Management of a Child with Stridor During Sleep
The immediate priority is to assess the severity of respiratory distress and determine whether this represents acute or chronic stridor, as this fundamentally changes management—acute stridor requires urgent intervention while chronic stridor typically needs diagnostic evaluation. 1
Initial Assessment and Severity Determination
Assess for signs of severe respiratory distress immediately:
- Look for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, agitation, or restlessness 1
- Apply high-flow oxygen to the face if available 1
- Position the child appropriately with chin lift and jaw thrust to help alleviate obstruction 1
- Monitor with pulse oximetry and waveform capnography if available 1
- Call for help immediately if SpO2 < 90%, bradycardia is present, or the child cannot speak/drink 1
Critical pitfall: Do not sedate a child with moderate-to-severe respiratory distress without airway expertise present, as sedation can worsen obstruction 1
Acute vs. Chronic Stridor Differentiation
If Acute Stridor (sudden onset):
The most common cause is croup, presenting with inspiratory or biphasic stridor, barking cough, and hoarse voice 2
Treatment for acute stridor:
- Corticosteroids (such as dexamethasone) are indicated 1
- Nebulized epinephrine provides rapid but transient relief for laryngeal edema 1
- Consider other acute causes if atypical: foreign body aspiration, bacterial tracheitis, or epiglottitis 2
If Chronic Stridor (persistent, present during sleep):
Laryngomalacia is the most common cause—the most frequent congenital laryngeal anomaly causing persistent stridor in children 3, 1, 4
Other chronic causes to consider:
- Vocal cord paralysis (third most common congenital laryngeal anomaly) 3, 1
- Subglottic hemangiomas 2
- Laryngeal webs, stenosis, or clefts 3, 1
- Tracheomalacia or bronchomalacia 3
Diagnostic Evaluation
Flexible bronchoscopy is the diagnostic procedure of choice for evaluating stridor, as it allows examination of laryngeal structure and function during inspiration and expiration in the most physiological conditions 3, 1
Indications for endoscopy:
- Any child with severe or persistent symptoms 3, 1
- Stridor associated with hoarseness 3, 1
- Stridor leading to oxygen desaturation or apnea 3, 1
- Stridor in older children (always an indication unless due to recent intubation) 3, 1
Important consideration: Up to 68% of children with upper airway abnormalities have concomitant abnormalities below the epiglottis, so inspect both upper and lower airways during endoscopy 3, 1
Clinical Clues from Stridor Characteristics
The phase of respiration helps localize the obstruction 5:
- Inspiratory stridor suggests obstruction above the glottis 5
- Expiratory stridor indicates lower tracheal obstruction 5
- Biphasic stridor suggests glottic or subglottic lesion 5
Management Based on Etiology
For laryngomalacia (most common):
- Most patients can be managed conservatively with resolution by 2 years of age 4
- Monitor for severe disease indicators: cyanosis, worsening stridor after feeding, inadequate weight gain 2
- Consider pharmacotherapy for gastroesophageal reflux disease 2
- Supraglottoplasty is the treatment of choice for severe disease or failure to improve 4, 2
For other structural abnormalities:
- Management depends on specific diagnosis and severity 1
- May require surgical intervention depending on the lesion 3