Upper-airway obstruction and stridor — branching viva

Station opening

Examiner: "Define stridor and explain how it helps you localise the obstruction." [1]

Strong candidate (must-hit)

• Defines stridor as the harsh, monophonic sound of turbulent airflow through a narrowed large airway; explains that the flow phase localises the level — inspiratory stridor is extrathoracic (supraglottic or glottic), biphasic stridor reflects a fixed subglottic lesion, and expiratory stridor is intrathoracic; and states that the first bedside judgement is always whether the child is compensating or exhausting, because a silent chest and falling effort are pre-terminal. [1]

Weak candidate

• "Stridor means the airway is blocked, so we give oxygen and steroids." [1]

Branch A — The two-year-old with a barking cough

Examiner: "A two-year-old has a two-day coryzal prodrome and now a barking cough, hoarse voice and inspiratory stridor when upset, but is pink, alert and drinking. What is it, how do you grade it, and how do you treat it?" [1]

Strong

• Diagnoses croup (parainfluenza laryngotracheobronchitis); grades severity with the Westley score (consciousness, cyanosis, air entry, stridor, retractions) as mild; treats with a single dose of oral dexamethasone 0.15 to 0.6 mg/kg for all severities, keeping the child calm; adds nebulised adrenaline 0.5 mL/kg of 1:1000 (maximum 5 mL) for severe obstruction with observation for rebound; cites the Cochrane glucocorticoid review and the mild-croup dexamethasone trial. [3] [4]

Weak

• "Give antibiotics and a chest x-ray and admit for the night." [1]

Branch B — The four-year-old who is toxic and drooling

Examiner: "A four-year-old with a few hours of high fever is toxic, drooling, sitting forward and refusing to lie down, with a muffled voice. What is your immediate approach?" [6]

Strong

• Recognises a toxic supraglottic airway emergency (epiglottitis or deep-neck infection), checks immunisation status; invokes the do-not-distress principle — keeps the child with the carer in the position of comfort, no throat examination, no cannulation, does not lie the child flat; calls the most senior anaesthetist and ENT surgeon and moves to theatre for a gentle gas induction with ENT ready for bronchoscopy or a surgical airway; gives intravenous cephalosporin only once the airway is secured. [6]

Weak

• "Examine the throat with a tongue depressor and get IV access and bloods first." [6]

Branch C — The toddler who choked on a peanut

Examiner: "A previously well toddler had a witnessed choking episode on a peanut and now has a persistent cough and a unilateral wheeze. The chest x-ray is reported as normal. What do you do?" [9]

Strong

• Diagnoses an inhaled foreign body on the basis of the choking history and the focal wheeze; states that a normal chest radiograph does not exclude a foreign body because most are radiolucent and films may show only subtle air trapping or be normal; proceeds to rigid bronchoscopy under general anaesthesia, which is both diagnostic and therapeutic; and explains that a missed foreign body causes recurrent pneumonia and bronchiectasis. [9]

Weak

• "The x-ray is normal, so I would reassure and discharge." [9]

Branch D — The thriving infant with stridor since birth

Examiner: "A two-month-old has had inspiratory stridor since the first weeks of life that is worse when feeding, crying and lying supine and better when prone. He is thriving. What is the likely diagnosis and management?" [10]

Strong

• Diagnoses laryngomalacia, the commonest cause of chronic infant stridor — inspiratory, positional, in a thriving non-toxic baby, usually resolving by 18 to 24 months; confirms with flexible awake laryngoscopy; manages with reassurance and growth and feeding monitoring; and reserves supraglottoplasty for the minority with severe obstruction, failure to thrive, apnoea or cor pulmonale. [10]

Weak

• "Give steroids and adrenaline as for croup." [10]

Close

Examiner: "Summarise your approach to the child with stridor in one sentence." [1] [6]

Strong

• "Stridor is turbulent flow through a narrowed large airway that I localise by phase and time course while judging whether the child is compensating or exhausting: for the non-toxic barking-cough child I diagnose croup clinically and give dexamethasone to all with adrenaline for the severe, and for the toxic, drooling or exhausting child I do not distress the airway, call senior anaesthetic and ENT help, and secure it by gentle gas induction in theatre." [1] [6]