extubating patient without cuff leak

  • decadron 10 mg q8 hours x24 hours
  • keeping cuff deflated to avoid any additional trauma from cuff pressure

This patient with respiratory failure has recovered from her acute critical illness and is ready for extubation according to the unit ventilator liberation protocol, yet because of the absence of a cuff leak (ie, a failed cuff leak test), she is at risk for reintubation owing to upper airway obstruction, presumably caused by laryngeal edema. However, the cuff leak test is an imperfect predictor of extubation failure, and there are major risks associated with unnecessary prolongation of invasive mechanical ventilation. Given this, and on the basis of a synthesis of existing evidence, American Thoracic Society (ATS)/American College of Chest Physicians (CHEST) guidelines recommend using cuff leak tests only to guide decision-making in patients who are at higher risk for postextubation stridor. These risk factors include longer duration of intubation (>6 days), being female, or previous unplanned extubation. The patient in this case has two well-documented risk factors for laryngeal edema (being female and 10 days of intubation). Thus, it is most appropriate to acknowledge the cuff leak test results in this case, and the failed cuff leak test should not be disregarded.

In a meta-analysis of randomized trials, administering systemic corticosteroids in patients with failed cuff leak tests reduces the rate of reintubation and postextubation stridor. On the basis of these results, the ATS/CHEST clinical practice guidelines recommend administering systemic corticosteroids at least 4 h before extubation in patients who are at high risk and have a failed cuff leak test. In addition to corticosteroids, careful planning for a potential reintubation and a difficult airway should take place before extubation, with appropriate operators and supplies.

These ATS/CHEST guidelines also state that a repeat cuff leak test is not necessary to determine extubation candidacy after the administration of corticosteroids, again owing to the risk of unnecessarily prolonged intubation. Furthermore, choice B is also incorrect because this patient should receive corticosteroids, and delaying an otherwise appropriate extubation for 24 h to repeat the cuff leak test is not necessary. Although the exact timing of extubation after the administration of corticosteroids remains unclear, the ATS/CHEST guidelines recommend that extubation is delayed for at least 4 h after administration of corticosteroids.

The most likely cause of this patient’s failed cuff leak test is laryngeal edema, and she has no other signs of airway obstruction distal to the endotracheal tube. Thus, bronchoscopic evaluation through the endotracheal tube is not likely to provide any meaningful information that will aid in the treatment of this patient. In addition, flexible bronchoscopic airway inspection of the larynx would be highly limited in the context of orotracheal intubation and is unlikely to inform decisions about extubation.123

Footnotes

  1. SEEK Questionnaires ↩

  2. Girard TD, Alhazzani W, Kress JP, et al; ATS/CHEST Ad Hoc Committee on Liberation from Mechanical Ventilation in Adults. An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols, ventilator liberation protocols, and cuff leak tests. Am J Respir Crit Care Med. 2017;195(1):120-133. PubMed ↩

  3. Kuriyama A, Umakoshi N, Sun R. Prophylactic corticosteroids for prevention of postextubation stridor and reintubation in adults: a systematic review and meta-analysis. Chest. 2017;151(5):1002-1010. PubMed ↩