PICU Q+A: stridor

—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

—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

—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.

—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.