Laryngeal air column width ratio in predicting postextubation stridor

Background Cuff leak test (CLT) has been used widely to assess upper airway patency before extubation but with low positive predictive value. Aim To assess the diagnostic accuracy of the airway column width ratio (ACWR) in predicting postextubation stridor (PES). Patients and methods 50 Patients who intubated >24 hours were observed for postextubation stridor and reintubation. Laryngeal ultrasound was done to measure the ACW with ETT cuff deflated immediately after intubation and 3–4 h before extubation. Cuff leak test was done. Results Fifty patients were included with mean age 58 ± 14.71 years, 68% were males and 32% were females. PES developed in 8% of patients. There was highly statistically significant difference between both groups regarding ACW before extubation and ACW ratio (p-value =0.006 and 0.000 respectively). The mean ACW ratio in stridor group (0.79 ± 0.03) was significantly lower than in non-stridor group (0.94 ± 0.04). Reintubation was higher in stridor group (100%) than non-stridor group (23.9%), P = 0.001. There was statistically significant higher duration of mechanical ventilation in stridor group (7.50 ± 0.58 vs. 4.23 ± 2.50 days, P = 0.013). A cut off point of ACW ratio ≤0.81 has a sensitivity 100% and Specificity 100%. Conclusion ACW showed excellent utility in prediction of patients with PES. Air column width ratio of ≤ 0.81 was a good predictor of PES.

Implementation of a Clinical Pathway to Reduce Rates of Postextubation Stridor

Background Unsuccessful extubation is associated with increased intensive care unit and hospital length of stays, hospital costs, morbidity, and mortality. The most common cause of reintubation is laryngeal edema, often evidenced by postextubation stridor. Objective To reduce the rates of postextubation stridor and reintubation in the neurocritical care unit at a large urban academic medical center. Methods A clinical pathway was created to aid in detecting patients expected to experience postextubation stridor and to guide prophylactic treatment. During the 12-week implementation phase, the pathway was completed on all intubated patients daily. Results The 12-week trial included a total of 606 days of mechanical ventilation. Checklists were completed for 531 days, a compliance rate of 88% for use of the clinical pathway. Of the 56 patients who were extubated during the trial, 54 had a checklist completed, for 96% compliance on the day of extubation. Outcomes after all nonpalliative extubations (n = 43) during the 12 weeks before and after implementation of the pathway (n = 56 periods) were evaluated by using χ2 tests. Implementation of the pathway was associated with a significant reduction in rates of postextubation stridor (χ2 = 6.2; P = .01), reintubation (χ2 = 5.5; P = .02), and reintubation due to postextubation stridor (χ2 = 8.3; P = .004). Conclusion The clinical pathway implemented in the neurocritical care unit was safe and effective in reducing rates of reintubation and reintubation due to postextubation stridor.

Stridor after Extubation

Postextubation stridor arises from glottic and subglottic edema caused by ischemia of the tracheal mucosa from pressure by the endotracheal tube. Multiple risk factors have been described; preventive measures include appropriate tube sizing, air leak tests, administration of steroids, and smooth airway management techniques, such as atraumatic intubation. When stridor does occur, cool humidified air as well as racemic epinephrine may be used as treatment. The patient is safe for discharge once symptoms have dramatically improved and the window for potential “rebound effect” from racemic epinephrine has passed with no further stridor.