Manejo del fracaso de la extubación en la unidad de terapia intensiva pediátrica / Management of extubation failure in the pediatric intensive care unit / Gestão de falha de extubação na Unidade de Terapia Intensiva Pediátrica

El fracaso de la extubación es la incapacidad de tolerar el retiro del tubo endotraqueal con necesidad de reintubación. Puede ser causada por la obstrucción de la vía aérea superior y por la aspiración o la incapacidad de manejar las secreciones, factores que se evidencian al retirar el tubo. La reintubación por fracaso respiratorio post-extubación debe ser evitada en lo posible, ya que aumenta el riesgo de neumonía asociada al respirador, la estancia hospitalaria y en terapia intensiva, y la morbimortalidad. Describimos el manejo del fracaso de la extubación de causa laríngea en la Unidad de Terapia Intensiva de un hospital pediátrico.

Extubation failure is the inability to tolerate removal of the endotracheal tube with subsequent reintubation. It can be caused by obstruction of the upper airway and aspiration or inadequate clearance of airway secretion, factors that become evident when removing the tube. Reintubation due to postextubation respiratory failure should be avoided if possible because it increases the risk of ventilator associated pneumonia, hospital and intensive care unit stay, and morbidity and mortality. We describe the management of failed extubation due to laryngeal cause in the Intensive Care Unit of a pediatric hospital.

Falha de extubação é a incapacidade de tolerar a remoção do tubo endotraqueal na necessidade de reintubação. Ela pode ser causada por obstrução das vias aéreas superiores e aspiração ou incapacidade para lidar com secreções, factores que são evidentes para remover o tubo. Reintubação devido a insuficiência respiratória pós-extubação deve ser evitada, se possível, porque aumenta o risco de pneumonia associada à ventilação mecânica, permanência hospitalar e terapia, morbidade e mortalidade. Nós descrevemos a gestão de extubação falhou devido à causa da laringe na Unidade de Terapia Intensiva de um hospital pediátrico.

Role of dexamethasone for prevention of post-extubation airway obstruction in critically ill adult patients

To evaluate whether dexamethasone started 24 hours prior to planned tracheal extubation in adults, can prevent post-extubation laryngeal oedema. Randomized placebo-controlled double-blind trial. Department of Anaesthsiology, Surgical ICU and Pain Management, Jinnah Postgraduate Medical Centre Karachi, from August 2006 to July 2008. Ninety-two patients who met weaning criteria after being intubated for more than 48 hours, with a cuff leak volume [CLV] of less than 110 ml were randomly allocated to two groups; receive either intravenous dexamethasone [5 mg] or identical volume of intravenous placebo [normal saline], and continued every six hours thereafter, for a total of four doses [total dose 20 mg] on the day preceding extubation. Cuff leak volume was measured at the time of the first injection, and one hour after each injection and 24 hours after the last injection. Patients were extubated twenty-four hours after the last injection of dexamethasone or identical volume of intravenous placebo. Occurrence of stridor was noted within 48 hours of extubation. Dexamethasone injection 24 hours prior to extubation increased the CLV significantly [P=0.001]. Post-extubation stridor was 54.6% significantly lower in the dexamethasone group than in placebo group [6/46 versus 15/46, P=0.025]. Dexamethasone given every six hours intravenously, commencing 24 hours before a planned tracheal extubation, substantially reduced the incidence of post-extubation stridor and re-intubation, in adult patients at high risk for post-extubation laryngeal oedema, as identified by the cuff leak test