From the Guidelines
Post extubation laryngeal edema is best treated with corticosteroids, particularly dexamethasone, which should be initiated at least 6 hours before extubation to reduce the risk of subglottic upper airway obstruction (UAO) and potentially decrease extubation failure. The treatment approach should prioritize the administration of systemic corticosteroids to prevent subglottic UAO after extubation, as suggested by recent guidelines 1. For adults, dexamethasone 4-8 mg IV every 6-8 hours for 24-48 hours is recommended, while for children, dexamethasone 0.5-0.6 mg/kg/day divided into 4 doses is appropriate. Some key points to consider in the management of post extubation laryngeal edema include:
- The use of racemic epinephrine via nebulization (0.5 mL of 2.25% solution diluted in 3 mL normal saline) for rapid but temporary relief through vasoconstriction in moderate to severe cases.
- Humidified oxygen therapy to maintain mucosal hydration and reduce irritation.
- Heliox (helium-oxygen mixture) may be used in severe cases to reduce airflow turbulence and work of breathing.
- Positioning patients upright to optimize airway patency and reduce edema.
- Close monitoring is essential, with preparation for possible reintubation in severe cases that don't respond to treatment. The most recent and highest quality study suggests that the timing of corticosteroid administration is crucial, with at least 6 hours before extubation being optimal, and higher doses may be preferable if this time window is not available 1. Additionally, guidelines recommend the use of a cuff leak test to predict the occurrence of laryngeal edema after extubation, particularly in patients with risk factors for inspiratory stridor 1. Early treatment is crucial as laryngeal edema can rapidly progress to complete airway obstruction. It is also important to note that maintaining a head-up position and avoiding unnecessary positive fluid balances can help reduce airway swelling, and intravenous corticosteroids for at least 12 hours in high-risk patients may reduce airway edema, post-extubation stridor, and reintubation rates 1. Overall, the management of post extubation laryngeal edema requires a multifaceted approach that includes the use of corticosteroids, racemic epinephrine, humidified oxygen therapy, and careful patient positioning and monitoring.
From the Research
Post Extubation Laryngeal Edema Treatment
- The treatment of post extubation laryngeal edema involves the use of corticosteroids, such as dexamethasone, to reduce inflammation and swelling in the larynx 2, 3, 4, 5.
- Nebulized epinephrine may also be used in combination with corticosteroids to help reduce swelling and improve breathing 3, 4.
- In severe cases of post extubation laryngeal edema, reintubation may be necessary to secure the airway and ensure adequate oxygenation 3, 4.
- The use of non-invasive positive pressure ventilation is not recommended as it may delay reintubation and worsen outcomes 3, 4.
- Helium/oxygen mixture inhalation is also not indicated as it does not improve outcomes and may delay reintubation 3.
Prevention of Post Extubation Laryngeal Edema
- The administration of multiple doses of dexamethasone before extubation has been shown to reduce the incidence of postextubation stridor and laryngeal edema in adult patients at high risk 5.
- A cuff leak test can be used to identify patients at low risk for postextubation respiratory insufficiency due to laryngeal edema, but no reliable test is available to identify high-risk patients 3.
- The decision to start corticosteroids should be made on an individual basis, taking into account the outcome of the cuff leak test and additional risk factors 3.