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A 9-month-old female baby was brought to the emergency room (ER) by her parents with reports of noisy breathing, poor feeding, inadequate weight gain and intermediate cyanotic spells noticed for the past month. She was a full-term baby weighing 2.8 kg at birth and had no other comorbidities. On

A 1-year 5-month-old boy presents with a 1-day history of severe biphasic stridor. He had multiple previous admissions for recurrent lower respiratory tract infections. On his last admission, a month earlier, he was seen for noisy breathing, where laryngomalacia was suspected and confirmed on non

Neonates are obligate nasal breathers. As a result, they are uniquely suspectable to nasal obstruction, particularly when bilateral, and can present with life-threatening respiratory distress, feeding concerns, or noisy breathing. The differential diagnosis for pediatric nasal obstruction is broad; nasal obstruction in the post-natal period can manifest in different levels of the nasal passageway and vary in laterality and severity. Clinicians must be able to quickly identify signs and symptoms, develop an appropriate differential diagnosis, and plan treatment to manage neonatal nasal obstruction. This review will use the newest literature to highlight common causes of neonatal nasal obstruction and discuss the epidemiology, presentation, associated problems, workup, management, and review controversial topics in neonatal obstruction. Neonatal nasal obstruction can be congenital; or secondary to neurogenic/neoplastic diseases, infectious processes, foreign bodies, inflammatory processes, or maternal factors; or can be indicative of underlying syndromic diseases.

Double Aortic Arch is a rare congenital cardiovascular anomaly. Its first successful surgery was performed by Robert Gross in 1945 at Children Hospital Boston, USA. It accounts for 0.4 to 1% of all congenital cardiac defects. Patients having a Double Aortic Arch mostly present with symptoms in the 1st week of life but depending upon the severity of symptoms can present at any age in childhood. We present a case report of two month old baby with noisy breathing, intermittent cough, gross jugular notch retraction and sub costal recession. His Cardiac CT was subsequently done which showed a Double Aortic Arch of left dominant variety encircling the trachea. Surgery was done and the encircling artery compressing the trachea was recognized, dissected and interrupted. Marked relief of tracheal and/or esophageal compression was evident from operation day. Post operative recovery was speedy. Patient’s follow up of was done at 1, 4 and 24 weeks. His recovery was unremarkable. Currently he was thriving well.

Objectives: Common terminal phase symptoms include pain, dyspnoea, anxiety, terminal restlessness, nausea and noisy breathing. This study identified the proportion of community pharmacies across tw...

A 60-year-old, Malaysian ex-smoker with no known medical illness was referred from a district hospital for severe acute exacerbation of COPD secondary to pneumonia. He had a 40-pack-year history of smoking but had quit smoking for the past 2 years., Repeated noisy breathing may be a tricky feature of lung infection. Recognising classical features in radiographs and CT scans may help in the diagnosis of severe lung infection and the start of life-saving treatment. http://bit.ly/2lQwe5y

Isolated laryngeal Leishmaniasis is a rare entity in the Indian subcontinent. We describe a case of a 45 year old male with hoarseness and noisy breathing. Patient’s initial histological and serological workup was inconclusive. Final biopsy findings (suggestive of Leishmania donovani), positive rK-39 serology and his native place being Bihar (endemic for Leishmaniasis) led us to the diagnosis. He was treated with high dose liposomal Amphotericin B to which he responded well. This case report highlights the importance of remaining aware of rare infectious causes of laryngitis. Timely diagnosis and intervention are crucial.

Laryngomalacia is a common cause of chronic noisy breathing that can present as stridor in infants and neonates. Mild cases of laryngomalacia are usually followed clinically and managed conservatively. However, the evaluation and diagnosis could be challenging in some patients. We present a case of a 3-week-old male infant with persistent and worsening noisy breathing, snoring, and poor weight gain, prompting further evaluation. The patient had an initial diagnosis of laryngomalacia and obstructive sleep apnea with complete resolution of loud breathing with continuous positive airway pressure. A repeated evaluation of the upper airway for further investigation led to the diagnosis of a neck mass compressing the airway. We review the clinical presentation, management, and follow-up of this patient, as well as the literature of possible etiologies. In the case of our patient, timely diagnosis and treatment had significant prognostic implications. CITATION: Leon-Astudillo C, Lee GS, Katwa U. An unusual case of noisy breathing in an infant. J Clin Sleep Med. 2019;15(1):149–152.

The diagnosis of vascular rings is challenging and may be delayed as symptoms overlap with more common conditions associated with childhood. Underlying genetic associations of this condition remain largely undiscovered. In this report, we present a patient with a double aortic arch and highlight the importance of diagnostic imaging. We also engage in a review of the important genetic considerations.

Flexible bronchoscopy is an efficient tool for diagnosing common respiratory complaints, including noisy breathing, chronic wheezing, and chronic cough. Accurate diagnosis involves not only recognition of anatomic abnormalities but also assessment of airway dynamics under conditions that can vary from sleep to forced exhalation. Thus, accurate diagnosis requires a recognition of the conditions under which the problem exists and an understanding of how the airways behave under normal and pathologic conditions. The bronchoscopist must understand the physiology of the airways under normal and abnormal conditions, taking into account how both transmural pressure and airways resistance can affect airway cross-sectional area. Aspects of the patient’s history, including timing, persistence, triggers, and predisposing factors for the problem, can all help identify which patient requires airway evaluation and under what conditions the evaluation will be most revealing. Similarly, the physical examination is directed toward the quality and characteristics of the abnormal sound, any associated changes to voice, clinical features that could predispose toward the problem, and the impact of the problem on the patient’s breathing effort and overall growth and development. Together, a careful history and physical examination, as well as an understanding of the conditions under which the respiratory abnormality occurs in a given patient, can enhance the diagnostic yield of the bronchoscopic procedure. Additionally, an understanding of dynamic airway mechanics under passive and dynamic conditions can help the endoscopist distinguish between normal and abnormal phenomena.

A 6-month-old female presented for 2 months of noisy breathing. Flexible laryngoscopy showed limited bilateral vocal fold abduction. Computed tomography revealed a non-enhancing 3.6 × 2.3 × 3.5 cystic prevertebral mass spanning C2-T. Using an endoscopic approach, the overlying mucosa was incised, and the cyst was freed and fully excised from the surrounding mucosa with blunt microlaryngeal instruments without complication. Three months postoperatively she had no respiratory issues and was eating well. Flexible laryngoscopy revealed bilateral vocal fold mobility. We propose that endoscopic removal of a cervical esophageal duplication cyst in selected cases is an alternative to open excision. Laryngoscope, 130:2053-2055, 2020.

“I need you to come look at the baby in room 8! The monitor keeps alarming for desaturations.” I walk to the patient room thinking through the many other tasks on my to-do list. As I enter the room, the smiling but noisy breathing child with bronchiolitis greets me. “We’ve deep suctioned him and he’s breathing more comfortably, but the pulse oximeter keeps dipping into the high 80s.” I look at the bedside monitor continuously tracking the patient’s heart rate, respiratory rate and oxyhemoglobin saturation, which now reads a perfect 100%. As I complete my assessment, I cannot help but wonder, “Why is this happy, well-appearing patient on a monitor?” As trainees, we are the frontline clinicians who rotate through different units within the hospital, and we observe situations like this almost every day, if not multiple times a day. Our perspective should make us the ideal stewards for identifying care processes that deviate from standard guidelines, but we are often not empowered to implement changes to improve the system and rather rely on the “higher-ups” to solve systems-based issues. As the call for “bending the value curve” has echoed through hospital systems and training programs, it is essential that we not only teach trainees about health care value but also empower them to identify examples of low-value care and give them tools and resources to be a more effective part of the solution.1 As part of the Hospital …

CARer-ADministration of as-needed sub-cutaneous medication for breakthrough symptoms in homebased dying patients: a UK study (CARiAD) Background While the majority of seriously ill people wish to die at home, only half achieve this. The likelihood of someone dying at home often depends on the availability of able and willing lay carers to support them. Whilst this often involves giving medication, people in the last days of life may be unable to take oral medication. Regular medications can be administered using a syringe driver. When top-up medication is required for breakthrough symptoms, a clinician must travel to the home to administer as-needed subcutaneous medication. Aims To determine if carer-administration of as-needed subcutaneous medication for four frequent breakthrough symptoms (pain, nausea, restlessness and noisy breathing) in home-based dying patients is feasible and acceptable in the UK. Methods Adult patients anticipated to be in the last weeks of life who were likely to lose the oral route and expressed a preference to die at home were recruited with their carers to an external randomised pilot trial across three UK sites (North Wales, South Wales and Gloucestershire). Patient/Carer dyads randomised to the intervention arm received a manualised training package delivered by their community nursing teams. Dyads in the control arm received usual care. Carers in both arms completed carer diaries and outcome measures. Results Forty dyads were recruited. The main outcomes of interest are feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcomes measures. Conclusions Findings will inform a definitive Phase III randomised controlled trial. This study is funded by the National Institute for Health Research (NIHR) HTA (Grant Reference Number 15/10/37). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

An 8-year-old girl presented with the complaints of gradually progressive dry cough for 2 months, which was aggravated at night. There was no history of fever, fast breathing or breathing difficulty, or noisy breathing. Her parents visited a local practitioner where she was investigated and, based

The history and physical examination in pediatric respiratory medicine remain our most important tools in the evaluation of children presenting with respiratory problems. They guide our differential diagnosis, clinical and investigative approach, and treatments. The global approach to a pediatric respiratory history and physical examination are described and illustrated with the aid of pictures and video in this chapter. Subsequently, approaches to common presentations in Respiratory Medicine including chronic cough, chest pain, dyspnea, cyanosis, noisy breathing, and clubbing are also reviewed.

Tracheo-oesophageal fistula (TEF) with oesophageal atresia is a common life threatening congenital malformation. H type TEF is a rare subtype (1.8 to 4.2% of all TEF) with the least association with congenital anomalies. We report two cases of H type TEF, first patient was a 2 month old girl who presented with the classical triad of symptoms, and the second patient was a 2 year old girl who presented with recurrent attacks of pneumonia, choking on feeding and noisy breathing. After radiological confirmation, optimization of pulmonary status and nutritional improvement, both underwent right cervicotomy with disconnection of the H fistula. Both patients are doing well on regular follow up. Detection of H fistula is difficult as compared to TEF since the clinical symptoms are variable, radiological detection difficult and diagnosis is based on a high degree of clinical suspicion. We present these two cases to document the history, presentation, clinical management and surgical procedure done in these patients.

Objective To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia. Methods Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). Results Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy. Conclusion Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

An 18-month-old girl child was brought by her parents to emergency service with noisy breathing and increased breathing effort progressive over several months, but significantly worsened for 1 week following fever and diarrhoea. She had a weak cry with no difficulty in feeding and coughing or

Background There has been no detailed analysis of the cause of intrathoracic large airway obstruction in infants in a resource-limited environment with a high prevalence of pulmonary tuberculosis (PTB) and human immunodeficiency virus (HIV). Aim To define the aetiology and severity of intrathoracic large airway obstruction in infants in a tertiary South African hospital with a high prevalence of PTB and HIV. Methods A retrospective study of infants was conducted with computerised tomography (CT) evidence of intrathoracic large airway obstruction from 1 January 2011 to 31 May 2014. CT scans were evaluated for the cause, site and severity of airway narrowing, with severity stratified as 'mild' (50%), 'moderate' (51-75%) or 'severe' (75%). Results Forty-four patients (28 males, 64%; median age 145 days, range 5-331), and 79 sites of attenuation were included. Vascular (22/44, 50%) and nodal (18/44, 41%) compressions accounted for over 90% of cases. Thirty-five patients (79.5%) had at least one site of moderate/severe attenuation, and 26 (59%) had multiple such sites. Adenopathy was the commonest cause of moderate/severe compression (18/35, 51%). All cases of nodal compression were of tuberculous origin. HIV-serology was recorded in 32 patients (73%), one of whom, with vascular compression, was HIV-infected. Half of the patients (11/22, 50%) with vascular compression had congenital abnormalities, most commonly cardiac anomalies (7/22, 32%). There were no synchronous vascular and nodal compressions. Conclusion Infantile intrathoracic large airway obstruction where there is a high prevalence of PTB and HIV is characterised by its extrinsic aetiology, severity and multicentricity, with more than half of all moderate/severe obstructions being caused by tuberculous adenopathy.

Upper respiratory tract secretion accumulation with noisy breathing (‘death rattle’) is caused by salivary secretions pooling within the hypopharynx. It occurs in people who cannot swallow, usually in the last days of life.1–3 It is reported in 12%–92% of dying patients3–6; the weighted mean prevalence is 35%.5 The noise and secretions can be distressing for some family members and staff.5–8 They are reportedly not associated with subjective respiratory distress,4 5 although those with the problem often have impaired consciousness so patient impact is unclear.5 Antimuscarinic drugs (eg, glycopyrronium and hyoscine butylbromide) reduce new secretion formation.2–4 Systematic reviews have found no benefit of antimuscarinics over placebo. They advise against their routine use once noisy upper respiratory tract secretions are present.3 5 9 Although they reduce production, they do not remove existing secretions. The idea of preventative prophylactic …

Introduction: Categorizing noisy breathing sounds is of major clinical relevance to identify the most likely underlying cause. However frequently mislabeling this sound increases the risk of wrong treatment. No standardized objective method is available for diagnosis. Analysis of exhaled breath volatile metabolites has the potential to fulfill this need. This study aimed to validate Selected Ion Flow Tube Mass Spectrometry (SIFT-MS) for analysis of breath volatiles. Method: Quality parameters of the SIFT-MS such as quantification limit and reproducibility were determined for selected voltiles linked to lung diseases. These were hexanol, pentanal, decanal, pentane, dodecane, p-xylene, decene, acetophenone, hexanoic acid, valeric acid, acetic acid, dimethyl disulphide and isoprene. Measurement uncertainty was calculated from absolute bias and reproducibility. A commercially available breath sampler ReCIVA®) with integrated sorbent tube trapping was optimized for use in infants (2-24 months). Results: Two of the 16 compounds resulted in a measurement uncertainty above 50% (theoratically acceptable). All others had an acceptable measurement uncertainty ranging from 12.28 to 38.78%. The quantification limit ranged from 1.48 to 14.12ppb with an exception of 70.71ppb for pentane. The mouth piece of the breath sampler was adjusted for infants and the flow volume of the clean air supply for inhalation was lowered from 40L/min (for adults) to 10L/min. Conclusion: SIFT-MS was suitable for analysis of exhaled breath volatiles. For some breath volatiles a preconcentration using sorbent tubes will be needed to assess them in the lower ppb level. This could be essential in the diagnosis and classification of noisy breathing infants. Limburg Clinical Research Program (LCRP) & VITO

Background Isolated mediastinal involvement in Langerhans cell histiocytosis (LCH) has been rarely reported. Case characteristics A 3-month-old boy presented with history of low grade intermittent fever, cough and noisy breathing for 2 weeks. Observation A chest X-ray showed massive mediastinal widening. Biopsy of the mass confirmed LCH. Outcome Patient is doing well after one year of treatment with LCH III protocol. Message Langerhans cell histiocytosis should be considered in differential diagnosis of mediastinal mass in infants.

We present the complex and rare case of an inhaled stoma button causing proximal tracheal stenosis in a laryngectomy patient. The patient was unaware he had inhaled his button and presented with increasing shortness of breath and noisy breathing. In this case we discuss the challenging management of the stenotic tracheal segment above the impacted stoma button and the surgical approach to this difficult airway. The distal foreign body was safely removed using rigid bronchoscopy and balloon dilatation. This difficult airway required multidisciplinary input from the ENT, cardiothoracic and anaesthetic teams.

A 28-year-old man presented to the ear, nose and throat outpatients clinic with a 5 year history of voice change and a 1 year history of dysphagia and worsening shortness of breath on lying prone. His partner had noted recent noisy breathing at night. He was systemically well with no past

Background - The sleep problems of children with intellectual disabilities remains a relatively neglected topic in spite of the consistent reports that such problems are common, often severe and persistent with potentially serious consequences for the children and their families. Children with Down syndrome (DS) are a case in point. They often suffer from obstructive sleep apnoea (OSA), early detection of which is recommended because of its potentially adverse effects on development. This study is concerned with aspects of assessment that have been considered important in helping to recognise OSA in children with DS. The relationships between different objective measures, and between these measures and parental reports of their child's sleep and daytime behaviour, were explored. Method - Overnight recordings were carried out on a group of children with DS (n = 31) involving video and audio recording, oximetry and activity monitoring during sleep. Parents also completed questionnaires concerning their child's sleep and daytime behaviour. Results - Parents' reports of restless sleep and noisy breathing were supported by objective measures of activity during sleep and audio recording respectively. No significant association was found between objective measures of restlessness during sleep and ‘snoring’ (see later for definition), nor were objective measures of restlessness related to reductions in overnight blood oxygen levels. However, the objective measure of snoring was significantly associated with reductions in overnight blood oxygen levels.All three of the objective measures were significantly associated with parental reports of various types of disturbed daytime behaviour. Conclusions - The findings have implications for aspects of screening for OSA in children with DS and for the interpretation of the relevance of the results to the children's daytime behaviour.

Sneezing and nasal discharge are a relatively common presentation in cats, often accompanied by involvement of the sinuses and the middle ear. Common associated clinical signs are noisy breathing and inappetence/weight loss. The best outcome for the patient occurs when a specific, treatable cause is identified; however, in a significant number of cases the nasal discharge is the chronic sequel to a respiratory virus infection. In such cases squamous metaplasia of the nasal mucosa means that complete resolution is unlikely, making good long-term management the goal. This article discusses the various causes of sneezing and chronic nasal discharge in the cat, and suggests diagnostic routes and therapeutic options.

Laryngomalacia literally means weak larynx. It is the most common cause of noisy breathing in infants and children constituting around 70% of cases. Its aetiology is not clear and various theories are proposed. Treatment remains following the child with regular weight monitoring in view of expected spontaneous resolution. However we cannot predict which child will resolve spontaneously and which child may need surgical intervention. We propose a new theory based on relative imbalance of demand supply of air, suggesting the increase in demand causing turbulent airflow, increasing suction pressure and causing collapse of laryngeal structures. This theory also helps us in predicting early, which child will resolve spontaneously and which child will need surgery. The methodology to evaluate hypothesis along with techniques and tools are also suggested.

Subglottic stenosis poses a challenging situation for otolaryngologist. In many cases tracheostomy is required to safeguard the airway. Recently, encouraging results in use of balloon dilatation for subglottic stenosis has led us to successfully treat a recurrent post-treatment short segment subglottic stenosis in a 37-year-old male patient who presented to us with complaints of breathlessness and noisy breathing. How to cite this article Kulkarni AS, Karnik P, Nataraj U. Balloon Dilatation of Recurrent Post-treatment Short Segment Subglottic Stenosis by Airway Balloon in an Adult. Int J Head and Neck Surg 2012;3(3):175-178.

Iatrogenic damage to the pediatric airway occurs rather often. Most injuries will heal without any sequelae because larynx and trachea of children tolerate considerable trauma. However, sometimes the injury is penetrating the mucosa and scar formation can lead to an obstruction of the airway which is followed by a tracheostomy and long term surgery. A great problem is the early detection of trauma since noisy breathing develops often late when scar formation has occluded more than 50% of the airway. A selection of photo documents of airway endoscopy out of more than 5000 photos from the years 1987-2007 were used to explain the development of injuries from minor lesions to large areas of necrosis of the mucosa of larynx and trachea of infants and children. The visualization of airway lesions might help to prevent iatrogenic damage.

Although clinicians place considerable weight on the identification of the various forms of noisy breathing, there are serious questions regarding both the accuracy (validity) and the reliability (repeatability) of these noises. To avoid diagnostic errors, clinicians need to consider the whole constellation of symptoms and signs, and not focus on the specific "type" of noise. Given the high error rate with "parent-reported wheeze" there is a need to reexamine the extensive literature on the epidemiology of wheeze in infants and young children, because parent-reported wheeze is unconfirmed by a clinician. It is obvious we need more high-quality research evidence to derive better evidence on the clinical utility of these noises, and their natural history.

Recognition of the signs and symptoms that are common in the final hours of life and a basic understanding of how to manage these signs and symptoms are important to helping the patient and family experience a good death in the home setting. The most common signs and symptoms, including pain, dyspnea, and terminal restlessness or delirium, and their management are discussed. Also addressed are other signs and symptoms, such as cardiovascular signs and symptoms including cold extremities, mottling, and changes in vital signs; respiratory signs and symptoms such as changes in breathing pattern, noisy breathing, and mandibular breathing; and neurological signs and symptoms such as disorientation, sensory changes, and semicomatose state. Changes in metabolism such as fatigue, surge of energy, and increased temperature are presented, along with decreased intake, excretion, and communication changes.

Background Noisy breathing is a common presenting symptom in children. The purpose of this study is to (a) assess parental ability to label wheeze, (b) compare the ability of parents of children with and without asthma to label wheeze and (c) determine factors affecting parental ability to label wheeze correctly. Methods This cross-sectional study in a tertiary hospital in Kuala Lumpur, Malaysia involved parents of children with asthma. Parents of children without asthma were the control group. Eleven validated video clips showing wheeze, stridor, transmitted noises, snoring or normal breathing were shown to the parents. Parents were asked, in English or Malay, “What do you call the sound this child is making?” and “Where do you think the sound is coming from?” Results Two hundred parents participated in this study: 100 had children with asthma while 100 did not. Most (71.5 %) answered in Malay. Only 38.5 % of parents correctly labelled wheeze. Parents were significantly better at locating than labelling wheeze (OR 2.4, 95 % CI 1.64–3.73). Parents with asthmatic children were not better at labelling wheeze than those without asthma (OR1.04, 95 % CI 0.59–1.84). Answering in English (OR 3.4, 95 % CI 1.69–7.14) and having older children with asthma (OR 9.09, 95 % CI 3.13–26.32) were associated with correct labelling of wheeze. Other sounds were mislabelled as wheeze by 16.5 % of respondents. Conclusion Parental labelling of wheeze was inaccurate especially in the Malay language. Parents were better at identifying the origin of wheeze rather than labelling it. Physicians should be wary about parental reporting of wheeze as it may be inaccurate. Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0616-8) contains supplementary material, which is available to authorized users.