• Paediatric stridor
    • Assessment
      • Disturb the patient as little as possible
      • Phase of the stridor may indicate level
        • Inspiratory
          • Above the cords (croup, epiglottitis
        • Expiratory
          • Below the cords (FB)
        • Biphasic
          • At or below cords (FB, tracheitis)
      • Ensure ENT aware
    • Croup
      • Causes 80% of stridor
      • Affects 6/12 - 3yrs with peak at 2 yrs
      • Develops 2-3 days into viral illness
      • Low grade fever, inspiratory stridor, fatigue, hypoxia and hypercarbia can ensue
      • Treatments
        • Humidified O₂
        • Steroids
          • 0.6mg/kg Dexamethasone oral
        • Nebulised adrenaline
          • 0.5ml/kg of 1:1000 adrenaline
      • Scoring croup
        • Score
          • 0
            • 1
              • 2
        • Breath sounds
          • Normal
            • Harsh
              • Delayed
        • Stridor
          • None
            • Insp
              • Insp & exp
        • Cough
          • None
            • Hoarse cry
              • Bark
        • Recession
          • None
            • Suprasternal recession
              • Intercostal recession
        • Cyanosis
          • None
            • In air
              • In 40% O₂
        • Mild = 0-3, mod = 4-6 (HDU), severe = 7-10 (I&V)
      • Intubate by Inhalational induction with CPAP applied via T-piece
      • A smaller than usual tube may be needed
      • Extubation when leak round tube (2-10 days)
    • Foreign body
      • Peak incidence 1-2yr olds
      • May need basic life support manoeuvres
      • Lower obstructions can cause gas trapping distally with pneumothorax, subcutaneous emphysema and pneumomediastinum
      • Collapse/consolidation may be seen on CXR
      • May be clinically similar to asthma
      • Rigid bronchoscopy with pt breathing spontaneously supplemented with up to 3mg/kg topical lignocaine is a reasonable technique
      • Dexamethasone and nebulised adrenaline will help with mucosal oedema post procedure
    • Retropharyngeal abscess or tonsillar abscess
      • Between posterior pharyngeal wall and pre-vertebral fascia
      • Infection from sinus, teeth or middle ear
      • Tonsillar abscess forms between superior constrictor and tonsil
      • Staph and strep are the usual causes
      • Avoid abscess rupture during intubation as can soil the lungs
      • Usually extubatable at the end of the case
    • Bacterial tracheitis
      • Due to staph, HiB, strep and Neisseria sp.
      • Signs and symptoms intermediate between croup and epiglottitis
      • URTI followed by deterioration over 8-10 hrs
      • Copious secretions and retro sternal pain
      • No dysphagia or drooling
      • Slough, pus and a pseudomembrane may cause occlusion
      • Bronchoscopy can be done before intubation to clear secretions
      • Ceftriaxone is a suitable antibiotic but consider MRSA
      • Average duration of ETT is 6-7 days
      • Tracheal stenosis can occur late on
    • Post intubation croup
      • Follows after routine intubation usually due to too large an ETT being used
      • Usually due to subglottic oedema
      • Treat with dexamethasone and observe for 2hrs
    • Epiglottitis
      • High fever, sore throat, dysphagia, stridor and drooling
      • Occurs in 2-6 yr olds, peak incidence at 3 yrs
      • Usually due to HiB but can be due to staph, strep and pneumococci
      • Distinguished from croup by fulminant onset, and toxic appearance of patients
      • Usually sat forward, mouth open and jaw protruding
      • Ensure ENT present
      • Induce in the sitting position, the glottis view may be obscured
      • Pressing on the chest may help visualise the opening
      • Recovery is usually within 2/7 of starting antibiotics (ceftriaxone 80mg/kg)
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/7/6/183.full.pdf?sid=37cc0ae8-4773-4c23-95cb-6ac20c6206cd