Corticosteroids for the Prevention of Pediatric Reintubation
Corticosteroids for the Prevention of Pediatric Reintubation
Objective: To determine whether corticosteroids are effective in preventing or treating postextubation stridor and in reducing the need for subsequent reintubation of the trachea in critically ill infants and children.
Design: Meta-analysis of published randomized controlled trials.
Data Sources: References of each trial from a MEDLINE search were reviewed, and experts in the field were contacted.
Study Selection: Any randomized controlled trial comparing the administration of corticosteroids with placebo on the prevalence of reintubation or postextubation stridor in infants or children receiving mechanical ventilation via an endotracheal tube in an intensive care unit.
Data Extraction: Data extraction and methodologic quality assessment were assessed independently by two reviewers.
Data Synthesis: Six controlled clinical trials met the criteria for inclusion; three trials pertain to neonates and three to children. Five trials examined the use of steroids for the prevention of reintubation (four of these evaluated postextubation stridor specifically); one trial examined the use of steroids to treat existing postextubation stridor in children. There was a nonsignificant trend toward a decreased rate of reintubation in all subjects when prophylactic steroids were used (n = 376, relative risk [RR] = 0.34, 95% confidence interval [CI] = 0.05-2.33). Prophylactic use of steroids reduced postextubation stridor in the pooled studies (n = 325, RR = 0.50, 95% CI = 0.28-0.88). In young children, there were significant reductions of postextubation stridor with preventive treatment (n = 216, RR = 0.53, 95% CI = 0.28-0.97), and a trend toward less stridor was observed in neonates (n = 109, RR = 0.42, 95% CI = 0.07-2.32). There was a nonsignificant trend toward a reduced reintubation rate when steroids were used to treat existing upper airway obstruction requiring reintubation (RR = 0.55, 95% CI = 0.17-1.78). Side effects were seldom reported and could not be evaluated.
Conclusions: Prophylactic administration of dexamethasone before elective extubation reduces the prevalence of postextubation stridor in neonates and children and may reduce the rate of reintubation.
Endotracheal intubation, although vital to facilitate mechanical ventilation in the intensive care unit and operating room, is associated with the potential development of glottic or subglottic edema, resulting in stridor on extubation. Such extrathoracic airway obstruction after endotracheal intubation may occur in up to 37% of critically ill pediatric patients. Extrapolating from studies assessing their role in the treatment of laryngotracheobronchitis, or on the basis of early anecdotal reports of postoperative patients, some clinicians administer corticosteroids in varying ways to intubated patients before extubation in an effort to avoid the development of postextubation stridor. Others use steroids to treat patients who develop stridor after extubation. Presuming that reactive edema develops in the glottic or subglottic mucosa because of pressure or irritation from the endotracheal tube, steroids may offer protection or treatment value by virtue of their anti-inflammatory actions.
Postextubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and reintubation 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 before widespread adoption of this practice.
The objective of this analysis was to determine whether corticosteroids are effective in preventing or treating postextubation stridor and reducing the need for subsequent reintubation of the trachea in critically ill neonates, infants, and children. A secondary objective was to determine the extent of detrimental effects of steroid therapy in this context.
Objective: To determine whether corticosteroids are effective in preventing or treating postextubation stridor and in reducing the need for subsequent reintubation of the trachea in critically ill infants and children.
Design: Meta-analysis of published randomized controlled trials.
Data Sources: References of each trial from a MEDLINE search were reviewed, and experts in the field were contacted.
Study Selection: Any randomized controlled trial comparing the administration of corticosteroids with placebo on the prevalence of reintubation or postextubation stridor in infants or children receiving mechanical ventilation via an endotracheal tube in an intensive care unit.
Data Extraction: Data extraction and methodologic quality assessment were assessed independently by two reviewers.
Data Synthesis: Six controlled clinical trials met the criteria for inclusion; three trials pertain to neonates and three to children. Five trials examined the use of steroids for the prevention of reintubation (four of these evaluated postextubation stridor specifically); one trial examined the use of steroids to treat existing postextubation stridor in children. There was a nonsignificant trend toward a decreased rate of reintubation in all subjects when prophylactic steroids were used (n = 376, relative risk [RR] = 0.34, 95% confidence interval [CI] = 0.05-2.33). Prophylactic use of steroids reduced postextubation stridor in the pooled studies (n = 325, RR = 0.50, 95% CI = 0.28-0.88). In young children, there were significant reductions of postextubation stridor with preventive treatment (n = 216, RR = 0.53, 95% CI = 0.28-0.97), and a trend toward less stridor was observed in neonates (n = 109, RR = 0.42, 95% CI = 0.07-2.32). There was a nonsignificant trend toward a reduced reintubation rate when steroids were used to treat existing upper airway obstruction requiring reintubation (RR = 0.55, 95% CI = 0.17-1.78). Side effects were seldom reported and could not be evaluated.
Conclusions: Prophylactic administration of dexamethasone before elective extubation reduces the prevalence of postextubation stridor in neonates and children and may reduce the rate of reintubation.
Endotracheal intubation, although vital to facilitate mechanical ventilation in the intensive care unit and operating room, is associated with the potential development of glottic or subglottic edema, resulting in stridor on extubation. Such extrathoracic airway obstruction after endotracheal intubation may occur in up to 37% of critically ill pediatric patients. Extrapolating from studies assessing their role in the treatment of laryngotracheobronchitis, or on the basis of early anecdotal reports of postoperative patients, some clinicians administer corticosteroids in varying ways to intubated patients before extubation in an effort to avoid the development of postextubation stridor. Others use steroids to treat patients who develop stridor after extubation. Presuming that reactive edema develops in the glottic or subglottic mucosa because of pressure or irritation from the endotracheal tube, steroids may offer protection or treatment value by virtue of their anti-inflammatory actions.
Postextubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and reintubation 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 before widespread adoption of this practice.
The objective of this analysis was to determine whether corticosteroids are effective in preventing or treating postextubation stridor and reducing the need for subsequent reintubation of the trachea in critically ill neonates, infants, and children. A secondary objective was to determine the extent of detrimental effects of steroid therapy in this context.
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