What is the initial approach to treating stridor?

Treatment of Stridor: Initial Approach

For acute stridor in children, immediately administer systemic corticosteroids (dexamethasone) and nebulized epinephrine for severe cases, while for post-extubation stridor in adults, prophylactic corticosteroids (prednisolone 1 mg/kg/day) should be given at least 6 hours before extubation in high-risk patients identified by a positive cuff leak test. 1, 2

Immediate Assessment and Stabilization

Assess respiratory distress severity first by looking for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, agitation, or restlessness 2. Apply high-flow oxygen to the face and position the child appropriately with chin lift and jaw thrust 2. Monitor with pulse oximetry and call for help immediately if SpO2 < 90%, bradycardia, or inability to speak/drink is present 2.

Critical pitfall: Never sedate a patient with moderate-to-severe respiratory distress without airway expertise present, as sedation can worsen obstruction 2.

Treatment Based on Clinical Context

Post-Extubation Stridor in ICU Patients

Prevention is key through risk stratification:

• Perform a cuff leak test before extubation in patients with at least one risk factor (female gender, nasal intubation, difficult/traumatic/prolonged intubation, large endotracheal tube, high cuff pressures) 1
• A positive test is defined as absolute leak volume < 110 mL or relative leak volume < 10% 1
• If the leak volume is low or nil, prescribe corticosteroids (prednisolone 1 mg/kg/day or equivalent) starting at least 6 hours before extubation with fractionated doses 1

The cuff leak test has excellent specificity (effective for identifying low-risk patients) but moderate sensitivity (less effective for identifying high-risk patients), so it works best to rule out rather than rule in post-extubation complications 1. Post-extubation stridor occurs in 1-30% of patients and increases reintubation risk to approximately 15% 1.

Acute Stridor in Children (Croup)

For mild to severe croup, administer systemic corticosteroids 3. For severe cases requiring urgent care or emergency department evaluation:

• Nebulized epinephrine (0.5 ml/kg of 1:1000 solution) provides rapid but transient relief (1-2 hours) 1, 2
• Use epinephrine to avoid intubation and stabilize children prior to transfer to intensive care 1
• Do not use nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to its short-lived effect 1
• Nebulized steroids (500 µg budesonide) may reduce symptoms in the first two hours 1

Post-Intubation Laryngeal Edema

Epinephrine nebulization provides rapid but transient relief, and corticosteroids such as dexamethasone may be beneficial 2. The evidence is stronger in neonates than older children 2.

Diagnostic Considerations

Direct visualization is essential when stridor persists or is severe:

• Any infant with a history of intubation who develops stridor should be evaluated 1
• Flexible fiberoptic laryngoscopy is the diagnostic procedure of choice for examining laryngeal structure and function 1, 2
• Endoscopy should be performed in any child with severe or persistent symptoms, associated hoarseness, or if it leads to oxygen desaturation or apnea 2
• Inspect both upper and lower airways, as anomalies below the epiglottis occur in up to 68% of cases 2

Chronic Stridor Management

For chronic stridor (most commonly laryngomalacia in infants):

• Most cases are self-limited and resolve as the airway enlarges by age 2 years 3, 4, 5
• Medical treatment with antireflux medications may be indicated due to strong association with gastroesophageal reflux disease 5
• Supraglottoplasty is reserved for severe cases with cyanosis, worsening stridor after feeding, or inadequate weight gain 3, 5

Key Clinical Pearls

The phase of stridor indicates location: inspiratory stridor suggests obstruction above the glottis, expiratory stridor indicates lower tracheal obstruction, and biphasic stridor suggests glottic or subglottic lesions 6. Laryngeal lesions often result in voice changes 6.

In older children, stridor is rare and always warrants endoscopy unless due to recent endotracheal intubation 2.