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

Background 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. Objectives To determine whether corticosteroids are effective in preventing or treating post- extubation stridor in critically ill infants, children, or adults. Search strategy We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles. The most recent searches were conducted in April 2007. Selection criteria Randomized controlled trial comparing 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 collection and analysis Three review authors independently assessed trial quality and extracted data. Main results Ten trials involving 2230 people were included: five 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). In neonates the two studies found heterogeneous results, but there was an overall non significant reduction in post extubation stridor ( RR 0.42; 95% CI 0.07 to 2.32). This decrease was seen only in the study on high- risk patients treated with multiple doses of steroids around the time of extubation. In children, the two studies were clinically heterogeneous. One study included children with underlying airway abnormalities and the other excluded this group. Prophylactic corticosteroids tended to reduce reintubation and significantly reduced post- extubation stridor in the study that included children with underlying airway abnormalities ( N = 62) but not in the study that excluded these children ( N = 153). In five adult studies ( total N = 1873), there was a non significant trend for prophylactic corticosteroid administration to reduce the risk of re- intubation ( RR 0.47; 95% CI 0.16 to 1.39) and post extubation stridor ( RR 0.49; 95% CI 0.20 to 1.19). These reductions were largely due to two studies that utilized repeated doses of methylprednisolone 12 to 24 hours prior to extubation. Side effects were uncommon and could not be aggregated. Authors' conclusions Using corticosteroids to prevent ( or treat) stridor after extubation has not proven effective for neonates, children or adults. However, given the consistent trends towards benefit, this intervention does merit further study.