Post-Extubation stridor (PES)

[Natascha Pramhofer]

Dear colleagues,

do you see post-extubation stridor regularly at your NICU? We recently had 2 quite severe cases of late preterm babies who at that time already were around 40+0 and that only had been on the ventilator for a few hours (1 for minor surgery and 1 for an MRI). They were treated with nebulized adrenaline and corticosteroids and luckily got better pretty fast. How do you treat it? Do you have any protocol on that and do you have a protocol or guideline on how to prevent it like some of our PICU colleagues (i.e. https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared Documents/Post Extubation Stridor UHL Childrens Intensive Care Guideline.pdf )?

Thank you in advance!

[Francesco Cardona]

Unfortunately we have seen a few cases, including some that needed further operations by our ENT. We think we see it more often with cuffed tubes we sometimes use (esp. for patients undergoing surgery). We treat if symptoms or if intubation was difficult and we fear swelling, mostly dexamethasone or prednisolone. Most resolves within 6h.

[bimalc]

On 4/24/2021 at 12:08 PM, Natascha Pramhofer said:

They were treated with nebulized adrenaline and corticosteroids and luckily got better pretty fast. How do you treat it?

Same as you, for the most part. Keys in my view are:

1) Anticipation of risk factors (length of intubation, cuffed tube, lack of leak, parenchymal lung disease which may make the child more prone to struggle with even transient upper airway narrowing, etc)

2) Early recognition/treatment with nebulized Epi and Steroids as well as consideration of heliox as a further temporizing measure until steroids can kick in

3) Shared mental model with frontline staff that re-intubation may be more challenging and/or need to happen fairly expeditiously if the airway cannot be preserved non-invasively

[Bernhard Bungert]

1. Anticipation: a. Was Intubation difficult? B. Is there a measurable Leak before extubation?  C. Cuffed tube. D. Longtime Ventilation. 

2. Preparation A. And or C and or D pos: Steroid 1 hr before Extraktion.

Always prepared for reintubation: stuff, medication, Equipment.

Take Extubation seriously as Intubation.