What is the appropriate first‑line management for a pediatric patient with a barky cough, inspiratory stridor that worsens when supine, and intermittent cyanotic spells with shortness of breath?

Management of Severe Laryngomalacia

This pediatric patient with barky cough, inspiratory stridor worsening when supine, and cyanotic spells requires flexible bronchoscopy for definitive diagnosis, followed by supraglottoplasty if severe laryngomalacia is confirmed. 1, 2

Clinical Presentation Analysis

This presentation is not typical croup despite the barky cough, because:

• Croup presents acutely with sudden onset over hours to days, not as a chronic/recurrent condition 1, 3
• Croup does not characteristically worsen when supine – this positional worsening is pathognomonic for laryngomalacia 2, 4
• Cyanotic spells with shortness of breath indicate severe airway obstruction requiring urgent evaluation beyond simple croup management 1, 2

The key distinguishing features pointing to laryngomalacia include:

• Inspiratory stridor (laryngomalacia causes inspiratory symptoms from supraglottic collapse) 5, 2
• Positional worsening when supine (gravity causes further collapse of floppy laryngeal structures) 2, 4
• Cyanotic episodes (indicating severe obstruction with oxygen desaturation) 1, 2
• Laryngomalacia is the most common cause of chronic stridor in infants, accounting for the overwhelming majority of cases 2, 4

Diagnostic Algorithm

Flexible bronchoscopy is indicated immediately for this patient because:

• Severe symptoms with oxygen desaturation/cyanosis mandate complete airway evaluation 1, 2
• Up to 68% of infants with stridor have concomitant lower airway abnormalities requiring full assessment 1, 5
• Flexible bronchoscopy is superior to rigid bronchoscopy for assessing airway dynamics with less positive pressure 5

Treatment Decision

When Supraglottoplasty is Indicated:

Supraglottoplasty is the definitive treatment when laryngomalacia causes:

• Cyanosis or oxygen desaturation 1, 4
• Worsening stridor after feeding 4
• Inadequate weight gain or failure to thrive 4
• Severe symptoms interfering with growth and development 4

When Reassurance is Appropriate:

Reassurance alone is only appropriate for mild laryngomalacia where:

• Symptoms do not interfere with growth and development 4
• No cyanosis or oxygen desaturation occurs 4
• Feeding is not compromised 4

This patient has cyanotic spells, making reassurance inadequate. 1, 4

When Tracheostomy is Indicated:

Tracheostomy is reserved for:

• Failed supraglottoplasty with persistent severe obstruction 4
• Multiple concomitant airway abnormalities requiring prolonged airway support 1
• This is not first-line management 4

Critical Pitfalls to Avoid

• Do not assume this is simple croup based solely on barky cough – the positional worsening and cyanosis indicate structural airway pathology 1, 2
• Do not discharge without bronchoscopy when severe symptoms (cyanosis, oxygen desaturation) are present 1, 2
• Do not delay subspecialty consultation when diagnosis is in doubt or symptoms are severe 4
• Do not miss concomitant abnormalities – complete airway evaluation is essential as 68% have additional pathology 1, 5

Interim Management While Arranging Bronchoscopy

• Maintain oxygen saturation ≥94% with supplemental oxygen 1
• Position patient upright or prone (avoid supine positioning that worsens obstruction) 2, 4
• Consider treatment for gastroesophageal reflux disease as adjunctive therapy until definitive management 4
• Ensure careful feeding techniques to prevent aspiration 4