Stridor

Stridor is a rough noise when breathing, produced by obstruction in the larynx or trachea. Mainly on inhalation.

[1], [2], [3], [4], [5], [6], [7], [8]

What causes a stridor?

• Most often the stridor is caused by croup.
• High degree of overlap between clinical manifestations.
• Auxiliary oxygen therapy can be misleading, since a child with severe distress on oxygen can turn pink.

How is the stridor manifested?

• Acute partial obstruction of the upper respiratory tract is manifested by stridor and increased work of breathing-the wiggling of the supple places of the thorax and the involvement of accessory muscles.
• Signs of worsening, requiring urgent intervention - hypoxia, fatigue, changes in the level of consciousness, increased work of breathing.
• Alertness towards children who do not show interest in the environment.

How is the stridor recognized?

Compare SpO2 in air and 100% oxygen.

Differential diagnosis

• Croup - a rough barking cough, fever, looks bad, but the current is favorable.
• Epiglottitis - intoxication, no cough, low stridor on inhaling and exhaling, drooling.
• Foreign body - a sudden onset without a prodromal period, coughing, choking and aphonia.
• Anaphylaxis - swelling of the face and tongue, wheezing in the lungs, urticaria rash.
• Hyphalic abscess - high fever, neck tension, dysphagia, accumulation of secretion products.
• Bacterial tracheitis - intoxication, soreness in the projection of the trachea.
• Previously existing stridor - congenital anomalies, laryngomalacia or subglottic stenosis.

[9], [10], [11], [12], [13], [14]

What should be done if there is a stridor?

• It's best to leave the child quietly in a comfortable position on the knees of the parent.
• Thoroughly inspect without touching the child.
• Assess the severity of respiratory distress and make assumptions about the most probable cause of what is happening.
• If the condition worsens, prepare for intubation.

Anesthesia in a child with airway obstruction

• Seek help from a more experienced anesthesiologist and an ENT specialist.
• Inhalation induction in the operating room in a calm environment.
• 100% O2 and sevoflurane (or halothane, if there is experience of its use, halothane is preferred for maintaining the depth of anesthesia).
• Induction can be performed by a child sitting alone or on the lap of the parent, if this position achieves the best airway patency.
• PPD facial mask - if the child is suffering.
• Achieving adequate depth of anesthesia will take a lot of time.
• Maintain independent breathing, constantly monitoring whether it is obtained by ventilating the bag. If so, if necessary, gently help inspiration, trying not to inflate the stomach. Once anesthesia of sufficient depth is achieved, a direct laryngoscopy without muscle relaxants. Intubate if possible - you may need a tube much smaller than you would expect with croup (do not cut the ETT in advance). Intubation can be difficult with epiglottitis - to look for air bubbles emerging from the glottis when it opens. Next, enter the buje-conductor and on it to start ETT. In most cases, an experienced anesthesiologist can intubate a child with a stridor, a life-threatening bronchoscopy in the hands of an experienced ENT surgeon.

[15], [16], [17], [18], [19], [20], [21], [22],

Further management

• After intubation, maintain anesthesia (intravenous infusion of propofol or inhalation anesthetic).
• It may be useful dexamethasone intravenously 0.6 mg / kg, if it was not previously administered.
• Translation into a pediatric ICU.
• Cefotaxime intravenously 50 mg / kg every 6 hours or ceftriaxone intravenously 50 mg / kg every 12 hours (epiglottitis).
• Extubation: Dexamethasone is often given (intravenously 0.25 mg / kg every 6 hours 2 or three doses) at least 6 hours before extubation. It is necessary that before attempting extubation, at a pressure of 20 cm H2O around ETT there was a slight air leakage.
• Radiography of soft tissues usually does not add useful information. Even if there is a leak, in some cases, in connection with edema, reintubation will still be required.