Dr David Vokes Otolaryngologist Head & Neck Surgeon Director ENT Associates, Auckland

11:00 - 11:55 WS #135: The Noisy Airway: Stridor, Stertor, Wheeze 12:05 - 13:00 WS #147: The Noisy Airway: Stridor, Stertor, Wheeze (Repeated) Rotorua GP CME Conference 2019 David Vokes, FRACS Laryngologist, Head & Neck Surgeon ENT Associates Auckland City Hospital • Why is this important? • Respiratory sounds • Respiratory sounds audible without a stethoscope • Stridor, Stertor, Wheeze • Review of causes of Stridor & Stertor • Telling the Difference between Stridor & Wheeze • Untreated • Morbidity • Mortality • Avoid delays • Failure to recognize • Misdiagnosis • “Difficult to treat asthma” • Asthma vs Upper Airway Obstruction • Normal respiratory sounds • Abnormal respiratory sounds

• Vesicular • Stridor • Wheeze • Crackles • Pleural friction rub • Mediastinal crunch • Inspiratory gasp • Squawk

• Stertor Stridor, Stertor & Wheeze • Definition • Stridor is a high-pitched musical sound produced as turbulent airflow passes through a narrowed segment of the upper respiratory tract • Pathophysiology • Obstruction of the upper airway • Timing & Quality • Inspiratory, expiratory, biphasic • Muscial, high pitch • Examples • Extrathoracic site (laryngomalacia, VCD/PVFM, laryngeal mass): inspiration • Intrathoracic site (tracheomalacia, extrinsic compression): expiration • Fixed lesions (croup, BVF paralysis, laryngeal mass, FB): biphasic • Definition • Wheeze is a musical sound that may be low or high pitched produced by airflow limitation in lower respiratory tract • Pathophysiology • Formed in the branches between the 2nd and 7th generations of the airway tree by coupled oscillation of gas and airway walls that have been narrowed to the point of apposition by a variety of mechanical forces (!) • Timing & Quality • Inspiratory, expiratory, biphasic • Musical, high (or low) pitch • Examples • Diffuse: Asthma, COPD • Localized: Airway obstruction (FB, tumour, mucus plug) • Definition • A low pitched sound resulting from vibration of pharyngeal tissues due to upper airway obstruction • Pathophysiology • Obstruction of the airway above the level of the larynx • Timing & Quality • Inspiratory • Non-musical, low pitch • Examples • SDB: OSA, UARS, Simple Snoring • Adenotonsillar hypertrophy

• Larynx • Trachea • Laryngomalacia • Tracheal Stenosis • Supraglottitis/Epiglottitis • Surgery • Croup (LTB) • Intubation • Foreign body • Tracheostomy • • Paradoxical VF Motion Malignant Neoplasm • • Bilateral VF Immobility External Compression • • Laryngeal Stenosis Tracheomalacia • • Malignant Neoplasm Tracheitis • • Benign Masses (Neoplastic/Non- External Trauma neoplastic) • Foreign Body • External Trauma • Intubation Trauma • aka. ILO, VCD • Intermittent episodes of inappropriate VF adduction • Precipitants • Exercise • Reflux • PND • Anxiety • US Series; n=95: 6 hospitalizations/year; 28% intubated! (Chest 2010; 138; 1213-23) • BVF Paralysis • Bilateral RLN/X palsy

• BVF Fixation • Rheumatoid arthritis • Posterior glottic stenosis (scar) • Scar!

• Supraglottic Stenosis • Posterior Glottic Stenosis • Subglottic Stenosis • Tracheal Stenosis

Bullous Pemphigoid • Scar!

• Supraglottic Stenosis • Posterior Glottic Stenosis • Subglottic Stenosis • Tracheal Stenosis • Scar!

• Supraglottic Stenosis • Posterior Glottic Stenosis • Subglottic Stenosis • Tracheal Stenosis

TransnasalTracheoscopy • Neoplasm • Malignant • Benign • Non-neoplastic • Cysts • Laryngocoele • Internal Trauma: common • Iatrogenic • Caustic ingestion • Inhalational

• External Trauma: uncommon • Iatrogenic • Blunt • Penetrating • Internal Trauma: common • Iatrogenic • Caustic ingestion • Inhalational

• External Trauma: uncommon • Iatrogenic • Blunt • Penetrating • Adults > Children

• Bacterial • H.influenzae b • S.Aureus, S.pneumoniae • Non-bacterial

• Airway management • 3rd gen Cephalosporins • Steroids • Pharynx • Oral Cavity • Adenotonsillar hypertrophy • Ludwig’s Angina • Lingual tonsillar hypertrophy • Malignant neoplasm • Tonsillitis • Peritonsillar abscess • Malignant neoplasm • Benign mass(neoplastic/non- neoplastic) • Sleep Disordered Breathing (Simple Snoring, UARS, OSA) • Tonsillar hypertrophy • Tonsillitis • Peritonsillar abscess • Benign Neoplasm

• 3% with snoring have an airway lesion • Snoring is a sound produced by vibration of the soft tissues of the upper airway (ie. stertor) during sleep

• Inspiratory, but can be biphasic.

• Regular snoring common • Between 30-60 years: 44 % M, 28 % F

• Occasional snoring almost universal Obesity-Hypoventilation Severe OSA Moderate OSA Mild OSA UARS Chronic Heavy Snoring Intermittent Snoring Quiet Breathing • Stridor & Wheeze both “musical” x=Time in seconds y=Amplitude

NEJM 2014; 370; 744-751 • Baughman & Loudon. Am Rev Respir Dis 1989; 139: 1407-09 • Similar • Frequency of sound signal of stridor and wheeze • Different • Timing of the Sound • Stridor: inspiration • Wheeze: expiration • Location of prominence of the sound • Stridor: signal more intense over neck • Wheeze: signal more intense over chest • We have read about it! • We have heard about it! • We have seen it!

• Abnormal airways sounds indicate airway obstruction • Stridor & Wheeze are both musical sounds, high in pitch • Stridor • Upper airway obstruction (larynx, trachea) • Inspiratory, Heard loudest over the neck • Wheeze • Lower airway obstruction • Expiratory, Heard loudest over the chest • Stertor • Upper airway obstruction (pharynx, oral cavity) • Inspiratory [email protected] [email protected]