What is the initial management for a patient presenting with stridor?

From the Guidelines

The initial management for a patient presenting with stridor should focus on securing the airway while identifying and treating the underlying cause, with the most recent and highest quality study suggesting a multidisciplinary approach to management 1. The first step in managing a patient with stridor is to position them upright to maximize airway patency and administer supplemental oxygen.

• Assess vital signs and perform a focused examination to determine the severity and potential cause of stridor.
• For acute inflammatory causes like croup or epiglottitis, nebulized epinephrine (racemic epinephrine 2.25% solution, 0.5 mL in 3 mL normal saline) provides rapid but temporary relief of airway edema through vasoconstriction, as supported by previous studies 1.
• Simultaneously, administer dexamethasone (0.6 mg/kg orally or parenterally, maximum 16 mg) to reduce inflammation, with effects beginning within 1-2 hours. In severe cases with respiratory distress, prepare for potential airway intervention including intubation or emergency cricothyroidotomy, following the guidelines for pediatric tracheostomy emergencies 1.
• Avoid agitating the patient, particularly with suspected epiglottitis, as this may worsen respiratory distress.
• Continuous monitoring of oxygen saturation, respiratory rate, and work of breathing is essential to detect deterioration. The urgency of management depends on the severity of respiratory compromise, with complete airway obstruction representing a true emergency requiring immediate intervention. Key considerations in the management of stridor include:
• Securing the airway
• Identifying and treating the underlying cause
• Administering supplemental oxygen and nebulized epinephrine as needed
• Preparing for potential airway intervention
• Continuous monitoring of the patient's condition.

From the Research

Initial Management of Stridor

The initial management of a patient presenting with stridor involves several key steps:

• Reduction of airway inflammation 2
• Treatment of bacterial infection 2
• Imaging, emergent airway stabilization, or surgical management may be necessary in some cases 2
• The history and physical examination guide initial management 2

Treatment Options

Some treatment options for stridor include:

• Nebulized racemic epinephrine, which has been shown to be effective in improving clinical scores in patients with croup 3
• Dexamethasone, which has been studied as a potential preventative measure for postextubation stridor, but its effectiveness is still debated 4, 5
• Inhalational induction, awake tracheostomy, awake fibreoptic intubation, or blind nasal intubation may be used in certain cases 6

Causes of Stridor

Stridor can be caused by a variety of factors, including:

• Upper airway obstruction 2, 6
• Croup 2, 3
• Deep neck infection, malignancy, angioneurotic oedema, trauma, and congenital anomalies like laryngomalacia 6
• Postextubation stridor in ventilated patients 4, 5