What is the appropriate management for a patient presenting with inspiration stridor?

Management of Inspiratory Stridor

Immediately administer high-flow oxygen, position the patient upright with chin lift/jaw thrust, apply waveform capnography, and summon advanced help while rapidly determining the underlying cause—post-extubation laryngeal edema, trauma, infection (croup), or congenital/structural pathology. 1

Immediate Stabilization (First 60 Seconds)

• Apply high-flow oxygen to the face immediately while assessing severity of respiratory distress by looking for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, or agitation 1
• Position the patient upright (35-degree head-up or sitting) with chin lift and jaw thrust to optimize airway patency and reduce work of breathing 2, 1
• Apply waveform capnography immediately if available, as this is a key intervention to improve airway management safety 1
• Monitor with pulse oximetry continuously 1

Critical recognition: Stridor indicates at least 50% airway narrowing and represents impending complete obstruction—this is not a "wait and see" situation 1, 3

Context-Specific Management

Post-Extubation Stridor (ICU/Post-Operative Setting)

• Administer nebulized epinephrine 1 mg immediately for symptomatic relief while steroids take effect in conscious patients 4, 2, 1
• Give systemic corticosteroids concurrently (equivalent to 100 mg hydrocortisone every 6 hours or dexamethasone 8 mg every 8 hours), though benefit is limited for established stridor 2, 1
• Perform flexible fiberoptic laryngoscopy when stridor persists or is severe to examine laryngeal structure and function 1
• Prepare for reintubation with videolaryngoscopy as first-line and front-of-neck access equipment ready, as approximately 15% of severe post-extubation stridor cases require reintubation 4, 2

Post-thyroid surgery specific: If suspected hematoma with airway compromise, use the SCOOP approach at bedside: Skin exposure, Cut sutures, Open skin, Open muscles (strap muscles), Pack wound—do not wait for operating room 4

Traumatic Stridor (Strangulation, Inhalation Injury, Airway Trauma)

• Move to controlled setting immediately with the most experienced available operator, as 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 1, 3
• Prepare for modified rapid sequence intubation using ketamine 1-2 mg/kg IV (maintains cardiovascular stability), rocuronium for paralysis, videolaryngoscopy first-line, smaller endotracheal tubes than predicted, and front-of-neck access equipment immediately available 3
• Limit intubation attempts to maximum of 3 before transitioning to surgical airway 3

Critical pitfall: Do NOT attempt awake intubation in a distressed patient with evolving airway obstruction—this will worsen obstruction 1, 3

Acute Infectious Stridor (Croup, Bacterial Tracheitis, Diphtheria)

• Administer systemic corticosteroids immediately for all cases of acute stridor in children (dexamethasone 0.6 mg/kg IV or IM for moderate-severe cases) 1, 5
• Give nebulized epinephrine (5 ml of 1:1000 solution, 5 mg) for severe cases, which provides rapid but transient relief lasting only 1-2 hours 1, 5
• Provide cold humidified oxygen and budesonide nebulization for mild cases 5
• Obtain ENT consultation early and consider early endotracheal intubation/tracheostomy for all patients with audible stridor at rest 5

Bacterial tracheitis specific: Administer injectable cloxacillin, amikacin, and clindamycin early 5

Chronic/Congenital Stridor (Laryngomalacia, Structural Lesions)

• Perform flexible laryngoscopy as the diagnostic procedure of choice to examine both upper and lower airways 1
• Most laryngomalacia cases can be managed conservatively with expectant observation, as symptoms typically self-resolve by 2 years of age 6, 7
• Supraglottoplasty is indicated for severe disease with feeding problems, aspiration, severe airway obstruction, hypoxia, or failure to thrive 6, 7
• Acid suppression therapy for those with gastroesophageal reflux contributing to symptoms 6

Prophylactic Steroid Protocol (High-Risk Extubation)

For prevention only—NOT for established stridor:

• Start corticosteroids at least 12 hours before extubation in high-risk patients (female gender, nasal intubation, difficult/traumatic/prolonged intubation, large endotracheal tube, high cuff pressures, low cuff leak volume) 4, 2, 1
• Dose: 100 mg hydrocortisone every 6 hours or dexamethasone 8 mg every 8 hours, continued for at least 12 hours 2
• Use fractionated doses for maximum effectiveness 4, 1

Critical pitfall: Single-dose steroids given immediately before extubation are completely ineffective and waste resources 2, 1

When to Escalate to Surgical Airway

• Severe respiratory distress unresponsive to medical management 1, 5
• Rapidly progressive airway obstruction with desaturation despite oxygen 1, 3
• Failed intubation after 3 attempts in traumatic/edematous airway 3
• Post-thyroid surgery hematoma with persistent compromise after wound evacuation 4

Key Pitfalls to Avoid

• Do NOT delay intervention waiting for the patient to "improve"—stridor represents progressive obstruction 1, 3
• Do NOT use steroids alone for mechanical obstruction (hematoma, tumor)—these require surgical intervention 2
• Do NOT use excessive positive pressure ventilation immediately post-intubation, as this can cause hemodynamic collapse 3
• Do NOT assume steroids will work immediately—nebulized epinephrine provides faster relief for acute symptoms 2, 1
• Do NOT transfer a deteriorating patient—bring the team and equipment to the patient 3