Davis, T. PICU Q+A: stridor, Don't Forget the Bubbles, 2013. Available at:
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.
- 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
- Tumors (vascular/oncological)
- Vascular slings and rings – double aortic arch, anomalous left pulmonary artery sling, etc
- 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
- Constitutional state (toxicity, fever, pulse rate)
- 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
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
- Lateral neck xray
- CT scan
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.