Stridor

• Stridor


  A high-pitched, noisy breathing sound caused by partial upper airway obstruction
• Settings where this guideline applies


  • Children's Assessment Unit (CAU)
  • Children's Wards
  • Accident & Emergency (A&E)
  • Children's Emergency Department (CHED)
• Staff this guideline is for


  • Medical staff
  • Nursing staff
• Acute stridor


  Sudden onset noisy breathing caused by partial upper airway obstruction
• Inhaled foreign body


  An object that has been breathed into the airway
• This guideline is for children over a month of age with acute stridor or suspected inhaled foreign body
• The document was created by Dr K. Grace Kuruvilla and Dr Anjay Pillai
• Dr K. Grace Kuruvilla


  Specialist Paediatric Registrar ST5
• Dr Anjay Pillai


  Consultant in Paediatric Respiratory Medicine
• Dr Priya Muthukumar


  Chief of Paediatric Services
• The document was supported by Dr James Gaynor (Consultant Paediatric anaesthetist), Dr Edward Snelson (Consultant in acute and emergency paediatric medicine), and Mr Andy Bath (Consultant in ENT)
• The document was assessed and approved by the Department Governance Meeting and the Clinical Guidelines Assessment Panel (CGAP)
• Date of approval


  23/02/2022
• The document will be reviewed before 23/02/2025
• The document will be reviewed by Dr Anjay Pillai
• The document has the reference number 1162 and is version 8
• This guideline does not deviate from any NICE recommendations as there are no relevant NICE guidelines
• Differential diagnosis of Acute Upper Airway Obstruction in Children


  • Viral laryngotracheobronchitis (Croup)
  • Bacterial tracheitis
  • Epiglottitis
  • Foreign body aspiration
  • Anaphylaxis
  • Inhalation injury and burns
  • Hereditary angioedema
  • Retropharyngeal abscess
  • Diphtheria
  • Congenital or acquired tracheal or laryngeal abnormalities
• Viral laryngotracheobronchitis (Croup)


  • Typically affects 6 months -3 years, peak incidence at 2 years and in late autumn, boys more affected than girls, sudden-onset seal-like barky cough, hoarse voice, low grade fever, with or without stridor, symptoms worse at night and with agitation
• Glucocorticosteroids


  Mainstay of treatment for croup, with or without nebulised adrenaline
• Bacterial tracheitis


  • Average age 4-6 years, preceding URTI, sick/septic looking child with respiratory distress, stridor, hoarse voice, high fever >38.5, productive cough and copious secretions, coexistent pneumonia, pus in trachea at intubation, caused by Staph aureus commonly, Haemophilus, Moraxella, Streptococcus and anaerobic organisms
• Intubation


  Up to 80% of bacterial tracheitis cases require intubation
• Management of bacterial tracheitis

  1. Assemble experienced team early

  2. Little or no response to nebulized adrenaline

  3. Put local anaesthetic cream early

  4. Management of septic child, IV cultures and antibiotics - Ceftriaxone 80mg/kg/day initially pending cultures
• Epiglottitis


  • Peak incidence 1-3 years, acute severe airway obstruction by H influenzae B, uncommon currently due to vaccination, sick/septic looking child, soft inspiratory stridor, high fever >38.5, rapidly increasing respiratory distress, child sits immobile with mouth open, does not wish to lie flat, drooling, unable to swallow
• Management of epiglottitis


  1. Assemble experienced senior multidisciplinary team early- intubation will be usually required and may be difficult

  2. Put local anaesthetic cream early

  3. IV cultures and antibiotics Ceftriaxone 80mg/kg/day
• Foreign body aspiration


  • Peak incidence age <3 years, more common in boys, sudden onset choking with coughing, stridor or wheeze, respiratory distress without preceding fever or illness
• Management of foreign body aspiration

  1. Cough should be encouraged

  2. Direct visualisation and removal of foreign body by rigid bronchoscopy under GA may be required
• Anaphylaxis


  • Acute onset exposure to triggers, itching, urticaria, facial swelling, respiratory and/ or cardiovascular compromise
• Management of anaphylaxis


  ABCDE management, IM adrenaline
• Inhalation injury and burns


  • History of exposure to smoke, carbonaceous deposits around mouth, sputum, singed nasal hair, facial burns, progressive airway compromise or oedema
• Management of inhalation injury and burns


  1. Early intubation by an experienced team

  2. Fluid replacement as per burns guidance
• Hereditary angioedema


  • Acute onset, localised non-pitting, non-pruritic, non-erythematous angioedema commonly affecting, eyelids, lips and tongue, airway oedema at the level of larynx causes stridor, dysphagia, voice changes
• Management of hereditary angioedema


  1. Steps to secure the airway as necessary

  2. Agents to treat allergic angioedema such as adrenaline, antihistamines and steroids will not be effective

  3. Treatment requires infusion of C1 esterase inhibitor
• Retropharyngeal abscess


  • Neck pain and swelling, may cause dysphagia, trismus, inspiratory stridor, fever and signs of systemic sepsis
• Management of retropharyngeal abscess


  1. Cultures and IV antibiotics

  2. May require surgical drainage
• Diphtheria


  • Extremely rare, may present at any age, history of inadequate immunisation, recent travel, low grade fever, dysphagia, inspiratory stridor, neck pain and swelling, voice hoarseness, greyish adherent membranous pharyngitis
• Management of diphtheria


  1. Nasal and pharyngeal swab cultures

  2. IV cultures and antibiotics- Ceftriaxone

  3. Administer diphtheria anti-toxin

  4. Treat contacts with erythromycin +/- immunisation
• Congenital or acquired tracheal or laryngeal abnormalities


  Upper airway endoscopy or bronchoscopy allows direct visualization of underlying abnormality
• Clinical algorithm for the Management of presumed viral croup


  1. Consider the differential diagnosis during the physical examination

  2. Treatment decision is based on the history and clinical severity of airway obstruction
• Westley score


  Used to aid assessment of croup severity