Skip to content

PICU Q+A: stridor

SHARE VIA:

Share on facebook
Share on twitter
Share on linkedin
Share on whatsapp

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.

About the authors

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

KEEP READING

High flow therapy – when and how?

Chest compressions in traumatic cardiac arrest

Searching for sepsis

The missing link? Children and transmission of SARS-CoV-2

Don’t Forget the Brain Busters – Round 2

An evidence summary of Paediatric COVID-19 literature

Urticaria

The fidget spinner craze – the good, the bad and the ugly

Parenteral Nutrition

Leave a Reply

Your email address will not be published.

1 thought on “PICU Q+A: stridor”

DFTB WORLD

EXPLORE BY TOPIC

We use cookies to give you the best online experience and enable us to deliver the DFTB content you want to see. For more information, read our full privacy policy here.
[cmplz-manage-consent]