Steroids May Prevent Extubation Failure in Children—Or May Not Be Necessary

NASHVILLE—Administration of prophylactic steroids to pediatric patients at high risk for extubation failure may be a safe and cost-effective practice, contended James D. Fortenberry, MD, during a pro/con debate at the Society of Critical Care Medicine’s 2009 Critical Care Congress. However, Louis Brusco, Jr, MD, argued that edema in the airway associated with difficult intubation is caused by trauma rather than inflammation, and thus would not be helped by steroids.

HIGH RISK MAY JUSTIFY USE

More so than in adults, the rate of extubation failure is high in children, said Dr. Fortenberry, Director of Critical Care Medicine (Pediatrics) at Emory University and Medical Director of Critical Care and Pediatric ECMO (Extracorporeal Membrane Oxygenation) and System Clinical Research at Children’s Healthcare of Atlanta. Patients at high-risk of extubation failure would seem to be good candidates for prophylactic steroids; however, the definition of high-risk varies between studies.

In a meta-analysis of three studies of neonates, the data showed no benefit overall for routine steroid use prior to extubation. However, for neonates in the high-risk group, defined as having experienced multiple manipulations of the airway and failed extubations, steroids conferred a 17% absolute risk reduction of reintubation.

Benefit for children might be extrapolated from a recent meta-analysis of six studies by Fan et al that involved more than 1,900 adult patients. Steroid use was associated with a significant decrease in laryngeal edema and in reintubation overall. In contrast to patients in older meta-analyses, patients in the newer studies were more likely to be high-risk, and to have received multiple doses initiated six to 12 hours before extubation, rather than single doses initiated an hour before extubation, he observed.

Due to the relative lack of pediatric data, it has been harder to find a benefit of prophylactic steroids in children, Dr. Fortenberry pointed out. In one older trial that excluded patients considered to be at high risk, there was no benefit from steroid use and even a trend toward increased risk of extubation failure. In another study, which included patients at high risk (eg, with airway anomalies or airway trauma), steroid use was associated with a significant decrease in stridor and reintubation.

Dr. Fortenberry noted that steroids are not associated with significant adverse affects and that the cost of therapy is low in comparison with a day of mechanical ventilation in the pediatric ICU.

INFLAMMATION OR TRAUMA?

Dr. Brusco, Assistant Professor of Clinical Anesthesiology at Columbia University in New York City, acknowledged that steroid therapy is inexpensive and that the concern about decreasing the chances of extubation failure is understandable—particularly for nonsurgical patients—considering that there is a chance of edema even with a routine intubation. However, “treating every difficult intubation with prophylactic steroids still doesn’t make sense to me,” he asserted.

Of the meta-analysis by Fan et al cited by Dr. Fortenberry, Dr. Brusco argued that the inclusion of one study in particular skewed the results toward showing a benefit of steroid use, even though the results of the studies overall were evenly split (ie, three showed benefit and three did not).

Dr. Brusco pointed out that even a small amount of edema in the narrow airway of the trachea or in the area of the vocal chords could be dangerous. “But most difficult intubations do not touch the vocal chords or the trachea any more than a successful intubation might.” He defined a difficult intubation as one that involves “multiple attempts at laryngoscopy that are traumatic.”

Local tissue damage to the hypopharynx caused by the laryngoscope is not caused by inflammatory reaction—which can be treated with steroids—but rather such phenomena as soft tissue edema and bleeding into tissues. In view of the fact that the hypopharynx has a much larger area than does the trachea or the vocal cords, physicians need to assess whether intubation attempts cause inflammatory edema that is clinically significant in the hypopharynx, vocal cords, and trachea.

Dr. Brusco concluded that there is a difference between the difficult laryngoscopy with an easy passage of the endotracheal tube—which would not necessarily require prophylactic steroids—and the difficult intubation with multiple laryngoscopies, multiple attempts to pass the endotracheal tube, and use of a Miller blade—which may.

—Adriene Marshall

Suggested Reading
Fan T, Wang G, Mao B, et al. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomized placebo controlled trials. BMJ. 2008;337:a1841

Return to table of contents