How to Prevent Edema Following an Extubation

Many intubated patients develop laryngeal edema.

Laryngeal edema affects almost 30 percent of patients following extubation, and 4 percent need to be reintubated because of it, according to a review from the Netherlands published in the 2009 issue of "Critical Care." Only some patients develop serious symptoms, and laryngeal edema usually resolves itself. Identification of risk factors, early treatment with corticosteroids and a cuff leak test can help prevent serious complications associated with edema following extubation. Epinephrine and oxygen/helium administration can also help.

Things You'll Need

• Cuff leak test equipment
• Corticosteroids
• Epinephrine
• Nebulizer
• Airway exchange catheter
• Oxygen/helium

Instructions

1. 

   Reintubation greatly increases mortality rates.

   Identify risk factors and perform a cuff leak test. Females, those with small trachea diameter, those intubated with large tubes and those intubated for a long time are all more likely to develop laryngeal edema and require reintubation. If the patient is at risk, have her exhale into a deflated cuff and measure the volume of leaked air. Record expiration over six breathing cycles and take the average of the lowest three values. Severe laryngeal edema lowers the leak volume. A positive cuff leak test with a leak volume of less than 110 ml increases the risk of reintubation.

2. 

   Corticosteroid therapy can reduce edema.

   Extubate or treat with steroids. If severe edema isn't present, the Netherlands researchers recommend going ahead with extubation. If the cuff leak test identifies severe edema, treatment with corticosteroids before extubation can help reduce swelling. Multiple doses of corticosteroids six to 12 hours before extubation helps prevent the worsening of laryngeal edema.

3. 

   Helium/oxygen mixtures experience less resistance in airways.

   Hook up the at-risk patient to an airway exchange catheter (AEC). This catheter is inserted above the intubation catheter. Although the equipment is uncomfortable, oxygen and/or helium may be administered through the catheter if serious complications develop. The AEC also helps guide reintubation catheters if necessary. A 40/60 helium/oxygen mixture will experience less resistance in the airways than oxygen-enriched air.

4. 

   Epinephrine nebulization may help reduce the need for reintubation.

   Observe the patient for one hour after extubation or after corticosteroid and AEC administration for symptoms of distress. If no signs of severe respiratory distress present themselves the extubated patient may be discharged and the AEC may be removed.

5. Administer steroids, epinephrine or oxygen and helium if adverse reactions occur and watch the patient for another hour before reintubating. Epinephrine nebulization may reduce laryngeal edema in extubated patients, although controlled clinical studies are lacking, report the Netherland scientists.

Tips & Warnings

• Tracheostomy may help at-risk patients avoid intubation-caused edema, but not enough research has been done to confirm this.

• Reducing tube size creates more complications rather than fewer in terms of edema following extubation, report the review researchers.

• There is no consensus on what an effective dosage of epinephrine is and it can cause side effects in those with coronary artery disease. Rebound edema may occur after epinephrine nebulization.

• Non-invasive positive pressure ventilation is sometimes used to help prevent reintubation, but the reviewers found increased mortality rates associated with its use.

References

• "Critical Care": Clinical review: Post-extubation laryngeal edema and extubation failure in critically ill adult patients