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Stridor in the Pediatric Patient

The distinct features of the pediatric airway make respiratory failure an important concern independent of the underlying cause.

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References

Cases

Case 1

It’s a busy shift on an unusually chilly and rainy July night. Emergency medical services (EMS) brings in a 9-month-old boy who woke up with a “squeaking” noise. His parents reported that he has had a fever, cough, rhinorrhea, and difficulty breathing for the past 2 days; however, they did not hear the noisy breathing until the night of presentation. When the patient is examined, it is noted that he has inspiratory stridor at rest, moderate subcostal retractions, and an occasional deep cough. Upper airway transmitted noises were present, but otherwise the patient had clear lungs.

The patient’s vital signs at presentation were: blood pressure (BP), 85/55 mm Hg; heart rate (HR), 163 beats/min; respiratory rate (RR), 55 breaths/min; and temperature (T), 101.8°F. Oxygen saturation was 90% on room air. The patient’s mother wants to know how the respiratory distress will be fixed and is inquiring if they will have to stay in the hospital overnight.

Case 2

As work begins on the child described above, EMS brings in a 3-year-old girl who appears to be in moderate-severe respiratory distress. Her parents report that she started to drool earlier in the day followed by coughing and occasional gagging. Her parents relay that they thought the symptoms were because of post-nasal drip due to her cold, but the respiratory distress seems to be getting worse, and she now has very noisy breathing and is reluctant to lay down. Upon examination, both inspiratory and expiratory stridor is heard, and it is noted that moderate subcostal retractions are present when the patient is supine.

The patient’s vital signs at presentation were: BP, 89/58 mm Hg; HR, 144 beats/min; RR, 52 breaths/min; and T, 99.5°F. Oxygen saturation was 88% on room air. The nursing staff asked what to do next and why the 2 stridor cases are being managed so differently.

Stridor

Stridor is a high-pitched, harsh sound heard during respiration, predominantly during inspiration, as a result of turbulent air passage.1-3 Stridor is not a diagnosis in itself, but rather a sign of underlying acute or chronic etiology, which needs to be classified based on elicited history and examination.1,4 While the etiology of obstruction may be infectious, congenital, mechanical, or traumatic, the distinct features of the pediatric airway make respiratory failure an important concern independent of the underlying cause.

Anatomy

There are several anatomical differences unique to the pediatric airway that make children, especially infants under 1 year of age, more susceptible to airway obstruction.5,6The pediatric larynx is more anterior and superior and less fibrous than adults, thereby more compliant.6,7 The pediatric epiglottis is longer, omega-shaped, and softer, and the tongue is larger in comparison to the size of the oral cavity, resulting in obstructed airflow.6,7 Children also have a larger and more prominent occiput, causing mechanical obstruction by flexion of the neck when supine.6 While the cricoid cartilage was previously believed to be the narrowest portion of the airway, more recent measurement techniques have challenged this and shown that the glottic and subglottic areas may be narrower in children.7,8

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