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PE25.4 | Stridor — SDL Guide (Part 2)

Management of Stridor

Management of stridor is fundamentally cause-specific — there is no single treatment for stridor as a symptom, and the approach differs entirely depending on whether the child has laryngomalacia, croup, epiglottitis, foreign body aspiration, or a fixed subglottic anomaly. However, the initial stabilisation steps are universal and apply before the definitive diagnosis is confirmed: maintain the airway, support oxygenation, and avoid manoeuvres that worsen the obstruction. This framework applies regardless of the suspected cause, and the few universal steps are completed within the first 2-3 minutes before cause-specific treatment is initiated. Understanding both the universal steps and the cause-specific pathways — and knowing which investigations are appropriate for each — allows a final-year student to manage the full range of stridulous children they will encounter in primary and referral practice.

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Universal initial stabilisation (all stridulous children with respiratory distress):
- Position the child upright or in their preferred posture (do NOT force supine)
- Administer supplemental humidified oxygen — blow-by in infants, mask in cooperative children
- Monitor SpO₂ continuously
- Avoid distress-provoking procedures (blood draw, throat examination, forced examination) until the child is stable
- Call for senior paediatric, ENT, and anaesthetic support if severe

Cause-specific management:

Laryngomalacia (chronic, thriving infant):
- Mild (normal weight gain, no apnoea): Parental reassurance + prone positioning for feeding and sleep + thickened feeds if GOR contributes; 90% spontaneous resolution by 18-24 months
- Severe (failure to thrive, recurrent apnoea, hypoxia): Supraglottoplasty (endoscopic division of shortened aryepiglottic folds and/or redundant arytenoid mucosa) — the definitive surgical treatment for refractory laryngomalacia

Croup (LTB):
- Mild (Westley <3): Single oral dexamethasone 0.15 mg/kg, discharge home
- Moderate (Westley 3-7): Nebulised adrenaline + dexamethasone 0.6 mg/kg, observe ≥2-4 h for rebound
- Severe (Westley ≥8): PICU, intubation if needed

Epiglottitis:
- Immediate team activation (paediatrics + ENT + anaesthetics)
- Keep child upright and calm; do NOT examine throat; do NOT place supine
- Controlled airway in OT under general anaesthesia + ENT surgical backup
- IV ceftriaxone 50-100 mg/kg/day post-intubation

Foreign body aspiration:
- Urgent rigid bronchoscopy for extraction
- Back blows and abdominal thrusts (Heimlich) only if child is choking and unable to breathe at all (complete obstruction) — do NOT perform blind finger sweeps
- Do NOT delay for X-ray if total obstruction is suspected

Subglottic haemangioma:
- Oral propranolol 2-3 mg/kg/day — first-line, induces involution; monitor heart rate and blood glucose during initiation; contraindicated in reactive airway disease

Anaphylaxis:
- IM adrenaline 0.01 mg/kg (1:1000 solution = 0.01 mL/kg) into the anterolateral thigh — FIRST priority
- Followed by IV fluids, antihistamines, corticosteroids

Investigations (after stabilisation, cause-directed):
- AP and lateral soft-tissue neck X-ray: steeple sign (croup), thumbprint sign (epiglottitis)
- Chest X-ray: asymmetric lung inflation or unilateral hyperinflation (FB in bronchus), mediastinal mass
- Flexible fibreoptic laryngoscopy (awake, in OPD): gold-standard for laryngomalacia, vocal cord paralysis — dynamic assessment under physiological conditions
- CT neck/thorax: vascular ring (CT angiography), subglottic mass
- Microlaryngoscopy and bronchoscopy (under GA): definitive assessment + biopsy of subglottic lesions

Self-Assessment — Stridor

Stridor is a synthesis topic — it requires integrating anatomy (stridor phase as a localising tool), clinical reasoning (acute vs chronic, cause-specific patterns), and management decision-making (which child needs immediate intervention versus monitoring). Before testing yourself, consider how you would approach a completely new clinical scenario: you encounter a stridulous child for the first time, and you have 30 seconds before you must decide whether to activate the emergency team. The two questions that resolve that decision are: (1) Is this child in immediate distress (SpO₂, work of breathing, cyanosis, tripod position)? and (2) Is this acute new-onset stridor or chronic stridor since early infancy? If the child is in distress or the stridor is acutely new, the emergency pathway activates. If the stridor is chronic, positional, feed-related, and the child is thriving, you have time for a systematic evaluation. Internalising this two-step triage is the practical payoff of this module.

Test yourself with the case-based quiz below.