Immediate Management of Expiratory Stridor
Administer nebulized epinephrine 1 mg immediately while applying high-flow oxygen, positioning the patient upright with chin lift, and preparing for potential airway intervention, as expiratory stridor indicates lower tracheal obstruction and represents at least 50% airway narrowing with imminent risk of complete obstruction. 1, 2, 3
Initial Stabilization Protocol
Assess severity immediately by looking for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, or agitation—these signs indicate critical airway compromise requiring urgent intervention. 1, 2
Apply high-flow oxygen to the face while simultaneously positioning the patient with chin elevation and mandibular traction (jaw thrust). 1, 2
Initiate continuous monitoring with pulse oximetry and waveform capnography if available, as capnography is a key safety intervention for airway management. 1, 2
Summon advanced help early if any signs of respiratory difficulty are present—do not delay this critical step. 1, 2
Localization and Clinical Context
Expiratory stridor specifically indicates obstruction in the lower trachea, distinguishing it from inspiratory stridor (supraglottic obstruction) or biphasic stridor (glottic/subglottic lesion). 3 This anatomic localization guides your diagnostic and therapeutic approach.
Post-Extubation Context (ICU Setting)
Give nebulized epinephrine 1 mg immediately for symptomatic relief while corticosteroids take effect—this is the first-line treatment for established post-extubation stridor. 1, 4
Prepare for reintubation with videolaryngoscopy as first-line approach to maximize first-pass success in edematous airways, and have front-of-neck access equipment ready before attempting reintubation. 1, 2, 4
Recognize that corticosteroids have limited benefit for established post-extubation stridor—they are primarily preventive, not therapeutic once stridor has developed. 1, 2
Understand the risk: post-extubation stridor occurs in 1-30% of patients and increases reintubation risk to approximately 15%. 1, 2
Trauma or Progressive Edema Context
Recognize that stridor after trauma indicates progressive edema that will worsen, not resolve spontaneously—immediate action is mandatory. 1, 2
Administer inhaled racemic epinephrine immediately to temporarily reduce airway edema while preparing for definitive intubation. 1, 2
Start systemic corticosteroids immediately (equivalent to 100 mg hydrocortisone every 6 hours or dexamethasone 8 mg every 8 hours), as they reduce inflammatory edema from direct airway injury (surgical, anesthetic, thermal, or chemical). 1, 4
Transfer to a controlled environment with the most experienced operator available for airway management. 1, 2
Critical distinction: Steroids have no effect on mechanical edema from venous obstruction (e.g., cervical hematoma)—these require surgical intervention, not medical management. 1, 2
Post-Thyroidectomy Hematoma
Use the SCOOP approach at bedside immediately—do not wait for the operating room: Skin exposure, Cut sutures, Open skin, Open muscles (strap muscles), Pack wound. 1, 4 This is a surgical emergency requiring immediate decompression.
Upper Airway Tumor
Do not use videolaryngoscopy if there is an upper aerodigestive tract tumor with stridor—this can worsen obstruction. 1, 2
Consider alternative difficult airway techniques with the most experienced operator available, as the combination of difficult upper airway and deteriorating gas exchange is extremely challenging. 1
Diagnostic Evaluation
Perform flexible fiberoptic laryngoscopy when stridor persists or is severe—this is the diagnostic procedure of choice for examining laryngeal structure and function. 1, 2
Inspect both upper and lower airways, as anomalies below the epiglottis occur in up to 68% of cases. 1, 2
Note that the cuff leak test has excellent specificity but only moderate sensitivity for predicting post-extubation airway complications—do not rely on it exclusively. 5, 1
Adjunctive Measures
Elevate the head of bed to 35 degrees to reduce airway inflammation. 1, 2
Avoid unnecessary positive fluid balances that worsen edema. 1, 2
Provide humidified high-flow oxygen and maintain capnography monitoring. 1, 2
Consider heliox for severe obstruction, though recognize it limits FiO2 delivery. 1, 2
Critical Pitfalls to Avoid
Do not attempt awake intubation in a distressed patient with evolving airway obstruction—this will worsen obstruction. 2, 4
Do not use excessive positive pressure ventilation immediately post-intubation—this can cause hemodynamic collapse. 1, 2
Do not assume steroids will work for mechanical obstruction (hematoma, tumor)—these require surgical intervention. 1, 2
Ensure adequate steroid dosing (equivalent to 100 mg hydrocortisone every 6 hours)—underdosing reduces efficacy. 1, 4
Do not use steroids empirically for all cases of hoarseness without specific indications such as airway trauma or high extubation risk. 1, 2