Post-extubation stridor in intensive care unit patients - Risk factors evaluation and importance of the cuff-leak

Objective: To evaluate the incidence and identify factors associated with the occurrence of post-extubation stridor and to evaluate the performance of the cuff-leak test in detecting this complication. Design: Prospective, clinical investigation. Setting: Intensive care unit of a university hospital. Patients: Hundred twelve extubations were analyzed in 112 patients during a 14-month period. Intervention: A cuff-leak test before each extubation. Measurements and results: The incidence of stridor was 12%. When we chose the thresholds of 130 ml and 12% to quantify the cuff-leak volume, the sensitivity and the specificity of the test were, respectively, 85% and 95%. The patients who developed stridor had a cuff leak significantly lower than the others, expressed in absolute values (372 +/- 170 vs 59 +/- 92 ml, p < 0.001) or in relative values (56 +/- 20 vs 9 +/- 13%, p < 0.001). Stridor was associated with an elevated Simplified Acute Physiology Score (SAPS II), a medical reason for admission, a traumatic or difficult intubation, a history of self-extubation, an over-inflated balloon cuff at admission to ICU and a prolonged period of intubation. These results provide a framework with which to identify patients at risk of developing a stridor after extubation. Conclusion: A low cuff-leak volume (< 130 ml or 12%) around the endotracheal tube prior to extubation is useful in identifying patients at risk for post-extubation stridor.