Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults

  • Review
  • Intervention

Authors

  • Robinder G Khemani,

    Corresponding author
    1. Childrens Hospital Los Angeles, Department of Anesthesiology Critical Care Medicine, Los Angeles, California, USA
    • Robinder G Khemani, Department of Anesthesiology Critical Care Medicine, Childrens Hospital Los Angeles, 4650 Sunset Blvd Mailstop 12, Los Angeles, California, 90027, USA. rkhemani@chla.usc.edu.

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  • Adrienne Randolph,

    1. Farley 517, MICU Children's Hospital, Boston, Massachusetts, USA
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  • Barry Markovitz

    1. Childrens Hospital Los Angeles, Department of Anesthesiology Critical Care Medicine, Los Angeles, California, USA
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Abstract

Background

Post-extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re-intubation proves necessary. Some clinicians use corticosteroids to prevent or treat post-extubation stridor, but corticosteroids may be associated with adverse effects ranging from hypertension to hyperglycaemia, so a systematic assessment of the efficacy of this therapy is indicated.

Objectives

To determine whether corticosteroids are effective in preventing or treating post-extubation stridor in critically ill infants, children, or adults.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and reference lists of articles. The most recent searches were conducted in January 2011.

Selection criteria

Randomized controlled trials comparing administration of corticosteroids by any route with placebo in infants, children, or adults receiving mechanical ventilation via an endotracheal tube in an intensive care unit.

Data collection and analysis

Three review authors independently assessed trial quality and extracted data.

Main results

Eleven trials involving 2301 people were included: six in adults, two in neonates, three in children. All but one examined use of steroids for the prevention of post-extubation stridor; the remaining one concerned treatment of existing post-extubation stridor in children. Patients were drawn from heterogeneous medical/surgical populations. Dexamethasone given intravenously at least once prior to extubation was the most common steroid regimen utilized (uniformly in neonates and children). In neonates the two studies found heterogeneous results, with no overall statistically significant reduction in post extubation stridor (RR 0.42; 95% CI 0.07 to 2.32). One of these studies was on high-risk patients treated with multiple doses of steroids around the time of extubation, and this study showed a significant reduction in stridor. In children, the two studies were clinically heterogeneous. One study included children with underlying airway abnormalities and the other excluded this group. Prophylactic corticosteroids tended to reduce reintubation and significantly reduced post-extubation stridor in the study that included children with underlying airway abnormalities (N = 62) but not in the study that excluded these children (N = 153). In six adult studies (total N = 1953), the use of prophylactic corticosteroid administration did not significantly reduce the risk of re-intubation (RR 0.48; 95% CI 0.19 to 1.22). While there was a significant reduction in the incidence of post extubation stridor (RR 0.47; 95% CI 0.22 to 0.99), there was significant heterogeneity (I2=81%, X2=26.36, df=5, p<0.0001). Subgroup analysis revealed that post extubation stridor could be reduced in adults with a high likelihood of post extubation stridor when corticosteroids were administered as multiple doses begun 12-24 hours prior to extubation compared to single doses closer to extubation; the test for interaction for multiple versus single doses indicated RRR 0.22 (95% CI 0.10 to 0.47) for stridor with multiple doses. Side effects were uncommon and could not be aggregated.

Authors' conclusions

Using corticosteroids to prevent (or treat) stridor after extubation has not proven effective for neonates or children. However, given the consistent trends towards benefit, this intervention does merit further study, particularly for high risk children or neonates. In adults, multiple doses of corticosteroids begun 12-24 hours prior to extubation do appear beneficial for patients with a high likelihood of post extubation stridor.

摘要

糖皮質激素(類固醇)對於拔管後產生喘鳴的新生兒、孩童與成人的預防和治療

背景

拔管後喘鳴(Post-extubation stridor)可能會延長病人待在重症加護病房的時間,特別容易發生在病人有嚴重的呼吸道阻塞,或是必須要重新插管的病人身上。有些臨床醫師會使用類固醇來預防或是治療拔管後喘鳴這種症狀。 但是投與類固醇可能會產生一些副作用例如:高血壓、高血糖等等。因此,對於做此種治療方法的療效需要全面性的評估。

目的

確立類固醇是否真的對預防或治療新生兒、孩童或成人發生嚴重拔管後喘鳴的症狀。

搜尋策略

我們搜尋了Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE 並參考了一系列的文章。 最近一次完成的研究是在2011年1月。

選擇標準

藉由隨機對照試驗(Randomized controlled trials, RCTs)比對在重症照護病房中經由氣管插管以進行機械性換氣的新生兒、孩童或成人間,經由各種給藥途徑投與類固醇與安慰劑的結果。

資料收集與分析

三位回顧作者獨立工作以評估試驗品質並回收數據。

主要結果

總共有11個試驗,2301名參與受試者: 其中有6項成人試驗、2項新生兒試驗與3項孩童試驗。全部的試驗中,有一項試驗是觀測拔管後喘鳴的預防,另一項試驗則是觀測正在發生拔管後喘鳴的孩童患者。受試者是從混合的醫藥/手術患者群中挑選出來的。 最常使用的類固醇療法是拔管前至少給予一劑由靜脈注射的Dexamethasone(新生兒與孩童給予方式一樣)。在新生兒的兩項試驗中有相異的結果: 在降低拔管後喘鳴的症狀並沒有顯著差異。(RR 0.42%;95% CI 為0.07到2.32) 其中一項研究是對在拔管時產生症狀的高風險患者投與多次劑量類固醇,而這項研究結果有明顯降低喘鳴的風險。 而在孩童的兩項實驗是臨床上異質性。其中一項研究的孩童有潛在性呼吸道異常情況而另一項研究則排除了這類病人。預防性給予類固醇傾向於降低再插管並明顯降低研究中有潛在呼吸道異常孩童發生拔管後喘鳴的症狀,(N=62)但是對另一組已排除此類患者的孩童沒有效果(N=153) 在六項成人研究中(總N=1953),預防性投與類固醇並沒有顯著降低再插管的風險(RR=0.48;95%CI為0.19到1.22)。但是,卻能有效降低發生拔管後喘鳴的發生率(RR=0.47;95%CI為0.22到0.99),這裡有著顯著的異質性(I2=81%, X2=26.36, df=5, p<0.0001) 由亞群體分析顯示,比起在拔管前只投與單次劑量藥品,在拔管前12至24小時投予多次劑量類固醇,可以降低拔管後喘鳴的成人患者的發生率。這個試驗中比較多次劑量與單次劑量 RRR=0.22(95%CI為0.10到0.47),喘鳴需使用多次劑量,其副作用很罕見,無法收集數據。

作者結論

使用類固醇以預防(或治療)新生兒、孩童拔管後喘鳴症狀的效果並未受到證實。然而,從利益的觀點來看,這項治療方法值得更深一步的探討,特別是具有高風險的孩童或新生兒。以成人來說,拔管前12至24小時投與多次劑量的類固醇明顯有利於發生高機率拔管後喘鳴的患者。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw

Plain language summary

Does taking inhaled steorids either before or after being intubated (having a tube down the throat to help you breathe) prevent the painful swelling that can result?

When people in intensive care need assistance breathing, they may need to have a breathing tube inserted down through their windpipe (trachea or airway - the passage to the lungs). After it is taken out (extubation), the airways can be swollen (inflamed). This swelling can make it hard to breathe, cause stridor (noisy breathing), and the tube may need to be replaced. Corticosteroids are anti-inflammatory drugs that might reduce this swelling. The review of 11 trials involving 2301 people found that using corticosteroids to prevent (or treat) stridor after extubation has not been proven overall effective for babies or children, but this intervention does merit further study particularly for those at high risk to fail extubation. For high risk adults, multiple doses of corticosteroids begun 12-24 hours before extubation appear to be helpful.

淺顯易懂的口語結論

請問在插管 (有一個管子延伸至喉嚨下以幫助呼吸) 前或後服用吸入性類固醇是否可以預防疼痛腫脹的產生?

在加護病房中的重症病人需要外力輔助呼吸,他們需要置入一個管子通過其氣管(氣管或呼吸道-通往肺部的途徑)。當這支管子被移除後(拔管),呼吸道可能產生腫脹(發炎反應),這種腫脹會導致病人呼吸困難,產生喘鳴(呼吸時發出雜音),這時候可能需要重新插管,而類固醇這種抗發炎藥物則可以幫助消除紅腫。回顧這11份試驗總計2301位受試者我們發現,新生兒或孩童投與類固醇以預防(或治療)拔管後喘鳴的效果並未受到全面性的證實,但這個治療方法仍值得被進一步研究。 而對於高風險的成人患者,拔管前12至24小時給予多劑量類固醇有利於減少拔管後喘鳴的發生。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw