Stridor, Stertor, and Snoring:
Pediatric Upper Airway
Obstruction
Nathan Page, MD
Pediatrics in the Red Rocks
June ?
• I have no disclosures
• I do not plan to discuss unapproved or off label use of products
Outline
• Pediatric airway anatomy
• Airway examination and key airway sounds
• What constitutes an airway emergency?
• Airway management tools
• Common pediatric airway emergencies
Laryngeal Anatomy
Pediatric Larynx Adult Larynx
Pediatric vs Adult Larynx
• Location
• Consistency
• Size
• Shape
• Configuration
Pediatric vs Adult Larynx
•Location
• Consistency
• Size
• Shape
• Configuration
Location
- More rostral
(i.e. higher)
- Cricoid reaches:
C4 at birth
C5 at 2yo
C6-7 at 15yo
Pediatric vs Adult Larynx
• Location
•Consistency
• Size
• Shape
• Configuration
Consistency
• Softer, more pliable tissues
• Submucosal tissue is looser, less fibrous
• Stenosis more likely with internal injury to larynx
Pediatric vs Adult Larynx
• Location
• Consistency
•Size
• Shape
• Configuration
Size
- Newborn larynx 1/3 adult size
- Greater cartilagenous portion of vocal cords (1/2 in infant, ¼-1/3 in adult),
leads to greater injury potential
Pediatric vs Adult Larynx
• Location
• Consistency
• Size
•Shape
• Configuration
Shape Adult Infant
Cylinder Funnel
• Narrowest portion of the pediatric larynx is the cricoid cartilage
• Narrowest portion of the adult larynx is the glottis (vocal cords)
Pediatric vs Adult Larynx
• Location
• Consistency
• Size
• Shape
•Configuration
Configuration
• Epiglottis is narrow, omega-
shaped (Ω)
• Cricoid slightly tilted
backward
• Vocal cords at sharper angle
Configuration
Thyroid cartilage more obtuse angle
Pediatric Larynx
Airway sounds
• Wheezing – intrathoracic obstruction (expiratory)
• Stertor –nasal/oropharyngeal obstruction (snoring – inspiratory)
• Stridor – laryngeal obstruction (inspiratory or biphasic)
Inspiration Expiration
Inspiration Expiration
Wheezing : Etiologies
• Asthma
• Bronchiolitis
• Structural obstruction of trachea or bronchi
• Foreign body
• Tumor
• Compression
Stertor : Etiologies
• Nasopharyngeal obstruction
• URI
• Adenoid hypertrophy
• Retropharyngeal abscess
• Craniofacial abnormalities
• Oropharyngeal obstruction
• Tonsillar hypertrophy
• Enlarged tongue
• Craniofacial abnormalities
Stridor
• Harsh sound caused by turbulent airflow
• Implies partial airway obstruction
• Laryngeal stridor – inspiratory or biphasic
Stridor : Etiologies
• Laryngomalacia-different types
• Vocal Cord Paralysis
• Foreign Bodies
• Infectious
• “Croup”, Epiglottitis
• Croup (Laryngotracheitis) Masquerade
• Subglottic Hemangioma
• Recurrent Respiratory Papillomatosis
• Post Intubation Glottic and Subglottic Lesions
• Congenital Glottic and Subglottic Stenosis
• Extra-Esophageal (Gastroesophageal) Reflux Disease/Eosinophilic
Esophagitis
• Laryngeal Clefts
• Trauma
Assessment Strategies
• Guide to diagnosis and intervention
• Age
• Congenital vs. Acquired
• Characteristics of stridor
• Clinical picture
Clinical Picture: History
• Onset: acute, chronic, • GERD symptoms
progression • Wheezing episodes
• Prior respiratory problems • Feeding problems:
• Ex-preemie (NICU stay) • FTT, weight gain
• Prior intubation • Choking episodes
• Acute events
Clinical Picture: Associated signs & symptoms
• Acute Disease
• Fever
• Drooling (new onset)
• Change in cry
• Decrease in oral intake
• Body position
Physical Examination
• Auscultation of bilateral lungs AND neck
- Asymmetric or unilateral wheezing
- Transmitted airway sounds
- Inspiratory vs expiratory vs biphasic stridor
• “Headless” stethoscope
What constitutes an airway emergency?
Assess Urgency
• Nasal flaring
• Tachypnea
• Retractions
• Drooling
• Cyanosis
• Desaturation is a very late sign!!!
• If the above are present – immediate action!
Severe Respiratory Distress
• 1.Evidence of supraclavicular, sternal, or intercostal, retractions
• 2.Nasal flaring (<2 yr)
• 3.Grunting respirations
• 4.Tripod position
• 5.Stridor at rest
• 6.Marked Wheezing
• 7. Pulse oximetry < 95%
From The Red Book page 5-5.
Croup (laryngotracheobronchitis)
• Fever, upper respiratory symptoms
• “Barky” cough
• Inspiratory stridor
• Starts after 6 months of age
• Hospitalized pt: IV steroids, mist tent, hydration, O2 sat
monitor
Laryngomalacia
Laryngomalacia
• Most common cause of stridor in infants
• Strong association with reflux
• Inspiratory stridor
• Resolves by 12-18 months in most cases
• Minority need surgery – 1-10%
Breaker videos
Tracheomalacia
• More common in preterm infants
• Expiratory stridor and cough
• May be aggravated by bronchodilators
• Reflux treatment can benefit
• Typically resolves with time
• Primary vs secondary
Secondary tracheomalacia
• Innominate artery compression
• Vascular rings and slings
Complete tracheal rings
Subglottic hemangioma
• “Croupy” symptoms
begin at 6-8 weeks
• Mean age at diagnosis is
4 mos
• Grows until one year
old, then slowly
regresses
Subglottic stenosis
• Barky cough and
inspiratory stridor
Risk factors:
• Prematurity
• Prior intubation
• GERD
• Can develop at any age
Retropharyngeal abscess
• Infection of lymph nodes in Average age 2-3 yo
the retropharyngeal space
Frequently requires operative drainage
• Fever
• Drooling
• Neck stiffness
Epiglottitis
• Infection of the DO NOT AGITATE CHILD.
epiglottis caused by
Haemophilus DO NOT EXAMINE THROAT.
influenzae type B
TRANSPORT UPRIGHT
• Upright posture IMMEDIATELY!
• Drooling
• Fever
• Stridor
• Muffled voice
Epiglottitis
Neoplasm
Aerodigestive Tract Foreign Bodies
• The Usual Suspects-you name it
Airway Foreign Bodies
• The usual suspects:
• Food -2/3 of Airway FB
• Non Food items
• Pen caps
• Tacks
• Pins
• Toys
• Insects
Airway Foreign Bodies-Food
• Frequency: • Fatalities:
• Peanut (26%) • Hot dog (16%)
• Seeds (7%) • Candy (10%)
• Meat (7%) • Grape (8%)
• Popcorn (5%) • Meat (7%)
• Carrot (5%) • Peanut (7%)
• Hot Dog • Carrot (6%)
• Chicken • Cookie (6%)
• Fish bone • Apple (5%)
• Apple • Popcorn (5%)
• Candy • Bread (4%)
Altkorn et al: Fatal and non fatal food injuries among children Intl J
Ped Otorhinolaryngol (2008) 72, 1041-1046
Airway Foreign Bodies-Food
• Children < 3 y.o. increased risk
• 69% of injuries (peanuts, seeds, popcorn, apples, carrots)
• 79% of deaths (Hot dogs, apples, bread, carrots, cookies, grapes)
• Incomplete dentition
• Immature swallowing coordination
• Easily distracted
Altkorn et al: Fatal and non fatal food injuries among children
Intl J Ped Otorhinolaryngol (2008) 72, 1041-1046
Airway Foreign Bodies
• History is key to diagnosis
• Witnessed choking event in 32-51%; subsequent coughing spell generates
concern
• Symptoms are mild or absent by time of evaluation in 60%--transient wheeze
• Asymptomatic interval- FB becomes lodged and reflexes fatigue. False sense of
security
• Complications- Erosion/ Obstruction/ Infection
Airway Foreign Bodies
• Physical Examination:
• Cough (69%),
• Decreased Breath Sounds (52%),
• Intermittent/ Unilateral Wheeze (45%),
• Intermittent Dyspnea
