Prophylactic Corticosteroids Decrease Stridor and Reintubation in High-risk Extubations

by Joseph Esherick, M.D., FAAFP, FHM

The overall incidence of extubation failure is about 15%, but this failure rate may be increased in patients with high risk characteristics.  Patients who have prolonged mechanical ventilation, those with high cuff pressures, poor cuff leaks, and those who have had neck surgery or neck trauma are at increased risk of post-extubation stridor and reintubation.  A poor cuff leak has been described either as a cuff leak less than 25% of the tidal volume or less than 110 mL in different studies.  In these patients, administration of prophylactic corticosteroids may decrease the incidence of post-extubation laryngeal edema and consequently decrease the rate of reintubation.

This meta-analysis and systematic review examined 11 randomized controlled trials that examined the efficacy of prophylactic steroids given prior to elective extubations in nearly 2,500 patients.  The trials were heterogeneous in terms of the timing of steroid administration and the type and amount of steroid administered.  All of the trials gave steroids at least 4 hours prior to extubation but some gave steroids for a full 24 hours prior to extubation.  The amount of steroid administered prior to extubations ranged from 100 mg hydrocortisone equivalents to 1,000 mg hydrocortisone equivalents.  The average amount of steroid given was 400 mg hydrocortisone equivalents (or dexamethasone 16 mg).

The study found that prophylactic corticosteroids reduced the rate of post-extubation airway events (RR=0.43) and decreased the rate of reintubation (RR = 0.42).  The number needed to treat (NNT) to prevent one reintubation was 16.  There was no significant increase in adverse events such as infection or GI bleed.

A poor cuff leak test seemed to be the best indicator of those ventilated patients at high risk for extubation failure.

Prophylactic steroids for patients on Mechanical ventilation

Kuriyama, A et al. Prophylactic Corticosteroids for Prevention of Postextubation Stridor and Reintubation in Adults: A Systematic Review and Meta-analysis. CHEST 2017; 151(5): 1002-1010.