Treatment of Stridor: Initial Approach

Immediate Assessment and Stabilization

The American College of Anaesthesiologists recommends assessing respiratory distress severity first by looking for accessory muscle use, tracheal tug, sternal/subcostal/intercostal retractions, agitation, or restlessness, and applying high-flow oxygen to the face and positioning the patient appropriately with chin lift and jaw thrust, and monitoring with pulse oximetry 1, 2

The Anaesthesia society recommends performing a cuff leak test before extubation in patients with at least one risk factor, and prescribing corticosteroids (prednisolone 1 mg/kg/day or equivalent) starting at least 6 hours before extubation with fractionated doses if the leak volume is low or nil 1, 3
The cuff leak test has excellent specificity but moderate sensitivity, and post-extubation stridor occurs in 1-30% of patients and increases reintubation risk to approximately 15% 3, 4

The Thorax society recommends administering systemic corticosteroids and nebulized epinephrine (0.5 ml/kg of 1:1000 solution) for severe cases, which provides rapid but transient relief (1-2 hours) 5
The Thorax society recommends using epinephrine to avoid intubation and stabilize children prior to transfer to intensive care, but not using nebulized epinephrine in children who are shortly to be discharged or on an outpatient basis due to its short-lived effect 5

The American Journal of Respiratory and Critical Care Medicine recommends direct visualization when stridor persists or is severe, and flexible fiberoptic laryngoscopy is the diagnostic procedure of choice for examining laryngeal structure and function 6
The American Journal of Respiratory and Critical Care Medicine recommends inspecting both upper and lower airways, as anomalies below the epiglottis occur in up to 68% of cases 2, 6

The American Thoracic Society recommends nebulised adrenaline (epinephrine) at 0.5 ml/kg of a 1:1000 solution for neonates with stridor to avoid intubation and stabilize prior to transfer to intensive care, with an effect lasting 1-2 hours 7

Nebulised adrenaline should be used in neonates with severe stridor and respiratory distress requiring stabilization before intubation or transfer to intensive care, with close monitoring due to its short-lived effect 7
The European Respiratory Society suggests nebulised adrenaline for post-extubation stridor in neonates who have been intubated, as it may provide temporary relief 7

The standard dose of nebulised adrenaline is 0.5 ml/kg of 1:1000 (1 mg/ml) adrenaline solution, which can be repeated as needed but requires continuous monitoring due to its short duration of action 7

Post-extubation edema in previously intubated neonates can be a cause of stridor, according to the American Society of Anesthesiologists and the European Society of Anaesthesiology 7, 8

The American Academy of Pediatrics advises against discharging a neonate home after nebulised adrenaline without extended observation (minimum 3 hours), as rebound obstruction is common 7
The American Thoracic Society warns that adrenaline should not be assumed to definitively treat the underlying problem, but rather provides temporary relief while preparing for definitive management 7