Extubation failure due to post-extubation stridor is better correlated with neurologic impairment than with upper airway lesions in critically ill pediatric patients

A Network Meta-analysis of Dexamethasone for Preventing Postextubation Upper Airway Obstruction in Children

Rationale: Periextubation 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 h before extubation) and the dose (high dose: ⩾0.5 mg/kg/dose). We performed Bayesian network meta-analysis 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. Results: Eight 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 than 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 curve 0.901 and 0.808, respectively). For preventing reintubation, the effect estimate was imprecise for all four dexamethasone regimens compared with no dexamethasone (very low certainty). HE and LE were the top-ranked regimens (surface under the cumulative ranking curve 0.803 and 0.720, respectively) for preventing reintubation. Sensitivity analysis showed that regimens that started >12 hours before extubation were likely more effective than regimens started >6 hours before extubation. Conclusions: Periextubation dexamethasone can prevent postextubation UAO in children, but effectiveness is highly dependent on timing and dosing regimen. Early initiation (ideally >12 h before 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.

Operational Definitions Related to Pediatric Ventilator Liberation

BACKGROUND

Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices.

RESEARCH QUESTION

Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches?

STUDY DESIGN AND METHODS

A panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions.

RESULTS

In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support.

INTERPRETATION

We propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

Multicenter randomized clinical trial comparing dexamethasone versus placebo in preventing upper airway obstruction after extubation in critically ill children

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.

Severe stridor and profound weakness after cerebral malaria

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.

Effectiveness of corticosteroids for post-extubation stridor and extubation failure in pediatric patients: a systematic review and meta-analysis

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.

High Breath-by-Breath Variability Is Associated With Extubation Failure in Children

OBJECTIVES

Extubation failure is multifactorial, and most tools to assess extubation readiness only evaluate snapshots of patient physiology. Understanding variability in respiratory variables may provide additional information to inform extubation readiness assessments.

DESIGN

Secondary analysis of prospectively collected physiologic data of children just prior to extubation during a spontaneous breathing trial. Physiologic data were cleaned to provide 40 consecutive breaths and calculate variability terms, coefficient of variation and autocorrelation, in commonly used respiratory variables (i.e., tidal volume, minute ventilation, and respiratory rate). Other clinical variables included diagnostic and demographic data, median values of respiratory variables during spontaneous breathing trials, and the change in airway pressure during an occlusion maneuver to measure respiratory muscle strength (maximal change in airway pressure generated during airway occlusion [PiMax]). Multivariable models evaluated independent associations with reintubation and prolonged use of noninvasive respiratory support after extubation.

SETTING

Acute care, children's hospital.

PATIENTS

Children were included from the pediatric and cardiothoracic ICUs who were greater than 37 weeks gestational age up to and including 18 years who were intubated greater than or equal to 12 hours with planned extubation. We excluded children who had a contraindication to an esophageal catheter or respiratory inductance plethysmography bands.

INTERVENTIONS

Noninterventional study.

MEASUREMENTS AND MAIN RESULTS

A total of 371 children were included, 32 of them were reintubated. Many variability terms were associated with reintubation, including coefficient of variation and autocorrelation of the respiratory rate. After controlling for confounding variables such as age and neurologic diagnosis, both coefficient of variation of respiratory rate(p < 0.001) and low PiMax (p = 0.002) retained an independent association with reintubation. Children with either low PiMax or high coefficient of variation of respiratory rate had a nearly three-fold higher risk of extubation failure, and when these children developed postextubation upper airway obstruction, reintubation rates were greater than 30%.

CONCLUSIONS

High respiratory variability during spontaneous breathing trials is independently associated with extubation failure in children, with very high rates of extubation failure when these children develop postextubation upper airway obstruction.

Accuracy of stridor-based diagnosis of post-intubation subglottic stenosis in pediatric patients

OBJECTIVE

To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis.

METHOD

Children who required endotracheal intubation for >24h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation.

RESULTS

A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72h or starting more than 72h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91).

CONCLUSIONS

Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72h or started more than 72h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72h following extubation.

Extubation Failure and Tracheostomy Placement in Children with Acute Neurocritical Illness

BACKGROUND

There is a lack of data describing the risk factors for extubation failure (EF) or tracheostomy placement in pediatric neurocritical care (NCC) patients.

METHODS

A retrospective chart review of children admitted to the pediatric intensive care unit who were intubated for >24 h with an acute neurocritical illness and had an extubation attempt. Bivariate and multivariate statistical analysis was performed to determine significant associations of demographic, neurologic, pulmonary, and clinical variables with EF and tracheostomy placement. Analysis of predictive factors for EF (within 48 h) and tracheostomy placement during the hospitalization was conducted on a first extubation attempt group (n = 193) and a second attempt group (n = 23) who experienced either EF or a "late re-intubation" (>48 h-7 days).

RESULTS

Traumatic brain injury (37.3%) and seizures/status epilepticus (31.4%) were the most common diagnoses with neuromuscular weakness patients having the highest risk for EF and tracheostomy placement. EF occurred in 20/193 (10.4%) patients after their first attempt and 6/23 (26.1%) after a second attempt. Compared to those with a fair/strong cough, patients with a weak/absent cough had a relative risk (RR) of 9.4 for EF (95% CI, 4.9-17.9, p < 0.001) and 6.7 (95% CI, 2.3-18.9, p = 0.01) for tracheostomy placement on the first and second attempts, respectively. Glasgow Coma Score (GCS), endotracheal tube (ETT) secretion characteristics, and pulmonary variables were not associated with EF or tracheostomy placement.

CONCLUSIONS

A weak/absent cough reflex is associated with an increased risk of failing extubation and placement of a tracheostomy in intubated pediatric NCC patients.

Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength

OBJECTIVE

Respiratory muscle weakness frequently develops during mechanical ventilation, although in children there are limited data about its prevalence and whether it is associated with extubation outcomes. We sought to identify risk factors for pediatric extubation failure, with specific attention to respiratory muscle strength.

DESIGN

Secondary analysis of prospectively collected data.

SETTING

Tertiary care PICU.

PATIENTS

Four hundred nine mechanically ventilated children.

INTERVENTIONS

Respiratory measurements using esophageal manometry and respiratory inductance plethysmography were made preextubation during airway occlusion and on continuous positive airway pressure of 5 and pressure support of 10 above positive end-expiratory pressure 5 cm H2O, as well as 5 and 60 minutes postextubation.

MEASUREMENTS AND MAIN RESULTS

Thirty-four patients (8.3%) were reintubated within 48 hours of extubation. Reintubation risk factors included lower maximum airway pressure during airway occlusion (aPiMax) preextubation, longer length of ventilation, postextubation upper airway obstruction, high respiratory effort postextubation (pressure rate product, pressure time product, tension time index), and high postextubation phase angle. Nearly 35% of children had diminished respiratory muscle strength (aPiMax ≤ 30 cm H2O) at the time of extubation, and were nearly three times more likely to be reintubated than those with preserved strength (aPiMax > 30 cm H2O; 14% vs 5.5%; p = 0.006). Reintubation rates exceeded 20% when children with low aPiMax had moderately elevated effort after extubation (pressure rate product > 500), whereas children with preserved aPiMax had reintubation rates greater than 20% only when postextubation effort was very high (pressure rate product > 1,000). When children developed postextubation upper airway obstruction, reintubation rates were 47.4% for those with low aPiMax compared to 15.4% for those with preserved aPiMax (p = 0.02). Multivariable risk factors for reintubation included acute neurologic disease, lower aPiMax, postextubation upper airway obstruction, higher preextubation positive end-expiratory pressure, higher postextubation pressure rate product, and lower height.

CONCLUSIONS

Neuromuscular weakness at the time of extubation was common in children and was independently associated with reintubation, particularly when postextubation effort was high.

Post-extubation stridor in Respiratory Syncytial Virus bronchiolitis: Is there a role for prophylactic dexamethasone?

Aim

The purpose of this study was to determine the incidence of reintubation due to upper airway obstruction in a homogeneous group of ventilated infants with Respiratory Syncytial Virus bronchiolitis. Our secondary objective was to determine whether prophylactic administration of dexamethasone prior to extubation was associated with decreased risk of reintubation.

Methods

This retrospective observational study in two Pediatric Intensive Care Units in 2 university hospitals in The Netherlands included two hundred patients younger than 13 months admitted with respiratory insufficiency caused by Respiratory Syncytial Virus bronchiolitis, requiring invasive mechanical ventilation. A logistic regression analysis with propensity score method was used to adjust for possible confounding.

Results

Reintubation due to post-extubation stridor occurred in 17 (8.5%) of 200 patients. After propensity score matching, administration of dexamethasone prior to extubation was associated with a significantly (p = 0.0011) decreased risk of reintubation due to post-extubation stridor compared to patients not receiving prophylactic dexamethasone (absolute risk reduction 13%, 95% CI 5.3–21%).

Conclusion

Reintubation due to post-extubation stridor is an important complication of ventilation for Respiratory Syncytial Virus bronchiolitis. Dexamethasone administered prior to extubation probably reduces the risk of post-extubation stridor necessitating reintubation in these infants. The results of this study support initiation of a placebo-controlled trial to confirm the beneficial effect of prophylactic dexamethasone.

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

RATIONALE

Subglottic edema is the most common cause of pediatric extubation failure, but few studies have confirmed risk factors or prevention strategies. This may be due to subjective assessment of stridor or inability to differentiate supraglottic from subglottic disease.

OBJECTIVES

Objective 1 was to assess the utility of calibrated respiratory inductance plethysmography (RIP) and esophageal manometry to identify clinically significant post-extubation upper airway obstruction (UAO) and differentiate subglottic from supraglottic UAO. Objective 2 was to identify risk factors for subglottic UAO, stratified by cuffed versus uncuffed endotracheal tubes (ETTs).

METHODS

We conducted a single-center prospective study of children receiving mechanical ventilation. UAO was defined by inspiratory flow limitation (measured by RIP and esophageal manometry) and classified as subglottic or supraglottic based on airway maneuver response. Clinicians performed simultaneous blinded clinical UAO assessment at the bedside.

MEASUREMENTS AND MAIN RESULTS

A total of 409 children were included, 98 of whom had post-extubation UAO and 49 (12%) of whom were subglottic. The reintubation rate was 34 (8.3%) of 409, with 14 (41%) of these 34 attributable to subglottic UAO. Five minutes after extubation, RIP and esophageal manometry better identified patients who subsequently received UAO treatment than clinical UAO assessment (P < 0.006). Risk factors independently associated with subglottic UAO included low cuff leak volume or high preextubation leak pressure, poor sedation, and preexisting UAO (P < 0.04) for cuffed ETTs; and age (range, 1 mo to 5 yr) for uncuffed ETTs (P < 0.04). For uncuffed ETTs, the presence or absence of preextubation leak was not associated with subglottic UAO.

CONCLUSIONS

RIP and esophageal manometry can objectively identify subglottic UAO after extubation. Using this technique, preextubation leak pressures or cuff leak volumes predict subglottic UAO in children, but only if the ETT is cuffed.

Defining sedation-related adverse events in the pediatric intensive care unit

BACKGROUND

Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry.

OBJECTIVES

To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial.

METHODS

In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates.

RESULTS

We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy.

CONCLUSIONS

Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.

Pediatric upper airway obstruction: interobserver variability is the road to perdition

PURPOSE

The purposes of the study are to determine the interobserver variability in the clinical assessment of pediatric upper airway obstruction (UAO) and to explore how variability in assessment of UAO may contribute to risk factors and incidence of postextubation UAO.

MATERIALS

This is a prospective trial in 2 tertiary care pediatric intensive care units. Bedside practitioners performed simultaneous, blinded UAO assessments on 112 children after endotracheal extubation.

RESULTS

Agreement among respiratory therapists, pediatric intensive care nurses, and pediatric intensive care physicians was poor for cyanosis (κ = 0.01) and hypoxemia at rest (κ = 0.14) and fair for consciousness (κ = 0.27), air entry (κ = 0.32), hypoxemia with agitation (κ = 0.27), and pulsus paradoxus (κ = 0.23). When looking at "stridor" and "retractions," defined using more than 2 grades of severity from the Westley Croup Score, the interrelater reliability was moderate (κ = 0.43 and κ = 0.47, respectively). This could be improved marginally by dichotomizing the presence or absence of stridor (κ = 0.54) or retractions (κ = 0.53). The overall incidence of UAO after extubation (stridor plus retractions) could range from 7% to 22%, depending on how many providers were required to agree.

CONCLUSIONS

Physical findings routinely used for UAO have poor interobserver reliability among bedside providers. This variability may contribute to inconsistent findings regarding incidence, risk factors, and therapies for postextubation UAO.

Scientific rationale for the use of alpha-adrenergic agonists and glucocorticoids in the therapy of pediatric stridor

Purpose. The most common pharmacological therapies used in the treatment of stridor in children are glucocorticosteroids (GC) and alpha-adrenergic (αAR) agonists. Despite the long-standing reported efficacy of these medications, there is a paucity of data relating to their actual mechanisms of action in the upper airway. Summary. There is compelling scientific evidence supporting the use of αAR-agonists and GCs in pediatric stridor. αAR signaling and GCs regulate the vasomotor tone in the upper airway mucosa. The latter translates into better airflow dynamics, as delineated by human and nonhuman upper airway physiological models. In turn, clinical trials have demonstrated that GCs and the nonselective αAR agonist, epinephrine, improve respiratory distress scores and reduce the need for further medical care in children with stridor. Future research is needed to investigate the role of selective αAR agonists and the potential synergism of GCs and αAR-signaling in the treatment of upper airway obstruction and stridor.

L-epinephrine and dexamethasone in postextubation airway obstruction: a prospective, randomized, double-blind placebo-controlled study

PURPOSE

This prospective randomized double-blind placebo-controlled study paired trial groups to investigate the effect of intravenous dexamethasone and nebulized L-epinephrine on the clinical development of postextubation laryngeal edema.

MATERIAL AND METHODS

Sixty-four patients aged 1 day to 12 years who needed intubation from August/1997 to February/1999 in the Pediatric Intensive Care Unit (PICU) of Santa Casa de São Paulo School of Medicine were paired according to age, height and weight, anthropometric z-scores, duration of tracheal intubation and number of intubation attempts. Patients received intravenous dexamethasone (0.2mg/kg every 6h), with or without nebulized L-epinephrine (0.5mg/kg every 4h) in the study groups; in the control groups, they received nebulized or intravenous isotonic saline solution, or both.

DEPENDENT VARIABLES

frequency and severity of the laryngeal edema (according to Westley Clinical Scoring System), as well as the time interval (min) between extubation and the first postextubation laryngeal edema scores. Postextubation respiratory rate and transcutaneous oxygen saturation were employed as indicators of the clinical conditions for extubation.

RESULTS

Laryngeal edema frequencies did not change according to treatments, chi(2) (3, N=64)=0.58, p>0.05, and the highest scores were not reached in the 24h after extubation, chi(ranks)(2) (3, N=16)=1.03, p>0.05.

CONCLUSIONS

Dexamethasone and l-epinephrine did not reduce the clinical progression of airway obstruction due to laryngeal edema in the early postextubation period.

Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults

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.

Does prophylactic use of dexamethasone have a role in reducing post extubation stridor and reintubation in children?

All children aged from 4 weeks to <5 year, were intubated for at least 48 hours [n=51] during 6 months. Data of the patients treated with DEX (0.5 ml/kg every 6 hours for 3 doses, beginning 6-12 hours prior to extubation) (n=30) were compared with control patients (who had not received medication) (n=21). The DEX and control groups were similar in age i.e., mean ages of DEX group were 16.85+/-14 months, and that of control group were 19.02 +/- 19 months, mean duration of intubation and mechanical ventilation in DEX group was 5.17 +/- 4.58 days, and that in control group was 3.98 +/- 3.60 days. There was no significant difference between DEX and control group in the incidence of postextubation stridor [17% (5/30) vs. 10% (2/21); p = 0.5] and the reintubation rate [7% (2/30) vs. 10% (2/21); p = 0.7]. Our data revealed that the prophylactic use of dexamethasone in planned extubation of high risk children were not effective.

Corticosteroids to prevent extubation failure: a systematic review and meta-analysis

PURPOSE

To determine whether corticosteroids reduce the rate of extubation failure in intensive care patients of all age groups.

METHODS

Medline, EMBASE, the Cochrane Central Register of Controlled Trials, bibliographies of relevant articles, selected conference abstracts and unpublished trial databases were searched. Randomised clinical trials (RCTs) evaluating corticosteroids for the purpose of preventing extubation failure in mechanically ventilated, critically ill patients of all ages were included. Two authors independently assessed the validity of included studies and extracted data regarding characteristics of the studies and the rates of reintubation and manifestations of laryngeal oedema.

RESULTS

Fourteen RCTs including 2,600 participants were included. The mean duration of ventilation prior to attempted extubation ranged from 3 to 21 days. There was a reduction in reintubation with the use of corticosteroids, with a pooled odds ratio (OR) of 0.56 (95% CI; 0.41-0.77, P < 0.0005). The effect of corticosteroids tended to be more pronounced in studies when used at least 12 h prior to attempted extubation (OR 0.41, 95% CI; 0.26-0.64). The results were consistent across neonatal, paediatric and adult populations. There was also a reduction in laryngeal oedema in participants receiving corticosteroids, with a pooled OR of 0.36 (95% CI 0.27-0.49, P < 0.0005).

CONCLUSIONS

Corticosteroids reduce laryngeal oedema and importantly reduce the incidence of extubation failure in critically ill patients of all ages.

Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults

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. Corticosteroids, however, may be associated with adverse effects ranging from hypertension to hyperglycemia, and a more systematic assessment of the efficacy of this therapy is indicated prior to widespread adoption of this practice.

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 April 2007.

SELECTION CRITERIA

Randomized controlled trial 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

Ten trials involving 2230 people were included: five 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, but there was an overall non significant reduction in post extubation stridor (RR 0.42; 95% CI 0.07 to 2.32). This decrease was seen only in the study on high-risk patients treated with multiple doses of steroids around the time of extubation. 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 five adult studies (total N = 1873), there was a non significant trend for prophylactic corticosteroid administration to reduce the risk of re-intubation (RR 0.47; 95% CI 0.16 to 1.39) and post extubation stridor (RR 0.49; 95% CI 0.20 to 1.19). These reductions were largely due to two studies that utilized repeated doses of methylprednisolone 12 to 24 hours prior to extubation. 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, children or adults. However, given the consistent trends towards benefit, this intervention does merit further study.

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

BACKGROUND

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.

METHODS

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.

FINDINGS

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.

INTERPRETATION

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.

Extubation failure in pediatric intensive care incidence and outcomes

OBJECTIVES

To evaluate the hypotheses that children requiring reintubation are at an increased risk of prolonged hospitalizations, congenital heart disease, and death compared with age- and disease-severity-matched control patients.

DESIGN

Prospective decision to evaluate all children undergoing extubation over a 5-yr time interval (1997-2001) with retrospective analysis of all failed extubation patients.

SETTING

A large multidisciplinary, dual-site, single-system pediatric intensive care unit caring for critically ill and injured children.

PATIENTS

All children intubated and ventilated during the study period (1997-2001).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Failed extubation was defined as the unanticipated requirement to replace an endotracheal tube within 48 hrs of extubation. One hundred thirty children of 3,193 pediatric intensive care unit patients failed extubation (4.1%). The median age of children who failed extubation was 6.5 months, compared with a median age of 21.3 months in the control population. The median age of failed extubation in children with cardiac disease was 9.3 months. Failed extubation patients had lengthier hospital and pediatric intensive care unit stays, longer duration of mechanical ventilation, and a higher rate of tracheostomy placement than nonfailed extubation patients (p < .001). Children with congenital heart disease who failed extubation had the longest duration of hospitalization (40.0 +/- 5.4 days). Conversely, cardiac patients who did not fail extubation had the shortest length of stay (11.2 +/- 0.4 days).

CONCLUSIONS

In the present trial, 4.1% of mechanically ventilated children failed extubation. Pediatric intensive care unit patients with failed extubation have longer hospital, pediatric intensive care unit, and ventilator courses but are not at increased risk of death relative to nonfailed extubation patients.

Possible risk factors associated with moderate or severe airway injuries in children who underwent endotracheal intubation

OBJECTIVE

To analyze the role of risk factors associated with moderate or severe airway injuries in children who underwent endotracheal intubation.

DESIGN

Prospective cohort study.

SETTING

Pediatric intensive care unit.

PATIENTS

All patients who required endotracheal intubation during a 25-mo period (October 1999 through October 2001). Exclusion criteria were death before extubation and weight of <1250 g.

INTERVENTIONS

Airway endoscopy at extubation and reevaluation for those reintubated.

MEASUREMENTS

Relative risks and 95% confidence intervals were calculated in the univariate risk factor analysis (age, sex, organ failure, difficult intubation, tube size, reintubation, tube changes, and duration of intubation). p Values were calculated from the chi-square test with Yates' correction or for trend, and a value of <.05 was considered significant. To define which of the main variables were independently associated with the outcomes of interest, we used logistic stepwise forward modeling. The Mantel-Haenszel method was used for the stratified analysis between the two independently associated variables.

RESULTS

The study population consisted of 215 patients (61 newborns and 154 children). Moderate lesions occurred in 24.2% of patients, and severe lesions in 10.7% of patients. Risk factors associated with moderate or severe injury in a univariate analysis were age, sex, organ failure, reintubation, tube changes, and longer duration of intubation. According to Mantel-Haenszel stratified analysis results, reintubation and tube changes were the only variables independently associated with the outcomes.

CONCLUSIONS

We concluded that to prevent morbidity secondary to airway injury, efforts should be directed to avoid reintubation and tube changes in the concerned scenario.

Extubation failure in pediatric intensive care: A multiple-center study of risk factors and outcomes

OBJECTIVE

To determine a contemporary failed extubation rate, risk factors, and consequences of extubation failure in pediatric intensive care units (PICUs). Three hypotheses were investigated: a) Extubation failure is in part disease specific; b) preexisting respiratory conditions predispose to extubation failure; and c) admission acuity scoring does not affect extubation failure.

DESIGN

Twelve-month prospective, observational, clinical study.

SETTING

Sixteen diverse PICUs in the United States.

PATIENTS

Patients were 2,794 patients from the newborn period to 18 yrs of age experiencing a planned extubation trial.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A descriptive statistical analysis was performed, and outcome differences of the failed extubation population were determined. The extubation failure rate was 6.2% (174 of 2,794; 95% confidence interval, 5.3-7.1). Patient features associated with extubation failure (p <.05) included age < or =24 months; dysgenetic condition; syndromic condition; chronic respiratory disorder; chronic neurologic condition; medical or surgical airway condition; chronic noninvasive positive pressure ventilation; the need to replace the endotracheal tube on admission to the PICU; and the use of racemic epinephrine, steroids, helium-oxygen therapy (heliox), or noninvasive positive pressure ventilation within 24 hrs of extubation. Patients failing extubation had longer pre-extubation intubation time (failed, 148.7 hrs, SD +/- 207.8 vs. success, 107.9 hrs, SD +/- 171.3; p <.001), longer PICU length of stay (17.5 days, SD +/- 15.6 vs. 7.6 days, SD +/- 11.1; p <.001), and a higher mortality rate than patients not failing extubation (4.0% vs. 0.8%; p <.001). Failure was found to be in part disease specific, and preexisting respiratory conditions were found to predispose to failure whereas admission acuity did not.

CONCLUSION

A variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.

Corticosteroids for the prevention of reintubation and postextubation stridor in pediatric patients: A meta-analysis

OBJECTIVE: To determine whether corticosteroids are effective in preventing or treating postextubation stridor and in reducing the need for subsequent reintubation of the trachea in critically ill infants and children. DESIGN: Meta-analysis of published randomized controlled trials. DATA SOURCES: References of each trial from a MEDLINE search were reviewed, and experts in the field were contacted. STUDY SELECTION: Any randomized controlled trial comparing the administration of corticosteroids with placebo on the prevalence of reintubation or postextubation stridor in infants or children receiving mechanical ventilation via an endotracheal tube in an intensive care unit. DATA EXTRACTION: Data extraction and methodologic quality assessment were assessed independently by two reviewers. DATA SYNTHESIS: Six controlled clinical trials met the criteria for inclusion; three trials pertain to neonates and three to children. Five trials examined the use of steroids for the prevention of reintubation (four of these evaluated postextubation stridor specifically); one trial examined the use of steroids to treat existing postextubation stridor in children. There was a nonsignificant trend toward a decreased rate of reintubation in all subjects when prophylactic steroids were used (n = 376, relative risk [RR] = 0.34, 95% confidence interval [CI] = 0.05-2.33). Prophylactic use of steroids reduced postextubation stridor in the pooled studies (n = 325, RR = 0.50, 95% CI = 0.28-0.88). In young children, there were significant reductions of postextubation stridor with preventive treatment (n = 216, RR = 0.53, 95% CI = 0.28-0.97), and a trend toward less stridor was observed in neonates (n = 109, RR = 0.42, 95% CI = 0.07-2.32). There was a nonsignificant trend toward a reduced reintubation rate when steroids were used to treat existing upper airway obstruction requiring reintubation (RR = 0.55, 95% CI = 0.17-1.78). Side effects were seldom reported and could not be evaluated. CONCLUSIONS: Prophylactic administration of dexamethasone before elective extubation reduces the prevalence of postextubation stridor in neonates and children and may reduce the rate of reintubation.

Trials of corticosteroids to prevent postextubation airway complications

We identified three randomized controlled trials (RCTs) that addressed whether preextubation steroid administration reduces postextubation complications in children. The pooled analysis of primary extubation in children demonstrated significantly less stridor (relative risk [RR], 0.57; 95% confidence interval [CI], 0.40 to 0.81) and a trend toward less reintubation (RR, 0.50; 95% CI, 0.02 to 13.87) with corticosteroids. One non-RCT in children who had failed extubation the first time found a significant reduction in duration of prolonged reintubation (> or = 6 days) and in failed reextubations. The four RCTs in adults reported very low reintubation rates, and no conclusions can be drawn. Only one RCT assessed postextubation stridor and found little difference. Overall, we found that corticosteroids decreased the risk of postextubation stridor in children by about 40%. However, the effect of corticosteroids in children and adults to reduce postextubation complications such as reintubation is uncertain.

The use of dexamethasone in the prevention of postextubation stridor in pediatric patients in PICU/NICU settings: an analytical review

ISSUES AND PURPOSE

Dexamethasone has been used to prevent postextubation stridor in children, but its use is controversial. Five randomized, controlled clinical trials were reviewed to analyze the effectiveness of prophylactic dexamethasone on postextubation stridor in pediatric patients.

CONCLUSIONS

Previous studies had inconsistent results. Several factors may contribute to postextubation stridor in pediatric patients. Postextubation stridor and extubation failure do not always result from airway edema.

PRACTICE IMPLICATIONS

In addition to prophylactic dexamethasone, other approaches should be used to prevent postextubation stridor, such as preparing the patient, following established guidelines, and providing appropriate postextubation care.

Pediatric airway issues

Airway management in the pediatric patient requires an understanding and knowledge of the differences and characteristics unique to the child and infant. New and exciting techniques are currently being explored and developed for management of the pediatric airway. Technology in the area of imaging has allowed clinicians to better visualize the airway and aberrations of it. Presently, there are many different modes and routes of ventilation and oxygenation that are being applied to the pediatric patient for different disease states. Work continues to probe for methods and ways that will allow us to take care of infants and children better and to provide the safest and most effective means of delivering that care. No doubt, there will be more advances and exciting ideas to come that lead to better management of the pediatric airway.