Post-extubation stridor

Reviewed and revised 28/3/2013

OVERVIEW

  • Post-extubation stridor is the presence inspiratory noise post-extubation indicated narrowing of the airway (can be supraglottic, but usually glottic and infraglottic)
  • ETT can cause laryngeal oedema and ulceration as well as at the site where the cuff abuts the trachea
  • incidence is 3-30% (!) in ICU

RISK FACTORS

Intubation factors

  • excessive airway manipulation
  • traumatic intubation
  • prolonged intubation attempt (>10min)
  • oroendotracheal intubation
  • larger tubes

Post-intubation factors

  • intubation > 36 hours
  • agitation while intubated
  • high cuff pressures
  • recurrent intubations

Patient factors

  • female
  • short neck
  • trauma patients
  • known airway pathology (tracheal stenosis, tracheomalacia)
  • children
  • small height:internal diameter ETT ratio

MANAGEMENT

Prior to extubation

  • attend to reversible risk factors
  • perform cuff leak test (see Cuff Leak Test)
  • pretreatment with IV steroids — dexamethasone 0.15mg/kg — or methylprednisolone 20mg (substantial improvement in ARCO study DB-MC-RCT)
  • high flow O2

Post-extubation

  • high flow O2
  • close observation and monitoring (e.g. SpO2, ETCO2, leave in arterial line until stable)
  • nebulised adrenaline (e.g. 0.5mL/kg of 1:1,000 up to a maximum dose of 5 mL)
  • consider non-invasive ventilation
  • re-intubation if develops airway obstruction or respiratory failure

References and links

litfl.com

Textbooks and journal articles

  • Epstein SK. Corticosteroids to prevent postextubation upper airway obstruction: the evidence mounts. Crit Care. 2007;11(4):156. PMC2206510.
  • François B, Bellissant E, Gissot V, Desachy A, Normand S, Boulain T, Brenet O, Preux PM, Vignon P; Association des Réanimateurs du Centre-Ouest (ARCO). 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet. 2007 Mar 31;369(9567):1083-9. PubMed PMID: 17398307.
  • Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care. 2007;11(4):R72. PMC2206529.
  • Wittekamp BH, van Mook WN, Tjan DH, Zwaveling JH, Bergmans DC. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care. 2009;13(6):233. PMC2811912.

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Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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