12-Hour Pretreatment With Methylprednisolone Versus Placebo for Prevention of Postextubation Laryngeal Oedema: A Randomized Double-Blind Trial
B. François, E. Bellissant, V. Gissot, A. Desachy, S. Normand, T. Boulain, O. Brenet, P.M. Preux, P. Vignon, and For Association des Re´animateurs du Centre-Ouest (ARCO)
(Lancet, 369:1083-1089, 2007)
Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France.
The efficacy of corticosteroids in reducing the incidence of postextubation laryngeal edema is controversial. The investigators sought to test their hypothesis that methylprednisolone started 12 hours before a planned extubation could prevent postextubation laryngeal edema. They conducted a placebo-controlled, double-blind multicenter trial in 761 adults in intensive care units. Patients who were ventilated for more than 36 hours and underwent a planned extubation received 20 mg methylprednisolone (n = 380) IV or placebo (n = 381) 12 hours before extubation and every 4 hours until tube removal. The primary end point was occurrence of laryngeal edema within 24 hours of extubation. Laryngeal edema was clinically diagnosed and deemed serious if tracheal reintubation was necessary. Analyses were done on a per protocol and intention-to-treat basis. Sixty-three patients could not be assessed, predominantly because of self-extubation (n = 16) or cancelled extubation (n = 44) between randomization and planned extubation. Six hundred ninety-eight patients were analyzed (343 in the placebo group, 355 in the methylprednisolone group).
Methylprednisolone markedly decreased the incidence of postextubation laryngeal edema [11 of 355 (3%) vs. 76 of 343 (22%), P < 0.0001], the global incidence of reintubations [13 of 355 (4%) vs. 26 of 343 (8%), P = 0.02], and the proportion of reintubations secondary to laryngeal edema [1 of 13 (8%) vs. 14 of 26 (54%), P = 0.005]. One patient in each group died after extubation, and atelectasis occurred in 1 patient given methylprednisolone.
The investigators concluded that methylprednisolone started 12 hours before a planned extubation substantially decreased the incidence of postextubation laryngeal edema and reintubation. Such pretreatment should be considered in adult patients before a planned extubation that follows a tracheal intubation of more than 36 hours.