What are the risk factors for the development of post-extubation stridor? Briefly outline the treatment of post extubation-stridor.
1) Duration of IPPV > 5 days
2) Traumatic or difficult intubation
3) Prior history of self extubation
4) Trauma, surgery or infection of upper airways
5) History of agitation
6) Female sex
7) High BMI
8) Over inflated cuff
9) Older age group
10) Elevated APACHE
11) Low GCS
12) Large ETT size
1) Adrenaline nebs: constrict arterioles, reduce oedema, useful in acute stridor.
2) Steroids: May be more useful in prevention rather than treatment, commenced 12 hr prior to extubation (recent Lancet paper). Also useful in children
3) CPAP – relief of symptoms, reduction in work of breathing (needs to be done with caution)
4) Heliox – improved patient comfort, shown to reduce need for intubation
5) If all above fail, endotracheal intubation and ventilation
A good article is available which details the predictors of stridor following intubation. Another specifically addresses the risk factors for laryngeal oedema and failure of extubation. The last one also contains a discussion of all the management strategies listed in the college answer.
Risk factors for post-extubation stridor
Management of post-extubation stridor
Jaber, Samir, et al. "Post-extubation stridor in intensive care unit patients."Intensive care medicine 29.1 (2003): 69-74.
Efferen, L. S., and A. Elsakr. "Post-extubation stridor: risk factors and outcome." Journal of the Association for Academic Minority Physicians: the official publication of the Association for Academic Minority Physicians 9.4 (1997): 65-68.
Wittekamp, B. H., et al. "Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients." Crit Care 13.6 (2009): 233.
Pluijms, Wouter A., et al. "Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review." Critical Care 19.1 (2015): 1-9.