Dr. J. Chisholm Presenting
Miller RL, Cole RP. Chest. 1996 Oct;110(4):1035-40. Association between reduced cuff leak volume and postextubation stridor.
STUDY OBJECTIVE: 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.
METHODS: 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.
RESULTS: 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. CONCLUSIONS: A
reduced cuff leak volume prior to extubation identifies a population at increased
risk for postextubation stridor.
Jaber S, Chanques G, Matecki S, et al. Intensive Care Med. 2003 Jan;29(1):69-74.Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test.
OBJECTIVE: 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.
DESIGN: Prospective, clinical
investigation.
SETTING: Intensive care unit of a university hospital.
PATIENTS:
Hundred twelve extubations were analyzed in 112 patients during a 14-month
period.
INTERVENTION: A cuff-leak test before each extubation.
MEASUREMENTS AND
RESULTS: 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.
CONCLUSION: 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.
Maury E, Guglielminotti J, Alzieu M, et al. J Crit Care. 2004 Mar;19(1):23-8.How to identify patients with no risk for postextubation stridor?
The aim of this study was first, to evaluate the value of cough following
tracheal tube cuff deflation, and second, to reassess the value of the cuff-leak
test to predict postextubation stridor (PES). In spontaneously breathing
patients, immediately before extubation, the tracheal tube was deflated and the
absence of cough was monitored. The tube was then obstructed with a finger, and
the absence of leak was monitored. Extubation was then performed. Four PESs were
observed after 115 extubations (incidence: 3.5%). The absence of cough was more
frequently observed when PES occurred than when it did not (75% v 21%, P =.04).
The absence of leak was observed in 100% of PES and in 20% of PES free
extubations (P =.01). The absence of both leak and cough was more frequently
observed in PES (75% v 7%, P <.0001). In the absence of leak, the likelihood
ratio of developing PES was 5.04 and rose to 10.4 when cough was also absent. The
likelihood ratio of not developing PES in the absence of leak alone was 0. We
conclude that in a population of medical intensive care unit spontaneously
breathing patients, just before extubation, the presence of leaking around the
endotracheal tube rules out PES, whereas the absence of cough and of leak are
good predictors of PES.
Cheng KC, Hou CC, Huang HC, Lin SC, Zhang H.Crit Care Med. 2006 May;34(5):1345-50.Intravenous injection of methylprednisolone reduces the incidence of
postextubation stridor in intensive care unit patients.
OBJECTIVE: To determine whether treatment with corticosteroids decreases the
incidence of postextubation airway obstruction in an adult intensive care unit.
DESIGN: Clinical experiment.
SETTING: Adult medical and surgical intensive care
unit of a teaching hospital.
PATIENTS: One hundred twenty-eight patients who were
intubated for >24 hrs with a cuff leak volume <24% of tidal volume and met
weaning criteria.
INTERVENTIONS: 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.
MEASUREMENTS AND MAIN RESULTS: 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).
CONCLUSIONS: 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.
Tuesday, April 28, 2009 at 12:58PM 