Stridor (peds)

This page is for pediatric patients. For adult patients, see: stridor.

Background

Cross section of a trachea and esophagus anatomy.

Tracheal anatomy.

• Stridor refers to harsh upper airway sounds, classically inspiratory
• A minimal amount of edema or inflammation in the pediatric airway can result in significant obstruction and can lead to rapid decompensation

Clinical Features

• Inspiratory stridor
  • Suggestive of extrathoracic obstruction (Pressure_trach < Pressure_atm)
  • Croup, metapneumovirus, foreign body, epiglottitis
• Expiratory stridor vs. wheezing
  • Suggestive of intrathoracic obstruction (Pressure_trach < Pressure_pleura)
  • Asthma, bronchiolitis

Differential Diagnosis

Pediatric stridor

<6 Months Old

• Laryngotracheomalacia
  • Accounts for 60%
  • Usually exacerbated by viral URI
  • Diagnosed with flexible fiberoptic laryngoscopy
• Vocal cord paralysis
  • Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
  • May have cyanosis or apnea if bilateral (less common)
• Subglottic stenosis
  • Congenital vs secondary to prolonged intubation in premies
• Airway hemangioma
  • Usually regresses by age 5
  • Associated with skin hemangiomas in beard distribution
• Vascular ring/sling

>6 Months Old

• Croup
  • viral laryngotracheobronchitis
  • 6 mo - 3 yr, peaks at 2 yrs
  • Most severe on 3rd-4th day of illness
  • Steeple sign not reliable- diagnose clinically
• Epiglottitis
  • H flu type B
    • Have higher suspicion in unvaccinated children
  • Rapid onset sore throat, fever, drooling
  • Difficult airway- call anesthesia/ ENT early
• Bacterial tracheitis
  • Rare but causes life-threatening obstruction
  • Symptoms of croup + toxic-appearing = bacterial tracheitis
• Foreign body (sudden onset)
  • Marked variation in quality or pattern of stridor
• Retropharyngeal abscess
  • Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Evaluation

• Assess airway
  • If unstable, see Difficult Airway Algorithm, Intubation and consider surgical intervention/consultation
  • If stable, consider imaging or direct visualization of larynx with fiberoptic scope or video laryngoscope GEMC:Airway Procedures
• CT of neck if mass/infection suspected

Management

• Treat underlying cause

Disposition

• Based on underlying cause

See Also

• Stridor