Incidence Of Postextubation Stridor Research Articles

Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis.

BackgroundEndotracheal intubation is a common procedure in Neonatal Intensive Care. While cuffed endotracheal tubes (ETT) are the standard of care in adults and children, their use in infants is controversial. The aim of this study was to compare the incidence of post-extubation stridor between uncuffed and cuffed ETTs in infants. We further evaluated the safety of cuffed ETTs in infants with a bodyweight between 2 and 3 kg and performed baseline analysis on development of subglottic stenosis.MethodsIn this retrospective study, we screened all infants admitted to two NICUs of the Medical University of Vienna between 2012 and 2019.The study cohort was screened twice: In the first screening we selected all infants who underwent the first intubation when attaining a bodyweight >2 kg (but <6 kg) to analyze the incidence of post-extubation stridor and only considered the first intubation of each included infant. Post-extubation stridor was defined as the administration of either epinephrine aerosol or any corticosteroid within 6 h post-extubation. In the second screening we searched for all infants diagnosed with acquired severe subglottic stenosis during the study period regardless their bodyweight and numbers of intubations.ResultsA total of 389 infants received at least one intubation during the study period. After excluding infants who underwent the first intubation below a bodyweight of 2 kg, 271 infants remained for final analysis with an average gestational age of 38.7 weeks at the time of intubation. Among those, 92 (33.9%) were intubated with a cuffed and 179 (66.1%) with an uncuffed ETT. Seven infants (2.6%) developed a clinically significant stridor: five of those were intubated with a cuffed and two with an uncuffed ETT (71.4 vs. 28.6%, p = 0.053). All of them had a bodyweight >3 kg at the time of intubation. Infants who developed subglottic stenosis were more often intubated with an uncuffed ETT.ConclusionIn this study, no difference in the incidence of post-extubation stridor between cuffed and uncuffed ETTs in infants with a bodyweight from 2 to 6 kg could be found. The use of uncuffed ETTs does not exhibit higher risk for the acquired subglottic stenosis in this cohort.

Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES).

ObjectiveTo study if protocolized monitoring of endotracheal tube (ETT) cuff pressure every 6 hours is better than adjusting endotracheal tube cuff inflation by the only bedside clinical assessment.Materials and methodsThis was a single-center prospective randomized controlled study done between July 1, 2017 and March 31, 2019. Children between 1 month and 18 years, intubated with cuffed ETT by our trained doctors were included. After obtaining consent, patients were randomized into two groups, standard group (SG) and cuff pressure monitoring group (MG). Sample size was calculated with 80 patients in each group with a power of 80%, significance level (alpha 0.05 and beta 0.2). In the SG, ETT cuff inflation was adjusted by clinical assessment (bedside minimal leak technique and monitoring the percentage of leak displayed on ventilator display) at 6 hours interval. In the MG, cuff pressures were monitored by the device every 6 hours to maintain between 20 and 25 mm Hg.ResultsOut of 543 mechanically ventilated children during the study period, 266 were eligible and randomized for study. During the study, 89 patients died and 17 were left against medical advice, leaving 80 patients in each group. Incidence of post-extubation stridor (PES), re-intubation rate, ventilator-associated pneumonia (VAP) rate, ventilator days, and length of pediatric intensive care unit (PICU) stay were analyzed and found no advantage of protocolized monitoring of cuff pressures in the reduction of any of the above variables.ConclusionOur findings if confirmed by large multicentric studies can bring an end to routine ETT cuff pressure measurements and emphasize more on clinical assessment. Clinical trial registry (CTRI/2019/05/019098).Indian Journal of Critical Care Medicine (2021): 10.5005/jp-journals-10071-23737How to cite this articleShaikh F, Janaapureddy YR, Mohanty S, Reddy PK, Sachane K, Dekate PS, et al. Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES). Indian J Crit Care Med 2021;25(2):181–184.

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

ObjectiveTo assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis. MethodChildren 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. ResultsA 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). ConclusionsAbsence 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.

Abstract PD-051: ROLE OF STEROIDS IN PREVENTION OF POST EXTUBATION STRIDOR

Aims & Objectives: Primary-To study the effect of prophylactic steroids on occurance of post extubation stridor (PES) in ventilated children. Secondary-To compare the severity of PES in ventilated children receiving prophylactic steroids or placebo. Methods Setting- PICU of Lok Nayak Hospital, Delhi in 2014 - 2015 Patients-Children aged 2 months to 12 years, ventilated for at least 48 hours and planned for extubation in next 6–12 hours.Children ventilated through tracheostomy, receiving steroids within 7 days before extubation, having unplanned self extubation, and previously failed extubation were excluded. Intervention-Group A received dexamethasone 0.15 mg/kg 6 hourly for 6 doses at extubation while group B received placebo (normal saline). Stridor scoring was done using Westley stridor score. Results Group A comprised of 42 children while group B had 38 children. PES occurred in total 48.7% children with 42.8% in dexamethasone group and 55.2% in placebo group (p=0.26). The median age of children with PES was 6 months and without PES was 18 months (p=0.05). Stridor score >4 was present in 28.5% of dexamethasone group vs 47.3% of placebo group (p=0.08). Median stridor scores were same in both groups (score 2 in each group). 38% patients in group A compared to 47.3% in Group B required adrenaline nebulization (p=0.40). There was no difference in the incidence of PES with the duration of ventilation (p=0.38). There were no significant adverse effects of steroids. Conclusions We didn’t find significant difference in the incidence of PES and severity of stridor in ventilated patients receiving dexamethasone or placebo.

Nebulized Fluticasone for Preventing Postextubation Stridor in Intubated Children: A Randomized, Double-Blind Placebo-Controlled Trial.

To evaluate the efficacy of nebulized fluticasone propionate in the prevention of postextubation stridor in children. Double-blind, placebo-controlled randomized clinical trial. PICU in a tertiary referral center. Children 1 month to 15 years old who underwent mechanical ventilation. Patients were randomly assigned into two groups after stratification based on age group receiving nebulized fluticasone 1,000 µg or normal saline solution, immediately after extubation. Vital signs and modified Westley score were evaluated for 6 hours after extubation. The primary outcome was the prevalence of postextubation stridor. One hundred forty-seven intubated children were enrolled into this study. Baseline characteristics between two groups were not different. There was no significant difference in the incidence of postextubation stridor (12/74 [16%] vs 13/73 [18%]; p = 0.797). However, when analyzing the subgroup of emergently intubated children, the fluticasone group had a longer delay median time for the initiation of noninvasive ventilation than the control group (380 [90-585] vs 60 [42-116] min; p = 0.044). The modified Westley scores at 30 and 60 minutes in the control group were significantly higher than the fluticasone group (4 vs 2, p = 0.04; 4.5 vs 0.5, p = 0.02, respectively). The single dose of 1,000-µg nebulized fluticasone did not decrease the prevalence of postextubation stridor. However, it might be beneficial in emergently intubated children.

Cuffed endotracheal tubes in neonates and infants undergoing cardiac surgery are not associated with airway complications

Study ObjectiveTo determine the incidence of postoperative airway complications in infants <5kg in weight undergoing cardiac surgery intubated with Microcuff (Kimberley-Clark, Roswell, GA) endotracheal tubes (ETTs). DesignRetrospective review of infants weighing <5.0 kg with congenital heart disease (CHD) presenting for cardiac surgery. SettingSingle-center, tertiary pediatric cardiac critical care unit at a university hospital. PatientsA total of 208 infants weighing <5 kg underwent cardiac surgery for CHD from 2008 to 2013. InterventionIntubation with Microcuff (Kimberley-Clark) ETTs. Study DesignRetrospective review of infants weighing <5.0 kg with CHD presenting for cardiac surgery to a single-center tertiary care university hospital. Measurements: Perioperative data were collected. Primary outcome was development of tracheal stenosis and/or reintubation for stridor. Stridor was defined as mild (≤2 doses of racemic epinephrine), moderate (>2 doses of racemic epinephrine), or severe (requiring reintubation). Secondary outcomes were variables possibly contributing to postextubation stridor. Infants with a tracheostomy, airway anomalies, and death prior to initial extubation were excluded. Logistic regression analysis was performed to evaluate the association between clinical risk factors and the incidence of postextubation stridor. ResultsA total of 208 infants weighing <5 kg underwent cardiac surgery for CHD from 2008 to 2013; 12 subjects were excluded for death prior to initial extubation. No infant developed tracheal stenosis. The incidence of any stridor was 20.9% (95% confidence interval, 15.8%-27.1%) with severe stridor in 2 cases (1%). Age at surgery, weight, duration of intubation, dexamethasone use, and ETT size were not significantly associated with postextubation stridor. Presence of a comorbidity was significantly associated with stridor (P=.01). ConclusionsMicrocuff ETTs in infants <5.0 kg in weight undergoing cardiac surgery are associated with a low incidence of severe postextubation stridor. Because cuffed ETTs allow for improved control of ventilation/oxygenation and decreased risk of aspiration, they should be considered for use in this high-risk population. Larger studies are needed to confirm these results.

Cuff-leak test combined with interventional bronchoscopy benefits early extubation for patients who received tarp surgery.

This study explored the performance characteristics of a cuff-leak test (CLT) combined with interventional fiberoptic bronchoscopy (FBS) for evaluating whether early nasoendotracheal extubation was possible for patients who had received transoral atlantoaxial reduction plate (TARP) internal fixation surgery. 318 patients who underwent surgery were retrospectively analyzed (between January 2006 and December 2012). Extubation was performed by conventional approach (CA group, until December 2008) and improved approach (IA group, from January 2009) including CLT and an interventional FBS procedure. The extubation success within 1-3days after surgery, incidence of postextubation stridor and tracheal reintubation were examined. More IA-treated patients experienced extubation during the first 2days than those CA-treated, median extubation time was 3 (2, 3) days in the CA group and 2 (1, 2) days in the IA group (all P<0.01). The incidence of stridor and reintubation was 5.69 and 0.57% in IA and 11.98 and 4.93% in CA, respectively (both P<0.05). For the CLT-positive patients in the IA group that remained intubated until day 3-4, interventional FBS was applied for safe extubation and achieved 100% success. Early extubation through IA is safe and interventional FBS assists successful extubation for CLT-positive patients who underwent TARP surgery.

English

Introduction Major head and neck surgeries especially in difficult airway patients have a great hazard for post-operative laryngo-pharyngeal oedema and airway obstruction. In this prospective study, mannitol was administrated intra-operatively in an attempt to reduce airway oedema and hence post-extubation airway collapse and obstruction. Materials and methods Two hundred patients undergoing maxillofacial and radical neck surgeries were randomly allocated into the following two equal groups: (1) Group M: in which 0.25 gm /kg mannitol was given after intubation and 30 minutes before the end of surgery. (2) Group C: in which similar volume of the infused mannitol but lactated Ringer was given in the same time points. Cuff-air leak test, flexible fiberoptic laryngoscopic assessment of the upper airway before extubation, post-extubation clinical evaluation of upper airway obstruction and incidence of post-extubation stridor have been conducted to evaluate airway oedema. Results The total mean cuff-leak volume was significantly higher in Group M than in the Group C. The incidence of moderate upper airway lesion was statistically significant lower in mannitol group than in control group. The incidence of post-extubation stridor (after failed cuff-leak test was 4/17 (24%) in the mannitol group and 6/26 (23%) in the control group after passed cuff-leak test it was 2/83 (0.02%) in the mannitol group and 4/74 (.05%) in the control group). Conclusion Pre-emptive use of mannitol in maxillo-facial and radical neck surgeries is effective and nearly side effect free to reduce airway oedema and post-extubation airway obstruction.

Intra-individual Variation of the Cuff-Leak Test as a Predictor of Post-Extubation Stridor

This was an evaluation of intra-individual variation of the cuff-leak test (ΔCLT) immediately post-intubation and pre-extubation, as a predictor of post-extubation stridor. Prospective, clinical investigation in the ICU of a non-university hospital. CLTs were performed immediately after intubation (T0) and before extubation (T1) to evaluate the differences in cuff leak (ΔCLT = CL(T1) - CL(T0)). We included 104 mechanically ventilated subjects in the study over a 12-month period. The incidence of post-extubation stridor was 6.7%. Stridor was more common in females of short stature. ΔCLT was considered as significant when CL(T1) - CL(T0) was negative. The sensitivity and the specificity of the test were 86% and 48%, respectively. When we tested the pre-extubation CLT alone with a threshold of 130 mL as a predictor of post-extubation stridor, the sensitivity and the specificity of the test were 86% and 76%, respectively. The intra-individual variation of CLT immediately post-intubation and pre-extubation does not improve the accuracy of a standard pre-extubation CLT to predict post-extubation stridor. Moreover, the standard pre-extubation CLT did not appear in our study to be an ideal test to detect post-extubation stridor. Larger studies should be performed before generalizing these preliminary results.

Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children

The use of cuffed tracheal tubes (TTs) in small children is still controversial. The aim of this study was to compare post-extubation morbidity and TT exchange rates when using cuffed vs uncuffed tubes in small children. Patients aged from birth to 5 yr requiring general anaesthesia with TT intubation were included in 24 European paediatric anaesthesia centres. Patients were prospectively randomized into a cuffed TT group (Microcuff PET) and an uncuffed TT group (Mallinckrodt, Portex, Rüsch, Sheridan). Endpoints were incidence of post-extubation stridor and the number of TT exchanges to find an appropriate-sized tube. For cuffed TTs, minimal cuff pressure required to seal the airway was noted; maximal cuff pressure was limited at 20 cm H(2)O with a pressure release valve. Data are mean (SD). A total of 2246 children were studied (1119/1127 cuffed/uncuffed). The age was 1.93 (1.48) yr in the cuffed and 1.87 (1.45) yr in the uncuffed groups. Post-extubation stridor was noted in 4.4% of patients with cuffed and in 4.7% with uncuffed TTs (P=0.543). TT exchange rate was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001). Minimal cuff pressure required to seal the trachea was 10.6 (4.3) cm H(2)O. The use of cuffed TTs in small children provides a reliably sealed airway at cuff pressures of <or=20 cm H(2)O, reduces the need for TT exchanges, and does not increase the risk for post-extubation stridor compared with uncuffed TTs.

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

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. To determine whether corticosteroids are effective in preventing or treating post-extubation stridor in critically ill infants, children, or adults. 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. 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. Three review authors independently assessed trial quality and extracted data. 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. 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.

Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients

Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients

Insights in pediatric ventilation: timing of intubation, ventilatory strategies, and weaning

Mechanical ventilation is a common intervention provided by pediatric intensivists. This fact notwithstanding, the management of mechanical ventilation in pediatrics is largely guided by a few pediatric trials along with careful interpretation and application of adult data. A low tidal volume, pressure limited approach to mechanical ventilation as established by the Acute Respiratory Distress Syndrome Network investigators, has become the prevailing practice in pediatric intensive care. Studies by these investigators suggest that high positive end expiratory pressure and recruitment maneuvers are not uniformly beneficial. High frequency oscillatory ventilation continues to be evaluated in an attempt to provide 'open lung' ventilation. Airway pressure release ventilation is a newer mode of ventilation that may combine the 'open lung' approach with spontaneous breathing. Prone positioning was demonstrated in a recent pediatric trial to have no effect on outcome, while calfactant was found to potentially improve outcomes in pediatric acute respiratory distress syndrome. Ventilator weaning protocols may not be as useful in pediatrics as in adults. Systemic corticosteroids decrease the incidence of post extubation stridor and may reduce reintubation rates. Mechanical ventilation with pressure limitation and low tidal volumes has become customary in pediatric intensive care units, and this lung protective approach will continue into the foreseeable future. Further investigation is warranted regarding use of high frequency oscillatory ventilation, airway pressure release ventilation, and surfactant to assist pediatric intensivists in application of these therapies.

Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients

Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients

The "air leak" test around the endotracheal tube, as a predictor of postextubation stridor, is age dependent in children.

The airleak test is measured with a manometer as the pressure necessary to generate an audible airleak around the endotracheal tube. Our objectives were to determine whether the airleak test predicts postextubation stridor in children and if age affects its sensitivity and specificity. A retrospective study. Pediatric intensive care unit. We studied all intubated patients admitted to our pediatric intensive care unit between July 1998 and December 1999. Patients were excluded if they had acute viral croup, tracheal surgery, hypotonic airway, or vocal cord paralysis or if they died before extubation. Medical records were reviewed for patient demographics, presence of an airleak on the day of extubation, airleak values, presence of postextubation stridor, and extubation failure secondary to upper airway obstruction. One hundred and five patients met our inclusion criteria and had an airleak test at the time of extubation. In children <7 yrs of age, the incidence of postextubation stridor was similar in patients with or without an airleak at >20 mm Hg (50% vs. 67.7%; >.05) with a sensitivity of 65.6% (95% confidence interval, 46.9-80.8). In children >or=7 yrs of age, the incidence of postextubation stridor was greater in patients with an airleak at >20 mm Hg (55.5% vs. 5.8%; p=.01) with a sensitivity of 83.3% (95% confidence interval, 36.8-99) in predicting postextubation stridor. Our study suggests that the airleak test has a low sensitivity when used as a screening test to predict postextubation stridor in young children (<7 yrs old), whereas in older children (>or=7 yrs old) the airleak test may predict postextubation stridor.

Bloodletting acupuncture for the prevention of stridor in children after tracheal extubation: a randomised, controlled study

Bloodletting acupuncture has been used for the treatment of a variety of upper respiratory tract problems, especially those of laryngeal origin. This study assesses its efficacy in reducing the incidence of stridor after tracheal extubation in children undergoing general anaesthesia with halothane. Sixty children were randomly allocated to an acupuncture group and a control group. In the acupuncture group, bloodletting acupuncture was performed before extubation. A blinded observer determined the presence and severity of postextubation stridor. The incidence of stridor in the acupuncture group was significantly higher than in the control group. In addition, the severity of stridor was significantly greater in the acupuncture group. It is concluded that in children undergoing halothane anaesthesia, the incidence of postextubation stridor cannot be reduced by bloodletting acupuncture.

The effect of dexamethasone on the incidence of post extubation stridor in pediatric patients

Post extubation stridor is due to reactive subglottic laryngeal edema at the cricoid ring. Dexamethasone has been used to reduce the incidence of stridor in such patients. The evidence in the literature however is not conclusive. We conducted a prospective, randomized, double blind study of dexamethasone versus placebo to assess the efficacy of dexamethasone in reducing the incidence of post extubation stridor in children. Fifty-one patients without any known preexisting upper airway problems were studied. There were 27 patients in the treatment group and 24 in the placebo group. Both groups had similar weight, age and length of intubation. Dexamethasone was given at a dose of 0.6 mg/kg at 12 h and 1 h prior to extubation for a total of 2 doses. The control group received placebo at corresponding times. There was no statistical difference in the incidence of post extubation stridor in the two groups. Ten of 24 children in the placebo group (41.7%) and 8 of 27 (30%) in the dexamethasone group developed stridor (P = 0.39). There were 3 patients in placebo group and 1 in dexamethasone group that needed reintubation, but again the difference was not statistically significant (P = 0.33). This study, although with relatively small sample size, suggests that routine use of dexamethasone to prevent post extubation stridor, in children without any known upper airway abnormality, is not warranted.

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

The incidence of post-extubation stridor (PES) in a pediatric intensive care unit (PICU) and the need for reintubation is not known. Predictors of success on a subsequent extubation attempt and the efficacy of dexamethasone treatment prior to a subsequent extubation attempt are not established. In a prospective randomized double blind-controlled study in two PICU's in a university children's hospital setting, of 5,566 admissions over 35-months, we identified 32 patients who failed primary extubation and were reintubated for PES. Twenty-six patients were enrolled in the study and three subsequently excluded. Twelve were randomized to receive dexamethasone and 11 received sodium chloride placebo. Fifteen patients succeeded study extubation and eight failed. Of those receiving dexamethasone, nine patients succeeded and three failed. Of those receiving placebo, six patients succeeded and five failed. There was a poor correlation between anatomical abnormalities of the airway and failure of study extubation. Extubation failure was better correlated with neurologic impairment in the patients. We present a stridor score and demonstrate that it is an excellent predictor of success versus failure for the study extubation. Dexamethasone pre-treatment did not reduce stridor score. We are unable to conclude if dexamethasone pre-treatment reduces extubation failure. We speculate that neurologic impairment leads to extubation failure in critically ill pediatric patients.

Cuffed Endotracheal Tubes in Pediatric Intensive Care

We prospectively studied 282 consecutive tracheal intubations (243 patients) in a pediatric intensive care unit during a 7-month period to compare cuffed and uncuffed endotracheal tube (ETT) utilization and outcome. The incidence of postextubation stridor in each ETT group was the major outcome measure after controlling for various patient risk factors. Patients whose ETTs were inserted in the operating room, who were less than 1 year of age, or who had ETTs in place for less than 72 hours were more likely to have had insertion of an uncuffed ETT. Patients whose ETTs were inserted in the emergency department or who were more than 5 years of age were more likely to have had insertion of a cuffed ETT. Those who had a cuffed ETT were older (mean 8.1 vs 2.5 years) and had ETTs in place longer (mean 6.1 vs 3.7 days) than patients with an uncuffed ETT. Of the 188 patients who subsequently had removal of their ETTs, the overall incidence of postextubation stridor was 14.9%, with no significant difference between the two ETT groups even after controlling for patient age, duration of intubation, trauma, leak around ETT before extubation, and pediatric risk of mortality score. Two patients in the cuffed ETT group and four patients in the uncuffed ETT group required reintubation for severe postextubation stridor. Long-term follow-up identified 33 patients (17%) who required hospital readmission. None of these was admitted with an upper airway problem. Two patients who previously had insertion of a cuffed ETT subsequently received tracheostomies for the primary purpose of long-term mechanical ventilation unrelated to any problem with the upper airway. We conclude that cuffed endotracheal intubation is not associated with an increased risk of postextubation stridor or significant long-term sequelae.