12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial

Dalmay, François; Bellissant, Éric; Gissot, Valérie; Desachy, Arnaud; Normand, Sandrine; Boulain, Thierry; Brenet, Olivier; Preux, Pierre‐Marie; Vignon, Philippe

doi:10.1016/s0140-6736(07)60526-1

Cited by 216 publications

(179 citation statements)

References 21 publications

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“…In adults, prophylactic corticosteroids benefit patients deemed to be at high risk for subglottic edema by virtue of low ETT cuff leak volume before extubation (4)(5)(6).…”

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confidence: 99%

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Khemani

Hotz

Morzov

et al. 2016

Am J Respir Crit Care Med

127

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Rationale: Subglottic edema is the most common cause of pediatric extubation failure, but few studies have confirmed risk factors or prevention strategies. This may be due to subjective assessment of stridor or inability to differentiate supraglottic from subglottic disease.Objectives: Objective 1 was to assess the utility of calibrated respiratory inductance plethysmography (RIP) and esophageal manometry to identify clinically significant post-extubation upper airway obstruction (UAO) and differentiate subglottic from supraglottic UAO. Objective 2 was to identify risk factors for subglottic UAO, stratified by cuffed versus uncuffed endotracheal tubes (ETTs).Methods: We conducted a single-center prospective study of children receiving mechanical ventilation. UAO was defined by inspiratory flow limitation (measured by RIP and esophageal manometry) and classified as subglottic or supraglottic based on airway maneuver response. Clinicians performed simultaneous blinded clinical UAO assessment at the bedside. Measurements and Main Results:A total of 409 children were included, 98 of whom had post-extubation UAO and 49 (12%) of whom were subglottic. The reintubation rate was 34 (8.3%) of 409, with 14 (41%) of these 34 attributable to subglottic UAO. Five minutes after extubation, RIP and esophageal manometry better identified patients who subsequently received UAO treatment than clinical UAO assessment (P , 0.006). Risk factors independently associated with subglottic UAO included low cuff leak volume or high preextubation leak pressure, poor sedation, and preexisting UAO (P , 0.04) for cuffed ETTs; and age (range, 1 mo to 5 yr) for uncuffed ETTs (P , 0.04). For uncuffed ETTs, the presence or absence of preextubation leak was not associated with subglottic UAO.Conclusions: RIP and esophageal manometry can objectively identify subglottic UAO after extubation. Using this technique, preextubation leak pressures or cuff leak volumes predict subglottic UAO in children, but only if the ETT is cuffed.

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“…In adults, prophylactic corticosteroids benefit patients deemed to be at high risk for subglottic edema by virtue of low ETT cuff leak volume before extubation (4)(5)(6).…”

mentioning

confidence: 99%

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Khemani

Hotz

Morzov

et al. 2016

Am J Respir Crit Care Med

127

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“…Development of clinical practice guidelines, summarized in Table 1, has been challenged by contradictory results of clinical trials. [1][2][3][4][5][6][7][8][9][10] One expert panel recommended corticosteroids for patients with acute respiratory distress syndrome (ARDS) and for septic shock; 11 however, perceived indications and contraindications for corticosteroid therapy often coexist in critically ill patients. This phenomenon may explain why only half the patients received corticosteroids in recent sepsis and ARDS studies where no protocol was established for their use.…”

mentioning

confidence: 99%

Corticosteroid use in the intensive care unit: a survey of intensivists

Lamontagne

Martinez

Adhikari

et al. 2013

Can J Anesth/J Can Anesth

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Objective The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice. Design Self-administered paper survey.Population Intensivists in academic hospitals with clinical trial expertise in critical illness. Measurements We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected -013-9929-3 North American centres actively enrolling patients in the multicentre Oscillation for ARDS Treated Early (OSCILLATE) Trial (ISRCTN87124254). Respondents used a four-point scale to grade how frequently they would administer corticosteroids in 14 clinical settings. They also reported their opinions on 16 potential near-absolute indications or contraindications for the use of corticosteroids. Main results Our response rate was 82% (103/125). Respondents were general internists (50%), respirologists (22%), anesthesiologists (21%), and surgeons (7%) who practiced in mixed medical-surgical units. A majority of respondents reported almost always prescribing corticosteroids in the setting of significant bronchospasm in a mechanically ventilated patient (94%), recent corticosteroid use and low blood pressure (93%), and vasopressorrefractory septic shock (52%). Although more than half of respondents stated they would almost never prescribe corticosteroids in severe community-acquired pneumonia (81%), acute lung injury (ALI, 76%), acute respiratory distress syndrome (ARDS, 65%), and severe ARDS (51%), variability increased with severity of acute lung injury. Near-absolute indications selected by most respondents included known adrenal insufficiency (99%) and suspicion of cryptogenic organizing pneumonia (89%), connective tissue disease (85%), or other potentially corticosteroidresponsive illnesses (85%). Conclusions Respondents reported rarely prescribing corticosteroids for ALI, but accepted them for bronchospasm, suspected adrenal insufficiency due to previous corticosteroid use, and vasopressor-refractory septic shock. These competing indications will complicate the design and interpretation of any future large-scale trial of corticosteroids in critical illness.123 Can J Anesth/J Can Anesth (2013) 60:652-659 DOI 10.1007/s12630 RésuméObjectif L'efficacite´des corticoste´roı¨des syste´miques demeure incertaine pour plusieurs maladies graves. Notre objectif primaire e´tait d'obtenir l'opinion des intensivistes en Ame´rique du Nord concernant leur perception de l'utilisation des corticoste´roı¨des dans la pratique clinique. Méthodologie Sondage auto-administre´sur papier. Population Intensivistes dans des hôpitaux universitaires ayant une expertise en matie`re d'e´tudes cliniques sur les maladies graves. Mesures Les e´le´ments du questionnaire ont e´te´cre´e´s dans des groupes de discussion; nous les ...

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“…5,6,17,18 Conversely, a lower incidence of post-extubation stridor and need for re-intubation has been shown in trials where higher risk patients were identified and where corticosteroids were initiated > six hours prior to planned extubation, and administered in multiple doses. 4,16,19 Accordingly, François et al 20 performed a large, well-designed randomized trial that significantly extends upon the experience from prior investigations. This work provides compelling evidence of benefit with the use of prophylactic corticosteroids in the prevention of post-extubation laryngeal edema, along with a reduced need for re-intubation attributable to major obstruction.…”

Section: Commentarymentioning

confidence: 96%

“…Many investigators have dismissed the risk of these adverse effects as being negligible, but have also been inconsistent in reporting them. 6,19,20 Therefore, the optimal intervention (i.e., corticosteroid drug, dose, schedule) that reduces the occurrence of post-extubation laryngeal edema, while also minimizing the potential for adverse effects, remains controversial.…”

Section: Commentarymentioning

confidence: 99%

Steroids to prevent post-extubation airway obstruction in adult critically ill patients

Bagshaw

Delaney

Farrell

et al. 2008

Can J Anesth/J Can Anesth

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Article appraised François B, Bellissant E, Gissot V, et al; 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; 369: 1083-9. Structured abstractBackground: The efficacy of corticosteroids for reducing the incidence of post-extubation laryngeal edema remains controversial.Objective: To evaluate whether methylprednisolone (MP) started 12 hr prior to planned tracheal extubation, can prevent post-extubation laryngeal edema.Design: Prospective, randomized, blinded, placebocontrolled trial performed in 15 intensive care units (ICU) across France.Methods: Inclusion criteria were adult (age >18 yr) patients who were scheduled for planned tracheal extubation after having received mechanical ventilation for > 36 hr. Exclusion criteria included pregnancy, history of post-extubation upper-airway obstruction, primary ICU admission diagnosis of throat disease or surgery, tracheostomy, and those who had been chronically treated with non-steroidal anti-inflammatory drugs or corticosteroids. Patients were randomly allocated to receive either corticosteroid or placebo. Allocation was stratified by site, and was concealed in sequentially numbered sealed opaque envelopes. Analyses were performed on a per-protocol and intention-to-treat basis.Intervention: Patients were allocated to either intravenous MP 20 mg initiated 12 hr prior to planned tracheal extubation, and continued every four hours thereafter with the final dose given immediately prior to extubation (total dose 80 mg) or identical volume of intravenous placebo (normal saline).Primary endpoint: The primary endpoint was occurrence of laryngeal edema within 24 hr of planned tracheal extubation. Laryngeal edema was clinically

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12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial

Cited by 216 publications

References 21 publications

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool

Corticosteroid use in the intensive care unit: a survey of intensivists

Steroids to prevent post-extubation airway obstruction in adult critically ill patients

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