Assessment and Management of Severe Stridor During Sleep in Children
A child with severe stridor during sleep requires immediate assessment for signs of critical airway obstruction (SpO2 < 90%, bradycardia, inability to speak/drink, accessory muscle use, retractions), and if present, emergency airway management should be initiated while calling for help and ENT consultation. 1
Immediate Severity Assessment
When evaluating a child with stridor during sleep, assess for these specific signs of severe respiratory distress: 1
- Oxygen saturation < 90% 1
- Bradycardia or heart rate changes 1
- Inability to speak or drink 1
- Accessory muscle use 1
- Tracheal tug 1
- Sternal, subcostal, or intercostal retractions 1
- Agitation or restlessness 1
- Cyanosis 2
Initial Management Based on Severity
For Severe Obstruction (SpO2 < 90% or bradycardia present):
Position the child upright and apply high-flow humidified oxygen immediately. 1, 3
Call for help immediately, including experienced ENT surgeon availability. 1
Optimize airway positioning with chin lift and jaw thrust. 1
Consider nebulized epinephrine for rapid (though transient) relief of laryngeal edema. 1, 3
Administer intravenous dexamethasone (0.15-1.0 mg/kg, maximum 8-25 mg) for anti-inflammatory effect. 3
Critical Pitfall to Avoid:
Do NOT sedate a child with moderate-to-severe respiratory distress without airway expertise present, as sedation can worsen obstruction. 1
Diagnostic Considerations Based on Stridor Characteristics
The phase of stridor provides critical diagnostic information: 4
- Inspiratory stridor suggests obstruction above the glottis (laryngomalacia, supraglottic lesions) 4
- Expiratory stridor indicates lower tracheal obstruction 4
- Biphasic stridor suggests glottic or subglottic lesion (subglottic stenosis, fixed airway lesions) 2, 4
Fixed lesions of the glottis or subglottis often produce biphasic stridor, whereas dynamic lesions usually cause only inspiratory stridor. 2
When Endoscopy is Mandatory
Flexible endoscopy of the airways is the diagnostic procedure of choice and must be performed in: 1
- Any child with severe or persistent symptoms 1
- Stridor associated with hoarseness 1
- Stridor leading to oxygen desaturation or apnea 1
- Older children with stridor (rare and always concerning unless recent intubation) 1
Important: Inspect both upper AND lower airways, as anomalies below the epiglotis are found in up to 68% of cases. 1
Common Etiologies in Sleep-Related Stridor
Laryngomalacia is the most common cause of chronic stridor in infants, typically presenting in the first 1-2 months of life with positional symptoms that worsen during sleep. 5, 6, 7
Subglottic stenosis should be suspected in children with history of prolonged intubation (≥7 days), three or more intubations, or inappropriately large endotracheal tubes. 2
Postextubation stridor is a significant marker for moderate to severe subglottic stenosis or laryngeal injury. 2
Vocal cord paralysis is the third most common congenital laryngeal anomaly causing stridor and may not cause symptoms until ventilatory requirements reach a critical point (such as during sleep). 1
Risk Stratification for Post-Intubation Laryngeal Edema
If the child has a history of intubation, assess these specific risk factors: 3
- Traumatic intubation 3
- Prolonged intubation (≥7 days) 2
- Repeated intubations (≥3 attempts) 2
- Tube size-to-gestational age ratio > 0.1 2
- Direct laryngeal trauma 3
For high-risk patients, begin dexamethasone therapy at least 12-24 hours before planned extubation if applicable. 3
Management Algorithm for Severe Stridor During Sleep
- Assess severity immediately using the criteria above 1
- If severe (SpO2 < 90%, bradycardia, severe retractions): 1
- If moderate distress but stable: 1
- Monitor continuously with pulse oximetry 1
Have equipment for emergency intubation or tracheostomy readily available, as deterioration can be rapid. 1