Problem-Solving: Stridor in Newborn Requiring NICU Care

QUESTION:

We have an infant in our NICU who is presenting with stridor during inhalation and congested/loud breathing on what appears to be during exhalation. I have found with some infants demonstrating stridor they won’t have that congested sound to them, but others will. I asked one of our 38-year veteran nurses and she said she has found the same thing; some will have the congested/loud breathing sound and others won’t. We also do not have ENT’s in house so those that we find have stridor are RARELY sent out for it and we never get to see a report if an infant is seen in out-patient what the findings are. I feel my area of expertise is lacking in this area and would love some more guidance and education on the topic. My question is: Is this typical and if it is what is the reason for the different sound?

ANSWER:

Sounds like you are describing inspiratory stridor. Can have varying etiologies, such as EER/LPR, laryngomalacia. Generally reflects a level of obstruction of the upper airway. The worry is that, with dynamic sucking, swallowing and breathing, it is not uncommon for the etiology/alterations related to the stridor to increase risk for airway invasion during PO feeding. With this clinical presentation, many physicians do not consult ENT, unfortunately, and assume its ok to just wait it out without knowing what’s causing the stridor. They perhaps due not understand the possible functional and safety implications.

In my experience, a clinical swallowing evaluation followed by an ENT consult/flexible scope at bedside can guide us to etiology, reinforce the need for a videoswallow study to objectify impact on physiology and likely interventions. The ENT may see reddened larynx or cords, altered airway structures that are known to adversely affect swallowing physiology.

Many infants with stridor mis-direct the bolus from below or above in my experience. The co-occurring congestion suggests either saliva/refluxate in the hypopharynx and/or laryngeal inlet (may be related to EER) and/or saliva (may be also related to EER and or poor swallowing), if congestion heard at rest. If congestion with PO, suggests potentially a mis-directed toward/above/in the airway. May be a combination of both.

Without hearing the infant, I am at a loss but loud breathing on exhalation suggests perhaps prolonged exhalation which may he be using to try to re-open the collapsing airway and/or to open the alveoli and add PEEP if there’s indeed some airway obstruction, or his trying to clear the congested material off the vocal cords or out of the supraglottic space perhaps. Just hypothesizing.

Other co-morbidities if present need to be correlated, though this may be an “isolated” altered airway problem. I use the quotes around “isolated” as it really is never truly isolated since it is part of a dynamic system (the swallow).  Could also be an additional component of lower airway alteration (tracheal/bronchial). ENT sounds essential to elucidate the integrity of the airway to assist you in your differential.

Clinical problem-solving is my passion. That’s why I developed my 2-day Advanced Pediatric Dysphagia seminar which will be offered again in 2019!