Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults.

Abstract

Post-extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re-intubation proves necessary. Corticosteroids, however, may be associated with adverse effects ranging from hypertension to hyperglycemia, and a more systematic assessment of the efficacy of this therapy is indicated prior to widespread adoption of this practice To determine whether corticosteroids are effective in preventing or treating post-extubation stridor in critically ill infants, children, or adults. Controlled trials were identified through MEDLINE, EMBASE and CINAHL. Bibliographies of all identified trials were examined, and authors of included trials were contacted to confirm the methodology and identify other potentially relevant trials. Any randomized controlled trial that compared administration of corticosteroids by any route with placebo in infants, children, or adults receiving mechanical ventilation via an endotracheal tube in an intensive care unit. Data from the included studies were extracted independently by two reviewers. The main outcome was the rate of tracheal re-intubation after extubation. The incidence of stridor was examined as a secondary outcome. Subgroup analysis was predetermined to compare preventative use of steroids before extubation and therapeutic use following extubation. Neonates, pediatric patients, and adults were compared separately. A random effects model was used throughout. Methodologic quality of trials was assessed independently by the two reviewers. Of 251 studies identified, only seven met the criteria for inclusion; three in adults, two in neonates, three in children. All but one examined use of steroids for the prevention of post-extubation stridor; the remaining one concerned treatment of existing post-extubation stridor in children. Patients were drawn from heterogeneous medical/surgical populations. Dexamethasone given intravenously at least once prior to extubation was the most common steroid regimen utilized (uniformly in neonates and children). Prophylactic intervention tended to decrease re-intubation rates among neonates and children, but did not reach statistical significance (neonates RR=0.1, 95% CI 0.01, 1.68; children RR=0.49, 95% CI 0.01, 19.65). Post-extubation stridor was reduced in children (n=216: RR=0.53, 95% CI 0.28, 0.97) but not in neonates. In the neonatal studies, a lower re-intubation rate was seen only in high risk patients treated with multiple doses of steroids around the time of extubation. In three adult studies (total n=1047), no difference in post-extubation stridor (RR=0.86, 95% CI 0.57, 1.30) or re-intubation rates (RR=0.95, 95% CI 0.52, 1.72) was detected. Side effects were reported seldomly and could not be aggregated. In neonates, there is a trend towards a reduced incidence of re-intubation in neonates receiving prophylactic dexamethasone prior to extubation. In children, prophylactic administration of dexamethasone prior to elective extubation reduces the incidence of post-extubation stridor, but the evidence is insufficient to conclude that rates of re-intubation are reduced. In adults, corticosteroids do not appear to reduce the need for re-intubation.