Endotracheal intubation is frequently complicated by
laryngeal edema, which may present as postextubation
stridor or respiratory difficulty or both. Ultimately, postextubation
laryngeal edema may result in
respiratory failure with subsequent reintubation. Risk factors for postextubation
laryngeal edema include female gender, large tube size, and prolonged intubation. Although patients at low risk for postextubation
respiratory insufficiency due to
laryngeal edema can be identified by the cuff leak test or laryngeal ultrasound, no reliable test for the identification of high-risk patients is currently available. If applied in a timely manner, intravenous or nebulized
corticosteroids can prevent postextubation
laryngeal edema; however, the inability to identify high-risk patients prevents the targeted pretreatment of these patients. Therefore, the decision to start
corticosteroids should be made on an individual basis and on the basis of the outcome of the cuff leak test and additional risk factors. The preferential treatment of postextubation
laryngeal edema consists of intravenous or nebulized
corticosteroids combined with nebulized
epinephrine, although no data on the optimal treatment algorithm are available. In the presence of
respiratory failure, reintubation should be performed without delay. Application of
noninvasive ventilation or inhalation of a
helium/
oxygen mixture is not indicated since it does not improve outcome and increases the delay to intubation.