What is the best course of action for a child with stridor at rest?

Management of Stridor at Rest in Children

A child with stridor at rest requires immediate assessment for severe airway obstruction and urgent intervention, as this represents a potentially life-threatening emergency requiring high-flow oxygen, immediate expert help, and preparation for advanced airway management.

Immediate Assessment and Stabilization

Critical Initial Actions

• Administer high-flow oxygen immediately to both the face and tracheostomy (if present), using two separate oxygen sources if available 1
• Call for help immediately - activate hospital resuscitation team (2222) or emergency services (999) if outside hospital 1
• Assess airway patency using the "look, listen, and feel" approach at both the mouth/nose and any tracheostomy site 1
• Position the child appropriately: chin lift ("sniffing the morning air") with or without jaw thrust; children under 2 years may benefit from a more neutral position with a rolled towel under the shoulders 1

Recognition of Severity

Stridor at rest is a critical sign indicating significant airway obstruction 1. Additional signs of severe respiratory distress include:

• Accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 1
• Agitation, restlessness, or obvious distress 1
• Cyanosis, silent chest, poor respiratory effort, fatigue, or reduced consciousness 1
• Note: Signs may become absent as obstruction worsens, indicating impending respiratory failure 1

Diagnostic Approach

Immediate Considerations

Stridor at rest mandates urgent evaluation - while not every infant with mild stridor requires endoscopy, any child with severe or persistent symptoms, associated hoarseness, oxygen desaturation, or apnea requires immediate airway assessment 1

Key Diagnostic Tool

• Flexible bronchoscopy is the diagnostic procedure of choice for evaluating stridor, allowing examination of laryngeal structure and function during inspiration and expiration in physiological conditions 1, 2
• Waveform capnography should be immediately available and used to monitor ventilation 1
• Important: Up to 68% of children with upper airway abnormalities have concomitant abnormalities below the epiglottis, so both upper and lower airways should be inspected 1, 2

Differential Diagnosis by Age and Acuity

Acute Causes (Requiring Immediate Intervention)

• Croup (viral infection): most common cause of acute stridor, typically with barking cough and hoarse voice 3
• Epiglottitis: presents with drooling, anxiety, and appears toxic; contraindication for flexible bronchoscopy 1
• Foreign body aspiration: consider in any acute presentation 1
• Bacterial tracheitis: severe presentation requiring urgent management 3
• Anaphylaxis: rapid onset with associated symptoms 1

Chronic Causes

• Laryngomalacia: most common congenital laryngeal anomaly and most frequent cause of persistent stridor in children 1, 2, 4
• Vocal cord paralysis: third most common congenital laryngeal anomaly 1, 2
• Laryngoceles, saccular cysts, laryngeal webs, laryngotracheal stenosis, laryngeal/tracheal clefts, hemangiomas 1, 2

Management Algorithm

If Child is Breathing Spontaneously with Stridor at Rest

1. Maintain oxygen delivery to face and any tracheostomy 1
2. Summon advanced airway expertise (anesthesiologists and ENT surgeons) 1
3. Prepare for rescue interventions including:
   • Emergency tracheostomy equipment 1
   • Rigid bronchoscopy with jet ventilation capability 1
   • Surgical cricothyrotomy (though carries major risk of failure in children <8 years) 1

If Respiratory Distress Worsens (SpO₂ <80% or Decreasing Heart Rate)

1. Continue oxygenation attempts with FiO₂ 100%, optimize head position, jaw thrust 1
2. Insert oral or nasopharyngeal airway or supraglottic airway device 1
3. Decompress stomach with nasogastric tube 1
4. Consider waking the child if SpO₂ >80% and sedation/anesthesia is contributing 1
5. Proceed to rescue techniques if SpO₂ <80%: emergency tracheostomy, rigid bronchoscopy with jet ventilation 1

Critical Pitfalls to Avoid

• Do not attempt flexible bronchoscopy in suspected acute epiglottitis - this is a contraindication 1
• Do not use nebulized adrenaline for croup in children about to be discharged - effects are short-lived (1-2 hours) and should only be used to stabilize prior to transfer or avoid intubation 1
• Avoid cricothyroid approaches in children <8 years - these carry major risk of failure and complications 1
• Do not assume single-level obstruction - inspect both upper and lower airways as multiple abnormalities are common 1, 2
• Recognize that an obstacle producing stridor in the upper airway is a contraindication to videolaryngoscopy 1

Monitoring Requirements

• Continuous pulse oximetry throughout assessment and treatment 1
• Waveform capnography when available - consistently identified as key intervention to improve airway safety 1
• Continuous observation by trained staff capable of recognizing deterioration 1
• Two oxygen pipeline sources ideally available at bedside for tracheostomy patients 1

Disposition

Any child with stridor at rest requires urgent specialist evaluation and should not be managed in primary care settings without immediate access to advanced airway expertise and equipment 1. Transfer to a facility with pediatric critical care, anesthesia, and ENT capabilities should be arranged immediately if not already present 1.