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

Management of Inspiratory Stridor

Immediately assess respiratory distress severity, apply high-flow oxygen, position the patient with chin lift and jaw thrust, and administer nebulized epinephrine 1 mg while determining the underlying cause—stridor indicates at least 50% airway narrowing and represents imminent complete obstruction. 1, 2

Immediate Stabilization

Airway assessment and support must be your first priority:

• Look for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, or agitation to gauge severity 1, 2
• Apply high-flow oxygen to the face immediately 1, 2
• Position with chin elevation and mandibular traction (jaw thrust) 1, 2
• Apply waveform capnography if available—this is a key safety intervention 1, 2
• Monitor with pulse oximetry continuously 1, 2
• Summon advanced help early if any signs of respiratory difficulty are present 1

Context-Specific Management Algorithm

Post-Extubation Stridor (ICU Setting)

For established post-extubation stridor, give nebulized epinephrine 1 mg immediately for symptomatic relief while steroids take effect. 1, 3

• Post-extubation stridor occurs in 1-30% of patients and increases reintubation risk to approximately 15% 1, 2
• Prepare for reintubation with videolaryngoscopy as first-line to maximize first-pass success in edematous airways 1, 3
• Have front-of-neck access equipment ready before attempting reintubation 1, 3
• Critical pitfall: Corticosteroids are primarily preventive—they have limited benefit for established post-extubation stridor 1, 2

Preventive protocol for high-risk patients:

• Perform a cuff leak test before extubation in any patient with at least one risk factor for laryngeal edema 1, 2
• If leak volume is low or nil, start corticosteroids at least 12 hours before extubation (not immediately before—this is ineffective) 1, 3
• Dose: 100 mg hydrocortisone every 6 hours OR dexamethasone 8 mg every 8 hours, continued for at least 12 hours 1, 2, 3
• Critical pitfall: Single-dose steroids immediately before extubation are completely ineffective and waste resources 3

Acute Stridor from Trauma or Progressive Edema

Stridor after trauma indicates progressive edema that will worsen, not resolve spontaneously—act immediately. 1, 2

• Administer inhaled racemic epinephrine immediately to temporarily reduce airway edema while preparing for intubation 1, 2
• Transfer to a controlled environment with the most experienced operator available 1, 2
• Start systemic corticosteroids immediately—steroids reduce inflammatory edema from direct airway injury (surgical, anesthetic, thermal, or chemical) 1, 3
• Critical distinction: Steroids have NO effect on mechanical edema from venous obstruction (e.g., cervical hematoma)—these require different interventions 1, 3

Post-Thyroidectomy Hematoma with Stridor

Use the SCOOP approach at bedside—do not wait for the operating room: 1, 2

• Skin exposure
• Cut sutures
• Open skin
• Open muscles (strap muscles)
• Pack wound

Stridor with Upper Airway Tumor

Do NOT use videolaryngoscopy if there is an upper aerodigestive tract tumor with stridor. 1

• Consider alternative difficult airway techniques with the most experienced operator 1
• The combination of difficult upper airway and deteriorating gas exchange is extremely challenging 1

Differential Diagnosis Considerations

Distinguish inspiratory stridor alone from inspiratory stridor with expiratory wheezing—this is essential to differentiate exercise-induced laryngeal dysfunction from exercise-induced bronchoconstriction. 4

• Inspiratory stridor with throat tightness during maximal exercise that resolves within 5 minutes suggests exercise-induced laryngeal dysfunction (EILD), not asthma 4
• EILD includes vocal cord dysfunction, exercise-induced laryngeal prolapse, and exercise-induced laryngomalacia 4
• Medications used to treat asthma (β2-agonists) are ineffective for EILD 4
• Flattening of the inspiratory curve on spirometry can be seen with EILD 4

Diagnostic Evaluation

When stridor persists or is severe, perform flexible fiberoptic laryngoscopy—this is the diagnostic procedure of choice. 1, 2

• Inspect both upper and lower airways, as anomalies below the epiglottis occur in up to 68% of cases 1
• Direct observation during symptomatic periods is essential for diagnosing vocal cord dysfunction 4
• Continuous laryngoscopy during exercise challenge can diagnose EILD 4
• The cuff leak test has excellent specificity but moderate sensitivity 1

Adjunctive Measures

• Maintain head-of-bed elevation to 35 degrees to reduce airway inflammation 1, 3
• Avoid unnecessary positive fluid balances that worsen edema 1, 3
• Provide humidified high-flow oxygen 1, 3
• Consider heliox for severe obstruction, though it limits FiO2 1, 3

Critical Pitfalls to Avoid

• Do NOT attempt awake intubation in a distressed patient with evolving airway obstruction—this will worsen obstruction 2
• Do NOT use excessive positive pressure ventilation immediately post-intubation—this can cause hemodynamic collapse 1, 2
• Do NOT use steroids empirically for all cases of hoarseness without specific indications like airway trauma or high extubation risk 1, 3
• Do NOT assume steroids will work for mechanical obstruction (hematoma, tumor)—these require surgical intervention 1, 3
• Do NOT underdose steroids—ensure equivalent to 100 mg hydrocortisone every 6 hours 1, 3