Impact of fiber-optic laryngoscopy on the weaning process from mechanical ventilation in high-risk patients for postextubation stridor

Abstract

The objective of this study was to assess the impact of fiber-optic laryngoscopy (FOL) on the weaning process from mechanical ventilation in critically ill patients with a positive cuff leak test (CLT) as compared with the current recommended strategy based on corticosteroids.In this prospective observational pilot study conducted over a 1-year period in a 15-bed ICU, CLT was systematically performed before extubation in all intubated patients having passed a spontaneous breathing trial (SBT). After the endotracheal tube cuff was deflated, cuff leak volume (CLVol) was assessed during assisted controlled ventilation. When CLT was positive (CLVol < 110 mL), patients either were evaluated using FOL by our half-time FOL-practitioner when present, or received corticosteroids.Among the 233 patients included, 34 (14.6%) had a positive CLT that hampered extubation. Seventeen were treated by corticosteroids and 17 were evaluated by FOL. In the corticosteroids group, the CLVol was still <110 mL at 24 hours in 9 patients (53%). Corticosteroids strategy merely prolonged the total duration of mechanical ventilation (7 [4–11] vs 4 [2–6] days, P = 0.01) by increasing the time between successful SBT and the moment when extubation was effectively achieved (30 [24–60] vs 1.5 [1–2] hours, P < 0.001). This resulted in 2 self-extubations (12%) and 9 FOL-guided extubations (53%) in the corticosteroids group. Massive swelling of the arytenoids was the most common feature shown by FOL. The patients evaluated by FOL who exhibited the thin anterior V-shaped opening of the vocal cords—the V sign—(n = 26, 100%) were immediately extubated without any stridor or respiratory failure afterward.In this pilot study, a FOL-based extubation strategy was feasible and reliable, and significantly reduced the duration of mechanical ventilation in patients with a positive CLT. We describe the “V sign” of FOL that safely allows a successful prompt extubation in patients considered at high risk for postextubation stridor.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

“…Therefore, the cuff-leak test in this group of patients can especially yield a false-negative result. Lemyze et al postulated that the anatomical relevance of a positive cuff-leak test has not been sufficiently investigated and can yield false-positive results [203], such as in cases where a large-diameter endotracheal tube is combined with a narrow glottis. The authors carried out fibreoptic laryngoscopy examinations in 34 patients with a positive cuff-leak test, and found that a subset of patients had relatively inconspicuous vocal cords, whereas swelling was observed in the vicinity where the stomach tube and endotracheal tube had compressed the tissue in between (posterior larynx in the area of the posterior commissure); this however, did not present as an impedance to extubation.…”