The Child with Stridor 1: Acute Stridor Chris Kingsnorth

Before We Begin

Overview Definition of stridor Differential diagnoses: Croup Acute epiglottitis Bacterial tracheitis Foreign body aspiration Laryngomalacia Subglottic stenosis

Stridor “…High-pitched breath sound resulting from turbulent air flow secondary to narrowing in the upper airway…” Most commonly the larynx https://en.wikipedia.org/wiki/File:Stridor_NP_OGG_2.ogg (Inspiratory and expiratory stridor in a 13-month child with croup)

Stridor Timing of stridor suggests the level of narrowing: Inspiratory: Laryngeal region Expiratory: Tracheobronchial region Biphasic: Subglottic/glottic region

Differential Diagnoses Acute Croup Acute epiglottitis Bacterial tracheitis Foreign body Chronic Laryngomalacia Subglottic stenosis

History Time course (acute vs. chronic) Coryzal Sx / fever Cough Drooling/ dysphagia Cyanosis/ apnoeas Possibility of FB aspiration (e.g. toys) Nature of stridor: timing, soft vs. harsh, present at all times vs. only when distressed

! Examination RR + effort (recession, tracheal tug) Confusion Cyanosis Drooling Cough Chest examination Never examine throat of child with severe stridor; this may precipitate acute airway obstruction !

Investigations If suspected epiglottitis/ respiratory failure: Bloods (FBC, U+E, CRP) ABG (respiratory failure, lactate) Blood cultures CXR

Acute Stridor: Croup

Croup: Epidemiology A.k.a acute laryngotracheobronchitis Most common cause of acute stridor 3 months  6 yrs (peak at 2 yrs) M > F Peak in Autumn months 80% = Parainfluenza virus (others inc. RSV, Rhinovirus)

Croup: Natural History Coryza + fever ↓ Stridor Hoarse voice Barking cough Wheeze Time course = days Larynx Trachea Bronchi Seal-like cough; usually worse at night

Croup: Clinical Features Stridor Hoarse voice Barking cough Wheeze Tachypnoea +/- recessions, tracheal tug Cyanosis if severe May not cough during consultation (worse at night) Child with croup. Note tachypnoea, barking cough, intercostal and subcostal recession, stridor and wheeze. Mild nasal flaring also visible.

Croup: Clinical Features Video showing spectrum of clinical features in mild, moderate and severe croup

Croup: Investigations Not required in most cases Unless unable to rule out epiglottitis

Croup: Severity Originally developed for research purposes; management should based on clinical assessment

Croup: Management Often resolves spontaneously Mild cases can be managed at home with good hydration, paracetamol and a single dose of oral corticosteroid If more severe may require admission, O2, nebulised adrenaline and IV hydration Elective intubation if deteriorates Recurrent croup may suggest subglottic stenosis

Acute Stridor: Acute Epiglottitis

Acute Epiglottitis: Epidemiology Life-threatening Paediatric emergency 2-7 years Most commonly bacterial infection H. influenzae Rare (HiB immunisation)

Acute Epiglottitis: Clinical Features Pyrexia Drooling Inability to swallow Stridor Characteristic tripod position Cough rare Can progress from presentation to death within hours

Acute Epiglottitis: Clinical Features Video showing clinical features of a young boy with acute epiglottitis. Note absence of cough and swallowing

Acute Epiglottitis: Management and Investigation Priority = protect and secure the airway: Do not examine throat Do not lie child down Avoid any examination/ investigations that will upset patient until after intubation May precipitate acute airway obstruction

Acute Epiglottitis: Management and Investigation Intubation Laryngoscopy (oedematous, cherry-red epiglottis)

Acute Epiglottitis: Management and Investigation Blood cultures Antibiotics (Cefotaxime; chloramphenicol if penicillin allergy) Lateral radiograph of the larynx shows ‘thumb sign’ (E) due to thickening of epiglottis

Acute Epiglottitis: Prognosis Recovery rapid with treatment Many children extubated within 48 hours of Abx

Acute Stridor: Bacterial Tracheitis

Bacterial Tracheitis: Epidemiology and Clinical Features Rare 3 wks – 16yrs Presents like croup with high fever but no response to standard croup Rx Hypothesis = viral infection with mucosal damage +/- local immunosuppression predisposes to bacterial infection S. aureus, S. pyogenes, S. pneumoniae, Moraxella, H. influenzae

Bacterial Tracheitis: Investigations and Management Direct visualization and culture of purulent tracheal secretions via laryngotracheobronchoscopy only definitive means of diagnosis Blood cultures Antibiotics (Cefotaxime) May require airway support

Acute Stridor: Foreign Body

Foreign Body: Epidemiology Can be life threatening depending on level and severity of obstruction To cause stridor must be lodged in upper airway (lower obstruction  wheeze) Toddlers (mobile + dextrous) Peanuts, small toys, beads, buttons etc History usually suggests FB aspiration Most common site = R main bronchus

Foreign Body: Clinical Features Stridor if significant upper airway obstruction Choking Cough Unilateral wheeze Respiratory distress Localised dull percussion of distal lung collapsed

Foreign Body: Investigations and Management Bronchoscopy CXR

Foreign Body: Emergency Management of Choking

What Now? Download slides/ notes pages Online MCQ: https://www.goconqr.com/en-GB/p/3950993-The-Child-with-Stridor-1--Acute-Stridor-quizzes Request a Podcast/ ask a question The Child with Stridor 2: Chronic Stridor

References Stridor sound clip: https://en.wikipedia.org/wiki/File:Stridor_NP_OGG_2.ogg Laryngoscopy images: http://www.simplyanesthesia.com/blog/?p=31 and http://www.researchposters.com/Posters/AAOHNSF/AAO2012/SP462.pdf

References Bronchoscopy image: https://wiki.uiowa.edu/download/attachments/39786418/23b.jpg?api=v2 FB CXR: http://lifeinthefastlane.com/lower-airway-foreign-body/ Choking algorithm: https://www.resus.org.uk/resuscitation-guidelines/