1. Morning Report
08/21/2009
Ali F. Ahrabi, MD

2. Stridor
Harsh, high-pitched, musical sound produced by turbulent airflow through a partially obstructed airway
May be inspiratory, expiratory, or biphasic depending on its timing in the respiratory cycle
Inspiratory stridor suggests an extrathoracic lesion (eg, laryngeal, nasal, pharyngeal)
Expiratory stridor implies an intrathoracic lesion (eg, tracheal, bronchial)

3. History

4. History
Age of onset, duration, severity, and progression; precipitating events (eg, crying, feeding); positioning (eg, prone, supine, sitting); quality and nature of crying; presence of aphonia; and other associated symptoms (eg, paroxysms of cough, aspiration, difficulty feeding, drooling, sleep disordered breathing).
Perinatal history is especially important and should include direct questioning regarding maternal condylomata, endotracheal intubation use and duration, and presence of congenital anomalies
Feeding and growth history, developmental history

5. Physical Exam

6. PE
Heart and respiratory rates, cyanosis, use of accessory muscles of respiration, nasal flaring, level of consciousness, and responsiveness
Physical examination of a patient with suspected acute epiglottitis is contraindicated
Note the presence of infection in the oral cavity; crepitations or masses in the soft tissues of the face, neck, or chest; and deviation of the trachea
Use care when examining (especially palpating) the oral cavity or pharynx because sudden dislodgement of a foreign body or rupture of an abscess can cause further airway compromise

7. PE
Drooling from the mouth suggests poor handling of secretions, Dysphagia
Observe the character of the cough, cry, and voice
The presence of fever and toxicity generally implies serious bacterial infections
Careful auscultation of the nose, oropharynx, neck, and chest helps to discern the location of the stridor
special attention to craniofacial morphology, patency of the nares, and cutaneous hemangiomas

8. Differential Diagnosis

9. Differential – Acute onset
Laryngotracheobronchitis (croup)
the most common cause of acute stridor in children
6 months to 2 years
barking cough that is worst at night
low-grade fever
Aspiration of foreign body
1-2 years
food such as nuts, hot dogs, popcorn, and hard candy
history of coughing and choking that precedes development of respiratory symptoms
Bacterial tracheitis
uncommon
younger than 3 years
secondary infection (most commonly due to Staphylococcus aureus) following a viral process (commonly croup or influenza)

10. Differential – Acute onset
Retropharyngeal abscess
complication of bacterial pharyngitis
younger than 6 years
abrupt onset of high fevers, difficulty swallowing, refusal to feed, sore throat, hyperextension of the neck, and respiratory distress
Peritonsillar abscess
infection in the potential space between the superior constrictor muscles and the tonsil
common in adolescents and preadolescents.
patient develops severe throat pain and trouble swallowing or speaking

11. Differential – Acute onset
Spasmodic croup (acute spasmodic laryngitis)
most commonly in children aged 1-3 years
presentation may be identical to croup
Allergic reaction (ie, anaphylaxis)
hoarseness and inspiratory stridor may be accompanied by symptoms (eg, dysphagia, nasal congestion, itching eyes, sneezing, wheezing) that indicate the involvement of other organs
Epiglottitis
medical emergency
most commonly in children aged 2-7 years
Clinically, the patient experiences an abrupt onset of high-grade fever, sore throat, dysphagia, and drooling

12. Differential - Chronic
Laryngomalacia
the most common cause of inspiratory stridor in the neonatal period and early infancy
accounts for up to 75% of all cases of stridor
Stridor may be exacerbated by crying or feeding
Placing the patient in a prone position with the head up improves the stridor
supine position worsens the stridor
usually benign and self-limiting and improves as the child reaches age 1 year

13. Differential - Chronic
Subglottic stenosis
inspiratory or biphasic stridor
congenital subglottic stenosis occurs when an incomplete canalization of the subglottis and cricoid rings causes a narrowing of the subglottic lumen.
acquired stenosis is most commonly caused by prolonged intubation
Vocal cord dysfunction
second most common cause of stridor in infants
unilateral vocal cord paralysis can be congenital or secondary to trauma at birth or time of cardiac or intrathoracic surgery
bilateral vocal cord paralysis
Pt present with aphonia and a high-pitched stridor that may progress to severe respiratory distress.
It is usually associated with CNS abnormalities, such as Arnold-Chiari malformation or increased intracranial pressure

14. Differential - Chronic
Laryngeal dyskinesia, exercise-induced laryngomalacia, and paradoxical vocal fold motion are other neuromuscular disorders
Laryngeal webs are caused by an incomplete recanalization of the laryngeal lumen during embryogenesis
Laryngeal cysts
Laryngeal hemangiomas (glottic or subglottic)
half of them are accompanied by cutaneous hemangiomas in the head and neck
Patients usually present with inspiratory or biphasic stridor that may worsen as the hemangioma enlarges
usually regress by age months

15. Differential - Chronic
Laryngeal papillomas
secondary to vertical transmission of the human papilloma virus in maternal condylomata or infected vaginal cells to the pharynx or larynx of the infant during the birth
Tracheomalacia
most common cause of expiratory stridor
Tracheal stenosis secondary to extrinsic compression

16. Lab ABG to evaluate oxygenation
Other labs as dictated by the clinical situation
Generally, no investigations are required for mild stridor

17. Imaging
Anteroposterior (AP) and lateral radiographs of the neck and chest
Barium esophagram may be performed if vascular compression, tracheoesophageal fistula, GER, or neurological dysfunction is suspected
Contrast-enhanced CT scanning can demonstrate mediastinal masses or aberrant vessels
An MRI may be helpful in delineating lesions of the upper airway and vascular anomalies
Direct laryngoscopy and bronchoscopy is the criterion standard for making a diagnosis in infants and children with stridor

18. Treatment As per severity of the presentation and underlying diagnosis
Ensure airway is adequate
O2 as required
Comfortable positioning
If airway compromised or child in severe distress or hypoxia: Anesthesia/ENT and intensive care

19. Treatment
Croup (infectious or spasmodic)

20. Croup Severity Inspiratory stridor None - 0 points
Upon agitation - 1 point
At rest - 2 points
Retractions
Mild - 1 point
Moderate - 2 points
Severe - 3 points
Air entry
Normal - 0 points
Mild decrease - 1 point
Marked decrease - 2 points
Cyanosis
None - 0 points
Upon agitation - 4 points
At rest - 5 points
Level of consciousness
Depressed - 5 points

21. Croup Treatment
The first rule of management is to keep the child as comfortable as possible
monitoring of the heart rate, respiratory rate, respiratory mechanics, and pulse oxymetry
Cool mist 
Randomized studies of children with moderate-to-severe croup revealed no difference in outcome between those who received cool mist and those who did not
The use of hot steam should be avoided because scalding has been reported
Mist tents can disperse fungus and molds if not properly cleaned and separates the child from the parent

22. Croup Treatment
Corticosteroids (decrease hospitalization rates by 86%)
single dose of dexamethasone has been shown to be effective in reducing the overall severity of croup if administered within the first 4-24 hours after onset of illness
The long half-life of dexamethasone (54 h) 
Dexamethasone (0.15 mg/kg) is as effective as 0.3 mg/kg or 0.6 mg/kg in relieving symptoms of mild-to-moderate croup
same efficacy if administered intravenously, intramuscularly, or orally.
A single oral dose of prednisolone (2 mg/kg) resulted in more return visits than a single oral dose of dexamethasone (0.6 mg/kg)
Inhaled budesonide has also proven to be effective but is more expensive

23. Croup Treatment Nebulized racemic epinephrine
is typically reserved for patients in moderate-to-severe distress
works by adrenergic stimulation
constriction of the precapillary arterioles, thereby decreasing capillary hydrostatic pressure fluid resorption from the interstitium and improvement in the laryngeal mucosal edema
beta-2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation
Can cause rebound effect
A child who is symptomatic enough to receive epinephrine may be discharged after at least 3 hours of observation

24. Croup Treatment Heliox
is a metabolically inert, nontoxic gas that is combined with oxygen. 
It has low viscosity and low specific gravity, which allows for greater laminar airflow through the respiratory tract
Helium decreases the force necessary to move the gas through the airways and decreases the mechanical work of respiratory muscles, which is clinically seen as less respiratory distress 
It has been shown to improve symptoms in very severe croup that failed to improve with racemic epinephrine