Repeated Doses of Steroid and Earlier Intervension before Extubation Decreased Laryngeal Edema during Extubation Oberved by Repeated Cuff Leak Tests-Two Cases Report, a Review and a New Theory

Abstract

Postextubation laryngeal edema may cause stridor and even reintubation. Cuff leak test has been reported as a valuable method to predict Postextubation laryngeal stridor. Steroid has been reported to contribute to the prevention of post-extubation laryngeal edema in children but the studies for adults did not show significant effect. We reviewed these studies and found the doses of steroid used may be too low and the time point of intervention may be to late. We reported a new method performing series of cuff leak tests to see the improvement of laryngeal edema when steroid was precribed in 2005 and found some possibly interesting dose-related effect on laryngeal edema. This clued us that if we prescribed more doses of steroid and prescribed them earlier, the benefit may make significance. Therefore, we planned to use this new method observing series of change of cuff leak volume with time when steroid were prescribed just before extubation. We report two cases. The fist case is an 87 year-old female. She was admitted to our intensive care unit due to gastric cancer with acute bleeding complicated with respiratory failure. After prolonged intubation, she failed to pass cuff leak test though discontinuation from mechanical ventilation. Therefore, we prescribed steroid with intravenous solu-cortef 100 mg per six hours since sixteen hours before extubation. Cuff leak tests were performed about every six hours during the steroid administration. She was extubated successfully and we found that the volumes of cuff leak did not increase significantly until thirteen hours after steroid administered. The second case is an 85 year-old female. She was admitted due to pneumonia with sepsis and respiratory failure. Her clinical condition improved four days later and passed the T-piece spontaneous breathing trial but failed to pass the cuff leak test. The same dose of steroid was prescribed and a modified course of series of cuff leak tests were performed. The volume of cuff leak increased markedly 17.5 hours after the first dose of steroid. She then experienced successful extubation with stridor. Though these two cases with the new model, we suppose that more doses of steroid and earlier intervension may prevent post-extubation laryngeal edema. This point of view has never been mentioned before. If the cohort study supports it in the future, this may largely change our concept for the steroid on post-extubation laryngeal edema. The optimal time course of intervention and dose of the steroid could also be studied with this model.