What is the appropriate evaluation and treatment for a patient experiencing respiratory squeaks (stridor), particularly in pediatric or geriatric populations, or in individuals with a history of respiratory disease?

Respiratory Squeaks (Stridor): Evaluation and Management

Immediate Assessment Priority

For any patient with respiratory squeaks (stridor), flexible bronchoscopy is the gold standard diagnostic procedure and should be performed when stridor is severe, persistent, associated with hoarseness, or causes oxygen desaturation or apnea. 1

Age-Specific Approach to Stridor

Infants and Young Children

Laryngomalacia is the most common cause of persistent stridor in infants and children, accounting for the majority of congenital laryngeal anomalies. 1

When to Perform Flexible Bronchoscopy in Pediatrics:

• Severe or persistent stridor 1
• Stridor associated with hoarseness 1
• Stridor leading to oxygen desaturation or apnea 1
• Any stridor in older children (not due to recent intubation) - this is rare and always warrants endoscopy 1
• Persistent/unexplained wheezing unresponsive to bronchodilators and anti-inflammatory therapy 1

Critical Diagnostic Considerations in Pediatrics:

Flexible bronchoscopy through the nose allows examination of adenoids, larynx, and hypopharynx under physiological conditions while stridor is audible, enabling real-time assessment of laryngeal structure and function during inspiration and expiration. 1

Up to 68% of children with stridor have abnormalities below the epiglottis, making complete upper and lower airway inspection essential during any airway endoscopy. 1

Common congenital causes include:

• Laryngomalacia (most common) 1
• Vocal cord paralysis (third most common congenital anomaly) - usually from CNS anomalies 1
• Laryngoceles and saccular cysts 1
• Laryngeal webs and atresia 1
• Laryngotracheal stenosis 1
• Congenital hemangiomas 1

Note: Laryngeal cleft may be missed by flexible bronchoscopy and requires rigid bronchoscopy if seriously suspected. 1

Geriatric and Adult Populations

Post-Intubation or Airway Trauma Stridor:

Intravenous corticosteroids must be started at least 12 hours before anticipated extubation in high-risk patients to prevent post-extubation stridor - single doses given immediately before extubation are completely ineffective. 2

Recommended dosing: 100 mg hydrocortisone every 6 hours (or dexamethasone 8 mg every 8 hours) for at least 12 hours. 2

Nebulized epinephrine (1 mg) should be given concurrently with steroids for established stridor to provide immediate relief while steroids take effect. 2

Mechanism-Based Treatment Approach:

Steroids only work for inflammatory airway edema from direct trauma (surgical, anesthetic, thermal, chemical) - they have NO effect on mechanical edema from venous obstruction (neck hematoma, tumor). 2

Differential Diagnosis Framework

Acute Stridor (Onset <48 hours):

Life-threatening causes requiring immediate intervention:

• Epiglottitis - acute onset with fever, drooling, anxious appearance 3
• Foreign body aspiration - localized monophonic wheeze may be present 1
• Peritonsillar or retropharyngeal abscess - fever, odynophagia, trismus 3
• Bacterial tracheitis 4

For suspected epiglottitis: Keep patient upright and calm, do NOT examine oropharynx, activate emergency services immediately. 3

Chronic Stridor (>4 weeks):

In infants with chronic stridor and persistent/unexplained wheezing unresponsive to bronchodilators:

• Primary tracheomalacia and bronchomalacia 1
• Tracheal stenosis and webs 1
• Vascular compression causing secondary tracheomalacia 1
• Tracheo-esophageal fistula 1
• Congenital cysts 1

Flexible bronchoscopy is superior to rigid bronchoscopy for assessing airway dynamics because less positive end-expiratory pressure is applied during examination. 1

Adjunctive Diagnostic Studies

When Chronic Aspiration is Suspected:

Video-fluoroscopic swallow study should be performed when stridor is accompanied by coughing/choking with meals, recurrent pneumonias, or excessive drooling. 3, 5

Silent aspiration occurs in 71% of patients with aspiration detected on swallow studies, making objective testing essential even without overt symptoms. 3

Radiographic Indications for Bronchoscopy:

• Recurrent/persistent atelectasis 1
• Recurrent pneumonia 1
• Persistent pulmonary infiltrates or mass lesions 1
• Localized hyperinflation (suggests partial bronchial obstruction) 1

Bronchoalveolar lavage should be performed during bronchoscopy to obtain samples for microbiological studies and exclude aspiration or interstitial lung disease. 1

Critical Pitfalls to Avoid

Do not give single-dose steroids immediately before extubation in adults - they waste resources and provide no benefit. 2

Do not assume steroids will work for mechanical obstruction from hematoma or tumor - these require different interventions. 2

Do not skip lower airway examination in pediatric patients - up to 68% have concomitant abnormalities below the epiglottis. 1

Do not perform oral examination in suspected epiglottitis - this can precipitate complete airway obstruction. 3

Ensure adequate steroid dosing (100 mg hydrocortisone q6h equivalent) - underdosing reduces efficacy. 2

Supportive Management During Evaluation

Maintain 35-degree head-up positioning to reduce airway swelling. 2

Avoid unnecessary positive fluid balances that worsen edema. 2

Provide high-flow humidified oxygen and monitor with capnography. 2

Have videolaryngoscopy and front-of-neck access equipment ready before attempting intubation in edematous airways. 2