Dexamethasone initiation may prevent post-extubation upper airway obstruction in children

High-dose dexamethasone initiation 12 hours before extubation prevented post-extubation upper airway obstruction in children, according to results of a study published in Annals of the American Thoracic Society.

“Pre-extubation corticosteroids have been used for decades to prevent post-extubation upper airway obstruction and extubation failure,” Narayan P. Iyer, MBBS, MD, neonatologist with the Fetal and Neonatal Institute at Children’s Hospital Los Angeles and Keck School of Medicine of USC, and colleagues wrote. “However, corticosteroid treatment regimens vary substantially based on the medication used, dose, timing and the number of doses administered.

Researchers conducted a study to compare the effectiveness of various corticosteroid treatment regimens on prevention of upper airway obstruction and reintubation in children. They searched MEDLINE, CINAHL and Embase and identified eight randomized trials of 903 children in whom corticosteroids were used to prevent upper airway obstruction. All studies used dexamethasone (ANI Pharmaceuticals) and were categorized based on timing of initiation and dose: high dose with early use, low dose with early use, high dose with late use and low dose with late use.

Early dexamethasone initiation was defined as more than 12 hours before extubation and high dose was defined as 0.5 mg/kg per dose or more.

Compared with no dexamethasone treatment, the most effective regimens to prevent upper airway obstruction were high dose with early use (OR = 0.13; 95% credible interval [CrI], 0.04-0.3), high dose with late use (OR = 0.39; 95% CrI, 0.19-0.74) and low dose with early use (OR = 0.15; 95% CrI, 0.04-0.58). Both high dose with early use and low dose with early use had the highest probability of ranking as the best regimens to prevent upper airway obstruction (surface under the cumulative rankings, 0.901 and 0.808, respectively).

In addition, high dose with early use and low dose with early use were the best regimens for preventing reintubation (surface under the cumulative rankings, 0.803 and 0.72, respectively).

Researchers reported an imprecise effect estimate for preventing reintubation among children for all four dexamethasone treatment regimens compared with no dexamethasone.

In a sensitivity analysis, initiating dexamethasone more than 12 hours before extubation was associated with a higher likelihood of effectiveness compared with initiating dexamethasone more than 6 hours before extubation.

“Given the complex nature of trade-offs with each patient, the decision to use a specific strategy of dexamethasone should be personalized taking into consideration the risk of post-extubation upper airway obstruction, risk factors for extubation failure, the potential for adverse effects and the time available before planned extubation,” the researchers wrote.