Post extubation stridor
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Post extubation stridor Presentation Transcript

  • 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
  • 5.  
  • 6.  
  • 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%
  • 13.  
  • 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
  • 21.  
  • 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%
  • 26.  
  • 27.  
  • 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
  • 32.