What is the initial approach to managing pediatric stridor?

Initial Approach to Managing Pediatric Stridor

Immediately assess for signs of critical airway obstruction—including oxygen saturation <90%, bradycardia, inability to speak or drink, accessory muscle use, and retractions—and if present, position the child upright, apply high-flow humidified oxygen, call for help including ENT consultation, and prepare for emergency airway management. 1

Immediate Severity Assessment

The first priority is rapid triage based on clinical signs of respiratory distress:

• Look for critical signs: SpO₂ <90%, bradycardia or heart rate changes, inability to speak or drink, accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, agitation, restlessness, or cyanosis 2, 1, 3
• Position the child appropriately: Use chin lift with or without jaw thrust in all ages; consider a neutral position in children under 2 years, potentially with a pillow or rolled towel under the shoulders to optimize airway patency 2
• Apply high-flow humidified oxygen to the face immediately if severe obstruction is present 1, 3
• Call for help immediately if signs of severe obstruction are present, including experienced ENT surgeon availability 1

Initial Airway Assessment and Stabilization

Assess airway patency by looking, listening, and feeling for airflow at the mouth/nose, supplemented by waveform capnography where available. 2

• Use pulse oximetry and waveform capnography for monitoring—these are key interventions to improve airway management safety 2, 3
• Evaluate the phase of stridor: Inspiratory stridor suggests obstruction above the glottis, expiratory stridor indicates lower tracheal obstruction, and biphasic stridor suggests glottic or subglottic lesions 1, 4
• Avoid sedation without airway expertise present if moderate-to-severe respiratory distress exists, as sedation can worsen obstruction 3

Acute Medical Management

For children with significant respiratory distress but not requiring immediate intubation:

• Administer nebulized epinephrine for rapid relief of laryngeal edema, particularly in post-intubation stridor or croup 1, 3
• Give intravenous or oral dexamethasone for anti-inflammatory effect 1, 3
• Maintain the child upright and minimize agitation, as distress can worsen obstruction 1

Common pitfall: Nebulized epinephrine provides only transient relief (typically 2 hours), so continued observation is essential even if initial improvement occurs. 3

Determining Need for Direct Visualization

Airway endoscopy should be performed in any child with severe or persistent stridor, if associated with hoarseness, or if it leads to oxygen desaturation or apnea. 2

Specific indications for flexible bronchoscopy include:

• Severe or persistent symptoms despite initial management 2
• Stridor in older children (rare but always warrants investigation unless clearly due to recent intubation) 2, 3
• History of prolonged intubation, three or more intubations, or inappropriately large endotracheal tubes (raises concern for subglottic stenosis) 1
• Postextubation stridor (significant marker for moderate-to-severe subglottic stenosis or laryngeal injury) 1

Flexible fiberoptic bronchoscopy is superior to rigid bronchoscopy for evaluating dynamic airway events and allows examination of the larynx in physiological conditions when stridor is audible. 2

Common Etiologies by Age and Presentation

Infants with Chronic Stridor

• Laryngomalacia is the most common congenital laryngeal anomaly and most frequent cause of persistent stridor in children 2, 3, 4
• Vocal cord paralysis is the third most common congenital laryngeal anomaly producing stridor, usually resulting from CNS anomalies 2, 3
• Up to 68% of cases have concomitant abnormalities below the epiglottis, so inspect both upper and lower airways 2, 3

Acute Stridor

• Viral croup is the most common cause of acute stridor, particularly in fall and early winter 4
• Life-threatening causes requiring immediate consultant involvement include epiglottitis, foreign body aspiration, bacterial tracheitis, allergic airway edema, and retropharyngeal abscess 5

Equipment Preparation

Have equipment for emergency intubation or tracheostomy readily available, as deterioration can be rapid. 1

• Ensure two oxygen sources are available (wall oxygen and backup supply) for simultaneous delivery to face and tracheostomy if applicable 2
• Keep suction equipment immediately accessible 2
• Maintain waveform capnography at bedside in critical care areas 2