What is the management for post-extubation stridor?

Management of Post-Extubation Stridor

Inhaled epinephrine should be used as first-line treatment for post-extubation stridor in conscious patients, followed by systemic corticosteroids if symptoms persist. 1, 2

Assessment and Diagnosis

• Post-extubation stridor affects 1-30% of extubated patients, typically presenting within minutes following extubation 1

• Risk factors include:

  • Female sex
  • Prolonged intubation (>48 hours)
  • Traumatic or difficult intubation
  • Large endotracheal tube size
  • High cuff pressures
  • Nasal intubation
  • Non-elective intubation 2, 3

• The cuff leak test should be performed before extubation in high-risk patients:

  • A leak <110 ml or <10% of tidal volume indicates high risk
  • Good specificity (92%) but moderate sensitivity (56%) 2

Treatment Algorithm

1. First-Line Treatment

• Nebulized epinephrine (L-epinephrine 1% solution or racemic epinephrine 2.25%)
  • Both formulations are equally effective 4
  • Effects last 30 minutes to 2 hours, requiring continuous monitoring
  • May need repeated doses 1, 2

2. Second-Line Treatment

• Systemic corticosteroids
  • Dexamethasone IV (>0.3 mg/kg)
  • Continue for at least 48 hours
  • Reduces reintubation rates (5.8% vs 17.0%) 2

3. Adjunctive Measures

• Heliox (helium-oxygen mixture)
  • Reduces stridor scores and respiratory distress
  • Particularly useful in pediatric patients 5
• Continuous positive airway pressure (CPAP)
  • Apply with 100% oxygen using reservoir bag and facemask
  • Ensure upper airway patency 1

4. For Refractory Cases

• Larson's maneuver:

  • Place middle finger of each hand between posterior mandible border and mastoid process
  • Displace mandible forward in jaw thrust
  • Apply deep pressure to relieve laryngospasm 1

• Reintubation if respiratory failure develops:

  • Consider propofol (1-2 mg/kg IV) for early laryngospasm
  • Suxamethonium (1 mg/kg IV) for severe cases with total cord closure 1

Prevention

• Prophylactic corticosteroids:

  • Administer to high-risk patients with positive cuff leak test
  • Start at least 6 hours before extubation, preferably 12-24 hours
  • Multiple doses are more effective than single doses 2, 6

• Preventive measures:

  • Use appropriate tube size (typically 8mm for men, 7mm for women)
  • Minimize intubation duration
  • Monitor and regulate cuff pressure 1

Monitoring and Follow-up

• Close observation for at least 24 hours after treatment

• Warning signs requiring immediate attention:

  • Worsening stridor
  • Increased work of breathing
  • Oxygen desaturation
  • Agitation 1

• Consider otolaryngology consultation for:

  • Persistent stridor despite treatment
  • Need for reintubation
  • Suspicion of structural laryngeal injury 2

Differential Diagnosis

Be aware of other causes of post-extubation stridor:

• Paradoxical vocal cord movement (more common in young females)
• Tracheal pseudomembranes (rare but life-threatening) 7
• Aspiration of blood clots
• Laryngospasm 1, 2

Special Considerations

• In pediatric patients, particularly infants:
  • Higher risk of post-extubation stridor
  • ETT size selection is critical (4.0 ETTs associated with higher risk than 3.5 ETTs) 3
  • Multiple doses of corticosteroids may be beneficial in high-risk neonates 6

Remember that post-extubation stridor is a potentially life-threatening condition requiring prompt recognition and treatment. Always have equipment for difficult airway management readily available when managing these patients.