CHILD WITH CONDITIONS PRESENTING WITH STRIDOR

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Stridor is a harsh noise during inspiration, which is due to narrowing of the air passages in the oropharynx, sub-glottis or trachea.

Causes

The major causes of severe stridor are:

  • Viral croup (commonly caused by measles or other viruses)
  • Foreign body inhalation
  • Retropharyngeal abscess
  • Diphtheria and trauma to the larynx
  • It may also occur in early infancy due to congenital abnormalities

Differential diagnosis

Diagnosis

Signs and symptoms

Viral croup

-        Barking cough

-        Respiratory distress

-        Hoarse voice

-        If due to measles, signs of measles

Retropharyngeal abscess

-        Soft tissue swelling in back of the throat

-        Difficulty in swallowing

-        Fever

Foreign body

-        Sudden history of choking

-        Respiratory distress

Diphtheria

-        Bull neck appearance due to enlarged cervical nodes and oedema

-        Red throat

-        Grey pharyngeal membrane

-        Blood-stained nasal discharge

-        No evidence of DPT vaccination

Epiglottitis

-        Soft stridor

-        ‘Septic’ child

-        Little or no cough

-        Drooling of saliva

-        Inability to drink

Congenital anomaly

-        Stridor present since birth

Anaphylaxis

-        History of allergen exposure

-        Wheeze

-        Shock

-         Urticaria and oedema of lips and face

Burns

-        Swollen lips

-        Smoke inhalation

Treatment

A child with severe croup should be admitted to the hospital

Steroid treatment

Dexamethasone oral

One dose of 0.6mg/kg

 

Adrenaline (nebulized)

2ml of 1:1000 solution given every hour with careful monitoring

Note: While this treatment can lead to improvement within 30 minutes in some children, it is often temporary and may last only about 2 hours.

Antibiotics are ineffective and should not be given

Monitor child closely and if a child with severe croup is deteriorating, refer for intubation and/or tracheostomy.

 

Diphtheria

Diphtheria antitoxin IM or IV

Give 40,000 immediately after initial intradermal test to detect hypersensitivity.

Note - Delay in giving antitoxin can increase the risk of mortality.

PLUS

Ampicillin 50mg/Kg (in cases of Co-infection)

Caution

Avoid using oxygen unless there is incipient airway obstruction

Supportive care

  • If the child has fever (≥ 39 °C) that appears to be causing distress, give paracetamol.
  • Encourage the child to eat and drink. If the child has difficulty in swallowing, nasogastric feeding is required
  • Avoid frequent examinations and invasive procedures when possible or disturbing the child unnecessarily

Complications

  • Myocarditis and paralysis may occur 2-7 weeks after the onset of illness
  • Signs of myocarditis include:
  • Weak and irregular pulse
  • Evidence of heart failure

Public health measures

  • Nurse the child by staff who have been fully vaccinated against diphtheria in a separate room
  • Give all vaccinated household contacts a diphtheria toxoid booster
  • Give all unvaccinated household contacts:
    • One dose of benzyl penicillin (600,000 U for those aged < 5years, 1,200.000 U for those > 5 years)
    • Give diphtheria toxoid, and check daily for 5 days for any signs of diphtheria