Stridor in Children

Background

• Stridor is an abnormal coarse, grating respiratory sound caused by turbulent airflow through a partially obstructed airway. It is often audible without a stethoscope.
• Stridor may occur with a mild obstruction, or may indicate a life-threatening obstruction and impending airway collapse.
• The most common cause of acute stridor in young children is croup. Acute stridor can also be due to other infections, or to noninfectious causes such as anaphylaxis or trauma.
• Chronic stridor can be due to a wide range of congenital and acquired lesions causing airway obstruction at any site(s) from nose to bronchus.
• Clinical findings, such as the phase(s) of respiration involved and age at presentation, can help identify the likely anatomic site and cause of the airway obstruction.

Evaluation

• If efforts at physical exam or testing worsen respiratory distress and lead to concern for impending respiratory failure, limit or defer further evaluation until the patient is in a setting that will allow for safe acute intervention.
• Take a careful history, including asking about
  • stridor onset, duration, and progression.
  • associated symptoms such as fever or cyanosis.
  • birth history, injuries, surgery, or underlying conditions.
• The physical exam should include assessments for
  • level of respiratory distress, stridor phase of respiration (inspiratory, expiratory, or biphasic), and associated abnormal respiratory sounds.
  • dysmorphic features, skin lesions, masses, or other abnormalities that may suggest a congenital or acquired cause of airway obstruction.
• Many causes of stridor in children are diagnosed clinically, however testing may be indicated for diagnostic uncertainty or diagnostic confirmation.
• Consider x-rays of neck soft tissues as initial imaging, with chest x-rays if lower airway obstruction is suspected.
• Additional testing to consider based on the clinical presentation and suspected underlying cause may include
  • a blood gas in children with severe respiratory distress.
  • a flexible and/or rigid airway endoscopy to allow direct visualization of the obstruction and possibly enable further diagnostic testing or intervention.
  • additional imaging such as
    • computed tomography (CT) or magnetic resonance imaging (MRI).
    • ultrasonography.
    • barium swallow or modified barium swallow.
    • airway fluoroscopy.
  • other testing as indicated, such as biopsy or genetic testing.

Management

• For severe respiratory distress or signs of impending respiratory failure:
  • Limit disturbances that increase respiratory distress or threaten airway patency.
  • Consult otolaryngology and anesthesia regarding possible need for intubation in the operating room.
  • Intubate emergently for apnea, significant hypoxemia, or respiratory arrest.
  • Be prepared to perform alternative airway stabilization procedure (such as cricothyroidotomy) if endotracheal intubation not successful.
• Definitive treatment varies depending on underlying cause.