What is the management for a patient with immediate post-operative stridor?

Management of Immediate Post-Operative Stridor

Immediately administer high-flow supplemental oxygen, position the patient head-up, and assess for airway compromise using the DESATS criteria (Difficulty swallowing, Early warning score increase, Swelling, Anxiety, Tachypnea, Stridor) - recognizing that stridor is a late sign requiring urgent intervention without delay. 1, 2, 3

Immediate Initial Actions

• Administer high-flow humidified oxygen immediately and position the patient upright to optimize airway patency and reduce venous congestion 1, 2
• Ensure an appropriately skilled anesthetist is immediately available, as life-threatening complications are not restricted to the immediate post-operative period 1
• Call for senior help immediately - do not delay while attempting conservative management if any signs of respiratory compromise are present 2, 4
• Keep the patient nil per os (NPO), as laryngeal competence may be impaired despite full consciousness 1

Critical Assessment Algorithm

Step 1: Identify the Cause

Post-operative stridor has distinct etiologies that determine management:

• Laryngeal edema from intubation trauma, surgical manipulation, or airway inflammation 1
• Neck hematoma causing external airway compression - most common within first 24 hours post-thyroid/neck surgery 3, 4
• Bilateral recurrent laryngeal nerve injury (rare but catastrophic) 1
• Laryngospasm from residual anesthetic effects or airway irritation 1
• Tracheomalacia unmasked after removal of long-standing goiter 1

Step 2: Determine Severity Using DESATS Criteria

Assess for signs of airway compromise 2, 3, 4:

• Difficulty swallowing or discomfort
• Early warning score increase (tachycardia, hypertension, altered mental status)
• Swelling of the neck (visible or palpable)
• Anxiety or agitation (hypoxia sign)
• Tachypnea or difficulty breathing
• Stridor (inspiratory = supraglottic; biphasic = glottic/subglottic)

Critical caveat: Stridor is a LATE sign of airway compromise - intervention must not be delayed until stridor develops. 1, 2, 3

Management Based on Clinical Scenario

Scenario A: Post-Thyroid/Neck Surgery with Suspected Hematoma

If ANY signs of airway compromise are present:

• Immediately proceed to bedside hematoma evacuation using the SCOOP approach without waiting for operating room availability 2, 3, 4:
  • Skin exposure
  • Cut sutures
  • Open skin
  • Open muscles (superficial and deep layers)
  • Pack wound
• A post-thyroid surgery emergency box must be at bedside containing wound opening equipment 3, 4
• Do NOT delay for imaging or flexible laryngoscopy if airway compromise is evident 2

If hematoma evacuation fails to resolve airway compromise:

• Proceed immediately to emergency tracheal intubation using videolaryngoscopy at first attempt 2
• If cannot intubate, cannot oxygenate: proceed directly to scalpel cricothyroidotomy - do not waste time with multiple intubation attempts 2

Scenario B: Inflammatory Laryngeal Edema (No Hematoma)

Medical Management:

• Administer nebulized racemic epinephrine (1 mg) to acutely reduce airway edema 1
• Initiate corticosteroids immediately if not already given - dexamethasone or equivalent to 100 mg hydrocortisone every 6 hours 1
  • Critical timing: Single-dose steroids given immediately before extubation are ineffective - must be started early and continued for at least 12 hours 1
  • Steroids reduce inflammatory edema from direct airway injury but have no effect on mechanical obstruction 1
• Consider heliox (helium-oxygen mixture) to reduce work of breathing, though this limits FiO2 delivery 1

If medical management fails or patient deteriorates:

• Do not delay reintubation - intubation becomes progressively more difficult as edema worsens 1
• Anticipate difficult reintubation due to airway distortion and edema 1
• Have equipment for front-of-neck access immediately available 1, 2

Scenario C: Suspected Laryngospasm

• Ensure full neuromuscular blockade if patient is still partially paralyzed - laryngospasm may be improved with complete muscle relaxation 1
• If suxamethonium was used at induction, rocuronium/sugammadex combination is preferred for reversal if needed 1
• Apply continuous positive airway pressure (CPAP) with 100% oxygen 1
• If laryngospasm persists despite optimal management, prepare for emergency airway intervention 1

Monitoring and Ongoing Care

• Continuous monitoring must include: respiratory rate, heart rate, blood pressure, continuous pulse oximetry, and ideally capnography using a facemask 1
• Critical limitation: Pulse oximetry is NOT a monitor of ventilation and can give false reassurance - clinical assessment of work of breathing is essential 1
• Patients should be observed in a recovery area with one nurse per patient, never fewer than two personnel total 1
• Monitor for 6-24 hours depending on severity - delayed airway compromise can occur 1

Location of Care

• At-risk extubations should occur in the operating theater with full airway equipment available 1
• Patients with airway compromise should remain in recovery or transfer to critical care environment - not to general ward 1
• If patient requires transfer, an anesthetist must accompany with portable monitoring 1

Common Pitfalls to Avoid

• Never ignore a patient who is agitated or complains of difficulty breathing, even if objective signs are absent - this is a cardinal sign of impending airway crisis 1
• Do not rely on drains to detect hematoma - clot formation may prevent free drainage, providing false reassurance 4
• Multiple intubation attempts worsen outcomes - early progression to front-of-neck airway is preferable to repeated failed attempts 2
• Stridor may not be present with significant airway injury - endoscopic evaluation may be needed to detect silent ulcerations that can progress to stenosis 5
• Patients with pre-existing airway abnormalities (tracheal deviation, tracheomalacia, previous difficult intubation) are at highest risk and require heightened vigilance 1

When to Perform Flexible Laryngoscopy

• If no immediate airway compromise but concerns are raised: arrange immediate senior surgical review and flexible endoscopic laryngeal assessment 2
• Flexible fiberoptic examination before extubation is prudent in patients with known difficult airways or significant airway manipulation 1
• Post-extubation laryngoscopy can identify vocal cord dysfunction, arytenoid injury, or other structural problems requiring specific management 1