SPC- Stridor

Question 1

What is stridor?

Answer 1

High pitched noise heard due to partially obstructed larynx or large airways

Question 2

What is stertor?

Answer 2

Inspiratory snoring noise (low pitched), coming from obstruction of the pharynx

Question 3

Why is any sign of airway obstruction very concerning in children?

Answer 3

Children’s airways are much narrower than adults and so obstruction can occur faster and more dramatically

Question 4

What are some causes of stridor?

Answer 4

Congenital- Laryngomalacia, web/stenosis, vascular rings
Inflammation- Laryngitis, epiglottitis, croup, anaphylaxis, peritonsilar abscess
Tumours- Haemangiomas, Papillomas
Trauma- Thermal (burns)/chemical, or from intubation
Foreign body
Laryngospasm

Question 5

What are the different types of stridor?

Answer 5

Inspiratory-(obstruction at or above the glottis)
Expiratory- Obstruction of Bronchi
Biphasic- Obstruction of the trachea

Question 6

What worrying features should be checked for when a patient presents with stridor?

Answer 6

Stridor is a sign of impending respiratory arrest. Worrying features include:
Swallowing difficulty/ Drooling
Pallor/ Cyanosis
Use of accessory muscles of ventilation
Tracheal tug

Question 7

What is the management of stridor?

Answer 7

This is a medical emergency and should be approached using the ABCDE algorithm. The airway is not patent and this requires urgent action.

• Give Oxygen or Heliox (mixture of oxygen and helium that is less dense and may reduce work of breathing)
• Nebulised Adrenaline (1ml of 1:1000 with 1 ml saline- causes bronchodilatation)
• Monitor O2 saturation, RR, HR,BP
• Escalate and call for ENT/Anaesthetic senior ASAP
• Be brief with history taking from patient or relative
• Secure the airway by the least invasive method possible (intubation, cricothyroidotomy, tracheostomy)

Question 8

How should the airway be managed if a patient presents with stridor?

Answer 8

• Endotracheal intubation (1st line, move on if not possible)
• Emergency Needle Cricothyroidotomy- If child less than 12 years of age (Very temporary procedure, only sustains life for 30-45 minutes)
• Surgical Cricothyroidotomy

Question 9

What is croup?

Answer 9

Also called acute laryngotracheobronchitis

Leading cause of stridor (if severe) involving inflammation of the larynx, trachea and bronchioles

Question 10

What is the main cause of croup?

Answer 10

Viral (95%)- Parainfluenza virus, Respiratory Syncytial virus

Question 11

What age group is croup commonly seen in?

Answer 11

Children (<6 years of age)

Question 12

What are the signs of croup?

Answer 12

Stridor
Barking cough
Hoarse voice
Infective signs

Question 13

What are the worrying signs of croup?

Answer 13

Stridor at rest
Cyanosis
Low SaO2
Increasing RR
Increasing HR
Fatigue/Tiredness
Altered consciousness level

Question 14

What is the treatment of croup?

Answer 14

If no stridor and mild can be treated at home
Prednisolone 1-2mg/kg PO or Dexamethasone 0.15mg/kg PO
If severe signs- Nebulised Adrenaline 1:1000
Failure to improve, repeat and refer to ITU

Question 15

Why is softer stridor more worrying?

Answer 15

Stridor is due to airway obstruction reducing flow. The sound is due to the volume of flow. Reduced volume indicates poor ventilation.

Question 16

What is acute epiglottitis?

Answer 16

Rapidly progressive inflammation of the epiglottis and adjacent tissues. It is a medical emergency as the inflammation can quickly cause airway obstruction

Question 17

How may children/adults present with acute epiglottitis?

Answer 17

Difficulty breathing
Swallowing difficulty
Drooling of saliva (as avoid swallowing due to pain)
Sore throat
Fever
Irritability
Muffled voice/crying (as pain created through talking due to inflammatory process)
Cough is absent
(Note- Relatively rare in children due to Hib vaccination, now more commonly presents in adults with severe sore throat and painful swallowing)

Question 18

What is the management of acute epiglottis?

Answer 18

Keep the patient upright
Do not try to visualise or examine the back of the throat (as this can cause laryngospasm and closure of the airway)
Escalate to an ENT/Anaesthetic Registrar
Diagnosis is made by laryngoscopy and the patient intubated and given dexamethasone and antibiotics
Surgical airway is intubation not possible

Question 19

What is laryngomalacia?

Answer 19

Main congenital abnormality of the larynx that is often noticeable within hours of birth
Excessive collapse and in-drawing of the supra-glotic airways during inspiration leading to airway obstruction
In 85% no treatment is needed and symptoms usually improve by 2 years old
Problems can occur with concurrent laryngeal infections or with feeding
Surgery can help in severe cases