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Post extubation stridor

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Post extubation stridor

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

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