What is the appropriate management for a patient with expiratory stridor, considering potential causes such as foreign body aspiration, subglottic stenosis, croup, or chronic conditions like smoking-related respiratory disease?

Management of Expiratory Stridor

Expiratory stridor indicates obstruction at or below the glottic level and requires immediate assessment for severity, with treatment directed at the underlying cause—most commonly lower tracheal or subglottic pathology rather than supraglottic disease. 1

Initial Assessment and Immediate Actions

• Position the patient upright immediately to optimize airway patency and reduce work of breathing while applying high-flow humidified oxygen 2, 3
• Assess severity by looking for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, or agitation 4
• Apply continuous waveform capnography if available, as this is critical for monitoring airway compromise 2
• Summon advanced help early if any signs of respiratory distress are present 4

Critical distinction: Expiratory stridor originates from obstruction at or below the glottic level, while inspiratory stridor suggests supraglottic or glottic obstruction 5, 1. Biphasic stridor (both inspiratory and expiratory) indicates glottic or subglottic lesions and represents more severe obstruction 1.

Diagnostic Approach Based on Acuity

Acute Onset (Hours to Days)

Foreign body aspiration must be ruled out first in acute expiratory stridor, particularly in children under 5 years who account for >90% of foreign body deaths 2:

• Sudden onset of respiratory distress with coughing, gagging, or wheezing in the absence of fever or antecedent respiratory symptoms strongly suggests foreign body rather than infection 2
• If obstruction is severe (unable to make sound), perform subdiaphragmatic abdominal thrusts in children >1 year until object is expelled 2
• For infants, deliver 5 back blows followed by 5 chest compressions (never abdominal thrusts due to risk of liver injury) 2
• Remove visible foreign bodies manually but never perform blind finger sweeps as these push objects deeper 2

Other acute causes requiring immediate intervention:

• Post-extubation stridor occurs in 12-37% of ICU patients and indicates significant airway edema 2
• Anaphylaxis with lower airway involvement
• Acute infectious tracheitis (bacterial croup)

Subacute/Chronic (Weeks to Months)

• Subglottic stenosis (congenital or acquired from prolonged intubation)
• Tracheal masses (rare but life-threatening if missed) 6
• Vascular rings or mediastinal masses causing extrinsic compression
• Tracheomalacia

Perform flexible fiberoptic laryngoscopy when stridor persists or is severe, as this is the diagnostic procedure of choice for examining both upper and lower airways 4, 5

Medical Management

Immediate Pharmacologic Interventions

• Administer nebulized epinephrine (1 mg) immediately for symptomatic relief in conscious patients with significant respiratory distress 2, 4, 7
• Nebulized epinephrine provides rapid but transient relief lasting only 1-2 hours, so prepare for definitive management 4

Corticosteroid Protocol

Steroids are effective only for inflammatory airway edema, not mechanical obstruction 2, 7:

• Give 100 mg hydrocortisone IV every 6 hours (or dexamethasone 8 mg every 8 hours) for at least 12 hours 2, 7
• Steroids reduce edema from direct airway injury (surgical, anesthetic, thermal, chemical trauma) but have no effect on mechanical edema from venous obstruction like neck hematoma 2, 7
• Single-dose steroids given immediately before intervention are ineffective and waste time 2, 7

Adjunctive Measures

• Maintain 35-degree head-up positioning to reduce airway swelling 7
• Consider heliox for severe obstruction, though this limits FiO2 delivery 2, 7
• Avoid excessive positive pressure ventilation which can worsen obstruction or cause hemodynamic collapse 3, 4

Airway Management for Severe Cases

If stridor indicates at least 50% airway narrowing and represents impending complete obstruction 3, 4:

• The most experienced available operator must manage the airway 3
• Move to a controlled setting with full monitoring and rescue equipment before attempting intubation 3
• Prepare videolaryngoscopy as first-line to maximize first-pass success in edematous airways 3, 4, 7
• Have front-of-neck access (FONA) equipment ready before attempting intubation, as this may rapidly progress to "cannot intubate, cannot oxygenate" 3
• Limit intubation attempts to maximum of 3 before transitioning to FONA 3
• Use smaller endotracheal tubes than predicted due to airway narrowing 3

Critical Pitfalls to Avoid

• Never delay intervention waiting for the patient to "improve"—progressive edema worsens, not resolves spontaneously 3, 4
• Do not attempt awake intubation in a distressed patient with evolving obstruction, as this worsens obstruction 3, 4
• Do not assume all stridor is croup—failure to diagnose tracheal masses or foreign bodies can be life-threatening 6
• Do not transfer a deteriorating patient to another location; bring the team and equipment to the patient 3, 4
• Do not use steroids for mechanical obstruction (hematoma, tumor, foreign body)—these require different interventions 7

Special Considerations

In post-extubation cases, up to 15% require reintubation within 48 hours, so extubation should be considered a "trial" with reintubation actively planned for 2, 4. CPAP, NIV, or high-flow nasal oxygen can reduce reintubation rates in high-risk patients 2.

In chronic cases with episodic symptoms, consider rare causes like tracheal masses, which may initially be misdiagnosed as asthma 6. Lateral neck x-ray can identify subglottic masses, but definitive diagnosis requires bronchoscopy 6.