Stridor in Children – Diagnostic Algorithm and Treatment

General and Airway

Empiric treatment of Stridor in Children

  • Racemic Epi
  • Nebulized steroids
  • Steroids IV
  • Emergent intubation?

Types of stridor:

  • Inspiratory → subglottic
  • Expiratory → supraglottic
  • Biphasic → subglottic, glottic
  • Sonorous → nasal

Rule Out Emergent Diagnosis and Causes of Stridor in Children

  1. Epiglottitis
  2. Retropharyngeal Abcsess
  3. Bacterial Tracheitis
  4. Foreign Body Aspiration

1. Epiglottitis

Definition of Epiglottitis

  • Acute inflammation of epiglottis and surrounding structure → serious, life threatening, airway emergency


  • Age: 2-8yo; Season: Winter
  • Viral type prodrome
  • Toxic, irritable, fever
  • Tripod position, hyperextended neck
  • The D’s: Drooling, Dyspnea, Dysphonia, Dysphagia

Diagnosis of Epiglottitis

  • Lateral neck Xray → “thumb print sign”
  • Diagnosis made on visualization of inflamed epiglottis

Treatment of Epiglottitis

  • Avoid agitation of child as this can worsen the airway (no IV, oral examination)
  • If emergent airway needed → use tube size 0.5-1 smaller than age
  • Ideal airway should be obtained in the OR, controlled conditions
  • Antibiotics (3rd gen Cephalosporin)

2. Retropharyngeal Abcsess


  • Clinical Presentation similar to meningitis but usually has normal mental status
  • Pathology: Deep neck space infection (URI vs penetrating trauma to oropharynx), can spread through neck → danger space → cause mediastinitis


  • Torticollis (stiff neck?) (36.5%)
  • ↓ Neck extension (45%), ↓ Neck flexion (12.5%)
  • Dysphagia
  • Trismus, toxic, fever
  • Stridor rare (3%)
  • Age:
    • 50% of cases occur between 6-12mos, 96% occur before 6 years of age (Arch Dis Child 1991;66:1227-30)
    • Lymph nodes of Rouviere that drain the retropharyngeal space atrophy after 6 years
  • Appearance: Child with neck in neutral, difficulty extending neck and uses eyes to look up
  • Often confused with meningitis:
    • ↓ Neck flexion in meningitis vs. ↓neck extension in RPA (Pediatrics 2003;111:1394-8)

Fever, Stiff Neck, Altered Menal Status ?

Consider Retropharyngeal Abcsess along with meningitis!!! (Similar presentations)

Work-up for Retropharyngeal Abcsess

  • Xray, lateral neck
    • Low yield, not widely used
  • CT neck
    • Helps localize where problem is
    • Difficult to differentiate between pus and cellulitis
  • US neck
    • May help distinguish between purulence vs adenitis vs abscess

Treatment of Retropharyngeal Abcsess

  • ENT Consultation
  • Antibiotics (alone treat 37%):
    • Clindamycin
  • OR if not improve

Complications of Retropharyngeal Abcsess

  • Airway compromise
  • Descending necrotizing mediastinitis
    • Spread from Retropharyngeal space → retrovisceral space → pierce alar fascia → Danger space
    • Rare in children
  • Internal jugular vein thrombosis
  • Mycotic aneurysms

3. Bacterial Tracheitis


  • Croup-like illness + toxic + not respond to therapy
  • Pathology: laryngeotracheobronchitis, subglottic edema and membranous secretions


  • Bacterial Tracheitis vs epiglottitis (J Otolaryngol 1989;18(3):101-4)
    • Tracheitis children have a cough, comfortable lying down, no drool
  • Age: 6m-8y; Season: fall/winter
  • Present similar to Epiglottitis/Croup
  • Cough, toxic, fever, respiratory distress
  • No response to treatment

Diagnosis of Bacterial Tracheitis

  • Frontal neck X-ray → Steeple sign (non-specific finding)
  • Endoscopic visualization of normal supraglottic structures and subglottic inflammation, pus in airway, ulcers, secretions

Treatment of Bacterial Tracheitis

  • Emergent airway → use tube size smaller than what is appropriate for their age
  • Ideally intubated , diagnosed, cultured in the OR under optimal conditions

4. Foreign Body Aspiration


  • Age: Infants/toddlers
  • Classic Triad (wheeze + cough + decreased breath sounds) present in only 1/3
  • Symptoms (3 stages)
    • Violent cough
    • Asymptomatic interval
    • Complications
Foreign Body Aspiration - Pathogenesis and Clinical Findings
Foreign Body Aspiration – Pathogenesis and Clinical Findings

Diagnosis of Foreign Body Aspiration

  • History
    • Only 50% diagnosed in first 24h
    • Usually asymptomatic in ED
    • Witnessed foreign body aspiration?
    • Elicit a choking/coughing episode in the history (sudden onset dyspnea/choking/cyanosis)
  • Xrays (normal in 2/3)
  • CT

Treatment of Foreign Body Aspiration

  • Position of comfort
  • ENT
  • Referral for bronchoscopy

Complications of Foreign Body Aspiration

  • Obstruction, infection, fever, cough



  • Peak incidence in 1-2 year
  • Organisms: Parainfluenza I (most common-80%), II and III, M. pneumoniae, RSV, Influenza (severe form), adenovirus

Croup - Pathogenesis and Clinical Findings
Croup – Pathogenesis and Clinical Findings

Clinical features of Croup

  • Age: 6m-4y; Season: fall-winter
  • Viral prodrome
  • Barky cough, hoarse (subglottic airway narrowing)
  • Fever: common in croup, but usually not toxic
  • Lateral Neck Xray: Steeple sign (non-specific finding)
  • Croup score? (See table)
  • Symptoms peak over 2 days and resolve over 1 week
  • Croup score: mild (0-4), mild/mod (5-6), moderate (7-8), severe (9-14), terminal (15)
Croup Score0123
ColorNormalDuskyCyanoticCyanotic on O2
Air movementNormalMildModerateMarked

Treatment of Croup

  • Cool mist
    • Sooths inflamed mucosa
    • Multiple studies show minimal efficacy in treating croup (JAMA 2006;295(11):274)
    • Generally not helpful
  • Steroids
    • Indication: all croup in the ED?
    • Decreased mortality for croup from 1/200 to 1/30,000
    • Multiple studies show efficacy, associated with a decrease in ED stay and ED bounce backs (Ann Emerg Med 2002;30(3):353)
    • Dose:
      • 0.15mg/kg vs 0.3mg/kg vs 0.6mg/kg?? (Max 10 mg)
      • All equally efficacious PO or IM or inhaled (Acad Emerg Med 2003;10:16)
      • IV formulation can be given po

  • Racemic epinephrine
    • Indication: mod/severe croup; stridor at rest → can help reduce need for emergent intubation
    • Dose: 0.25-0.5ml of 2.25% solution with saline to total of 3ml
    • Racemic Epineprine vs Epinephrine?
      • Equivalent: substitute with epinephrine 0.5ml /kg of 1:1000, 5ml max with equal efficacy (Pediatrics 1992;89(2):302) (Cochrane Database Syst Rev. 2011 Feb 16)
    • Rebound phenomenon?
      • No need for admission for observation, if significantly improved → can be safely discharged after 3 hours (Ann Emerg Med 1995;25:331-7)
    • Repeat Epinephrine
      • Usually 2 doses of epinephrine = Admit
      • But, if they respond to the 2nd epinephrine, well-appearing and observed 2-4 hours without decompensation → can possibly discharge home
  • Summary: may give cool mist, steroids for all kids in ED, epinephrine only if they have stridor.

Croup - Treatment Algorithm
Croup – Treatment Algorithm


  • Discharge: well-appearing, normal color, no stridor at rest, no ALOC (Altered Level of Consciousness)
  • Admit: Moderate croup score, toxic appearing, respiratory distress, received more than 2 doses of nebulized epinephrine

Discharge Criteria:

– Good PO intake
– RR < 40
– Sat > 94%
– Well appearing

Consider Congenital Causes of Stridor in Children

Stridor present since birth? Congenital Causes of Stridor:

  • Laryngomalacia
  • Subglottic stenosis
  • Vocal cord paralysis
  • Vascular ring
  • Webs
  • Papillomas