Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients*

Abstract

A reduced cuff leak volume is a reliable indicator to identify patients at high risk to develop stridor. Treatment with a single or multiple injections of methylprednisolone can effectively reduce the occurrence of postextubation stridor.

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

“…In total, 698 patients were included in the final analysis (n = 355, in the MP group; n = 343, in the placebo group). The median duration of intubation prior to randomization was six days (intra-quartile range [4][5][6][7][8][9][10][11]. The groups were similar at baseline apart from a higher rate of nasotracheal intubation in those allocated to MP.…”

“…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.…”

“…These findings are further supported by two smaller, but similar randomized trials, where patients' tracheas were intubated for > 24 hr, while receiving multiple doses of corticosteroids started 24 hr prior to planned extubation. 4,19 However, a notable distinction is that each of these two small trials identified high risk patients by performing a cuff-leak test (either < 24% or < 110 mL). 4,19 Both showed that corticosteroids reduce the incidence of post-extubation stridor, but also importantly, showed a quantitative improvement in cuff-leak volume over time.…”

“…1 Observational studies suggest the incidence of post-extubation laryngeal edema in ICU patients, characterized by stridor and/or respiratory distress, ranges from 4-22% depending on the specific population being investigated. [2][3][4][5][6] The need for re-intubation attributable to laryngeal edema is estimated to occur in 1-2% of patients overall. 3,5,6 Numerous factors have been associated with a higher risk for post-extubation stridor in ICU patients, including female sex, large ratio of endotracheal tube size to laryngeal size, traumatic and/or difficult intubation, history of self-extubation, longer duration of intubation, higher severity of illness, non-surgical admissions, and a primary diagnosis of head/neck trauma.…”

O uso do teste de escape do balonete como fator preditor de laringoespasmo

“…Aliado a isso, estudos recentes mostram que a utilização de corticoterapia pré-extubação (e a continuidade de seus efeitos pós-extubação), aumentam o valor de escape e reduzem a incidência de estridor em pacientes com alto risco de desenvolver laringoespasmo (volume de escape < 110 mL) 20,21 . Em geral, o TEB apresenta valores preditivos negativos elevados, o que evidencia importância significativa para a observação de ausência de estridor pós-extubação.…”