PICU Q+A: stridor

Cite this article as:
Davis, T. PICU Q+A: stridor, Don't Forget the Bubbles, 2013. Available at:
https://dontforgetthebubbles.com/picu-qa-stridor/

PICU Q+A: This Q+A is about stridor in a previously well child.

1a: List the possible causes of stridor at rest in a previously well 3 year old child.
1b: What features elicited on history, examination and imaging would help in refining the diagnosis?
1c: What are the indications for intubation in this situation?
1d: List the key management issues in securing the airway.

This is based on teaching from Sydney Children’s Hospital PICU.

List the possible causes of stridor at rest in a previously well 3 year old child.

—Anatomical position

  • —Nose and pharynx: adenoids/tonsillitis, retropharyngeal abscess. (rare – diphtheria)
  • —Larynx: —croup, spasmodic laryngitis, epiglottitis, vocal cord paralysis, foreign body, subglottic haemangioma
  • —Trachea: bacterial tracheitis, external compression

—Extrathoracic

  • —Tumors (vascular/oncological)
  • —Vascular slings and rings – double aortic arch, anomalous left pulmonary artery sling, etc
  • —Anaphylaxis

What features elicited on history, examination and imaging would help in refining the diagnosis?

—History

  • —Age of child: neonate, infant or older child
  • —Timing of event: acute vs chronic
  • —Noise characteristics: inspiratory/expiratory respiratory cycle phase of stridor, sturtor, associated wheeze
  • —Constitutional symptoms
  • —Respiratory compromise + association with feeding, sleep, activities
  • —Foreign body suspicion or history (e.g. choking on food)
  • —Other clues – immunisation status, medical history e.g. asthma, atopy, Down syndrome

—Examination

  • —Constitutional state (toxicity, fever, pulse rate)
  • —Stridor
  • —Drooling
  • —Cough
  • —Speech
  • —Tachypnoea
  • —Tracheal tug on inspiration
  • —Intercostal and subcostal indrawing on inspiration
  • —Asynchrony of chest and abdominal wall movement
  • —Cyanosis in air
  • —Facial burns, soot around mouth, singed nasal hair

Differential

Croup: voice – hoarse; cough – barking; fever – yes; saliva – minimal; neck swelling – little; begins – slowly; season – autumn.

Epiglottitis: voice – muffled; cough – usually none; fever – yes; saliva – lots; neck swelling – lots; begins – suddenly; season – all year

Imaging

  • —CXR
  • —Lateral neck xray
  • —Fluoroscopy
  • —CT scan
  • —MRI

What are the indications for intubation in this situation?

—Impending respiratory arrest

  • —Hypoxaemia and hypercarbia with tachycardia, confusion and poor perfusion
  • —Decreased conscious level, bradycardia, silent chest, episodes of apnoea
  • —Evolving disease – epiglottitis

—Score of >7 on croup score

  • —Severe respiratory distress and lethargy, cyanosis despite aggressive medical management.

List the key management issues in securing the airway.

—Do not agitate child…

  • —To inspect the oropharynx
  • —To send the patient to radiology for a lateral neck X-ray
  • —To insert an IV and agitate child to take unneccessary gases

—Preparation for intubation

  • —Gas induction, ETT + at least one size smaller, difficult airway equipment, surgical tracheostomy kit, ventilator, post-intubation securing devices, sedation drugs and monitoring, e.g. pCO2
  • —Failed intubation backup plan

—MDT Team involvement

  • —Senior anaesthetist, ENT surgeons on scene, theatre staff standby, ICU staff fully informed
  • —Transport team (if relevant)
  • —Decision regarding ongoing supplemental therapy – steroids, neb adrenaline, O2, antibiotics
  • Induction sitting up may be necessary
  • Decision regarding : awake, sedated vs anaesthetised child/RSI
  • —Parental consent and information update.

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About Tessa Davis

AvatarTessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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Author: Tessa Davis Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

One Response to "PICU Q+A: stridor"

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    Lauren Witek 8 months ago .Reply

    Do you send out emails? Joining list?

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