What is the appropriate management of stridor in an adult?

Management of Stridor in Adults

Stridor in adults is a life-threatening emergency requiring immediate airway assessment and preparation for urgent intubation, with dyspnea, desaturation, and stridor being absolute indications for urgent intubation 1.

Immediate Emergency Management

Initial Assessment and Stabilization

• Recognize stridor as a sign of critical airway obstruction requiring immediate senior decision-maker involvement 1
• Position patient head-up to reduce airway swelling 1
• Initiate continuous oxygen delivery with high-flow nasal oxygen (HFNO) or CPAP/NIV for peroxygenation 2, 1
• Alert the emergency airway team immediately and prepare for front-of-neck airway (FONA) 3

Parallel Diagnostic Evaluation

While preparing for airway management, rapidly assess the etiology:

• Nasendoscopy/laryngoscopy to visualize the airway - normal mucosal appearance is reassuring but clinical signs lack sensitivity 1
• Look for specific features:
  • Burns/thermal injury: hoarseness, dysphagia, drooling, carbonaceous sputum, singed facial/nasal hairs 1
  • Epiglottitis: severe presentation with stridor indicates compromised airway 4
  • Vocal cord dysfunction: abductor impairment on laryngoscopy 5

Definitive Airway Management Algorithm

For Stable, Cooperative Patients

• Awake fiberoptic intubation is the preferred technique when time permits 1, 4
• Requires minimal airway swelling and patient cooperation
• Allows preservation of spontaneous ventilation

For Unstable or Deteriorating Patients

Do not delay intubation - the airway will only become more difficult:

1. Modified rapid sequence intubation (RSI) with:

   • Videolaryngoscopy as first-line (increases success, minimal movement) 1
   • Bougie readily available 1
   • Ramped/head-up positioning 1
   • Avoid multiple intubation attempts 1

2. If intubation fails:

   • Do NOT attempt prolonged facemask ventilation or supraglottic airway rescue in the setting of stridor 1
   • Proceed immediately to emergency front-of-neck airway (FONA) using scalpel technique with vertical incision 2, 1

Critical Pitfall

The most dangerous error is delaying definitive airway management - stridor indicates severe obstruction where rapid refractory hypoxemia will occur if intubation fails 1. Have FONA equipment immediately available before any intubation attempt 4, 3.

Specific Etiology Considerations

Burns/Thermal Injury

• Obtain specialist burns center advice early 1
• If not requiring urgent intubation: observe in high-dependency area, head-up positioning, nil-by-mouth, regular reassessment 1
• Avoid large volume fluid resuscitation (worsens airway swelling) 1
• Use uncut tracheal tube to accommodate facial swelling 1
• Avoid succinylcholine after 24 hours post-injury (hyperkalaemia risk) 1

Epiglottitis

• Early intubation is justified when stridor is present 4
• Fiberoptic nasal intubation preferred with immediate surgical airway capability on hand 4
• Administer systemic dexamethasone and antibiotics 4

Post-Extubation Stridor Prevention

For patients at high risk (positive cuff-leak test), prophylactic corticosteroids before elective extubation reduce postextubation airway events (RR 0.34) and reintubation (RR 0.35) 6. This does not apply to acute stridor management but to prevention in intubated patients.

Key Principles

• Maximize first-attempt intubation success rather than managing failure 2
• Confirm ventilation with waveform capnography 2
• Multidisciplinary teamwork with senior clinician involvement 2, 1
• Document neurological status before airway management 1
• Stridor represents partial airway obstruction that can rapidly progress to complete obstruction - act decisively 7, 3