Comparison of Cuff Leak Test, Laryngeal Ultrasonography, and Videolaryngoscopy for the prediction of post-extubation stridor

Rubina Khullar Mahajan, Apoorva Gupta, Parshotam Lal Gautam, Gunchan Paul, Vikalp Khatri

Abstract

Background and Aims

Post-extubation stridor (PES) leading to reintubation is a frequent complication of endotracheal intubation. This study was done to evaluate the sensitivity, specificity, predictive values, and diagnostic accuracy of the cuff leak test (CLT), laryngeal ultrasound (LUS), and videolaryngoscopy (VL) for the prediction of PES.

Material and Methods

This prospective, observational study was conducted on 80 adult patients intubated for at least 24 hours. Within 6 hours before extubation, CLT and LUS were done, with the endotracheal tube cuff inflated and deflated. Cuff leak volume (CLV), leak volume fraction ratio (LVFR), and airway column width difference (ACWD) were noted. The grade of peri-laryngeal edema was noted with VL. Statistical analysis was performed using the Chi-square test and Mann-Whitney U test.

Results

After extubation, patients were divided into two groups: PES (n=23, 28.8%) and non-PES (n=57, 71.25%). Reintubation rate was 100%, for those with PES, whereas the was no reintubation in those with no PES. CLV <245 ml predicted the possibility of PES (p=0.001) with a sensitivity 91.3%, negative predictive value (NPV) 95.65%, specificity 77.19%, positive predictive value (PPV) 61.76%, and accuracy 81.25%. LVFR <28% predicted PES (p=0.001) with a sensitivity 65.22%, specificity 94.74%, PPV 83.3%, NPV 87.1%, accuracy 86.25%. ACWD <0.45 mm (p<0.003) predicted chances of PES with sensitivity 56.2%, specificity 78.95%, PPV 52%, NPV 81.82%, and accuracy 72.5%. VL scale >2 predicted a significantly higher (p=0.001) risk of PES, (sensitivity 52.1%, specificity 92.98%, PPV 75%, NPV 82.81%, accuracy 81.25%).

Conclusions

An algorithmic approach should be adopted. All patients should undergo CLT before extubation. For patients with positive CLT, LVFR and videolaryngoscopy assessment should be done.  ACWD should be used only in combination with other parameters.

Keywords: Cuff-leak, laryngeal ultrasound, videolaryngoscopy, post-extubation, stridor

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