Respiratory Emergency

Common Acquired Causes of Stridor
  Viral Croup Bacterial Tracheitis
(Bacterial Croup)
Epiglottitis Peritonsillar Abscess Retropharyngeal Abscess Foreign Body Aspiration
Etiology Parainfluenza viruses (occasionally respiratory syncytial virus and rhinovirus) Staphylococcus aureus (most)  Streptococcus pneumoniae  Polymicrobial Polymicrobial Variable
Sunflower seed
Balloons/other toys

S. pyogenes 

S. pneumoniae 

S. aureus 

Haemophilus influenzae   Oral anaerobes Gram-negative rods
Oral anaerobes
Age 6 mo–3 y old 3 mo–13 y old All ages 10–18 y old (most) 6 mo–4 y old Any
Peak 1–2 y old  Mean, 5–8 y old


Classically 1–7 y old  6 mo–5 y old (rare)  Rare >4 years  6 mo–5 y old most common
80% < 3 years
Onset 1–3 d


2–7 d viral upper respiratory infection Rapid, hours


Antecedent pharyngitis


Insidious over 2–3 d after an upper respiratory infection or local trauma Immediate or delayed possible


Suddenly worse over 8–12 h
Effect of positioning on symptoms None




Worse supine Worse supine


Neck stiffness and hyperextension Usually none
Prefer erect, chin forward Location-dependent
Stridor Inspiratory and expiratory Inspiratory Uncommon Inspiratory when severe Location-dependent
Cough Seal-like bark Usually No No No Often transient or positional
  Possible thick sputum      
Voice Hoarse Usually normal


Not muffled Possibly raspy

"Hot potato"

Primarily if at or above glottis
Drooling No Rare Yes Often Yes Rare—often if esophageal
Dysphagia Occasional No Yes Yes Yes Rare—typically if esophageal
Radiologic appearance Subglottic narrowing "steeple"  Subglottic narrowing Enlarged epiglottis May see enlarged tonsillar soft tissue  Thickened bulging retropharyngeal soft tissue


Often normal
Irregular tracheal margins


Thickened aryepiglottic folds

“thumb print” sign
Possible radiopaque density
Ball-valve effect
Segmented atelectasis
Management O2
Racemic Epi
-Keep the pt seated & uprighjt.
-O2 & administer NEB racemic or L-Epinephrine.
-Heliox also can be attempted
- Solumedrol/
-Keep the pt seated & uprighjt.
-O2 & administer NEB racemic or L-Epinephrine.
-Heliox also can be attempted
- Solumedrol/
- Solumedrol 125 mg IV
- Rocephin 2g IM
1. Immediate airway stabilization is the first priority. Intubate unstable pt before CT.
2. ABx:
3.  Dexamethasone 0.15 to 0.6 mg/kg IV
 - Max: 10 mg
4. Consult otolaryngology
If Stable:
-- Remove foreign body by bronchoscopy or laryngoscopy in controlled environment.
If unable to speak, move air poorly, or cyanotic:
- Infant: Place infant over arm or rest on lap. Give five back blows between the scapulae. If unsuccessful, turn infant over & give give chest thrusts ( not abdominal thrust)
- Child: Perform five abdominal thrusts (Heimlich maneuver) from behind a sitting of standing child.

After back, chest, &/or abdominal thrusts, open mouth using tongue-jaw lift & remove foreign body if visualized. Do not attempt blind finger sweeps. Magill forceps may be used to retrieve objects in the posterior pharynx. Ventilate if unconscious & repeat sequence as needed

If there is complete airway obstruction & pt cannot be ventilated by bac-mask or ETT, consider percutaneous (needle cricothyrotomy)