In this episode, I’ll discuss how racemic epinephrine via nebulization is thought to help treat stridor.
Stridor is an abnormal inspiratory sound and is a sign of airway obstruction that requires immediate attention.
Stridor can be caused by a mass or foreign body in the upper airway, or by laryngeal edema. Laryngeal edema post endotracheal extubation is the most likely cause of stridor in an adult patient in the ICU.
Stridor can indicate impending respiratory failure and should be treated as a medical emergency.
Other than re-intubation, treatments for post-extubation stridor include dexamethasone, heliox, and racemic epinephrine via nebulizer.
There are no randomized trials that support the efficacy of nebulized racemic epinephrine in adult patients with post-extubation stridor. Rather, epinephrine is used for theoretical benefits based on its mechanism of action. Epinephrine causes vasoconstriction and decreased blood flow, which should diminish edema formation. If post-extubation stridor is due to laryngeal edema, it is hoped that epinephrine’s effects will inhibit edema and relieve the airway obstruction.
Because there are no trials supporting the use of racemic epinephrine for this indication, there is not a consensus about the effective dose to use. At my institution, the respiratory therapists like to repeat a dose of nebulized epinephrine, so I make sure I have two ampules available of 2.25%, 0.5 mL racemic epinephrine in the event a patient develops post-extubation stridor.
Members of my Hospital Pharmacy Academy have access to practical training from a pharmacist’s point of view on the prevention and management of post-extubation stridor in the ICU. This is in addition to many other resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.