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

Esther S Veldhoen,Marije P Hennus,Louis J Bont,Job Van Woensel,Charlotte A Smulders,Job C Calis,Teus H Kappen,Paulien A M Raymakers-Janssen,Yu Ru Kou

doi:10.1371/journal.pone.0172096

Abstract

AimThe 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.MethodsThis 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.ResultsReintubation 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%).ConclusionReintubation 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.

Highlights

Respiratory Syncytial Virus (RSV) is the most common cause of seasonal acute respiratory tract infections in children and accounts for more than 80% of lower respiratory tract infections (LRTI) in infants [1,2,3]
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
This study examined the incidence of post-extubation stridor requiring reintubation and the effectiveness of prophylactic dexamethasone on reintubation rates for post-extubation stridor in infants with RSV-LRTI, the most common cause of infant respiratory failure in PICUs in winter months

Summary

Introduction

Respiratory Syncytial Virus (RSV) is the most common cause of seasonal acute respiratory tract infections in children and accounts for more than 80% of lower respiratory tract infections (LRTI) in infants [1,2,3]. In approximately 10% of hospitalized RSVinfected patients, almost exclusively infants, invasive mechanical ventilation is required because of severe respiratory failure [4,8]. Mean duration of mechanical ventilation is approximately seven days [9]. Even though they are life-saving, intubation and subsequent invasive mechanical ventilation are associated with complications of the upper airway. Post-extubation stridor, persistent subglottic stenosis, and vocal cord paralysis are the most important upper airway complications [6,10,11,12,13]. One small study suggests that the EF rate is higher (15%) in infants with a viral bronchiolitis [9]

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Methods

Conclusion