A 30-year-old female with a past medical history of moderate persistent asthma, substance abuse disorder, and allergic rhinitis was brought to the emergency department (ED) by paramedics after being found down in a subway station surrounded by empty medication bottles and was noted to have needle tracks on her arms. In the ED, she was intubated for airway protection with a 7.0 endotracheal tube. She was then admitted to the ICU where her toxicology panel was positive for cocaine, oxycodone, and methadone. Her mental status improved over the next 72 hours, and she was converted from volume control ventilation to pressure support. She was able to tolerate pressure support 5/5 with an FiO2 of 0.30, a respiratory rate of 18, and tidal volume of 600 mL. Given her clinical improvement, the team contemplated extubation. Prior to extubation, her endotracheal cuff is deflated. The discrepancy between her inspiratory and expiratory volumes is less than 110 mL, but no audible cuff leak is appreciated.
What is the next most appropriate step?
A. Extubate the patient as she was intubated for less than 72 hoursCorrect Answer: D
The decision to test for an endotracheal cuff leak is controversial. Endotracheal intubation can lead to laryngeal edema and has been associated with an incidence of postextubation stridor that is 6% to 37%. The American Thoracic Society Guidelines indicate that a “cuff-leak” test to evaluate for laryngeal edema should only be performed in high-risk patients. High-risk patients are defined as those with traumatic intubation, intubation >6 days, large endotracheal tube, those who have been repeatedly reintubated and extubated, and women. This patient’s largest risk factor is her gender. The guidelines then go on to recommend repeating a cuff-leak test if the initial testing demonstrated an absent leak. If no leak is present on the repeat testing, steroids are recommended. Lee et al. performed a randomized control trial of patients with less than 110 mL difference between inspiratory and expiratory volumes. Patients in the treatment arm received dexamethasone 5 mg q6h for 24 hours Cuffleak volumes were checked every 6 hours, and the change in volumes in the steroid group demonstrated significant improvement within the first 6 hours with little additional benefit after.
References: