin Smith

STRIDOR

• Predominantly inspiratory wheeze due to large airways (larynx/trachea/major bronchi) obstruction

Causes of Stridor (children)

• InfectionsCroup

Epiglottitis

Pseudomembranous croup

Retropharyngeal abscess

Diphtheria

Infectious mononucleosis

• Foreign Body

• Anaphylaxis / angioneurotic oedema

• Other (eg burns)

Causes Of Stridor (adult)

• Neoplasms– Larynx– Trachea– Major bronchi

• Anaphylaxis• Goitre (retrosternal)• Trauma (eg

strangulation, burns, irritant gases)

• Other (eg bilateral vocal cord palsy; Wegener’s granulomatosis; cricoarytenoid arthritis (RA); tracheopathia

Coal Miner who had been trapped in roof-fall 12 years previously

Pea in Left Upper Lobe Bronchus

Investigation of stridor

• Laryngoscopy (beware in acute epiglottitis)

• Bronchoscopy

• Flow volume loop

• Chest X ray

• Other imaging (CT; thyroid scan)

Treatment of laryngeal obstruction

• Treat underlying cause eg foreign body removal, anaphylaxis

• Mask bag ventilation with high flow O2

• Cricothyroidotomy

• Tracheostomy

Heimlich Manoeuvre

Foreign body inhalation

(café coronary syndrome)

Rapid upward thrust in epigastrium forces upward movement of diaphragm and forced expiration

Treatment of malignant airway obstruction

Tumour removal:laser; photodynamic therapy; cryotherapy; diathermy;

surgical resection

Tumour compression: intraluminal stent

Radiotherapy (external beam; brachytherapy)

(Chemotherapy; Corticosteroids)

Anaphylaxis

Acute Anaphylaxis

• Type 1 (immediate) hypersensitivity (IgE)

• Flushing, pruritus, urticaria,

• Angioneurotic oedema (lips, tongue face, larynx, bronchi)

• (abdominal pain, vomiting)

• Hypotension (vasodilatation and plasma exudation) circulatory collapse (shock)

• Stridor, wheeze and respiratory failure

Causes of anaphylaxis

• Foods eg nuts; shellfish

• Insect venom (bee, wasp)

• Drugs (eg penicillin, aspirin, anaesthetics)

• Other eg latex

Treatment of anaphylaxis (1)

• IM Epinephrine (adrenaline)

• IV antihistamine

• IV corticosteroid

• High flow O2

• Nebulised bronchodilators

• Endotracheal intubation if necessary

Treatment of anaphylaxis (2)

• Allergen avoidance (where possible)

• Desensitisation (immunotherapy) eg venom

• Self-administered epinephrine

STILL AWAKE ??

Epworth Sleepiness Scale

• SITUATIONS– sitting and reading– watching TV– sitting inactive in public eg

theatre– car passenger for 1h– lying down to rest in the

afternoon– sitting talking– sitting after lunch without

alcohol– In car, stopped for few

minutes in traffic

• CHANCES OF DOZING

– 0 = would never doze

– 1 = slight chance of dozing

– 2 = moderate chance

– 3 = high chance

NORMAL = <10/24

Obstructive sleep apnoea

Sleep apnoea/hypopnoea syndrome

Snoring

Relaxation of pharyngeal dilator muscles during sleep (esp. REM)

Upper airway narrowing, turbulent airflow and vibration of soft palate and tongue base

Obstructive Apnea

Obstructive Sleep Apnoea

• Intermittent upper airway collapse in sleep

• apnoeas or hypopnoeas ± hypoxaemia

• recurrent arousals / sleep fragmentation

• 1-4% adult population (3,000 – 12,000 in Tayside – only 1500 currently treated)

Risk Factors for Sleep Apnoea• Enlarged tonsils, adenoids• Obesity• Retrognathia• Acromegaly, hypothyroidism• Oropharyngeal deformity• Neurological: stroke, MS, myesthenia gravis,

myotonic dystrophy• Drugs: benzodiazepines, opiates, alcohol,• Post-operative period after anaesthesia

Consequences of Sleep Apnoea

• excessive daytime sleepiness

• personality change

• cognitive / functional impairment

• Major impact on daytime function

Consequences of Sleep Apnoea

• 7-fold increase in RTA

• Driving simultion – equivalent to being twice legal limit for alcohol

Consequences of Sleep Apnoea

• Independent risk factor for hypertension• Activated sympathetic system• Raised CRP• Impaired endothelial function• Impaired glucose tolerance• (probable increased risk of stroke and

cardiovascular events)

All improved by CPAP

Obstructive Sleep Apnoea

Diagnosis

• Snoring & EDS (raised Epworth score)

• Overnight sleep study

- oximetry

- domicillary recording (airflow, oximetry, thoracic/abdominal movement)

- full polysomnography

Obstructive Sleep Apnoea

Treatment

• Remove underlying cause

• CPAP (continuous positive airway pressure)

- most effective therapy

Effect of Positive Airway Pressure on Upper Airway Patency

Continuous Positive Airway Pressure (CPAP) therapy

Obstructive Sleep Apnoea

Other RxMandibular Advancement Device- improves snoring- moderate reduction in AHI- use in mild OSA (AHI 5-15/hr)Surgery (UPPP, laser Rx)- avoid if sleep apnoea (future CPAP less effective)- may be used in simple snoring