Steroid Use for Extubation in Pediatrics

Introduction to Steroid Therapy

The American Academy of Pediatrics recommends administering dexamethasone at least 6-12 hours before planned extubation in children with high risk of upper airway obstruction, using a dose of 0.5 mg/kg (maximum 8-10 mg) every 6 hours, with optimal benefit when started 12-24 hours before extubation 1, 2

The American College of Critical Care Medicine suggests that dexamethasone 0.5 mg/kg per dose (maximum 8-10 mg) should be administered every 6 hours, starting at least 6-12 hours before planned extubation 1, 2
Early administration (>12 hours before) is significantly more effective than late administration (<6 hours) 1

The American Thoracic Society identifies pressure of cuff leak >25 cmH₂O as the most important predictor of upper airway obstruction 1
Prolonged intubation (>48-72 hours), traumatic intubation, or multiple intubation attempts are also risk factors for upper airway obstruction 1

The use of dexamethasone reduces the incidence of post-extubation upper airway obstruction (OR 0.40, 95% CI: 0.21-0.73), representing 205 fewer cases per 1,000 patients 1, 2
Dexamethasone does not significantly reduce overall extubation failure rates (OR 0.55, 95% CI: 0.21-1.46) 1

The American Academy of Pediatrics states that dexamethasone facilitates weaning from ventilation and extubation in infants with bronchopulmonary dysplasia 3
High-dose dexamethasone (≈0.5 mg/kg/day) is associated with long-term neurocognitive adverse effects 4
Low-dose dexamethasone (<0.2 mg/kg/day) may facilitate extubation with fewer adverse effects 4
Hydrocortisone at low doses (1 mg/kg/day) may be a safer alternative in the first 2 weeks of life 4

Neonates who have an indeterminate risk of upper airway obstruction, especially when using uncuffed endotracheal tubes, should be considered for prophylactic dexamethasone to prevent post‑extubation airway compromise 5