What are the guidelines for managing stridor in patients?

Management of Stridor

For post-extubation or airway trauma-related stridor, administer inhaled epinephrine immediately for rapid symptom relief, combined with intravenous corticosteroids (100 mg hydrocortisone every 6 hours or dexamethasone 8 mg every 8 hours) started at least 12 hours before anticipated extubation in high-risk patients. 1

Immediate Assessment and Stabilization

Determine the Etiology and Severity

• Identify the anatomic location by the quality of stridor: inspiratory stridor indicates supraglottic obstruction, expiratory stridor suggests lower tracheal obstruction, and biphasic stridor points to glottic or subglottic lesions 2
• Assess for laryngeal injury by checking for voice changes, which indicate laryngeal involvement 2
• Evaluate neck positioning: hyperextension suggests extrinsic airway obstruction 2
• In traumatic cases (strangulation, intubation injury, tracheal fracture), look for subcutaneous emphysema, crepitus, pneumothorax, or pneumomediastinum 3
• Obtain arterial blood gas analysis to objectively classify severity and detect impending respiratory failure, as clinical assessment alone has poor interobserver reliability 4

Immediate Interventions for Severe Distress

• Position the patient upright at 35 degrees to reduce airway edema and optimize diaphragmatic function 1, 3
• Administer high-flow humidified oxygen with continuous pulse oximetry and capnography monitoring 1, 3
• For conscious patients with post-extubation stridor, use inhaled epinephrine (1 mg nebulized) to provide immediate reduction of airway edema 5, 1
• Avoid unnecessary positive fluid balances that worsen edema 1, 3

Pharmacologic Management

Corticosteroids for Airway Edema

The timing and dosing of steroids is critical for efficacy:

• For prophylaxis in high-risk patients, start intravenous corticosteroids at least 12 hours before anticipated extubation using 100 mg hydrocortisone every 6 hours or dexamethasone 8 mg every 8 hours 1
• Single doses given immediately before extubation are completely ineffective and should never be used 1
• Continue steroids for at least 12 hours to achieve benefit 1
• Consider prophylactic steroids for patients with low cuff leak volume before extubation 1

Important limitations:

• Steroids only work for inflammatory edema from direct airway injury (intubation trauma, thermal injury, chemical injury) 1
• Steroids have no effect on mechanical obstruction from venous obstruction, neck hematoma, or tumor 1
• Do not use steroids empirically for simple hoarseness or laryngitis without specific indications 1

Nebulized Epinephrine

• Administer nebulized epinephrine (1 mg) concurrently with steroids for immediate symptomatic relief while steroids take effect 1
• This is particularly effective for post-extubation stridor in conscious patients 5

Airway Management in Critical Cases

When Intubation is Required (Traumatic Stridor, Progressive Obstruction)

The most experienced available operator must manage these high-risk airways: 6

• Move to a controlled setting with full monitoring and rescue equipment immediately available 6
• Prepare videolaryngoscopy as first-line to maximize first-pass success in edematous airways 5, 6, 3
• Have front-of-neck access (FONA) equipment ready before attempting intubation, as these airways can rapidly progress to "cannot intubate, cannot oxygenate" 6
• Use modified rapid sequence intubation with ketamine 1-2 mg/kg IV (maintains cardiovascular stability) and rocuronium for neuromuscular blockade 6
• Prepare smaller endotracheal tubes than predicted, as edema narrows the glottic opening 6
• Have a bougie immediately available to facilitate tube passage through narrowed airways 6
• Limit intubation attempts to maximum 3 before transitioning to FONA 6

Critical pitfalls to avoid:

• Do not delay intubation waiting for the patient to "improve"—stridor following trauma indicates progressive edema that worsens, not resolves 6
• Do not attempt awake intubation in a distressed patient with evolving obstruction, as this worsens obstruction 6
• Avoid excessive positive pressure ventilation immediately post-intubation to prevent hemodynamic collapse 6
• Do not use videolaryngoscopy if an obstacle producing stridor is present in the upper airway 5

Special Considerations for Tracheal Fracture

• Avoid positive pressure ventilation if possible as it may worsen air leaks 3
• Tracheostomy may be necessary for upper tracheal injuries 3
• Antibiotics should be used if infection is suspected 3

Etiology-Specific Management

Pediatric Stridor

• Laryngomalacia is the most common cause of chronic stridor in infants and can usually be managed conservatively with resolution by 2 years of age 7
• Croup is the most common cause of acute stridor in children 2
• For severe laryngomalacia or failure to improve, supraglottoplasty is the treatment of choice with resolution of stridor in the majority postoperatively 7

Adult Stridor

• Hypopharyngeal malignancies are the most common cause in adults 4
• Tracheobronchomalacia should be considered in COPD patients presenting with stridor and respiratory failure, as it is often underdiagnosed and may require stent placement 8

Psychogenic Stridor

• This is a diagnosis of exclusion only after thorough history, physical examination, and direct laryngoscopy fail to detect anatomical abnormalities 9
• All structural and pathological causes must be excluded first 9

Monitoring and Follow-up

• Close observation for signs of respiratory deterioration is essential 3
• Regular assessment of airway patency and monitoring for infection or mediastinitis 3
• Maintain head-up positioning throughout the recovery period 3
• Create an airway alert in the patient's medical record if future airway management is anticipated to be difficult 3