Laryngeal stenosis

Grade I (compensated stenosis)

At this stage, the patient's body is still coping with the airway narrowing on its own, but immediate medical assistance is required to prevent deterioration. The main approach relies on the local action on the mucous membrane.

The drug of choice at this stage is an inhaled glucocorticosteroid. Budesonide suspension must be used.

• The baseline dosage is 1 mg.
• The drug must be diluted in 2 ml of normal saline.
• Drug delivery is performed strictly via a nebulizer.

After the first inhalation, the medical worker is required to evaluate the clinical effect in 15–20 minutes. If symptoms persist, a repeated inhalation at the same dose (1 mg) is permitted after 30 minutes.

In case of complete ineffectiveness of topical therapy, the algorithm changes drastically. There is a switch to systemic glucocorticosteroids. Either Dexamethasone (at a dose of 0.15 to 0.6 mg/kg) or Prednisolone (2–5 mg/kg) is used. Administration is carried out intramuscularly, after which the patient is subject to mandatory hospitalization.

Grade II (subcompensated stenosis)

When the condition progresses to a subcompensated form, the threat to life escalates. Outpatient monitoring, scheduled hospitalization, or transfer to a day care unit is strictly unacceptable.

• Organizational measures: An ambulance crew must be called. The patient requires emergency hospitalization exclusively.
• Therapeutic tactics: The medication load increases significantly. The physician may choose one of two paths. The first is the use of higher doses of topical steroids: Budesonide is prescribed at a dose of 2 mg once, or this dose is divided into two administrations of 1 mg with a 30-minute interval. The second path is the immediate starting administration of systemic GCS. In this case, Dexamethasone (strictly 0.6 mg/kg) or Prednisolone (2–5 mg/kg) is used, administered intramuscularly or intravenously.

Special attention is paid to condition monitoring. The criteria for transferring the patient to the intensive care unit (ICU) or critical care unit are the lack of clinical response to the ongoing high-dose therapy or an objective drop in oxygen saturation (SpO2 < 92%).

Grades III–IV (decompensated stenosis and asphyxia)

These are extremely severe, critical conditions in which the body's reserves are depleted, and there is a direct threat of respiratory arrest.

• Routing: The only permissible option is immediate hospitalization directly to the intensive care unit (ICU). The admission ward, pulmonology department, or a regular step-down unit are not suitable for such patients.
• Respiratory support: The baseline measure when SpO2 drops below 92% is the delivery of humidified oxygen. Medical personnel must be in a state of constant readiness for radical airway management measures: endotracheal intubation or tracheostomy in case of progressive respiratory failure.
• Pharmacotherapy: At the stage of decompensation and asphyxia, an aggressive combination strategy is applied. The physician carries out a simultaneous intervention: systemic GCS (Dexamethasone at a maximum dose of 0.6 mg/kg or Prednisolone 2–5 mg/kg) are administered AND high-dose Budesonide nebulizer inhalations (2 mg) are performed concurrently.

Evaluation of the patient's condition dynamics and vital signs is performed continuously, with mandatory monitoring every 15–20 minutes for timely therapy adjustment.

Class and exam questions

What else to study on this topic

• Methodology and rules for diluting Budesonide suspension with normal saline
• Pharmacodynamics of systemic GCS during intramuscular and intravenous administration
• Equipping the physician's workstation for emergency endotracheal intubation
• Technique of oxygen therapy with humidified oxygen during a drop in SpO2
• Algorithm for differential diagnosis between Grade I and Grade II stenosis

Other topics in "Chapter 13. Main syndromes requiring emergency care"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.