FROM CHEST
Prophylactic corticosteroids before elective extubation could significantly reduce postextubation stridor and the incidence of reintubation, particularly in patients at high risk of airway obstruction, suggests a systematic review and meta-analysis.
While current guidelines for the management of tracheal extubation call for prophylactic use of corticosteroids in patients with airway compromise, Akira Kuriyama, MD, of Kurashiki Central Hospital in Japan, and coauthors noted that there is an outstanding question as to which patients are most likely to benefit.
Writing in the February 20 online edition of Chest, they reported on an analysis of 11 randomized, controlled trials of prophylactic corticosteroids given before elective extubation, involving 2,472 participants (Chest 2017 Feb 20. doi: 10.1016/j.chest.2017.02.017 ).
They found that the use of prophylactic corticosteroids was associated with a significant 57% reduction in the incidence of postextubation airway obstruction, laryngeal edema, or stridor, and a 58% reduction in reintubation rates, compared with placebo or no treatment.
A subgroup analysis showed that the benefit in reduction of postextubation airway events was evident only in the six trials that selected patients at high risk of airway obstruction, identified by a cuff-leak test (RR = 0.34), and was not seen in trials with an unselected patient population. Similarly, the reduced incidence of reintubation was evident in trials of high-risk individuals (RR = 0.35) but not in the general patient population.
The authors noted that while the latest systematic reviews had shown that corticosteroids reduce the incidence of postextubation stridor and reintubation, only one review examined the efficacy in high-risk populations and even then, it was a pooled subgroup analysis of only three trials.
“The numbers needed to prevent one episode of postextubation airway events and reintubation in individuals at high risk for postextubation airway obstruction were 5 (95%; CI: 4-7) and 16 (95%; CI: 8-166) respectively,” they wrote, noting that routine administration of corticosteroids before elective extubation is not recommended.
“While the use of prophylactic corticosteroids was associated with few adverse events, it is reasonable to use the cuff-leak test as a screening method, and administer prophylactic steroids only to those who are at risk of developing postextubation obstruction, given our study findings.”
Two of the six trials that identified high-risk individuals used a cuff-leak volume less than 24% of tidal volume during inflation, three used a cuff-leak volume of less than 110 mL, and one used a cuff-leak volume less than 25% of tidal volume.
“This potentially indicates that cuff-leak testing, while applied with varying cut-off values, might be able to select those at similar risk for airway obstruction and underlines the importance of screening for high-risk patients,” the authors said.
Researchers also noted that the longer patients were intubated, the lower the effect size of prophylactic corticosteroids on both postexutubation airway events and reintubation.
“Patients thus tended to benefit from prophylactic corticosteroids to prevent postextubation airway events and subsequent reintubation when the duration of mechanical ventilation was short,” they wrote.
The authors noted that the included trials did differ in terms of populations, corticosteroid protocols, and observation periods. However, they pointed out that the statistical heterogeneity in their primary outcome analysis was due to the risk of postextubation airway obstruction.
No conflicts of interest were declared.
