Post-extubation Stridor Research Articles

Measurement of leak volume as a diagnostic predictor of post-extubation stridor in pediatric patients

Background Endotracheal intubation can cause post-extubation stridor (PES). The PES may prolong the length of stay in the hospital and be associated with increased morbidity and mortality, particularly if re-intubation is necessary. The leak volume (LV) test is a simple method to detect airway edema. Objective To evaluate the efficacy of LV and percent leak volume (PLV) in predicting PES. Methods Inspired tidal volume (VTi) and expired tidal volume (VTe) were observed for six respiratory cycles during positive pressure ventilation before extubation. The average of the six VTi and six VTe values were recorded. The LV was the difference between average VTi and average VTe. The conversion of the ratio of LV to average VTi into percentage was defined as PLV. Both LV and PLV were analyzed to determine cut-off values in predicting PES. Results Among 77 patients, 39 patients (50.6%) developed PES. Both LV and PLV showed a significant decrease in patients with PES.The ROC analysis showed that LV at a cut-off point of < 18.34 ml gave a sensitivity of 82.1% and specificity of 57.9%, whereas PLV < 13.83% yielded 79.5% sensitivity and 57.9% specificity for predicting PES. The LV and PLV had an area under the ROC curve of 0.770 (95%CI 0.665 to 0.874; P<0.001) and 0.706 (95%CI 0.59 to 0.821; P=0.01) respectively. Conclusion Leak volume and percent leak volume can be used as markers to predict PES in pediatric patients.

Scope of a short & obese patient for thymoma surgery with the risk of difficulty in weaning from general anaesthesia

Obese patients had more difficulty with tracheal intubation and a higher incidence of post-extubation stridor. Obesity is such a ubiquitous issue in our culture, and it is a significant risk factor for many diseases, thus it is not surprising that many obese patients are treated in ICU. The objective of this article is to explore challenges for short, obese patients (Little’s) in the critical care setting. Obese patients have a strong correlation between lung function and body fat distribution, with greater impairment when fat accumulates in the chest and abdomen. Mediastinal masses, particularly those located in the anterior mediastinum, can cause perioperative morbidity and mortality by causing major airway and vascular compression, which may be exacerbated under general anesthesia.

Getting the dose right using physiologically-based pharmacokinetic modeling: dexamethasone to prevent post-extubation stridor in children as proof of concept.

Critically ill patients show large variability in drug disposition due to e.g., age, size, disease and treatment modalities. Physiologically-based pharmacokinetic (PBPK) models can be used to design individualized dosing regimens taking this into account. Dexamethasone, prescribed for the prevention post-extubation stridor (PES), is metabolized by the drug metabolizing enzyme CYP3A. As CYP3A4 undergoes major changes during childhood, we aimed to develop age-appropriate dosing recommendations for children of dexamethasone for PES, as proof of concept for PBPK modeling to individualize dosing for critically ill patients. All simulations were conducted in Simcyp™ v21 (a population-based PBPK modeling platform), using an available dexamethasone compound model and pediatric population model in which CYP3A4 ontogeny is incorporated. Published pharmacokinetic (PK) data was used for model verification. Evidence for the dose to prevent post-extubation stridor was strongest for 2-6 year old children, hence simulated drug concentrations resulting from this dose from this age group were targeted when simulating age-appropriate doses for the whole pediatric age range. Dexamethasone plasma concentrations upon single and multiple intravenous administration were predicted adequately across the pediatric age range. Exposure-matched predictions of dexamethasone PK indicated that doses (in mg/kg) for the 2-6 years olds can be applied in 3 month-2 year old children, whereas lower doses are needed in children of other age groups (60% lower for 0-2 weeks, 40% lower for 2-4 weeks, 20% lower for 1-3 months, 20% lower for 6-12 year olds, 40% lower for 12-18 years olds). We show that PBPK modeling is a valuable tool that can be used to develop model-informed recommendations using dexamethasone to prevent PES in children. Based on exposure matching, the dose of dexamethasone should be reduced compared to commonly used doses, in infants <3 months and children ≥6 years, reflecting age-related variation in drug disposition. PBPK modeling is an promising tool to optimize dosing of critically ill patients.

Protocolized Sedation Utilizing COMFORT-B Scale versus Non-protocol-directed Sedation in Mechanically Ventilated Children - An Open-label, Randomized Controlled Trial.

This study aimed to determine the effect of protocolized sedation using the COMFORT-B scale on the duration of mechanical ventilation (DMV). Eighty children with anticipated Duration of mechanical ventilation (DMV) >24h admitted to the Pediatric intensive care unit (PICU) were randomized into one group that received protocolized sedation (PS) using the COMFORT behavioural (COMFORT-B) scale, and another group that received non-protocolized sedation (NPS). The primary outcome was the impact on the DMV. The DMV was significantly lower in PS (PS: 3.5 [3-7] vs. NPS group: 8.5 [4.25-13.75] d; p = 0.008). The cumulative dose and duration of fentanyl in the PS group was significantly lower (median [IQR]; 120 [62.88-279.12] vs. 320.4 [110.88-851.52] μg/kg; p = 0.007 and 4 [2.25-7.75] vs. 8 [4-17.5] d; p = 0.009, respectively). The authors found a decrease in DMV and sedation related adverse events (SRAE) like ventilator associated pneumonia (VAP), accidental extubation, post-extubation stridor and dose and duration of sedative agents with PS.

Commentary: Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis.

Commentary: Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis.

The usefulness of ultrasonographic measurement of the laryngeal air column width difference before extubation as a predictor of secondary airway obstruction after extubation in children

Background: Postextubation airway obstruction, also called postextubation stridor, is one of the most frequent complications of orotracheal intubation and the main cause of extubation failure (EF). Several potential predictors of extubation outcomes have been investigated, although their predictive value and clinical usefulness are limited. Laryngeal ultrasound and measurements are new, noninvasive, easily reproducible methods for extubation success. The objective of the study was to determine the usefulness of measuring the laryngeal air column width difference (LACWD) as a predictor of EF. Subjects and Methods: This prospective observational study was conducted from December 2022 to March 2023. Patients older than 30 days and up to 16 years of age admitted to the pediatric intensive care unit (PICU) and intubated with an endotracheal tube with a balloon for &gt;24 h and with their first attempt at extubation were evaluated. The LACWD was measured before extubation. The first measurement was made with the balloon inflated and the second with the balloon deflated, calculating the difference between the two measurements. Results: Forty-five patients were assessed. The median number of days in the PICU was 8 (interquartile range 2–6). We found that the greater the difference in the air column, the lower the risk of EF ([P = 0.418] odds ratio [OR] =0.101 95% confidence interval [CI] =0.000–26.000), and the greater the number of days (&gt;3), the greater the risk of EF ([P = 0.819] OR = 0.996; 85% CI = 0.965–1.028). Conclusions: No statistically significant relationship was found in the LACWD in our patients. We believe that it is important to carry out an extended study, with age group stratification, to assess its use.

Factors Associated With Post-Extubation Stridor in Infants Intubated in the Pediatric ICU.

Post-extubation stridor (PES) is a common problem in the pediatric intensive care unit (PICU) and is associated with extubation failure, longer length of stay, and increased mortality. Infants represent a large proportion of PICU admissions and are at higher risk for PES, making identification and mitigation of factors associated with PES important in this age group. What factors are associated with PES in infants (age less than 1 year) intubated in the PICU? The primary outcome was PES as defined by the need for racemic epinephrine within 6 h of extubation. Secondary outcomes were heliox administration and reintubation. Statistical analyses were performed with Fisher's exact test for univariate analyses and multivariate logistic regression. 518 patient charts were retrospectively reviewed. 24.1% of patients developed PES. Duration of mechanical ventilation greater than 48 h was associated with increased risk of PES (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.13-2.71, P = .01), as was nonelective intubation (OR = 2.92, 95% CI 1.91-4.46, P < .01). The presence of a cuff, gastroesophageal reflux disease, prematurity, and known upper airway abnormality had no association with PES. 4.0 endotracheal tubes (ETTs) had an increased association with PES compared to 3.5 ETTs (OR = 1.96, 95% CI 1.18-3.27, P < .01). There was no difference in risk of PES between 3.5 and 3.0 ETTs. In infants intubated in the PICU, mechanical ventilation greater than 48 h and nonelective intubation were associated with PES. 4.0 ETTs were associated with higher risk of PES compared to 3.5 ETTs. These findings may help providers in ETT selection and to identify infants that may be at increased risk of PES.

Hyperthyroidism and Blunt Multi-System Trauma

We report a case of multi-system trauma after a motor vehicle collision with documented hyperthyroidism. Intensive care was required including a tube thoracostomy and a tracheostomy. Elevated thyroid function tests were noted and the patient responded to anti-thyroid medication. The patient was decannulated prior to discharge to home. 48 year-old male driver was involved in a rollover motor vehicle collision with ejection. He was intubated in the field and transported to a Level 1 trauma center. At the time of admission his blood pressure was 184/132 with a pulse of 118 and a respiratory rate of 24. The initial abdominal ultrasound was negative and the pelvis was stable on exam. The chest x-ray revealed a moderate right pneumothorax with 1st and 2nd rib fractures. A right chest tube was inserted. An admission arterial blood gas revealed a PH of 7.11, PC02 of 63 and a Pa02 of 134 with a bicarbonate of 20 and a base deficit of 9. A CT survey revealed thyromegaly with surrounding blood and a spleen laceration with a blush. Intensive care unit observation ensued and no further therapy for the spleen injury was required. The patient remained hypertensive and tachycardic. Thyroid function tests were obtained. Free T4 and T3 were both elevated and TSH was very low. He appeared toxic and a presumptive diagnosis of thyrotoxicosis was made with impending thyroid storm. Methimazole was initiated along with beta-blockade (propranolol). The thyroid function tests remained elevated and he was switched to Propylthiouracil. His vital signs stabilized and he was eventually extubated. Post-extubation stridor developed and a tracheostomy was performed. He was weaned and eventually decannulated. He was discharged to home in satisfactory condition on daily anti-thyroid medication.

Acquired laryngomalacia as a cause of post-extubation stridor and extubation failure following craniotomy: a case report

BackgroundLaryngomalacia is a dynamic airway condition characterized by flaccid laryngeal tissue and inward collapse of supraglottic structures during inspiration. Although it may cause airway obstruction and requires careful management, there have been few reports regarding laryngomalacia after surgery. We report a case of adult-onset laryngomalacia occurred after craniotomy requiring reintubation.Case presentationA 21-year-old man was admitted to the ICU after craniotomy for a cerebellopontine angle tumor. He developed severe stridor immediately after extubation on the postoperative day 2 and required reintubation. On the postoperative day 5, similar episode occurred following re-extubation and fiberoptic laryngoscopy revealed a collapsed epiglottis and left arytenoid into the glottis. A diagnosis of laryngomalacia was made, and he underwent tracheostomy. Laryngomalacia had completely improved; however, bilateral vocal cord paralysis was detected 2 weeks later.ConclusionsAcquired laryngomalacia should be considered as a possible mechanism of the airway symptoms in a patient with neurological dysfunction.

Preventing Laryngeal Edema Using Single Dose Methylprednisolone in Critically Ill Patients

Background: Post extubation stridor (PES) is a common concern in mechanically ventilated patients, and various therapies have been explored to prevent its occurrence. This study aimed to compare the effectiveness of a single dose of corticosteroid with a placebo in patients at high risk for PES, as determined by cuff leak volume and laryngeal air column width difference (LACWD). Methodology: A randomized clinical trial was conducted in a tertiary care hospital, involving 222 patients aged &gt;18 years of both genders who had been on mechanical ventilation for more than 24 hours and were planned for extubation. Group A (intervention) received methylprednisolone sodium succinate at a dose of 40 mg in 2 ml normal saline, while Group B (placebo) received 2 ml normal saline. Patients were divided into two groups based on cuff leak percentage and LACWD: a low-risk group (Group 1) with cuff leak &gt; 24% and/or LACWD &gt; 0.9 mm, and a high-risk group (Group 2) with cuff leak &lt; 24% and/or LACWD &lt; 0.9 mm. Results: Post extubation stridor occurred in 2 (2.7%) patients in Group 1 (low-risk group) and in 34 (23.0%) patients in Group 2 (high-risk group) (p=0.00). In Group 2, PES was observed in 9 (12.2%) patients who received methylprednisolone (Group A) and in 25 (33.8%) patients who received the placebo (Group B) (p=0.00). Reintubation was required in 1 (1.4%) patient in Group 1 and in 18 (12.2%) patients in Group 2 (p=0.00). Among Group 2 patients, reintubation was needed in 5 (5.24%) patients in Group A and 14 (18.9%) patients in Group B (p=0.01). Patients who developed PES had significantly lower mean cuff leak and mean LACWD compared to those who did not develop PES (19.6% vs 22.6%; p=0.00 and 0.79 mm vs 0.85 mm; p=0.004, respectively). Notably, PES was observed more frequently in females. Conclusions: Treatment with methylprednisolone significantly reduced the incidence of PES and the need for reintubation in high-risk patients compared to the placebo group. Patients who developed PES had lower cuff leak and LACWD values, and a higher proportion of females experienced PES.

A Scoping Review of Ultrasonographic Techniques in the Evaluation of the Pediatric Airway.

Point-of-care ultrasound is making rapid advancements in pediatrics, and ultrasonographic assessment of the airway is being employed in many specialties such as the pediatric, cardiac, and neonatal intensive care units, emergency department, pulmonary clinic, and the perioperative setting. This scoping review provides a technical description of image acquisition and interpretation, accompanying ultrasound images of the hallmark airway applications in pediatrics, and supporting evidence when available. We describe and illustrate ultrasound-determined endotracheal tube (ETT) sizing, ETT placement and depth confirmation, vocal fold assessment, prediction of post-extubation stridor, difficult laryngoscopy prediction, and cricothyrotomy guidance. This review aims to provide the descriptions and images necessary to learn and apply these skills at the point of care in the pediatric patient.

Persistent Post-Extubation Stridor in an Intensive Care Unit: A Decision Dilemma

Stridor is a harsh, wheezing, often high-pitched sound produced by rapid, turbulent flow of air through a narrowed supraglottic region to proximal trachea and can be inspiratory, expiratory, or biphasic.[1] The incidence of post-extubation stridor varies from 2 to 42% in pediatric intensive care unit (ICU).[2] Factors like traumatic intubation, multiple attempts, prolonged intubation, use of cuffed or inappropriate sized tube, lower age, inadequate analgesia, and sedation are associated with significant risk of post-extubation stridor.[2] [3] Here, we report a case of persistent post-extubation stridor in a patient with traumatic brain injury, who was medically managed, thus avoiding reintubation. Informed consent for reporting this case was obtained from the child's parents.

Predictive factors of extubation failure in pediatric cardiac intensive care unit: A single-center retrospective study from Thailand.

Extubation failure increases morbidity and mortality in pediatric cardiac patients, a unique population including those with congenital heart disease or acquired heart disease. This study aimed to evaluate the predictive factors of extubation failure in pediatric cardiac patients and to determine the association between extubation failure and clinical outcomes. We conducted a retrospective study in the pediatric cardiac intensive care unit (PCICU) of the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, from July 2016 to June 2021. Extubation failure was defined as the re-insertion of the endotracheal tube within 48 hours after extubation. Multivariable log-binomial regression with generalized estimating equations (GEE) was performed to explore the predictive factors associated with extubation failure. We collected 318 extubation events from 246 patients. Of these, 35 (11%) events were extubation failures. In physiologic cyanosis, the extubation failure group had significantly higher SpO2 than the extubation success group (P < 0.001). The predictive factors associated with extubation failure included a history of pneumonia before extubation (RR 3.09, 95% CI 1.54-6.23, P = 0.002), stridor after extubation (RR 2.57, 95% CI 1.44-4.56, P = 0.001), history of re-intubation (RR 2.24, 95% CI 1.21-4.12, P = 0.009), and palliative surgery (RR 1.87, 95% CI 1.02-3.43, P = 0.043). Extubation failure was identified in 11% of extubation attempts in pediatric cardiac patients. The extubation failure was associated with a longer duration of PCICU stay but not with mortality. Patients with a history of pneumonia before extubation, history of re-intubation, post-operative palliative surgery, and post-extubation stridor should receive careful consideration before extubation and close monitoring afterward. Additionally, patients with physiologic cyanosis may require balanced circulation via regulated SpO2.

Laryngeal Ultrasonography and Percent Leak Volume in Predicting Post-Extubation Stridor in The Pediatric Intensive Care Unit Patients

Background: Endotracheal tube intubation can be associated with laryngeal edema, which may present as post-extubation stridor (PES). PES may prolong length of stay in pediatric intensive care unit, particularly if reintubation was necessary. Objective: To evaluate the efficacy of laryngeal ultrasonography and percent leak volume (PLV) in predicting PES in pediatric patients. Materials and Methods: A prospective study of 43 pediatric patients admitted to pediatric intensive care unit was conducted. Laryngeal ultrasonography was performed to measure air column width (ACW) within 24 hours after intubation. Within four hours before extubation, laryngeal ultrasonography was repeated. Air column width ratio (ACWR) was calculated by ACW before extubation divided by ACW after intubation. PLV was calculated by the difference between inspiratory and expiratory tidal volume divided by inspiratory tidal volume. Both of ACWR and PLV were analyzed to determine the optimal cut-off value for predicting PES. Results: Twenty-two patients (51%), developed PES. Receiver operating characteristics curve (ROC) analysis showed that ACWR at cut-off point ≤0.94 had a sensitivity of 72.7%, specificity of 61.9%, positive predictive value (PPV) of 66.7%, and accuracy of 67.4% in predicting PES. A cut-off point of PLV of less than 9.74% had 59.1% sensitivity, 57.1% specificity, 59.1% PPV, and 58.1% accuracy in predicting PES. ACWR and PLV had an area under the ROC curve (AUC) of 0.722 (p=0.013, 95% CI 0.56 to 0.87) and 0.602 (p=0.253, 95% CI 0.43 to 0.77), respectively. Conclusion: ACWR measured by laryngeal ultrasonography of 0.94 or less may be helpful in predicting PES. ACWR is more accurate than PLV in predicting PES. Keywords: Laryngeal ultrasonography; Percent leak volume; Post-extubation stridor

Effect of Implementing Selected Nursing Interventions on Experiencing Post-Extubation Stridor in Ventilated Patients

Post-extubation stridor occur in less than one quartile between extubated patients and it may be asymptomatic or mildly symptomatic for ICU staff. Extubated patients may need reintubation after extubation, which increases the mortality rate among those patients.

Complications during mechanical ventilation-A pediatric intensive care perspective.

Mechanical ventilation is a common procedure performed in pediatric intensive care units, with over 20% of patients requiring invasive ventilator support. The most common indication for endotracheal intubation and ventilation in the pediatric population is respiratory failure either due to respiratory embarrassment or neurologic pathology. Despite the use of ventilation modes that are lung protective in the pediatric population, complications of mechanical ventilation occur frequently. These include atelectasis, post-extubation stridor, perioral tissue damage, ventilator associated pneumonia, mucus plugging, pneumothorax, pneumomediastinum, and ICU neuromyopathy. The purpose of this review is to discuss the risk factors, presentation and management of complications associated with mechanical ventilation in the pediatric population.

712: RISK FACTORS FOR POST-EXTUBATION STRIDOR IN CONGENITAL HEART SURGICAL PATIENTS

Introduction: Post extubation stridor (PES) is a serious complication in children requiring mechanical ventilation. The goal of this study was to identify risk factors associated with PES in children undergoing corrective surgery for congenital heart disease (CHD), and to examine the association of PES with clinical outcomes. Methods: A retrospective analysis of children undergoing corrective surgery for CHD in 2021 was performed. Patients were excluded if they did not have complete data recorded in the medical record. Univariate analyses were performed using a Mann-Whitney U Test or Fisher’s Exact Test where appropriate. Logistic regression was used to conduct a multivariate analysis. Patients noted to have stridor at the time of extubation and those who received racemic epinephrine within 24 hours of extubation were considered to have developed PES. Results: Of 91 patients (mean 6.6 months, range 0.07-97.6 months; 51% male), 15 (16.4%) developed PES. Variables associated with the development of PES included requiring cardiopulmonary bypass (p=0.011), requiring aortic cross clamping (p=0.040), requiring circulatory arrest or regional perfusion (p=0.003), and requiring total body cooling (p=0.003). However, multivariate analysis including these variables did not yield any statistically significant associations. Age (p=0.203), BMI (p=0.234), length of mechanical ventilation (p=0.579), and use of an endotracheal tube larger than predicted (p=0.596) were not found to be significant risk factors for developing PES. Patients who developed PES were more likely to require reintubation (p< 0.001), require an ENT consult (p< 0.001), develop unilateral vocal fold paralysis (p< 0.048), require an ENT surgical intervention (p< 0.001), and require CPAP after extubation (p< 0.001). Developing PES was not associated with longer PICU and hospital length of stay (p=0.350, 0.105, respectively). Conclusions: Intra-operative variables associated with more complex surgeries are associated with the development of PES after CHD corrective surgery. The development of PES in this population was associated with important morbidities, including reintubation and ENT interventions. Further studies are required to identify modifiable variables to decrease this important clinical complication.

Postextubation stridor in paediatric cardiac surgery patients

Background: Paediatric patients undergoing cardiac surgery are likely to be prone to developing postextubation stridor (PES) due to their airway anatomy and several factors related to surgery, Aim: To examine the incidence and risk factors for PES in paediatric patients undergoing cardiac surgery. Methods: The study was prospectively conducted in the paediatric cardiac postsurgical ICU (PICU) at a tertiary referral hospital from November 2010 to January 2012. All paediatric patients presenting with immediate stridor or its developing within 24 hours after extubation were included. Only those patients who were ventilated for at least 6 hours after surgery, but not more than 7 days and deemed fit for elective extubation were considered. Results: Of the 1328 patients admitted to the PICU, 29 patients (2.18%) met the criteria for PES. Of these, 22 (75.6%) were &lt; 1 year old. Ten patients (34%) did not respond to conservative approach or Noninvasive Ventilation (NIV) and had to be reintubated. Six patients were reintubated within an hour, three in &lt; 6 hours and one after 12 hours of extubation. Conclusion: PES is common in paediatric postcardiac surgical patients. Infants are more prone to develop PES. Majority of them can be successfully managed with conservative measures and noninvasive ventilation. The onset of PES varies from immediately after extubation to 3 hours after extubation. Up to one-third of the patients with PES may require reintubation and is common in the first hour after extubation. Patients who develop PES need close observation in the first few hours after extubation.

Postextubation stridor in the ICU

Endotracheal intubation is one of the commonest procedures performed in the intensive care unit. Once the requirement of the tube is no longer present and the patient has recovered the ability to maintain airway, clear secretions and has adequate gas exchange, extubation is done. Occasionally, the patients can develop postextubation stridor. This CME article describes the various causes of postextubation stridor, its clinical features, diagnosis and management.

Use of Bedside Laryngeal Ultrasound to Predict Post-extubation Stridor in Critically Ill Mechanically Ventilated Children

Use of Bedside Laryngeal Ultrasound to Predict Post-extubation Stridor in Critically Ill Mechanically Ventilated Children