Do steroids prevent reintubation in children with laryngotracheobronchitis?

Abstract

Classic laryngotrachoebronchitis (LTB) is an inflammatory process, with oedema and secretions that involve the entire laryngotracheobronchial tree. The severity of lower airway disease in African children with LTB has previously been documented. The aim of the present study was to determine whether steroids prevent reintubation in African children with classic LTB. = 0.06) in the univariate analysis (odds ratio 1.00-1.14), but showed no statistically significant difference in multivariate analysis. Of the variables used as predictors of reintubation, none acted either as a preventive factor or as a risk factor. The present results suggest that steroids should not be recommended at any stage in treatment of intubated patients with classic LTB. Prospective studies should evaluate the major risk factors for reintubation: duration of intubation, trauma to the airway at intubation and during ICU stay, and dose and timing of steroids. They should also evaluate whether upper airway disease is present alone or in association with lower airway disease.

Background:

Classic laryngotrachoebronchitis (LTB) is an inflammatory process, with oedema and secretions that involve the entire laryngotracheobronchial tree. The severity of lower airway disease in African children with LTB has previously been documented. The aim of the present study was to determine whether steroids prevent reintubation in African children with classic LTB.

Method and results:

= 0.06) in the univariate analysis (odds ratio 1.00-1.14), but showed no statistically significant difference in multivariate analysis. Of the variables used as predictors of reintubation, none acted either as a preventive factor or as a risk factor.

Conclusion:

The present results suggest that steroids should not be recommended at any stage in treatment of intubated patients with classic LTB. Prospective studies should evaluate the major risk factors for reintubation: duration of intubation, trauma to the airway at intubation and during ICU stay, and dose and timing of steroids. They should also evaluate whether upper airway disease is present alone or in association with lower airway disease.

Introduction

]. Also, the most clinically important end-point for intubated LTB patients is reintubation. The higher rate of airway complications that occur after extubation in children may be accounted for by their smaller airway diameter.

]. No study has as yet documented the effectiveness of steroids in African children with classic LTB.

ratio, pneumonia, atelectasis) were also analyzed.

Statistical analysis

< 0.05 was considered statistically significant.

Results

ratio on admission was grade 3 (range grades 1-3) and the median number of days intubated was 9 (range 1-38).

The overall mortality of the group as a whole was approximately 3.66% (three out of 82 patients). All of these patients died after extubation. The cause of death in two of these patients was septic shock, with underlying malnutrition. Both of these patients were recovering from measles acquired in the preceding 2 weeks. One of these patients was given steroids. The third patient had a cardiorespiratory arrest, which was sudden and unexpected. No immediate cause was identified. This patient did not receive any steroids.

).

= 0.88 and 0.64, respectively). The negative B coefficient for steroids suggested that the greater the steroid use, the more likely it was that reintubation would be required. This trend is not surprising in the malnourished, septic child who embarks on a course of steroids, and whose disease process is potentially aggravated.

ratio, which together indicate infection and lower airway disease, suggest a greater likelihood of reintubation in the presence of these factors, although none of these associations was statistically significant. This tendency is to be expected in sick, intubated children.

Frequency distribution of steroid intake.

Estimated coefficients, odds ratios and 95% confidence intervals for predictors of reintubation in univariate logistic regression

CI, confidence interval; OR, odds ratio.

Estimated coefficients, odds ratios and 95% confidence intervals for predictors of reintubation in multivariate logistic regression

= 0.25). CI, confidence interval; OR, odds ratio.

Discussion

] stated that the dose of prednisolone used in their study, although less than the suggested ideal, was nevertheless effective. The mean dose of dexamethasone in the present study of 0.4 mg/kg was therefore acceptable. However, the lack of standardization of steroids with respect to timing of onset of use, the dose used and the types used are major limitations to this study.

Steroids were shown to have no effect alone or in association with other variables in preventing reintubation. Of the variables used as predictors of reintubation, none acted either as a preventive or as a risk factor.

The natural history of classic LTB is different from that of laryngotracheitis. Apart from significant lower airway disease, a major factor is that patients with LTB have endotracheal tubes in place for a longer period, and are therefore at risk of ongoing upper airway inflammation and nosocomial infection. The fact that steroids did not alter the frequency of reintubation in classic LTB does not proscribe against their use in patients with laryngotracheitis as the primary diagnosis on admission to hospital.

ratio, were shown to have no effect on the incidence of reintubation. In the present group of patients, it is probable that these factors in combination rendered steroid use non-beneficial, by acting as cocontributors to lower airway pathology. Steroids would not be expected to be of benefit in such a group.

] designed a prospective study model in laryngotracheitis and steroid usage, and outlined all areas of controversy.

The major limitations of the present study are that the timing of onset of steroid use varied, the dose of steroids was not standardized, different types of steroids were used, and the duration of steroid use differed. Prospective studies should evaluate carefully the major risk factors for reintubation, including the following: duration of intubation; trauma at time of intubation and during ICU stay; dose of steroids; and timing of steroids. They should also evaluate what particular subset of patients is involved with respect to upper airway involvement. The use of the term croup should be avoided as it is often used interchangeably to describe distinctly different clinical entities. The side effects of acute steroid therapy should also be documented. Every effort should be taken to prevent nosocomial infection and maintain proper airway care (humidification and proper sedation to minimize airway trauma), because these factors may act as confounding variables for reintubation. In addition, the degree of airway leakage should be standardized, because this may further act as a confounding variable for reintubation. Tracheal aspirates at the time of intubation should be routinely examined because bacterial isolates may predict the lack of response to steroids or the need for earlier antibiotic therapy.

The results of the present retrospective study suggest that steroids may not be beneficial in the treatment of African patients who are intubated for classic LTB. A prospective randomized controlled trial needs to be undertaken in this particular population group to support these findings.

Keywords

• croup
• laryngotracheobronchitis
• reintubation
• risk factors
• steroids