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

Management of Inspiratory Stridor

Immediately assess respiratory distress severity by looking for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, or agitation, apply high-flow oxygen to the face, position the patient with chin lift and jaw thrust, and monitor with pulse oximetry while determining the underlying cause. 1

Initial Stabilization

• Deliver high-flow oxygen to both the face and tracheostomy (if present), requiring two oxygen sources if available 2
• Position appropriately: chin lift with or without jaw thrust in older children and adults; more neutral positioning in children under 2 years with a pillow or rolled towel under shoulders 2
• Apply waveform capnography immediately if available, as this is a key intervention to improve airway management safety 2
• Summon advanced help early if signs of respiratory distress are present, including clinicians with advanced airway skills and ENT surgeons 2

Context-Specific Management

Post-Extubation Stridor in ICU Patients

Prevention is critical and more effective than treatment:

• Perform a cuff leak test before extubation in any patient with at least one risk factor for laryngeal edema (female gender, nasal intubation, difficult/traumatic/prolonged intubation, large endotracheal tube, high cuff pressures) 2
• The test involves deflating the cuff and measuring the difference between inspired and expired tidal volumes; thresholds of <110 mL absolute leak or <10% relative leak indicate high risk 2
• Prescribe corticosteroids (prednisolone 1 mg/kg/day or equivalent) if leak volume is low or nil, starting at least 6 hours before extubation with fractionated doses 2, 1
• The cuff leak test has excellent specificity and negative predictive value but low sensitivity, meaning it effectively identifies low-risk patients but may miss some high-risk cases 2

If stridor develops post-extubation:

• Post-extubation stridor occurs in 1-30% of patients and increases reintubation risk to approximately 15% 1
• Corticosteroids are primarily preventive; their benefit for established post-extubation stridor is limited 3
• Consider reintubation if respiratory distress is severe, as laryngeal edema typically worsens over the first 24 hours 3

Acute Stridor in Children (Croup)

• Administer systemic corticosteroids immediately for all cases 1
• Give nebulized epinephrine (0.5 mL/kg of 1:1000 solution) for severe cases, which provides rapid but transient relief lasting only 1-2 hours 1
• 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

Traumatic Stridor (Post-Strangulation or Trauma)

This represents a true airway emergency requiring aggressive management:

• Do not delay intubation waiting for the patient to "improve"—stridor following trauma indicates progressive edema that will worsen, not resolve spontaneously 3
• Administer inhaled racemic epinephrine immediately to temporarily reduce airway edema while preparing for intubation 3
• Move to a controlled setting with the most experienced available operator, full monitoring, and rescue equipment immediately available 3
• Prepare for front-of-neck access (FONA) with scalpel technique before attempting intubation, as this airway may rapidly progress to "cannot intubate, cannot oxygenate" 3
• Use modified rapid sequence intubation with videolaryngoscopy as first-line, ketamine 1-2 mg/kg IV for induction, rocuronium for paralysis, and smaller endotracheal tubes than predicted 3
• Limit intubation attempts to a maximum of 3 before transitioning to FONA 3

Diagnostic Evaluation

When to Pursue Direct Visualization

• Perform flexible fiberoptic laryngoscopy when stridor persists or is severe, as this is the diagnostic procedure of choice for examining laryngeal structure and function 1
• Inspect both upper and lower airways, as anomalies below the epiglottis occur in up to 68% of cases 1
• In children, evaluation under anesthesia may be required for severe distress 4

Anatomic Localization by Stridor Characteristics

• Inspiratory stridor suggests airway obstruction above the glottis 5
• Expiratory stridor indicates obstruction in the lower trachea 5
• Biphasic stridor suggests a glottic or subglottic lesion 5
• Voice changes often accompany laryngeal lesions 5

Common Pitfalls to Avoid

• Do not attempt awake intubation in a distressed patient with evolving airway obstruction, as this will worsen obstruction 3
• Do not use excessive positive pressure ventilation immediately post-intubation, as this can cause hemodynamic collapse 3
• Do not transfer a deteriorating patient to another location—bring the team and equipment to the patient 3
• Recognize that stridor indicates at least 50% airway narrowing and represents impending complete obstruction 3

Special Populations and Uncommon Causes

• In infants, laryngomalacia is the most common cause of chronic stridor and usually resolves by 2 years of age; supraglottoplasty is indicated for severe disease 4
• In children with cerebral palsy and generalized dystonia, consider laryngeal dystonia if stridor is present when awake, worse when agitated, and absent when asleep 6
• In children with meningomyelocele or relevant neurological history, consider Chiari malformation causing vocal cord paralysis 7