What is the approach to managing a patient with stridor?

From the Guidelines

The management of a patient with stridor requires prompt assessment and intervention to secure the airway, with the most recent and highest quality study suggesting that a cuff leak test should be performed before extubation to predict the occurrence of laryngeal edema 1.

Approach to Stridor

The approach to managing a patient with stridor involves several key steps:

• Evaluate the severity of respiratory distress and provide supplemental oxygen while positioning the patient upright to optimize airflow.
• For acute inflammatory causes like croup, administer nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 3 mL normal saline) and dexamethasone (0.6 mg/kg orally or parenterally, maximum 16 mg) 1.
• In cases of suspected epiglottitis or severe airway compromise, avoid agitating the patient and arrange for controlled intubation in an operating room with ENT and anesthesia present.
• For anaphylaxis-induced stridor, give intramuscular epinephrine (0.01 mg/kg of 1:1000 solution, maximum 0.5 mg) and consider antihistamines and steroids.
• Foreign body obstruction may require back blows and chest thrusts in children or abdominal thrusts in adults, with surgical intervention if these fail.
• Continuous monitoring of oxygen saturation, heart rate, and respiratory effort is essential, and preparation for emergency airway management including intubation or cricothyroidotomy should be available.

Prevention of Post-Extubation Stridor

To prevent post-extubation stridor, corticosteroids should probably be prescribed to prevent extubation failure related to laryngeal edema, with the treatment started at least 6 hours before extubation 1. Some key points to consider:

• A cuff leak test should be performed before extubation to predict the occurrence of laryngeal edema.
• The cuff leak test generally has a good specificity and negative predictive value, but a low sensitivity and positive predictive value.
• Other diagnostic approaches, such as ultrasound assessment of the column of air around the endotracheal tube, have been proposed but have not significantly improved the clinical value of the test.
• The prevention of pathology in the larynx requires eradication of risk factors whenever possible, including the choice of a “moderate” diameter for the endotracheal tube and monitoring and regulating the pressure of the balloon to prevent undue pressure on the mucosa.

Treatment of Post-Extubation Stridor

Inhaled epinephrine should be used to treat post-extubation stridor in conscious patients 1. Some key points to consider:

• Antinauseants should be ordered pro re nata with opioids.
• There is no recommendation for the routine use of anticholinergic medication to prevent upper airway secretions, Lasix to prevent congestive heart failure post extubation, or methylprednisolone to prevent post-extubation stridor.
• Each ICU should develop and utilize protocols for the management of post-extubation stridor.

From the Research

Approach to Stridor

The approach to managing a patient with stridor involves several key steps, including:

• Determining the severity of respiratory compromise and the need for immediate intervention 2
• Identifying the underlying cause of stridor, which can be located anywhere in the extrathoracic or intrathoracic airway 2
• Reducing airway inflammation and treating bacterial infections, if present 3
• Considering imaging, emergent airway stabilization, or surgical management, if necessary 3

Management Strategies

Management strategies for stridor may include:

• Nebulized racemic epinephrine, which has been shown to be effective in treating croup and reducing stridor 4, 5
• Corticosteroids, which can help reduce airway inflammation 5
• Helium-oxygen mixture (heliox) therapy, which can help reduce airway resistance and improve breathing 5
• Supplemental oxygen, which may be necessary in severe cases of stridor 5

Inpatient Treatment

Inpatient treatment for stridor may be necessary in some cases, particularly if the patient requires ongoing monitoring and treatment. Studies have shown that inpatient interventions, such as racemic epinephrine administration and heliox therapy, are infrequent and most commonly occur in patients who are symptomatic upon admission 5. Asymptomatic patients may be candidates for outpatient management 5.

Comparison of Treatment Options

Comparisons of treatment options for stridor have shown that racemic epinephrine and l-epinephrine are both effective in reducing stridor, with no significant differences in improvement or adverse side effects 6. L-epinephrine may be a less expensive and more widely available alternative to racemic epinephrine for the treatment of postextubation laryngeal edema 6.