What is the initial approach to treating stridor in a neonate delivered with face to pubis (breech) presentation?

Treatment of Stridor in Neonates Delivered Face-to-Pubis

Immediate Assessment and Stabilization

Begin with immediate assessment for signs of critical airway obstruction, including oxygen saturation < 90%, bradycardia, accessory muscle use, retractions, or inability to feed, and if present, position the neonate upright, apply high-flow humidified oxygen, and call for help including ENT consultation. 1, 2

Critical Signs Requiring Emergency Intervention

• Oxygen saturation < 90% 1, 2
• Bradycardia or heart rate changes 2
• Inability to feed or drink 1, 2
• Accessory muscle use, tracheal tug, or sternal/subcostal/intercostal retractions 1, 2
• Agitation, restlessness, or cyanosis 1, 2

Initial Medical Management

For Moderate to Severe Stridor

• Administer nebulized epinephrine for rapid but transient relief of laryngeal edema - this provides immediate symptom reduction while other interventions take effect 1, 2
• Give intravenous dexamethasone for anti-inflammatory effect - the evidence is stronger in neonates than older children for corticosteroid benefit in post-intubation laryngeal edema 1, 2

Airway Positioning

• Optimize head position with chin lift and jaw thrust 3, 1
• Position the neonate upright if tolerated 2
• Decompress the stomach with nasogastric tube to reduce aspiration risk and improve respiratory mechanics 3

Diagnostic Evaluation

Flexible endoscopy of the airway is the gold standard diagnostic procedure and should be performed in any neonate with severe or persistent stridor, associated hoarseness, oxygen desaturation, or apnea. 3, 1, 4

Key Diagnostic Considerations

• Inspect both upper and lower airways - up to 68% of infants with stridor have concomitant abnormalities below the epiglotis 1, 5
• Assess the phase of stridor (inspiratory, expiratory, or biphasic) - biphasic stridor suggests glottic or subglottic lesions such as subglottic stenosis 1, 2
• Evaluate for birth trauma-related injuries - face-to-pubis delivery can cause laryngeal trauma, vocal cord paralysis, or subglottic injury 1

Timing of Endoscopy

• Perform endoscopy under general anesthesia with experienced anesthesiologist present 3, 4
• Use 2% lidocaine for local anesthesia of the vocal cords 3
• Monitor heart rate, oxygen saturation, blood pressure, and temperature continuously 3

Common Etiologies in Neonates

Most Likely Causes

• Laryngomalacia - the most common congenital laryngeal anomaly and cause of persistent stridor in neonates, characterized by collapse of supraglottic structures 1, 5, 6, 7
• Vocal cord paralysis - the third most common congenital laryngeal anomaly, which may result from birth trauma in face-to-pubis delivery 1, 5
• Subglottic stenosis - particularly if there was history of intubation during delivery 2, 5

Critical Pitfalls to Avoid

• Never sedate without airway expertise present if moderate-to-severe respiratory distress exists, as sedation can worsen obstruction 1
• Do not assume single-level pathology - always evaluate the entire airway as multiple lesions occur in approximately 10% of cases 1, 5, 4
• Avoid cricothyroid approaches in neonates - all cricothyroid approaches carry major risk of failure and complications, and catheter techniques are not recommended in children less than 8 years old 3
• Do not delay ENT consultation if stridor persists, worsens, or is associated with feeding difficulties, as deterioration can be rapid 2, 4

Preparation for Emergency Airway Management

If the neonate deteriorates despite initial management:

• Have equipment for emergency intubation or tracheostomy readily available 2
• Call experienced ENT surgeon immediately 3
• Consider rigid bronchoscopy with jet ventilation as a rescue technique 3
• Prepare for possible surgical airway if front-of-neck access becomes necessary 3