The child with stridor

Question 8 from the first paper of 2020 and Question 27 from the first paper of 2016 were mainly about the handling of a paediatric airway, but the first half was also about stridor in children, and its causes. When you search for this as a string, usually four or five articles surface from the bubbling ooze of medical literature, of which for some reason three are usually different copies of Florence Cavanaghs' 1965 opus for the Proceedings of the Royal Society of Medicine. That's not a good reference. Of the current lietarture, the best single resource is probably a free copy of the 2016 article by Pfleger and Eber, if you can get a hold of it by nefarious means. An alternative might be the UpToDate article on this topic. Both of these recent resources were pillaged for information and used to construct the summary which follows.

Unfortunately, a discussion of the management of stridor depends extensively on where the stridor is coming from and what's causing it, and so this brief summary article cannot make any sensible attempt to address the management questions. All that can be done is the discussion of the various causes of stridor, and the arrangement and rearrangement of these causes into tables - according to the chronciity of the problem, the anatomical site of obstruction or vague aetiological categories. These different ways of representing the same thing should hopefully allow the trainees to settle on one specific method of remembering this information.  Some remember better when the causes are laid out according to a familiar mnemonic (VINDICATE, VITAMIN C etc) whereas others prefer to stroll anatomically through the airway, discussing the obstructions they encounter along the way.

Indications for intubation

This was asked about in Question 8 from the first paper of 2020, for 30% of the marks, i.e. they probably expected an answer with some depth. If one is hanging one's hat on the diagnosis of croup, one might benefit from bring up the Croup Score at this stage:

By this scoring system, intubation should be considered in anybody who scores 7-10. Though this is a directive which comes from a truly ancient manuscript (Downes et al, 1975), it still gets quoted in modern literature.

For non-coup, copnsider this list from Gray et al (2017):

• Suspected epiglottitis
• Inhalational injury
• Falling conscious level
• Increasing respiratory failure, indicated by:
  • Rising PaCO₂
  • Exhaustion
  • Hypoxia (SpO2 <9₂% despite high flow oxygen administered via mask)