Intravenous dexamethasone for extubation of newborn infants

Background

Endotracheal tubes are foreign bodies that may injure the upper airway causing laryngeal edema. This in turn may result in failure of extubation in preterm infants. Corticosteroids have been used prophylactically to reduce upper airway obstruction and facilitate extubation.

Objectives

To determine the effects of intravenous corticosteroids on the incidence of endotracheal reintubation, stridor, atelectasis and adverse side effects in newborn infants having their endotracheal tube removed following a period of intermittent positive pressure ventilation (IPPV).

Search strategy

Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) (dexamethasone and extub*), MEDLINE (MeSH search terms "dexamethasone", "extubat*" and "exp infant, newborn"), previous reviews including cross references, abstracts of conferences and symposia proceedings, expert informants and journal handsearching mainly in the English language. These searches were updated in August 2007.

Selection criteria

Trials were included that used random or quasi-random patient allocation and compared intravenous steroids given immediately prior to a planned extubation with placebo.

Data collection and analysis

Data were extracted independently by the two authors and analysed in RevMan for all trials. Prespecified subgroup analyses were performed to examine differences in response between infants at high risk for upper airway edema and those receiving routine prophylaxis prior to extubation.

Main results

Administration of dexamethasone prior to extubation significantly reduced the need for reintubation of the trachea. This result applies to both the high-risk group and to the total population of infants enrolled. However, the incidence of extubation failure was zero in the trial that attempted to exclude infants at high risk of airway edema. The side effects of higher blood sugar levels and glycosuria were found in the two trials where these were sought.

Authors' conclusions

Implications for practice
Dexamethasone reduces the need for endotracheal reintubation of neonates after a period of IPPV. In view of the lack of effect in low-risk infants and the documented and potential side effects, it appears reasonable to restrict its use to infants at increased risk for airway edema and obstruction, such as those who have received repeated or prolonged intubations.

Implications for research
Issues of dosage and applicability to the extremely low birthweight population could be addressed in future trials. Outcomes such as chronic lung disease, duration of assisted ventilation and length of hospital stay as well as long-term neurodevelopment should also be examined.