Stridor and Croup

Stridor is a high-pitched inspiratory sound suggesting upper airway obstruction. In children, croup is the most common cause, but life-threatening differentials exist and must be considered.

Differential Diagnoses & Key Features

1. Croup (Laryngotracheobronchitis)

   • Cause: Typically viral (parainfluenza), ages 6 months–3 years, autumn/winter peak.

   • Symptoms: Barking “seal-like” cough, inspiratory stridor, hoarse voice.

   • Signs: Worse at night, often mild fever, responds to adrenaline and corticosteroids.

2. Bacterial Tracheitis

   • Presentation: Toxic appearance, high fever, thick purulent secretions.

   • May appear like croup but does not respond well to adrenaline.

   • Suspect in acute onset with severe airway compromise.

3. Epiglottitis

   • Key: Drooling, muffled voice, “tripod” posture, no barking cough.

   • Rapid progression, possible airway occlusion, consider Hib vaccination history.

4. Foreign Body Aspiration

   • History of sudden choking, partial airway obstruction.

   • Possibly unilateral decreased breath sounds or localized wheeze.

5. Retropharyngeal Abscess

   • Drooling, muffled “hot potato” voice, neck stiffness.

   • More common in older children, can see bulge in posterior pharynx on exam/imaging.

General Management for Stridor

1. Initial

   • Urgent transfer to paediatric facility if moderate-severe or uncertain cause.

   • Keep child calm, upright (minimizes airway narrowing).

   • Avoid throat exam (risk of airway spasm in epiglottitis).

   • Oxygen if SpO₂ <94%.

   • NBM (nil by mouth) if severe, risk of aspiration.

   • Continuous monitoring of airway and vitals.

2. Severe Cases

   • Minimal handling; child in position of comfort.

   • Prepare for advanced airway intervention (possible intubation, surgical airway in epiglottitis or if obstructed).

Croup Management

Mild/Moderate Croup

• Corticosteroids:

  • Prednisolone 1 mg/kg PO once daily (max 50 mg) for up to 3 days, or

  • Dexamethasone 0.15 mg/kg PO (max 12 mg), single or repeated dose if needed.

• If unable to tolerate oral: Nebulised budesonide 2 mg every 12 hours (48 hours).

• Ensure adequate hydration, observe for progression.

Moderate/Severe Croup

• Nebulised Adrenaline (e.g. 5 mL of 1:1000 adrenaline) + Corticosteroids.

• Monitor for rebound stridor (usually 2–3 hours after adrenaline effect wears off).

Key Notes

• Antibiotics are not for viral croup.

• Sign of Worsening: Stridor at rest, marked sternal/intercostal retractions.

Other Serious Causes

Epiglottitis/Bacterial Tracheitis

• Urgent antibiotics, potential intubation if airway compromised.

• Typically require hospital admission and ENT/ICU support.

Quick Tips

• Foreign Body suspicion: Sudden onset choking + localized findings → urgent imaging/bronchoscopy.

• Retropharyngeal Abscess: Neck stiffness, drooling, “hot potato” voice → urgent ENT referral.

• If croup-like but toxic or no response to standard croup therapy → suspect bacterial tracheitis.