Intubation is required for patients whose airways are damaged or who are unable to breathe spontaneously. Such a condition can happen for various reasons, including cardiac arrest, airway obstruction, loss of consciousness or low consciousness, injury or trauma to the neck, and respiratory failure or apnea. This situation is also induced when patients need to have surgery under general anesthesia. [2] However, intubation comes with its own set of risks. For example, intubation may lead to airway irritation and narrowing, which can cause difficulty breathing after the procedure. Corticosteroids may be used alongside intubation to reduce risks and improve patient comfort.
Extubation (or the process of removing intubation) following prolonged intubation comes with the risk of post-intubation tracheal stenosis, or the narrowing of the airways. While this is a relatively rare side effect, tracheal stenosis can be quite severe, often increasing the amount of time the patient must stay in the Intensive Care Unit and sometimes requiring reintubation. Thus, many practitioners seek to prevent the risk of stridor when intubation is necessary. [3]
One preventative measure commonly employed during intubation is the use of corticosteroids for their anti-inflammatory properties, with the prevalent method being the intravenous injection of dexamethasone. In 2009, a meta-analysis of various randomized controlled trials of patients who were given corticosteroids prior to extubation was conducted and found that, while there was not significant evidence to show that this technique was effective in neonates or children, there was a significant improvement in preventing re-intubation and post-intubation stridor in adults when multiple doses of corticosteroid were administered 12-24 hours prior to extubation. The authors emphasized that the dosage and timing of this intervention was critical, as a single dose of corticosteroid administered prior to extubation did not appear to have these preventative qualities. It was also deemed critical to recognize that corticosteroids were not a good solution to the dilemma of possible tracheal stenosis in neonate and pediatric patients, as in this case the patients would be subject to the possible adverse side effects of medicine while not receiving significant benefit. [4] (Side effects of corticosteroids can be quite severe, ranging from hyperglycemia, to osteoporosis and fractures, to psychiatric episodes, to cardiovascular issues.) [5]
A recent (2023) review article in compared the efficacy of various corticosteroids in the prevention of post-extubation re-intubation and stridor. Through this meta-analysis, Feng et al. found that methylprednisolone and dexamethasone are the most potent in preventing these undesirable post-extubation outcomes. [6] In contrast, they found that hydrocortisone (a corticosteroid commonly found in topical form to prevent swelling and itchiness in skin conditions [7]) was not effective in this regard. [6] With these most recent results in mind, physicians can better mitigate the risk of post-intubation inflammatory side effects with corticosteroids, and the medical field as a whole will be able to set standards for what such preventative practices should look like.
References
(1) Intubation: When Needed, Benefits, and Risks. https://www.healthline.com/health/intubation#when-needed.
(2) Intubation: Purpose, Procedure and Potential Risks. https://my.clevelandclinic.org/health/articles/22160-intubation.
(3) De, S.; De, S. Post Intubation Tracheal Stenosis. Indian Journal of Critical Care Medicine 2008, 12 (4), 194–197. https://doi.org/10.4103/0972-5229.45081.
(4) Markovitz, B.; Randolph, A.; Khemani, R. G. Corticosteroids for the Prevention and Treatment of Post-Extubation Stridor in Neonates, Children and Adults. In Cochrane Database of Systematic Reviews; The Cochrane Collaboration, Ed.; John Wiley & Sons, Ltd: Chichester, UK, 2008; p CD001000.pub2. https://doi.org/10.1002/14651858.CD001000.pub2.
(5) Hodgens, A.; Sharman, T. Corticosteroids. In StatPearls; StatPearls Publishing: Treasure Island (FL), 2023.
(6) Feng, I.-J.; Lin, J.-W.; Lai, C.-C.; Cheng, K.-C.; Chen, C.-M.; Chao, C.-M.; Wang, Y.-T.; Chiang, S.-R.; Liao, K.-M. Comparative Efficacies of Various Corticosteroids for Preventing Postextubation Stridor and Reintubation: A Systematic Review and Network Meta-Analysis. Front. Med. 2023, 10, 1135570. https://doi.org/10.3389/fmed.2023.1135570.
(7) Hydrocortisone (Topical Application Route) Side Effects – Mayo Clinic. https://www.mayoclinic.org/drugs-supplements/hydrocortisone-topical-application-route/side-effects/drg-20073814.