By Samuel Nadler, MD, PhD

Critical Care, Pulmonary Medicine, The Polyclinic Madison Center, Seattle; Clinical Instructor, University of Washington, Seattle

Dr. Nadler reports no financial relationships relevant to this field of study.

SYNOPSIS: This meta-analysis demonstrated the administration of steroids between one to 24 hours prior to extubation reduced the risk of reintubation for patients at risk for post-extubation stridor.

SOURCE: Kuriyama A, Umakoshi N, Sun R. Prophylactic corticosteroids for prevention of postextubation stridor and reintubation in adults: A systematic review and meta-analysis. Chest 2017;151:1002-1010.

Post-extubation stridor is associated with prolonged length of stay in the ICU and duration of mechanical ventilation with associated costs, morbidity, and mortality.1 Prevention strategies such as prophylactic steroids may reduce these harms, but not every intubated patient is at risk. Identification of patients who might benefit from prophylactic steroids would maximize benefit and limit harms from unnecessary steroid administration.

This meta-analysis and systematic review focused on the benefits of prophylactic steroids for patients at elevated risk for post-extubation stridor. The authors examined 11 randomized, controlled studies that contained 2,472 patients. Included were trials in medical, surgical, and mixed ICUs, with sample sizes ranging from 71-700 patients from multiple countries.

Overall, prophylactic steroids were associated with reduced risk of post-extubation respiratory failure (relative risk [RR], 0.24-0.48). A subgroup analysis demonstrated that risk reduction is statistically significant only in patients identified as high risk prior to extubation.

High-risk patients demonstrated a reduced risk of events (RR, 0.34; 95% CI, 0.24-0.48), while unselected patients did not (RR, 0.62; 95% CI, 0.24-1.61). Similarly, the risk of reintubation was reduced with steroid administration in high-risk patients (RR, 0.35; 95% CI, 0.20-0.64), but not in unselected patients (RR, 0.53; 95% CI, 0.15-1.89). This finding was robust, with sensitivity analyses showing consistent effect sizes and precision. The number needed to treat to prevent post-extubation events and airway obstruction was five and 16, respectively.

COMMENTARY

This study is an update of previous analyses of the use of steroids to prevent post-extubation stridor. It further helps specify which patients are at risk and demonstrates that various steroid regimens are effective. Cuff leak testing identified high-risk patients. Several criteria were used, including cuff leak volume < 24-25% of tidal volume or total cuff leak volume < 110 mL.

Effective steroid regimens included 40 mg IV methylprednisolone every six hours for four doses prior to extubation, dexamethasone 5 mg IV every six hours for four doses prior to extubation, and methylprednisolone 40 mg one time four hours before extubation. The effects seemed greatest in individuals intubated for shorter periods, but this finding remains controversial.

The positive predictive value of a negative cuff leak test for post-extubation stridor is poor.2 However, this meta-analysis indicated that prophylactic steroids in selected patients would reduce reintubation and other airway events.

The decision to treat is based on risk vs. benefits. Of the trials included in this study, only half reported on adverse effects, but no gastrointestinal bleeding events were reported and only one patient receiving steroids became infected.

There does not appear to be significant harms associated with such short-term steroid use. Thus, a short course of steroids to prevent post-extubation stridor and the need for reintubation seems reasonable and evidence-based in high-risk patients.

REFERENCES

  1. Frutos-Vivar F, Esteban A, Apezteguia C, et al. Outcome of reintubated patients after scheduled extubation. J Crit Care 2011;26:502-509.
  2. Pluijms WA, van Mook WN, Wittekamp BH, Bergmans DC. Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: Updated review. Crit Care 2015;19:295.