Is patient in significant respiratory distress Is there significant respiratory difficulty or increased work of breathing

Respiratory collapse may be imminent and urgent control of airway needed if patient is significantly uncomfortable or becoming fatigued. Look for sternal retractions, nasal flaring, and appearance of exhaustion or terror.

B. How long has patient had stridor? Under what circumstances did stridor begin? Did it begin acutely? Was event witnessed (eg, choking)? What evaluation and treatment took place, during this episode and previously, and what were the results? Recent or previous airway manipulation (eg, intubation) or trauma may cause subglottic stenosis or other laryngeal lesions. If acute in onset, stridor may progress from partial to complete airway obstruction (eg, aspirated foreign body, infection, trauma).

C. Is patient hoarse? Listen to voice or cry. Lesions that cause significant dysphonia (severe hoarseness) can cause sudden, complete airway obstruction (eg, laryngeal papillomas, exudative infections, aspirated foreign bodies).

D. How severe is stridor? Episodes of cyanosis or apparent life-threatening event (ALTE) suggest a severe problem.

E. Is there additional relevant history? If aspiration, coughing, or choking has occurred with feeding, evaluate for local or generalized neurologic problems (eg, paralyzed vocal fold, general hypotonia) or anatomic abnormalities (eg, tracheoesophageal fistula). When difficulty breathing interferes with feeding, the problem is severe. Acute respiratory infections can cause airway problems (eg, croup) or exacerbate underlying problems (eg, sub-glottic stenosis). Significant cardiac, neurologic, or pulmonary abnormalities may indirectly cause airway problems or interfere with child's ability to compensate.

III. Differential Diagnosis. Stridor is a sign, not a discrete diagnosis, suggesting partial airway obstruction, generally in the larynx, trachea, or bronchi.

A. Laryngomalacia. Collapse of supraglottic structures during inspiration. Can be congenital (infants), generally improving over time, or acquired (children with neurologic problems).

Subglottic Narrowing. Most commonly from subglottic stenosis, usually acquired, especially after prolonged or traumatic intubation; but can be congenital. Other causes include subglottic hemangiomas and subglottic cysts.

Aspirated Foreign Body. Sometimes history or radiographic findings provide evidence of an aspirated foreign body. However, coughing may subside or, in a young or developmentally delayed child, episode may not be witnessed. Radiographs may be nondiagnostic. Endoscopy should be considered if there is a suggestive history, despite lack of physical findings, or a suggestive radiograph, despite lack of history.

Ingested (Esophageal) Foreign Body. Can cause extrinsic compression of airway.

Croup. Viral illness causing subglottic narrowing from subglottic edema. Onset occurs over a few days, and child has low-grade fever.

Epiglottitis. Inflammation and edema of structures immediately superior to vocal folds. Infectious epiglottitis has rapid onset, and child appears toxic, with high fever. Can be caused by mechanical, chemical, or thermal trauma.

Vocal Fold Paralysis. Dynamic cause of airway obstruction. If unilateral, child has mild stridor and weak cry; if bilateral, more severe stridor. Can be caused by central lesion (eg, Chiari malformation) or peripheral lesion (eg, trauma to recurrent laryngeal nerve during cardiac surgery). Can be congenital or acquired. Exudative Tracheitis. Staphylococcal or other bacterial infection of trachea and larynx; may follow viral infection. Can cause sudden, complete airway obstruction.

Recurrent Respiratory Papilloma. Viral lesion with predilection for vocal folds; often presents with hoarseness preceding stridor. Can cause sudden, complete airway obstruction. Vascular Ring or Sling. Congenital malformation of major vessels (eg, double aortic arch), causing extrinsic compression of trachea.

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