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APPROCH TO STRIDORAPPROCH TO STRIDOR

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Stridor, although a relatively common Stridor, although a relatively common occurrence, can be frightening to both child occurrence, can be frightening to both child and parents.and parents.

StridorStridor is a harsh, high-pitched respiratory is a harsh, high-pitched respiratory sound, which is usually inspiratory but it can be sound, which is usually inspiratory but it can be biphasic and is produced by turbulent airflow; it biphasic and is produced by turbulent airflow; it is not a diagnosis but a sign of upper airway is not a diagnosis but a sign of upper airway obstruction obstruction

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PATHOPHYSIOLOGYPATHOPHYSIOLOGYStridor is an externally audible sound Stridor is an externally audible sound associated with respiration. It is produced by associated with respiration. It is produced by turbulent air flow through large airways. It turbulent air flow through large airways. It occurs when a normal respiratory volume of air occurs when a normal respiratory volume of air moves through narrowed airways, which results moves through narrowed airways, which results in the normal laminar flow becoming turbulent. in the normal laminar flow becoming turbulent. Stridor thus signifies partial airway obstructionStridor thus signifies partial airway obstruction

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DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISStridor may occur in a wide variety of disease Stridor may occur in a wide variety of disease processes affecting the large airways from processes affecting the large airways from the nares to the bronchi but most often arises the nares to the bronchi but most often arises with disorders of the larynx and trachea.with disorders of the larynx and trachea. For the purposes of differential diagnosis, it For the purposes of differential diagnosis, it is helpful to categorize the common causes is helpful to categorize the common causes of stridor as acute or chronic in onset and to of stridor as acute or chronic in onset and to further divide acute onset into febrile and further divide acute onset into febrile and afebrile causes.afebrile causes. In addition, life-threatening causes of stridor In addition, life-threatening causes of stridor must be considered during the earliest must be considered during the earliest phases of evaluation.phases of evaluation.

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Common Causes of StridorCommon Causes of Stridor– Acute, FebrileAcute, Febrile

CroupCroupTracheitisTracheitisEpiglottitisEpiglottitisRetropharyngeal abscessRetropharyngeal abscess

Acute, AfebrileAcute, AfebrileForeign bodyForeign bodyCaustic or thermal injury to airwayCaustic or thermal injury to airwaySpasmodic croupSpasmodic croupAngioneurotic edemaAngioneurotic edema

ChronicChronicLaryngomalaciaLaryngomalaciaVascular anomaliesVascular anomaliesAdenotonsillar hyperplasiaAdenotonsillar hyperplasia

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Life-threatening Causes of Life-threatening Causes of StridorStridor

Usually FebrileUsually FebrileEpiglottitisEpiglottitisRetropharyngeal abscessRetropharyngeal abscessTracheitisTracheitis

Usually AfebrileUsually AfebrileForeign bodyForeign bodyAngioneurotic edemaAngioneurotic edemaNeck traumaNeck traumaNeoplasm (compressing trachea)Neoplasm (compressing trachea)Thermal or caustic injury Thermal or caustic injury

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Stridor with Acute Onset in the Stridor with Acute Onset in the Febrile ChildFebrile Child

LaryngotracheitisLaryngotracheitis (croup) is by far the most (croup) is by far the most common cause of stridor in the febrile child. common cause of stridor in the febrile child.

Clinical manifestation&examinationClinical manifestation&examination

Radiographs of the neck (steeple sign)Radiographs of the neck (steeple sign)

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EpiglottitisEpiglottitis This dramatic, potentially lethal condition is characterized by an This dramatic, potentially lethal condition is characterized by an acute potentially fulminating course of high fever, sore throat, acute potentially fulminating course of high fever, sore throat, dyspnea, and rapidly progressing respiratory obstruction. dyspnea, and rapidly progressing respiratory obstruction.

healthy child suddenly develops a sore throat and fever. Within a healthy child suddenly develops a sore throat and fever. Within a matter of hours, the patient appears toxic, swallowing is difficult, and matter of hours, the patient appears toxic, swallowing is difficult, and breathing is labored. Drooling is usually present and. The child may breathing is labored. Drooling is usually present and. The child may assume the tripod position .assume the tripod position .

Stridor is a late finding and suggests near-complete airway Stridor is a late finding and suggests near-complete airway obstruction. Complete obstruction of the airway and death can obstruction. Complete obstruction of the airway and death can ensue unless adequate treatment is provided.ensue unless adequate treatment is provided.

The barking cough typical of croup is rare. Usually, no other family The barking cough typical of croup is rare. Usually, no other family members are ill with acute respiratory symptoms.members are ill with acute respiratory symptoms. Dignosis large, “cherry red” swollen epiglottis by laryngoscopy Dignosis large, “cherry red” swollen epiglottis by laryngoscopy Classic radiographs of a child who has epiglottitis show the “thumb Classic radiographs of a child who has epiglottitis show the “thumb sign sign

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The clinical picture of a The clinical picture of a retropharyngeal retropharyngeal abscessabscess is similar to epiglottitis, except is similar to epiglottitis, except symptoms appear more gradually with a mean symptoms appear more gradually with a mean duration of illness between 5 and 6 days. In duration of illness between 5 and 6 days. In addition to drooling and stridor, meningismus addition to drooling and stridor, meningismus and torticollis caused by muscular irritation by and torticollis caused by muscular irritation by the abscess may be present.the abscess may be present.

Physical examination may reveal midline Physical examination may reveal midline fullness of the oropharynx.fullness of the oropharynx.

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Strdor with Acute Onset in the Strdor with Acute Onset in the Afebrile ChildAfebrile Child

A foreign body in either the trachea or esophagus may A foreign body in either the trachea or esophagus may produce stridor. There may be a history of choking on produce stridor. There may be a history of choking on food or a small object.food or a small object. Physical examination varies, depending on location of Physical examination varies, depending on location of the foreign body.the foreign body.Ingestion of either caustic or hot substances may Ingestion of either caustic or hot substances may result in injury to the airway or hypopharynx. result in injury to the airway or hypopharynx. Symptoms of airway compromise may be delayed for Symptoms of airway compromise may be delayed for as long as 6 hours. Drug abuse is yet another as long as 6 hours. Drug abuse is yet another potential source of injury: thermal epiglottitis has been potential source of injury: thermal epiglottitis has been reported after inhalation of crack smoke, a screen reported after inhalation of crack smoke, a screen from a crack pipe, and a marijuana cigarette.from a crack pipe, and a marijuana cigarette.

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Chronic StridorChronic StridorThe age at onset narrows the differential diagnosis.The age at onset narrows the differential diagnosis. Stridor noted shortly after birth is most likely caused by a structural defect. Stridor noted shortly after birth is most likely caused by a structural defect. This type of stridor tends to slowly worsen and is severe only when the This type of stridor tends to slowly worsen and is severe only when the infant is stressed such as during crying.infant is stressed such as during crying. LaryngomalaciaLaryngomalacia is the most common cause of congenital stridor. Stridor is the most common cause of congenital stridor. Stridor associated with laryngomalacia is positional and is ameliorated by placing associated with laryngomalacia is positional and is ameliorated by placing the infant in the prone position.the infant in the prone position. Other congenital causes of stridor include Other congenital causes of stridor include laryngeal webs, laryngeal laryngeal webs, laryngeal diverticula, vocal cord paralysis, subglottic stenosis, tracheomalacia, and diverticula, vocal cord paralysis, subglottic stenosis, tracheomalacia, and vascular anomalies, such as a double aortic arch or a vascular slingvascular anomalies, such as a double aortic arch or a vascular sling. . Stridor in infants has also been reported to be associated with Stridor in infants has also been reported to be associated with gastroesophageal refluxgastroesophageal reflux..Stridor in older children may be caused by Stridor in older children may be caused by papillomas or neoplastic papillomas or neoplastic processes.processes. Patients with papillomas generally present between 2 to 4 years of age Patients with papillomas generally present between 2 to 4 years of age with complaints of hoarseness and stridor. Neoplastic processes causing with complaints of hoarseness and stridor. Neoplastic processes causing tracheal compression can also lead to stridor in the older child.tracheal compression can also lead to stridor in the older child.

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Psychogenic,Psychogenic, also called functional, stridor is an also called functional, stridor is an uncommon cause of stridor in the older child.. uncommon cause of stridor in the older child.. Adolescent girls are diagnosed three times more Adolescent girls are diagnosed three times more often with this condition than are males.often with this condition than are males.

. Characteristically, stridor improves when the . Characteristically, stridor improves when the patient is unaware that he or she is being patient is unaware that he or she is being observed, and it may clear with cough. observed, and it may clear with cough.

The diagnosis can be confirmed only by direct The diagnosis can be confirmed only by direct laryngoscopy in the symptomatic patient when laryngoscopy in the symptomatic patient when the vocal cords are noted to be adducted during the vocal cords are noted to be adducted during inspiration.inspiration.

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EVALUATION AND DECISIONEVALUATION AND DECISIONThe first priority is to ensure the airway is adequate by The first priority is to ensure the airway is adequate by assessing level of consciousness, color, perfusion, air assessing level of consciousness, color, perfusion, air entry, breath sounds, and work of breathing, including entry, breath sounds, and work of breathing, including respiratory rate, nasal flaring, and retractions. respiratory rate, nasal flaring, and retractions.

The child may then be evaluated systematically. In the The child may then be evaluated systematically. In the child with acute onset of stridor, history should focus child with acute onset of stridor, history should focus on associated symptoms such as fever, duration of on associated symptoms such as fever, duration of illness, drooling, rhinorrhea, and history of illness, drooling, rhinorrhea, and history of choking .Immunization status should be verified, choking .Immunization status should be verified, particularly particularly H. influenzaeH. influenzae vaccination. vaccination. In the case of a child with chronic stridor, important In the case of a child with chronic stridor, important historical points include onset and progression of historical points include onset and progression of stridor, as well as ameliorating and aggravating stridor, as well as ameliorating and aggravating factors.factors.

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Several characteristics of stridor, such as associated Several characteristics of stridor, such as associated phase of respiration, pitch, and length of respiratory phase of respiration, pitch, and length of respiratory phase, can help determine the level of obstruction. phase, can help determine the level of obstruction.

Inspiratory stridor occurs with obstruction of the Inspiratory stridor occurs with obstruction of the extrathoracic trachea, biphasic stridor when both extrathoracic trachea, biphasic stridor when both extrathoracic and intrathoracic trachea are involved, and extrathoracic and intrathoracic trachea are involved, and expiratory stridor when only the intrathoracic trachea is expiratory stridor when only the intrathoracic trachea is involved.involved. The pitch of the stridor also helps determine location. The pitch of the stridor also helps determine location. Laryngeal and subglottic obstructions are associated Laryngeal and subglottic obstructions are associated with high-pitched stridor. In contrast, obstruction of the with high-pitched stridor. In contrast, obstruction of the nares and nasopharynx results in lower-pitched snoring nares and nasopharynx results in lower-pitched snoring or snorting sounds also called or snorting sounds also called stertorstertor. Because the . Because the passage of saliva and the flow of air are impeded in passage of saliva and the flow of air are impeded in pharyngeal obstruction, these patients often have a pharyngeal obstruction, these patients often have a gurgling quality of breathing.gurgling quality of breathing.–

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EVALUATION AND DECISIONEVALUATION AND DECISION

Last, the relative length of inspiratory and Last, the relative length of inspiratory and expiratory phase may be helpful. In expiratory phase may be helpful. In children with laryngeal obstruction, the children with laryngeal obstruction, the time of inspiration is greatly increased, time of inspiration is greatly increased, whereas expiration tends to be prolonged whereas expiration tends to be prolonged in bronchial obstruction. Both inspiration in bronchial obstruction. Both inspiration and expiration times are increased in and expiration times are increased in patients with tracheal obstruction.patients with tracheal obstruction.

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Physical examination should include careful Physical examination should include careful examination of the nares and oropharynx with examination of the nares and oropharynx with particular attention to increased secretions, drooling, particular attention to increased secretions, drooling, visible mass, and abnormal phonation. Regional visible mass, and abnormal phonation. Regional findings such as adenopathy, neck masses, findings such as adenopathy, neck masses, meningismus, trauma, or bruising should also be meningismus, trauma, or bruising should also be sought. sought.

Position of comfort should be noted. Children with Position of comfort should be noted. Children with airway obstruction at the level of the larynx and above airway obstruction at the level of the larynx and above usually hyperextend their heads upon their necks and usually hyperextend their heads upon their necks and lean forward (“sniffing” position) in an effort to lean forward (“sniffing” position) in an effort to straighten their upper airway and maximize air entry. straighten their upper airway and maximize air entry. This posture does not help relieve more distal This posture does not help relieve more distal obstruction.obstruction.

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Quality of the voice or cry should be noted as normal, Quality of the voice or cry should be noted as normal, hoarse (croup, vocal cord paralysis, papilloma), weak hoarse (croup, vocal cord paralysis, papilloma), weak (neuromuscular disorder), or aphonic (laryngeal (neuromuscular disorder), or aphonic (laryngeal obstruction by a foreign body).obstruction by a foreign body).

Response to therapies, such as nebulized racemic Response to therapies, such as nebulized racemic epinephrine (croup), should be noted.epinephrine (croup), should be noted.

Emergency management of the child with stridor Emergency management of the child with stridor depends on its severity and its likely cause. Oxygen, depends on its severity and its likely cause. Oxygen, humidified air, nebulized epinephrine, corticosteroids, humidified air, nebulized epinephrine, corticosteroids, laryngoscopy, intubation, and even emergency laryngoscopy, intubation, and even emergency cricothyroidotomy or tracheostomy all havecricothyroidotomy or tracheostomy all have

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Febrile ChildFebrile Child In the febrile child with stridor, the onset is generally acute and the In the febrile child with stridor, the onset is generally acute and the

most likely, as well as concerning, diagnostic possibilities are croup, most likely, as well as concerning, diagnostic possibilities are croup, epiglottitis, and bacterial tracheitis. epiglottitis, and bacterial tracheitis.

Radiographs of the neck may be helpful in evaluation and should be Radiographs of the neck may be helpful in evaluation and should be considered if diagnosis other than croup is suspected .considered if diagnosis other than croup is suspected .

If epiglottitis is strongly suspected, a lateral neck radiograph should be If epiglottitis is strongly suspected, a lateral neck radiograph should be obtained in the ED, or the child should be taken to the operating room to obtained in the ED, or the child should be taken to the operating room to have direct visualization of the epiglottis under controlled conditions.have direct visualization of the epiglottis under controlled conditions.

increased prevertebral width (retropharyngeal abscess), swollen increased prevertebral width (retropharyngeal abscess), swollen

epiglottis or aryepiglottic folds (epiglottitis), and irregular tracheal borders or epiglottis or aryepiglottic folds (epiglottitis), and irregular tracheal borders or stranding across the trachea (tracheitis). stranding across the trachea (tracheitis).

Radiographic findings consistent with croup are a narrowed subglottic Radiographic findings consistent with croup are a narrowed subglottic area on anteroposterior view (the “steeple sign”) and ballooning of the area on anteroposterior view (the “steeple sign”) and ballooning of the hypopharynx, best appreciated on the lateral view.hypopharynx, best appreciated on the lateral view.

. To properly interpret the prevertebral space, the lateral neck radiograph . To properly interpret the prevertebral space, the lateral neck radiograph must be taken with the patient's head extended and during inspiration. must be taken with the patient's head extended and during inspiration. Normal tracheal buckling, which is seen during expiration in a young child, Normal tracheal buckling, which is seen during expiration in a young child, may be misinterpreted as tracheal mass lesion or deviation from an extrinsic may be misinterpreted as tracheal mass lesion or deviation from an extrinsic mass In children, the preverterbral space should be less than 75% the width mass In children, the preverterbral space should be less than 75% the width of the body of c4of the body of c4

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Afebrile ChildAfebrile Child In the afebrile child with acute onset of stridor, the duration In the afebrile child with acute onset of stridor, the duration

of stridor, the likelihood of foreign-body aspiration, and the of stridor, the likelihood of foreign-body aspiration, and the child's age are all key elements to consider. child's age are all key elements to consider.

Emergent otolaryngologic or surgical consultation should be Emergent otolaryngologic or surgical consultation should be obtained in a child with evidence of airway obstruction if either obtained in a child with evidence of airway obstruction if either aspirated foreign body or trauma is a likely cause of stridor. aspirated foreign body or trauma is a likely cause of stridor.

Angioneurotic edema, an AD trait, is characterized by rapid Angioneurotic edema, an AD trait, is characterized by rapid onset of swelling without discoloration, urticaria, or pain. onset of swelling without discoloration, urticaria, or pain. Symptoms may occur in affected patients as young as 2 years Symptoms may occur in affected patients as young as 2 years of age but usually are not severe until adolescence; they may of age but usually are not severe until adolescence; they may be precipitated by trauma, emotional stress, or menses. be precipitated by trauma, emotional stress, or menses. Determination of the C1 esterase inhibitor level should be Determination of the C1 esterase inhibitor level should be considered if angioneurotic edema is suspected.considered if angioneurotic edema is suspected.

A child with chronic stridor generally does not require an A child with chronic stridor generally does not require an extensive evaluation in the ED unless significant respiratory extensive evaluation in the ED unless significant respiratory distress is present. distress is present.

The infant with chronic stridor who is otherwise well should be The infant with chronic stridor who is otherwise well should be referred to an otolaryngologist. referred to an otolaryngologist.

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TREATMENTTREATMENTThe mainstay of treatment for children with The mainstay of treatment for children with croupcroup is airway management is airway management

Most children with either acute spasmodic Most children with either acute spasmodic croup or infectious croup can be managed croup or infectious croup can be managed safely at homesafely at home. . Mist has been traditionally used Mist has been traditionally used to treat croupto treat croup. . Given the risk of burns and the Given the risk of burns and the observation that cold night air is also beneficial observation that cold night air is also beneficial led to the use of cool mist led to the use of cool mist

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Nebulized racemic epinephrineNebulized racemic epinephrine is an accepted is an accepted treatment for moderate or severe crouptreatment for moderate or severe croup. . The mechanism of The mechanism of action is constriction of the precapillary arterioles through the action is constriction of the precapillary arterioles through the ββ--adrenergic receptors, causing fluid resorption from the adrenergic receptors, causing fluid resorption from the interstitial space and a decrease in the laryngeal mucosal interstitial space and a decrease in the laryngeal mucosal edemaedema..DOSE DOSE indicationsindications includes moderate to severe includes moderate to severe stridor at reststridor at rest,, the the possible need for intubation, respiratory distress, and hypoxiapossible need for intubation, respiratory distress, and hypoxia. . The duration of activity of racemic epinephrine is <2 hrThe duration of activity of racemic epinephrine is <2 hr. . Therefore, observation is mandatedTherefore, observation is mandated. . The symptoms of croup The symptoms of croup may reappearmay reappear. . Patients can be safely discharged home after a 2–3 hr Patients can be safely discharged home after a 2–3 hr period of observation provided they have no stridor at rest; period of observation provided they have no stridor at rest; have normal air entry, normal color, and normal level of have normal air entry, normal color, and normal level of consciousness; and have received steroids consciousness; and have received steroids Nebulized epinephrine should still be used cautiously in Nebulized epinephrine should still be used cautiously in patients with tachycardia, heart conditions such as tetralogy of patients with tachycardia, heart conditions such as tetralogy of Fallot, or ventricular outlet obstruction because of possible Fallot, or ventricular outlet obstruction because of possible side effectsside effects..

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The effectiveness of The effectiveness of oral corticosteroidsoral corticosteroids in viral croup is in viral croup is well establishedwell established. . Corticosteroids decrease the edema in the Corticosteroids decrease the edema in the laryngeal mucosa through their antilaryngeal mucosa through their anti--inflammatory actioninflammatory action. . Oral steroids are beneficial, even in mild croup, as measured by Oral steroids are beneficial, even in mild croup, as measured by reduced hospitalization, shorter duration of hospitalization, and reduced hospitalization, shorter duration of hospitalization, and reduced need for subsequent interventions such as epinephrine reduced need for subsequent interventions such as epinephrine administrationadministration. . Most studies that demonstrated the efficacy of Most studies that demonstrated the efficacy of oral dexamethasone used aoral dexamethasone used a single dose of 0.6 mgsingle dose of 0.6 mg//kgkg; ; a dose a dose as low as 0.15 mgas low as 0.15 mg//kg may be just as effectivekg may be just as effective.. Intramuscular dexamethasoneIntramuscular dexamethasone and and nebulized budesonidenebulized budesonide have have an equivalent clinical effect.an equivalent clinical effect.The only adverse effect described in the treatment of croup with The only adverse effect described in the treatment of croup with corticosteroids was the development ofcorticosteroids was the development of Candida albicansCandida albicans laryngotracheitis in a patient who received dexamethasone, laryngotracheitis in a patient who received dexamethasone, 1 mg1 mg//kgkg//24 hr, for 8 days24 hr, for 8 days.. Corticosteroids should not be administered to children with Corticosteroids should not be administered to children with varicella or tuberculosis varicella or tuberculosis ((unless the patient is receiving unless the patient is receiving appropriate antituberculosis therapyappropriate antituberculosis therapy) ) because they worsen the because they worsen the clinical courseclinical course. .

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AntibioticsAntibiotics are not indicated in croup are not indicated in croup..

A heliumA helium--oxygen mixture oxygen mixture ((HelioxHeliox) ) may be may be effective in children with severe croup who effective in children with severe croup who may need intubationmay need intubation. .

Children with croup should be hospitalized for Children with croup should be hospitalized for any of the following progressive stridor, severe any of the following progressive stridor, severe stridor at rest, respiratory distress, hypoxia, stridor at rest, respiratory distress, hypoxia, cyanosis, depressed mental status, poor oral cyanosis, depressed mental status, poor oral intake, or the need for reliable observation intake, or the need for reliable observation ::

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EpiglottitisEpiglottitis treatment oftreatment ofEpiglottitisEpiglottitis is a medical emergency and warrants immediate treatment with is a medical emergency and warrants immediate treatment with anan artificial airwayartificial airway placed under controlled conditions, either in an placed under controlled conditions, either in an operating room or intensive care unitoperating room or intensive care unit. . All patients should receive oxygen All patients should receive oxygen Racemic epinephrine and corticosteroids are ineffectiveRacemic epinephrine and corticosteroids are ineffective. . Cultures of blood, epiglottic surface, and, in selected cases, cerebrospinal Cultures of blood, epiglottic surface, and, in selected cases, cerebrospinal fluid should be collected after airway stabilizationfluid should be collected after airway stabilization. . Ceftriaxone, cefotaxime, or a combination of ampicillin and sulbactamCeftriaxone, cefotaxime, or a combination of ampicillin and sulbactam should be given parenterally, pending culture and susceptibility reports, should be given parenterally, pending culture and susceptibility reports, because from 10–40% ofbecause from 10–40% of HH. . influenzaeinfluenzae type b cases are resistant to type b cases are resistant to ampicillinampicillin. . antibiotics should be continued for 7–10 daysantibiotics should be continued for 7–10 days After insertion of the artificial airway, the patient should improve After insertion of the artificial airway, the patient should improve immediatelyimmediatelyChemoprophylaxis is not routinely recommended for household, childChemoprophylaxis is not routinely recommended for household, child--care, care, or nursery contacts of patients with invasiveor nursery contacts of patients with invasive HH. . influenzaeinfluenzae type b infections, type b infections, but careful observation is mandatory with prompt medical evaluation when but careful observation is mandatory with prompt medical evaluation when exposed children develop a febrile illnessexposed children develop a febrile illness. . Indications for rifampin Indications for rifampin prophylaxisprophylaxis (20 (20 mgmg//kg orally once a day for 4 days; maximum dose, 600 mgkg orally once a day for 4 days; maximum dose, 600 mg) ) for all household members arefor all household members are: (: (11) ) any contact <48 mo of age who is any contact <48 mo of age who is incompletely immunized; incompletely immunized; ((22) ) any contact <12 mo who has not received the any contact <12 mo who has not received the primary vaccination series; or primary vaccination series; or ((33) ) an immunocompromised child in the an immunocompromised child in the householdhousehold

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Acute laryngeal swelling on an allergic Acute laryngeal swelling on an allergic basisbasis responds to epinephrineresponds to epinephrine. . Corticosteroids are frequently required Corticosteroids are frequently required ((2–2–4 mg4 mg//kgkg//24 hr of prednisone24 hr of prednisone).).

After recovery, the patient and parents After recovery, the patient and parents should be discharged with a preloaded should be discharged with a preloaded syringe of epinephrine to be used in syringe of epinephrine to be used in emergenciesemergencies. . Reactive mucosal swelling, Reactive mucosal swelling, severe stridor, and respiratory distress severe stridor, and respiratory distress unresponsive to mist therapy may follow unresponsive to mist therapy may follow endotracheal intubation for general endotracheal intubation for general anesthesia in childrenanesthesia in children. .

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Tracheotomy and Endotracheal Tracheotomy and Endotracheal IntubationIntubation

Both procedures should always be performed in an Both procedures should always be performed in an operating room or intensive care unit if time permits; operating room or intensive care unit if time permits; prior intubation and general anesthesia greatly prior intubation and general anesthesia greatly facilitate performing a tracheotomy without facilitate performing a tracheotomy without complicationscomplications. . The use of a nasotracheal tube that is The use of a nasotracheal tube that is 0.5–1.0 mm smaller than estimated by age is 0.5–1.0 mm smaller than estimated by age is recommended to facilitate intubation and reduce longrecommended to facilitate intubation and reduce long--term sequelaeterm sequelae. . Endotracheal intubation or tracheotomy is required Endotracheal intubation or tracheotomy is required for most patients with bacterial tracheitis and all young for most patients with bacterial tracheitis and all young patients with epiglottitispatients with epiglottitis. . It is rarely required for patients with It is rarely required for patients with laryngotracheobronchitis, spasmodic croup, or laryngotracheobronchitis, spasmodic croup, or laryngitislaryngitis. .

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