STRIDOR
SLEEP APNOEA
Dr Robin Smith
STRIDOR
• Predominantly inspiratory wheeze due to
large airways (larynx/trachea/major
bronchi) obstruction
Causes of Stridor (children)
• Infections
Croup
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 rooffall 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)
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•
•
•
•
•
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
•
•
•
•
•
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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
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•
•
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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 Rx
Mandibular 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