Stridor

see Paediatric airway Management

Overview

Assessment of severity

Cyanosis Stridor Retractions Mental state
Mild No Inspiratory only
With exertion/irritation

 

None/Slight Normal
Moderate No Inspiratory only
At rest
Moderate Normal
Severe Yes Inspiratory +/- expiratory Marked Agitated
Terminal Yes or pale/grey Diminishing stridor
(exhaustion)
Diminishing effort (exhaustion) Moribund

Causes

Diagnosis Epiglottitis Croup Bacterial tracheitis Foreign Body Spasmodic Croup
Pathology H.inf (B) - (now less frequently due to vaccination) Viral S.aureus FB Allergy due to viral URTI
Epidemiology Autumn/Winter Autumn/Winter
Age 2-6 yrs
20-40 yrs
(bimodal)
6mo-3yo 1mo-10yo
Chronology Rapid onset (hrs)
Progressive
Gradual (days)
Self limiting
3-5 days (up to 10 days)
Progressive Acute Self limiting
History Dysphagia Viral Prodrome
Worse at night
History of coughing/choking
Examination Fever > 39
Soft stridor
Drooling
Muffled voice
'Tripod position'
'Sniffing the morning air'
Fever < 39
Harsh stridor
Barking cough
Hoarse voice
Rhinorrhea
High fever
Septic
Biphasic stridor
+/- Barking cough
Afebrile
WCC Normal Normal
X-ray
 
(see below)
Enlarged epiglottis
Loss of vallecula/pyriform sinus
'Steeple sign' Fuzzy air column Possibly visualised
Management Prophylactic intubation
Ceftriaxone
Adrenaline neb
Steroid PO/IM/neb
Prophylactic intubation
Flucloxacillin
Humdified air

Investigations (rarely needed to clinch the diagnosis - use in mild cases and diagnostic uncertainty)

Disposition

Admit

Discharge others only after appropriate treatment and observation for 4 hrs with no stridor at rest