Introduction
The recent article by Feng et al. has drawn attention to the management of intubation and extubation in the field of critical care anesthesia (1). The article reviews some random control trials on the effect of different types of hormones on the prevention of post-intubation extubation stridor and reintubation. Using the PICOS principle, all relevant literature was reviewed and analyzed, then summarized for each trial. A net meta-analysis was performed to evaluate the quality of the articles and a subgroup analysis was attempted, resulting in 11 RCTs being included. The results of the study showed the superiority of using cortisol.
Discussion
In our clinical work, especially in tonsil and adenoidectomies in children, we have observed that many patients present with post-extubation stridor. So this side effect caught our attention. Through a brief literature search, we learned of the earlier and more frequent use of hormones to prevent the onset of this side effect. This team's meta-analysis of the literature did a good job of summarizing the results of the research over time and effectively demonstrated that hormones are a more effective means of relief.
However, it is unfortunate that the type of disease the patient has is not well-defined in this article. Regarding hormonal prevention of post-extraction stridor, most of them are still focused on the patients in the intensive care unit, and only this study by Amoozadeh and Beigmohammadi suggests the effect of hormones before extubation in general anesthesia procedures (2). We made the following list of relevant postoperative extubation stridor after a literature search (Table 1).
Table 1
| Intervention | Dose | Route of administration | n | Primary author | Age | Type of surgery and technique | Anesthetic details | Time range | Type of research | Hospital and country |
|---|---|---|---|---|---|---|---|---|---|---|
| Supine/ prone | / | / | 242 | Xiang (3) | NA | ERCP | NA | NA | A randomized controlled trial | NA |
| Supine/ lateral | / | / | 92 | Jung (4) | 3–12 yr | NA | NA | NA | A randomized clinical trial | Yungpook National University; Korea |
| Albuterol spray | 2 puffs | inhaled | 120 | Maddah (5) | 52.34 ±8.95 yr | NA | NA | In 2021 | A bouble-blind randomized clinical trial | 5 Azar Educational Hospital in Gorgan; Northern Iran |
| Dexamethasone | 8 mg TID first 24 h; 4 mg BID next 24 h | iv | 110 | Amoozadeh (2) | 52.1 ± 14.1 yr | Neck surgery | NA | April 2021 to July 2021 | An observational prospective cohort study | Imam Khomeini Hospital's; Iran |
| Remifentanil/ ambroxol hydrochloride/ budesonide suspension | Remifentanil/ 0.5 μg/g; ambroxol 15 mg hydrochloride; budesonide suspension 0.5 mg | iv/ inhaled | 46 | Yang (6) | NA | Removing the tonsil under general anesthesia and adenoidectomy under nasal endoscope | NA | NA | A randomized clinical trial | Cangzhou Central Hospital; China |
| Tracheal tubes | / | / | 2246 | Weiss (7) | 1.93 (1.48) yr in the cuffed and 1.87 (1.45) yr in the uncuffed | ENT, Head surgery, Cleft, Thoracic, Abdominal, Laparoscopy, Urology, Limb, Cardiac catheterization, Gastroenter, Radiology, and Others | NA | NA | A prospective, randomized, controlled multi-center trial | University Children's Hospital Zurich; 24 European pediatric anesthesia centers; Switzerland |
| Bloodletting acupuncture | / | / | 60 | Saghaei (8) | 33.8 (18.6); 38.37 (15.5) (month) | Scheduled for elective surgery | Atropine 10 μg.kg−1; Midazolam 25–100 μg.kg−1; thiopental 5 mg.kg−1; Fentanyl 1 μg.kg−1; Succinylcholine 2 mg.kg−1; halothane | NA | A double-blind, randomized trial | NA |
| Cuffed vs. uncuffed endotracheal intubation | / | / | 40 | Nishat (9) | 3–10 yr | Oral surgeries, | Sevoflurane | February to December 2019 | A randomized controlled study | NA |
| Lidocaine | topical 4 mg/kg of 2%; intravenous 1 mg/kg of 2% iv | / | 134 | Koç (10) | 7.1 ± 1.7; 6.7 ± 1.3 yr; 7.6 ± 2.4 yr; 6.3 ± 0.8 yr | Tonsillectomy and/or adenoidectomy | Atropine, 0.015 mg/kg, meperidine, 1 mg/kg; gas mixture of N2O, O2, and halothane | NA | A randomized controlled trial | NA |
| Dexmedetomidine | Dexmedetomidine 2.0 μg/kg | im | 100 | Ambesh (11) | 35.64 ± 14.93 yr; 38.08 ± 12.58 yr | Laminectomy for PIVD | Midazolam (0.05 mg/kg); Propofol (1.5–2.0 mg/kg); fentanyl (2.0 μg/kg); Vecuronium bromide (0.12 mg/kg), mixture of 50% air in oxygen and isoflurane (1%). | September 2014 to September 2016 | A double blind placebo controlled study | Departm NA Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow |
| Sealing cuff pressure | / | / | 60 | Al-Metwalli (12) | 8.35 ± 1.63 yr; 8.45 ± 1.76 yr; 8.2 ± 1.54 yr | Dental surgery | N2O free general anesthesia; 0.2 mg/kg oral diazepam; fentanyl 2 μg/kg and propofol 2.5 mg/kg. | NA | A prospective controlled, randomized, blinded study. | NA |
| Flexible laryngeal mask | / | / | 90 | Naguib (13) | 3.24 ± 0.857 yr; 3.13 ± 0.815 yr | NA | Atropine 0.01 mg/kg; Fentanyl 1 μg/kg; Sevoflurane 3.5% in oxygen to air of 1:1 | July 2018 to April 2019. | A randomized trial | Department of Pediatric Surgery, Tanta University Hospitals; Egypt |
The review of prophylaxis of post-extubation stridor.
In addition, we also noted that some of the differences in the induction and maintenance of anesthesia may also affect the extubation of patients, such as dexmedetomidine (11). Feng's et al. also pointed out that some of the data in the literature is missing and incomplete, and we believe that this part of the data is also often a relatively critical part of the data that affects the results, for example, the use of some sedative and antagonistic drugs (1). It is hoped that there will be a careful description of randomized controlled trials in the future, which will also help us to have a more comprehensive and accurate understanding of drug efficacy.
At the same time, we found two studies on extubation position and bloodletting acupuncture interesting, both of which showed that extubation in the lateral position may reduce the probability of postoperative dyspnea (3, 4, 8).
Statements
Author contributions
YS: Writing – original draft. HZ: Funding acquisition, Writing – review & editing. YM: Writing – original draft. YA: Funding acquisition, Supervision, Writing – review & editing.
Funding
The author(s) declare financial support was received for the research, authorship, and/or publication of this article. The research received the grant from the Youth Science Fund Program of National Natural Science Foundation of China (NSFC) (No. 82202366).
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1.
FengIJLinJ-WLaiC-CChengK-CChenC-MChaoC-Met al. Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis. Front Med. (2023) 10:1135570. 10.3389/fmed.2023.1135570
2.
AmoozadehLBeigmohammadiMT. The effect of dexamethasone on the reduction of airway edema and the success of extubation in patients with head and neck surgery admitted to the intensive care unit. Tehran Univ Med J. (2022) 80:128–34. Available online at: https://www.embase.com/search/results?subaction=viewrecord&id=L2019206701&from=export
3.
XiangJ-HWeiPZhangY-JLiL-LLiXWangJet al. Safety of prone emergence from general endotracheal anesthesia in patients undergoing ERCP: a randomized controlled trial. Surg Endosc. (2023) 37:7493–501. 10.1007/s00464-023-10187-7
4.
JungHKimHJLeeY-CKimHJ. Comparison of lateral and supine positions for tracheal extubation in children : a randomized clinical trial. Anaesthesist. (2019) 68:303–8. 10.1007/s00101-019-0590-2
5.
MaddahSABarzegariA. The effect of albuterol spray on hypoxia and bronchospasm in patients with chronic obstructive pulmonary disease (COPD) under general anesthesia: a bouble-blind randomized clinical trial. Ethiop J Health Sci. (2023) 33:491–8. 10.4314/ejhs.v33i3.12
6.
YangQLiuZHChangYL. Clinical research on airway intervention before tracheal extubation after general anesthesia on snoring children. Eur Rev Med Pharmacol Sci. (2017) 21:109–13.
7.
WeissMDullenkopfAFischerJEKellerCGerberACEuropean Paediatric Endotracheal Intubation StudyGroup. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth. (2009) 103:867–73. 10.1093/bja/aep290
8.
SaghaeiMRazaviS. Bloodletting acupuncture for the prevention of stridor in children after tracheal extubation: a randomised, controlled study. Anaesthesia. (2001) 56:961–4. 10.1046/j.1365-2044.2001.02228.x
9.
NishatMAhmadKTabassamSDurraniNAul HaqUul HaquF. Comparison of cuffed vs Uncuffed endotracheal intubation efficacy in cleft palate surgery procedure in children. Pak J Med Health Sci. (2021) 15:2379–81. 10.53350/pjmhs211592379
10.
KoçCKocamanFAygençEOzdemCCekiçA. The use of preoperative lidocaine to prevent stridor and laryngospasm after tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg. (1998) 118:880–2. 10.1016/S0194-5998(98)70290-6
11.
AmbeshSPDubeyM. Effect of intramuscular dexmedetomidine administration before extubation on post-extubation haemodynamics, postoperative sedation, and analgesic requirements: a double blind placebo controlled study. Asian J Anesthesiol. (2021) 59:102–10. 10.6859/aja.202109_59(3).0004
12.
Al-MetwalliRRSadekS. Safety and reliability of the sealing cuff pressure of the Microcuff pediatric tracheal tube for prevention of post-extubation morbidity in children: a comparative study. Saudi J Anaesth. (2014) 8:484–8. 10.4103/1658-354X.140856
13.
NaguibTMAhmedSA. Evaluation of flexible laryngeal mask airway(®) in tongue trauma repair: a randomized trial. Anesth Pain Med. (2019) 9:e92929. 10.5812/aapm.92929
Summary
Keywords
corticosteroids, extubation, stridor, commentary, meta-analysis
Citation
Sun Y, Zhao H, Ma Y and An Y (2023) Commentary: Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis. Front. Med. 10:1289321. doi: 10.3389/fmed.2023.1289321
Received
05 September 2023
Accepted
01 November 2023
Published
17 November 2023
Volume
10 - 2023
Edited by
Zhongheng Zhang, Sir Run Run Shaw Hospital, China
Reviewed by
Lei Zhao, Capital Medical University, China
Updates
Copyright
© 2023 Sun, Zhao, Ma and An.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Youzhong An 2211110449@stu.pku.edu.cn
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.