Stridor
OVERVIEW
- Stridor = sound on inspiration associated with airway narrowing
HISTORY
- stridor at rest implies a reduction in airway diameter of >50%
- progression of symptoms
- positional exacerbation
- whether patient wakes at night having difficulty breathing
- dysphagia
- drooling
- severe obstruction -> coughing becomes difficult -> chest infections
EXAMINATION
- Airway assessment
- Neck examination
- Nasal endoscopy – photos helpful, doesn’t involve LA to cords which could precipitate total airway obstruction, be aware that a nice view in the sitting position doesn’t mean the same in the supine position
INVESTIGATION
- CT – more helpful in subglottic assessment
Define site of obstruction
- Supraglottic
- Laryngeal
- Subglottic – mid tracheal & lower tracheal/bronchial
MANAGEMENT
Supraglottic & Laryngeal Lesions
- Inhalational induction
- Awake tracheostomy
Inhalational Induction
- 2 anaesthestists
- experienced assistance
- vasoconstrictor + LA to nose
- surgeon in theatre scrubbed for emergency tracheostomy
- sevo/O2 induction (may need halothane)
- don’t bag if becomes apnoeic (allow CO2 rise)
- insert NP airway if required
- wait for pupils to become small and central
- laryngoscopy (long, McCoy)
- assess whether can intubate
(1) attempt intubation only twice (2) tracheostomy while breathing spontaneously
- sudden complete airway obstruction -> immediate tracheostomy or single attempt @ rigid bronchoscope
Awake Tracheostomy
Indications
- severe stridor
- large tumour
- gross anatomical distortion
- larynx not visible on nasal endoscopy
Technique
- no sedation
- helium/O2 mix -> improves symptoms
- be aware of giving high FiO2 -> can precipitate CO2 narcosis
- prepare in sitting position
- once in place -> confirm with CO2
Post op
- Analgesia
- Humidification
- If intubated – leave Cook Airway catheter in place until patient fully awake
- Dexamethasone
- May need PEEP or IPPV post
Mid Tracheal Lesions
- ie. thyroid mass
- ensure that patient can be intubated to below level of obstruction
- normal induction may be appropriate
- any suggestion of malignant tracheal invasion -> awake fiberoptic intubation (AFOI)
Lower Tracheal & Bronchial Obstruction
- mediastinal masses (lymphoma, invasive carcinoma)
- beaware of invading thyroid carcinomas -> tracheal collapse with muscle relaxation -> have a ridgid bronchoscope available.
- if obstruction close to the carina or invading the bronchus -> can’t do tracheostomy or give muscle relaxation -> may need bypass.
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Textbooks and journal articles
- Hillman DR, Platt PR, Eastwood PR. The upper airway during anaesthesia. Br J Anaesth. 2003 Jul;91(1):31-9. PMID: 12821563. [Fulltext]
- Mason RA, Fielder CP. The obstructed airway in head and neck surgery. Anaesthesia. 1999 Jul;54(7):625-8. PMID: 10417451.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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