Chapter 69. Upper Respiratory Emergencies—Stridor and Drooling

The physical sign common to all causes of upper respiratory tract obstruction is stridor. Laryngomalacia, due to a developmentally weak larynx, accounts for 60% of stridor in the neonatal period, but is self-limited and rarely requires treatment. Common causes of stridor in children > 6 months of age discussed here include viral croup, epiglottitis, bacterial tracheitis, airway foreign body, retropharyngeal abscess, and peritonsillar abscess. Other etiologies including Ludwig's angina and oropharyngeal trauma are covered in Chapter 153.

Viral croup is responsible for most cases of stridor after the neonatal period. It is usually a benign, self-limited disease caused by edema and inflammation of the subglottic area. Children ages 6 months to 3 years are most commonly affected, with a peak at an age of 12 to 24 months.

Clinical Features

Croup occurs mainly in late fall and early winter, typically, beginning with a 1- to 5-day prodrome of cough and coryza, followed by a 3- to 4-day period of classic barking cough, though cough and stridor may be abrupt in onset. Symptoms peak on days 3 to 4 and are often perceived as more severe at night. Physical examination classically shows a biphasic stridor, although the inspiratory component usually is much greater.

Diagnosis and Differential

The diagnosis of croup is clinical: a barking, seal-like cough and history or finding of stridor in the appropriate setting is diagnostic. The differential diagnosis includes epiglottitis, bacterial tracheitis, or foreign body aspiration. Radiographs are not necessary, unless other causes are being considered. Lateral neck and chest radiographs may demonstrate the normally squared shoulders of the subglottic tracheal air shadow as a pencil tip, hourglass, or “steeple sign” though this sign is neither sensitive nor specific for croup.

Emergency Department Care and Disposition

1. Patients with significant stridor should be kept in a position of comfort with minimal disturbance; monitor pulse oximetry and provide oxygen as needed.

2. Administer dexamethasone 0.15 to 0.6 milligrams/kilogram (10 milligrams max) PO or IM (may use the IV formulation orally). Nebulized budesonide (2 milligrams) may be clinically useful in moderate to severe cases. Even patients with very mild croup symptoms benefit from steroids, therefore most ED patients diagnosed with croup should be treated with corticosteroids.

3. Nebulized racemic epinephrine, 0.05 mL/kg/dose up to 0.5 mL of a 2.25% solution, should be used to treat moderate to severe cases (significant stridor at rest). Alternatively L-epineprhine (1:1000), 0.5 mL/kg (to a maximum of 5 mL) can be used. Children with stridor associated only with agitation do not need epinephrine.

4. Although intubation should be performed when clinically indicated, aggressive treatment with epinephrine results in less than a 1% intubation rate. When necessary, consider a smaller endotracheal tube than estimated by age to avoid trauma to the inflamed mucosa.

5. Helium plus oxygen (Heliox), typically in a 70:30 mixture, may prevent the need for intubation in the most severe cases. Heliox can be effectively given with a maximum oxygen concentration of 40%, therefore, patients requiring higher FiO2 are not candidates for Heliox.

6. Children with persistent stridor at rest, tachypnea, retractions, and hypoxia or those who require more than two treatments of epinephrine should be admitted to the hospital.

7. Discharge criteria include the following: at least 3 hours since the last dose of epinephrine, nontoxic appearance, no clinical signs of dehydration, room air oxygen saturation greater than 90%, parents able to recognize changes in the patient's condition, and no social concerns with access to telephone and relatively short transit time to the hospital.

Epiglottitis is life threatening and can occur at any age. Historically caused by Haemophilus influenza, vaccination has decreased the occurrence of epiglottitis and shifted the median age of presentation toward older children and adults. In immunized children, most cases are caused by strep and staph species.

Clinical Features

Classically, there is abrupt onset of high fever, sore throat, and drooling. Symptoms may progress rapidly to stridor and respiratory distress. Cough may be absent and the voice muffled. The patient is toxic in appearance and may assume a tripod or sniffing position to maintain the airway. The presentation in older children and adults can be subtler. The only complaint may be severe sore throat, with or without stridor. The diagnosis is suggested by severe sore throat, normal-appearing oropharynx, and a striking tenderness with gentle movement of the hyoid.

Diagnosis and Differential

Radiographs are usually unnecessary to make the diagnosis in patients with a classic presentation. If the diagnosis is uncertain, then lateral neck films should be taken at the bedside in extension and during inspiration with a minimum of disturbance. If it is necessary for the patient to be moved to the radiology suite, a physician trained in airway management should be present at all times. The epiglottis is normally tall and thin, but in epiglottitis, it is very swollen and appears squat and fat like a thumbprint (called the “thumb sign”) at the base of the hypopharynx (Fig. 69-1). False negative radiographic evaluations do occur, and, if suspicion remains, gentle direct visualization of the epiglottis is necessary to exclude the diagnosis. Blood cultures are positive in up to 90% of patients, whereas cultures from the epiglottis are less sensitive.

Emergency Department Care and Disposition

1. Keep the patient seated and upright. Provide oxygen and administer nebulized racemic or L-epinephrine. Heliox also can be attempted.

2. In the event of total airway loss, attempt bag-valve-mask ventilation.

3. Alert a referral center or pediatric otolaryngologist to coordinate decisions regarding definitive management.

4. The most experienced individual should perform intubation as soon as the diagnosis is made. Use sedation, paralytics, and vagolytics as indicated. Multiple endotracheal tube sizes must be immediately available. For the patient who is able to maintain their airway, use of paralytics must be accompanied by the certainty that intubation will be successful or that a surgical airway can immediately be performed if unsuccessful.

5. Steroids may be employed to decrease mucosal edema of the epiglottis. Use methylprednisolone 1 milligram/kilogram IV every 6 hours or dexamethasone 0.15 to 0.6 milligrams/kilogram IV.

6. Administer antibiotics only after airway management: cefuroxime 50 milligrams/kilogram IV per dose, cefotaxime 50 milligrams/kilogram IV per dose, or ceftriaxone 50 milligrams/kilogram IV per dose are appropriate empiric options. In regions with increased cephalosporin resistance, vancomycin 10 milligrams/kilogram/dose should be added.

Bacterial tracheitis (membranous laryngotracheobronchitis or “bacterial croup”) is uncommon and can present as either a primary or secondary infection. The mean age of presentation is between 4 and 8 years of age, compared with younger ages as had been previously described. It is usually caused by S aureus, S pneumoniae, or β-lactamase–producing gram-negative organisms (Haemophilus influenza and Moraxella catarrhalis).

Clinical Features

Patients with bacterial tracheobronchitis have more respiratory distress than do patients with croup. Children appear septic and present similarly to those with epiglottitis, with the following exceptions: severe inspiratory and expiratory stridor, occasionally with thick sputum production, and a raspy hoarse voice but no dysphagia.

Diagnosis and Differential

Radiographs of the lateral neck and chest usually demonstrate subglottic narrowing of the trachea with irregular densities and ragged and indistinct borders.

Emergency Department Care and Disposition

1. Manage patients as above for epiglottitis; more than 85% require intubation. Ideally, perform intubation and bronchoscopy in the operating room where cultures and Gram stain may be obtained to guide antibiotic therapy.

2. Administer empiric parenteral antibiotics: ampicillin/sulbactam 50 milligrams/kilogram/dose or ceftriaxone 50 milligrams/kilogram IV per dose plus clindamycin 10 milligrams/kilogram/dose. In areas with increasing S. aureus resistance, consider the addition of vancomycin 10 milligrams/kilogram IV every 6 hours.

Foreign body (FB) aspirations cause more than 3000 deaths each year and have a peak incidence between ages 1 and 3 years. In children younger than 6 months, the cause is usually secondary to a feeding by a well-meaning sibling. The most common FB aspirations fall into 2 groups: food and toys. Commonly aspirated foods include peanuts, sunflower seeds, raisins, grapes, hot dogs, but almost any object may be aspirated. Unlike small round metal objects, aspirated vegetable matter commonly causes intense pneumonitis and subsequent pneumonia and suppurative bronchitis. A FB aspiration should be suspected if there is a history of sudden onset of coughing or choking and should be considered in all children with unilateral wheezing.

Clinical Features

At presentation many patients are asymptomatic. There may or may not be a witnessed aspiration. The primary symptom is cough, which is classically abrupt in onset, and may be associated with gagging, choking, stridor, or cyanosis. Signs depend on the location of the FB and the degree of obstruction: stridor with a FB in the laryngotracheal area; wheezing with a bronchial FB. Symptoms are unreliable in localizing the level of FB, however: wheeze is present in 30% of laryngotracheal FB aspirations and stridor is found in up to 10% of bronchial aspirations. Eighty percent to 90% of FBs are located in the bronchus. Patients with immediate onset of severe stridor and cardiac arrest usually have laryngotracheal aspirations.

Diagnosis and Differential

FB aspiration is easily confused with more common causes of upper respiratory diseases because 36% of patients have fever, 35% have wheezes, and 38% have rales. Plain chest radiographs can be normal in > 50% of tracheal FB and 25% of bronchial FB; more than 75% of FB in children < 3 years of age are radiolucent. In cases of complete obstruction, atelectasis may be found. In partial obstructions, a ball valve effect occurs, with air trapping caused by the FB leading to hyperinflation of the obstructed lung. Thus, in a stable cooperative child, inspiratory and expiratory posteroanterior chest radiographs may be helpful. In a stable but noncooperative child, decubitus films may be used but are less sensitive than fluoroscopy. FB aspiration is definitively diagnosed preoperatively in only one-third of cases; thus, if clinically suspected, laryngoscopy is indicated.

Upper esophageal FB are usually radiopaque and can impinge on the posterior aspect of the trachea. Patients may present with stridor, and typically have dysphagia. Radiographically, flat FBs such as coins are usually oriented in the sagittal plane when located in the trachea (which appear as a thick line in an anterioposterior chest radiograph) and in the coronal plane when in the esophagus (which appear round on an anterioposterior chest radiograph).

Emergency Department Care and Disposition

1. If FB aspiration or airway obstruction is clearly present, perform BLS procedures to relieve airway obstruction (see Chapter 3).

2. If BLS maneuvers fail, undertake direct laryngoscopy with Magill forceps to remove the FB. If the FB cannot be seen, orotracheal intubation with dislodgement of the FB distally may be lifesaving.

3. Consider racemic epinephrine or Heliox as symptomatic palliatives.

4. Definitive treatment usually requires rigid bronchoscopy in the operating room under general anesthesia.

Clinical Features

Retropharyngeal abscess is the second most commonly seen deep neck infection, and usually occurs in children between 6 months and 4 years of age. Patients classically appear toxic and present with fever, drooling, dysphagia, and inspiratory stridor. Patients may hold their neck in an unusual position with torticollis, hyperextension, or stiffness. Dysphagia and refusal to feed occur before significant respiratory distress. Patients may develop rapidly fatal airway obstruction from sudden rupture of the abscess pocket. Aspiration pneumonia, empyema, mediastinitis, and erosion into the jugular vein and carotid artery are reported complications.

Diagnosis and Differential

Physical examination of the pharynx may show a retropharyngeal mass. Although palpation commonly will demonstrate fluctuance, this could lead to rupture of the abscess. Lateral neck radiograph performed during inspiration may show a widened retropharyngeal space. The diagnosis is suggested when the retropharyngeal space at C2 is twice the diameter of the vertebral body or greater than one half the width of C4. CT of the neck with IV contrast is thought to be almost 100% sensitive and very helpful in differentiation between cellulitis and abscess.

Emergency Department Care and Disposition

1. Immediate airway stabilization is the first priority. Intubate unstable patients before performing CT.

2. Antibiotic choice is controversial because most retropharyngeal abscesses contain mixed flora. Consider ampicillin/sulbactam 50 milligrams/kilogram/dose IV hours and/or clindamycin 10 milligrams/ kilogram IV hours. Substitute ceftriaxone 50 milligrams/kilogram/dose for ampicillin/sulbactam in the penicillin-allergic patient.

3. Consider adjunctive treatment with parenteral steroids (eg, dexamethasone 0.15 to 0.6 milligrams/kilogram IV to a maximum of 10 milligrams).

4. Consult otolaryngology for operative incision and drainage as indicated. Although cellulitis and some very small abscesses may do well with antibiotics alone, most require surgery.

Clinical Features

Peritonsillar abscess in children most commonly presents in adolescents with an antecedent sore throat. Patients usually appear acutely ill with fevers, chills, dysphagia/odynophagia, trismus, drooling, and a muffled “hot potato” voice.

The uvula is displaced away from the affected side. As a rule, the affected tonsil is anteriorly and medially displaced.

Diagnosis and Differential

The diagnosis can typically be made through careful visualization of the oral cavity. Classic findings include uvular deviation away from the abscess, soft palate displacement, trismus, and localized fluctuance; airway compromise may occur. In typical cases, imaging studies are unnecessary, though in patients with toxic appearance or atypical exam findings, computed tomography (CT) with contrast or ultrasound is indicated.

Emergency Department Care and Disposition

1. Treat most cases with needle aspiration, antibiotics, and pain control. Administer topical (eg, benzocaine or endocaine spray), oral (eg, oxycodone or vicodin), or parenteral (eg, fentanyl, morphine) analgesics, then aspirate the abscess using a large gauge needle. Avoid deep penetration which could injure adjacent vascular structures and result in significant bleeding. The last centimeter of the tip of a needle guard can be cut off, and carefully reattached to the aspirating syringe, covering all but the end of the needle, to limit the depth of penetration.

2. Consider clindamycin 10 milligrams/kilogram IV hours or ampicillin/sulbactam 50 milligrams/kilogram/dose IV hours. Definitive follow-up is essential in all cases. Oral antibiotics for outpatient treatment include amoxicillin/clavulanate 22.5 milligrams/kilogram/dose given twice daily.

3. Formal incision and drainage in the operating room is sometimes necessary, especially in young or uncooperative patients. Most patients can be discharged safely on oral antibiotics following drainage.