Can steroid injections be used to treat stridor?

Steroid Treatment for Stridor

Yes, intravenous corticosteroids should be administered for stridor, particularly when related to airway edema from intubation or airway trauma, but they must be given as multiple doses starting at least 12 hours before anticipated extubation for prevention, or immediately for treatment of established stridor. 1

Prophylactic Steroid Administration

Timing and Dosing Requirements

• Steroids must be started at least 12 hours before extubation in high-risk patients to be effective, with single doses given immediately before extubation being ineffective. 1
• The recommended dose is equivalent to 100 mg hydrocortisone every 6 hours (or dexamethasone 8 mg every 8 hours), continued for at least 12 hours. 1
• In critically ill adults, intravenous corticosteroids for at least 12 hours in high-risk patients may reduce airway edema, post-extubation stridor, and reintubation rates. 1

Patient Selection for Prophylaxis

• Prophylactic steroids should be considered for patients with a low cuff leak volume (typically <200 ml or <88 ml depending on the study) before extubation. 1, 2, 3
• High-risk patients include those with prolonged intubation, younger age, female gender, traumatic intubation, or underlying airway abnormalities. 2, 4
• Multiple doses of corticosteroids begun 12-24 hours prior to extubation appear beneficial for adults with high likelihood of post-extubation stridor. 4

Treatment of Established Stridor

Immediate Management

• When stridor develops after extubation, intravenous dexamethasone (5-8 mg every 8 hours for 3 days) should be administered immediately. 2, 3
• Approximately 80% of patients with post-extubation stridor improve with steroid treatment. 3
• Nebulized adrenaline (1 mg) should be given concurrently to provide immediate relief by reducing airway edema. 1

Monitoring Response

• The cuff leak test and ultrasound-guided laryngeal air column width difference are non-invasive methods to monitor regression of laryngeal edema after steroid treatment. 2, 3
• Clinical response should be assessed within 1 hour; patients requiring reintubation may still benefit from continued steroid therapy, with 64% avoiding recurrent stridor after reintubation. 3

Important Mechanism and Limitations

What Steroids Treat vs. Don't Treat

• Steroids reduce inflammatory airway edema resulting from direct airway injury (surgical, anesthetic, thermal, or chemical trauma). 1
• Steroids have NO effect on mechanical edema secondary to venous obstruction (e.g., neck hematoma). 1
• All steroids are equally effective when given in adequate doses. 1

Evidence Quality by Population

• In adults, multiple-dose prophylactic steroids significantly reduce post-extubation stridor (RR 0.47) when given 12-24 hours before extubation. 4
• In children, prophylactic steroids reduce stridor particularly in those with underlying airway abnormalities, but evidence is mixed for routine use. 4
• In neonates, evidence is insufficient except for high-risk patients receiving multiple doses around extubation time. 4, 5

Critical Pitfalls to Avoid

• Do not give single-dose steroids immediately before extubation - they are ineffective and waste resources. 1
• Do not use steroids empirically for all cases of hoarseness or laryngitis without specific indications like airway trauma or high extubation risk. 1
• Do not assume steroids will work for mechanical obstruction (hematoma, tumor) - these require different interventions. 1
• Ensure adequate dosing (equivalent to 100 mg hydrocortisone q6h) - underdosing reduces efficacy. 1

Adjunctive Measures

• Maintain 35-degree head-up positioning to reduce airway swelling. 1
• Avoid unnecessary positive fluid balances that worsen edema. 1
• Provide high-flow humidified oxygen and monitor with capnography. 1
• Consider heliox for severe obstruction, though it limits FiO2. 1