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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