Stridor Score Research Articles

Abstract PD-051: ROLE OF STEROIDS IN PREVENTION OF POST EXTUBATION STRIDOR

Aims & Objectives: Primary-To study the effect of prophylactic steroids on occurance of post extubation stridor (PES) in ventilated children. Secondary-To compare the severity of PES in ventilated children receiving prophylactic steroids or placebo. Methods Setting- PICU of Lok Nayak Hospital, Delhi in 2014 - 2015 Patients-Children aged 2 months to 12 years, ventilated for at least 48 hours and planned for extubation in next 6–12 hours.Children ventilated through tracheostomy, receiving steroids within 7 days before extubation, having unplanned self extubation, and previously failed extubation were excluded. Intervention-Group A received dexamethasone 0.15 mg/kg 6 hourly for 6 doses at extubation while group B received placebo (normal saline). Stridor scoring was done using Westley stridor score. Results Group A comprised of 42 children while group B had 38 children. PES occurred in total 48.7% children with 42.8% in dexamethasone group and 55.2% in placebo group (p=0.26). The median age of children with PES was 6 months and without PES was 18 months (p=0.05). Stridor score >4 was present in 28.5% of dexamethasone group vs 47.3% of placebo group (p=0.08). Median stridor scores were same in both groups (score 2 in each group). 38% patients in group A compared to 47.3% in Group B required adrenaline nebulization (p=0.40). There was no difference in the incidence of PES with the duration of ventilation (p=0.38). There were no significant adverse effects of steroids. Conclusions We didn’t find significant difference in the incidence of PES and severity of stridor in ventilated patients receiving dexamethasone or placebo.

Efficacy of systemic glucocorticoids combined with inhaled steroid on children with acute laryngitis

Objective: To evaluate the efficacy of systemic glucocorticoid (steroid) combined with high dose inhaled steroid in the treatment of children with acute laryngitis. Methods: A total of 78 children with acute laryngitis were randomly divided into study group(n=40) and control group(n=38) between November 2016 and April 2017. In addition to routine treatment of anti infection and symptomatic treatment, Dexamethasone injection(0.3-0.5 mg/kg, 1-3 d, according to the patient's condition) was provided to each group. In addition to the treatment mentioned above, the study group were assigned to receive 1.0 mg Budesonide suspension for inhalation, oxygen-driven atomizing inhalation, every/30 minutes, 2 times in a row, after that every 12 hours. The improvement of inspiratory dyspnea, hoarseness, barking cough and wheezing of both groups was evaluated at 30 min, 1 h, 2 h, 6 h, 12 h, 24 h and 72 h after treatment.Sigmaplot 11.5 software was used to analyze the data. Results: No significant difference was detected in terms of inspiratory dyspnea, hoarseness, barking cough or stridor score before treatment between the two groups(P>0.05). Compared with those before treatment, symptoms of inspiratory dyspnea, hoarseness, barking cough and stridor score of both groups improved markedly at 12 h and 24 h after treatment(P<0.05). While there was no significant difference regarding inspiratory dyspnea, hoarseness, barking cough or stridor score at each time point after treatment between the two groups(P>0.05). The effective rate was 92.50% and 92.11% in study group and control group, respectively, and no significant difference was noted (P>0.05). Conclusion: Compared with single systemic glucocorticoid, systemic glucocorticoids combined with inhaled steroid possessed similar efficacy in treating acute laryngitis and relieving laryngeal obstruction of children.

Nebulized 0.5, 2.5 and 5 ml l-epinephrine for post-extubation stridor in children: a prospective, randomized, double-blind clinical trial

Nebulized L-epinephrine has been recommended for the treatment of viral croup. However, the few studies assessing its effect on post-extubation stridor (PES) have shown conflicting results. We compared the efficacy and safety of nebulized L-epinephrine at three different doses for the treatment of PES. We conducted a prospective, randomized, double-blind trial including all consecutive children with a PES score of ≥4 (Westley score). The primary efficacy outcome was change in PES score at 40 min. A reduction of ≥2 points in stridor score was defined as clinically significant. A total of 96 patients were randomly assigned to receive one of three doses of nebulized L-epinephrine upon achieving a PES score of 4 or more following extubation. Stridor score and vital signs were recorded before treatment, and at 20, 40, 60 and 180 min after nebulization. Baseline characteristics were similar among all study groups. No significant difference was detected among the treatments based on change in Westley score by intent-to-treat analysis. In addition, the difference in the number of patients who clinically improved among the treatment groups was not significant (p = 0.54). Patients receiving 5 ml nebulized epinephrine had a significant increase of systolic and diastolic blood pressure at 40 and 180 min. Nebulized L-epinephrine at doses of 0.5, 2.5 and 5 ml demonstrated a lack of dose response in effect on PES and a modestly clinically significant increase in undesired side effects (heart rate and blood pressure) at higher doses.

Efficacy of jaw thrust device in the upper airway obstruction

Objective To evaluate the efficacy of jaw thrust device in the upper airway obstruction. Methods Thirty-five ASA Ⅰ or Ⅱ patients aged 18-64 yr with body mass index < 30 kg/m2 undergoing elective surgery under general anesthesia were included in this study. The anesthesia face mask was placed and held tightly by 4 straps of JTD and connected to the anesthesia machine. Anesthesia was induced with midazolam, propefol, fentanyl and atracurium. When muscle relaxation was achieved, tracheal intubation was not performed. The airway obstruction was assessed by airway peak pressure and stridor score (breathing sounds detected by auscultation over the trachea). And then tracheal intubation was performed, and the patients were mechanically ventilated. Results There was no significant difference in airway pressure and stridor scores between JTD and jaw thrust maneuver. Conclusion JTD can effectively lift the jaw and improve the upper airway obstruction. Key words: Airway obstruction; Anesthesia, general

Aerosolized L-epinephrine vs budesonide for post-extubation stridor: A randomized controlled trial

To compare the efficacy and adverse effects of aerosolized L-epinephrine vs budesonide in the treatment of post-extubation stridor. Randomized controlled trial. Pediatric intensive care unit (PICU) of a tertiary teaching and referral hospital. Sixty two patients with a stridor score ?4 following extubation. Patients were randomized to receive either aerosolized L-epinephrine (n=32) or budesonide (n =30). Respiratory rate, heart rate, stridor score, blood pressure and oxygen saturation were recorded from 0 min to 24 hours. Stridor score remaining at >4, need for renebulization and reintubation between 20 min to 24 hours were primary outcome measures. Tachycardia (HR > normal for age), hypertension (BP >95th centile for age) and hypoxia (SpO2 < 92% for 5 min) were secondary outcome measures. Both drugs showed a significant and comparable decline in the median (95% CI) stridor scores from baseline to 60 min [4 (4.10-4.50) to 2.00 (1.46-2.67) for budesonide vs 4 (4.12-5.00) to 2.00 (1.31 -2.75) for epinephrine]. At 2 hours, the stridor scores were significantly lower in the epinephrine as compared to budesonide group [0.00 (0.69-1.81) vs 3.00(1.75-3.32); P =0.02)]. However, the proportion of patients with stridor score >4 at any time between 20 min to 24 hrs (53.3% vs 53.1%; P=0.99), need for renebulization (40% vs 43.8%; P=0.76) and reintubation (20% vs 25%, P=0.638), and adverse effects were similar in both groups. Both aerosolized L-epinephrine and budesonide were equally effective in their initial therapeutic response in post-extubation stridor. However, epinephrine showed a more sustained effect.

The Effects of Jaw Thrust and the Lateral Position on Heart Rate Variability in Anesthetized Children with Obstructive Sleep Apnea Syndrome

Airway obstruction occurs in anesthetized children with obstructive sleep apnea syndrome (OSAS). The inspiratory attempts against the occluded airway lead to an increased sympathetic activity. Heart rate variability (HRV) analysis provides information about the autonomic nervous system. The low-frequency component/high-frequency component ratio of HRV is considered to be an index of sympatho-parasympathetic balance. We investigated the effects of general anesthesia, the neutral neck position, and jaw thrust in the supine and lateral positions on HRV in 20 children (aged 3-9 yr), with OSAS. HRV was recorded before and after anesthesia induction, at the neutral neck position and with jaw thrust maneuver in the supine and lateral positions with the patients breathing 5% sevoflurane. General anesthesia with the patient in the neutral neck position increased airway obstruction. The patients' stridor scores improved with the airway maneuver of jaw thrust and lateral position. The low-frequency component/high-frequency component ratio and heart rate increased at the postinduction measurement and reached the highest value with the patient in the neutral neck position. The values significantly decreased with the jaw thrust maneuver and with the patient in the supine and lateral positions. Ultra-short-term entropy of HRV decreased after anesthetic induction and reached the lowest value with the patient in the neutral neck position. The values increased during jaw thrust and with patients in the supine and lateral positions. Changes of HRV induced by inhaled anesthesia, jaw thrust, and lateral positioning procedures corresponded to changes in the stridor score of children with OSAS.

The Endoscopically Measured Effects of Airway Maneuvers and the Lateral Position on Airway Patency in Anesthetized Children with Adenotonsillar Hypertrophy

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing children with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers such as chin lift and jaw thrust on airway patency (stridor score and upper airway dimensions by endoscopy) in anesthetized children scheduled for adenotonsillectomy. Eighteen children aged 1-11 yr were anesthetized with sevoflurane. During spontaneous breathing with 5% sevoflurane and 100% oxygen, upper airway dimensions and stridor score were recorded. After baseline recording, chin lift and jaw thrust were performed in both the supine and the lateral decubitus position. Chin lift, jaw thrust, and lateral position increased the airway dimensions and improved the stridor score. Moreover, lateral positioning enhanced the effects of these airway maneuvers on airway patency. We concluded that lateral positioning combined with airway maneuvers provided better airway patency for anesthetized children with adenotonsillar hypertrophy.

The Effects of Chin Lift and Jaw Thrust While in the Lateral Position on Stridor Score in Anesthetized Children with Adenotonsillar Hypertrophy

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing patients, especially in pediatric anesthesia with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea and also decreases collapsibility of the pharynx in anesthetized adults with obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers, such as chin lift and jaw thrust, on airway patency (stridor score) in anesthetized children scheduled for adenotonsillectomy. Thirty children aged 1-10 yr were anesthetized with sevoflurane. During spontaneous breathing of 5% sevoflurane, stridor score was recorded. After baseline recording, chin lift and jaw thrust were performed on patients in both the supine and the lateral decubitus positions. Chin lift and jaw thrust improved the stridor score. Furthermore, lateral positioning dramatically enhanced the effects of these airway maneuvers on airway patency. Jaw thrust combined with lateral positioning provided easy airway management for the anesthesiologists. We conclude that lateral positioning combined with airway maneuvers significantly improved airway patency compared with the airway maneuvers alone for patients in the supine position.

The Effect of Chin Lift, Jaw Thrust, and Continuous Positive Airway Pressure on the Size of the Glottic Opening and on Stridor Score in Anesthetized, Spontaneously Breathing Children

The Effect of Chin Lift, Jaw Thrust, and Continuous Positive Airway Pressure on the Size of the Glottic Opening and on Stridor Score in Anesthetized, Spontaneously Breathing Children

The Effect of Chin Lift, Jaw Thrust, and Continuous Positive Airway Pressure on the Size of the Glottic Opening and on Stridor Score in Anesthetized, Spontaneously Breathing Children

Chin lift and jaw thrust are two common maneuvers used to improve the patency of the upper airway during general anesthesia. We investigated the effect of these maneuvers combined with continuous positive airway pressure (CPAP) on the size of glottic opening and on stridor score. Forty children, aged 2--9 yr, premedicated with midazolam and spontaneously breathing end-tidal 1% halothane and equal parts of nitrous oxide and oxygen, were studied. A flexible fiberoptic bronchoscope was placed via mask and one nostril to the level of the junction of the soft palate and oropharynx. Video recordings and simultaneous stridor scores were obtained during six conditions: 1) chin unsupported, 2) manual chin lift, 3) chin lift and CPAP 10 cm H(2)O, 4) repeat chin unsupported, 5) manual jaw thrust, and 6) jaw thrust and CPAP 10 cm H(2)O. Videos were analyzed to determine the percentage of glottic opening (POGO) score. POGO score increased (P < 0.05) in Conditions 2, 3, 5, and 6. With increasing POGO score there was a decrease in stridor score (P < 0.05). Chin lift and jaw thrust maneuvers combined with continuous positive airway pressure improve the view of the glottic opening as viewed by flexible nasal laryngoscopy and decrease stridor in anesthetized, spontaneously breathing children.

Extubation failure due to post-extubation stridor is better correlated with neurologic impairment than with upper airway lesions in critically ill pediatric patients

The incidence of post-extubation stridor (PES) in a pediatric intensive care unit (PICU) and the need for reintubation is not known. Predictors of success on a subsequent extubation attempt and the efficacy of dexamethasone treatment prior to a subsequent extubation attempt are not established. In a prospective randomized double blind-controlled study in two PICU's in a university children's hospital setting, of 5,566 admissions over 35-months, we identified 32 patients who failed primary extubation and were reintubated for PES. Twenty-six patients were enrolled in the study and three subsequently excluded. Twelve were randomized to receive dexamethasone and 11 received sodium chloride placebo. Fifteen patients succeeded study extubation and eight failed. Of those receiving dexamethasone, nine patients succeeded and three failed. Of those receiving placebo, six patients succeeded and five failed. There was a poor correlation between anatomical abnormalities of the airway and failure of study extubation. Extubation failure was better correlated with neurologic impairment in the patients. We present a stridor score and demonstrate that it is an excellent predictor of success versus failure for the study extubation. Dexamethasone pre-treatment did not reduce stridor score. We are unable to conclude if dexamethasone pre-treatment reduces extubation failure. We speculate that neurologic impairment leads to extubation failure in critically ill pediatric patients.

Racemic versus l-epinephrine aerosol in the treatment of postextubation laryngeal edema: Results from a prospective, randomized, double-blind study

To determine whether any advantage exists using racemic epinephrine instead of the more potent and less expensive levo(1)-epinephrine in the treatment of postextubation laryngeal edema. Prospective, double-blind, randomized study. Pediatric intensive care unit in a university teaching hospital. Twenty-eight patients with stridor during the immediate postextubation period. After extubation, patients demonstrating clinically important stridor were randomized in a double-blind fashion to receive an aerosol containing either 2.25% racemic or 1% l-epinephrine. Heart rate, respiratory rate, blood pressure, and stridor score were determined at 20, 40, and 60 mins and 4 and 8 hrs after the initial aerosol administration. Patients in both groups demonstrated significant (p < .01) reductions in stridor score after aerosol administration. No significant differences were observed between treatment groups in improvement in stridor score or the number of subsequent aerosols required. Respiratory rate decreased significantly 40 and 60 mins after l-epinephrine but not after racemic epinephrine. No significant change in heart rate or blood pressure occurred after aerosol administration in either group. These data suggest that aerosolized l-epinephrine is as effective as aerosolized racemic epinephrine in the treatment of postextubation laryngeal edema without additional adverse side effects. When dosed appropriately, l-epinephrine is a less expensive and more widely available alternative to racemic epinephrine for the treatment of postextubation laryngeal edema.

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

To assess the effectiveness of a helium-oxygen mixture in reducing post-extubation stridor in children hospitalized for burns or trauma. Randomized, controlled crossover trial. Harborview Medical Center's Burn and Trauma ICUs from March to September 1989. 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. Each treatment (helium-oxygen and oxygen-supplemented room air) was given in random order for 15 min after extubation. Respiratory distress was assessed by a physician blinded to treatment order using a standard stridor score and clinical judgment. 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. 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.