What is the initial management for a patient presenting with stridor?

Initial Management of Stridor

Immediately administer high-flow humidified oxygen, position the patient upright, call for senior anesthesia help without delay, and prepare for emergency airway intervention, as stridor indicates at least 50% airway narrowing and represents impending complete obstruction. 1, 2

Immediate Resuscitative Actions

• Administer high-flow humidified oxygen immediately to maximize oxygenation while preparing for definitive airway management 3, 2
• Position the patient upright (head-up 30-45°) to optimize airway patency, reduce venous congestion, and decrease work of breathing 3, 2
• Call for the most experienced available operator immediately without attempting conservative management, as stridor is a late sign requiring urgent intervention 1, 2
• Keep the patient nil per os (NPO) as laryngeal competence may be impaired despite full consciousness 3, 2
• Move to a controlled setting with full monitoring (continuous pulse oximetry, capnography, respiratory rate, heart rate, blood pressure) and rescue equipment immediately available 1, 2

Critical Assessment

Assess for specific etiologies that dictate management:

• Post-thyroid/neck surgery with suspected hematoma: Immediately proceed to bedside hematoma evacuation using the SCOOP approach without waiting for operating room availability 2
• Post-strangulation injury: Recognize that stridor indicates progressive edema that will worsen, not resolve spontaneously, requiring immediate intubation 1
• Post-operative stridor: Use DESATS criteria (Difficulty swallowing, Early warning score increase, Swelling, Anxiety, Tachypnea, Stridor) to determine severity 2
• Pediatric acute infectious causes: Croup is the most common etiology in children presenting to emergency departments 4, 5

Medical Temporizing Measures

While preparing for airway intervention:

• Administer nebulized racemic epinephrine (1 mg) immediately to temporarily reduce airway edema 1, 2
• Initiate systemic corticosteroids (dexamethasone or equivalent to 100 mg hydrocortisone every 6 hours), though benefit is primarily for post-extubation stridor prevention rather than acute traumatic edema 3, 1, 2
• Consider heliox (helium-oxygen mixture) to reduce work of breathing, though this limits FiO2 delivery 2

Airway Intervention Strategy

Prepare for emergency intubation with the following approach:

• Use videolaryngoscopy as first-line device to maximize first-pass success in edematous or distorted airways 1, 2
• Prepare for front-of-neck access (FONA) with scalpel technique immediately before attempting intubation, as this airway may rapidly progress to "cannot intubate, cannot oxygenate" 1, 2
• Use modified rapid sequence intubation (RSI) with ketamine 1-2 mg/kg IV (maintains cardiovascular stability and preserves airway reflexes) and rocuronium for neuromuscular blockade 1
• Have vasopressors immediately available as hemodynamic instability is common during RSI in critically ill patients 1
• Prepare smaller endotracheal tubes than predicted as airway edema narrows the glottic opening 1
• Have a bougie immediately available to facilitate tube passage through narrowed airways 1
• Limit intubation attempts to maximum of 3 before transitioning to FONA, as each failed attempt worsens laryngeal trauma and edema 1, 2

Post-Intervention Management

• Transfer to ICU for ongoing mechanical ventilation and monitoring after securing the airway 6, 2
• Use PEEP to stent upper airways in cases of malacia 3
• Consider corticosteroids for patients at risk (low cuff leak volume) at least 6 hours before planned extubation 3
• Perform serial laryngoscopy to assess for return of vocal cord function before considering extubation in cases of bilateral recurrent laryngeal nerve injury 6

Critical Pitfalls to Avoid

• Never delay intervention hoping for spontaneous improvement, as progressive airway edema worsens over time, not resolves 1, 2
• Never ignore a patient who is agitated or complains of difficulty breathing, even if objective signs are absent, as this is a cardinal sign of impending airway crisis 3, 2
• Do not rely on pulse oximetry alone, as it lags behind clinical deterioration and provides false reassurance until sudden decompensation occurs 3, 6, 2
• Avoid awake intubation in a distressed patient with evolving airway obstruction, as this will worsen obstruction 1
• Do not rely on drains to detect hematoma in post-surgical patients, as clot formation may prevent free drainage 2
• Avoid multiple intubation attempts, as early progression to front-of-neck airway is preferable to repeated failed attempts 1, 2

Equipment Requirements

A difficult airway trolley must be immediately available with:

• Videolaryngoscope 1, 2
• Cricothyroidotomy kit 1, 2
• Bougies of various sizes 1
• Endotracheal tubes smaller than predicted 1
• Capnography equipment 3, 2