Stridor (croup)

Stridor (croup)

Stridor or barking cough (also known as croup), is a sound heard mostly during inspiration (phase of breathing when air flows into the lungs), because of an obstruction of the upper airway from the nose level to mid-trachea level. Severe stridor can also be heard during expiration (phase of breathing when air is expuled from the lungs).
Stridor can be an isolated finding or accompanied by fever and other viral symptoms such as rhinorrhea and cough. Stridor can also be accompanied by hoarseness.
Some of the parents who have heard stridor in the past can identify it, but some of the parents, especially first-time parents, will not always be able to recognize a barking cough.

As with any other condition in medicine, the etiologies for stridor are diverse, from simple viral infections, to anatomical problems causing obstruction.
It is important to differentiate between congenital stridor, which is heard soon after delivery in a baby who is a few days or weeks old, and acquired stridor which can happen at any age (though mostly happens in infants), out of complete health or during viral infection.
Congenital stridor has different etiologies which I will not specify in this post, such as weakness of the vocal cords area or the cartilage in the trachea, which can cause dynamic obstruction during inspiration (called laryngomalacia or tracheomalacia). Other reasons may be anatomical problems of the vocal cords, trachea or blood vessels that are causing external pressure on the trachea. Therefore congenital stridor requires a thorough evaluation and exclusion of many different reasons, as per the recommendation of the pediatrician.

The goal of this post is to focus on healthy children with acute stridor, which is not congenital or chronic. Of course there are many reasons for this type of stridor, some anecdotal at best, but I will focus on the two most common etiologies which are – viral induced stridor and allergy induced stridor (also known as spasmodic stridor).

What is viral croup (viral stridor)?

One of the most common diagnosis in children. Mostly infants, in kindergarten age, which are prone for viral infections. The clinical manifestation is mostly of a child with mild viral symptoms (runny nose and low fever), that goes to sleep, and wakes up in the middle of the night with a stressful barking cough, looking like he desperately needs air. Stridor is more common in the evening and night hours. In many cases the child goes to sleep with a mild viral symptoms,
Just to be accurate with medical definitions – Stridor is a disease of the upper airways. If the physician will diagnose viral croup with involvement of the larynx, than the diagnosis is laryngitis (infection of the vocal cords area). Sometimes the physician will diagnose, in addition to stridor, involvement of the lower airways, and then the diagnosis will be laryngotracheitis or laryngotracheobronchitis. It all depends to which extant the lower airways are involved in the infection. It is not very relevant to the treatment, as you will see ahead.

What is allergic stridor (or spasmodic croup)?

A child, mostly in the ages of 1-3 years old, went to sleep as a healthy child with no fever or viral symptoms, and wakes up in the middle of the night with sudden onset stridor.
This stridor is caused by allergic induced edema in the vocal cord area.

It doesn’t matter which of these two diagnoses are correct (viral or allergic) both of them has pretty much the same treatment.

So what is the treatment for stridor in children?

First you need to confirm the diagnosis with a pediatrician, so another important medical condition will not be missed.
As for treatment in the middle of the night – you need to let the child breath dry and cold air, for example, going outside to a balcony. It is not uncommon to see parents speeding to the emergency room in the middle of the night with the car windows down, but by the time they arrived to the ER the stridor is long gone.
Steroids – sometimes relieve the edema in the vocal cords. They work very well on children with stridor. In the community health care facilities, they can be given via inhalation, inhaler, syrup or as pills dissolved in water. Each method has its advantages and disadvantages, but in the middle of the night you can try steroids with a quick relieve of symptoms.
If there is fever or pain, I recommend giving some medicine to lower the fever and relieve pain.
Being stressed will not help, the child is already not at his best, and stressed parents will only get him feeling more anxious and breathe faster and harder.
Bronchodilator Inhalations or inhalers which are not steroids will not help in most of the cases (because they work on the lowe respiratory tract).
In most cases it is a viral infection, and antibiotics will not help.

When to go visit the doctor?

I recommend go see your pediatrician in every event of significant stridor, including one that doesn’t resolve by morning. The physician will most probably give the diagnosis of viral or spasmodic stridor, but can at least prescribe some medication that will lower the chance for the stridor to reoccur.
You should go see your pediatrician when there is a possibility that there was an event of foreign body aspiration.
You should always see your pediatrician in cases of stridor with high fever, excessive salivation and respiratory distress (to rule out bacterial infection or foreign body aspiration).
Adolescences with a new stridor need to be evaluated.

In summary:

This is a very common medical condition in children, which can be very stressful in the middle of the night, especially if the parents did not encountered stridor in the past.

Even though the diagnosis and treatment are simple, it is important to treat and reduce the child’s discomfort as well as rule out any other important diagnosis.


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