November 2017 Management of Airway Volume 14, Number 11 Obstruction and Stridor in Authors Ashley Marchese, MD Department of Pediatrics, Yale-New Haven Hospital, New Haven, CT Pediatric Patients Melissa L. Langhan, MD, MHS Associate Professor of Pediatrics and Emergency Medicine; Fellowship Director, Director of Education, Pediatric Emergency Abstract Medicine, Yale University School of Medicine, New Haven, CT Peer Reviewers Stridor is a result of turbulent air-flow through the trachea from Steven S. Bin, MD upper airway obstruction, and although in children it is often Associate Clinical Professor of Emergency Medicine and Pediatrics; Medical Director, Emergency Department, UCSF School of Medicine, due to croup, it can also be caused by noninfectious and/or con- Benioff Children’s Hospital, San Francisco, CA genital conditions as well as life-threatening etiologies. The his- Alexander Toledo, DO, PharmD, FAAEM, FAAP tory and physical examination guide initial management, which Chief, Section of Pediatric Emergency Medicine; Director, Pediatric Emergency Department, Arizona Children’s Center at Maricopa includes reduction of airway inflammation, treatment of bacterial Medical Center, Phoenix, AZ infection, and, less often, imaging, emergent airway stabilization, Prior to beginning this activity, see “Physician CME Information” or surgical management. This issue discusses the most common on the back page. as well as the life-threatening etiologies of acute and chronic stridor and its management in the emergency department. Editor-in-Chief Clinical Emergency Medicine and Professor of Pediatrics, University Joshua Nagler, MD, MHPEd Vincent J. Wang, MD, MHA Pediatrics, David Geffen School of of Hawaii John A. Burns School of Assistant Professor of Pediatrics and Professor of Pediatrics, Keck Ilene Claudius, MD Medicine at UCLA; EMS Fellowship Medicine, Honolulu, HI Emergency Medicine, Harvard Medical School of Medicine of the Associate Professor, Department Director, Harbor-UCLA Medical School; Fellowship Director, Division University of Southern California; Madeline Matar Joseph, MD, FACEP, of Emergency Medicine and Center, Department of Emergency of Emergency Medicine, Boston Associate Division Head, Division Pediatrics, USC Keck School of FAAP Medicine, Los Angeles, CA Professor of Emergency Medicine Children’s Hospital, Boston, MA of Emergency Medicine, Children's Medicine, Los Angeles, CA Hospital Los Angeles, Los Michael J. Gerardi, MD, FAAP, and Pediatrics, Chief and Medical James Naprawa, MD Angeles, CA Editorial Board FACEP, President Director, Pediatric Emergency Attending Physician, Emergency Jeffrey R. Avner, MD, FAAP Associate Professor of Emergency Medicine Division, University Department USCF Benioff International Editor Chairman, Department of Medicine, Icahn School of Medicine of Florida College of Medicine- Children's Hospital, Oakland, CA at Mount Sinai; Director, Pediatric Jacksonville, Jacksonville, FL Lara Zibners, MD, FAAP, FACEP Pediatrics, Maimonides Infants & Joshua Rocker, MD Emergency Medicine, Goryeb Honorary Consultant, Paediatric Children’s Hospital of Brooklyn; Stephanie Kennebeck, MD Associate Chief, Division of Emergency Medicine, St. Mary's Professor of Clinical Pediatrics, Children's Hospital, Morristown Associate Professor, University of Pediatric Emergency Medicine, Medical Center, Morristown, NJ Hospital Imperial College Trust, Albert Einstein College of Medicine, Cincinnati Department of Pediatrics, Cohen Children's Medical Center; London, UK; Nonclinical Instructor Children's Hospital at Montefiore, Sandip Godambe, MD, PhD Cincinnati, OH Assistant Professor of Emergency of Emergency Medicine, Icahn Bronx, NY Chief Quality and Patient Safety Medicine and Pediatrics, Hofstra Anupam Kharbanda, MD, MS School of Medicine at Mount Sinai, Steven Bin, MD Officer, Professor of Pediatrics and Chief, Critical Care Services Northwell School of Medicine, New New York, NY Associate Clinical Professor, UCSF Emergency Medicine, Attending Children's Hospitals and Clinics of Hyde Park, NY Physician, Children's Hospital of the School of Medicine; Medical Director, Minnesota, Minneapolis, MN Steven Rogers, MD Pharmacology Editor Pediatric Emergency Medicine, UCSF King's Daughters Health System, Associate Professor, University of Tommy Y. Kim, MD, FAAP, FACEP Aimee Mishler, PharmD, BCPS Benioff Children's Hospital, San Norfolk, VA Associate Professor of Pediatric Connecticut School of Medicine, Emergency Medicine Pharmacist, Francisco, CA Ran D. Goldman, MD Emergency Medicine, University of Attending Emergency Medicine Maricopa Medical Center, Richard M. Cantor, MD, FAAP, Professor, Department of Pediatrics, California Riverside School of Medicine, Physician, Connecticut Children's Phoenix, AZ FACEP University of British Columbia; Riverside Community Hospital, Medical Center, Hartford, CT Research Director, Pediatric Quality Editor Professor of Emergency Medicine Department of Emergency Medicine, Christopher Strother, MD and Pediatrics; Director, Pediatric Emergency Medicine, BC Children's Riverside, CA Assistant Professor, Emergency Steven Choi, MD, FAAP Emergency Department; Medical Hospital, Vancouver, BC, Canada Medicine, Pediatrics, and Medical Assistant Vice President, Melissa Langhan, MD, MHS Director, Central New York Poison Montefiore Health System; Director, Joseph Habboushe, MD, MBA Associate Professor of Pediatrics and Education; Director, Undergraduate Control Center, Golisano Children's Montefiore Network Performance Assistant Professor of Emergency Emergency Medicine; Fellowship and Emergency Department Hospital, Syracuse, NY Medicine, NYU/Langone and Simulation; Icahn School of Medicine Improvement; Executive Director, Director, Director of Education, Montefiore Institute for Performance Ari Cohen, MD, FAAP Bellevue Medical Centers, New Pediatric Emergency Medicine, Yale at Mount Sinai, New York, NY York, NY; CEO, MD Aware LLC Improvement; Associate Professor Chief of Pediatric Emergency University School of Medicine, New Adam E. Vella, MD, FAAP of Pediatrics, Albert Einstein College Medicine, Massachusetts General Tim Horeczko, MD, MSCR, FACEP, Haven, CT Associate Professor of Emergency of Medicine, Bronx, NY Hospital; Instructor in Pediatrics, Medicine, Pediatrics, and Medical FAAP Robert Luten, MD Harvard Medical School, Boston, MA Associate Professor of Clinical Education, Director Of Pediatric Professor, Pediatrics and CME Editor Emergency Medicine, David Geffen Emergency Medicine, Icahn School Jay D. Fisher, MD, FAAP Emergency Medicine, University of Deborah R. Liu, MD School of Medicine, UCLA ; Core of Medicine at Mount Sinai, New Clinical Professor of Pediatric and Florida, Jacksonville, FL Associate Professor of Pediatrics, Emergency Medicine, University Faculty and Senior Physician, Los York, NY Keck School of Medicine of USC; Garth Meckler, MD, MSHS of Nevada, Las Vegas School of Angeles County-Harbor-UCLA Associate Professor of Pediatrics, David M. Walker, MD, FACEP, FAAP Division of Emergency Medicine, Medicine, Las Vegas, NV Medical Center, Torrance, CA University of British Columbia; Director, Pediatric Emergency Children's Hospital Los Angeles, Marianne Gausche-Hill, MD, FACEP, Alson S. Inaba, MD, FAAP Division Head, Pediatric Emergency Medicine; Associate Director, Los Angeles, CA FAAP, FAEMS Pediatric Emergency Medicine Medicine, BC Children's Hospital, Department of Emergency Medicine, Medical Director, Los Angeles Specialist, Kapiolani Medical Center Vancouver, BC, Canada New York-Presbyterian/Queens, County EMS Agency; Professor of for Women & Children; Associate Flushing, NY Case Presentations Upper airway obstruction in children can range from partial to complete, and often presents with A 20-month-old boy is brought into the ED by his stridor, a high-pitched breath sound produced by mother who is concerned because he woke up with a turbulent air-flow through a partially obstructed barky cough and he sounded like he was having diffi- airway. Stridor can be acute or chronic, and culty breathing. Prior to tonight, he had 2 days of fever acquired or congenital. Because stridor is a sign and a runny nose. The mother states that her son's voice and not a diagnosis, the underlying etiology must 2,3 sounds more hoarse than usual. The boy’s vital signs are be identified to guide management. In the ED, notable for a fever of 39.2°C (102.6°F), a respiratory rate identifying severe and life-threatening causes of of 60 breaths/min, and a pulse oximetry reading of 98% stridor and acting quickly are crucial to prevent- on room air. He is not in significant acute distress when ing respiratory failure. you walk into the room, but you immediately notice The cause of upper airway obstruction can often inspiratory stridor at rest, and subcostal retractions. be identified through history and physical examina- The physical examination is otherwise notable for clear tion alone. The age of the child is an important con- rhinorrhea and transmitted upper airway sounds in the sideration. While chronic and congenital etiologies lungs. The nurse asks if you would like to order urgent of stridor are more common in neonates and infants medications or imaging. Do you give racemic epineph- aged < 6 months, acute infectious etiologies are more 4 rine and/or dexamethasone immediately? Is a chest x-ray prevalent in older infants and children. The most necessary? How long should you observe this patient common cause of acute stridor in children present- before deciding on his disposition? ing to the