What is the initial management of a patient presenting with inspiratory stridor?

Initial Management of Inspiratory Stridor

Position the patient upright immediately, apply high-flow humidified oxygen, and summon advanced airway help while preparing for potential emergency intubation or surgical airway. 1, 2

Immediate Stabilization Actions

Positioning and Oxygenation

• Sit the patient fully upright to optimize airway patency and reduce work of breathing 1, 2
• Apply high-flow humidified oxygen immediately to maximize oxygen delivery through the narrowed airway 1
• Keep the patient nil per os (NPO) as laryngeal competence is impaired despite full consciousness 1

Early Recognition of Severity

• Inspiratory stridor indicates at least 50% airway narrowing and represents impending complete obstruction 1, 2
• Look for signs of severe respiratory distress: accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, or agitation 2
• Apply continuous waveform capnography if available for real-time monitoring of airway compromise 2

Mobilize Resources Immediately

• Summon the most experienced airway operator available as this is a high-risk airway requiring expert management 2, 3
• Call for help early if any signs of respiratory distress are present 2
• Prepare videolaryngoscopy and front-of-neck access (cricothyroidotomy) equipment before attempting intubation 2, 3

Pharmacologic Interventions

First-Line Therapy

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

Corticosteroid Protocol

• Give hydrocortisone 100 mg IV every 6 hours (or dexamethasone 8 mg every 8 hours) for at least 12 hours 1, 2
• Steroids are effective only for inflammatory airway edema (surgical/anaesthetic/thermal/chemical injury), not mechanical obstruction from venous obstruction or external compression 1, 2
• Start steroids as soon as possible in high-risk patients; single-dose steroids given immediately before potential extubation are ineffective 1

Airway Management Decision-Making

When to Intubate

• Proceed with intubation if the patient shows progressive respiratory distress, declining mental status, or inability to maintain oxygenation despite medical management 2, 3
• Do not delay intubation waiting for the patient to "improve" — inspiratory stridor with respiratory distress indicates progressive edema that will worsen, not resolve spontaneously 3

Intubation Technique

• Use videolaryngoscopy as first-line to maximize first-pass success in edematous airways 2, 3
• Prepare smaller endotracheal tubes than predicted as airway edema narrows the glottic opening 3
• Have a bougie immediately available to facilitate tube passage through the narrowed airway 3
• Limit intubation attempts to a maximum of 3 before transitioning to front-of-neck access 3, 4

If Laryngospasm Develops

• Laryngospasm is a protective exaggeration of normal glottic closure reflex triggered by blood, secretions, or surgical debris, causing signs of upper airway obstruction including stridor 1
• Reduce or release cricoid pressure if applied, as it can worsen airway obstruction 1, 4
• Administer succinylcholine immediately if laryngospasm causes complete airway obstruction with failed mask ventilation 4
• If not relieved promptly, laryngospasm may result in post-obstructive pulmonary oedema and hypoxic cardiac arrest 1

Critical Pitfalls to Avoid

• Do not attempt awake intubation in a distressed patient with evolving airway obstruction, as this will worsen obstruction 3
• Do not transfer the patient to another location if deteriorating — bring the team and equipment to the patient 3
• Avoid factors that impede venous drainage (tight neck dressings, head-down positioning) 1
• Do not give repeated doses of sedatives hoping to improve the situation — this wastes time and deepens the crisis 4

Special Considerations

Post-Extubation Context

• If stridor develops after extubation, up to 15% require reintubation within 48 hours 2
• Consider CPAP, NIV, or high-flow nasal oxygen to reduce reintubation rates in high-risk patients 2
• If the patient uses CPAP at home, have it available for use in recovery 1

Heliox as Adjunct

• Heliox (helium-oxygen mixture) may be helpful in reducing work of breathing through narrowed airways, but limits the FiO2 that can be delivered 1