Acute Stridor

Stridor
- Harsh, vibratory sound produced when airway
become partially obstructed, resulting in
turbulence airflow in the respiratory passage.
 Ddx of acute stridor?
Infective
- laryngotracheobronchitis
- epiglotitis
- bacterial tracheitis
- diphteria
- paratonsillar abscess
- retropharyngeal abscess
Immune-mediated
- angioedema
- anaphylaaxis
Foreign body
Inhalational injury
 Acute
stridor

Fever No fever

Mild High fever

fever History of choking
(>38.5) or allergy

Throat normal Throat: grey Throat :bulging Throat: swollen Normal throat
exudate pharynx epiglottitis

Retropharyngeal *Acute Angioneurotic

*Viral Bacterial Diphteriae Foreign
abscess epiglottitis edema
croup tracheitis body

6m-4yrs Any age

Dysphonia Urticaria
<3yrs <2yrs 3-7 yrs Wheeze
6m-2 1-2 Unimmunised Neck Sudden onset
years years Bull neck hyperextended Drools
Dysphagia Prefers sitting
 Croup
Croup (laryngotracheobronchitis) is a
condition due to obstruction of the
larynx

It is a clinical syndrome characterized by

barking cough
stridor
hoarseness of voice
respiratory distress of varying severity
 Epidemiology
Affects children between 6months to
6 years
Peak incidence is between age 1 to 2
years
Boys > girls
 Aetiological agent
Parainfluenza virus (74%)
Respiratory syncytial virus
Influenza virus
Adenovirus
Enterovirus
Measles
Mumps
Rhinovirus
 Pathophysiology
Viral invasion of laryngeal, tracheal & bronchial
mucosa

Inflammation, hyperemia, edema, epithelial

necrosis

Irritation Subglottic Vocal cord

narrowing swelling

Mobility of the vocal

Cough Airway
cords becomes impaired
obstruction

Stridor Hoarseness of
voice
Clinical Features
 Symptoms
Late
Early (12-72hrs)
Barking
Low gradecough
fever
Harsh
Coryzalstridor,
symptoms
predominantly on
inspiration
Hoarseness of voice
Start and worse at night
 Signs
Tachypnea
Tachycardia
Respiratory distress
Nasal flaring, head bobbing, grunting,
recessions
Central cyanosis, d/t severe hypoxemia
Auscultation
Reduced breath sound
Expiratory rhonchi
 Croup Severity Assessment
Mild Moderate Severe
Behaviour Normal Some / Increasing
intermittent irritability,
irritability lethargy
Stridor When active / Some stridor Stridor at rest
upset at rest
Respiratory Normal Tachypneic Markedly
rate with tracheal increased or
tug, nasal decreased
flaring with tracheal
tug, nasal
flaring
Accessory None or Moderate Marked chest
muscle use minimal chest wall wall
recessions recessions
Oxygen Normal Normal Hypoxaemia
saturation

http://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/
 Diagnosis
Clinically
Examine pharynx to exclude
Acute epiglottitis
Retropharyngeal abscess
Neck radiograph exclude foreign
body
 Investigation
FBC lymphocytosis
Pulse oximetry measure O2
saturation
Neck radiograph Steeple Sign
( laryngeal air column narrowing
below vocal cord)
Laryngoscopy exclude peritonsillar
abscess

Figure 1. Normal anteroposterior
radiograph of the upper airway, with the
normal appearance of the subglottic region.
Figure 2. Anteroposterior radiograph of the
upper airway of a patient with croup. The
subglottic tracheal narrowing produces an
inverted V appearance known as the steeple
sign.
 Management
Home admission
Hospital
Mild in severity
Moderate, severe
Ease of
Toxic access to hospital
looking
Age oral intake
Poor
Parental
Age understanding
<6 months
Unreliable caregivers at home
Long distance from hospital
Lack reliable transport
 MILD MODERATE SEVERE
Outpatient In patient In patient

Dexamethasone Dexamethasone Nebulised adrenaline

Oral/parenteral Oral/parenteral 0.3- 0.5mg/kg 1:1000
0.15kg/single dose 0.6mg/kg single dose
May repeat at 12 & and
24h and/or
Dexamethasone
Prednisolone Nebulised budesonide Parenteral 0.3-
1-2mg/kg/stat 2mg stat 0.6mg/kg
& 1mg 12hourly
or if vomiting and

Nebulised budesonide Nebulised budesonide

2mg single dose only 2mg stat
& 1mg 12hourly

and
No improvement/ Oxygen
Improvement
deterioration

No
Home Nebulised improvement/deterioration
adrenaline Intubate & ventilate
 Consider IV fluids if poor oral intake
Antibiotics not recommended unless
Bacterial super-infection strongly
suspected
Patient is very ill
 Complications
Respiratory arrest
Epiglottitis (swelling of tissue over
vocal cords)
Atelectasis (collapse of lung tissue)
Middle Ear Infection
Bacterial tracheitis
Pneumonia
Meningitis
Septic Arthritis
 Prognosis
Resolves within 3-7 days
Recurrent are frequent between 3
and 6 years of age
 Viral croup is the commonest cause
of acute onset of stridor
However, other conditions need to be
considered in patient presenting with
stridor