Step 1 of 6
Triage & Airway Stabilisation
Stable vs unstable? Minimal handling, position of comfort, airway team activation if compromised.
The first decision in every child with stridor is whether the airway is stable. Unstable signs — cyanosis, hypoxia, apnea, severe retractions, silent chest, exhaustion, altered sensorium, head-bobbing — mandate immediate paediatric airway activation (ENT + anaesthesia + PICU), minimal handling, a position of comfort, and humidified oxygen.
Critical safety warning — avoid forceful oral examination in a toxic child, suspected supraglottitis, or severe distress. Direct visualisation may precipitate complete obstruction. Maintain the child on a parent's lap, in their chosen posture, and prepare for controlled airway management in the operating theatre.
If the child is stable, proceed to localisation (Step 2) and structured history / examination (Step 3).
- Assess airway stability first — work of breathing, SpO₂, mental status
- Recognise severe-distress signs — cyanosis, silent chest, head-bobbing, exhaustion
- Minimise handling, position of comfort, humidified oxygen
- Activate paediatric airway team (ENT + anaesthesia + PICU) early
- Avoid forceful oral exam in suspected supraglottitis
- Quiet child + poor air entry = critical obstruction
Key statistics
Critical narrowing from oedema
One mm of subglottic oedema in an infant ≈ 50% cross-sectional area reduction (Poiseuille).
Progression risk in severe distress
rapid
Acute upper airway obstruction can progress rapidly to respiratory failure or cardiopulmonary arrest; clinical recognition and timely paediatric airway activation are protective.
★ High-yield pearls (chapter-wide)
- Stridor is a symptom, not a diagnosis — the priority is always airway stability → localisation → aetiology → definitive management.
- Loudness of stridor does NOT correlate with severity. A quiet child with poor air entry may be critically obstructed; a noisy child may be far less compromised.
- Avoid forceful oral examination in a toxic / drooling child — risk of precipitating complete airway obstruction in supraglottitis.
- One millimetre of subglottic oedema critically narrows a paediatric airway because resistance scales with the fourth power of the radius.
- Normal chest X-ray does NOT exclude foreign-body aspiration — clinical suspicion mandates rigid bronchoscopy.
- Phase of stridor localises the lesion — inspiratory (supraglottic), biphasic (glottic / subglottic), expiratory (tracheal / bronchial), stertor (nasopharyngeal).
- Synchronous airway lesions are present in 8–58 % of severe laryngomalacia cases — complete airway evaluation, not just supraglottic.
- Persistent stridor despite first-line therapy mandates flexible laryngoscopy and, if non-diagnostic, microlaryngoscopy + bronchoscopy with aerodigestive workup.
Evidence base
3 sources- HIGHCummings Otolaryngology — Head and Neck Surgery, 7th ed (Paediatric Airway section)
Flint PW et al. · Elsevier · 2020Standard textbook
Canonical reference for paediatric airway anatomy, stridor evaluation, and operative airway technique — anchors stability assessment, endoscopic technique, and surgical pathways throughout this chapter.
- HIGH
Pfleger A & Eber E · Paediatr Respir Rev · 2013Narrative reviewPMID 23598067
Modern paediatric pulmonology review of acute severe upper airway obstruction — anchors emergency triage and controlled-airway pathway. Vol 14(2):70-77.
- MOD
Harless J, Ramaiah R, Bhananker SM · Int J Crit Illn Inj Sci · 2014Narrative reviewPMID 24741500
Reviews paediatric airway anatomic differences and management principles — supports the triage and stabilisation step. Vol 4(1):65-70.
Decision tree
Airway stability is the first gate. For a stable child, the phase of stridor splits the algorithm into three columns — each terminating in one of eight diagnosis-keyed pathways. The supraglottitis red-flag pattern (toxic, drooling, tripod) bypasses the phase flow and goes straight to controlled airway in theatre.