Stridor = high-pitched inspiratory sound from upper airway obstruction. Position of choice: keep child calm in caregiver's lap. Do NOT examine pharynx or lay flat if epiglottitis suspected. Anticipate failed airway in difficult cases — call ENT/anesthesia early.
🚩 Red-flag clues (must not miss)
- •Drooling + tripod + toxic + 'hot potato' voice + no cough = epiglottitis
- •Sudden choking event in toddler with focal wheeze/stridor = foreign body
- •Stridor + barky cough + viral prodrome = croup (most common 6 mo–6 y)
- •Stridor + drool + neck stiffness + muffled voice = retropharyngeal abscess
- •Stridor + urticaria/angioedema/hypotension after exposure = anaphylaxis
History
- Onset (sudden vs gradual), preceding illness, choking event
- Vaccination (Hib for epiglottitis, DTaP for diphtheria)
- Previous intubation (subglottic stenosis), atopy
Exam
- Position child takes spontaneously — do not force supine
- PAT, SpO₂, retractions (suprasternal, intercostal, subcostal)
- Drool, voice quality, cough character
- Auscultate for asymmetry (FB)
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Croup (laryngotracheobronchitis) | Barky cough, viral prodrome, 6 mo–6 y | Dexamethasone 0.6 mg/kg ×1; nebulized epi if moderate–severe |
| Epiglottitis | Toxic, drool, tripod, no cough, unvaccinated | Keep calm; OR for intubation by anesthesia + ENT; ceftriaxone + vanc |
| Bacterial tracheitis | Toxic + croup-like + thick exudate, fails epi | Intubation; vanc + ceftriaxone |
| Foreign body | Sudden choking, focal wheeze, asymmetric breath sounds | If complete obstruction: BLS maneuvers; partial: rigid bronch in OR |
| Retropharyngeal abscess | Neck stiffness, drool, hot potato voice | Lateral neck XR (prevertebral widening), CT, ENT, IV abx |
| Peritonsillar abscess | Older child, trismus, deviated uvula | Drainage, abx |
| Anaphylaxis | Trigger + urticaria + airway | Epi 0.01 mg/kg IM (max 0.3–0.5 mg) |
| Angioedema (hereditary) | Family hx, no urticaria, recurrent | C1-INH concentrate; icatibant |
| Subglottic stenosis | History of prior intubation, biphasic stridor | ENT, scope |
| Vocal cord dysfunction | Adolescent, exercise, normal SpO₂ | Speech therapy |
| Diphtheria (rare) | Unvaccinated, gray pseudomembrane | Antitoxin + erythromycin; isolate |
| Asthma exacerbation | Wheeze (lower airway), atopy, response to bronchodilator | SABA + steroid; mag if severe |
| Bronchiolitis (RSV) | Infant, wheeze, viral, winter | Supportive; HFNC if hypoxic; no routine SABA/steroid |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Dexamethasone (croup) | 0.6 mg/kg PO/IV/IM ×1 (max 16 mg) | Single dose; effective within 1–2 h |
| Racemic epinephrine nebulized (croup) | 0.05 mL/kg of 2.25% (max 0.5 mL) in 3 mL NS | Or L-epi 5 mL of 1:1000; observe ≥ 3 h post-dose for rebound |
| Epinephrine IM (anaphylaxis) | 0.01 mg/kg IM (max 0.3 mg < 30 kg, 0.5 mg adult), repeat q5–15 min | Anterolateral thigh; do NOT delay for IV |
| Albuterol | Neb 0.15 mg/kg (min 2.5 mg, max 5 mg) | Asthma, lower airway |
| Ceftriaxone (epiglottitis/RTA) | 50 mg/kg IV (max 2 g) | |
| Vancomycin (bacterial tracheitis) | 15 mg/kg IV q6h |
Management / next steps
- Position of comfort; supplemental O₂ blow-by; SpO₂
- Croup: dex ± neb epi; observe 3 h after epi for rebound, discharge if room-air SpO₂, no stridor at rest, tolerating PO
- Epiglottitis: do NOT examine throat; OR for controlled intubation
- FB: leave undisturbed if partial; rigid bronch
Source: https://fprmed.com/fprmedcom/Pages/Pedi/PediRespiratory_Emergencies.html
← Back to Pediatric DDx