Prevention and management of Post Extubation Stridor - Library
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Prevention and management of Post
Extubation Stridor
1. Introduction and Who Guideline applies to
The following policy outlines the prevention and management of post-extubation
stridor on PICU/CICU. It applies to Medical and nursing staff on PICU/CICU involved
in the management of patients at risk of or with post extubation stridor
This guidance can be used as an aid and learning tool by medical, nursing and allied
health professional staff involved in the in the management of patients at risk of or
with post extubation stridor in paediatric patients within East Midlands Congenital
Heart Centre and Leicester Children’s Hospital.
2. Guideline Standards and ProceduresOverview:
Post-extubation stridor (PES) is a well-recognised complication of intubation
particularly in children owing to their anatomically narrower upper airway. It is a
manifestation of trauma associated laryngeal-subglottic oedema and inflammation
caused by pressure of the endotracheal tube. PES has associations with increased
morbidity including prolonged hospital stay, risks of failed extubation – reintubation,
airway trauma and nosocomial infection. In some instances, PES may also result
from poor clearance of secretions, brainstem dysfunction, vocal cord paralysis, vocal
cord granuloma, or subglottic stenosis.
Most cases resolve spontaneously but a minority develop more serious
complications such as subglottic or tracheal stenosis, necrotising tracheobronchitis
and tracheal perforation.
Title: Post Extubation Stridor 1 of 6
Version:3 Approved by PICU/CICU Clinical Practice Group May 2018
Trust Ref: C119/2016 Next Review: May 2021
NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL
Policies and Guidelines Library.
Incidence:
Variable, 1.6-6%
Risk Factors:
Patient related factors: age (1 - 4 years), pre-existing tracheal irritation (GOR,
infection) or airway pathology, neurological impairment
Tube/intubation related factors: Incorrect size, cuff pressure too high (>25
cmH2O), traumatic or repeated intubation attempts
Care related factors: excessive movement of tube in trachea
(fixation/sedation) aggressive tracheal suctioning, presence of NG tube, self
extubation, excessive coughing with an ETT in place
Important PICU differentials - Vocal cord palsy
Vocal cord palsy is a complication of cardiothoracic surgery occurring as a
consequence of the recurrent laryngeal nerve damage; unilateral or bilateral.
Incidence 4 - 20%; Association with Aortic arch surgery, Norwood procedure.
Diagnosis: laryngoscopy.
Consequences: failed extubation, prolonged mechanical ventilation, delayed oral
feeding (aspiration has been described in almost half of cases. (7) Spontaneous
recovery occurs in 1/3-2/3 patients; usually within 6 months. (8) In a small number
of patients, the widening of the glottic space or very rarely tracheostomy may be
indicated.
Prevention of Post - Extubation Stridor:
Factors associated with reducing incidence post extubation stridor:
o Using correct size tube
o Monitoring cuff pressure (keep below 20cmH2O, but not deflated as
ridges cause trauma)
o Preventing friction of tube in trachea (adequate fixation and keeping
child comfortable)
o Prevention of unplanned extubation
Title: Post Extubation Stridor 2 of 6
Version:3 Approved by PICU/CICU Clinical Practice Group May 2018
Trust Ref: C119/2016 Next Review: May 2021
NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL
Policies and Guidelines Library.High risk patients:
o Traumatic/multiple airway instrumentation
o Intubation for more than 14 days
o Previous failed extubation
Steroids:
o Cochrane review (2008) looking at use of prophylactic steroids to
reduce re-intubation rates showed there was a trend in neonates and
adults towards fewer re-intubations in patients pre-treated with
steroids, which was more pronounced in patients at high risk, though it
never reached statistical significance. Dose of dexamethasone used in
the studies ranged from 0.25-0.5mg/kg given 6h before extubation and
every 6h for up to 24 h after extubation [6]. Some more recent studies
looking at similar factors showed that corticosteroids are effective in the
prevention of laryngeal oedema if started several hours before
extubation [2]. This conclusion was also supported by two meta-
analyses done subsequently – incidence of laryngeal oedema and
hence stridor is reduced if intravenously administered corticosteroids
are started well in advance and if multiple doses are administered [2 & 3].
It was also observed that in various studies, dexamethasone was given
4 – 6h before extubation and carried on thereafter post-extubation
every 6h to next 24h, had the best results [2, 3 &4]. Over the last few
years, much knowledge has been gathered into this area and a trend is
seen at using lower dose of dexamethasone (0.2mg/kg) [2, 3 & 4]. A
recent study on adults showed no difference at low v’s high dose of
dexamethasone used for post extubation stridor [10].
Dose of steroids:
o Dose of dexamethasone - 0.2mg/kg given 6h before extubation and
every 6h for up to 24h after extubation (the prescribed dose could be
rounded off to the nearest whole number; max 0.25mg/kg/dose)
Title: Post Extubation Stridor 3 of 6
Version:3 Approved by PICU/CICU Clinical Practice Group May 2018
Trust Ref: C119/2016 Next Review: May 2021
NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL
Policies and Guidelines Library.Management of Post - Extubation stridor
Reassurance, sit child up, humidified supplemental oxygen
Adrenaline nebulizer - 0.4ml/kg per dose (max 5ml) of 1:1000 Adrenaline
dilute into 2-4ml of 0.9% Sodium chloride via facemask [Ref: BNF and
UpToDate]
(Adrenaline will only be effective if laryngeal oedema is present. No studies of
its efficacy in post extubation failure). Can be repeated up to 3 times every 15
- 20min (watch for rebound phenomen after 2-4 hours) [9]
Budesonide nebuliser via facemask and O2 – 1 mg for two doses 30 minutes
apart and then a 12h until clinical improvement [1, 3 & 4]
Dexamethasone 0.2 mg/kg iv or oral QDS (6h before and every 6h for up to
24 h after extubation)
If re-intubation is required use of a smaller un-cuffed tube is recommended to
avoid additional trauma to the airway
Treatment options include vasoconstrictor nebulisations (adrenaline) and use of
corticosteroids. However these are associated with their own risks and expense.
There is a growing interest in the use of inhaled steroids, however their efficacy as
compared to systemic steroids in the treatment of PES yet need to be proved. As per
the latest evidence, application of non-invasive ventilation or use of helium/oxygen
mixture is not indicated as it does not improve outcome and increases the delay to
intubation [2 & 3]. However, NIV such as high flow, CPAP and/or BiPAP could possibly
be used as rescue therapy or bridge while waiting for adrenaline/steroids to work or
definitive treatment modality, which could be re-intubation. Similarly, for use of heliox
too, modern day evidence is lacking; possibly the justification for its use could be
very similar to non-invasive ventilation.
Conclusions:
Post extubation stridor is a not uncommon complication of short and long term
intubation in children. It may be prevented by paying attention to details of paediatric
intubation (correct tube, correct fixation), by repeated measurement of cuff pressure
if used and adequate sedation of the agitated child. In the recent studies,
intravenous corticosteroids have shown benefit in preventing/reducing the laryngeal
oedema and stridor by more than 50% if used appropriately. Management is by
providing reassuring environment, oxygen and re-intubation with a smaller tube if
necessary. Current treatment of choice includes nebulised adrenaline and
corticosteroids - intravenous and nebulized in the management of post extubation
stridor; however efficacy of both individually as well as the combination of both has
Title: Post Extubation Stridor 4 of 6
Version:3 Approved by PICU/CICU Clinical Practice Group May 2018
Trust Ref: C119/2016 Next Review: May 2021
NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL
Policies and Guidelines Library.not been established in clinical trials for the use of post extubation stridor (unlike in
viral croup). Heliox and NIV do not reduce laryngeal oedema and therefore stridor
and hence not recommended – however could be used to buy time to establish
definitive solution for upper airway obstruction.
3. Education and Training
Training and raising awareness are on-going processes. On-going awareness is
promoted through the induction and continuous bedside teaching. Training is
provided for medical staff during lunchtime teaching (Wednesdays) and other
sessions, and at junior doctors’ induction training. Nursing education is supported by
the Practice Development teams, and nursing educators.
4. Monitoring Compliance
What will be How will compliance Monitoring Frequency Reporting
measured to monitor be monitored Lead arrangements
compliance
Adherence to the Audit PICU Cons On-going CPM/RISK
guideline
5. Supporting References (maximum of 3)
1. Chiwane S, Sarnaik A. Postextubation Stridor: What’s All That Beyond the
Noise? Paed Crit Care; 2017 (May); 18 (5). DOI:
10.1097/PCC.0000000000001143
2. Post-extubation stridor – Deranged physiology.
http://www.derangedphysiology.com/main/required-reading/airway-
management/Chapter%203.1.2/post-extubation-stridor
3. Plujims WA, NKA van Mook W, Witterkamp BHJ. Postextubation laryngeal
edema and stridor resulting in respiratory failure in critically ill adult
patients: updated review. Crit Care. 2015; 19(1): 295.
doi: 10.1186/s13054-015-1018-2
4. Abbasi S, Moradi S, Talakoub R. Effect of nebulized budesonide in preventing
postextubation complications in critically patients: A prospective,
randomized, double-blind, placebo-controlled study. Adv Biomed Res.
2014; 3: 182. doi: 10.4103/2277-9175.139543
Title: Post Extubation Stridor 5 of 6
Version:3 Approved by PICU/CICU Clinical Practice Group May 2018
Trust Ref: C119/2016 Next Review: May 2021
NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL
Policies and Guidelines Library.5. Hollander D, Muckart D. Post Extubation Stridor in Children ( review article).
South African Journal Critical Care 2008, Volume 25, No 1
6. The Cochrane Library 2008. Corticosteroids for the prevention and treatment
of post extubation stridor in neonates, children and adults
7. Truong MT, Messner AH., Kerschner JE, et al. Pediatric vocal fold paralysis
after cardiac surgery: rate of recovery and sequelae. Otolaryngol Head
Neck Surg.2007; 137(5):780-784.
8. Joo D, Duarte VM, Ghadiali MT, Chhetri DK. Recovery of vocal fold paralysis
after cardiovascular surgery. Laryngoscope. 2009;119(7):1435-1438.
9. UpToDate. Jagannathan N, Burjek N. Complications of pediatric airway
management. Updated March 2018.
10. Chang-Yi Lin, Kuang-Hua Cheng, Li- Kuo Kou. Comparison of High- and Low-
dose Dexamethasone for Preventing Postextubation Airway Obstruction in
Adults: A Prospective, Randomized, Double blind, Placebo-controlled
Study. International Journal of Gerontology 10 (2016) 11e16.
6. Key Words Post extubation stridor, steroids, laryngeal oedema, vocal cord palsy
___________________________________________________________________
CONTACT AND REVIEW DETAILS
Guideline Lead (Name and Title) Executive Lead:
Bedangshu Saikia Consultant Simon Robinson
REVIEW RECORD
Description Of Changes (If Any)
Added Vocal cord palsy as important PICI differential
Dose of Adrenaline neb changed according BNF
Added inhal steroids as a treatment option
Added comment about Heliox/NIV
Dose of Dexamethasone unified to 0.2 mg/kg a 6h
Title: Post Extubation Stridor 6 of 6
Version:3 Approved by PICU/CICU Clinical Practice Group May 2018
Trust Ref: C119/2016 Next Review: May 2021
NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL
Policies and Guidelines Library.You can also read
