Effectiveness of corticosteroids for post-extubation stridor and extubation failure in pediatric patients: a systematic review and meta-analysis

Satoshi Kimura, JiYoon B Ahn, Mai Takahashi, Sohee Kwon, Stefania Papatheodorou, Satoshi Kimura, JiYoon B Ahn, Mai Takahashi, Sohee Kwon, Stefania Papatheodorou

Abstract

Background: While the results of previous meta-analyses have shown beneficial effects of corticosteroid therapy on post-extubation stridor and extubation failure in adults, these results might not be generalizable to children because of the differences in anatomy and structure. We aimed to determine the benefits of corticosteroids on those outcomes in pediatric populations.

Methods: We searched PubMed, EMBASE, and reference lists of articles from inception until February 2019. Randomized controlled trials and observational studies on the efficacy of systemic corticosteroid administration given prior to elective extubation in mechanically ventilated pediatrics were eligible. Outcomes included post-extubation stridor indicating laryngeal edema and extubation failures.

Results: A total of ten randomized controlled trials with 591 pediatric patients were included: seven of the ten studies for post-extubation stridor/suspected upper airway obstruction and nine of the ten studies for extubation failure. The estimate of pooled odds ratios (ORs) for post-extubation stridor/suspected upper airway obstruction was 0.40 (95% CI: 0.21-0.79). When analysis was restricted to trials that had explicit data for infants and explicit data for pediatric patients under 5 years old excluding infants, the estimates of pooled ORs were 0.53 (95% CI: 0.20-1.40) and 0.68 (95% CI: 0.38-1.22), respectively. For pediatric patients who received corticosteroids, there was a 0.37-fold lower odds of extubation failure than that in pediatric patients who did not receive corticosteroids (OR, 0.37; 95% CI, 0.22-0.61). While three observational studies were included in this review, their estimates have a potential for bias and we did not perform a meta-analysis.

Conclusions: Despite a relatively small sample size in each randomized controlled trial and wide ranges of ages and steroid administration regimens, our results suggest that the use of corticosteroids for prevention of post-extubation stridor and extubation failure could be considered to be acceptable in pediatric patients.

Keywords: Breathing; Glucocorticoids; Laryngeal edema; Mechanical ventilation; Pediatrics; Respiratory sounds.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Study selection workflow
Fig. 2
Fig. 2
Risk of bias summary of randomized controlled trials
Fig. 3
Fig. 3
Result of meta-analysis for effects of corticosteroids on incidence of stridor/suspected upper airway obstruction in randomized controlled trials. An odds ratio (OR) less than 1 favors corticosteroid administration
Fig. 4
Fig. 4
Result of meta-analysis for effects of corticosteroids on incidence of extubation failure in randomized controlled trials. An odds ratio (OR) less than 1 favors corticosteroid administration

References

    1. Roberts RJ, Welch SM, Devlin JW. Corticosteroids for prevention of postextubation laryngeal edema in adults. Ann Pharmacother. 2008;42(5):686–691. doi: 10.1345/aph.1K655.
    1. Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Datab Syst Rev. 2009;3:Cd001000.
    1. Jaber S, Chanques G, Matecki S, Ramonatxo M, Vergne C, Souche B, et al. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med. 2003;29(1):69–74. doi: 10.1007/s00134-002-1563-4.
    1. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care. 2005;50(12):1632–1638.
    1. Cheng KC, Chen CM, Tan CK, Chen HM, Lu CL, Zhang H. Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients. Minerva Anestesiol. 2011;77(5):503–509.
    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(9):933–936. doi: 10.1007/BF02044118.
    1. Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Crit Care Med. 1991;19(3):352–355. doi: 10.1097/00003246-199103000-00012.
    1. Darmon JY, Rauss A, Dreyfuss D, Bleichner G, Elkharrat D, Schlemmer B, et al. 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(2):245–251. doi: 10.1097/00000542-199208000-00004.
    1. Torres A, Gatell JM, Aznar E, el-Ebiary M, Puig de la Bellacasa J, Gonzalez J, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med. 1995;152(1):137–141. doi: 10.1164/ajrccm.152.1.7599812.
    1. Esteban A, Alia I, Tobin MJ, Gil A, Gordo F, Vallverdu I, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1999;159(2):512–518. doi: 10.1164/ajrccm.159.2.9803106.
    1. Malhotra D, Gurcoo S, Qazi S, Gupta S. Randomized comparative efficacy of dexamethasone to prevent postextubation upper airway complications in children and adults in ICU. Ind J Anaesth. 2009;53(4):442–449.
    1. Way WL, Sooy FA. Histologic changes produced by endotracheal intubation. Ann Otol Rhinol Laryngol. 1965;74(3):799–812. doi: 10.1177/000348946507400318.
    1. Rhen T, Cidlowski JA. Antiinflammatory action of glucocorticoids–new mechanisms for old drugs. N Engl J Med. 2005;353(16):1711–1723. doi: 10.1056/NEJMra050541.
    1. Kuriyama A, Umakoshi N, Sun R. Prophylactic corticosteroids for prevention of postextubation stridor and reintubation in adults: a systematic review and meta-analysis. Chest. 2017;151(5):1002–1010. doi: 10.1016/j.chest.2017.02.017.
    1. McCaffrey J, Farrell C, Whiting P, Dan A, Bagshaw SM, Delaney AP. Corticosteroids to prevent extubation failure: a systematic review and meta-analysis. Intensive Care Med. 2009;35(6):977–986. doi: 10.1007/s00134-009-1473-9.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097.
    1. Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. .
    1. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. doi: 10.1136/bmj.d5928.
    1. .
    1. Glenn AJ, Viguiliouk E, Seider M, Boucher BA, Khan TA, Blanco Mejia S, et al. Relation of vegetarian dietary patterns with major cardiovascular outcomes: a systematic review and meta-analysis of prospective cohort studies. Front Nutr. 2019;6:80. doi: 10.3389/fnut.2019.00080.
    1. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–188. doi: 10.1016/0197-2456(86)90046-2.
    1. Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27(5):335–371. doi: 10.1016/S0033-0620(85)80003-7.
    1. Cochran WG. The comparison of percentages in matched samples. Biometrika. 1950;37(3–4):256–266. doi: 10.1093/biomet/37.3-4.256.
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–560. doi: 10.1136/bmj.327.7414.557.
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–634. doi: 10.1136/bmj.315.7109.629.
    1. Doyle LW, Davis PG, Morley CJ, McPhee A, Carlin JB. Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial. Pediatrics. 2006;117(1):75–83. doi: 10.1542/peds.2004-2843.
    1. Couser RJ, Ferrara TB, Falde B, Johnson K, Schilling CG, Hoekstra RE. Effectiveness of dexamethasone in preventing extubation failure in preterm infants at increased risk for airway edema. J Pediatr. 1992;121(4):591–596. doi: 10.1016/S0022-3476(05)81154-0.
    1. Ferrara TB, Georgieff MK, Ebert J, Fisher JB. Routine use of dexamethasone for the prevention of postextubation respiratory distress. J Perinatol. 1989;9(3):287–290.
    1. Courtney SE, Weber KR, Siervogel RM, Spohn WA, Guo S, Malin SW, et al. Effects of dexamethasone on pulmonary function following extubation. J Perinatol. 1992;12(3):246–251.
    1. Harel Y, Vardi A, Quigley R, Brink LW, Manning SC, Carmody TJ, et al. Extubation failure due to post-extubation stridor is better correlated with neurologic impairment than with upper airway lesions in critically ill pediatric patients. Int J Pediatr Otorhinolaryngol. 1997;39(2):147–158. doi: 10.1016/S0165-5876(97)01488-2.
    1. Cesar RG, de Carvalho WB. L-Epinephrine and dexamethasone in postextubation airway obstruction: a prospective, randomized, double-blind placebo-controlled study. Int J Pediatr Otorhinolaryngol. 2009;73(12):1639–1643. doi: 10.1016/j.ijporl.2009.08.004.
    1. Tellez DW, Galvis AG, Storgion SA, Amer HN, Hoseyni M, Deakers TW. Dexamethasone in the prevention of postextubation stridor in children. J Pediatr. 1991;118(2):289–294. doi: 10.1016/S0022-3476(05)80505-0.
    1. Anene O, Meert KL, Uy H, Simpson P, Sarnaik AP. Dexamethasone for the prevention of postextubation airway obstruction: a prospective, randomized, double-blind, placebo-controlled trial. Crit Care Med. 1996;24(10):1666–1669. doi: 10.1097/00003246-199610000-00011.
    1. Drago BB, Kimura D, Rovnaghi CR, Schwingshackl A, Rayburn M, Meduri GU, et al. Double-blind, placebo-controlled pilot randomized trial of methylprednisolone infusion in pediatric acute respiratory distress syndrome. Pediatr Crit Care Med. 2015;16(3):e74–81. doi: 10.1097/PCC.0000000000000349.
    1. Lukkassen IM, Hassing MB, Markhorst DG. Dexamethasone reduces reintubation rate due to postextubation stridor in a high-risk paediatric population. Acta Paediatr. 2006;95(1):74–76. doi: 10.1080/08035250500325066.
    1. Saleem AF, Bano S, Haque A. Does prophylactic use of dexamethasone have a role in reducing post extubation stridor and reintubation in children? Indian J Pediatr. 2009;76(5):555–557. doi: 10.1007/s12098-009-0067-4.
    1. Laham JL, Breheny PJ, Rush A. Do clinical parameters predict first planned extubation outcome in the pediatric intensive care unit? J Intensive Care Med. 2015;30(2):89–96. doi: 10.1177/0885066613494338.
    1. Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet. 1992;340(8822):745–748. doi: 10.1016/0140-6736(92)92293-O.
    1. Khemani RG, Randolph A, Markovitz B. Steroids for post extubation stridor: pediatric evidence is still inconclusive. Intensive Care Med. 2010;36(7):1276–1277. doi: 10.1007/s00134-010-1805-9.

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다