Post Extubation Post Extubation StridorStridorCritical Care Grand RoundsCritical Care Grand Rounds

April 7, 2008April 7, 2008

Janice D Chisholm, BSc, MD, FRCPCJanice D Chisholm, BSc, MD, FRCPC

Post Extubation StridorPost Extubation Stridor

DefinitionDefinition EpidemiologyEpidemiology The Cuff LeakThe Cuff Leak Use of SteroidsUse of Steroids

ProphylaxisProphylaxis

TreatmentTreatment How do I use this info clinically?How do I use this info clinically? ConclusionsConclusions

the development of upper airway the development of upper airway obstruction after extubationobstruction after extubation

MinorMinor Audible high pitched inspiratory wheeze with Audible high pitched inspiratory wheeze with

respiratory distressrespiratory distress MajorMajor

Severe respiratory distress needing tracheal Severe respiratory distress needing tracheal reintubation secondary to upper airway reintubation secondary to upper airway obstructionobstruction

DefinitionDefinition

Prolonged intubation can lead to edema, Prolonged intubation can lead to edema, inflammation, and ulcerationinflammation, and ulceration Level of cords and cuff siteLevel of cords and cuff site At autopsy, 54% had ulcers on posterior At autopsy, 54% had ulcers on posterior

cords and 93% had mucosal inflammation cords and 93% had mucosal inflammation and/or edemaand/or edema

IncidenceIncidence 2-22% of patients intubated > 24 hrs2-22% of patients intubated > 24 hrs

Increased mortality and prolonged ICU Increased mortality and prolonged ICU staystay

Occurs after 36hrs of intubationOccurs after 36hrs of intubation Occurs shortly after extubationOccurs shortly after extubation Reintubation rate is 1-10%Reintubation rate is 1-10%

The Cuff Leak TestThe Cuff Leak Test

Auscultation testAuscultation test No leak – no sound heard by auscultationNo leak – no sound heard by auscultation Mild – leak heard using the stethoscopeMild – leak heard using the stethoscope Significant – sound of leak heard without Significant – sound of leak heard without

stethoscopestethoscope Cuff Leak Volume (CLV)Cuff Leak Volume (CLV)

Exhaled tidal volume is measured before Exhaled tidal volume is measured before and after cuff deflationand after cuff deflation

ml or % of tidal volumeml or % of tidal volume

Early studies suggested that a failed cuff Early studies suggested that a failed cuff leak test did not preclude uneventful leak test did not preclude uneventful extubationextubation

ProblemsProblems Small studiesSmall studies Observational or prospective cohortObservational or prospective cohort Study populations – surgical, short duration Study populations – surgical, short duration

of intubationof intubation

Miller,RL, Cole, RP. Association between reduced cuff leak volume and postextubation stridor. Chest 1996; 110:1035

100 intubations on 88 patients100 intubations on 88 patients Cuff leak measured 24 hrs prior to extubationCuff leak measured 24 hrs prior to extubation Post extubation stridor 6% Post extubation stridor 6% 17% reintubation rate17% reintubation rate

50% when stridor present50% when stridor present

CLV 180 ml vs 360 ml (stridor vs normal)CLV 180 ml vs 360 ml (stridor vs normal) CLV 110 ml – PPV 80%, NPV 98%CLV 110 ml – PPV 80%, NPV 98% No risk factors identifiedNo risk factors identified

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 MSICU112 intubated patients MSICU Cuff-leak test 24 hrs prior to extubationCuff-leak test 24 hrs prior to extubation Evaluated for stridor and need for Evaluated for stridor and need for

reintubation over 48 hrsreintubation over 48 hrs

ResultsResults

12% incidence of post extubation stridor12% incidence of post extubation stridor Avg time to stridor 3.2+/- 3.3 hrsAvg time to stridor 3.2+/- 3.3 hrs Extubation failureExtubation failure

10% overall10% overall 69% of stridulous patients69% of stridulous patients 2% non-stridulous2% non-stridulous

CLV 130 ml or 12% - sensitivity 85%, CLV 130 ml or 12% - sensitivity 85%, specificity 95%specificity 95%

Risk factors for Developing Post Risk factors for Developing Post Extubation StridorExtubation Stridor

Sicker patientsSicker patients SAPSII 38SAPSII 38±13 vs. 50±16 p<0.005±13 vs. 50±16 p<0.005

Intubated in ICU or prehospitalIntubated in ICU or prehospital 62% developed stridor p<0.02762% developed stridor p<0.027

Traumatic or difficult intubationTraumatic or difficult intubation 7% vs 54% p<0.0017% vs 54% p<0.001

High balloon cuff pressuresHigh balloon cuff pressures 40±20 vs 83±35 cm H40±20 vs 83±35 cm H22O p<0.001O p<0.001

Duration of intubationDuration of intubation 5.5±6.3 vs. 10.9±7.0 days p<0.0015.5±6.3 vs. 10.9±7.0 days p<0.001

Prior self extubationPrior self extubation Medical vs. surgical admissionMedical vs. surgical admission

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, MICU115 extubations, MICU Spontaneously breathingSpontaneously breathing Immediately prior to extubation, cuff Immediately prior to extubation, cuff

deflated and absence of cough was deflated and absence of cough was monitoredmonitored

ETT then occluded and the absence of ETT then occluded and the absence of leak was monitoredleak was monitored

Results:Results:

3.5% incidence of stridor3.5% incidence of stridor 100% of patients with stridor had no leak vs. 100% of patients with stridor had no leak vs.

20% of patients without stridor20% of patients without stridor 75% with stridor had no cough vs. 21% without 75% with stridor had no cough vs. 21% without

stridor stridor 75% with stridor had no leak and no cough vs 75% with stridor had no leak and no cough vs

7% without stridor7% without stridor Cuff leak no stridorCuff leak no stridor No leak or cough beware of stridorNo leak or cough beware of stridor

Steroid ProphylaxisSteroid Prophylaxis

Why steroids?Why steroids? Predicted to suppress mucosal inflammation and Predicted to suppress mucosal inflammation and

tissue swellingtissue swelling

In children, steroids decrease post extubation In children, steroids decrease post extubation stridor by 40%stridor by 40%

Unclear, if steroids change the reintubation Unclear, if steroids change the reintubation rate in childrenrate in children

Multiple positive and negative studies in adultsMultiple positive and negative studies in adults Timing and dose are importantTiming and dose are important

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 Prospective, randomized, double blind studystudy

77 patients in MSICU77 patients in MSICU Randomly assigned to receive 100 mg Randomly assigned to receive 100 mg

hydrocortisone or placebo 1 hr prior to hydrocortisone or placebo 1 hr prior to extubationextubation

Examined immediately after extubation Examined immediately after extubation and q6h X 24hrsand q6h X 24hrs

ResultsResults

77 patients randomized77 patients randomized 22% developed stridor22% developed stridor 1 / 77 reintubated because of stridor1 / 77 reintubated because of stridor Steroids did not decrease incidence of Steroids did not decrease incidence of

stridorstridor Risk factors to develop stridor:Risk factors to develop stridor:

Female RR 2.29Female RR 2.29

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 controlledRandomized, double blind, placebo controlled 321 patients extubated321 patients extubated 128 of these had CLV <24% and were 128 of these had CLV <24% and were

randomized to 1 of 3 groupsrandomized to 1 of 3 groups No intervention (control)No intervention (control) 40 mg methylprednisolone q6h X 24hrs (4 inj)40 mg methylprednisolone q6h X 24hrs (4 inj) 40 mg methylprednisolone 24hrs pre-extubation (1 40 mg methylprednisolone 24hrs pre-extubation (1

inj)inj)

Patients were extubated 1 hr post last dosePatients were extubated 1 hr post last dose

6-7 hours post injection is required to exert the 6-7 hours post injection is required to exert the protective effect of methylprednisoloneprotective effect of methylprednisolone

Risk FactorsRisk Factors

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 controlledRandomised, double blind, placebo controlled Treatment groupTreatment group

20 mg IV methylprednisolone q4h X 12hrs prior to 20 mg IV methylprednisolone q4h X 12hrs prior to extubation (total 80 mg)extubation (total 80 mg)

Primary endpoint – laryngeal edema within 24 Primary endpoint – laryngeal edema within 24 hrs of extubationhrs of extubation

Assessed at 10 m, 30 m, 1h, 1.5h, 3 h, 6h, 12h Assessed at 10 m, 30 m, 1h, 1.5h, 3 h, 6h, 12h and 24 h by the same investigatorand 24 h by the same investigator

698 patients analysed698 patients analysed

ResultsResults

Methylprednisolone significantly Methylprednisolone significantly decreased postextubation laryngeal decreased postextubation laryngeal edema 22% vs. 3%edema 22% vs. 3%

Steroid had no effect on the severity or Steroid had no effect on the severity or onset of stridoronset of stridor 80% of stridor occurred within 30 min 80% of stridor occurred within 30 min

Steroid decreased the incidence of Steroid decreased the incidence of reintubation 8%vs 4%reintubation 8%vs 4%

Treatment of StridorTreatment of Stridor

Elevate HOBElevate HOB Steroids (Dex 4-8 mg q8-12 hrs)Steroids (Dex 4-8 mg q8-12 hrs) HelioxHeliox Nebulized epinephrineNebulized epinephrine

2.25% racemic epinephrine vs 1% l-2.25% racemic epinephrine vs 1% l-epinephrineepinephrine

Consider reintubationConsider reintubation

What do I do now?What do I do now?

Identify those at riskIdentify those at risk FemalesFemales Uncontrolled/traumatic intubationsUncontrolled/traumatic intubations

Pre-hospital, ICU, wardsPre-hospital, ICU, wards No sedation No sedation

Duration of intubationDuration of intubation >24-36 hrs, <7-10 days>24-36 hrs, <7-10 days

Previous self extubationPrevious self extubation High cuff pressures in first 24hrsHigh cuff pressures in first 24hrs

Perform cuff – leak testPerform cuff – leak test If CLV <10-24% If CLV <10-24% ±± absent cough then consider absent cough then consider

delaying extubation and treating with steroidsdelaying extubation and treating with steroids

If high risk patient and/or low CLV pretreat with If high risk patient and/or low CLV pretreat with steroids for 12 hours pre extubationsteroids for 12 hours pre extubation

Patients with a good cuff leak probably don’t Patients with a good cuff leak probably don’t need steroidsneed steroids

Observe for stridor especially in first 30 min Observe for stridor especially in first 30 min post extubationpost extubation

ConclusionsConclusions

Post extubation stridor is a sigificant Post extubation stridor is a sigificant complication of tracheal intubationcomplication of tracheal intubation

Testing cuff leak is important at Testing cuff leak is important at identifying those who may be at riskidentifying those who may be at risk

Steroids given 6-24 hrs before extubation Steroids given 6-24 hrs before extubation reduce the incidence of stridor and reduce the incidence of stridor and reintubationreintubation