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Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults
Abstract
Background:
Post-extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re-intubation proves necessary. Some clinicians use corticosteroids to prevent or treat post-extubation stridor, but corticosteroids may be associated with adverse effects ranging from hypertension to hyperglycaemia, so a systematic assessment of the efficacy of this therapy is indicated.
Objectives:
To determine whether corticosteroids are effective in preventing or treating post-extubation stridor in critically ill infants, children, or adults.
Search strategy:
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles. The most recent searches were conducted in January 2009.
Selection criteria:
Randomized controlled trials comparing administration of corticosteroids by any route with placebo in infants, children, or adults receiving mechanical ventilation via an endotracheal tube in an intensive care unit.
Data collection and analysis:
Three review authors independently assessed trial quality and extracted data.
Main results:
Eleven trials involving 2301 people were included: six in adults, two in neonates, three in children. All but one examined use of steroids for the prevention of post-extubation stridor; the remaining one concerned treatment of existing post-extubation stridor in children. Patients were drawn from heterogeneous medical/surgical populations. Dexamethasone given intravenously at least once prior to extubation was the most common steroid regimen utilized (uniformly in neonates and children). In neonates the two studies found heterogeneous results, with no overall statistically significant reduction in post extubation stridor (RR 0.42; 95% CI 0.07 to 2.32). One of these studies was on high-risk patients treated with multiple doses of steroids around the time of extubation, and this study showed a significant reduction in stridor. In children, the two studies were clinically heterogeneous. One study included children with underlying airway abnormalities and the other excluded this group. Prophylactic corticosteroids tended to reduce reintubation and significantly reduced post-extubation stridor in the study that included children with underlying airway abnormalities (N = 62) but not in the study that excluded these children (N = 153). In six adult studies (total N = 1953), the use of prophylactic corticosteroid administration did not significantly reduce the risk of re-intubation (RR 0.48; 95% CI 0.19 to 1.22). While there was a significant reduction in the incidence of post extubation stridor (RR 0.47; 95% CI 0.22 to 0.99), there was significant heterogeneity (I(2)=81%, X(2)=26.36, df=5, p<0.0001). Subgroup analysis revealed that post extubation stridor could be reduced in adults with a high likelihood of post extubation stridor when corticosteroids were administered as multiple doses begun 12-24 hours prior to extubation compared to single doses closer to extubation; the test for interaction for multiple versus single doses indicated RRR 0.22 (95% CI 0.10 to 0.47) for stridor with multiple doses. Side effects were uncommon and could not be aggregated.
Authors' conclusions:
Using corticosteroids to prevent (or treat) stridor after extubation has not proven effective for neonates or children. However, given the consistent trends towards benefit, this intervention does merit further study, particularly for high risk children or neonates. In adults, multiple doses of corticosteroids begun 12-24 hours prior to extubation do appear beneficial for patients with a high likelihood of post extubation stridor.
... Steroids reduce incidence of upper airway complications and reintubations in high risk patients in a meta-analysis of adult patients 7 . Studies in pediatric patients are heterogeneous, with small sample sizes, involving different ages, diagnoses, doses and timings of steroids therapy 4,7 . ...
... There are few randomized double-blind studies performed in children 3,5,8,9,18,19 (one include adults and children 5 ), and our study is one of the largest (see Table 5). Two meta-analysis were published in 2009 4,20 . The review by Khemani et al. concluded that dexamethasone prior to extubation in children reduces the incidence of stridor, but the evidence is insufficient to conclude that rates of re-intubation are reduced 4 . ...
... Two meta-analysis were published in 2009 4,20 . The review by Khemani et al. concluded that dexamethasone prior to extubation in children reduces the incidence of stridor, but the evidence is insufficient to conclude that rates of re-intubation are reduced 4 . The meta-analysis by McCaffrey et al. 20 concluded that corticosteroids reduce laryngeal edema and importantly reduce the incidence of extubation failure in critically ill patients of all ages. ...
To analyze the effectiveness of dexamethasone in preventing upper airway obstruction (UAO) symptoms after extubation and the need of reintubation in critically ill children. Multicenter, prospective, double-blind, randomized, phase IV clinical trial involving five pediatric intensive care units. Children between 1 month and 16 years-of-age intubated for more than 48 h were included. Patients were randomized to receive placebo or dexamethasone 0.25 mg/kg every 6 h, 6-to-12 h prior to extubation (four doses). 48 h follow-up was carried out after extubation. Severity of UAO symptoms (Taussig score, stridor) and reintubation requirement were compared. 147 patients were randomized (10 were excluded), 70 patients received dexamethasone and 67 placebo. No global differences were found in the presence of stridor or moderate-to-severe UAO symptoms (Taussig ≥ 5), but Taussig ≥ 5 was less frequent in patients less than 2 years-of-age treated with steroids (p = 0.014). Median Taussig score was lower in the dexamethasone group 1 h after extubation, p < 0.001. 27 patients required reintubation, 9 due to UAO: 3 (4.3%) in the dexamethasone group and 6 (8.9%) in the placebo group, p = 0.319. In those intubated > 5 days, reintubation due to UAO was higher in the placebo group (2.4% vs. 14.3, p = 0.052). Nebulized epinephrine and budesonide were required more frequently in the placebo group in the first 2 h (p = 0.041) and 1 h (p = 0.02) after extubation, respectively. No relevant side effects were observed. Dexamethasone prior to extubation did not significantly reduce moderate-severe UAO symptoms, except for patients under 2-years of age. Dexamethasone could decrease Taussig score and the need of rescue therapies, as well as reintubation rates in those intubated for more than 5 days.
... [3][4][5][6][7][8] Dexamethasone is a potent glucocorticoid which is often used prophylactically to prevent PES. 9 The potential benefit of dexamethasone is based on its anti-inflammatory actions, which inhibits the release of inflammatory mediators and decreases capillary permeability. Although being commonly used in ICUs as prophylaxis for PES, 9 there is scarcity of data from developing countries regarding its efficacy in children. ...
... [3][4][5][6][7][8] Dexamethasone is a potent glucocorticoid which is often used prophylactically to prevent PES. 9 The potential benefit of dexamethasone is based on its anti-inflammatory actions, which inhibits the release of inflammatory mediators and decreases capillary permeability. Although being commonly used in ICUs as prophylaxis for PES, 9 there is scarcity of data from developing countries regarding its efficacy in children. 10,11 A systematic assessment of efficacy of corticosteroids in PES is required before widespread recommendation of this treatment. ...
... Various studies have used different doses of dexamethasone ranging from 0.15 to 0.5 mg/kg. 1,2,9,12,16,17 Studies have shown that a low dose of dexamethasone (0.15 mg/kg) is equally effective in treatment of croup. 18 As we had been using a dose of 0.15 mg/kg in our current practice for managing PES, we wanted to evaluate its efficacy in prevention of PES through this study. ...
Background and aims:
Postextubation stridor (PES) is a serious complication in ventilated patients which increases the length of stay in intensive care units (ICUs). We studied the efficacy of dexamethasone in prevention of PES in ventilated children.
Materials and methods:
A randomized, double-blinded, placebo-controlled trial was carried out in pediatric ICU. Children (2 months to 12 years) who underwent mechanical ventilation for 48 hours were randomized into two groups to receive either dexamethasone at 0.15 mg/kg/dose or normal saline for 6 doses with first dose given 6-12 hours prior to planned extubation. Patients were hourly monitored for vital signs and appearance of stridor using Westley croup score (WCS) within 72 hours after extubation. Whenever the score exceeded 4, nebulized adrenaline (1:1,000 at 0.5 mL/kg/dose) was given. The primary outcome was occurrence of PES.
Results:
Dexamethasone group comprised of 42 children while placebo group had 38 children. Baseline characteristics of two groups were similar. Overall PES occurred in 48.7% patients, 42.8% (18/42) in dexamethasone group, and 55.2% (21/38) in placebo group [p = 0.26, odds ratio (OR) 95% confidence interval (CI) = 0.60 (0.25-1.47)]. WCS >4 was present in 28.5% (12/42) of dexamethasone group vs 47.3% (18/38) of placebo group [p = 0.08, OR (95% CI) = 0.37 (0.12-1.06)]. There was no difference in reintubation rates in two groups [p = 0.9, OR (95% CI) = 1.06 (0.32-3.51)].
Conclusion:
We found no beneficial role of the studied dose of dexamethasone (0.15 mg/kg) over placebo on the incidence of PES.
How to cite this article:
Ritu, Jhamb U. Dexamethasone in Prevention of Postextubation Stridor in Ventilated Children: A Randomized, Double-blinded, Placebo-controlled Trial. Indian J Crit Care Med 2020;24(12):1230-1235.
... Dosing recommendations vary significantly between (hospital) guidelines, demonstrating the lack of consensus with respect to optimal dosing (17). The most commonly recommended IV dose is 0.5 mg/kg/dose for children of all ages from 1 month to 18 years old (18)(19)(20)(21) and 0.25 mg/kg/dose for neonates (20)(21)(22). In children, guidelines recommend initiating treatment 6 to 12 h prior to extubation and then every 6 h for up to 6 doses (17, 19,20); whereas in neonates, the first dose is often given 4 h prior to extubation, followed by a dose every 8 h for 3 doses (20). ...
... Iyer and colleagues demonstrated in a network metaanalysis that early initiation (>12 h) of low dose dexamethasone intervention, i.e., < 0.5 mg/kg/dose, is as effective as early initiation of high doses (≥0.5 mg/kg/dose) to prevent PES (14). Furthermore, a subgroup analysis in adults revealed that PES could be reduced when corticosteroids were administered as multiple doses and initiated 12-24 h prior to extubation compared to single doses closer to extubation (18). No such comparison has been made with pediatric patients. ...
Introduction
Critically ill patients show large variability in drug disposition due to e.g., age, size, disease and treatment modalities. Physiologically-based pharmacokinetic (PBPK) models can be used to design individualized dosing regimens taking this into account. Dexamethasone, prescribed for the prevention post-extubation stridor (PES), is metabolized by the drug metabolizing enzyme CYP3A. As CYP3A4 undergoes major changes during childhood, we aimed to develop age-appropriate dosing recommendations for children of dexamethasone for PES, as proof of concept for PBPK modeling to individualize dosing for critically ill patients.
Methods
All simulations were conducted in Simcyp™ v21 (a population-based PBPK modeling platform), using an available dexamethasone compound model and pediatric population model in which CYP3A4 ontogeny is incorporated. Published pharmacokinetic (PK) data was used for model verification. Evidence for the dose to prevent post-extubation stridor was strongest for 2–6 year old children, hence simulated drug concentrations resulting from this dose from this age group were targeted when simulating age-appropriate doses for the whole pediatric age range.
Results
Dexamethasone plasma concentrations upon single and multiple intravenous administration were predicted adequately across the pediatric age range. Exposure-matched predictions of dexamethasone PK indicated that doses (in mg/kg) for the 2–6 years olds can be applied in 3 month-2 year old children, whereas lower doses are needed in children of other age groups (60% lower for 0–2 weeks, 40% lower for 2–4 weeks, 20% lower for 1–3 months, 20% lower for 6–12 year olds, 40% lower for 12–18 years olds).
Discussion
We show that PBPK modeling is a valuable tool that can be used to develop model-informed recommendations using dexamethasone to prevent PES in children. Based on exposure matching, the dose of dexamethasone should be reduced compared to commonly used doses, in infants <3 months and children ≥6 years, reflecting age-related variation in drug disposition. PBPK modeling is an promising tool to optimize dosing of critically ill patients.
... BMI was categorized as underweight (BMI < 18.5 kg/m 2 ), slightly underweight (18.5-24.99 kg/m 2 ), slightly overweight (25)(26)(27)(28)(29).99 kg/m 2 ), and overweight (≥30.00 kg/m 2 ). Smoking status was divided into three categories: nonsmoker, current or ex-smoker, and unspecified. ...
... Third, we did not investigate the adverse events attributed to corticosteroid administration. Although adverse events related to corticosteroid use in the intubated population are rare, 28 attention should be paid especially to high-risk populations (e.g., patients with uncontrollable DM). Finally, this was an observational study. ...
Objectives
To clarify whether treatment with systemic corticosteroids at a certain dose was associated with better outcomes in patients with epiglottitis requiring airway management (tracheotomy or airway intubation).
Methods
This was a retrospective cohort study on patients hospitalized for epiglottitis requiring airway management from a nationwide inpatient database (between July 2010 and March 2019). Patients treated with systemic corticosteroids equivalent to methylprednisolone ≥40 mg/d within 2 days of admission and patients who were not treated with corticosteroids within 2 days of admission were compared after inverse probability of treatment weighting using covariate balancing propensity score. The primary outcome was all‐cause 30‐day in‐hospital mortality, and secondary outcomes included all‐cause 7‐day in‐hospital mortality, length of hospital stay, and total medical cost.
Results
There were 1986 and 1771 patients in the corticosteroid and control groups, respectively. A total of 72 of 3757 (1.9%) patients died within 30 days of admission, including 17 of 1986 (0.9%) patients in the corticosteroid group and 55 of 1771 (3.1%) in the control group (weighted odds ratio, 0.28 [95% confidence interval, 0.11–0.70]; weighted risk difference, −2.2% [−3.2% to −1.3%]). Treatment with corticosteroids was associated with lower total medical costs (weighted median, 6,587; weighted difference, $‐1,123 [−2,238 to −8]) but not all‐cause 7‐day in‐hospital mortality (weighted odds ratio, 0.63 [0.22–1.82]; weighted risk difference, −0.3% [−0.9 to 0.2]) and length of hospital stay (weighted median, 13 vs. 13 days; weighted difference, −0.2 days [−2.1 to 1.8]).
Conclusions
Systemic corticosteroids may be beneficial to patients with epiglottitis requiring airway management.
Level of Evidence
3 Laryngoscope, 133:344–349, 2023
... There were over 10 corticosteroid treatments reported in previous studies, all with different dosing and timings [5]. Although several studies found a multiple dose strategy may be more efficient than a single-dose strategy [1,18,21,22], this is not optimal for ED use due to relative complexity over a single dose. In addition, a multiple dose strategy requires a longer pre-extubation period, which may cause unnecessary delays and increase the risk of complications in the ED setting. ...
... Although few studies reported severe complications associated with prophylactic corticosteroids before extubation [10,18,21,24,25], a recent study led by Kuriyama [22] reported significantly increased blood glucose levels caused by corticosteroid use, especially among patients with underlying diabetes mellitus. Hyperglycemia, considered as an adaptive-stress response, is frequently present in critically ill patients [26]. ...
Background
Post-extubation stridor (PES) is one of the most common complications of invasive respiratory support, with severe cases leading to possible extubation failure (reintubation within 48 h) and increased mortality. Previous studies confirmed that prophylactic corticosteroids play an important role in reducing the risk of PES and extubation failure. However, few studies have looked at the efficacy of corticosteroids on preventing PES in patients after an emergency intubation.
Aim
To evaluate whether a single dose of methylprednisolone given over a set timeframe before extubation is effective in preventing PES in patients after an emergency intubation.
Methods
A multicenter, randomized, placebo-controlled trial will be performed in an emergency department (ED) setting. The trial will include 132 patients who fail a cuff-leak test (CLT) prior to the intervention. Patients will be randomly assigned to either intravenous methylprednisolone (40 mg) or placebo 4 h prior to extubation. Other eligible patients who pass the CLT will be included in a non-intervention (observation) group. The primary endpoint is the incidence of PES within 48 h after extubation. Secondary endpoints include oxygen therapy, respiratory support requirements, reintubation secondary to PES, adverse effects within 48 h after extubation, hospital length of stay, and hospital mortality.
Discussion
Patients who are intubated on an emergency basis have a higher risk of intubation-related complications. Previous studies have examined treatment regimens involving more than 10 different variations on corticosteroid treatments for PES prevention, while for ED therapy, only a simple and effective treatment would be appropriate. Corticosteroid administration is usually accompanied by adverse effects; thus, this study will be important for further risk stratification among intubated ED patients.
Trial registration
Chictr.org.cn ChiCTR2000030349 . Registered on 29 February 2020.
... There were over 10 corticosteroid treatments reported in previous studies, all with different dosing and timings [5]. Although several studies found a multiple dose strategy may be more e cient than a single dose strategy [1,17,22,23], this is not optimal for ED use due to relative complexity over a single-dose. In addition, a multiple dose strategy requires a longer pre-extubation period, which may cause unnecessary delays and increase the risk of complications in the ED setting. ...
... Although few studies reported severe complications associated with prophylactic corticosteroids before extubation [9,17,22,25],a recent study led by Kuriyama [23] reported signi cantly increased blood glucose levels caused by corticosteroid use, especially among patients with underlying diabetes mellitus. Hyperglycemia, considered as an adaptive-stress response, is frequently present in critically ill patients [24]. ...
Background: Post-extubation stridor (PES) is one of the most common complications of invasive respiratory support, with severe cases leading to possible extubation failure (reintubation within 48 hours) and increased mortality. Previous studies confirmed that prophylactic corticosteroids play an important role in reducing the risk of PES and extubation failure. However, few studies have looked at the efficacy of corticosteroids on preventing PES in patients after an emergency intubation.
Aim: To evaluate whether a single dose of methylprednisolone given over a set timeframe before extubation is effective in preventing PES in patients after an emergency intubation.
Methods: A multicenter, randomized, placebo-controlled trial will be performed in an emergency department (ED) setting. The trial will include 132 patients who fail a cuff-leak test (CLT) prior to the intervention. Patients will be randomly assigned to either intravenous methylprednisolone (40mg) or placebo four hours prior to extubation. Other eligible patients who pass the CLT will be included in a non-intervention (observation) group. The primary endpoint is the incidence of PES within 48 hours after extubation. Secondary endpoints include oxygen therapy, respiratory support requirements, reintubation secondary to PES, adverse effects within 48 hours after extubation, hospital length of stay and hospital mortality.
Discussion: Patients who are intubated on an emergency basis have a higher risk of intubation-related complications. Previous studies have examined treatment regimens involving more than 10 different variations on corticosteroid treatments for PES prevention, while for ED therapy only a simple and effective treatment would be appropriate. Corticosteroid administration is usually accompanied by adverse effects, thus this study will be important for further risk stratification among intubated ED patients.
Trial registration: Chictr.org.cn, ChiCTR2000030349. Registered on 29 Feb 2020.
... However, the benefits of corticosteroids for the prevention of PES are seen following repeated doses of corticosteroids, or administration 12-24 hours pre-extubation. 83 The frequency and severity of adverse effects of systemic corticosteroids outweigh the benefits given their short duration of action. A repeat cuff leak test is not required after the administration of systemic steroids. ...
Background and purpose
Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists).
Methods
A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as “ISCCM consensus statement on weaning from mechanical ventilator”. As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost–benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning.
Result
This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions).
Conclusion
This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards.
How to cite this article
Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233–S248.
... Extubation should be deferred if CLT is negative (i.e., if leak is absent). IV corticosteroids should be administered before attempting extubation again [6]. ...
Critically ill burn patients pose several unique challenges to care providers. The concepts of fluid resuscitation, nutritional management, organ support and wound care are rapidly evolving. There is a pressing need to review emerging evidence and incorporate these into practice for the effective management of burn patients. We have searched the PubMed and Google Scholar databases to review the current evidence on the acute care management of adult as well as paediatric burn patients. The rationales for current practices have been integrated into the review. The management of critically ill burn patients requires an in-depth knowledge of the pathophysiology of burn injury, a tailored approach for timely resuscitation, timely diagnosis of organ specific problems, and comprehensive wound care. This review will help the doctors and healthcare providers involved in the management of critical burn patients in their day-today practice.
... Without quantitative intracuff pressure monitoring, pressure over 90 cm H 2 O had been frequently detected [74,75]. Due to the high incidence of PES, routine prophylactic corticosteroid pretreatment had been adopted in many PICUs and anesthesiology departments prior to extubation with a proven positive effect on PES reduction [76]. The ultrasound evaluation of air column width before and after cuff deflation may be used in the prediction of PES, as it showed high accuracy [77]. ...
Traditionally, uncuffed tubes were used in pediatric patients under 8 years in pursuit of reducing the risk of postextubation stridor. Although computed tomography and magnetic resonance imaging studies confirmed that the subglottic area remains the narrowest part of pediatric airway, the use of uncuffed tubes failed to reduce the risk of subglottic swelling. Properly used cuffed tubes (correct size and correct cuff management) are currently recommended as the first option in emergency, anesthesiology and intensive care in all pediatric patients. Clinical practice particularly in the intensive care area remains variable. This review aims to analyze the current recommendation for airway management in children in emergency, anesthesiology and intensive care settings.
... [5,19] The prophylactic use of corticosteroids for the prevention of post-extubation stridor and extubation failure remains controversial, though targeted use for at-risk populations maybe beneficial. [25][26][27][28] During our study, dexamethasone was administered prior to extubation to those assessed to be at high risk of upper airway obstruction. These generally were children who had multiple attempts at intubation, prolonged intubation or pre-existing concerns about upper airway compromise, or the absence of a leak around the ETT. ...
BACKGROUND. Extubation failure contributes to poor outcome of mechanically ventilated children, yet the prevalence and risk factors have been poorly studied in South African (SA) children. OBJECTIVE. To determine the prevalence, risk factors and outcomes of extubation failure in an SA paediatric intensive care unit (PICU). METHODS. This was a prospective, observational study of all mechanically ventilated children admitted to a tertiary PICU in Cape Town, SA. Extubation failure was defined as requiring re-intubation within 48 hours of planned extubation. RESULTS. There were 219 episodes of mechanical ventilation in 204 children (median (interquartile range (IQR)) age 8 (1.6 - 44.4) months). Twenty-one of 184 (11.4%) planned extubations (95% confidence interval (CI) 7.2% - 16.9%) failed. Emergency cardiac admissions (adjusted odds ratio (aOR) 7.58 (95% CI 1.90 - 30.29), dysmorphology (aOR 4.90; 95% CI 1.49 - 16.14), prematurity (aOR 4.39; 95% CI 1.24 - 15.57), and ventilation >48 hours (aOR 6.42 (95% CI 1.57 - 26.22) were associated with extubation failure. Children who failed extubation had longer durations of ventilation (231 hours (146.0 - 341.0) v. 53 hours (21.7 - 123.0); p<0.0001); longer duration of PICU (15 (9 - 20) days v. 5 (2 - 9) days; p<0.0001) and hospital length of stay (32 (21 - 53) days v. 15 (8 - 27) days; p=0.009); and higher 30-day mortality (28.6% v. 6.7%; p=0.001) than successfully extubated children. CONCLUSIONS. Extubation failure was associated with significant morbidity and mortality in our setting. Risk factors for extubation failure identified in our context were similar to those reported in other settings.
... A Cochrane review concluded that the use of corticosteroids to either prevent or treat stridor after extubation has not proven effective, but "consistent trends toward benefit" were noted. Intravenous dexamethasone, administered at least once prior to extubation, was the most common steroid regimen used; in the literature, however, no evidence exists over which steroid is the most effective (29,40). In conclusion, corticosteroids seem to be beneficial for infants and children, but definitive evidence of efficacy is lacking. ...
Ventilation is one of the most common procedures in critically ill children admitted to the pediatric intensive care units (PICUs) and is associated with potential severe side effects. The longer the mechanical ventilation, the higher the risk of infections, mortality, morbidity and length of stay. Protocol-based approaches to ventilation weaning could have potential benefit in assisting the physicians in the weaning process but, in pediatrics, clear significant outcome difference related to their use has yet to be shown. Extubation failure occurs in up to 20% of patients in PICU with evidences demonstrating its occurrence related to a worse patient outcome including higher mortality. Various clinical approaches have been described to decide the best timing for extubation which can usually be achieved by performing a spontaneous breathing trial before the extubation. No clear evidence is available over which technique best predicts extubation failure. Within this review we summarize the current strategies of ventilation weaning and extubation readiness evaluation employed in the pediatric setting in order to provide an updated view on the topic to guide intensive care physicians in daily clinical practice. We performed a thorough literature search of main online scientific databases to identify principal studies evaluating different strategies of ventilation weaning and extubation readiness including pediatric patients receiving mechanical ventilation. Various strategies are available in the literature both for ventilation weaning and extubation readiness assessment with unclear clear data supporting the superiority of any approach over the others.
... I G U R E 1 (A) Cognitive aid for R2D2 extubation planner (front). (B) Cognitive aid for R2D2 extubation planner (rear with prompts)pediatric settings have suggested that there is not enough evidence to make strong recommendations regarding their efficacy in reducing postextubation complications.19,20 A more recent study suggests there may be some reduction in postextubation issues if steroids are administered for 24 h prior to extubation, rather than only 6 h.21 ...
Comprehensive airway management of the paediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the peri‐extubation period. Equally important is performing a comprehensive risk assessment and developing a strategy that optimizes the likelihood of safe extubation. This includes a team‐focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation. This review summarises extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.
... First-line management of postextubation stridor often includes steroid administration due to its success in viral laryngotracheobronchitis. [22][23][24][25] Yet, this did not achieve resolution in our case, triggering further investigation. Fortuitously, an ad hoc laryngoscopy formally diagnosed the vocal cord abnormality. ...
Cerebral malaria (CM) is defined by WHO as coma (Blantyre Coma Score 2 or less) in a patient with Plasmodium falciparum parasitaemia and no alternative cause of coma identified. Mortality is approximately 15%–30% in African children and up to one-third of survivors have neurological sequelae. We present a patient with severe stridor and prolonged profound weakness during an intensive care admission with CM. These complications initially presented a diagnostic dilemma in our limited resourced setting. The stridor failed to improve with empiric steroids and a subsequent opportunistic ENT consult diagnosed vocal cord paresis. The weakness was so profound that the patient was unable to lift his head during the acute illness. The child received intensive physiotherapy, and at 1-month follow-up, the stridor and weakness had resolved.
... However, it was not possible to explain why the score values were higher at 5 and 30 minutes. 32 No statistically significant differences were found in relation to total length of time in ICU and reintubation rate between groups. Frequency of reintubation of patients was 12.9% (n ¼ 11). ...
Extubation failure is a common event in intensive care units. Corticosteroids are effective in preventing failure in adults, but no consensus has been reached on this matter in pediatrics. We assessed the efficacy of intravenous dexamethasone in mechanically ventilated children and adolescents for more than 48 hours, with at least one risk factor for failure. Extubations were scheduled 24 hours in advance when possible, and patients were randomly assigned into two groups: one group received a loading dose followed by up to four doses of dexamethasone, and the other group received no corticosteroids. Need for reintubation and length of stay in the pediatric intensive care unit were similar in both groups, and frequency of reintubation was 12.9%.
Background
Airway management during the perioperative period is a vital component of perioperative care. However, there is a lack of consensus on the selection of medications, timing of administration, and the management of airway complications. This consensus aimed to promote a more rational and standardized application of airway management medications.
Methods
Clinical medical and pharmaceutical experts were invited to participate in this study using the modified Delphi method. Participants completed two rounds of online surveys, with the second round based on the responses from the first round.
Results
Participants (n = 42) reached a consensus on 11 clinical issues and formed 11 recommendations for clinical practice, each with a consensus degree of more than 80%. The recommendations covered aspects of preoperative, intraoperative, and postoperative risk factors evaluation, along with crucial points of medication monitoring in preventing and treating perioperative pulmonary complications.
Conclusions
The modified Delphi method resulted in consensus recommendations for the perioperative physician–pharmacist airway co‐management. We hope this consensus will prevent pulmonary complications and improve patient outcomes through collaborative discussions between physicians and pharmacists.
The process of liberating a patient from a prolonged course of mechanical ventilation is challenging for the pediatric intensive care team, and the prevalence of children requiring prolonged mechanical ventilation (PMV) for neurological and neuromuscular diseases, airway abnormalities, or chronic lung diseases is increasing, adding an additional complexity. The weaning process is highly related to PMV. Extubation failure and the need for more than one liberation attempt significantly prolong the duration of mechanical ventilation. Pediatric critical care providers should make the effort to improve the management of those patients requiring PMV. PMV patients might fall into the difficult-to-wean category. Overall, the liberation process in children with PMV should follow a standardized protocol and the same steps as any otherwise routine wean-off. Therefore, weaning in patients with PMV should follow the Clinical Practice Guidelines for Pediatric Ventilator Liberation, although keeping in mind the relevant nuances and the specific subpopulation to which the patient belongs. Additionally, noninvasive respiratory support plays a key role in weaning, as a component of de-escalation respiratory support or as a unique component of the PMV process.
Objective
To study the efficacy of intravenous dexamethasone in preventing postextubation airway obstruction (PEAO).
Design
A double-blinded randomized controlled trial.
Study setting
The study was conducted in level 3 PICU at AIIMS, Raipur, India, from December 2019 to September 2022.
Subjects
Children requiring intubation for at least 24 hours and not beyond 14 days were included. Children with upper airway anomalies or who received corticosteroids within the last 7 days were excluded.
Intervention
The children who satisfied the inclusion criteria were randomized into dexamethasone or placebo group by stratified variable block randomization. Dexamethasone (0.5 mg/kg/dose) or placebo was given four doses (–12 hr., –6 hr., 0 hr., and 6 hr. of extubation).
Outcome
The occurrence of any clinically significant stridor (Westley stridor score ≥3) was the primary outcome.
Measurements and main results
Of the seventy (n = 70) children included in the study, 35 received dexamethasone while 35 received placebo. Westley stridor score ≥3 was present in 25.71% (n = 9) in dexamethasone group vs 31.42% (n = 11) in placebo (p = 0.792). Reintubation occurred in 14.28% (n = 10/70) patients, 11.42% (4/35) in dexamethasone group, and 17.14% (6/35) in placebo group (p = 0.734). Five children in the dexamethasone group and six in placebo group died (p = 1.00). There was no difference in the length of PICU stay (p = 0.84) and hospital stay (p = 0.75) among both the groups.
Conclusion
Administration of multiple doses of dexamethasone may not help in the prevention of reintubation but may help in the reducing the incidence of clinically significant stridor.
How to cite this article
Varghese AR, Kambagiri P, Sahoo MR, Jindal A, Goel AK. Role of Intravenous Dexamethasone in Prevention of Postextubation Airway Obstruction in Mechanically Ventilated Children in Pediatric Intensive Care Unit: A Double-blind Randomized Controlled Trial. Indian J Crit Care Med 2024;28(11):1063–1068.
Background
Prophylactic corticosteroids have been widely used to mitigate the inflammatory response induced by cardiopulmonary bypass (CPB). However, the impact of this treatment on clinically important outcomes in infants remains uncertain.
Methods
We systematically searched databases (Medline, Embase, and Cochrane Central Register of Controlled Trials), Clinical Trials Registry, and Google Scholar from inception to March 1, 2024. Randomized controlled trials (RCTs) in which infants undergoing on-pump cardiac surgery received prophylactic corticosteroids or placebo were selected. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. Considering clinical heterogeneity between studies, the random-effects model was used for analysis. Subgroup analyses on the neonatal studies and sensitivity analyses by the leave-one-out method were also conducted.
Results
Eight RCTs comprising 1,920 patients were included. Our analysis suggested no significant difference in postoperative mortality (2.1% vs. 3.3%, risk ratio (RR) = 0.71, 95% confidence interval (CI) [0.41, 1.21]). Significantly increased insulin treatment in infants (19.0% vs. 6.5%, RR = 2.78, 95% CI [2.05, 3.77]) and significantly reduced duration of mechanical ventilation in neonates (mean difference = -22.28 h, 95% CI [-42.58, -1.97]) were observed in the corticosteroids group. There were no differences between groups for postoperative acute kidney injury, cardiac arrest, extracorporeal membrane oxygenation support, low cardiac output syndrome, neurologic events, infection, or length of postoperative intensive care unit stay.
Conclusions
Current evidence does not support the routine prophylactic use of corticosteroids in infants undergoing cardiac surgery with CPB. Further large-scale research is needed to investigate the optimal agent, dosing regimen, and specific impact on various types of cardiac surgery.
Trial registration
This systematic review and meta-analysis was registered at the International Prospective Register of Systematic Reviews (CRD42023400176).
Dexamethasone is a synthetic glucocorticoid approved for treating disorders of various organ systems in both adult and pediatric populations. Currently, approved pediatric dosing recommendations are weight‐based, but it is unknown whether differences in dexamethasone drug disposition and exposure exist for children with obesity. This study aimed to develop a population pharmacokinetic (PopPK) model for dexamethasone with data collected from children with obesity. Dexamethasone was given as either IV or oral/enteral administration, and a salt factor correction was used for dexamethasone sodium phosphate injection. A PopPK analysis using dexamethasone plasma concentration versus time was performed using the software NONMEM. A virtual population of 1000 children with obesity across three age groups was generated for dosing simulations. Data from 59 study participants with 82 PK plasma samples were used in the PopPK analysis. A one‐compartment model with first‐order absorption and the inclusion of total body weight as a covariate characterized the data. No other covariates were included in the PopPK model. Single and multiple IV dose(s) of 0.5 and 1 mg/kg every 8 h resulted in 68% or more of virtual children with obesity attaining simulated exposures that were within exposure ranges previously reported in adult studies. In conclusion, this was the first study to characterize dexamethasone's PopPK in children with obesity. Simulation results suggest that virtual children with obesity receiving oral doses of 0.5 and 1 mg/kg had generally comparable dexamethasone exposures as adult estimates. Additional studies are needed to characterize the dexamethasone's target exposure in children.
Objectives
This study was aimed at determining the extubation failure (EF) rate in a pediatric intensive care unit (PICU), and assessing the etiology, associated risk factors, and outcomes.
Methods
We conducted a retrospective study on 335 pediatric patients admitted to King Abdulaziz University Hospital between 2018 and 2020, ranging in age from 1 month to 14 years, who required invasive mechanical ventilation (MV) for >24 h. Extubation readiness was determined by the attending pediatric intensive care physician, according to the patients’ clinical status and extubation readiness criteria.
Results
In the cohort of 335 patients, 42 experienced issues during extubation (failure rate, 12.5%). Cardiovascular disease (42.9%) was the main primary admission condition in patients with EF. Younger age (median, interquartile range [IQR]: 4, 1.38–36 months) was strongly associated with EF compared with successful extubation (median, IQR: 12, 2–48; p = 0.036), and with a high predicted mortality rate (10.9%; p < 0.001) and Pediatric Risk of Mortality III (PRISM) score (13; p < 0.001). Furthermore, prolonged ICU stay (25.5 days; p < 0.001) and longer MV requirements (4 days; p < 0.001) before extubation in patients with EF were associated with a high mortality rate (∼12%; p < 0.001). Interestingly, dexamethasone administration before extubation significantly alleviated EF risk (28.3%; p < 0.001).
Conclusion
A higher EF rate in younger patients may potentially be associated with longer ICU stays, prolonged MV requirements before extubation, and the primary diagnostic condition. Dexamethasone effectively alleviated EF incidence. Further research with a rigorous evidence-based study design is necessary to substantiate the factors identified as predictors of EF and to develop strategies to avoid EF.
Objectives
To make recommendations on the diagnosis and treatment of post-extubation laryngitis (PEL) in children with or without other comorbidities.
Methods
A three-iterative modified Delphi method was applied. Specialists were recruited representing pediatric otolaryngologists, pediatric and neonatal intensivists. Questions and statements approached topics encompassing definition, diagnosis, endoscopic airway evaluation, risk factors, comorbidities, management, and follow-up. A consensus was defined as a supermajority >70%.
Results
Stridor was considered the most frequent symptom and airway endoscopy was recommended for definitive diagnosis. Gastroesophageal reflux and previous history of intubation were considered risk factors. Specific length of intubation did not achieve a consensus as a risk factor. Systemic corticosteroids should be part of the medical treatment and dexamethasone was the drug of choice. No consensus was achieved regarding dosage of corticosteroids, although endoscopic findings help defining dosage and length of treatment. Non-invasive ventilation, laryngeal rest, and use of comfort sedation scales were recommended. Indications for microlaryngoscopy and bronchoscopy under anesthesia were symptoms progression or failure to improve after the first 72-h of medical treatment post-extubation, after two failed extubations, and/or suspicion of severe lesions on flexible fiberoptic laryngoscopy.
Conclusions
Management of post-extubation laryngitis is challenging and can be facilitated by a multidisciplinary approach. Airway endoscopy is mandatory and impacts decision-making, although there is no consensus regarding dosage and length of treatment.
Invasive mechanical ventilation is prevalent and associated with significant morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation is significant. As a first step to minimizing that variation, the first evidence-based Pediatric Ventilator Liberation Guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider barriers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will 1) summarize guideline recommendations, 2) discuss recent evidence and identify practice gaps relating to those recommendations, and 3) hypothesize about potential barriers and facilitators to their implementation in clinical practice.
Background
Perioperative airway management following midface advancements in children with Apert and Crouzon/Pfeiffer syndrome can be challenging, and protocols often differ. This study examined airway management following midface advancements and postoperative respiratory complications.
Methods
A multicenter, retrospective cohort study was performed to obtain information about the timing of extubation, perioperative airway management, and respiratory complications after monobloc / le Fort III procedures.
Results
Ultimately, 275 patients (129 monobloc and 146 Le Fort III) were included; 62 received immediate extubation and 162 delayed extubation; 42 had long-term tracheostomies and nine perioperative short-term tracheostomies. Short-term tracheostomies were in most centers reserved for selected cases. Patients with delayed extubation remained intubated for three days (IQR 2 – 5). The rate of no or only oxygen support after extubation was comparable between patients with immediate and delayed extubation, 58/62 (94%) and 137/162 (85%) patients, respectively. However, patients with immediate extubation developed less postoperative pneumonia than those with delayed, 0/62 (0%) versus 24/161 (15%) (P = 0.001), respectively. Immediate extubation also appeared safe in moderate/severe OSA since 19/20 (95%) required either no or only oxygen support after extubation. The odds of developing intubation-related complications increased by 21% with every extra day of intubation.
Conclusions
Immediate extubation following midface advancements was found to be a safe option, as it was not associated with respiratory insufficiency but did lead to fewer complications. Immediate extubation should be considered routine management in patients with no/mild OSA and should be the aim in moderate/severe OSA after careful assessment.
Decision and timing of removing a tracheal tube is a challenge, as extubation is a critical phase of the process that led the patient to be intubated. It is not a manoeuvre exempt of risks and morbidity, especially in critical care patients, and after neck surgery. It is essential to understand and assess the causes that may result in extubation failure to take measures that lead to success. Certain surgical procedures carry a higher risk of problems at the time of extubation. In this sense, at-risk extubation is also considered when re-intubation can be challenging. Measures should be taken to prevent and detect problems early, to optimize patient conditions prior to extubation, and to put in place strategies to deal with the potential need for re-intubation.
The neonate is at risk for increased peri-anesthetic complications, and this risk is magnified in the preterm neonate. A discussion of complications and risks for all procedures and therapeutic options is beyond the scope of this chapter. Therefore, the focus herein is to provide an overview of the adverse events to which neonates are particularly vulnerable. Please refer to Chap. 18 for a detailed discussion of anesthetic neurotoxicity.KeywordsAnesthetic complicationsNeonatePeri-anesthetic complicationsPreterm neonateIncomplete maturationPotential risksAnesthetic agentsPeri-anesthetic mortalityAirway complicationsTransfusionsOxygen toxicityAdverse events
Objectives:
We performed our standard air leak, leak percentage, and cuff leak percentage tests in pediatric patients intubated with microcuff pediatric tracheal tubes (MPTTs) just before extubation. We examined the association between test findings and the subsequent occurrence of post-extubation laryngeal edema (PLE).
Design:
Prospective, single-center, observational study.
Setting:
PICU (June 1, 2020 to May 31, 2021).
Patients:
Pediatric patients intubated and scheduled for extubation during the day shift in the PICU.
Interventions:
Multiple pre-extubation leak tests were performed on each patient immediately before extubation. In our center, the standard leak test is positive if a leak is audible at 30 cm H2O applied pressure with the MPTT cuff deflated. Two other tests were calculated in the pressure control-assist control ventilator mode using the following formulas: leak percentage with deflated cuff = (inspiratory tidal volume [Vt]-expiratory Vt) × 100/inspiratory Vt; cuff leak percentage = (expiratory Vt with inflated cuff-expiratory Vt with deflated cuff) × 100/expiratory Vt with inflated cuff.
Measurements and main results:
The diagnostic criteria for PLE was made by at least two healthcare professionals and included upper airway stricture with stridor-requiring nebulized epinephrine. Eighty-five pediatric patients (< 15 yr) who had been intubated for at least 12 hours using the MPTT were included. Positive rates for the standard leak, leak percentage (cutoff 10%), and cuff leak percentage (cutoff 10%) tests were 0.27, 0.20, and 0.64, respectively. The standard leak, leak percentage, and cuff leak tests showed sensitivities of 0.36, 0.27, and 0.55, respectively; and specificities of 0.74, 0.81, and 0.35, respectively. PLE occurred in 11 of 85 patients (13%), and there were no instances of needing reintubation.
Conclusions:
The pre-extubation leak tests in current practice for intubated pediatric patients in the PICU all lack diagnostic accuracy for PLE.
Background: Postnatal corticosteroids (PC) are widely used in very preterm infants. International reports and national multicenter trials describe a marked variability across countries and inter-sites, in the use of PC. Few information is available on therapeutic indications and prescription characteristics of PC.
Aim: The main objective of this study was to describe the exposure to PC in a large cohort of preterm infants born at less than 32 weeks of gestation, according to the prescription data of 41 tertiary-care NICUs in France. Secondary objectives were to describe therapeutic indications, day of life (DOL) of the first exposure, route of administration, duration, cumulative dose for each drug, and differences in exposure rates across centers.
Methods: We conducted a prospective observational cohort analysis from January 2017 to December 2021, in 41 French tertiary-care NICUs using the same computerized order-entry system.
Results: In total, 13,913 infants [birth weight 1144.8 (±365.6) g] were included. Among them, 3633 (26.1%) were exposed to PC, 21.8% by systemic and 10.1% by inhaled route. Within the study population, 1,992 infants (14.3%) received the first corticosteroid treatment in the first week of life and 1641 (11.8%) after DOL 7. The more frequent indications were prevention and/or treatment of bronchopulmonary dysplasia, and arterial hypotension. Hydrocortisone was the more often prescribed molecule. For systemic PC the first exposure occurred in mean at DOL 9.4 (±13.5), mean duration of treatment was 10.3 (±14.3) days, and the cumulative dose (expressed as the equivalent dose of hydrocortisone) was in median [IQR] 9.0 [5.5–28.8] mg/kg. For inhaled PC, the first exposure occurred in mean at DOL 34.1 (±19.7), and mean duration of treatment 28.5 (±24.4) days. The exposure rate ranged from a minimum of 5% to a maximum of 56% among centers, and significantly increased over the study period (p < 0.0001).
Conclusion: In this French cohort of very preterm infants, around one patient out to five was exposed to PC during hospital stay in the NICU. The exposure occurred early, starting from the first week of life. Exposure rate widely varied among centers. Pharmacoepidemiology studies are useful to increase knowledge on corticosteroid utilization patterns in preterm infants.
Any respiratory disorder, even the mild forms, could affect the health state of any human being. This is why respiratory care is considered an ingredient part of care in every patient, and this is undoubtedly much more important in patients with congenital heart disease. In this chapter, the principles of respiratory care in the postoperative period in congenital heart disease patients are discussed with the following subtitles: “How does the pediatric patient differ from the adult patient?,” “Principles and Goals of mechanical ventilation in the postoperative period,” “Ventilation considerations specific for congenital heart patient,” Strategies for ventilation and ventilator modes,” “Readiness for extubation and extubation failure,” “Non-invasive ventilation, i.e. NIPPV—RAM cannula, nCPAP, High flow nasal cannula, etc.,” and “Miscellaneous issues, including Extra-corporeal CO2 removal (ECCO2R), High-frequency oscillatory ventilation (HFOV), Inhalational routes of drug delivery, Chest physiotherapy, Chronic respiratory failure, and tracheostomy.”
A 6-month-old infant presented with clinicoradiological features of a shunt dysfunction. Magnetic resonance imaging brain showed multiple leptomeningeal cysts in the posterior fossa, with the largest in the right cerebellopontine (CP) angle cistern causing compression on the brain stem and fourth ventricle. There was gross hydrocephalus with the malpositioned shunt tube. He underwent shunt revision followed by right retromastoid craniectomy and decompression of the right CP angle cyst. Following extubation, he developed stridor that was diagnosed initially as subglottic edema and treated with humidified oxygen, systemic corticosteroids, and nebulized adrenaline. Failure to resolve the symptoms warranted a video laryngoscopy that revealed right vocal cord palsy (VCP), and he was reintubated. He was started on steroids and got extubated on a nasal continuous positive airway pressure and was gradually weaned off. Intraoperative handling of the vagus nerve while decompressing the cyst led to a right VCP, which was communicated later to the anesthesiologist. Neurological cause and association need to be considered as one of the differentials while managing postoperative stridor after posterior fossa surgery in an infant. Timely communication between the surgeon and anesthesiologist is paramount for reducing morbidity.
Rationale: Peri-extubation corticosteroids are commonly used in children to prevent upper airway obstruction (UAO). However, the best timing and dose combination of corticosteroids is unknown.
Objectives:To compare effectiveness of different corticosteroid regimens in preventing UAO and reintubation.
Methods:MEDLINE, CINAHL and Embase search identified randomized trials in children using corticosteroids to prevent UAO. All studies used dexamethasone. The studies were categorized based on timing of initiation of dexamethasone (early use: >12 hours prior to extubation) and the dose (high dose: (>/= 0.5mg/kg/dose). We performed Bayesian network meta-analysis (NMA) with studies grouped into four regimens- High dose, Early use (HE); Low dose, Early use (LE); High dose, Late use (HL) and Low dose, Late use (LL).
Results:8 trials (n=903) were included in the analysis. For preventing UAO, (odds ratio, 95% credible interval), HE (0.13; 0.04, 0.36), HL (0.39; 0.19, 0.74) and LE (0.15; 0.04, 0.58) regimens appear to be more effective compared to no dexamethasone (low certainty). HE and LE had the highest probability of being the top ranked regimens for preventing UAO [surface under the cumulative ranking (SUCRA) 0.901 and 0.808 respectively]. For preventing reintubation, the effect estimate was imprecise for all four dexamethasone regimens compared to no dexamethasone (very low certainty). HE and LE were the top ranked regimens (SUCRA 0.803 and 0.720 respectively) for preventing reintubation. Sensitivity analysis showed that regimens which started >12 hours prior to extubation were likely more effective than regimens started >6 hours prior to extubation.
Conclusions:Peri-extubation dexamethasone can prevent post-extubation UAO in children but effectiveness is highly dependent on timing and dosing regimen. Early initiation (ideally >12 hours prior to extubation) appears to be more important than the dose of dexamethasone. Ultimately the specific steroid strategy should be personalized considering the potential for adverse events associated with dexamethasone and the individual risk of UAO and reintubation.
Anaesthesia for robotic surgeries done in steep trendelenburg position are associated with risks such as facial oedema, conjunctival chemosis, raised intraocular pressure, laryngeal oedema, and delayed awakening. We proposed the use of the cuff leak test in them to record the frequency of laryngeal oedema at the end of surgery and attempted to find its correlation with probable risk factors. We conducted a prospective observational study of 100 patients aiming primarily to assess the frequency of positive cuff leak test in robotic abdominal surgeries performed in trendelenburg position. The secondary outcomes were to check its correlation with intravenous fluid administration, duration of pneumoperitoneum, and angle of trendelenburg position. We also recorded the frequency of chemosis, the frequency of post-extubation stridor in 24 h post-operatively, and the frequency of reintubation. Out of 100 participants undergoing elective abdominal robotic surgery in trendelenburg position, ninety were analysed. Total 31.6% (n = 30) participants showed positive cuff leak test. Chemosis was observed in 31 (32.6%) participants. No patient experienced post-extubation stridor or required reintubation during post-operative follow up. There was a no correlation between cuff leak test and intravenous fluid, duration of pneumo-peritoneum, or with angle of trendelenburg. The frequency of positive cuff leak test was high in patients at the end of robotic surgery but none of these patients had post-extubation stridor or required reintubations. There was no correlation with the fluid, angle, or duration of surgery. Clinical Trials Registry of India (CTRI/2017/04/008289), ctri.nic.in.
Résumé
Les urgences chirurgicales néonatales sont peu fréquentes mais leur prise en charge anesthésique doit prendre en compte les multiples particularités physiologiques du nouveau-né et la physiopathologie de la malformation congénitale sous-jacente. Le comportement pharmacocinétique de la plupart des agents anesthésiques est modifié. L’immaturité hépatique est responsable, pour un grand nombre d’entre eux, d’une augmentation de la demi-vie d’élimination. Les capacités d’adaptation du myocarde sont limitées et les désaturations surviennent très rapidement au cours de toute apnée. Hyperoxie, hypotension, hyper- et hypocapnie sont délétères. Les apports hydroélectrolytiques sont assurés par une solution isotonique glucosée à 1 % et le remplissage vasculaire par du sérum physiologique en évitant les apports excessifs. La problématique de la hernie de coupole diaphragmatique réside dans l’agénésie pulmonaire sous-jacente. Le contrôle de l’hypertension artérielle pulmonaire est déterminant. La cure de l’atrésie de l’œsophage type 3 expose surtout aux difficultés ventilatoires jusqu’à la fermeture de la fistule, avec une place croissante pour la chirurgie thoracoscopique. Le laparoschisis conduit à des tableaux de gravité très variables selon l’atteinte digestive associée. Les cures de hernie de coupole, d’omphalocèle et de laparoschisis peuvent être responsables d’un syndrome du compartiment abdominal à l’origine d’une défaillance multiviscérale. Une analgésie insuffisante modifie le contrôle spinal et supra-spinal de la douleur. L’administration de la morphine tient compte des modifications de son métabolisme. L’anesthésie locorégionale exercerait des effets favorables après chirurgie majeure, en particulier sur la durée de ventilation contrôlée. Une immaturité des fonctions immunitaires augmente le risque infectieux.
Post-extubation failure is a high risk complication for patients in intensive care unit. Laryngeal edema and laryngeal stridor have been studied as causes of post-extubation failure. Part of the strategies for the prevention of post-extubation failure and management of stridor or laryngeal edema is the use of steroids. The discrepancy between the time, the dos, the patient and the type of steroid forces to create a strategy that standardizes its use. This review focuses on identify patients who benefit from the use of steroids, type of steroid that should be uses, timing and correct dose.
Otolaryngologic procedures in the pediatric population can present unique challenges to the anesthesiologist. Pediatric patients should not be considered “little adults” because they display differences in physical characteristics, physiology, pharmacology, coping strategies, emotional needs, and care coordination compared with the adult population. This chapter focuses on patient optimization, risk evaluation and mitigation, anesthetic concerns for specific pediatric conditions, and the perioperative management of children undergoing otolaryngologic procedures.
Objective
Multi‐dose dexamethasone pretreatment reduces risk of post‐extubation airway obstruction (PEAO). However, its optimal dose is not known. We planned to compare 24h pretreatment with low‐dose dexamethasone (LDD) (0.25 mg/kg/dose) versus high‐dose dexamethasone (HDD) (0.5 mg/kg/dose) in reducing risk of PEAO.
Design
Stratified (for age and intubation duration) randomized open‐label non‐inferiority trial.
Setting
15‐bed Pediatric Intensive Care Unit in a lower‐middle‐income country.
Patients
Children (3mo ‐ 12yrs) intubated for ≥48h and planned for first extubation (February’17 ‐ March’19). Upper airway conditions, chronic respiratory diseases, chronic NSAID therapy, steroid or intravenous immunoglobulin in last 7 days, presence of gastrointestinal bleeding, hypertension, and hyperglycemia were exclusions.
Interventions
LDD (n=144) or HDD (n=143) (q6h) for a total of 6 doses. Extubation was planned immediately after 5th dose. Non‐inferiority margin was kept at 12% from baseline.
Measurements and Main Results
Patients were monitored for PEAO for 24h. 238 patients were included in per‐protocol analysis. 78 patients (33%) developed PEAO. Risk difference between LDD (41/121, 0.34) and HDD (37/117, 0.32) arms was non‐significant (0.02; 90% CI, ‐0.07 to 0.12). Incidence of reintubation was similar (LDD, 10/121, 8.3% vs HDD, 9/117, 7.7%; p=0.87). HDD regimen appears to be better for children intubated for more than 7 days, which is an independent risk factor for development of PEAO.
Conclusions
Non‐inferiority of 24h pretreatment with LDD regimen compared to HDD regimen in reducing risk of PEAO and reintubation was not demonstrated amongst non‐selected patients in our clinical setting. HDD may be continued till more evidence is available through larger trials amongst children at high risk of developing PEAO.
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Respiratory failure is one of the most common reasons for admission to the pediatric intensive care unit (PICU), and about half of the patients admitted to PICU need ventilator support. Development of mechanical ventilation has dramatically changed the outcome of pediatric respiratory failure from a commonly fatal condition to a one with very low mortality. Mechanical ventilation has evolved from negative pressure ventilation to modern positive ventilation delivered with multiple options of ventilation modes. This chapter reviews the basic principles of conventional mechanical ventilation and the pathophysiological impact of ventilation to provide readers with essential keys for the management of children with respiratory failure.
Injury or illness is defined as critical when one or more organ systems are either in danger of failing or have begun to fail. In this situation, the possibility of incomplete recovery or death exists. Critical care comprises the monitoring, support, treatment, and interventions for the organ systems in failure. Pediatric critical care not only encompasses bedside management of children’s severe, potentially life-threatening medical or surgical illness but also extends to providing support to the child’s family or caregivers. The challenge lies in the complex balance of providing support of single or multiple organ systems in failure while at the same time minimizing adverse consequences of treatment. Critical care provision in the developing world faces multiple challenges inherent to a resource-limited setting. Nonetheless, it is possible to provide context-appropriate measures that greatly enhance the provision of healthcare and reduce morbidity and mortality.
Background
While the results of previous meta-analyses have shown beneficial effects of corticosteroid therapy on post-extubation stridor and extubation failure in adults, these results might not be generalizable to children because of the differences in anatomy and structure. We aimed to determine the benefits of corticosteroids on those outcomes in pediatric populations.
Methods
We searched PubMed, EMBASE, and reference lists of articles from inception until February 2019. Randomized controlled trials and observational studies on the efficacy of systemic corticosteroid administration given prior to elective extubation in mechanically ventilated pediatrics were eligible. Outcomes included post-extubation stridor indicating laryngeal edema and extubation failures.
Results
A total of ten randomized controlled trials with 591 pediatric patients were included: seven of the ten studies for post-extubation stridor/suspected upper airway obstruction and nine of the ten studies for extubation failure. The estimate of pooled odds ratios (ORs) for post-extubation stridor/suspected upper airway obstruction was 0.40 (95% CI: 0.21–0.79). When analysis was restricted to trials that had explicit data for infants and explicit data for pediatric patients under 5 years old excluding infants, the estimates of pooled ORs were 0.53 (95% CI: 0.20–1.40) and 0.68 (95% CI: 0.38–1.22), respectively. For pediatric patients who received corticosteroids, there was a 0.37-fold lower odds of extubation failure than that in pediatric patients who did not receive corticosteroids (OR, 0.37; 95% CI, 0.22–0.61). While three observational studies were included in this review, their estimates have a potential for bias and we did not perform a meta-analysis.
Conclusions
Despite a relatively small sample size in each randomized controlled trial and wide ranges of ages and steroid administration regimens, our results suggest that the use of corticosteroids for prevention of post-extubation stridor and extubation failure could be considered to be acceptable in pediatric patients.
It has been suggested that the quality of clinical trials should be assessed by blinded raters to limit the risk of introducing bias into meta-analyses and systematic reviews, and into the peer-review process. There is very little evidence in the literature to substantiate this. This study describes the development of an instrument to assess the quality of reports of randomized clinical trials (RCTs) in pain research and its use to determine the effect of rater blinding on the assessments of quality. A multidisciplinary panel of six judges produced an initial version of the instrument. Fourteen raters from three different backgrounds assessed the quality of 36 research reports in pain research, selected from three different samples. Seven were allocated randomly to perform the assessments under blind conditions. The final version of the instrument included three items. These items were scored consistently by all the raters regardless of background and could discriminate between reports from the different samples. Blind assessments produced significantly lower and more consistent scores than open assessments. The implications of this finding for systematic reviews, meta-analytic research and the peer-review process are discussed.
To evaluate the incidence and identify factors associated with the occurrence of post-extubation stridor and to evaluate the performance of the cuff-leak test in detecting this complication.
Prospective, clinical investigation.
Intensive care unit of a university hospital.
Hundred twelve extubations were analyzed in 112 patients during a 14-month period.
A cuff-leak test before each extubation.
The incidence of stridor was 12%. When we chose the thresholds of 130 ml and 12% to quantify the cuff-leak volume, the sensitivity and the specificity of the test were, respectively, 85% and 95%. The patients who developed stridor had a cuff leak significantly lower than the others, expressed in absolute values (372+/-170 vs 59+/-92 ml, p<0.001) or in relative values (56+/-20 vs 9+/-13%, p<0.001). Stridor was associated with an elevated Simplified Acute Physiology Score (SAPS II), a medical reason for admission, a traumatic or difficult intubation, a history of self-extubation, an over-inflated balloon cuff at admission to ICU and a prolonged period of intubation. These results provide a framework with which to identify patients at risk of developing a stridor after extubation.
A low cuff-leak volume (<130 ml or 12%) around the endotracheal tube prior to extubation is useful in identifying patients at risk for post-extubation stridor.
Prophylactic steroid therapy to reduce the occurrence of postextubation laryngeal edema is controversial. Only a limited number of prospective trials involve adults in an intensive care unit. The purpose of this study was to ascertain whether administration of multiple doses of dexamethasone to critically ill, intubated patients reduces or prevents the occurrence of postextubation airway obstruction. Another specific objective of our study was to investigate whether an after-effect (that is, a transient lingering benefit) exists 24 hours after the discontinuation of dexamethasone.
A randomized, placebo-controlled, double-blind trial was conducted in an adult medical intensive care unit of a tertiary care hospital. Eighty-six patients who had been intubated for more than 48 hours with a cuff leak volume (CLV) of less than 110 ml and who met weaning criteria were randomly assigned to receive either dexamethasone (5 mg; n = 43) or placebo (normal saline; n = 43) every six hours for a total of four doses on the day preceding extubation. CLV was measured before the first injection, one hour after each injection, and 24 hours after the fourth injection. Extubation was carried out 24 hours after the last injection. Postextubation obstruction (defined as the presence of stridor) was recorded within 48 hours of extubation.
Administration of dexamethasone during the 24-hour period preceding extubation resulted in a statistically significant increase in the CLV (p < 0.05). The significant increase of CLV and change of CLV relative to baseline tidal volume (percentage) occurred not only throughout the treatment period, but also 24 hours after the last dexamethasone injection. The incidence of postextubation stridor was significantly lower in the dexamethasone group than in the placebo group (10% [4/40] versus 27.5% [11/40]; p = 0.037), whereas there was no significant difference in reintubation rate between the two groups (2.5% [1/40] versus 5% [2/40]; p = 0.561).
Prophylactic administration of multiple-dose dexamethasone is effective in reducing the incidence of postextubation stridor in adult patients at high risk for postextubation laryngeal edema. The after-effect of dexamethasone may validate the reduced incidence of postextubation stridor after multiple doses of dexamethasone.
NCT00452062.
Background: The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation.Study Design: Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis.Results: Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 58 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p Conclusions: A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.
A National Register of transfusion-transmitted infections was opened by the French Society of Blood Transfusion on 1 October, 1986. Out of 54 initially reported cases of HIV-infection, allegedly transmitted by blood components, further investigation could be completed in 33 cases. The transfusional origin of contamination was considered as established or probable in 28/33 cases, either because a potentially infectious unit was identified among those transfused to the recipient (23/28), or because the recipient was known to be seronegative before transfusion (5/28), or both (10/28). In 5/33 cases transfusion was considered as presumably responsible for contamination because no other risk factor was found in the recipient.
Among the 33 documented cases of HIV-transmission by screened blood, 29 (88%) occurred between 1985 and 1987, and four (12%) during 1988.
Out of 19 implicated donors later found seropositive, 16 belonged to a high-risk group for HIV-infection. The majority of HIV-infections occurred as a consequence of blood donation in the window period between contamination and the appearance of detectable antibodies in the donor's serum (11/19). In three instances, however, human and operational errors led to the release of seropositive units.
We conclude that the main value of this Register is to provide a potential trend-indicator of transfusion-related infectious risks, to allow objective documentation of reported cases and to contribute to the improvement of blood transfusion practice.
The efficacy of corticosteroids in reducing the incidence of postextubation laryngeal oedema is controversial. We aimed to test our hypothesis that methylprednisolone started 12 h before a planned extubation could prevent postextubation laryngeal oedema.
We did a placebo-controlled, double-blind multicentre trial in 761 adults in intensive-care units. Patients who were ventilated for more than 36 h and underwent a planned extubation received intravenous 20 mg methylprednisolone (n=380) or placebo (381) 12 h before extubation and every 4 h until tube removal. The primary endpoint was occurrence of laryngeal oedema within 24 h of extubation. Laryngeal oedema was clinically diagnosed and deemed serious if tracheal reintubation was needed. Analyses were done on a per protocol and intention-to-treat basis. This trial is registered at ClinicalTrials.gov, number NCT00199576.
63 patients could not be assessed, mainly because of self-extubation (n=16) or cancelled extubation (44) between randomisation and planned extubation. 698 patients were analysed (343 in placebo group, 355 in methylprednisolone group). Methylprednisolone significantly reduced the incidence of postextubation laryngeal oedema (11 of 355, 3%vs 76 of 343, 22%, p<0.0001), the global incidence of reintubations (13 of 355, 4%vs 26 of 343, 8%, p=0.02), and the proportion of reintubations secondary to laryngeal oedema (one of 13, 8 %vs 14 of 26, 54%, p=0.005). One patient in each group died after extubation, and atelectasia occurred in one patient given methylprednisolone.
Methylprednisolone started 12 h before a planned extubation substantially reduced the incidence of postextubation laryngeal oedema and reintubation. Such pretreatment should be considered in adult patients before a planned extubation that follows a tracheal intubation of more than 36 h.
We evaluated the use of dexamethasone in the management of acute laryngotracheobronchitis (croup). Thirty patients, ranging in age from eight to 60 months, were evaluated in a prospective, double-blind study. Patients received dexamethasone, 0.3 mg/kg at the time of admission and a similar dose 2 hours later, and were compared with a placebo group receiving saline. Sixteen patients received dexamethasone and 14 patients received the placebo. Severity of each group was scored by a standardized system. Patients receiving dexamethasone had a mean admission score of 8.46 points; patients receiving placebo, 8.14. Twenty-four hours after admission the patients in the treatment group had a mean score of 1.19 as contrasted with a score of 5.58 for the placebo group (P less than 0.01). We concluded that dexamethasone when administered in adequate dosage by an intramuscular route hastens the recovery of infants and children with acute uncomplicated croup.
Incidence of and contributory factors in postintubation laryngeal edema were determined in 7875 children under 17 years of age. Data were assembled in the manner of a prospective study. With an overall incidence of 1 percent, children between ages 1 and 4 were most susceptible. Excessive size of the endotracheal tube was suspect in half of the cases. Other factors that increase trauma to the larynx while an endotracheal tube is in place showed significant correlation to the total incidence of postintubation laryngeal edema. No tracheostomies were required.
We studied 50 preterm infants who had multiple or traumatic endotracheal intubations, or whose duration of endotracheal intubation was > or = to 14 days, and who were considered at high risk for airway edema. These infants were enrolled in a prospective, randomized, controlled clinical trial to assess whether prophylactic dexamethasone therapy would be effective in the prevention of postextubation stridor and respiratory distress. At study entry, both groups had similar weights, postnatal ages, methylxanthine use, ventilator settings, blood gas values, and pulmonary function test results (dynamic compliance, total respiratory resistance, tidal volume, peak-to-peak transpulmonary pressure, minute ventilation, and peak inspiratory and expiratory flow rates). Patients underwent blood gas studies, physical examinations, and pulmonary function testing at baseline (4 hours before extubation) and again 2 to 4 hours and 18 to 24 hours after extubation. Twenty-seven infants received dexamethasone, 0.25 mg/kg per dose, at baseline, and then every 8 hours for a total of three doses; 23 infants received saline solution at corresponding times. Eighteen to twenty-four hours after extubation, total pulmonary resistance increased by 225% from baseline in the control group compared with 33% in the dexamethasone group (p < 0.006), and the dexamethasone group had a greater tidal volume, a greater dynamic compliance, and a lower arterial carbon dioxide pressure. Of 23 control infants, 10 had postextubation stridor compared with 2 of 27 dexamethasone-treated patients (p < 0.006). Of the 23 control patients, 4 required reintubation compared with none of the treated group (p < 0.05). We conclude that the prophylactic use of corticosteroids for the prevention of postextubation stridor and respiratory distress is efficacious in low birth weight, high-risk preterm infants.
Dexamethasone is often given to intubated neonates to facilitate successful extubation. To study the effects of dexamethasone on pulmonary function immediately following extubation, we conducted a randomized, blinded, placebo-controlled trial in 51 infants. All infants had been intubated for a minimum of 3 days but no more than 30 days. Mean weight at extubation was 2.41 kg in treated infants, 2.25 kg in control infants. When infants were deemed ready for extubation, dexamethasone 0.5 mg/kg/dose or an equal volume of normal saline was given in three doses 8 hours apart. The final dose was given 1 hour before extubation. Esophageal pressure, air flow integrated to tidal volume (Vt), respiratory rate, and heart rate were measured before extubation, immediately following extubation, and every 20 minutes for 80 minutes. Total pulmonary resistance (RTP), dynamic lung compliance (CL), and minute ventilation (VE) were calculated. Forty-two infants completed the study; 19 infants received dexamethasone and 23 received placebo. There was no difference between the two groups in gestational age, weight at study, or length of intubation. Vt, RTP, VE, and CL were not significantly different between the two groups over time; however, RTP increased over time in the placebo group. Heart rate was significantly lower in the dexamethasone group. We conclude that dexamethasone appears to have limited effect on pulmonary function immediately following extubation in the population studied. Further studies should evaluate the drug effect beginning at least 1 hour after extubation.
Because laryngeal edema (LE) after tracheal extubation is likely to result from an exudative response, corticosteroids often are given routinely as a preventive treatment. No adequate controlled study supports this strategy, however. A prospective, randomized, placebo-controlled, double-blind, multicenter trial that included 700 consecutive patients requiring tracheal intubation and mechanical ventilation was conducted to determine risk factors for LE occurrence after tracheal extubation in adults and to evaluate the efficacy of corticosteroids in its prevention. One hour before extubation, patients were given either an intravenous bolus of 8 mg dexamethasone or a placebo. Patients were divided into two groups: 1) those in whom short-duration intubation (SDI, less than 36 h) was administered; and 2) those in whom long-duration intubation (LDI, more than 36 h) was administered. Minor LE was diagnosed when either stridor or laryngeal dyspnea, or both, occurred; major LE was diagnosed when reintubation due to LE was required, with LE evidenced during direct laryngoscopy. The overall incidence of LE was 4.2% and varied among the six participating centers from 2.3 to 6.9% (not significant). In only seven patients (1%), all with LDI, was tracheal reintubation required for LE. Laryngeal edema occurred more frequently after LDI than after SDI (7.2 vs. 0.9%; P less than 0.001). It also was more frequent in female than in male patients (20/284 vs. 8/379; P less than 0.05), irrespective of intubation duration and treatment. There was no association between LE and either difficulty/route of intubation or admission diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)
To assess whether there is any advantage in the use of corticosteroid to prevent postextubation stridor in children, we conducted a prospective, randomized, double-blind trial of dexamethasone versus saline solution. The patients were evaluated and then randomly selected to receive either dexamethasone or saline solution according to a stratification based on risk factors for postextubation stridor: age, duration of intubation, upper airway trauma, circulatory compromise, and tracheitis. Dexamethasone, 0.5 mg/kg, was given every 6 hours for a total of six doses beginning 6 to 12 hours before and continuing after endotracheal extubation in a pediatric intensive care setting. There was no statistical difference in incidence of postextubation stridor in the two groups; 23 of 77 children in the placebo group and 16 of 76 in the dexamethasone group had stridor requiring therapy (p = 0.21). We conclude that the routine use of corticosteroids for the prevention of postextubation stridor during uncomplicated pediatric intensive care airway management is unwarranted.
To determine which factors are the best predictors of postextubation stridor in pediatric trauma patients.
Prospective cohort study.
The Burn and Trauma ICUs at Harborview Medical Center from March to September 1989.
Children were eligible for the study if they were less than 15 yr old, were intubated for greater than 12 hr, and did not have underlying cardiopulmonary disease. The study included 25 patients with 30 extubations. RISK FACTORS ASSESSED: Age, type of injury (burn vs. trauma), location of intubation ("field" vs. hospital), endotracheal tube size, length of intubation, and presence of an airleak around the tube at the time of extubation at 30 cm H2O pressure.
Moderate to severe postextubation stridor requiring treatment with racemic epinephrine, helium-oxygen, reintubation, or tracheostomy.
Treatment for postextubation stridor was required after 11 (37%) of 30 extubations, with five reintubations and one tracheostomy. The best predictor of postextubation stridor was absence of an airleak at the time of extubation (sensitivity 100%, positive predictive value 79%, p less than .001), followed by type of injury (facial burn vs. all others; sensitivity 64%, positive predictive value 88%, p less than .001). After controlling for these two factors, no other factor studied was a significant predictor of postextubation stridor.
In pediatric trauma patients, mechanism of injury (facial burn vs. other) and absence of an airleak at the time of extubation are the strongest factors predicting postextubation stridor. Patients with one or both risk factors require special attention to airway management.
The use of adrenocorticoids to reduce the morbidity associated with laryngotracheitis (croup) remains controversial despite ten published reports of randomized trials involving 1,286 patients. To determine whether, viewed in aggregate, these studies demonstrate a significant benefit of steroid treatment for this disorder, a meta-analysis of the nine methodologically satisfactory trials was performed. Clinical improvement 12 and 24 hours posttreatment and incidence of endotracheal intubation were evaluated. For each end point, an estimate of the overall effect was obtained by calculating a typical odds ratio and 95% confidence interval. This analysis indicates that the use of steroids in children hospitalized with croup is associated with a significantly increased proportion of patients showing clinical improvement 12 hours (odds ratio = 2.25, 95% confidence interval = 1.66, 3.06) and 24 hours (odds ratio = 3.19, 95% confidence interval = 1.70, 5.99) posttreatment and a significantly reduced incidence of endotracheal intubation (odds ratio = 0.21, 95% confidence interval = 0.05, 0.84). Higher initial doses of steroid (greater than or equal to 125 mg of cortisone or greater than or equal to 100 mg of hydrocortisone) were associated with a larger proportion of patients improved 12 hours posttreatment than was seen with lower doses. These results support the use of steroids in the treatment of hospitalized children with croup and, in the absence of a randomized clinical trial of sufficient size, provide the most reliable estimate of the impact of steroid therapy on the morbidity associated with croup. In addition, the results of this meta-analysis may be used to estimate the number of subjects who would be required to conduct a randomized clinical trial of steroids for the treatment of croup.
To determine whether a single dose of dexamethasone (0.6 mg/kg) is useful in the treatment of acute laryngotracheitis (croup), 29 hospitalized patients with acute laryngotracheitis were randomly assigned in a double-blind fashion to receive either parenterally administered dexamethasone (n = 16) or a saline placebo (n = 13). Severity of the illness was assessed by a clinical croup score based on retractions, stridor, air entry, cyanosis, and level of consciousness. Twelve hours from the time of injection, the patients receiving the dexamethasone had a statistically significant decline in median croup score from 4.5 to 1.0 (p less than 0.001), whereas the patients receiving the placebo did not. By 24 hours, a decline of two or more points in the total croup score was noted in 85% of the patients in the dexamethasone group compared with 33% of the patients in the placebo group (p = 0.027). During this same period, only 19% of patients receiving dexamethasone required two or more racemic epinephrine treatments in comparison with 62% of patients who received the placebo (p less than 0.05). There was no statistical difference between the two groups in improvement in oxygen saturation, respiratory rates, or duration of hospitalization. We conclude that dexamethasone is beneficial in reducing the overall severity of moderate to severe acute laryngotracheitis during the first 24 hours after injection.
We evaluated the routine use of dexamethasone for the prevention of postextubation respiratory distress by entering 60 ventilated infants into a prospective, randomized, blinded study. Thirty minutes before extubation, 30 infants were given a single dose of intravenous dexamethasone (0.25 mg/kg), and 30 infants received saline placebo. Infants were intubated orotracheally for at least 48 hours following a single intubation and were maintained on low ventilator settings (F10(2) less than 0.35, intermittent mandatory ventilation [IMV] less than 6, positive end-expiratory pressure [PEEP] less than 4) at least 12 hours before extubation. Following extubation, all infants weighing less than 1500 g were routinely placed on nasal continuous positive airway pressure (NCPAP). There was no difference between the two groups in postextubation Downes' score, serum pH, PCO2, or oxygen requirement at 30 minutes, 6 hours, and 24 hours. Respiratory acidosis occurred in one steroid-treated patient and in two placebo-treated infants. Stridor occurred in four infants in each group. No infant developed postextubation lobar atelectasis or required reintubation. We conclude that prophylactic administration of dexamethasone does not improve the immediate postextubation course of infants following a single intubation and that its routine use at the time of extubation is not indicated.
The role of corticosteroids in the prevention of post-extubation laryngeal oedema was evaluated in a randomized study of 276 patients under mechanical ventilation. Fifty per cent of the patients received methylprednisolone 40 mg intramuscularly and intravenously. The nasotracheal tubes used had a large volume, low-pressure balloon. Laryngeal oedema, confirmed by laryngoscopy, occurred in six patients (2%), 4 of whom were in the corticosteroid-treated group, and required immediate reintubation in 4 cases. Thus, the incidence of laryngeal oedema was not modified by corticosteroids. Regular prescription of corticosteroids does not seem to be useful before extubation of patients intubated with large volume, low-pressure balloon tubes.
To determine whether dexamethasone prevents postextubation airway obstruction in young children.
Prospective, randomized, double-blind, placebo-controlled study.
Pediatric intensive care unit of a university teaching hospital.
Sixty-six children, < 5 yrs of age, intubated and mechanically ventilated for > 48 hrs.
Patients were randomized to receive intravenous dexamethasone (0.5 mg/kg, maximum dose 10 mg) or saline, every 6 hrs for six doses, beginning 6 to 12 hrs before elective extubation.
Dependent variables included the presence of stridor, Croup Score, and pulsus paradoxus at 10 mins, 6, 12, and 24 hrs after extubation; need for aerosolized racemic epinephrine and reintubation. The dexamethasone and placebo groups were similar in age (median 3 months [range 1 to 57] vs. 4 months [range 1 to 59], p = .6), frequency of underlying airway anomalies (3/33 vs. 3/33, p = 1.0), and duration of mechanical ventilation (median 3.3 days [range 2.1 to 39] vs. 3.5 days [range 2.1 to 15], p = .7). The dexamethasone group had a lower frequency of stridor, Croup Score, and pulsus paradoxus measurement at 10 mins and at 6 and 12 hrs after extubation. Fewer dexamethasone-treated patients required epinephrine aerosol (4/31 vs. 22/32, p < .0001) and reintubation (0/31 vs. 7/32, p < .01). Three patients exited the study early-one patient in the dexamethasone group had occult gastrointestinal hemorrhage and one patient in each group had hypertension.
Pretreatment with dexamethasone decreases the frequency of postextubation airway obstruction in children.
Laryngotracheal injury or edema in the setting of intubation may narrow the upper airway and predispose toward postextubation stridor. The presence or absence of an audible airleak when the sealing balloon cuff of the endotracheal tube is deflated has been demonstrated to be a marker of laryngotracheal edema in high-risk patients. We hypothesized that (1) the volume of the cuff leak can be quantified in a general medical ICU population, and (2) the cuff leak volume can be correlated with likelihood of postextubation stridor.
Within 24 h of both the initiation and termination of mechanical ventilation, the cuff leak volume, defined as the difference between the inspiratory tidal volume and the averaged expiratory tidal volume while the cuff around the endotracheal tube was deflated, was recorded.
In 100 consecutive intubations, the preextubation cuff leak volume was 349 +/- 163 mL [mean +/- SD]). Overall, 6% of extubations were accompanied by postextubation stridor. The mean cuff leak volume measured within 24 h of planned extubation was significantly lower in those who subsequently developed stridor in comparison to those who did not (180 +/- 157 mL vs 360 +/- 157 mL; p = 0.012). The positive predictive value for postextubation stridor in the setting of a cuff leak less than 110 mL was 0.80, the predictive value for absence of postextubation stridor with a cuff leak volume greater than 110 mL was 0.98, and the specificity of the test was 0.99. No other demographic factors or indexes related to mechanical ventilation were significantly different between the two groups.
A reduced cuff leak volume prior to extubation identifies a population at increased risk for postextubation stridor.
To evaluate the risk factors for postextubation laryngeal stridor and its prevention by hydrocortisone in adult patients.
Prospective, randomized, double-blind, placebo controlled study.
Medical and surgical ICU of a tertiary teaching hospital.
77 consecutive patients of both sexes, who had undergone tracheal intubation for more than 24 h and fulfilled the weaning criteria, were eligible for the study. Patients were excluded if they were less than 15 years of age, had a disease or the surgery of the throat, or had been extubated during the current hospitalization.
The control group received placebo (normal saline 3 cc) and the experimental group received hydrocortisone 100 mg by intravenous infusion 60 min before extubation.
Patients were observed 24 h after extubation for symptoms or signs of laryngeal edema or stridor: prolonged inspiration with accessory usage of respiratory muscles or crowing sound with inspiration or reintubation.
The overall incidence of postextubation stridor was 22% (17/77). Only one patient (1%), who belonged to the control group, needed reintubation. 39% of female patients and 17% of male patients developed stridor. The relative risk of females developing this complication was 2.29. 7/39 of the hydrocortisone group and 10/38 of patients in the control group developed postextubation stridor.
Hydrocortisone did not significantly reduce the incidence of postextubation laryngeal edema or stridor. From the risk factors evaluated, we were unable to demonstrate a statistical correlation between postextubation stidor and the duration of the intubation, the patient's age, the internal diameter of the endotracheal tube, or the route of intubation. However, female patients were more likely to develop this complication.
The incidence of post-extubation stridor (PES) in a pediatric intensive care unit (PICU) and the need for reintubation is not known. Predictors of success on a subsequent extubation attempt and the efficacy of dexamethasone treatment prior to a subsequent extubation attempt are not established. In a prospective randomized double blind-controlled study in two PICU's in a university children's hospital setting, of 5,566 admissions over 35-months, we identified 32 patients who failed primary extubation and were reintubated for PES. Twenty-six patients were enrolled in the study and three subsequently excluded. Twelve were randomized to receive dexamethasone and 11 received sodium chloride placebo. Fifteen patients succeeded study extubation and eight failed. Of those receiving dexamethasone, nine patients succeeded and three failed. Of those receiving placebo, six patients succeeded and five failed. There was a poor correlation between anatomical abnormalities of the airway and failure of study extubation. Extubation failure was better correlated with neurologic impairment in the patients. We present a stridor score and demonstrate that it is an excellent predictor of success versus failure for the study extubation. Dexamethasone pre-treatment did not reduce stridor score. We are unable to conclude if dexamethasone pre-treatment reduces extubation failure. We speculate that neurologic impairment leads to extubation failure in critically ill pediatric patients.
The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation.
Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis.
Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 5 8 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p < 0.001). There were no differences in Injury Severity Score, endotracheal tube size, or reason for intubation between these groups.
A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.
Endotracheal tubes are foreign bodies that may injure the upper airway causing laryngeal edema. This in turn may result in failure of extubation in preterm infants. Corticosteroids have been used prophylactically to reduce upper airway obstruction and facilitate extubation.
In newborn infants having their endotracheal tube removed following a period of intermittent positive pressure ventilation (IPPV), what are the effects of intravenous corticosteroids on the incidence of endotracheal reintubation, stridor, atelectasis and adverse side effects?
Searches were made of the Cochrane Controlled Trials Register (dexamethasone and extub*), Medline (MeSH search terms "dexamethasone", "extubat*" and "exp infant, newborn"), previous reviews including cross references, abstracts of conferences and symposia proceedings, expert informants and journal handsearching mainly in the English language.
Trials were included which used random or quasi-random patient allocation, and which compared intravenous steroids given immediately prior to a planned extubation with placebo.
Data were extracted independently by the two authors and analysed in Revman for all trials. Prespecified subgroup analyses were performed to examine differences in response between infants at high risk for upper airway edema and those receiving routine prophylaxis prior to extubation.
Administration of dexamethasone prior to extubation significantly reduced the need for reintubation of the trachea. This result applies to both the high risk group and to the total population of infants enrolled. However, the incidence of extubation failure was zero in the trial that attempted to exclude infants at high risk of airway edema. The side effects of higher blood sugar levels and glycosuria were found in the 2 trials where these were sought.
Implications for practice Dexamethasone reduces the need for endotracheal reintubation of neonates after a period of IPPV. In view of the lack of effect in low risk infants and the documented and potential side effects, it appears reasonable to restrict its use to infants at increased risk for airway edema and obstruction, such as those who have received repeated or prolonged intubations. Implications for research Issues of dosage and applicability to the extremely low birthweight population could be addressed in future trials. Longer term outcomes such as chronic lung disease, duration of assisted ventilation and length of hospital stay should also be examined.
Laryngeal edema secondary to endotracheal intubation may require early re-intubation. Prior to extubation the absence of leak around an endotracheal tube may predict laryngeal edema after extubation. We evaluated the usefulness of a quantitative assessment of such a leak to identify the patients who will require early re-intubation for laryngeal edema.
This prospective study included 76 patients with endotracheal intubation for more than 12 h. The leak, in percent, was defined as the difference between expired tidal volume measured just before extubation, in volume-controlled mode, with the cuff inflated and then deflated. The best cut-off value to predict the need for re-intubation for significant laryngeal edema was determined and the patients were divided into two groups, according to this cut-off value.
Eight of the 76 patients (11%) needed re-intubation for laryngeal edema. Patients requiring re-intubation had a smaller leak than the other patients [9 (3-18) vs 35 (13-53)%, p<0.01]. The best cut-off value for gas leak was 15.5%. The high leak group included 51 patients, of whom only two patients (3%) required re-intubation. The low leak group included 25 patients, among whom six patients (24%) required re-intubation ( p<0.01). The sensitivity of this test was 75%, the specificity 72.1%, the positive predictive value 25%, the negative predictive value 96.1% and the percent of correct classification 72.4%.
A gas leak around the endotracheal tube greater than 15.5% can be used as a screening test to limit the risk of re-intubation for laryngeal edema.
To determine whether treatment with corticosteroids decreases the incidence of postextubation airway obstruction in an adult intensive care unit.
Clinical experiment.
Adult medical and surgical intensive care unit of a teaching hospital.
One hundred twenty-eight patients who were intubated for >24 hrs with a cuff leak volume <24% of tidal volume and met weaning criteria.
: Patients were randomized into a placebo group (control, n = 43) receiving four injections of normal saline every 6 hrs, a 4INJ group (n = 42) receiving four injections of methylprednisolone sodium succinate, or a 1INJ group (n = 42) receiving one injection of the corticosteroid followed by three injections of normal saline. Cuff volume was assessed 1 hr after each injection, and extubation was performed 1 hr after the last injection. Postextubation stridor was confirmed by examination using bronchoscopy or laryngoscopy.
The incidences of postextubation stridor were lower both in the 1INJ and the 4INJ groups than in the control group (11.6% and 7.1% vs. 30.2%, both p < .05), whereas there was no difference between the two treated groups (p = .46). The cuff leak volume increased after the second and fourth injection in the 4INJ group and after a second injection in the 1INJ group compared with the control group (both p < .05).
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.
To evaluate the efficacy and safety of prophylactic corticosteroid therapy in preventing postextubation laryngeal edema (PELE) and the need for reintubation in adults.
Literature was accessed through MEDLINE (1966-January 2008) and the Cochrane Library using the terms laryngeal edema, airway obstruction, postextubation stridor, intubation, glucocorticoids, and corticosteroids. Bibliographies of cited references were reviewed and a manual search of abstracts from recent pulmonary and critical care meetings was completed.
All English-language, placebo-controlled, randomized studies evaluating the use of prophylactic corticosteroids for the prevention of postextubation laryngeal edema or postextubation stridor (PES) in adults were reviewed.
Although laryngoscopy is the gold standard method for diagnosing PELE, PES is more commonly used for diagnosis in clinical practice. While 3 older studies failed to demonstrate benefit with the prophylactic administration of corticosteroid therapy in terms of reducing PELE, PES, or the need for reintubation, each of these studies evaluated only a single dose of steroid therapy that was initiated only 30-60 minutes prior to a planned extubation in a population of patients at low-risk for PELE. In comparison, 3 newer studies, each using 4 doses of corticosteroid therapy initiated 12-24 hours prior to a planned extubation in patients deemed to be at high baseline risk for developing PELE, demonstrated a reduction in PELE, PES, and the need for reintubation; no safety concerns were identified. Current evidence therefore suggests that prophylactic intravenous methylprednisolone therapy (20-40 mg every 4-6 h) should be considered 12-24 hours prior to a planned extubation in patients at high-risk for PELE (eg, mechanical ventilation > 6 days).
Data from the most recent well-designed clinical trials suggest that prophylactic corticosteroid therapy can reduce the incidence of PELE and the subsequent need for reintubation in mechanically ventilated patients at high-risk for PELE. Based on this information, clinicians should consider initiating prophylactic corticosteroid therapy in this population. Further studies are needed to establish the optimal dosing regimens as well as the subgroups of patients at high risk for PELE who will derive the greatest benefit from this preventive steroid therapy.
Multiple injections of hydrocortisone for the prevention of post extubation stridor in acute respiratory failure
- C Shih
- Chen
- C Tu
- H Chen
- J Lee
- W Tsai
- Hsu
Intravenous dexamethasone for extubation of newborn infants
- Davis
Upper airway disease
- Backofen
Multiple injections of hydrocortisone for the prevention of post extubation stridor in acute respiratory failure
- J Shih C Chen W Tu C Chen H Lee
- W Tsai
- Hsu
Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone
- Ho
Dexamethasone in the prevention of postextubation stridor in children
- Tellez
Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation
- Sandu