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

Initial Management of Stridor

The initial management of a patient presenting with stridor should focus on immediate assessment of airway patency, administration of supplemental oxygen, and treatment with inhaled epinephrine and corticosteroids while preparing for possible airway intervention. 1, 2

Assessment and Immediate Actions

• Rapidly assess ABCs (Airway, Breathing, Circulation) with particular attention to the degree of respiratory distress and need for immediate airway intervention 1
• Provide supplemental oxygen to maintain oxygen saturation ≥90% through simple oxygen delivery systems (nasal cannula or face mask) 1
• Position the patient appropriately - typically in an upright or semi-recumbent position to optimize airway patency 1
• Avoid agitating the patient as anxiety can worsen airway obstruction 2
• Obtain arterial blood gas (ABG) analysis to objectively assess for respiratory failure or impending respiratory failure, which is more reliable than clinical assessment alone 3

Pharmacological Management

• Administer inhaled epinephrine (racemic epinephrine or L-epinephrine) as first-line treatment for acute stridor to reduce airway edema 1, 2
• Give systemic corticosteroids (such as dexamethasone or prednisolone) to reduce inflammation and edema 2
• Start corticosteroids at least 6 hours before any planned extubation in patients with known risk factors for post-extubation stridor 1
• Consider a cuff leak test before extubation in intubated patients to predict the risk of post-extubation laryngeal edema 1

Determining Severity and Need for Intervention

• Classify severity based on objective parameters including:
  • Presence of hypoxemia (SpO2 <90%) 1
  • Evidence of respiratory failure on ABG (hypoxemia, hypercapnia, acidosis) 3
  • Presence of accessory muscle use, retractions, or altered mental status 2
• Prepare for possible intubation if the patient shows signs of:
  • Progressive respiratory distress despite initial management 1
  • Impending respiratory failure on ABG analysis 3
  • Severe stridor with minimal air movement 2, 4

Diagnostic Considerations

• Determine if stridor is acute or chronic, as this guides management approach 2, 4
• Note the phase of respiration when stridor occurs:
  • Inspiratory stridor suggests obstruction above the glottis (e.g., laryngomalacia, epiglottitis) 4
  • Expiratory stridor indicates obstruction in the lower trachea 4
  • Biphasic stridor suggests a glottic or subglottic lesion (e.g., croup, foreign body) 4
• Consider the most common causes based on patient age:
  • In children: croup (acute) or laryngomalacia (chronic) 5, 2
  • In adults: post-extubation laryngeal edema, foreign body, or malignancy 1, 3

Special Considerations

• For post-extubation stridor, consider reintubation if stridor is severe and not responsive to medical therapy 1
• In suspected foreign body aspiration, avoid blind finger sweeps which may push the object further into the airway 1
• For suspected infectious causes (epiglottitis, bacterial tracheitis), obtain appropriate cultures but do not delay treatment 1
• Consider consultation with otolaryngology early in the management for possible direct laryngoscopy or bronchoscopy 2

Pitfalls to Avoid

• Relying solely on clinical assessment of stridor severity without objective measures like ABG analysis 3
• Delaying definitive airway management in progressive respiratory distress 1
• Failing to recognize that stridor after extubation may indicate need for reintubation 1
• Overlooking non-respiratory causes of stridor such as mega-esophagus due to achalasia, which can cause tracheal compression 6
• Underestimating the severity of stridor in children, who have smaller airways and can decompensate rapidly 5, 2