Severe Stridor
Cyanosis, lethargy, marked retractions, impending respiratory failur present
Call for help: Activate emergency response team and prepare for airway intervention.
- Positioning: Keep the patient upright if possible to reduce airway collapse.
- Oxygenation: Provide high-flow oxygen (humidified if available) via a non-rebreather mask or bag-valve mask.
- Nebulized Epinephrine (if upper airway edema suspected):
- Racemic epinephrine (2.25% solution, 0.5 mL in 3 mL saline) via nebulizer
- L-epinephrine (1:1000) 0.5 mL/kg (max 5 mL) via nebulizer
- Dexamethasone (if inflammatory cause suspected):
- IV/IM Dexamethasone (0.6 mg/kg, max 10 mg)
- Admit for observation and monitor.
- Severe or worsening stridor:
- Noninvasive ventilation (e.g., Heliox) if partial obstruction
- Intubation (if unstable airway) – preferably with an experienced provider using a small endotracheal tube.
- Emergency surgical airway (cricothyroidotomy or tracheostomy) if intubation fails or complete obstruction occurs.
- Croup (Laryngotracheobronchitis) → Dexamethasone + nebulized epinephrine
- Epiglottitis → IV antibiotics (Ceftriaxone), avoid agitation, possible intubation
- Anaphylaxis → IM epinephrine + IV steroids + antihistamines
- Foreign body aspiration → Back blows (infants), Heimlich maneuver (adults), or bronchoscopy
- Tumor/Mass compression → ENT consult, imaging (CT/MRI), possible surgery or radiation
++++++++++++++++++
Severe stridor is a medical emergency requiring immediate intervention. Management depends on the underlying cause, severity, and stability of the airway. Here’s an approach to handling severe stridor:
1. Immediate Assessment (ABC Approach)
- Airway: Assess for signs of complete obstruction (e.g., inability to speak, cyanosis, silent stridor).
- Breathing: Check respiratory effort, use of accessory muscles, and oxygen saturation.
- Circulation: Monitor for tachycardia, hypotension, or signs of shock.
References
1. https://www.drugs.com/dosage/dexamethasone.html#Usual_Pediatric_Dose_for_Croup