Implementation of a Clinical Pathway to Reduce Rates of Postextubation Stridor

Unsuccessful extubation is associated with increased intensive care unit and hospital length of stays, hospital costs, morbidity, and mortality. The most common cause of reintubation is laryngeal edema, often evidenced by postextubation stridor.

To reduce the rates of postextubation stridor and reintubation in the neurocritical care unit at a large urban academic medical center.

A clinical pathway was created to aid in detecting patients expected to experience postextubation stridor and to guide prophylactic treatment. During the 12-week implementation phase, the pathway was completed on all intubated patients daily.

The 12-week trial included a total of 606 days of mechanical ventilation. Checklists were completed for 531 days, a compliance rate of 88% for use of the clinical pathway. Of the 56 patients who were extubated during the trial, 54 had a checklist completed, for 96% compliance on the day of extubation. Outcomes after all nonpalliative extubations (n = 43) during the 12 weeks before and after implementation of the pathway (n = 56 periods) were evaluated by using χ ² tests. Implementation of the pathway was associated with a significant reduction in rates of postextubation stridor (χ ² = 6.2; P = .01), reintubation (χ ² = 5.5; P = .02), and reintubation due to postextubation stridor (χ ² = 8.3; P = .004).

The clinical pathway implemented in the neurocritical care unit was safe and effective in reducing rates of reintubation and reintubation due to postextubation stridor.