Management of stridor

2. HISTORY TAKING
 STRIDOR - Physical sign (NOT a disease)
 TO DETERMINE CAUSE OF STRIDOR
1) TIME OF ONSET CONGENITAL
ACQUIRED
2) MODE OF ONSET SUDDEN – Foreign body ,Oedema
GRADUAL/PROGRESSIVE-
Laryngomalacia ,Subglottic Haemangioma
3) DURATION SHORT- Foreign Body ,Oedema,Infection
LONG -Laryngomalacia,Laryngeal Stenosis,Subglottic
Haemangioma,Anomalies of tongue/Jaw

3. 4) RELATION TO FEEDING-Aspiration in Laryngeal Paralysis,
Oesophageal Atresia, Laryngeal Cleft
5) CYANOTIC SPELLS – Need for airway maintenance
6) ASPIRATION / INGESTION OF FOREIGN BODY
7) LARYNGEAL TRAUMA- Blunt injury to Larynx--Intubation,
Endoscopy

4. PHYSICAL EXAMINATION
 STRIDOR -Always associated with Respiratory Distress
 RECESSION in Suprasternal notch , Sternum , Intercostal
spaces , Epigastrium may be seen during inspiration
 SITE OF OBSTRUCTION found based on Inspiratory /
Expiratory/ Biphasic stridor
 ASSOCIATED CHARACTERISTICS CAUSE
(a) Snoring / Snorting sound Nasal/Nasopharyngeal
(b) Gurgling sound and muffled voice Pharyngeal
(c) Hoarse cry or voice Laryngeal at vocal cord
( Cry is normal in Laryngomalacia and Subglottic stenosis)
(d) Expiratory wheeze Bronchial obstruction

5.  INFECTIVE CONDITION - Associated fever
Example- Acute laryngitis, Epiglottitis, Laryngo- tracheo-bronchitis
Diphtheria
 PRONE POSITION- Stridor of Laryngomalacia, Micrognathia,
Macroglossia and Innominate artery compression disappears when
lying on prone position
 AUSCULTATION – With Stethoscope /Unaided over nose ,open
mouth or chest – Localizes the site of origin of Stridor
 LOCAL PATHOLOGY – Examination of nose,mouth ,jaw,larynx ,
larynx,pharynx to exclude local pathology

8. FLEXIBLE FIBREOPTIC
LARYNGOSCOPY
Done under topical anaesthesia as outdoor procedure-- Allows
examination of nose, nasopharynx and larynx
Helps in the diagnosis of-
 Laryngomalacia
 Vocal cord paralysis
 Laryngeal cysts
 Congenital anomalies of larynx e.g. Laryngeal web or clefts
ADULTS Indirect laryngoscopy
INFANTS/CHILDREN Flexible fibreoptic laryngoscopy

9. INVESTIGATIONS
 TESTS required depend on HISTORY and CLINICAL EXAMINATION
1) SOFT TISSUE RADIOGRAPH OF NECK (LATERAL and PA VIEW)
Example -Radiograph of the neck - Typical Subglottic narrowing, or Steeple
sign of Croup on PA view

10. 2) XRAY CHEST OR FLUOROSCOPY
Detects Radiolucent Foreign Bodies
3) OESOPHAGOGRAM with contrast
For Tracheobronchial fistula or aberrant vessels or Oesophageal atresia
4) CT SCAN with contrast
For Mediastinal mass and Congenital vascular anomalies compressing the
trachea or bronchi
Example-
Anomalous innominate artery
Double aortic arch
Anomalous left pulmonary artery
5) ANGIOGRAPHY- For vascular anomalies

11. DIRECT LARYNGOSCOPY
Microlaryngoscopy and bronchoscopy under general anaesthesia
• Done in operation theatre with full preparation for resuscitative measures to
deal with respiratory distress
• Patient monitored for oxygen saturation, pulse, blood pressure and
electrocardiography
• Services of an expert anaesthetist are essential
• Anaesthesia is induced with insufflation and i.v. route established

12. • Patient kept on spontaneous respiration.
• After quick and short direct laryngoscopy, bronchoscope is inserted to examine
the air passage from the subglottis to bronchi for any obstruction
• Secretions collected for culture and sensitivity, crusts and foreign body if any
removed.
• After bronchoscopy, child is intubated and examination of larynx or
oesophagus done.

13. LARYNGOSCOPY IN EPIGLOTTITIS

14. TREATMENT OF STRIDOR
Once the diagnosis has been made, treatment
of exact cause can be planned.

15. MANAGEMENT OF CROUP-
 Racemic epinephrine :
0.05 ml/kg/dose ( with a maximum of 0.5ml) .Given via
nebulisation over 15 minutes.
 L- epinephrine
0.5ml/kg/dose ( max. of 5 ml) .Given via nebulisation over
15 minutes.
 Dexamethasone
0.6 mg/kg IV, IM as single dose
• Nebulized Budesonide has proved as effective as adrenaline
nebulizer
• Antibiotics are not indicated unless there is Bacterial
superinfection

16. MANAGEMENT OF EPIGLOTTITIS
• Once the diagnosis of epiglottitis is suspected, urgent
hospitalization is required (ICU or OT or Anaesthetic room with
resuscitation facilities)
• Intubate child under general anaesthesia
• Urgent tracheostomy (very rare) if intubation impossible
• Culture for blood, and epiglottic surface should be collected(Only
after airway is secured).

17.  Start patient on antibiotics immediately (e.g. Cefotaxime,
ceftriaxone, or meropenem) for at least 10 days as most
patients have concomitant bacteremia.
• Tracheal tube removed usually within 24 hours (Depending on
patient’s progress)
• Most children recover fully within 2-3 days

18. MANAGEMENT OF LARYNGOMALACIA
 EXPECTANT OBSERVATION- As most symptoms resolve
spontaneously as the child and airway grows
 SURGICAL INTERVENTION – Endoscopic
Supraglottoplasty for patients with severe obstruction
(Especially when there are other life-threatening events
associated together.e.g. cor pulmonale, cyanosis, failure to
thrive).

19. MANAGEMENT OF FOREIGN BODY
ASPIRATION
Most cases of inhalation events not witnessed, hence diagnosis
depends on high index of suspicion
• Immediately do a lateral neck X-ray, AP-Chest X-ray(but hard
to detect at times)
• Prompt endoscopic removal of foreign object with rigid
instruments Treatment of choice