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
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.
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.
Epiglottitis
Key: Drooling, muffled voice, “tripod” posture, no barking cough.
Rapid progression, possible airway occlusion, consider Hib vaccination history.
Foreign Body Aspiration
History of sudden choking, partial airway obstruction.
Possibly unilateral decreased breath sounds or localized wheeze.
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
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.
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
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.
