Stridor In children
🔎 Definition &
Significance
- Stridor
= เสียงหายใจ high-pitched, monophonic จาก turbulent airflow ใน upper
airway
- บ่งชี้ว่า มี airway obstruction ระดับ
supraglottis →
trachea
- เป็น symptom ที่ต้องประเมินเร่งด่วน เพราะอาจนำไปสู่ respiratory failure
⚙️ Pathophysiology (key concept)
- เกิดจาก airway narrowing → ↑
airflow velocity →
↓ pressure
(Bernoulli effect) →
airway collapse + vibration →
stridor
- Airway
resistance ∝ 1 / r⁴
→ เด็กเล็ก narrowing เล็กน้อย → resistance เพิ่มมาก
📍 Anatomical
Classification
1. Extrathoracic airway
- Supraglottis
/ glottis / subglottis
- collapse
ง่าย → inspiratory stridor
2. Intrathoracic airway
- Trachea
(intrathoracic), bronchi
- → expiratory stridor หรือ wheeze-like
🎧 Auscultatory Clues (สำคัญมากใน ER)
|
Type |
Suggest |
|
Inspiratory stridor |
Extrathoracic obstruction |
|
Expiratory stridor |
Intrathoracic obstruction |
|
Biphasic stridor |
Fixed airway obstruction |
|
Stertor (low-pitched) |
Naso/oropharyngeal obstruction |
🧠 Differential Diagnosis
(แบ่งตามเวลา)
⚡ Acute / Subacute
(life-threatening ต้องคิดก่อน)
Common + Important
- Croup
(laryngotracheitis) →
most common
- Epiglottitis
→ drooling, toxic,
tripod
- Bacterial
tracheitis
- Foreign
body aspiration
- Anaphylaxis
- Retropharyngeal
/ peritonsillar abscess
- Airway
burn / caustic ingestion
👉 Key pattern
- Fever
+ toxic → bacterial
infection
- Sudden
onset, no fever → FB /
anaphylaxis
- Barking
cough → croup
🔁 Intermittent
- Spasmodic
croup
- Vocal
cord dysfunction (ILO)
- Hypocalcemia
(laryngospasm)
- Papillomatosis
🕰️ Chronic
Congenital
- Laryngomalacia
(most common infant)
- Tracheomalacia
- Vocal
cord paralysis
- Vascular
ring
- Subglottic
stenosis
Acquired
- Tumor
/ mediastinal mass
- Post-intubation
stenosis
- RRP
(HPV)
🧾 Clinical Assessment
(practical approach)
🚨 1. Initial rapid
assessment (ABCs)
- Airway
patency
- Work
of breathing (retraction, nasal flaring)
- Hypoxemia
/ fatigue
- Do
NOT delay airway management for investigations
🗣️ 2. History (key clues)
- Age → congenital vs acquired
- Onset
→ acute vs chronic
- Associated:
- Drooling
→ supraglottic
obstruction
- Hoarseness
→ vocal cord
- Barking
cough → croup
- Rash
→ anaphylaxis
- Feeding-related
→ aspiration /
TEF
🔍 3. Physical exam
- Observe
breathing pattern
- Position
(tripod in epiglottitis)
- Listen
over neck (not just chest)
- Look
for:
- Retraction,
cyanosis
- Neck
swelling
- Skin
hemangioma → airway
hemangioma
🧪 Investigations (เฉพาะ stable patient)
Imaging
- X-ray
neck
- Croup
→ steeple sign
- Epiglottitis
→ thumb sign
- Chest
X-ray
- FB,
mass, vascular ring
- CT
- structural
lesion, abscess, tumor
Airway visualization (gold standard)
- Flexible
laryngoscopy
- Bronchoscopy
(especially FB)
Spirometry (เด็กโต)
- Flow-volume
loop → localization
⚠️ Red Flags (ต้องจัดการ
airway ทันที)
- Drooling
+ tripod
- Severe
retraction / fatigue
- Altered
mental status
- Cyanosis
/ hypoxia
- Rapid
progression
🩹 Management Principles
- Priority
= airway first
- Oxygen
+ minimal agitation
- Avoid
unnecessary exam in unstable (เช่น tongue depressor ใน suspected epiglottitis)
- Prepare
for:
- Intubation
- Surgical
airway (rare)
Cause-specific
- Croup
→ steroid + nebulized
epinephrine
- Epiglottitis
→ airway + IV
antibiotics
- Anaphylaxis
→ IM epinephrine
- FB → bronchoscopy
🧠 Key Takeaways (สำหรับใช้งานจริง)
- Stridor
≠
wheeze → think upper
airway
- Timing
of sound = localization clue
- Acute
onset → life-threatening
causes first
- Do
not send unstable patient to X-ray
- Definitive
diagnosis = airway visualization
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