Acute Stridor
By
Yehia Abo Arida
Ward 7
Stridor
 It is a harsh, high-pitched respiratory
sound, which is usually inspiratory but
it can be biphasic and is produced by
turbulent airflow; it is not a diagnosis but
a sign of upper airway obstruction .
Causes of acute stridor
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Laryngotracheobronchitis ( croup) .
Epiglottitis .
Bacterial tracheitis .
Foreig body
Angioedema .
Hypocalcemic tetany .
Edema after endotracheal intubation .
Assessment of severity of stridor
 Timing :
– The prominent phase of respiratory noise should be inspiratory
– Expiratory stridor ----- more severe , or intrathoracic obstruction .
 Work of breathing :
– Increased RR .
– Sternal ( supra – sub ) recession .
 How effective is the breathing :
– Chest expansion .
– Breath sounds for air entery .
 Is there adequate oxygenation :
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Is HR increased .
Pallor , cyanosis .
O2 saturation .
Activity level .
Worrying signs in children with
stridor
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High fever or signs of toxicity
Rapid onset .
Drooling & dysphagia .
Muffled voice & quiet stridor .
Angioedema .
Age less than 4 mths .
Skin cavernous hemangioma .
Previous ventilation as a neonate .
Croup
Is derived from an old
scottish word , roup ,
which means to cry
out in a hoarse voice .
Viral croup ( ALTB )
 Viral croup is the most common cause of acute
stridor in children .
 Most patients with croup are between ages of 3
mths and 5 yrs , with the peak around 1-2 yrs .
 Common pathogens include parainfluenza
viruses ( 1,2 & 3 ) account for 75% of cases;
others include influenza ( A&B ) , RSV &
measles V .
 Mycoplasma pneumoniae has rarely been
isolated from children with croup .
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 The term laryngotracheobronchitis refers to
viral infection of the glottic and subglottic
regions . Some clinicians use the term
laryngotracheitis for the most common & most
typical form of croup and reserve the term LTB
for more severe form .
 Inflammation & partial obstruction of the upper
airways result in a barkelike or brassy cough&
inspiratory stridor & may be associated with
hoarseness & RD .
 Small children are at higher risk because
of the relative small size of their upper
airways. . .
 Unlike relatively rare conditions as epiglottitis
& bacterial tracheitis , croup has :
– a more insidious onset over a few days .
– systemic toxicity & fever are considerably less .
– have typical barking cough , often associated
with hoarse voice , stridor & low grade fever .
 As in many respiratory conditions , symptoms
are often worse at night .
Assessment & evaluation
 Mild:
– well , active child .
– barking cough .
– stridor with agitation
– minimal sings of increased WOB .
 MODERATE :
– stridor at rest .
– some signs of increased WOB .
 SEVERE :
– stridor at rest + expiratory component .
– marked increased WOB .
– increased RR & HR
– agitation & pallor .
– as AW obstruction became very serious stridor
became quieter .
– agitation turn to exhaustion .
Acute spasmodic croup
 Some children develop recurrent short lived
episodes of croup without preceding coryzal
prodrome that is seen in classical viral croup.
 children are afebrile & awake suddenly with acute
stridor during night .
 recurrence occurs on subsequent 2-3 nights .
 it occurs in children of the same age group , during
same season & sometimes same virus can isolated .
 children with recurrent spasmodic croup often have
a strong atopic or asthmatic family background .
Radiographs
 Croup is a clinical diagnosis and does not require
a radiograph of the neck .
 It may show the typical subglottic narrowing or (
steeple sign ) on AP view , which may be present
as a normal variation or in epiglottitis & may be
absent in patient with croup .
 Should be considered in patient with atypical
presentation .
 May be helpful to distinguish severe LTB &
epiglottitis , but airway management should
always take priority .
 Steeple sign (croup \ normal \ epiglottitis ) due
to subglottic narrowing .
Treatment
 Majority of cases will have a mild illness that
can be managed at home .
 Those with significant RD and stridor at rest
will require treatment & reassessment .
 Those showed significant improvement
following treatment may be considered for
discharge home .
 There should be a low threshold for
admission in :
– children under age of 12 mths .
– all children with marked RD .
– those with oxygen requirement on presentation.
– those with parents remain anxious about
discharge .
 Parents of children not requiring
admission should receive clear
instructions when to return :
– chest wall recession .
– tachypnoea .
– color changes .
– inability to feed .
– decreased level of consciousness .
Therapies may be effective
 Simple measures :
– in all cases it is very important to keep the child
and parents calm .
– direct inspection of the throat can be dangerous
and result in complete obstruction of the airway.
– neck x ray is no longer useful and carry the risk
of further upset and deterioration .
 Humidification :
– steam inhalation for croup is widely used but of
little proven benefits .
– the percieved benefits ( placebo effect ) may be
due to presence in a warm calming environment .
– a steamy bathroom with hot water tap running
and plug opened is accepted , but use of kettle
and boilers should discouraged , because it carry
the risk of scalding .
 Adrenaline ( epinephrine ) :
– nebulized adrenaline is very effective in severe
croup .
– duration of action between 20 minutes and 3
hours .
– it is used in most cases when intubation is
considered.
– weaning effect of adrenaline result in return to
pretreatment baseline rather than a true
rebound .
– for children with severe croup , the period of
improvement on adrenaline is long enough to
allow the steroid to start working .
 Steroids :
– Corticosteroids improve clinical parametrs .
– Decrease the admission rate .
– decrease duration of hospital stay .
– Decrease the need for repeated nebulized
adrenaline in children with croup .
– nebulized budesonide or oral dexamethazone
showed equal effect in treating children with
croup .
– approximately 1-5 % of croup cases require
ETT before introduction of steroid therapy .
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Intubation :
– a small numbers of children will still require ET
for severe croup .
– The decision to intubate should be based on
worsening airway obstruction , signs of
exhaustion or impending respiratory failure .
– Children with epiglottitis and bacterial tracheitis
require specialist care , with input from senior
ENT & anethetic stuff .
– IV antibiotics & intubation are often required .
– steroid & adrenaline have minimal effect on
these condition .
Mild croup
 Reassurance .
 May worse by night ( advice to return ) .
 Dexamethazone PO (0.3- 0.6 mg\kg \ dose).
Moderate croup
 Cardio respiratory monitor
 Dexamethazone PO&\or nebulized budesonide
(pulmicort) 2 mg stat .
 Reassess in 2 hours
– If improved ------- discharge .
– If no improvement :
 Consider nebulized adrenaline 1: 1000
– 2.5 ml for those younger than 1 year .
– 2.5 - 5 ml for older than 1 year .
– If improved -----observe for 4 hrs & discharge .
Severe croup
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Cardio respiratory monitor .
Oxygen to maintain O2 sat ( 92% or more ) .
Nebulized adrenaline ( 1\1000) Q 1-4 hrs .
IV dexamethazone ( 0.3-0.6 mg\kg\dose ) . Or
Nebulized budesonide ( pulmicort ) 2mg .
IF no improvement consider BGA , ICU .
Intubation & ventillation may be required .
Bacterial traheitis
 Bacterial infection of upper airway , does not
involve the epiglottis but, like epiglottitis and
croup , is capable of causing life-threatening
airway obstruction .
 Staph aureus is the most commonly
isolated organism .
 Most patients were below 3 yrs , but in
recent case series the mean age has been
between 5-7 yrs .
 I t may be considered as bacterial
complication of disease , rather than a
primary bacterial illness .
Clinical manifestations
 Typically child has a brassy cough , apparently as
a part of LTB .
 High fever and toxicity with RD immediately or
after few days of apparent improvement .
 Patient can lie flat , does not drool , and does not
have dysphagia associated with epiglottitis .
 the usual treatment for croup is ineffective ,
intubation or tracheostomy may be necessary .
 The major pathologic feature is mucosal swelling
at level of ciricoid cartilage , complicated by
copious thick purulent secretions sometimes
causing pseudomembrane .
Diagnosis
 Diagnosis is based on evidence of bacterial
upper airway disease (high fever – purulent
airway secretions & absent classic finding of
epiglottitis ) .
 XR not needed , but may show classic
findings (pseudomembrane detachment in
the trachea ) .
 Purulent material is noted below the cords
during ET intubation .
 Black arrow points tracheal pseudomemerane
(bacterial tracheitis \ diphtheria )
Treatment
 Antimicrobial therapy , which usually
includes antistaph agents , should be
instituted in any patient whose course
suggest bacterial traheitis .
 When diagnosed by direct laryngoscopy , or
suspected on clinical background , an
artificial airway should be strongly
considered .
 Supplemental oxygen may be necessary .
Complications
 CXR showed :
– Patchy infiltrates & show focal densities.
– Subglottic narrowing .
 Cardio respiratory arrest can occur if
airway management is not optimal .
 Toxic shock syndrome has been
associated with staph tracheitis .
Prognosis
 oxygen therapy continued . For most of
patients is excellent .
 Patient become afebrile within 2-3 days of
institution of antimicrobial therapy , but
prolonged hospitalization may be necessary.
 After extubation the patient should be
observed carefully while antibiotics and O2
continued .
Epiglottitis
 Dramatic potentially lethal condition characterized by an acute ,
potentially fulminating course of high fever , sore throat ,
dyspnea & rapidly progressing respiratory obstruction .
 Degree of RD at presentation is variable.
 Often the otherwise healthy child develops sore throat and
fever within a matter of 4-6 hrs .Child appear toxic ,swallowing
is difficult and saliva drooling .
 He sitting upright and assume tripod position( leaning forward
,chin up, bracing on the arm ) .
 A brief period of air hunger with restlessness may be followed
by cyanosis and coma .
 Stridor is a late and suggest near complete airway obstruction.
 If no treatment provided complete obstruction of airway and
death .
 barking cough typical of croup is rare .
Diagnosis
 laryngoscopy :
– Showed large( cherry red) , swollen epiglottis
– Other supraglottic structures especially
aryepiglottic fold , occasionally more involved .
– It should be performed in a controlled
environment as OR or ICU .
 Lateral radiograph of upper airway :
– Showed the classical ( thumb sign ) .
 Red arrow points ( normal & swollen epiglottis)
known as thumb sign or thumb print .
Intial management of suspected
epiglottitis
 Do not :
– Examine the throat .
– Put the child flat .
– Order a lateral XR of the neck .
– Upset the child by trying to gain iv access or
place an O2 mask .
 Do :
– Call airway team .
– Stay with the child and parents .
– Allow the child to sit on knee of his mother .
– Measure O2 sat if possible .
– Give O2 therapy if absolutely needed and well
tolerated .
Treatment
 Immediate treatment with artificial airway placed in OT
or ICU .
 All cases should receive oxygen unless the mask
causes excessive agitation .
 Racemic epinephrine & corticosteroids are ineffective .
 Blood & epiglottic surface C&S and in selected cases
CSF should be collected after stabilization of airway.
 Cefotriaxone, cefotaxime , or combination of
ampicillin and salbactum should be given parenterally,
pending C&S reports .
 Antibiotics should be continued for 7-10 days .
Chemoprophylaxis
 Not routine for household , child-care or nursery
contacts of patient with invasive HIb infection , but
observation & medical evaluation is mandatory
when exposed child develop febrile illness .
 Indication for rifampin prophylaxis :
– Any contact less than 1y & incompletely immunized .
– Any contacts less than 2 yrs of age who has not
received the primary vaccination series .
– An immunocompromised child in the household .
– Dose : (20 mg \kg \d ) once , for 4 days , maximum dose
is 600 mg \ day .
Prognosis
 Length of hospitalization and mortality rate
increase as infection spread to involve a greater
portion of respiratory tract , except in epiglottitis in
which local infection may prove to be fatal .
 Causes of death in croup are :
– Laryngeal obstruction .
– Complications of tracheostomy .
– rarely , fatal out-of-hospital arrest due to viral LTB have
been reported .
 Untreated epiglottitis has mortality rate of 6%
but if treatment initiated the prognosis is
excellent .
 The outcome of LTB ,and spasmodic croup is also
excellent .