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#2
11.11.2008, 18:06
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Нет ли возможности выложить этот эдиторалс в полнотекстовом виде на фалообменнике ? (Сайт пароль требует)
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#3
11.11.2008, 18:15
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Published 20 October 2008, doi:10.1136/bmj.a1565
Cite this as: BMJ 2008;337:a1565 Editorials Preventing postextubation airway complications in adults Corticosteroids should be given only to patients at high risk of reintubation To receive artificial ventilation for acute respiratory failure adult patients usually have an endotracheal tube placed through the mouth and larynx into the upper trachea. Although initially life saving, the endotracheal tube causes mechanical irritation of the larynx and trachea, which in turn may cause inflammation and oedema. Infected oral secretions pooling in the larynx above the cuff of the endotracheal tube will exacerbate the inflammation. While present the endotracheal tube acts as a stent, but when it is removed these processes may narrow the upper airway, leading to symptoms and signs of upper airway obstruction and at worst the need for reintubation. In the linked meta-analysis (doi:10.1136/bmj.a1841), Fan and colleagues assess whether steroids are effective in preventing postextubation laryngeal oedema and reducing the need for subsequent reintubation of the trachea in critically ill adults.1 The scale of the problem is difficult to assess, because estimates of the incidence of signs or symptoms of upper airway obstruction after extubation vary from 2.3% in unselected ventilated patients2 to 22% in those ventilated for more than 36 hours,3 and estimates of reintubation rates vary from 1% of all patients2 to 19% of patients with evidence of laryngeal oedema before extubation.4 However, even if the risk in the general population in intensive care is small, the problem remains clinically important, as reintubation distresses patients, stresses staff, and carries a risk of increased mortality independent of the patient’s severity of illness.5 In an attempt to reduce the risk of reintubation, corticosteroids are sometimes prescribed to reduce upper airway oedema before extubation. The use of corticosteroids in this context is certainly plausible. Postmortem studies have found oedema, inflammatory changes, and neutrophil infiltrates caused by endotracheal intubation, and these effects have been shown to be reduced by corticosteroids in experimental studies.6 In vivo corticosteroids also produce a time dependent and dose related reduction in airway oedema (as assessed by the size of the leak of ventilator gas around the endotracheal tube during inspiration when the sealing cuff is deflated4). However, whether reducing laryngeal oedema with corticosteroids causes an overall benefit to the patient remains contentious. A recent systematic review based on five clinical trials and 1873 patients concluded that corticosteroids did not significantly alter reintubation rates in adults and so their use was not recommended.7 Fan and colleagues’ review includes an additional 80 patients from another study and comes to a very different conclusion, suggesting that corticosteroids markedly reduce reintubation rates (odds ratio 0.29, 95% confidence interval 0.15 to 0.58).1 The difference in results comes from a combination of the new data, and a careful selection of the "most appropriate" data from the five other studies. Where possible, Fan and colleagues included only patients who needed reintubation for laryngeal oedema and excluded those who were reintubated for other reasons, who would not respond to corticosteroids and who would dilute any effect. This selection allowed them to use a less conservative (fixed effects) model than that used in the previous review.7 However, the authors note the possibility of publication bias and that most of the studies did not report an intention to treat analysis, both of which can lead to an overestimation of treatment effects. Because corticosteroids are potent drugs with a range of side effects, and even brief courses are harmful in critically unwell patients with head injuries (probably by mechanisms unrelated to the head injury),8 a closer examination of the balance between risks and benefits is warranted before acting on their conclusion that multiple dose steroids reduce reintubation rates. Given these concerns and the difference in the results of the two meta-analyses, it may be prudent to give steroids only to patients at high risk of reintubation, a view reinforced by Fan and colleagues’ analysis of this subgroup. Although factors identified as increasing the risk of reintubation include female sex,2 3 short stature, admission after trauma,3 and (in some studies) prolonged intubation,2 arguably the most useful way to assess the risk of reintubation is to measure the leak around the deflated endotracheal tube cuff; a value of 18% or less of tidal volume or an absolute value of 110 ml per breath carry the best predictive power for the occurrence of laryngeal oedema.4 More sophisticated studies are needed to determine whether steroids usefully alter a patient’s overall course after extubation. These should probably only enrol patients at high risk; use multiple dose regimens given sufficiently early before extubation to have an effect; and be analysed on an intention to treat basis using patient centred and institution centred outcomes, such as duration of artificial ventilation, length of stay in the intensive care unit or hospital, and mortality. These trials need to be large to produce a reliable estimate of effect and to detect infrequent but serious complications of steroids. A major practical barrier exists to undertaking this research and to using corticosteroids clinically to reduce reintubation rates. To pretreat patients with corticosteroids assumes extubation is a predictable event,9 or that the intensive care unit has sufficient capacity to delay extubation for 12-24 hours after a successful trial of spontaneous breathing while the corticosteroids take effect. Neither assumption may be the case for most intubated patients in intensive care. Cite this as: BMJ 2008;337:a1565 Duncan Young, consultant in intensive care medicine, Peter Watkinson, consultant in intensive care medicine 1 Intensive Care Society Trials Group, Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Oxford OX3 9DU [Ссылки доступны только зарегистрированным пользователям ] Research, doi:10.1136/bmj.a1841 -------------------------------------------------------------------------------- Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed. References Fan T, Wang G, Mao B, Xiong Z, Zhang Y, Liu X, et al. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials. BMJ 2008;337:a1841.[Abstract/Free Full Text] Darmon JY, Rauss A, Dreyfuss D, Bleichner G, Elkharrat D, Schlemmer B, et al. Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study. Anesthesiology 1992;77:245-51.[CrossRef][ISI][Medline] Francois B, Bellissant E, Gissot V, Desachy A, Normand S, Boulain T, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet 2007;369:1083-9.[CrossRef][ISI][Medline] Cheng KC, Hou CC, Huang HC, Lin SC, Zhang H. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients. Crit Care Med 2006;34:1345-50.[CrossRef][ISI][Medline] Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998;158:489-93.[Abstract/Free Full Text] Biller H, Harvey J, Bone R. Laryngeal edema: an experimental study. Ann Otol Rhinol Laryngol 1970;79:1084-7.[ISI][Medline] Markovitz BP, Randolph AG, Khemani RG. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev 2008;(2):CD001000. Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, et al. Effect of intravenous corticosteroids on death within 14 days in 10 008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004;364:1321-8.[CrossRef][ISI][Medline] Siegel MD. Prevention of postextubation laryngeal oedema. Lancet 2007;370:25.
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#4
11.11.2008, 18:59
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Спасибо. Мы, кстати, что-то подобное уже здесь обсуждали :
http://forums.rusmedserv.com/showthread.php?t=31504
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Линейный вид
