Stridor
Theory
Stridor is a harsh, high-pitched inspiratory upper airway noise. This is one of the most serious signs a patient can have and needs immediate assessment and management.
It is a sign of impending airway loss and as such is a sudden and significant threat to life.
Patients on the ward are susceptible to acute airway obstruction, especially if they have an altered conscious state due to opiate analgesia, confusion or the residual effects of anaesthetic agents.
These non-mechanical causes of stridor can be more easily treated than mechanical causes (haematoma, foreign body), which are more difficult.
Management focuses on relieving or preventing airway obstruction and ensuring a patent airway.
Immediate intern management
Attend patient and make rapid assessment.
If patient unconscious/severe respiratory distress/respiratory arrest
- Tell nursing staff to call Code Blue then move to head end of bed.
- Perform triple manoeuvre – chin lift, jaw thrust, head tilt.
- Clear mouth – suction secretions, vomitus.
- Insert Guedel airway/nasopharyngeal airway and administer oxygen.
- Bag and mask patient until help arrives.
- Intubate and insert cuffed ETT.
If stridor and early signs of respiratory distress
- Sit patient up and administer oxygen by mask.
- Call MET Code or ask senior staff for urgent assistance.
- Perform basic airway manoeuvres to assist patient in obtaining a clear airway.
- Perform continuous pulse oximetry.
- Carry out rapid clinical assessment for causes.
- Insert IV line and take set routine blood tests, including ABGs.
- Definitive treatment of underlying cause once help arrives or if patient deteriorating and these conditions exist:
Acute mechanical obstruction
Clear airway
- Clear mouth.
- Suction secretions.
- Sweep out foreign body from pharynx.
Surgical airway
- Cricothyroidotomy
- Tracheostomy
Post-operative neck haematoma
Open neck wound down to and including the deep fascial sutures.
If still obstructed and trachea on view, attempt to incise and insert endotracheal tube.
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Clinical features (obtain rapidly)
History
- Basic information about patient
- Events resulting in development of stridor
- Recent drug administration/operation
Examination
- Pt in extremis
- Stridor
- Respiratory distress
- Sitting forward, intercostal recession, tachypnoeic
- Cyanosis
- Drooling
- Swelling face/tongue
Causes
- Acute mechanical obstruction
- Sputum plug
- Altered conscious state
- Laryngospasm
- Acute asthma attack
- Angio-oedema
- Disruption ETT/tracheostomy
- Neck haematoma post neck surgery
- Trauma
- Burns
- Tumours
Stridor is a harsh, high-pitched inspiratory upper airway noise
Investigations
- Cardiac monitor
- Basic blood tests
- ABG – less useful
- CXR
Cricothyroidotomy
- Feel for the prominence of the thyroid cartilage
- Incise horizontally in space inferior to thyroid cartilage (This is cricothyroid membrane)
- Insert handle of scalpel into incision and twist to open incision and allow insertion of endotracheal tube
Definitive treatment
Call for help early. Stridor = acute threat to life.
Stridor is a sign of impending airway loss. Treatment is aimed at identifying and treating the underlying cause.
- Acute mechanical obstruction – relieve obstruction/obtain secure airway
- Sputum plug – suction airway and relieve obstruction
- Altered conscious state – simple airway manoeuvre +/- intubation
- Laryngospasm – adrenaline, antihistamines and secure airway
- Acute asthma – Ventolin nebulisers x3 +/- IV steroids + atrovent
- Angio-oedema – adrenaline, antihistamines and secure airway
- Disruption ETT/tracheostomy – rapidly secure airway
- Neck haematoma – evacuate haematoma and secure airway
- Trauma – basic airway manoeuvres and secure airway
- Burns – secure airway (ETT/surgical airway)
- Tumours – secure airway (ETT/surgical airway)
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