Management of Stridor
Stridor is an unusual, high pitched inspiratory sound which indicates significant airway obstruction and is usually caused by tracheal obstruction although can be a result of obstruction of the main bronchi. It is essential to distinguish it from other causes of dyspnoea as it signifies airway compromise.
Stridor represents an emergency situation and may require urgent ENT or Respiratory assessment. You may need to discuss the patient with ITU in order to secure the airway, particularly if the history is not clear cut. Discuss any patients with a Registrar or above immediately. Where relevant the West of Scotland guideline on the Management of newly presenting patients with a mediastinal mass causing airway compromise may be helpful. See http://www.intranet.woscan.scot.nhs.uk/, under guidelines and protocols, then acute oncology guidelines.
Assessment / Monitoring
The initial assessment includes:
- Assess airways, breathing and circulation – immediate resuscitation as needed
- Oxygen saturations
- CXR – portable if patient not safe to go to department
Obtain full history including:
- The development of new or worsening respiratory symptoms
- Details of known malignancies and their treatment
- Medication including use of and contraindications to corticosteroids
Treatment / drug therapy
Treatment should include:
- Oxygen (humidified if possible)
- Dexamethasone oral (unless swallowing problems then IV) 8mg twice daily (morning and lunchtime) if no contraindications and add in gastroprotection if appropriate (e.g. omeprazole oral 20mg once daily or lansoprazole 30mg once daily if no contraindications).
- Nebulised salbutamol 5mg when required
- Treatment of any infection
- If severe and not improving on conservative management may need to consider:
- Tracheostomy if upper airway obstruction – discuss with oncall ENT
- Nebulised adrenaline – discuss with senior doctor used to giving this e.g. ITU
Definitive treatment includes:
- Radiotherapy if appropriate – discuss with on-call clinical oncologist
- Laser / stenting for tracheal obstruction - discuss with local Respiratory team
If no other treatment options then make patient comfortable with sedation. Always discuss with senior member of team.
- Consider Heliox 80:20 if available (helium oxygen mix which is less viscous than air and easier to inhale past obstruction).