Post extubation stridor
- 1. Post Extubation Stridor Critical Care Grand Rounds April 7, 2008 Janice D Chisholm, BSc, MD, FRCPC
- 2. Post Extubation Stridor Definition Epidemiology The Cuff Leak Use of Steroids Prophylaxis Treatment How do I use this info clinically? Conclusions
- 3. the development of upper airway obstruction after extubation Minor Audible high pitched inspiratory wheeze with respiratory distress Major Severe respiratory distress needing tracheal reintubation secondary to upper airway obstruction Definition
- 4. Prolonged intubation can lead to edema, inflammation, and ulceration Level of cords and cuff site At autopsy, 54% had ulcers on posterior cords and 93% had mucosal inflammation and/or edema
- 7. Incidence 2-22% of patients intubated > 24 hrs Increased mortality and prolonged ICU stay Occurs after 36hrs of intubation Occurs shortly after extubation Reintubation rate is 1-10%
- 8. The Cuff Leak Test Auscultation test No leak – no sound heard by auscultation Mild – leak heard using the stethoscope Significant – sound of leak heard without stethoscope Cuff Leak Volume (CLV) Exhaled tidal volume is measured before and after cuff deflation ml or % of tidal volume
- 9. Early studies suggested that a failed cuff leak test did not preclude uneventful extubation Problems Small studies Observational or prospective cohort Study populations – surgical, short duration of intubation
- 10. Miller,RL, Cole, RP. Association between reduced cuff leak volume and postextubation stridor. Chest 1996; 110:1035 100 intubations on 88 patients Cuff leak measured 24 hrs prior to extubation Post extubation stridor 6% 17% reintubation rate 50% when stridor present CLV 180 ml vs 360 ml (stridor vs normal) CLV 110 ml – PPV 80%, NPV 98% No risk factors identified
- 11. Jaber, S, Chanques, G, Matecki, S, et al. Post-extubation stridor in intensive care unit patients. Risk factors, evaluation and importance of the cuff-leak test. Intensive Care Med 2003; 29:69. 112 intubated patients MSICU Cuff-leak test 24 hrs prior to extubation Evaluated for stridor and need for reintubation over 48 hrs
- 12. Results 12% incidence of post extubation stridor Avg time to stridor 3.2+/- 3.3 hrs Extubation failure 10% overall 69% of stridulous patients 2% non-stridulous CLV 130 ml or 12% - sensitivity 85%, specificity 95%
- 14. Risk factors for Developing Post Extubation Stridor Sicker patients SAPSII 38 ±13 vs. 50±16 p<0.005 Intubated in ICU or prehospital 62% developed stridor p<0.027 Traumatic or difficult intubation 7% vs 54% p<0.001 High balloon cuff pressures 40±20 vs 83±35 cm H 2 O p<0.001 Duration of intubation 5.5±6.3 vs. 10.9±7.0 days p<0.001 Prior self extubation Medical vs. surgical admission
- 15. Maury, E, Guglielminotti,J, Alzieu, M, et al. How to identify patients with no risk for postextubation stridor? J Crit Care 2004;19:23 115 extubations, MICU Spontaneously breathing Immediately prior to extubation, cuff deflated and absence of cough was monitored ETT then occluded and the absence of leak was monitored
- 16. Results: 3.5% incidence of stridor 100% of patients with stridor had no leak vs. 20% of patients without stridor 75% with stridor had no cough vs. 21% without stridor 75% with stridor had no leak and no cough vs 7% without stridor Cuff leak no stridor No leak or cough beware of stridor
- 17. Steroid Prophylaxis Why steroids? Predicted to suppress mucosal inflammation and tissue swelling In children, steroids decrease post extubation stridor by 40% Unclear, if steroids change the reintubation rate in children Multiple positive and negative studies in adults Timing and dose are important
- 18. Ho, LI, Harn, HJ, Lien, TC, et al. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone. Intensive Care Medicine 1996; 22:933 Prospective, randomized, double blind study 77 patients in MSICU Randomly assigned to receive 100 mg hydrocortisone or placebo 1 hr prior to extubation Examined immediately after extubation and q6h X 24hrs
- 19. Results 77 patients randomized 22% developed stridor 1 / 77 reintubated because of stridor Steroids did not decrease incidence of stridor Risk factors to develop stridor: Female RR 2.29
- 20. Cheng, KC, Hou, CC, Huang, HC, et al. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Crit Care Med 2006; 34:1345 Randomized, double blind, placebo controlled 321 patients extubated 128 of these had CLV <24% and were randomized to 1 of 3 groups No intervention (control) 40 mg methylprednisolone q6h X 24hrs (4 inj) 40 mg methylprednisolone 24hrs pre-extubation (1 inj) Patients were extubated 1 hr post last dose
- 22. 6-7 hours post injection is required to exert the protective effect of methylprednisolone
- 23. Risk Factors
- 24. Francois, B, Bellissant, E, Desachy, A, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal edema: a randomised double-blind trial. The Lancet 2007; 369:1083-1089 Randomised, double blind, placebo controlled Treatment group 20 mg IV methylprednisolone q4h X 12hrs prior to extubation (total 80 mg) Primary endpoint – laryngeal edema within 24 hrs of extubation Assessed at 10 m, 30 m, 1h, 1.5h, 3 h, 6h, 12h and 24 h by the same investigator 698 patients analysed
- 25. Results Methylprednisolone significantly decreased postextubation laryngeal edema 22% vs. 3% Steroid had no effect on the severity or onset of stridor 80% of stridor occurred within 30 min Steroid decreased the incidence of reintubation 8%vs 4%
- 28. Treatment of Stridor Elevate HOB Steroids (Dex 4-8 mg q8-12 hrs) Heliox Nebulized epinephrine 2.25% racemic epinephrine vs 1% l-epinephrine Consider reintubation
- 29. What do I do now? Identify those at risk Females Uncontrolled/traumatic intubations Pre-hospital, ICU, wards No sedation Duration of intubation >24-36 hrs, <7-10 days Previous self extubation High cuff pressures in first 24hrs
- 30. Perform cuff – leak test If CLV <10-24% ± absent cough then consider delaying extubation and treating with steroids If high risk patient and/or low CLV pretreat with steroids for 12 hours pre extubation Patients with a good cuff leak probably don’t need steroids Observe for stridor especially in first 30 min post extubation
- 31. Conclusions Post extubation stridor is a sigificant complication of tracheal intubation Testing cuff leak is important at identifying those who may be at risk Steroids given 6-24 hrs before extubation reduce the incidence of stridor and reintubation