Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients

Bastiaan H J Wittekamp, Walther N K A van Mook, Dave H T Tjan, Jan Harm Zwaveling, Dennis C J J Bergmans, Bastiaan H J Wittekamp, Walther N K A van Mook, Dave H T Tjan, Jan Harm Zwaveling, Dennis C J J Bergmans

Abstract

Laryngeal edema is a frequent complication of intubation. It often presents shortly after extubation as post-extubation stridor and results from damage to the mucosa of the larynx. Mucosal damage is caused by pressure and ischemia resulting in an inflammatory response. Laryngeal edema may compromise the airway necessitating reintubation. Several studies show that a positive cuff leak test combined with the presence of risk factors can identify patients with increased risk for laryngeal edema. Meta-analyses show that pre-emptive administration of a multiple-dose regimen of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation. If post-extubation edema occurs this may necessitate medical intervention. Parenteral administration of corticosteroids, epinephrine nebulization and inhalation of a helium/oxygen mixture are potentially effective, although this has not been confirmed by randomized controlled trials. The use of non-invasive positive pressure ventilation is not indicated since this will delay reintubation. Reintubation should be considered early after onset of laryngeal edema to adequately secure an airway. Reintubation leads to increased cost, morbidity and mortality.

Figures

Figure 1
Figure 1
Laryngeal edema. Courtesy of L. Baijens.
Figure 2
Figure 2
Incidence of reintubation and mortality.
Figure 3
Figure 3
Post-extubation laryngeal edema therapy flow chart. AEC, airway exchange catheter; NaCl, 0.9% saline; NPPV, non-invasive positive pressure ventilation; PES, post-extubation stridor.

References

    1. Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med. 1998;158:489–493.
    1. Colice GL, Stukel TA, Dain B. Laryngeal complications of prolonged intubation. Chest. 1989;96:877–884. doi: 10.1378/chest.96.4.877.
    1. Cheng KC, Hou CC, Huang HC, Lin SC, Zhang H. Intravenous injection of methylprednisolone reduces the incidence of pos-textubation stridor in intensive care unit patients. Crit Care Med. 2006;34:1345–1350. doi: 10.1097/.
    1. Darmon JY, Rauss A, Dreyfuss D, Bleichner G, Elkharrat D, Schlemmer B, Tenaillon A, Brun Buisson C, Huet Y. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study. Anesthesiology. 1992;77:245–251. doi: 10.1097/00000542-199208000-00004.
    1. Esteban A, Alia I, Gordo F, Fernandez R, Solsona JF, Vallverdu I, Macias S, Allegue JM, Blanco J, Carriedo D, León M, de la Cal MA, Taboada F, Gonzalez de Velasco J, Palazón E, Carrizosa F, Tomás R, Suarez J, Goldwasser RS. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156:459–465.
    1. Francois B, Bellissant E, Gissot V, Desachy A, Normand S, Boulain T, Brenet O, Preux PM, Vignon P. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet. 2007;369:1083–1089. doi: 10.1016/S0140-6736(07)60526-1.
    1. Ho LI, Harn HJ, Lien TC, Hu PY, Wang JH. Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone. Intensive Care Med. 1996;22:933–936. doi: 10.1007/BF02044118.
    1. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care. 2005;50:1632–1638.
    1. Daley BJ, Garcia Perez F, Ross SE. Reintubation as an outcome predictor in trauma patients. Chest. 1996;110:1577–1580. doi: 10.1378/chest.110.6.1577.
    1. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997;112:186–192. doi: 10.1378/chest.112.1.186.
    1. Gowardman JR, Huntington D, Whiting J. The effect of extubation failure on outcome in a multidisciplinary Australian intensive care unit. Crit Care Resusc. 2006;8:328–333.
    1. Torres A, Gatell JM, Aznar E, el Ebiary M, Puig de la Bellacasa J, Gonzalez J, Ferrer M, Rodriguez Roisin R. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med. 1995;152:137–141.
    1. Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care. 2007;11:R72. doi: 10.1186/cc5957.
    1. Wang CL, Tsai YH, Huang CC, Wu YK, Ye MZ, Chou HM, Shu SC, Lin MC. The role of the cuff leak test in predicting the effects of corticosteroid treatment on postextubation stridor. Chang Gung Med J. 2007;30:53–61.
    1. Erginel S, Ucgun I, Yildirim H, Metintas M, Parspour S. High body mass index and long duration of intubation increase post-extubation stridor in patients with mechanical ventilation. Tohoku J Exp Med. 2005;207:125–132. doi: 10.1620/tjem.207.125.
    1. Fan T, Wang G, Mao B, Xiong Z, Zhang Y, Liu X, Wang L, Yang S. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials. BMJ. 2008;337:a1841. doi: 10.1136/bmj.a1841.
    1. Kastanos N, Estopa Miro R, Marin Perez A, Xaubet Mir A, Agusti Vidal A. Laryngotracheal injury due to endotracheal intubation: incidence, evolution, and predisposing factors. A prospective long-term study. Crit Care Med. 1983;11:362–367. doi: 10.1097/00003246-198305000-00009.
    1. Whited RE. Posterior commissure stenosis post long-term intubation. Laryngoscope. 1983;93:1314–1318.
    1. Esteller More E, Ibanez J, Matino E, Adema JM, Nolla M, Quer IM. Prognostic factors in laryngotracheal injury following intubation and/or tracheotomy in ICU patients. Eur Arch Otorhinolaryngol. 2005;262:880–883. doi: 10.1007/s00405-005-0929-y.
    1. Thomas R, Kumar EV, Kameswaran M, Shamim A, al Ghamdi S, Mummigatty AP, Okafor BC. Post intubation laryngeal sequelae in an intensive care unit. J Laryngol Otol. 1995;109:313–316.
    1. Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope. 1984;94:367–377. doi: 10.1288/00005537-198403000-00014.
    1. Burns HP, Dayal VS, Scott A, van Nostrand AW, Bryce DP. Laryngotracheal trauma: observations on its pathogenesis and its prevention following prolonged orotracheal intubation in the adult. Laryngoscope. 1979;89:1316–1325.
    1. Hartley M, Vaughan RS. Problems associated with tracheal extubation. Br J Anaesth. 1993;71:561–568. doi: 10.1093/bja/71.4.561.
    1. Mackle T, Meaney J, Timon C. Tracheoesophageal compression associated with substernal goitre. Correlation of symptoms with cross-sectional imaging findings. J Laryngol Otol. 2007;121:358–361. doi: 10.1017/S0022215106004142.
    1. Maury E, Guglielminotti J, Alzieu M, Qureshi T, Guidet B, Offenstadt G. How to identify patients with no risk for postextubation stridor? J Crit Care. 2004;19:23–28. doi: 10.1016/j.jcrc.2004.02.005.
    1. Sandhu RS, Pasquale MD, Miller K, Wasser TE. Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation. J Am Coll Surg. 2000;190:682–687. doi: 10.1016/S1072-7515(00)00269-6.
    1. Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest. 1996;110:1035–1040. doi: 10.1378/chest.110.4.1035.
    1. Ding LW, Wang HC, Wu HD, Chang CJ, Yang PC. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur Respir J. 2006;27:384–389. doi: 10.1183/09031936.06.00029605.
    1. Efferen LS, Elsakr A. Post-extubation stridor: risk factors and outcome. J Assoc Acad Minor Phys. 1998;9:65–68.
    1. Jaber S, Chanques G, Matecki S, Ramonatxo M, Vergne C, Souche B, Perrigault PF, Eledjam JJ. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med. 2003;29:69–74.
    1. Rashkin MC, Davis T. Acute complications of endotracheal intubation. Relationship to reintubation, route, urgency, and duration. Chest. 1986;89:165–167. doi: 10.1378/chest.89.2.165.
    1. Balestrieri F, Watson CB. Intubation granuloma. Otolaryngol Clin North Am. 1982;15:567–579.
    1. Harrison GA, Tonkin JP. Prolonged (therapeutic) endotracheal intubation. Br J Anaesth. 1968;40:241–249. doi: 10.1093/bja/40.4.241.
    1. Donnelly WH. Histopathology of endotracheal intubation. An autopsy study of 99 cases. Arch Pathol. 1969;88:511–520.
    1. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1981;70:65–76. doi: 10.1016/0002-9343(81)90413-7.
    1. de Bast Y, De Backer D, Moraine JJ, Lemaire M, Vandenborght C, Vincent JL. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. 2002;28:1267–1272. doi: 10.1007/s00134-002-1422-3.
    1. Fisher MM, Raper RF. The 'cuff-leak' test for extubation. Anaesthesia. 1992;47:10–12. doi: 10.1111/j.1365-2044.1992.tb01943.x.
    1. Benjamin B. Prolonged intubation injuries of the larynx: endoscopic diagnosis, classification, and treatment. Ann Otol Rhinol Laryngol Suppl. 1993;160:1–15.
    1. Biller HF, Harvey JE, Bone RC, Ogura JH. Laryngeal edema. An experimental study. Ann Otol Rhinol Laryngol. 1970;79:1084–1087.
    1. Kryzer TC Jr, Gonzalez C, Burgess LP. Effects of aerosolized dexamethasone on acute subglottic injury. Ann Otol Rhinol Laryngol. 1992;101:95–99.
    1. Gaussorgues P, Boyer F, Piperno D, Gerard M, Leger P, Robert D. Do corticosteroids prevent postextubation laryngeal edema? Prospective study of 276 adults [letter] Crit Care Med. 1988;16:649. doi: 10.1097/00003246-198806000-00021.
    1. Markovitz BP, Randolph AG, Khemani RG. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev. 2008;Apr 16(2):CD001000.
    1. Hawkins DB, Crockett DM, Shum TK. Corticosteroids in airway management. Otolaryngol Head Neck Surg. 1983;91:593–596.
    1. Roberts RJ, Welch SM, Devlin JW. Corticosteroids for prevention of postextubation laryngeal edema in adults. Ann Pharmacother. 2008;42:686–691. doi: 10.1345/aph.1K655.
    1. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004;32:1689–1694. doi: 10.1097/01.CCM.0000134835.05161.B6.
    1. Dark A, Armstrong T. Severe postoperative laryngeal oedema causing total airway obstruction immediately on extubation. Br J Anaesth. 1999;82:644–646.
    1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269–1277. doi: 10.1097/00000542-200305000-00032.
    1. Mort TC. Continuous airway access for the difficult extubation: the efficacy of the airway exchange catheter. Anesth Analg. 2007;105:1357–1362. doi: 10.1213/01.ane.0000282826.68646.a1. table of contents.
    1. Salmela K, Roberts PJ, Lautenschlager I, Ahonen J. The effect of local methylprednisolone on granulation tissue formation. II. Mechanisms of action. Acta Chir Scand. 1980;146:541–544.
    1. Walters JA, Gibson PG, Wood-Baker R, Hannay M, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2009;Jan 21(1):CD001288.
    1. MacDonnell SP, Timmins AC, Watson JD. Adrenaline administered via a nebulizer in adult patients with upper airway obstruction. Anaesthesia. 1995;50:35–36. doi: 10.1111/j.1365-2044.1995.tb04510.x.
    1. Irwin RS, Rippe JM. Irwin and Rippe's Intensive Care Medicine. 6. Philadelphia: Lippincott Williams & Wilkins; 2007.
    1. Esteban A, Frutos Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, Epstein SK, Hill NS, Nava S, Soares MA, D'Empaire G, Alía I, Anzueto A. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350:2452–2460. doi: 10.1056/NEJMoa032736.
    1. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev. 2006;Oct 18(4):CD002884.
    1. Chung YH, Chao TY, Chiu CT, Lin MC. The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation. Crit Care Med. 2006;34:409–414. doi: 10.1097/01.CCM.0000198105.65413.85.
    1. Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population. Chest. 1999;116:1029–1031. doi: 10.1378/chest.116.4.1029.

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