Management of Vocal Cord Paralysis with Stridor

Immediate Assessment and Stabilization

The American Academy of Otolaryngology-Head and Neck Surgery recommends that stridor with vocal cord paralysis represents impending respiratory failure requiring immediate intervention 1, 2
Positioning the patient upright immediately can reduce work of breathing and facilitate respiratory effort, as suggested by clinical guidelines 3
Administering high-flow humidified oxygen (FiO2 1.0) can help maintain oxygenation while assessing the airway 3
The British Journal of Anaesthesia suggests calling for senior anesthesia/critical care support immediately, as this is a potentially difficult airway requiring expert management 4, 3

Recent head, neck, or chest surgery is the most common cause of iatrogenic vocal cord paralysis, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
The American Academy of Otolaryngology-Head and Neck Surgery also notes that recent endotracheal intubation can cause vocal cord injury, edema, or arytenoid dislocation 1, 5, 2

For bilateral vocal cord paralysis with respiratory distress, the American Academy of Otolaryngology-Head and Neck Surgery recommends tracheostomy as the gold standard 1
Pre-oxygenation with head-up positioning and high-flow nasal oxygen is essential before intubation, as suggested by the British Journal of Anaesthesia 4, 3
Limiting intubation attempts to a maximum of three can help reduce trauma and the risk of "can't intubate, can't ventilate" scenario 3

Close monitoring in the ICU for 6-24 hours post-intervention is essential, as upper airway injury can cause delayed airway compromise, according to the Intensive Care Medicine journal 5, 2
Keeping the patient NPO initially can help prevent aspiration, as laryngeal protective reflexes may be impaired even when conscious 2, 3
The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing swallowing function before reintroducing oral nutrition, progressing through stages to demonstrate adequate airway protective reflexes 5

The American Academy of Otolaryngology-Head and Neck Surgery warns against delaying airway intervention waiting for diagnostic workup, as stridor with vocal cord paralysis can progress rapidly to complete airway obstruction 1
Avoiding excessive sedation or opioids is crucial, as they can worsen upper airway obstruction and reduce protective reflexes, according to the British Journal of Anaesthesia 2, 4