Nebulized Fluticasone for Preventing Postextubation Stridor—Is It Really Effective?

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I read with interest the study published in the recent issue of Pediatric Critical Care Medicine by Prasertsan et al (1) evaluating the efficacy of nebulized fluticasone in reducing the occurrence of postextubation stridor. However, I have few concerns which need further clarification. Nebulized epinephrine was administered to patients with modified Westley Croup Score (mWCS) higher than 4 and repeated every 30 minutes if the score remained more than 4. If so, the mWCS being significantly higher in the placebo group compared with the fluticasone group (median [interquartile range], 4 [3–5] vs 2 [0–4]; p = 0.04 and 4.5 [1.5–7.3] vs 0.5 [0–2.3]; p = 0.02 at 30 min and 60 min, respectively) (Fig. 2 in [1]) should have received a higher number of doses of epinephrine nebulization. On the contrary, the fluticasone group ended up receiving significantly higher number of doses of epinephrine compared with placebo (2.5 [1–3] vs 1 [1–2]); p value equals to 0.055 in the overall group and in the subgroup requiring emergency intubation (2.5 [1–3] vs 2 [1–2]). An observer bias or calculation error could explain this phenomenon.
Time to first dose of epinephrine and time to start noninvasive positive pressure ventilation favored fluticasone group compared with placebo ([52 (30–315) vs 30 (20–170); p = 0.163] and [180 (52–470) vs 60 (50–195); p = 0.265], respectively), though it did not reach a statistical significance. A shorter duration of intubation, and effective management strategies with dexamethasone, epinephrine nebulization, and noninvasive positive pressure ventilation leading on to an overall lower occurrence rate of stridor could possibly explain the inability to prove a clear superiority of fluticasone over placebo.

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