Aerosolized L-epinephrine vs Budesonide for Post-extubation Stridor: A Randomized Controlled Trial.

Objective: To compare the efficacy and adverse effects of aerosolized L-epinephrine vs budesonide in the treatment of post-extubation stridor. Study design: Randomized controlled trial. Setting: Pediatric intensive care unit (PICU) of a tertiary teaching and referral hospital. Subjects: Sixty two patients with a stridor score ≥4 following extubation. Intervention: Patients were randomized to receive either aerosolized L-epinephrine (n=32) or budesonide (n =30). Respiratory rate, heart rate, stridor score, blood pressure and oxygen saturation were recorded from 0 min to 24 hours. Outcome measures: Stridor score remaining at ≥4, need for re-nebulization and re-intubation between 20 min –24 hours were primary outcome measures. Tachycardia (HR > normal for age), hypertension (BP >95th centile for age) and hypoxia (SpO2 <92% for 5 min) were secondary outcome measures. Results: Both drugs showed a significant and comparable decline in the median (95% CI) stridor scores from baseline to 60 min [4 (4.10-4.50) to 2.00 (1.46-2.67) for budesonide vs 4 (4.12-5.00) to 2.00 (1.31 -2.75) for epinephrine]. At 2 hours, the stridor scores were significantly lower in the epinephrine as compared to budesonide group [0.00 (0.69-1.81) vs 3.00(1.75-3.32); P =0.02)]. However, the proportion of patients with stridor score ≥4 at any time between 20min-24 hrs (53.3% vs 53.1%; P=0.99), need for renebulization (40 % vs 43.8 %; P=0.76) and re-intubation (20% vs 25%, P=0.638), and adverse effects were similar in both groups. Conclusions: Both aerosolized L-epinephrine and budesonide were equally effective in their initial therapeutic response in post-extubation stridor. However, epinephrine showed a more sustained effect.