Repeated Doses of Steroid and Earlier Intervension before Extubation Decreased Laryngeal Edema during Extubation Oberved by Repeated Cuff Leak Tests-Two Cases Report, a Review and a New Theory

以cuff leak test發現早期及反覆類固醇投予改善長期插管病患之喉部水腫－兩病例報告，回顧及一個新的理論

呂云傑(Yun-Chieh Lu)

《東港安泰醫護雜誌》 12卷2期 (2006/06) Pp. 97-103

https://doi.org/10.7078/TSMHMNJ.200606.0097

摘要

拔除氣管內管併發喉部水腫可引起喘鳴，甚至於呼吸衰竭。Cuff leak test已被報告為一有助於預測拔管後喘鳴的方法。而類固醇，研究顯示有助於預防兒童拔管後喘鳴的發生，但在成人，其效用仍未確立。
回顧此三篇成人研究，我們發現，此間所使用之類固醇剤量可能太小且用得太晚。去年我們曾提出一個新的觀察方式，以多次cuff leak test來看長期插管病患喉部水腫之系列變化，發現可能之剂量相關之效果。此一結果驅使我們以此方法來研究拔管前所需類固醇之剤量。
我們提出兩病例。一位八十七歲女性病例，因胃癌合併大量上腸胃道出血導致呼吸衰竭及插管，復因喉部水腫及多痰而無法拔管。我們每六小時給予靜脈注射solu-cortef 100毫克，並自首剤量之前起每六小時測量cuff leak test。結果發現病患於十二小時後可通過cuff leak test，並成功地拔管。另一位為八十五歲女性，因肺炎導致敗血症及呼吸衰竭而插管。病情穩定後亦因喉部嚴重水腫而無法拔管。經同樣剤量類固醇投予，並自首剤量之前起十七點五小時後cuff leak量達80毫升而成功拔管。
透過此病患觀察，我們發現增加類固醇剤量及及早投與，可能有效降低拔管後喉部水腫，此一論點未曾被提出過。同時將來可以此觀察模式，經大量病例，找出最適剤量及開始投與時間。

關鍵字

喉部水腫 ； 類固醇 ； cuff leak test ； 拔管

並列摘要

Postextubation laryngeal edema may cause stridor and even reintubation. Cuff leak test has been reported as a valuable method to predict Postextubation laryngeal stridor. Steroid has been reported to contribute to the prevention of post-extubation laryngeal edema in children but the studies for adults did not show significant effect.
We reviewed these studies and found the doses of steroid used may be too low and the time point of intervention may be to late. We reported a new method performing series of cuff leak tests to see the improvement of laryngeal edema when steroid was precribed in 2005 and found some possibly interesting dose-related effect on laryngeal edema. This clued us that if we prescribed more doses of steroid and prescribed them earlier, the benefit may make significance. Therefore, we planned to use this new method observing series of change of cuff leak volume with time when steroid were prescribed just before extubation.
We report two cases. The fist case is an 87 year-old female. She was admitted to our intensive care unit due to gastric cancer with acute bleeding complicated with respiratory failure. After prolonged intubation, she failed to pass cuff leak test though discontinuation from mechanical ventilation. Therefore, we prescribed steroid with intravenous solu-cortef 100 mg per six hours since sixteen hours before extubation. Cuff leak tests were performed about every six hours during the steroid administration. She was extubated successfully and we found that the volumes of cuff leak did not increase significantly until thirteen hours after steroid administered.
The second case is an 85 year-old female. She was admitted due to pneumonia with sepsis and respiratory failure. Her clinical condition improved four days later and passed the T-piece spontaneous breathing trial but failed to pass the cuff leak test. The same dose of steroid was prescribed and a modified course of series of cuff leak tests were performed. The volume of cuff leak increased markedly 17.5 hours after the first dose of steroid. She then experienced successful extubation with stridor.
Though these two cases with the new model, we suppose that more doses of steroid and earlier intervension may prevent post-extubation laryngeal edema. This point of view has never been mentioned before. If the cohort study supports it in the future, this may largely change our concept for the steroid on post-extubation laryngeal edema. The optimal time course of intervention and dose of the steroid could also be studied with this model.

並列關鍵字

laryngeal edema ； steroid ； cuff leak test ； extubation