What is the protocol for managing a patient with stridor at Stanford hospital?

From the Guidelines

The protocol for managing a patient with stridor at Stanford Hospital begins with rapid assessment and securing the airway, with immediate interventions including nebulized epinephrine and intravenous dexamethasone, as recommended by recent guidelines 1.

Key Interventions

• Position the patient upright to optimize airway patency and administer humidified oxygen.
• Nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 3 mL normal saline) and intravenous dexamethasone (0.6 mg/kg, maximum 10 mg) are used as first-line treatments for stridor, as suggested by studies 1.
• For severe cases, prepare for potential intubation or surgical airway management with appropriate equipment at bedside.

Diagnostic Workup

• Lateral neck radiographs, flexible laryngoscopy if stable, and possibly CT imaging to identify the cause of stridor.
• Common etiologies include croup in children, anaphylaxis, foreign body aspiration, angioedema, or vocal cord dysfunction.

Monitoring and Targeted Therapy

• Continuous monitoring of oxygen saturation, respiratory rate, and work of breathing is essential.
• For specific causes, targeted therapy should be initiated promptly - such as epinephrine for anaphylaxis (0.3-0.5 mg IM), antihistamines for allergic reactions, or heliox (70:30 helium:oxygen mixture) for partial airway obstruction, as recommended by guidelines 1.

Importance of Urgent Attention

Stridor requires urgent attention as it indicates significant upper airway narrowing, typically to less than 4-5 mm in adults, which can rapidly progress to complete obstruction if not properly managed, highlighting the need for prompt intervention as emphasized in recent studies 1.

From the Research

Stridor Protocol at Stanford Hospital

There is no specific information available on the stridor protocol at Stanford hospital. However, the management of stridor in patients can be understood through various studies:

• Stridor is a high-pitched extrathoracic noise associated with turbulent airflow, commonly associated with respiratory distress in infants 2.
• The differential diagnosis of stridor depends on the location of the obstruction, age of the patient, and acuity of the symptoms 2, 3.
• History, age of the child, and physical examination together often allow a presumptive diagnosis, and further investigations may be necessary to establish a definite diagnosis 3.
• Flexible airway endoscopy is the diagnostic procedure of choice in most circumstances 3.
• The management of stridor includes reduction of airway inflammation, treatment of bacterial infection, and, less often, imaging, emergent airway stabilization, or surgical management 4.

Causes and Diagnosis of Stridor

• Stridor can be caused by congenital anomalies, noninfectious and/or congenital conditions, as well as life-threatening etiologies 3, 4.
• The most common reason for stridor is laryngomalacia, and most patients can be managed conservatively with resolution of symptoms by 2 years of age 2.
• In children who do not improve or have severe disease, supraglottoplasty is the treatment of choice, and the majority will have resolution of stridor postoperatively 2.

Treatment of Stridor

• Intravenous or nebulized corticosteroids can prevent postextubation laryngeal edema, but the inability to identify high-risk patients prevents the targeted pretreatment of these patients 5.
• The preferential treatment of postextubation laryngeal edema consists of intravenous or nebulized corticosteroids combined with nebulized epinephrine 5.
• However, a study found that the routine use of corticosteroids for the prevention of postextubation stridor during uncomplicated pediatric intensive care airway management is unwarranted 6.