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Steroids for laryngeal edema

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Given that the groups were not comparable in their baseline characteristics, their estimates have a potential for bias. Therefore, we did not perform a meta-analysis. The estimate of pooled ORs for post-extubation stridor was 0. Publication bias was not assessed by the funnel plot and the Egger test because of the small number of studies.

In sensitivity analysis, including six trials that used stridor as a main assessment [ 11 , 27 , 28 , 32 , 33 , 34 ], the estimate of pooled ORs for post-extubation stridor was 0. An odds ratio OR less than 1 favors corticosteroid administration. When analysis was restricted to trials with data for infants [ 27 , 28 , 31 , 32 ], the estimate of pooled ORs was 0.

When analysis was restricted to trials with data for pediatrics under five years old, not including infants [ 31 , 32 ], the estimate of pooled ORs was 0. It was not feasible to conduct other age-subgroup analyses because most of the studies included a wide range of age groups and did not have accurate data for the incidence based on age categories. Reports for nine of the 10 RCTs, including patients, showed the incidence of extubation failure [ 11 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].

Pediatric patients who received corticosteroids had a 0. In sensitivity analysis, excluding one trial that included patients with acute respiratory distress syndrome and in which death and withdrawal from the study, as well as reintubation, were defined as extubation failure [ 26 ], the estimate of pooled ORs was 0.

Result of meta-analysis for effects of corticosteroids on incidence of extubation failure in randomized controlled trials. When restricting analysis to trials with data in infants in the sensitivity analysis [ 27 , 28 , 29 ], the estimate of pooled ORs for extubation failure was 0. Other age-subgroup analyses could not be conducted because patients with a wide range of ages were included in each study.

Potential adverse effects of corticosteroids were infrequently assessed in the RCTs. Among them, hyperglycemia was the most frequently assessed potential adverse effect of corticosteroids, followed by gastrointestinal bleeding, infection, hypertension, and glycosuria Table 1. Because of the small sample size and infrequent reporting of adverse effects of corticosteroids, we could not robustly assess the adverse effects of corticosteroids for pediatric patients.

In meta-regression analysis for the RCTs that provided enough evidence, [ 11 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ], we assessed whether there were a linear relationships between the effect size and covariates including cumulative corticosteroid dose, time from the first administration to extubation, and mean or median age.

As shown in Additional file 1 : Table S4, each coefficient of those covariates did not have statistical significance. The effects of corticosteroids on laryngeal edema possibly resulting in stridor after and on extubation failure in pediatric patients were assessed in this study. Although only a limited number of subgroup analyses for different age categories could be performed because each trial included children with various ages, the analyses showed neither a significant difference in odds of stridor for pediatric patients under five years old, not including infants, nor a significant difference in odds of extubation failure for infants.

In , McCaffey et al. However, there are some concerns about their conclusion. First, although the authors included three papers for neonates and four papers for pediatrics in their analyses, they combined those data with data for adults and analyzed the data together. Since the airway anatomy and structure are different for different ages, it may be inappropriate to analyze those data together.

Second, they included a study conducted by Tibballs et al. Since croup is one of the diseases in which corticosteroids are effective, those patients should be excluded from a meta-analysis to assess the effect of corticosteroids on laryngeal edema. In the same year, a Cochrane Systematic Review [ 2 ] evaluated the effects of corticosteroids for these age groups separately.

The results of their meta-analyses showed that there was no statistically significant reduction in the rate of reintubation among neonates risk ratio RR , 0. They only found a significant reduction in the incidence of post-extubation stridor among children with heterogeneity RR, 0.

Based on these results, they concluded that the use of corticosteroids to prevent stridor after extubation has not been proven to be effective for neonates or children [ 2 ] and there has not been a consensus regarding the recommendation of corticosteroids for preventing post-extubation stridor in pediatric patients [ 39 ]. After excluding one study in which not only stridor, but also other elements for the scoring assessment that might not be related to upper airway obstruction were used [ 31 ], we obtained consistent results regarding the significant effect of corticosteroids.

Trials for patients with respiratory distress disease were excluded in sensitivity analysis because corticosteroids might have an impact on pulmonary function and the incidence of reintubation, but there was still a significant effect on incidence of extubation failure. Our results suggest that the use of corticosteroids for prevention of post-extubation stridor and extubation failure should be considered to be acceptable in pediatric patients until clear evidence is provided by large-scale and appropriately conducted RCTs.

One of the main purposes of this review was to assess the effects of corticosteroids separately by age groups. Due to the lack of sufficient data and the wide range of age groups in each study, however, we could conduct only a limited number of subgroup analyses for infants and children under 5 years old.

In these subgroup analyses, we did not find significant effect of corticosteroids on either outcome except for the effect of corticosteroids for extubation failure in infants. In addition, there was also heterogeneity in the indication of corticosteroids among the selected population.

Corticosteroids were given for patients with known laryngeal edema, patients at high risk for laryngeal edema, or another reason. Since it is difficult to conduct subgroup analyses considering both indication of corticosteroids and age, it is still unclear which population should receive corticosteroids before extubation.

Although they did not show statistical significance, the trends of more effectiveness for a larger amount of cumulative corticosteroid dose and for longer duration between the first dosing and planned extubation are consistent with results from a Cochrane Systematic Review conducted by Khemani et al.

A positive coefficient of age in meta-regressions could be interpreted as beneficial effects of corticosteroids for younger patients, but it was also not statistically significant. Although our study provides the latest insight regarding this topic using rigorous methodology, this study also has some limitations.

First, the sample sizes of the primary studies were relatively small and it is likely that some data for outcomes were not reported. However, exchangeability between the compared groups was demonstrated in the primary studies, and we can therefore assume that randomization was effective. Although the effects of corticosteroids on stridor and reintubation were statistically significant, sample sizes might have been too small to detect significant differences in the effects for different ages, different cumulative amounts of corticosteroids, and different durations between the first administration and extubation in the meta-regression analysis.

In addition, it was not possible to conduct some subgroup analyses based on age groups in our study, and some analyses restricted to certain age groups failed to show significant effects of corticosteroids on both outcomes, possibly because of the small sample size. Although the same intravenous corticosteroid was used in all but one of the studies, heterogeneity of age and detailed corticosteroid regimen makes it difficult to assess the dose—response effects of those medications based on the available data.

In addition, possible difference of the type of tracheal tube, cuffed tube or uncuffed tube, in each patient and in each study could have different impact on the incidence and the severity of laryngeal edema, potentially contributing to the heterogeneity.

We were not able to test for publication bias in our analysis because less than 10 studies were available, therefore the tests would be underpowered. Finally, because of the small sample sizes and infrequent reporting of adverse effects of corticosteroids, we could not robustly assess the adverse effects of corticosteroids for those pediatric patients. Our meta-analysis showed that the use of corticosteroids is associated with significant reductions in post-extubation stridor and extubation failure in pediatric patients.

These findings need careful interpretations because of a relatively small number of sample size in each RCT and a wide range of ages and corticosteroid administration regimens. Larger and properly conducted RCTs are needed to verify our results and provide adequate evidence of the side-effects. Corticosteroids for prevention of postextubation laryngeal edema in adults. Ann Pharmacother. Article Google Scholar. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults.

Cochrane Datab Syst Rev. Google Scholar. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care.

PubMed Google Scholar. Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients. Minerva Anestesiol. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone. Predictors of postextubation stridor in pediatric trauma patients. Crit Care Med. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study.

Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Randomized comparative efficacy of dexamethasone to prevent postextubation upper airway complications in children and adults in ICU. Ind J Anaesth. Histologic changes produced by endotracheal intubation.

Ann Otol Rhinol Laryngol. Rhen T, Cidlowski JA. Antiinflammatory action of glucocorticoids—new mechanisms for old drugs. N Engl J Med. Prophylactic corticosteroids for prevention of postextubation stridor and reintubation in adults: a systematic review and meta-analysis. Corticosteroids to prevent extubation failure: a systematic review and meta-analysis.

PLoS Med. Relation of vegetarian dietary patterns with major cardiovascular outcomes: a systematic review and meta-analysis of prospective cohort studies. Front Nutr. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. Beta blockade during and after myocardial infarction: an overview of the randomized trials.

Prog Cardiovasc Dis. Cochran WG. The comparison of percentages in matched samples. Measuring inconsistency in meta-analyses. Bias in meta-analysis detected by a simple, graphical test. Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial.

Effectiveness of dexamethasone in preventing extubation failure in preterm infants at increased risk for airway edema. J Pediatr. Routine use of dexamethasone for the prevention of postextubation respiratory distress. J Perinatol. Effects of dexamethasone on pulmonary function following extubation. Extubation failure due to post-extubation stridor is better correlated with neurologic impairment than with upper airway lesions in critically ill pediatric patients.

Int J Pediatr Otorhinolaryngol. L-Epinephrine and dexamethasone in postextubation airway obstruction: a prospective, randomized, double-blind placebo-controlled study. Dexamethasone in the prevention of postextubation stridor in children. Dexamethasone for the prevention of postextubation airway obstruction: a prospective, randomized, double-blind, placebo-controlled trial.

Double-blind, placebo-controlled pilot randomized trial of methylprednisolone infusion in pediatric acute respiratory distress syndrome. Pediatr Crit Care Med. Dexamethasone reduces reintubation rate due to postextubation stridor in a high-risk paediatric population.

Acta Paediatr. Does prophylactic use of dexamethasone have a role in reducing post extubation stridor and reintubation in children? Indian J Pediatr. Do clinical parameters predict first planned extubation outcome in the pediatric intensive care unit? J Intensive Care Med. Nebulized epinephrine is thought to decrease LE through vasoconstriction, although high-quality evidence on the efficacy is lacking.

In pediatric upper airway obstruction caused by severe viral croup, it has been shown to decrease upper airway obstruction scores, and a beneficial effect has been suggested in upper airway obstruction of other etiologies [ 47 — 49 ]. The optimal dosage is currently unknown, although 1 mg in 5 ml has been suggested [ 49 ]. The efficacy of combined intravenous corticosteroids and nebulized epinephrine on PLE has been investigated in pediatric patients, although administration of corticosteroids was started before extubation and treatment was not limited to symptomatic patients [ 50 ].

In this overall well-designed study, dexamethasone and nebulized epinephrine did not prevent clinical progression of airway obstruction due to PLE. Therefore, the efficacy of both intravenous corticosteroids and nebulized epinephrine as well as the combination of both treatments has not been established.

The inhalation of a helium-oxygen mixture heliox decreases airway resistance and thus work of breathing. Therefore, heliox does not lead to a reduction of LE but may decrease work of breathing and buy time to establish a definitive solution for the upper airway obstruction and this may be useful in circumstances in which it is difficult to intubate patients. However, in the context of PLE, it should similar to NIV not lead to a delay to intubation since that may potentially lead to a worse outcome.

Based on the best available evidence, a practical extubation algorithm, including prevention and treatment of PLE and PRF, may be proposed Fig. However, it should be emphasized that the CLT effectively identifies low-risk patients only.

Treatment of all patients with a positive CLT would result in overtreatment. Therefore, one could decide to perform a CLT in all patients and start pretreatment with corticosteroids in the presence of additional risk factors only, as suggested in the algorithm.

Alternatively, a CLT could be performed in patients with risk factors only. Proposed extubation algorithm. In patients with a positive CLT, the decision to start pretreatment with corticosteroids should be made on an individual basis and on the basis of the presence of additional risk factors.

If corticosteroid therapy is considered to be indicated, treatment should be started at least 4 hours before extubation and multiple doses should be administered. However, if PLE or PES leads to respiratory insufficiency, reintubation is the only definitive resolution and should not be postponed. Competing interests. The manuscript was prepared and edited by WAP.

All authors helped to revise and improve the manuscript and read and approved the final manuscript. National Center for Biotechnology Information , U. Journal List Crit Care v. Crit Care. Published online Sep Wouter A. Author information Copyright and License information Disclaimer. Pluijms, Email: moc. Corresponding author. This article has been cited by other articles in PMC.

Abstract Endotracheal intubation is frequently complicated by laryngeal edema, which may present as postextubation stridor or respiratory difficulty or both. Introduction Laryngeal edema LE is a frequent complication of intubation and is caused by trauma to the larynx [ 1 , 2 ]. Etiology PRF may result from liberation failure i. Incidence of postextubation laryngeal edema, stridor, and respiratory failure Postextubation laryngeal edema and stridor Earlier studies have reported an incidence of PLE ranging from 5.

Table 1 Incidence of postextubation stridor, postextubation laryngeal edema, and reintubation. Open in a separate window. Postextubation respiratory failure As mentioned earlier, PRF may result from liberation failure or extubation failure [ 5 ]. Table 2 Risk factors for complications following extubation. Assessment of airway patency before extubation In an effort to allow identification of patients at risk for PLE, several tests have been evaluated for the assessment of airway patency before extubation, including the cuff leak test CLT , ultrasonography, and video laryngoscopy.

Table 3 Measurement of the cuff leak volume in mechanically ventilated patients. Before performing the cuff leak test, first suction endotracheal and oral secretions and set the ventilator in the assist control mode. With the cuff inflated, record displayed inspiratory and expiratory tidal volumes to see whether these are similar.

Record cuff pressure. Deflate the cuff. Directly record the expiratory tidal volume over the next six breathing cycles as the expiratory tidal volume will reach a plateau value after a few cycles. Average the three lowest values. The difference between the inspiratory tidal volume measured before the cuff was deflated and the averaged expiratory tidal volume is the cuff leak volume.

Table 4 Predictive value of the cuff leak test and laryngeal ultrasonography for postextubation stridor, laryngeal edema, and reintubation. Ultrasonography Several studies on the assessment of airway patency using ultrasonography have been published in recent years [ 15 , 23 , 28 ]. Video laryngoscopy Results on the use of video laryngoscopy for the assessment of airway patency have been published in one case series, including only three patients [ 37 ].

Table 5 The effect of corticosteroids on postextubation laryngeal edema, stridor, respiratory distress, and reintubation. Treatment Reintubation should be performed without delay in the presence of respiratory insufficiency due to PLE. Footnotes Competing interests The authors declare that they have no competing interests.

References 1. Laryngeal complications of prolonged intubation. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients.

Epstein SK. Decision to extubate. The decision to extubate in the intensive care unit. Laryngotracheal injury due to endotracheal intubation: incidence, evolution, and predisposing factors. A prospective long-term study. Crit Care Med. Post intubation laryngeal sequelae in an intensive care unit. J Laryngol Otol. Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Tracheoesophageal compression associated with substernal goitre. Correlation of symptoms with cross-sectional imaging findings.

Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study. The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation. Post-intubation laryngeal injuries and extubation failure: a fiberoptic endoscopic study.

Predicting laryngeal edema in intubated patients by portable intensive care unit ultrasound. J Crit Care. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care.

The role of the cuff leak test in predicting the effects of corticosteroid treatment on postextubation stridor. Chang Gung Med J. How to identify patients with no risk for postextubation stridor? Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation. J Am Coll Surg. Association between reduced cuff leak volume and postextubation stridor.

Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur Respir J. Efferen LS, Elsakr A. Post-extubation stridor: risk factors and outcome. J Assoc Acad Minor Phys. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients.

Minerva Anestesiol. Intra-individual variation of the cuff-leak test as a predictor of post-extubation stridor. Laryngeal ultrasonography versus cuff leak test in predicting postextubation stridor. J Cardiovasc Thorac Res. Effect of nebulized budesonide in preventing postextubation complications in critically patients: a prospective, randomized, double-blind, placebo-controlled study. Adv Biomed Res. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study.

Eur Arch Otorhinolaryngol. Reintubation as an outcome predictor in trauma patients. High body mass index and long duration of intubation increase post-extubation stridor in patients with mechanical ventilation. Tohoku J Exp Med. Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population. Cuff-leak test predicts the severity of postextubation acute laryngeal lesions: a preliminary study. Eur J Anaesthesiol. Determinants of the cuff-leak test: a physiological study.

Use of video laryngoscopy and camera phones to communicate progression of laryngeal edema in assessing for extubation: a case series. J Intensive Care Med. Rose L, Redl L. Survey of cuff management practices in intensive care units in Australia and New Zealand. Am J Crit Care. Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia.

Corticosteroids for prevention of postextubation laryngeal edema in adults. Ann Pharmacother. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev. The efficacy of noninvasive ventilation in managing postextubation respiratory failure: a meta-analysis.

Heart Lung. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med.

DRAGON PHOENIX GOLD BRACELET

Although NIV has been shown to be effective in the prevention of intubation in respiratory insufficiency in general, it was shown to be ineffective in the treatment of respiratory insufficiency following extubation [ 42 ]. More than that, NIV for PRF has been associated with increased mortality, probably due to the increased delay to intubation [ 43 ].

The use of airway exchange catheters AECs , which has been included in the Difficult Airway Society extubation guidelines for patients at risk for PRF, provides important advantages [ 44 ]. Firstly, the AEC may facilitate over-the-wire insertion of an endotracheal tube in the instance of difficult visualization of the glottis and this is not uncommon in the presence of LE [ 45 ]. Unfortunately, identification of patients at risk for PRF is difficult since no reliable test is available.

The current treatment of choice for PLE consists of intravenous corticosteroids and nebulized epinephrine. Corticosteroids decrease LE by diminishing the inflammatory response and decreasing capillary vessel dilation and permeability. However, the efficacy of corticosteroids in the treatment of PLE has not been investigated and thus no data on the most effective dose are available. Based on the dosages used in the prevention of PLE, a dosage of methylprednisolone 20—40 mg or dexamethasone 5 mg could be suggested and therapy might be continued for 24—48 hours after extubation [ 11 , 16 , 26 , 30 ].

Nebulized epinephrine is thought to decrease LE through vasoconstriction, although high-quality evidence on the efficacy is lacking. In pediatric upper airway obstruction caused by severe viral croup, it has been shown to decrease upper airway obstruction scores, and a beneficial effect has been suggested in upper airway obstruction of other etiologies [ 47 — 49 ].

The optimal dosage is currently unknown, although 1 mg in 5 ml has been suggested [ 49 ]. The efficacy of combined intravenous corticosteroids and nebulized epinephrine on PLE has been investigated in pediatric patients, although administration of corticosteroids was started before extubation and treatment was not limited to symptomatic patients [ 50 ].

In this overall well-designed study, dexamethasone and nebulized epinephrine did not prevent clinical progression of airway obstruction due to PLE. Therefore, the efficacy of both intravenous corticosteroids and nebulized epinephrine as well as the combination of both treatments has not been established. The inhalation of a helium-oxygen mixture heliox decreases airway resistance and thus work of breathing.

Therefore, heliox does not lead to a reduction of LE but may decrease work of breathing and buy time to establish a definitive solution for the upper airway obstruction and this may be useful in circumstances in which it is difficult to intubate patients. However, in the context of PLE, it should similar to NIV not lead to a delay to intubation since that may potentially lead to a worse outcome. Based on the best available evidence, a practical extubation algorithm, including prevention and treatment of PLE and PRF, may be proposed Fig.

However, it should be emphasized that the CLT effectively identifies low-risk patients only. Treatment of all patients with a positive CLT would result in overtreatment. Therefore, one could decide to perform a CLT in all patients and start pretreatment with corticosteroids in the presence of additional risk factors only, as suggested in the algorithm.

Alternatively, a CLT could be performed in patients with risk factors only. Proposed extubation algorithm. In patients with a positive CLT, the decision to start pretreatment with corticosteroids should be made on an individual basis and on the basis of the presence of additional risk factors.

If corticosteroid therapy is considered to be indicated, treatment should be started at least 4 hours before extubation and multiple doses should be administered. However, if PLE or PES leads to respiratory insufficiency, reintubation is the only definitive resolution and should not be postponed. Competing interests. The manuscript was prepared and edited by WAP. All authors helped to revise and improve the manuscript and read and approved the final manuscript.

National Center for Biotechnology Information , U. Journal List Crit Care v. Crit Care. Published online Sep Wouter A. Author information Copyright and License information Disclaimer. Pluijms, Email: moc. Corresponding author. This article has been cited by other articles in PMC. Abstract Endotracheal intubation is frequently complicated by laryngeal edema, which may present as postextubation stridor or respiratory difficulty or both. Introduction Laryngeal edema LE is a frequent complication of intubation and is caused by trauma to the larynx [ 1 , 2 ].

Etiology PRF may result from liberation failure i. Incidence of postextubation laryngeal edema, stridor, and respiratory failure Postextubation laryngeal edema and stridor Earlier studies have reported an incidence of PLE ranging from 5. Table 1 Incidence of postextubation stridor, postextubation laryngeal edema, and reintubation. Open in a separate window. Postextubation respiratory failure As mentioned earlier, PRF may result from liberation failure or extubation failure [ 5 ].

Table 2 Risk factors for complications following extubation. Assessment of airway patency before extubation In an effort to allow identification of patients at risk for PLE, several tests have been evaluated for the assessment of airway patency before extubation, including the cuff leak test CLT , ultrasonography, and video laryngoscopy.

Table 3 Measurement of the cuff leak volume in mechanically ventilated patients. Before performing the cuff leak test, first suction endotracheal and oral secretions and set the ventilator in the assist control mode. With the cuff inflated, record displayed inspiratory and expiratory tidal volumes to see whether these are similar.

Record cuff pressure. Deflate the cuff. Directly record the expiratory tidal volume over the next six breathing cycles as the expiratory tidal volume will reach a plateau value after a few cycles. Average the three lowest values.

The difference between the inspiratory tidal volume measured before the cuff was deflated and the averaged expiratory tidal volume is the cuff leak volume. Table 4 Predictive value of the cuff leak test and laryngeal ultrasonography for postextubation stridor, laryngeal edema, and reintubation.

Ultrasonography Several studies on the assessment of airway patency using ultrasonography have been published in recent years [ 15 , 23 , 28 ]. Video laryngoscopy Results on the use of video laryngoscopy for the assessment of airway patency have been published in one case series, including only three patients [ 37 ]. Table 5 The effect of corticosteroids on postextubation laryngeal edema, stridor, respiratory distress, and reintubation.

Treatment Reintubation should be performed without delay in the presence of respiratory insufficiency due to PLE. Footnotes Competing interests The authors declare that they have no competing interests. References 1. Laryngeal complications of prolonged intubation.

The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Epstein SK. Decision to extubate. The decision to extubate in the intensive care unit. Laryngotracheal injury due to endotracheal intubation: incidence, evolution, and predisposing factors.

A prospective long-term study. Crit Care Med. Post intubation laryngeal sequelae in an intensive care unit. J Laryngol Otol. Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Tracheoesophageal compression associated with substernal goitre. Correlation of symptoms with cross-sectional imaging findings. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone.

A placebo-controlled, double-blind, multicenter study. The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation. Post-intubation laryngeal injuries and extubation failure: a fiberoptic endoscopic study.

Predicting laryngeal edema in intubated patients by portable intensive care unit ultrasound. J Crit Care. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone.

The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care. The role of the cuff leak test in predicting the effects of corticosteroid treatment on postextubation stridor. Chang Gung Med J. How to identify patients with no risk for postextubation stridor? Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation.

J Am Coll Surg. Association between reduced cuff leak volume and postextubation stridor. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur Respir J. Efferen LS, Elsakr A. Post-extubation stridor: risk factors and outcome.

J Assoc Acad Minor Phys. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients. Minerva Anestesiol. Intra-individual variation of the cuff-leak test as a predictor of post-extubation stridor.

Laryngeal ultrasonography versus cuff leak test in predicting postextubation stridor. J Cardiovasc Thorac Res. Effect of nebulized budesonide in preventing postextubation complications in critically patients: a prospective, randomized, double-blind, placebo-controlled study. Adv Biomed Res. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Eur Arch Otorhinolaryngol.

Reintubation as an outcome predictor in trauma patients. High body mass index and long duration of intubation increase post-extubation stridor in patients with mechanical ventilation. Tohoku J Exp Med. Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population.

Cuff-leak test predicts the severity of postextubation acute laryngeal lesions: a preliminary study. Eur J Anaesthesiol. Determinants of the cuff-leak test: a physiological study. Use of video laryngoscopy and camera phones to communicate progression of laryngeal edema in assessing for extubation: a case series. J Intensive Care Med. Rose L, Redl L. Survey of cuff management practices in intensive care units in Australia and New Zealand.

Am J Crit Care. Prolonged endotracheal intubation can result in inflammation, swelling, and ulceration of laryngotracheal areas of contact, especially the vocal cords, and the inflated cuff areas. An early study published by Darmon et al. Severe post-extubation intubation laryngeal edema requiring tracheostomy in a patient who had undergone bilateral modified radical neck dissection about seven years before the current urologic intervention has been reported with a probable explanation for increased edema risk being the destruction of lymphatics, or venous engorgement of the neck.

In brief, the risk for post-intubation laryngeal edema can be summarized into three categories intubation factors, post-intubation factors, and patient factors. The determination of the exact prevalence of post-intubation laryngeal edema is challenging because of wide variations in definition, diagnostic criteria, and the methods employed for the detection.

This variation is further compounded by differences in the study population, and also due to differences like endotracheal tube material with the latter pertaining especially to the older studies. The reported overall incidence of post-extubation failure requiring reintubation varies from 1. The literature offers other epidemiological data. Concerning gender differences, for instance, the incidence of edema is higher in females.

Laryngeal edema with decreased vocal cod mobility was present in almost two-thirds of the patients with stridor. Only half of the patients with post-extubation stridor got reintubated, and only half of the patients who got reintubated had post-extubation stridor. Previous studies had also noted a significant number of intubated patients having varying degrees of edema and ulceration of larynx. An endotracheal tube placed even for a short period causes superficial mucosal damage, whereas chronic placement might cause pressure necrosis of deeper layers involving submucosa, perichondrium, and even the cartilage.

The laryngeal, as well as tracheal mucosa, are affected similarly. The sites of contact in the larynx usually involve the medial aspect of arytenoid cartilages, vocal cords, cricoarytenoid joints, posterior part of the glottis, and sub-glottis. While the area at the level of vocal cord commonly forms the area of contact in the larynx, the mucosal area in contact with the inflated cuff is involved in the trachea.

If the edema involves only the arytenoids and the false cords, it does not cause luminal obstruction. Whenever the edema, ulceration, granulation, or vocal cord dysfunction causes laryngeal luminal narrowing, the resultant increase in airflow velocity manifests as stridor, which is a sign of clinically significant airway obstruction. There is an association between laryngeal edema with resultant decreased vocal cord mobility, with the latter predisposing to adducted positioning of the cords, thereby increasing the work of breathing.

The risk of aspiration is also high in patients with reduced vocal cord mobility, which increases the risk of respiratory failure. It should also be noted that the above-mentioned factors edema, ulceration, granulation, or vocal cord dysfunction causing luminal narrowing will be present as single or in varying combinations in a given patient. It is assumed that stridor and respiratory distress occur when more than half of the luminal area is obstructed. A study in cynomolgus monkeys has shown significant polymorphonuclear infiltration at the laryngeal contact areas after experimental intubation.

This infiltration was maximum at hours and was significantly reduced at 96 hours. Laryngeal edema is the commonest laryngeal injury detected after intubation, and the majority of endoscopically visualized laryngeal edema after extubation remains asymptomatic or mildly symptomatic. Most patients with post-intubation laryngeal edema complain of mild symptoms like throat ache, difficulty to speak, or swallow.

However, severe laryngeal edema makes a common etiology of post-extubation stridor in almost two-thirds of the cases, and nearly half of the patients with stridor get reintubated. Associated vocal cord edema may cause significant restriction of vocal cord movements, which will aggravate the stridor. Though most cases of post-intubation laryngeal edema develop within 24 hours of tube placement and manifest immediately in the ensuing minutes to hours following extubation, a report of intractable post-extubation laryngeal edema presenting as late as 14 hours to 48 hours after post-surgery extubation is also observed in the literature.

Usually, the laryngeal inflammation and swelling usually resolve in one or two days after extubation. If symptoms persist, the possibility of other injuries sustained during endotracheal tube placement such as hematoma, laceration, avulsion, or due prolonged intubation such as ulceration, granulomas, adhesions, and paralysis needs to be looked into.

Many of the reintubations in planned extubations occurs within the first 24 hours after the extubation, and rarely reach up to 72 hours. The vast majority of post-intubation laryngeal edema which has been ascertained after extubation is asymptomatic or mildly symptomatic, as shown in the fibreoptic endoscopic evaluation of patients within six hours after extubation [6]. However, post-intubation laryngeal edema with significantly decreased vocal cord mobility constituted almost two-thirds of patients presenting with post-extubation stridor, and nearly half of them got reintubated in the coming hours.

As a consequence, several tests have been proposed for the evaluation of airway patency before extubation. These methods include the cuff leak test CLT , ultrasonography, and video laryngoscopy. Laryngeal edema is the major contributor for post-extubation stridor, as it also causes diminished mobility of oedematous vocal cords.

In particular, the CLT ascertains the space available between the larynx and endotracheal tube, and a reduced or absent cuff leak could be due to a variety of causes, including post-intubation laryngeal injuries which involve laryngeal edema the most common etiology , copious secretions and laryngotracheal narrowing.

On the other hand, the cuff leak could be increased by associated or isolated conditions like tracheomalacia. The CLT could be assessed qualitatively as well as quantitatively. A qualitative assessment is done by deflating the cuff and auscultating the tracheal area for any audible leak.

The quantitative test is done by putting the patient in volume control mode and calculating the difference between the inspiratory tidal volume and the average value of lowest three expiratory tidal volumes obtained over a period of 6 breaths cuff leak volume. A negative leak test predicts risk for post-extubation failure with varying sensitivity and specificity.

This variation could be explained by the fact that the cuff leak volume is determined not only by the expiratory leak via peri tubal space but also by the inspiratory leak volume, which depends on the inspiratory flow and the compliance of the lung. Prophylactic methylprednisolone is advised in such patients with negative leak tests, as described above. It measures the Air Column Width ACW , which is the width of the acoustic shadow at the level cords before and after cuff deflation in the intubated patients.

This approach has been shown to predict the risk of post-extubation stridor. The ACWD is the difference in the air column measurement in the intubated and deflated state. Laryngeal ultrasonography is a simple, rapid, and non-invasive evaluation which could be done at the bedside. Ding et al.

Another study by Sutheresan et al. Video laryngoscopy or fiber optic endoscopy evaluation is conceptually promising in that they would be able to visualize the peri laryngeal structures and abnormalities. Unlike CLT, video laryngoscopy or fibreoptic evaluation can identify and differentiate between the structural versus functional laryngeal abnormalities e.

However, the utility of the above modalities in the prediction of post-extubation laryngeal edema or stridor is yet to be evaluated. Steroids have been studied in the prophylactic administration to prevent post-extubation stridor by various randomized trials and reviews, with most of them suggesting positive results.

Thus many experts use methylprednisolone in the dose of 20 mg intravenous IV 4 hourly over 12 hours prior to extubation or a single dose methylprednisolone 40 mg IV at least 4 hours before extubation based on the methodologies of the positive randomized trials. Evidence for clinical benefits of adrenaline nebulization in the management of post-extubation stridor or laryngeal edema lacks in adults though adrenaline nebulization is used in pediatric populations to relieve upper airway edema in acute severe croup.

The combined use of intravenous steroids and adrenaline nebulization did not mitigate the progression of airway obstruction secondary to laryngeal edema in a randomized study in neonates and children. Heliox helium and oxygen mixture has been shown to decrease the post-extubation stridor scores in pediatric trauma patients. Thus, it may only provide more time before a more definite intervention at airway obstruction is executed.

The clinical efficacy of Heliox in adults is yet to be proven. The extubation in such cases needs to be monitored closely. An airway exchanger could be kept up to an hour or so in the larynx after extubation , anticipating the need to thread the endotracheal tube in case of any unexpected difficulty in reintubation.

If the patient continues to be asymptomatic after an hour, the active monitoring could be reduced, and routine plans are carried out appropriately. If the patient is significantly symptomatic in the post-extubation period but slowly getting better clinically within this one hour period, IV steroids and adrenaline nebulization are continued for 24 to 48 hours. Reintubated patients are also continued on IV steroids and adrenaline nebulizations for 24 to 48 hours before reassessing for extubation versus tracheostomy.

Head end elevation has been ensured to reduce the venous congestion, which is expected to mitigate the edema. A multicentre randomized study on the trial of non-invasive ventilation NIV in patients with post-extubation respiratory failure observed increased mortality in patients who were assigned to the NIV group likely due to delay in reintubation. The authors concluded that NIV neither reduces reintubation rate or mortality in post-extubation respiratory failure.

Post extubation stridor is symptomatic varying severity form of laryngotracheal narrowing in an extubated patient. It is clinically diagnosed by the unique inspiratory crowing sound. About two-thirds of post-extubation stridor is caused by severe post-intubation laryngeal edema, and nearly half of the patients with post-extubation laryngeal edema will get reintubated. Laryngospasm is the exaggerated glottic closure reflex due to the stimulation of the superior laryngeal nerve.

It could happen abruptly in patients who are extubated after anesthesia. This occurs in patients who are not adequately conscious of countering the laryngeal reflexes in response to vocal cord irritating events like endotracheal tube removal, pooling of secretions, blood, or foreign body in the airway. Treatment is the removal of inciting cause, positive pressure bag, and masking with a simultaneous jaw thrust maneuver.

Larson's maneuver is the application of pressure with fingertips at the laryngospasm notch, which could rapidly reverse the condition. Angiooedema could occur due to various drugs, including opioids, calcium-channel blockers, fibrinolytic agents, and NSAIDs. It usually responds to steroids and antihistaminics. Anaphylaxis is treated with adrenaline injection. Severe bronchospasm and pulmonary edema can sometimes mimic laryngeal edema.

Post-extubation stridor could rarely cause negative pressure pulmonary edema. The clinical outcomes include post-extubation stridor, reintubation, mechanical ventilation duration, length of stay in ICU, and ICU and in-hospital mortality. Larger RCTs are being planned after the result of this trial.

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M-JP contributed to the conception of the study and coordinated audible high-pitched inspiratory wheeze and. Problems associated with tracheal extubation. Continuous airway access for the in predicting post-extubation stridor. Intravenous injection of methylprednisolone reduces that they have no competing. The effect of local methylprednisolone. Article PubMed Google Scholar. The role of the cuff oxygenation and relieving distress associated Bishop MJ: Mechanisms of laryngotracheal. To our knowledge, this was 3: Otolaryngol Head Neck Surg consistent with the results of the two recent studies in treatment period, but also 24 settings [ 2122. How to identify patients with leak to predict postextubation stridor. Major laryngeal edema: respiratory distress 2-mg dose of nebulized budesonide post-extubation stridor in patients with mechanical ventilation.

in appropriate doses, can be helpful in alleviating laryngeal edema in intubated high-risk patients susceptible to airway obstruction, such as those requiring repeated or prolonged intubations. legal.sportnutritionclub.com › articles. Conclusions: Data from the most recent well-designed clinical trials suggest that prophylactic corticosteroid therapy can reduce the incidence of PELE and the.