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.