A Network Meta-analysis of Dexamethasone for Preventing Postextubation Upper Airway Obstruction in Children

Abstract

Rationale: Periextubation corticosteroids are commonly used in children to prevent upper airway obstruction (UAO). However, the best timing and dose combination of corticosteroids is unknown. Objectives: To compare effectiveness of different corticosteroid regimens in preventing UAO and reintubation. Methods: MEDLINE, CINAHL, and Embase search identified randomized trials in children using corticosteroids to prevent UAO. All studies used dexamethasone. The studies were categorized based on timing of initiation of dexamethasone (early use: >12 h before extubation) and the dose (high dose: ⩾0.5 mg/kg/dose). We performed Bayesian network meta-analysis with studies grouped into four regimens: high dose, early use (HE); low dose, early use (LE); high dose, late use (HL); and low dose, late use. Results: Eight trials (n = 903) were included in the analysis. For preventing UAO (odds ratio; 95% credible interval), HE (0.13; 0.04-0.36), HL (0.39; 0.19-0.74), and LE (0.15; 0.04-0.58) regimens appear to be more effective than no dexamethasone (low certainty). HE and LE had the highest probability of being the top-ranked regimens for preventing UAO (surface under the cumulative ranking curve 0.901 and 0.808, respectively). For preventing reintubation, the effect estimate was imprecise for all four dexamethasone regimens compared with no dexamethasone (very low certainty). HE and LE were the top-ranked regimens (surface under the cumulative ranking curve 0.803 and 0.720, respectively) for preventing reintubation. Sensitivity analysis showed that regimens that started >12 hours before extubation were likely more effective than regimens started >6 hours before extubation. Conclusions: Periextubation dexamethasone can prevent postextubation UAO in children, but effectiveness is highly dependent on timing and dosing regimen. Early initiation (ideally >12 h before extubation) appears to be more important than the dose of dexamethasone. Ultimately, the specific steroid strategy should be personalized, considering the potential for adverse events associated with dexamethasone and the individual risk of UAO and reintubation.

Keywords: dexamethasone; extubation; meta-analysis; upper airway obstruction.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses flow diagram showing flow of information through the different phases of the systematic review. NICU = neonatal intensive care unit.

Figure 2.

Forest plot of effect estimates and 95% CIs of the pairwise meta-analysis. CI = confidence intervals; GI = gastrointestinal; IMV = invasive mechanical ventilation; IV = inverse variance; M-H = mantel-haenszel; PICU = pediatric intensive care unit; SD = standard deviation.

Figure 3.

Cumulative probability curves and surface under the cumulative ranking curve (SUCRA) values for different dexamethasone regimens. For each regimen, the cumulative probability of being ranked first through fifth is displayed. The more the curve for a certain regimen is located toward the upper left corner, the higher its SUCRA value and the better its effectiveness. UAO = upper airway obstruction.

Figure 4.

Effect estimates (95% Crl) and GRADE certainty of effect estimate for all comparisons in the 12-hour model. Crl = credible interval; OR = odds ratio; UAO = upper airway obstruction.

Figure 5.

Effect estimates (95% Crl) and GRADE certainty of effect estimate for all comparisons in the 6-hour model. Crl = credible interval; OR = odds ratio; UAO = upper airway obstruction.