Episode 6- Can we use corticosteroids to reduce reintubation rates?

Hello and welcome back to ER-Rx. In this episode, we will go over the use of corticosteroids given to mechanically-ventilated patients to reduce the risk of reintubation. Further, we will talk about who should get them as well as which agent, which dose, and which frequency is best. As a little bit of background, laryngeal edema, as evidenced by post-extubation stridor, is one cause of extubation failure that can lead to reintubation. Reintubation prolongs mechanical ventilation and ICU durations, both of which have been shown to increase morbidity, mortality, and cost. One surrogate for the presence of laryngeal edema is the cuff leak test. During a cuff leak test, the team will deflate the cuff of the endotracheal tube to verify that gas is able to move around the tube. If not, or if we have a negative cuff leak test, this suggests the presence of laryngeal edema. Keep in mind that the cuff leak test isn’t perfect, and many patients without a cuff leak may still be safely extubated. Also, ideally, we should only do this test on high-risk patients, and we’ll talk more on this later. This is where corticosteroids come in. Corticosteroids have historically been used to decrease laryngeal edema so that we can avoid post-extubation stridor and reintubation.

To answer the questions above, we turn to a study published in 2017 by Kuriyama, et al. They ran a meta-analysis and systematic review to assess the efficacy of prophylactic corticosteroids (compared to placebo or standard cares) to prevent post-extubation stridor and reintubation in mechanically-ventilated adults. This study looked at 11 trials with over 2000 patients. So, which agents were used in the trials that composed the meta-analysis? Five studies used dexamethasone, four used methylprednisolone, and two used hydrocortisone. Which doses and which frequencies were used? Trials included in this meta-analysis used both single and multi-dose regimens. Single dose regimens included methylprednisolone 40 mg IV plus 40 mg IM 30 minutes prior to extubation, dexamethasone 8 mg IV 60 minutes prior to extubation, and hydrocortisone 100 mg IV 60 minutes prior to extubation. Multi-dose regimens included methylprednisolone 20-40 mg IV given every 4-6 hours x 4 doses, with the last injection just before extubation, or they use dexamethasone 5 mg IV every 6 hours x 4 doses with the last dose 24 hours prior to extubation. The pattern is that in the multi-dose regimens, the corticosteroid was usually given at least 12 hours before extubation and repeated almost every half-life. However, in a regression analysis, the authors found no effect on the total dose given, the total number of doses given, or the time from the first dose to extubation. And this makes sense because steroids work quickly, so there’s no need to wait 12-24 hours after the last dose to extubate. Also, it doesn’t make much sense pharmacokinetically to re-dose some of these agents. For example, dexamethasone has a long biological half-life of around 48 hours, and methylprednisolone has a biological half life of about 24 hours. Therefore, one dose should be plenty.

To answer the last and most important question of, “who should get corticosteroids to reduce the risk of reintubation”, we have to return to the cuff leak test. Per the American Thoracic Society and American College of Chest Physicians joint guideline, we should only perform the cuff leak test in high risk patients, meaning patients at high risk of reintubation. In high risk patients with no cuff leak, the guidelines recommend a 1 x dose of a steroid, for example you can use 40-60 mg of IV methylprednisolone, or 4-8 mg IV of dexamethasone, and then extubate the patients 4-6 hours after the dose. The authors also recommend not rechecking the cuff leak after giving the steroids and waiting the 4-6 hours because the cuff leak test has only been validated prior to giving steroids. Also, I have to reiterate that the cuff leak test itself is not a perfect test nor a requirement for extubation; it is simply a risk stratification tool.

Going back to our meta-analysis, the authors found that prophylactic corticosteroids significantly reduced the incidence of post-extubation airway events as well as reintubation by about 57%. However, this effect was most pronounced in patients deemed to be at high risk of reintubation, and they were identified as being high risk in the first place through a negative cuff leak test. The authors state that the routine administration of corticosteroids before extubation is not recommended. All in all, corticosteroids should ideally only be given to patients who are at high risk for failing extubation and who also have a negative cuff leak test.

In conclusion, the agent and dose that we use is largely up to the team. But, the dose of the corticosteroid should at least mimic the doses that were studied in published trials. In patients who are at high risk of reintubation who also failed the cuff leak test, I would give 1 dose, wait 4-6 hours, then extubate. This is the practice recommended in the guidelines. Obviously practice in your ICU may vary. A more conservative option is that if the patient is high risk of reintubation with no cuff leak, and the provider is okay with leaving the patient intubated for another day, we can give them the multi-dose 24 hour regimens of your chosen corticosteroid and attempt extubation the next day. In patients who are at low risk of reintubation, ideally, we would not check the cuff leak test nor give a corticosteroid prior to extubation.

As always, thank you so much for your time. Please remember to subscribe to our podcast and check out our website at errxpodcast.com