OBJECTIVES: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles. The most recent searches were conducted in January 2009.
SELECTION CRITERIA: Three review authors independently assessed trial quality and extracted data.
MAIN RESULTS: Eleven trials involving 2301 people were included: six 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, with no overall statistically significant reduction in post extubation
stridor (RR 0.42; 95% CI 0.07 to 2.32). One of these studies was on high-risk patients treated with multiple doses of
steroids around the time of extubation, and this study showed a significant reduction in
stridor. 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 six adult studies (total N = 1953), the use of prophylactic
corticosteroid administration did not significantly reduce the risk of re-intubation (RR 0.48; 95% CI 0.19 to 1.22). While there was a significant reduction in the incidence of post extubation
stridor (RR 0.47; 95% CI 0.22 to 0.99), there was significant heterogeneity (I(2)=81%, X(2)=26.36, df=5, p<0.0001). Subgroup analysis revealed that post extubation
stridor could be reduced in adults with a high likelihood of post extubation
stridor when
corticosteroids were administered as multiple doses begun 12-24 hours prior to extubation compared to single doses closer to extubation; the test for interaction for multiple versus single doses indicated RRR 0.22 (95% CI 0.10 to 0.47) for
stridor with multiple doses. 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 or children. However, given the consistent trends towards benefit, this intervention does merit further study, particularly for high risk children or neonates. In adults, multiple doses of
corticosteroids begun 12-24 hours prior to extubation do appear beneficial for patients with a high likelihood of post extubation
stridor.