Dexamethasone for Traumatic Swelling of the Larynx
Intravenous dexamethasone is recommended for managing traumatic laryngeal swelling, with repeated doses before and after extubation to decrease the incidence of stridor and need for reintubation. 1
Mechanism and Dosing
- Dexamethasone exerts anti-inflammatory properties that reduce pain and swelling in traumatic laryngeal edema 2
- For acute traumatic laryngeal swelling, an initial dose of 1.0-1.5 mg/kg of dexamethasone is recommended 3
- For ongoing management, repeated doses of intravenous dexamethasone every 6 hours before and after tracheal extubation have proven useful in decreasing stridor and reintubation risk 2, 1
- Most studies use dexamethasone doses ranging from 0.15 to 1.0 mg/kg, with maximum doses between 8-25 mg 2
Timing and Administration
- Begin corticosteroid therapy at least 12-24 hours before planned extubation in high-risk patients 1, 4
- Continue with repeated doses every 6 hours through and after extubation 1, 4
- The significant benefit of dexamethasone persists for at least 24 hours after the last dose, providing an "after-effect" that helps prevent postextubation stridor 4
Risk Assessment and Monitoring
- A negative leak test (no leak when cuff is deflated or leak smaller than 12% of expired volume) indicates increased risk of laryngeal edema and should prompt consideration for dexamethasone therapy 2
- Patients with traumatic laryngeal swelling should be monitored closely for signs of airway compromise, including stridor, difficulty breathing, arterial oxygen desaturation, and tachypnea 1
- Position patients with airway compromise upright and administer high-flow humidified oxygen 1
Additional Interventions
- Consider epinephrine nebulization for post-extubation stridor caused by laryngeal edema, which has a quick onset (30 minutes) but transient effect (2 hours) 2
- Have equipment for reintubation readily available, including consideration of airway exchange catheters in high-risk cases 2, 1
- If extubation is at risk due to laryngeal anomaly or trauma, an assessment by an ENT surgeon is recommended 2
Evidence Quality and Limitations
- The beneficial effect of dexamethasone has been clearly demonstrated in neonates at risk for laryngeal edema following traumatic or repeated intubation 2
- In adults, prophylactic multiple-dose dexamethasone is effective in reducing the incidence of postextubation stridor in patients at high risk for postextubation laryngeal edema 4
- Some studies in pediatric populations show mixed results regarding routine use of corticosteroids for prevention of postextubation stridor 5, 6
- One animal study found that dexamethasone did not ameliorate subglottic ischemic injury in rabbits, suggesting potential limitations in certain types of laryngeal trauma 7
Special Considerations
- For patients with neurologic conditions requiring dexamethasone, higher doses may be used (10 mg IV every 6 hours for grade 3 neurotoxicity) 2
- The risk of harm from short-term steroid therapy (24 hours or less) is negligible 3
- Patients with endocrine disorders already receiving exogenous steroids or in whom steroid administration may interfere with normal glucose-insulin regulation (e.g., diabetics) may require special consideration 2