Steroids to prevent post extubation stridor and reintubation

Kuriyama A, Umakoshi N, Sun R published a systemic review and meta- analysis of recent trials regarding use of steroids to prevent post extubation stridor and reintubation.

BACKGROUND

Earlier meta-analysis of trials of steroids by Fan T et el, Jaber S et el , Khemani RG et el and McCaffrey J et el suggested the potential of corticosteroids to prevent post-extubation stridor and reintubation. Since the publication of these meta- analysis, newer trials were published. This meta-analysis looks at the new trials. 

PATIENTS/TRIALS 

11 parallel randomized controlled trials were selected involving 2472 participants for analysis. The mean age of participants was 61.9 years (range 39.6–74), and 47% of these were female. The median sample size was 128 (range 71–700). Two trials were conducted in medical ICUs, one in a surgical ICU, and eight in mixed (medical and surgical) ICUs.  Six trials were performed in Taiwan, three in France and one each in China and Pakistan.

SELECTION OF HIGH RISK PATIENTS

Patients who were on mechanical ventilation, high risk patients were selected based on cuff-leak volume <24% of tidal volume during inflation, or a cuff-leak volume <110 mL.

INTERVENTION

Five trials used dexamethasone (8mg IV 60 minutes before extubation, 5mg IV q6hrs for 24 hours before extubation ), four trials used methylprednisolone (40 mg IV and 40mg IM 30 min before extubation or 20-40mg IV q6hrs for 24 hours before extubation) and two hydrocortisone(100mg IV 1hr before extubation). Four trials used a single steroid dose, and four used four doses. One trial compared the use of one or two administrations of the same dosage, one trial compared one versus four administrations of the same dosage, and one trial compared four administrations of different dosages.

RESULTS

Use of prophylactic corticosteroids was associated with a reduced incidence of post-extubation airway events [risk ratio (RR) 0.43, 95% CI 0.29–0.66] and reintubation (RR 0.42, 95% CI 0.25–0.71) compared with placebo or no treatment. This association was prominent in participants at high risk for developing post-extubation airway complications, defined using cuff-leak test, with a reduced incidence of post-extubation airway events (RR 0.34,
95% CI 0.24–0.48) and reintubation (RR 0.35, 95% CI 0.20– 0.64). Rare adverse events.