Stridor

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Stridor is an emergency condition. It has a characteristic noise in the inspiratory phase of breathing. This occurs when there is an obstruction of the upper airway from the nasopharnyx down to the trachea and main bronchi. The obstruction is usually in the subglottic area. 

It is commonly a viral illness, and may be preceded usually by the common cold. Measles may also be complicated by Laryngotracheobronchitis (LTB). Two important causes of stridor in children are viral croup (LTB) and acute epiglottitis.

In the management of stridor, steroids are most useful when given within 6 hours of onset of symptoms. Cough syrups containing opiates and atropine are contraindicated.

Stridor in Children

Cause

  • Viral (laryngotracheobronchitis)
  • Bacterial infection 
  • Acute epiglottitis 
  • Inflammatory obstruction 
  • Inhalation of hot fumes e.g. in fire outbreaks
  • Angioneurotic oedema
  • Retropharyngeal abscess
  • Inhalation of a foreign body
  • Congenital malformation of the larynx e.g. laryngomalacia

Symptoms

  • Low grade fever
  • Hoarse voice
  • Barking cough
  • Breathing difficulty
  • Restlessness  

Signs

  • Stridor
  • Low grade fever
  • Restless apprehensive child when obstruction is severe
  • Hoarse voice
  • Barking cough
  • Laboured breathing e.g. suprasternal, supraclavicular, substernal and intercostals retractions 
  • Tachypnoea
  • Cyanosis in severe obstruction 
  • Reddened throat

Investigations

  • Sputum culture
  • Lateral soft tissue X-ray of neck 
  • Chest X-ray

TreatmentTreatment Objectives

  • To avoid aggravation of the obstruction with thick or crusted secretions
  • To ensure early and timely relief of obstruction

Non-pharmacological treatment

  • Ensuring good hydration including liberal oral fluids 
  • Ensure maximum rest for the child
  • Establish the airway by intubation or tracheostomy in severe obstruction 

Pharmacological treatment 

For hydration of very sick patients who cannot drink

1st Line Treatment

Evidence Rating: [C]

  • Dextrose saline, IV, 5%

For restless and distressed children who require oxygen

  • Oxygen, 1-6 L as required (based on oxygen saturation level)

For steroid therapy

  • Dexamethasone, oral/IM/IV, 

Children 

0.6 mg/kg stat.

Or

  • Budesonide, nebulised, 

Children 

2 mg stat.

Or

  • Prednisolone, oral, 

Children 

1-2 mg/kg stat.

Or

  • Hydrocortisone, IV, 

Children

4 mg/kg 6 hourly for 2-3 days 

Note: Steroids are most useful when given within 6 hours of onset of symptoms. Antibiotics should be given in suspected secondary bacterial infection. Cough syrups containing opiates and atropine are contraindicated

In superimposed bacterial infection

1st Line Treatment 

Evidence Rating: [C]

  • Cloxacillin, IV, 

Children 

5-12 years; 250 mg 6 hourly for 7 days

1-5 years; 125 mg 6 hourly for 7 days

< 1 year; 62.5 mg 6 hourly for 7 days

And

  • Gentamicin, IV, 

Children 

1-12 years; 2.5 mg/kg 8 hourly for 7 days

< 1 year; 2.5 mg/kg 12 hourly for 7 days

And

  • Metronidazole, IV, 

Children 

7.5 mg/kg 8 hourly for 7 days 

2nd Line Treatment 

Evidence Rating: [C]

  • Cefuroxime, IV,

Children 

20 mg/kg 8 hourly

And

  • Metronidazole, IV, 

Children 

7.5 mg/kg 8 hourly for 7 days

For severe Croup

  • Adrenaline, 1:1000 solution, nebulised, 2 ml stat.

Then

Repeat hourly if effective

Referral Criteria

Refer cases with severe obstruction and complications in children to a Paediatrician or ENT specialist.  Also refer all cases of stridor if there is no expertise to intubate or perform tracheostomy to a specialist.

Stridor in Adults

Cause

  • Inflammatory obstruction 
  • Acute epiglottitis
  • Laryngeal tumour
  • Vocal cord paralysis
  • Retropharyngeal abscess
  • Inhalation of a foreign body

Symptoms

  • Hoarse voice
  • Breathing difficulty
  • Restlessness  

Signs

  • Stridor
  • Laboured breathing
  • Tachypnoea
  • Cyanosis in severe obstruction 

Investigations

  • Lateral soft tissue X ray of neck
  • Chest X-ray 

TreatmentTreatment Objectives

  • To ensure early and timely relief of obstruction

Non-pharmacological treatment

  • Establish the airway by intubation or tracheostomy in severe obstruction 

Pharmacological treatment 

1st Line Treatment

Evidence Rating: [C]

For oxygen therapy

  • Oxygen, 1-6 L as required (based on oxygen saturation level)

For steroid therapy 

  • Hydrocortisone, IV, 100 mg 6 hourly for 2-3 days 

For superimposed bacterial infection

1st Line Treatment 

Evidence Rating: [C]

  • Amoxicillin + Clavulanic Acid, IV, 

600 mg 8 hourly

Or

1.2 g 12 hourly

And

  • Metronidazole, IV, 

500 mg 8 hourly for 7 days 

2nd Line Treatment 

Evidence Rating: [C]

  • Cefuroxime, IV,

750 mg 8 hourly

And

  • Metronidazole, IV,

500 mg 8 hourly for 7 days

Referral Criteria

Refer all cases of stridor if there is no expertise to intubate or perform tracheostomy to a specialist.