Dexamethasone Dosing for Laryngeal Edema
For adults at high risk of laryngeal edema (prolonged intubation >48 hours with low cuff leak), administer dexamethasone 5 mg IV every 6 hours for 4 doses starting 24 hours before planned extubation. 1
Evidence-Based Dosing Regimens
Adults
- Standard prophylactic dose: 5 mg IV every 6 hours for 4 doses (total 20 mg over 24 hours) beginning the day before extubation 1
- Alternative acute dosing: 10 mg IV as initial dose for established laryngeal edema 2, 3
- Equivalent to: Approximately 100 mg hydrocortisone every 6 hours 2
Pediatric Patients
- Prophylactic dose: 0.5 mg/kg IV (maximum 8 mg) every 6 hours for 4 doses 4
- Administer at: 4 hours prior to extubation, at extubation, then 6 and 12 hours post-extubation 4
Clinical Context and Timing
Steroids must be started early because anti-inflammatory effects require 6-12 hours to manifest 2. Single-dose steroids given immediately before extubation are ineffective 2.
When to Use Prophylactic Dexamethasone
High-risk criteria for adults:
- Intubation duration >48 hours with cuff leak volume <110 mL 1
- Traumatic or repeated intubation attempts 2
- Direct airway injury (surgical, thermal, or chemical) 2
High-risk criteria for children:
Important Caveats
Pediatric efficacy differs from adults: Prophylactic dexamethasone significantly reduces postextubation stridor in children but evidence in adults shows reduced stridor incidence (10% vs 27.5%) without significant reduction in reintubation rates 4, 1. The French guidelines note that beneficial effects in neonates have not been clearly demonstrated in older children 2.
Mechanism of action: Steroids only reduce inflammatory edema from direct airway injury, not mechanical edema from venous obstruction (e.g., neck hematoma) 2.
Administration Details
- Administer slowly over several minutes to avoid perineal burning; if this occurs, slow or pause the infusion 5
- Continue for at least 12 hours for effectiveness 2
- The "after-effect" persists 24 hours after the last dose, validating the reduced stridor incidence 1
Adjunctive Therapy
If stridor develops despite prophylaxis:
- Nebulized epinephrine 1 mg (0.5 mL/kg of 1:1000 solution, maximum 5 mL) provides rapid but transient relief (30 minutes onset, 2 hours duration) 2
- Note: One study found dexamethasone and L-epinephrine did not reduce clinical progression when used together in the early postextubation period 6
Monitoring and Safety
- Monitor glucose levels, especially in diabetic patients 5
- Consider prophylactic proton pump inhibitor for GI protection 5
- Never abruptly discontinue after more than a few days of treatment; taper gradually to prevent adrenal insufficiency 5
- Consider antifungal prophylaxis if steroids continued beyond 48-72 hours 5