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Pediatric Stridor, Aspiration, and Cough

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Chad Keller

on 13 November 2013

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Transcript of Pediatric Stridor, Aspiration, and Cough

Ohio Health Doctors Hospital
Stridor worsens with crying, feeding, or in supine position in the first few weeks of life

High Pitched Inspiratory Stridor

NPL confirms diagnosis--also document signs of reflux
Pediatric Stridor, Aspiration, and Cough
Abnormal sound due to turbulent airflow

Inspiratory: Supraglottic

Expiratory: Intrathoracic

Biphasic: Fixed anatomic obstruction

High Pitched: Neonates with laryngomalacia
Stertor vs Stidor
Caution that agitation from scope can precipitate airway emergency.

Use of NPL is invaluable, but Rigid Laryngotracheobronchoscopy is standard for evaluation of patient with stridor
Rigid Scope
IV steroids o.5-1.0 mg/kg shold be given periop

Spray Larynx with topical lidocaine to reduce laryngospasm

Airway can be sized by intubating with a cuffless ET tube and documenting when air leak is appreciated at <20cmH2o
Chad Keller, D.O. PGY-3
1. Has patient ever been intubated?

2. Has patient ever had any surgical airway interention?

3.Difficult Feeding? Hoarseness?
(This indicates Reflux Symptoms)

4.Croup Episodes?

5. Neurologic or cardiac abnormalities?
Key History Points
Stertor is like snoring or grunting

Video of Stridor
Most Common Cause of Stridor in a Child?
Immature cartilages and/or immature neuromuscular tone of larynx

This leads to obsruction of the supraglottis
Inward collapse of aryepiglottic folds


Long tubular epiglottis that folds on its self

Anteromedial collapse of the corniculate and cuneiform cartilages

Posterior inspiratory displacement of the epiglottis against posterior pharyngeal wall

Inferior collaps of epiglottis toward the vocal folds

Short aryepiglottic folds

Signs and Symptoms
Natural Course and Treatment
Natural course is sponatneous resolution over the first 1-2 years of life

Medical management: Aggressive Acid Suppresion

Surgical interention if FTT, cor pulmonale and/or cyanosis
Surgery: Supraglottaoplsty

Vascular Anomolies
Most Common:
Abberant Right Subclavian Artery

High-Riding innominate artery

Pulmonary artery sling

Vascular rings and Slings
Aberant Right Subclavian Artery
Most kids present with dysphagia Lusoria 2/2 retroesophageal course of artery

Diagnosis often made by barium esophagram that shows filling defect of the esophagus and this is confirmed by CTA, MRI, or MRA

Abberant Course of Innominate Artery
Commonly compresses the anterior tracheal wall

In symptomatic children:
"recurrent croup",
recurrent pneumonia,
expiratory, and
biphasic stridor can occur

Application of pressure to the anterior trachea with brochoscope diminishes the brachial pulse
Diagnosis made by CTA, MRI, or MRA

Normally passes from its origin on aortic arch left of midline across the anterior trachea to right side

Pulmonary Artery Sling or Vascular Ring

2 Most Common: Double Aortic Arch and Right Aortic Arch with Left Ligamentum Arteriosum

Double Aortic Arch 2/2 to persistence of embryologic bilateral 4th brachial arch vessels and dorsal aorta

Pulmonary Artery Sling when left main pulmonary artery arises as branch of right pulmonary artery 2/2 to 6th brachial arch abnormality

What congenital anomaly is Pulmonary Sling associated with?
Complete Tracheal Rings

Parainfluenza Virus Type 1

RSV and Parainfluenza Types 2/3 less commonly

6 months to 3 years most commonly affected

When under 1 year of age explore possibility of airway abnormality or stenosis

AKA Croup
2-3 day prodrome of URI
Barking Cough
Inspiratory stridor
Steeple Sign
shows narrowing of subglottis
Thumbprint Sign
shows edematous epiglottis

Treatment Options
Self limited
Blow-By O2 supplementtion
Nebulized Raecemic Epi
Heliox to reduce work of breathing

Vocal Cord Immobility
3rd MC cause of congenital stridor

Seen in:
Arnold-Chiari Malformation


Traujma from stretch injury to RLN (i.e cardiac surgery)

Vocal Cord Immobility
Weak Voice

Inspiratory Stridor and abnormal cough

Vocal fold movement can be difficult to distinguish between Bernoulli effect

Can be misdiagnosed in place of pseudoparalyisis or CA joint ankylosis

If very uncertain Laryngeal EMG can be performed
Treat underlying cause

Most idiopathic cases resolve in first 2 years of life
Subglottic Stenosis
Congenial vs. Acquired

Subglottis: Lower surface of true vocal cords to the inferior margin of the cricoid cartilage

Narrowest part of infants airway

Typtically 4-7 mm

Less than 4 mm in newborn and less thatn 3.5 mm in premature infant is diagnostic

Acquired Subglottic Stenosis
Most common Type

2/2 to prolonged intubation from lung disease

Risk Factors include:

Prolonged Intubation
Too large ET Tube
Recurrent Intubation
Presence of infection during intubation

Blunt, Penetrating, or Caustic Trauma

Iatrogenic from Cricothyriodotomy, High Trach, or Laser Surgery
Congenital Subglottic Stenosis
When all other causes are ruled out
Failure during embryogenesis for laryngeal lumen to recanalize


Membranous or Cartilagenous
i.e. Eliptical Cricoid

Grade I/II: medical management with close observation, GERD therapy
Grade III/IV: Surgery

Options Include:

Trach, Endoscopic Dilation, Posterior and Anterior Cricoid Split, Cartilage Grafting, Cricotracheal Resectio

Cough and choking with feeding
Recurrent PNA?
Recurrent Respiratory Infection?

NPL can detect vocal cord mobility and obvious structural abnormalities

FEES to evaluate swallowing mechanism

Limitation to FEES is the white out stage precludes the swallow itself
Radiographic Studies

Videoflouroscopic swallow study


Upper GI series

Gold Standard: Evaluation of phases of swallowing with barium by SLP

Abnormal Radiographic Findings on a Modified Barium Swallow
Oral Preparatory:

Lack of Bolus Formation

Adherence to hard palate

Reduced Esophageal Peristalsis

Modified Barium Swallow

Delayed Oral transit time

Reduced tongue elevation

Tongue incoordination

Delayed Pharyngeal Transit Time
Pooling in Pharyneal Recesses
Residule in Pharyngeal Recesses
Laryngeal Penetration
Cricopharyngeal Dysfunction
Abnormal Findings on Modified Barium Swallow
Laryngeal Cleft
Grade I: Involving only the interarytenoid muscle

Grade II: involving part of the cricoid

Grade III:
involving all the cricoid

Grade IV: extending into the cleft

Signs and Symptoms
Recurrent Pneumonia?
Cyanotic Episodes with Feeding?

D/L and Bronch

Palpate interarytenoid Muscular Cleft
Mild Clefts Can be observed
Severe Clefts require surgical intervention
i.e. endoscopic or open
Trahceal Esophageal Fistulas
V: Vertebral Abnormalities

A: Anal Atresia

C: CV abnormalities


R: Renal Insufficiency

L: Limb Abnormalities

Methods of Control of Sialorrhea
SMG Reouting: Involves tonsillectomy and rerouting Warthin's Ducts to Fossae
Excision of SMG
Parotid Duct Ligation

1. Commit to memory an anatomic image of where all the cough receptors are located and use it as a systematic map to direct the evaluation.

Through out the Airways and UGI tract as well as pericardium and diaphram

Concentrated in the larynx and carina
No receptors lie beyond the terminal bronchioles

Also found in the nose, nasopharynx, posterior oropharynx, EAC, TM, stomach, esophagus, and pleura
Is Cough Physiologic or Pathologic
Cough Reflex Arc Has 5 components
1. Cough Receptors
2. Afferent Nerves
3. Poorly defined cough center
4. Efferent Nerves
5. Effector Muscles

Apply Basic Science
Consider Etiologies outside of ENT

i.e. Neurologic Causes such as Vagus Neurilemomas

i.e. Orthopedic Causes such as cervical osteophytes
Don't Forget Functional Etiologies
i.e. Tic Cough, Habit Cough
Diagnosis of exclusion
The History
Is the cough Wet or Dry?
Duration of Cough?
What are classic Characteristics
The Physical Examination
Evaluation for asthma, i.e. Wheezing, Crepitations

80% of Asthma Exacerbations are 2/2 viral infection

Digital Clubbing raises suspicion for Cystic Fibrosis
The Diagnostic Tests
Chest Xray


High Resolution chest and sinus CT are gold standards for evaluating airway anatomy

PPD to rule out TB

Gram Stain, acid fast stain and culture of sputum

Elusive Diagnosis
Pay attention to Choanal Atresia

If you suspect FB

If you supect food impaction or esophagitis
Children are not just small adults
Viruses that cause common cold in adults may cause signicant respiratory distress in children

Distinct maturational differences in the airway anatomy

Vastly different responses to medication

Medical History from limited parental perception
Chronic Productive Cough
Investigate for:


Primary Dyskinesia

Don't ignore a cough when there should be one.
Most common reason is loss of the cough receptor or afferent limb of reflex

Phases of Cough

1) Initial inspiratory phase, TVC maximally abducted, lungs fill with high volume air

2) Rapid closure of the larynx, expiratory muscle contraction to increase airway pressure

3) Glottis suddenly opens and rapid airflow expectorates mucous or FB

Velocity is maintained by continued narrowing of the opened supraglottic larynx

Etiologies of Cough


Sinonasal Causes of cough
a. No data in children to demonstrate Post Nasal Drip
b. More likely to be infectious or inflammatory etiology

2. Airway lesions and Cough
a. Tracheomalacia may impede airway secretion

3. Enviornmental Toxicants
a. Smoke Inhalation

4. Chronic Nocturnal Cough
a. Occurs in children with Rhinosinusitis

5. Post-Infectous Cough
a. Common in day care children
b. Walking PNA: Mycoplasma

6. FB
a. Single most important part of physical exam is the double-headed stethoscope

a. Defined as a cough that improves or is eliminated with GERD specific therapy
b. Therapy Duration: 2 month trial

OTC Expectorants and cough suppressants are waste of money

American academy of peds recommends against Codeine and Dextromethorphan

Cough in children is based upon etiology so treat accordingly

Nonspecific Cough Treatment
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