Stridor or Wheeze

APPROACH TO CHILD WITH
STRIDOR OR WHEEZE
STRIDOR
DEFINITION
 Harsh medium-pitched inspiratory sound
associated with obstruction of the

laryngeal area or extra thoracic trachea.
 Maybe biphasic.
CAUSES OF STRIDOR
 Infective: Epiglottitis,
Laryngotracheobronchitis, Tracheitis,
Retropharyngeal abscess
 Malignancy: Tumor compression, Papilloma
 Allergic: Angioneurotic oedema
 Congenital: Laryngomalacia, Laryngeal web,
Vascular ring
 Aspiration: Foreign body
 Neuronal: Paralysis of vocal cord
 Others: Gastroesophageal reflux, TEF, macroglossia,
micrognathia, hysterical stridor, hypocalcemia
Historical Information in the
Evaluation of Stridor in Children
Historical data: Possible etiology
Age of onset Vocal cord paralysis, congenital lesions
such as laryngeal web and vascular ring
Birth
4-6wks Laryngomalacia
1-4yrs Croup, epiglottitis, foreign body

aspiration
Chronicity
Foreign body aspiration, infections such
Acute onset as croup and epiglottitis
Long duration Structural lesion such as laryngomalacia,

laryngeal web or larynogotracheal
stenosis
Precipitating factors Possible etiology
Worsening with straining or Laryngomalacia, subglottic
crying hemangioma
Worsening in a supine position Laryngomalacia, tracheomalacia,

macroglossia, micrognathi
Worsening at night Viral or spasmodic croup
Worsening with feeding Tracheoesophageal fistula,

tracheomalacia, neurologic
disorder, vascular compression
Antecedent upper respiratory Croup, bacterial tracheitis
tract infection
Choking Foreign body aspiration,

tracheoesophageal fistula
Associated symptom Possible etiology
Barking cough Croup
Brassy cough Tracheal lesion
Drooling Epiglottitis, foreign body in esophagus,
retropharyngeal
Weak cry Laryngeal anomaly or neuromuscular
disorder
Hoarseness Croup, vocal cord paralysis
Snoring Adenoidal or tonsillar hypertrophy

Past health Possible etiology
Endotracheal intubation Vocal cord paralysis,
Birth trauma, perinatal Laryngotracheal stenosis,

asphyxia, cardiac problem vocal cord paralysis
Atopy Angioneurotic edema, spasmodic

croup
Psychosocial stress Hysterical stridor

Physical Examination Findings in the
Evaluation of Stridor in Children
Physical findings Possible etiology
General
Cyanosis Hypoventilation with hypoxia
Fever Underlying infection
Toxicity Epiglottitis
Bradycardia Hypothyroidism
Quality of stridor
Inspiratory Obstruction above glottis
Expiratory Obstruction at or below lower trachea
Biphasic Glottic or subglottic lesion

Physical findings Possible etiology
Position of child Extrinsic obstruction at or above

Hyperextension of the neck larynx
Leaning over, drooling Epiglottitis
Lessening of stridor in prone Laryngomalacia

position
Chest finding
Prolonged inspiratory phase Laryngeal obstruction
Prolonged expiratory phase Tracheal obstruction
Unilateral decreased air entry Foreign body in ipsilateral

bronchus
Associated signs Possible etiology
Arrhythmias, significant heart Structural heart disease

murmurs, abnormal heart sounds
Cutaneous hemangiomas Subglottic hemangioma
Peripheral neuropathy Vocal cord paralysis
Urticaria/angioneurotic edema Angioneurotic edema

INVESTIGATION
 CBC
 Depending on degree of RD – ABG
 X ray
 PA and Lateral view neck
 AP and lateral views of the chest
 Inspiratory and Expiratoy films, decubitus view:
Foreign body
 Bronchoscopy
 Barium swallow: vascular compression or
gastroesophageal reflux
 Videofluoroscopy : tracheomalacia, foreign body
aspiration and vocal cord dysfunction.
 CT or MRI
TREATMENT
 Establish airway
 Maintain vitals
 Oxygen
 Croup: humidified oxygen racemic epinephrin,
dexamethasone
 Epiglottitis/ tracheitis: Antibiotics
 Retropharyngeal abscess: Surgical drainage
 Bilateral vocal cord paralyses: Tracheostomy
 Laryngomalacia: usually self limited
 Others: specific treatment
APPROACH TO CHILD WITH
WHEEZE
 Wheezing is a high-pitched whistling sound,
heard when air flows through partially
obstructed airways.
 Wheezing is often louder during exhalation,
however it may be heard during inhalation
as well.
 By age of 6 yrs 50% of children would have
had at least one episode of wheezing.
PATHOPHYSIOLOGY
PHYSIOLOGICAL PROPERTIES
PREDISPOSING TO WHEEZE
 bronchial smooth muscle content
Hyperplasia of mucus smooth muscle glands
 radius of conducting airways resulting in overall turbulent flow
 resistace of peripheral airways due to  airway size
 Chest wall compliance
Diaphragm (Hz insertion,  fatigue resist muscle)
Defficient colleteral ventilation

Differntial diagnosis of
Wheezing in Infancy
 Infection
 Viral: RSV, parainfluenza, adenovirus, influenza,
rhinovirus
 Other: Chlamydia trochomatis, TB, Histoplasmosis
 Asthma
 Foreign body
 Anatomical Abnormalities
 Inherited: CF, Immunodeficiency states
 Bronchopulmonary dysplasia
 Aspiration syndromes
 Interstital lung disease
DIFFERENCIAL DIAGNOSIS
OF ASTHMA IN CHILDREN
Upper respiratory tract Middle Respiratory tract
Allergic rhinitis Laryngotracheobronchomalacia
Chronic rhinits Laryngotracheobronchitis
Sinusitis Laryngeal web, cyst or stenosis

Adenoid or tonsilar Vascular ring, sling or external
haypertrophy mass compressing the airway
Nasal foreign body Vocal cord dysfunction/

paralysis
Tracheo eosophageal fistula
Foreign body aspiration
Chronic bronchitis
Toxic inhalation
Lower Respiratory Tract
• Bronchopulmonary dysplasia
• Viral bronchiolitis
• Gastroesophageal reflux
• Bronchiectasis (CF, immune deficiency, immotile cillia
syndrome)
• Bronchiolitis obliterans
• Interstitial lung disease
• Hypersensitivity pneumonitis
• Pulmonary eosinophilia
• Pulmonary hemosiderosis
• Pneumonia
• Pulmpnary edema
• Medication with chronic cough ( Acetylcholinestrase inhibitor)
Causes of wheeze
 Bilateral  Unilateral
 Asthma  Pneumonia
 Bronchiolitis  Foreign body
 Mycoplasma  Mediastinal mass
 Cystic fibrosis  Tuberculosis
 Alpha 1 antitrypsin  Bronchiectasis
deficiency  Vascualr ring
 Severe pneumonia
APPROACH: HISTORY
 Age of onset, number and frequency of
wheezing episodes.
 Relation of the episode to viral and/ or
aeroallergen exposure
 History of choking episode or foreign body
ingestion.
 History of weight loss, fever or other systemic
complication
 Presence of allergic disease such as
conjunctivits, rhinitis and / or eczema
 Exposure to tobacco smoke
 Family history of asthma or atopy,
PHYSICAL EXAMINATION:
 Assessment of degree of respiratory distress
and work of breathing.
 Wheeze with features of upper airways
obstruction:- croup, tracheomalacia, or
bronchomalacia.
 Wheeze with crackles:- infection, BPD, or
pulmonary edema
 Location of wheeze unilateral or bilateral
 Growth curve
 Systemic examination
INVESTIGATION
 As indicated
 Chest X ray
 Pulmonary function test
 ABG
 CBC
 Specific tests
Lung Function Abnormalities
in Asthma
Spirometry
 Air flow limitation
 Low FEV1
 FEV1/FVC < 0.8
 Bronchodilator response to inhaled ß agonist
 Improvement in FEV1 > or = 12%
 Exercise challenge
 Worsening in FEV1 > or = 15%
 Peak flow morning to afternoon variation > or =20%
TREATMENT
 Maintain vitals, oxygen
 Specific treatment based on underlying
etiology
 Asthma: ß2 agonist, glucocorticoids, leukotriene
modifier, mast cell stabilizer, theophylline.
 Bronchiolitis: cool humidified oxygen
 GERD: Avoidance of food <2hrs before bed, head
end elevation of bed by 6in, antacid, prokinetics.
PROGNOSIS
 60% of children with early onset
wheezing will stop wheezing by 6yrs
 14% will have persistent asthma with

features of irreversible loss of lung
function by age of 6 yrs
References
• Nelson
• Ghai Essential Paeds
• prsharma.com
• AAFP.org
• Allrefer.com

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APPROACH TO CHILD WITH

associated with obstruction of the

1-4yrs Croup, epiglottitis, foreign body

Long duration Structural lesion such as laryngomalacia,

Worsening in a supine position Laryngomalacia, tracheomalacia,

Worsening at night Viral or spasmodic croup

Worsening with feeding Tracheoesophageal fistula,

Choking Foreign body aspiration,

Barking cough Croup

Brassy cough Tracheal lesion

Drooling Epiglottitis, foreign body in esophagus,

Hoarseness Croup, vocal cord paralysis

Snoring Adenoidal or tonsillar hypertrophy

Endotracheal intubation Vocal cord paralysis,

Birth trauma, perinatal Laryngotracheal stenosis,

Atopy Angioneurotic edema, spasmodic

Psychosocial stress Hysterical stridor

Biphasic Glottic or subglottic lesion

Position of child Extrinsic obstruction at or above

Leaning over, drooling Epiglottitis

Lessening of stridor in prone Laryngomalacia

Prolonged expiratory phase Tracheal obstruction

Unilateral decreased air entry Foreign body in ipsilateral

Arrhythmias, significant heart Structural heart disease

Cutaneous hemangiomas Subglottic hemangioma

Peripheral neuropathy Vocal cord paralysis

Urticaria/angioneurotic edema Angioneurotic edema

Hyperplasia of mucus smooth muscle glands

 radius of conducting airways resulting in overall turbulent flow

 resistace of peripheral airways due to  airway size

 Chest wall compliance

Diaphragm (Hz insertion,  fatigue resist muscle)

Defficient colleteral ventilation

Sinusitis Laryngeal web, cyst or stenosis

Nasal foreign body Vocal cord dysfunction/

 14% will have persistent asthma with

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