Initial Management of Stridor
Stridor represents critical airway compromise requiring immediate, aggressive intervention—the patient must be moved to a controlled setting with full monitoring, the most experienced operator available, videolaryngoscopy prepared as first-line, and front-of-neck access equipment at bedside before any intervention attempts. 1, 2, 3
Immediate Recognition and Stabilization
Stridor is a late sign of airway obstruction, indicating at least 50% airway narrowing and representing impending complete obstruction that will worsen, not improve spontaneously 1, 3, 4
Move the patient immediately to a controlled setting (operating room, ICU, or emergency department) with full monitoring and rescue equipment available 1
Keep the patient upright to optimize airway patency and reduce work of breathing 1
Administer high-flow supplemental oxygen immediately while preparing for definitive intervention 3
Call for the most experienced available operator to manage this high-risk airway, as stridor represents evolving edema or obstruction requiring expert management 1
Immediate Pharmacologic Temporizing Measures
Administer nebulized racemic epinephrine (1 mg) immediately to temporarily reduce airway edema while preparing for intubation 1, 2
Start intravenous corticosteroids (hydrocortisone 100 mg IV every 6 hours or dexamethasone 8 mg IV every 8 hours) to reduce inflammatory airway edema, though benefit requires at least 12 hours to manifest 2
Do not delay definitive airway management waiting for pharmacologic interventions to work, as these provide only temporary relief in evolving obstruction 1, 2
Preparation for Intubation
Prepare videolaryngoscopy as first-line device to maximize first-pass success in edematous or distorted airways 1, 2, 3
Have front-of-neck access (FONA) equipment with scalpel technique immediately available at bedside before attempting intubation, as this airway may rapidly progress to "cannot intubate, cannot oxygenate" 1, 3
Prepare smaller endotracheal tubes than predicted, as stridor indicates significant narrowing of the glottic opening 1
Have a bougie immediately available to facilitate tube passage through the narrowed airway 1
Ensure vasopressors are drawn up and ready, as hemodynamic instability is common during rapid sequence intubation in critically ill patients 1
Intubation Technique
Use modified rapid sequence intubation (RSI) as the most appropriate technique for patients with airway obstruction 1
Preoxygenate thoroughly, though this may be limited by patient distress 1
Use ketamine 1-2 mg/kg IV as induction agent, as it maintains cardiovascular stability and preserves airway reflexes better than other agents 1
Use rocuronium for neuromuscular blockade to ensure full paralysis before laryngoscopy, preventing coughing and further airway trauma 1
Avoid succinylcholine if significant time has passed since injury due to potential hyperkalemia risk 1
Limit intubation attempts to a maximum of 3 before transitioning to front-of-neck access 1
Critical Pitfalls to Avoid
Do not delay intubation waiting for the patient to "improve"—stridor indicates progressive edema or obstruction that will worsen, not resolve spontaneously 1, 3
Do not attempt awake intubation in a distressed patient with evolving airway obstruction, as this will worsen obstruction 1
Do not transfer the patient to another location if they are deteriorating—bring the team and equipment to the patient 1
Do not rely on pulse oximetry alone, as it lags behind clinical deterioration and can provide false reassurance until sudden decompensation occurs 3
Do not attempt conservative management with nebulizers alone in patients with mechanical obstruction (bilateral vocal cord paralysis, foreign body, tumor), as these require definitive airway intervention 3
Etiology-Specific Considerations
Post-Extubation or Intubation-Related Stridor
Perform cuff leak test before extubation in ICU patients with at least one risk factor for inspiratory stridor to predict laryngeal edema 5
If cuff leak volume is low or nil, corticosteroids should be prescribed at least 6 hours (ideally 12 hours) before extubation to prevent extubation failure 5, 2
Use cuff leak test in pediatric patients at increased risk for post-extubation stridor 5
Post-Thyroidectomy Stridor
Immediately call for senior anesthesia help without attempting conservative management, as this represents bilateral recurrent laryngeal nerve injury requiring emergency reintubation 3
Do not use nebulized epinephrine or steroids for bilateral vocal cord paralysis, as these treat edema, not mechanical obstruction from paralyzed vocal cords 3
Infectious or Inflammatory Causes
Consider epiglottitis in children with stridor, drooling, fever, and toxic appearance—these patients require controlled intubation in the operating room without agitating the child 5
Suspect diphtheria in patients with low-grade fever, pseudomembranous pharyngitis, and stridor—urgent treatment with diphtheria antitoxin and antibiotics is required without waiting for laboratory confirmation 5
Foreign Body
Obtain neck, chest, and abdominal radiographs to assess presence, location, and size of radiopaque objects 5
Perform CT scan if plain radiographs are negative but clinical suspicion remains high, or if perforation or other complications are suspected 5
Diagnostic Workup After Stabilization
Arterial blood gas analysis provides objective assessment of respiratory failure and impending failure, superior to clinical classification alone for guiding management 6
Direct laryngoscopy or bronchoscopy may be required to identify the underlying cause, but should only be performed in a controlled setting with ability to secure the airway 7, 4
Inspiratory stridor suggests obstruction above the glottis, expiratory stridor indicates lower tracheal obstruction, and biphasic stridor suggests glottic or subglottic lesion 4