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
- CCC — Cuff Leak Test
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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