Management of Inspiratory Stridor

Initial Assessment and Stabilization

The American College of Physicians recommends immediately assessing respiratory distress severity by looking for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, or agitation, applying high-flow oxygen to the face, positioning the patient with chin lift and jaw thrust, and monitoring with pulse oximetry while determining the underlying cause 1
The Anaesthesia society suggests delivering high-flow oxygen to both the face and tracheostomy (if present), requiring two oxygen sources if available, and positioning appropriately with chin lift with or without jaw thrust in older children and adults 2
The Anaesthesia society also recommends applying waveform capnography immediately if available, as this is a key intervention to improve airway management safety, and summoning advanced help early if signs of respiratory distress are present 2

The Anaesthesia society recommends performing a cuff leak test before extubation in any patient with at least one risk factor for laryngeal edema, and prescribing corticosteroids if leak volume is low or nil, starting at least 6 hours before extubation with fractionated doses 3, 1
The Praxis Medical Insights society notes that post-extubation stridor occurs in 1-30% of patients and increases reintubation risk to approximately 15%, and that corticosteroids are primarily preventive, with limited benefit for established post-extubation stridor 1, 4
The Praxis Medical Insights society recommends administering systemic corticosteroids immediately for all cases of acute stridor in children, and giving nebulized epinephrine for severe cases, which provides rapid but transient relief lasting only 1-2 hours 1
The Praxis Medical Insights society suggests that stridor following trauma indicates progressive edema that will worsen, not resolve spontaneously, and recommends administering inhaled racemic epinephrine immediately to temporarily reduce airway edema while preparing for intubation, and moving to a controlled setting with the most experienced available operator 4

The Praxis Medical Insights society recommends performing flexible fiberoptic laryngoscopy when stridor persists or is severe, as this is the diagnostic procedure of choice for examining laryngeal structure and function, and inspecting both upper and lower airways 1

The Praxis Medical Insights society warns against attempting awake intubation in a distressed patient with evolving airway obstruction, as this will worsen obstruction, and against using excessive positive pressure ventilation immediately post-intubation, as this can cause hemodynamic collapse 4
The Praxis Medical Insights society notes that stridor indicates at least 50% airway narrowing and represents impending complete obstruction, and recommends recognizing this to provide appropriate care 4

The American Society of Anesthesiologists recommends administering nebulized epinephrine 1 mg immediately for symptomatic relief in conscious patients with post-extubation stridor, while steroids take effect 5
The American Society of Anesthesiologists suggests preparing for reintubation with videolaryngoscopy as first-line and front-of-neck access equipment ready, as approximately 15% of severe post-extubation stridor cases require reintubation 6
In cases of post-thyroid surgery suspected hematoma with airway compromise, the American Society of Anesthesiologists recommends using the SCOOP approach at bedside: Skin exposure, Cut sutures, Open skin, Open muscles (strap muscles), Pack wound—do not wait for operating room 7

The American Society of Anesthesiologists recommends starting corticosteroids at least 12 hours before extubation in high-risk patients, with a dose of 100 mg hydrocortisone every 6 hours or dexamethasone 8 mg every 8 hours, continued for at least 12 hours 6