Steroids reduce upper airway oedema and improve the chance of successful endotracheal extubation in high risk critically ill adults receiving mechanical ventilation.
Date First Published:
March 22, 2025
Last Updated:
September 9, 2025
Report by:
Dr Danial Khan, ACCS ST3 Doctor in Emergency Medicine (Critical Care Unit, Salford Care Organisation Northern Care Alliance NHS Foundation Trust)
Search checked by:
Dan Horner, Critical Care Unit, Salford Care Organisation Northern Care Alliance NHS Foundation Trust
Three-Part Question:
In [adults undergoing endotracheal extubation after a period of mechanical ventilation] does [prior administration of systemic corticosteroids] result in [decreased rates of reintubation and/or associated morbidity]
Clinical Scenario:
A 68 year old man has been mechanically ventilated in the intensive care unit for six days following presentation with severe community acquired pneumonia. He is now established on a spontaneous ventilation mode and passed a spontaneous breathing trial this morning. The nursing team perform a cuff leak test (deflating his endotracheal tube cuff) which shows no air leak, suggesting a high risk of laryngeal oedema and potential extubation failure. On the ward round, the ICU consultant suggests delaying any trial of extubation to administer prophylactic corticosteroids. You have not seen this practice before. Although you understand that airway swelling can cause stridor and increase the risk of extubation failure, you are also aware that that corticosteroids carry risks (e.g. increased infection) and worry that delaying a trial of extubation may increase the risk of iatrogenic lung injury. The consultant is also not clear on the agent, dose, timing and duration of a steroid course for this indication. You decide to get a coffee after the ward round and review the literature.
Search Strategy:
Medline (1946 to August 11th 2025) and Embase (1980 to August 8th 2025) databases were searched via the OVID interface using the following search criteria:
(exp Extubation OR "extubation"[MeSH Terms] OR "extubation"[Title/Abstract] OR "endotracheal extubation"[Title/Abstract]) AND (exp corticosteroids OR exp steroids OR "glucocorticoids"[MeSH Terms] OR exp dexamethasone OR exp Hydrocortisone "corticosteroids"[Title/Abstract] OR "steroids"[Title/Abstract] OR "glucocorticoids"[Title/Abstract]) AND (exp respiratory tract intubation OR exp intubation OR exp larynx oedema OR "reintubation"[MeSH Terms] OR "reintubation"[Title/Abstract] OR "laryngeal edema"[MeSH Terms] OR "laryngeal edema"[Title/Abstract] OR "postextubation stridor" [Title/Abstract])) Limits: English language, humans, 1990-2026, articles with abstracts, meta-analysis or systematic review
(exp Extubation OR "extubation"[MeSH Terms] OR "extubation"[Title/Abstract] OR "endotracheal extubation"[Title/Abstract]) AND (exp corticosteroids OR exp steroids OR "glucocorticoids"[MeSH Terms] OR exp dexamethasone OR exp Hydrocortisone "corticosteroids"[Title/Abstract] OR "steroids"[Title/Abstract] OR "glucocorticoids"[Title/Abstract]) AND (exp respiratory tract intubation OR exp intubation OR exp larynx oedema OR "reintubation"[MeSH Terms] OR "reintubation"[Title/Abstract] OR "laryngeal edema"[MeSH Terms] OR "laryngeal edema"[Title/Abstract] OR "postextubation stridor" [Title/Abstract])) Limits: English language, humans, 1990-2026, articles with abstracts, meta-analysis or systematic review
Outcome:
Outcome: 1104 abstracts retrieved and screened, of which 4 were deemed to be directly relevant to the original three-part question and demonstrated the highest level of evidence
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Prophylactic Corticosteroids for Prevention of Postextubation Stridor and Reintubation in Adults: A Systematic Review and Meta-analysis. Kuriyama et al. 2017 Japan/China | 11 Randomised Controlled Trials (RCTs) involving 2,472 adults undergoing extubation after mechanical ventilation. Prophylactic corticosteroids (Methylprednisolone, dexamethasone and hydrocortisone) vs. placebo/no treatment |
Systematic review & meta-analysis 1a Subgroup exploratory analyses for high-risk populations (positive cuff leak test / no laryngeal airflow on cuff deflation) |
Post-extubation airway events, defined as a composite of stridor, laryngeal oedema, or airway obstruction requiring intervention. | Risk ratio: 0.43 (95% CI 0.29 to 0.66, p = 0.001) | Heterogeneity in steroid regimens (agent, dose, timing) Most benefit driven by reduced event rate in high risk patients Limited follow up and adverse event reporting. |
| Reintubation rate | Risk Ratio: 0.42 (95% CI: 0.25-0.7 p = <0.001 | ||||
| Post-extubation airway events in high-risk patients | RR: 0.34 (95% CI, 0.24 to 0.48) | ||||
| Reintubation events in high-risk patients | RR, 0.35 (95% CI, 0.20- 0.64) | ||||
| Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis. Feng et al. 2023 China / Taiwan | 11 RCTs involving 2,371 adults undergoing extubation after mechanical ventilation. Compared different corticosteroid regimes within network |
Systematic review & network meta-analysis 1a |
Reintubation events: Dexamethasone vs Placebo | Odds ratio: 0.34 (95% CI 0.13 to 0.85) | Substantial heterogeneity among trials, with variable dosing and timing regimens. Limited reporting of adverse effects. 6 of 11 included RCTs had a population of ‘high risk’ patients for laryngeal oedema. Generalisability therefore affected and results may not apply to broader patient population. |
| Reintubation events: Dexamethasone vs Methylprednisolone | Odds ratio: 0.80 (95% CI 0.85 to 2.29) | ||||
| Reintubation events: Dexamethasone vs Hydrocortisone | Odds ratio: 0.52 (95% CI 0.13 to 2.13) | ||||
| Ranked order of interventions (using surface area under cumulative ranking curve) for reducing the risk of reintubation | 1.tDexamethasone 2.tMethylprednisolone 3.tHydrocortisone | ||||
| Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials. Jaber S, Jung B, Chanques G, et al. 2009 France | 7 RCTs involving 1846 adult patients receiving mechanical ventilation >24hrs Compared effect of corticosteroid vs placebo to prevent reintubation (primary outcome) Included predefined subgroup analysis of high-risk patients (defined in 3 RCTS by minimal/low cuff leak) |
Meta-analysis of RCTs 1a |
Reintubation events: Any steroid vs placebo | RR = 0.58, 95% (95% CI = 0.41 to 0.81) P = 0.001. NNT = 28 | Small overall sample sizes within individual trials. Wide variability in corticosteroid used, dose, and timing of administration around extubation period. Did not examine risks or side effects of steroid use Comparison of reintubation rates in non-high-risk subgroup (remaining 4 RCTs) suggests no potential difference – as such significant result may be driven by dramatic reduction in reintubation events in high-risk population, in isolation |
| Reintubation events in predefined subgroup at high risk for laryngeal oedema: Any steroid vs placebo | RR = 0.38, 95% (CI = 0.21-0.72) P = 0.003. NNT = 9 | ||||
| Comparison between Multiple Doses and Single-Dose Steroids in Preventing the Incidence of Reintubation after Extubation among Critically Ill Patients: A Network Meta-Anal Ahn C, Na MK, Choi KS, et al. 2021 South Korea | 9 RCTs involving 2,098 critically ill adults comparing multiple-dose vs single-dose vs placebo steroid regimens before extubation. | Network meta-analysis of RCTs 1a |
Reintubation events: Multiple dose steroid vs placebo | OR 0.43 95% CI 0.25–0.72. | Only two trials directly compared single vs multiple dosing (limiting power to detect small differences). Moderate certainty for the indirect comparison. Variations in steroid types and doses between studies. Safety outcomes not well reported (short-term steroid side effects were not systematically assessed). |
| Reintubation events: Single dose steroid vs placebo | OR 0.31 95% CI 0.14–0.69. | ||||
| Reintubation events: Multiple vs Single doses of steroid. | No statistically significant difference (OR 1.22, 95% CI 0.32–4.74). Surface ranking favoured a single-dose slightly (probability 87% best vs 63%). |
Author Commentary:
Current evidence suggests that up to a fifth of patients undertaking a planned extubation on the intensive care unit fail the procedure, requiring reintubation within the next 72h.1 Extubation
Current evidence suggests that up to a fifth of patients undertaking a planned extubation on the intensive care unit fail the procedure, requiring reintubation within the next 72h.1 Extubation failure is associated with an increased duration of mechanical ventilation, ICU stay, high tracheostomy rate and overall increase in mortality.1 While some of these events may be unpredictable, all patients can still be evaluated for risk of failure and should be optimised for their trial of extubation. Multiple meta-analyses report that prophylactic corticosteroids administered prior to planned extubation significantly reduce the incidence of post-extubation stridor and significantly decrease the need for subsequent reintubation in adults. As such, corticosteroids should be strongly considered during optimisation. The benefit of corticosteroids appears to be most pronounced in patients with identifiable risk factors for laryngeal oedema (e.g. prolonged intubation, female sex, or positive cuff leak test).1 2 The benefit appears negligible in low-risk patients, therefore broad prescribing seems inappropriate and individualised therapy likely to be superior.8 The optimal timing, regime and dosing of steroids prior to extubation attempt remain areas of ongoing inquiry. Steroids appear to have maximal clinical effectiveness when administered at least 4–12 h prior to extubation, not immediately beforehand.3 4 There is no clear endpoint for therapy prior to extubation attempt (such as return of airflow during cuff deflation). The evidence reviewed indicates that methylprednisolone and dexamethasone are the agents with the greatest efficacy, although clarity on dosing strategy is lacking.11 Commonly used schedules include methylprednisolone 20 mg IV every 6 h OR dexamethasone 5 mg IV every 6h leading up to extubation (roughly equivalent to 30mg Prednisolone / 150mg hydrocortisone). There is no good evidence to support multiple dosing regimens over a single dose 6h prior to attempt. Older trials suggest that a multiple-dose course of steroids (e.g. four doses of dexamethasone 5 mg over 24 hours) may confer more sustained protection against airway oedema and stridor.5 However, a recent network meta-analysis found no significant difference in reintubation rates between a single-dose steroid prophylaxis and a multi-dose regimen.10 In practice, many clinicians use multiple doses for high-risk cases, but a one-time dose of steroid before extubation appears to be an equally effective and evidence-based approach. In regards to safety, short courses of corticosteroids in this context appear to be well tolerated. None of the larger trials reviewed report a significant increase in infectious complications, bleeding, or other steroid-related adverse events attributable to prophylactic use.3 5 6 The typical duration of therapy is only 24–48 hours, which likely minimises the risk of side effects. Nonetheless, formal data on safety are limited, as most studies did not rigorously track longer term adverse events or complications potentially attributable to steroid use. Clinicians should remain vigilant for transient hyperglycaemia, delirium and/or risk of worsening infection, but these risks must be weighed against the clinical benefits of successful liberation from mechanical ventilation. Overall, the evidence supports a targeted strategy. This approach is now favoured within international guidelines - the American Thoracic Society / American College of Chest Physicians (ATS/ACCP) ventilator liberation guidelines suggest performing a cuff leak test in mechanically ventilated adults who otherwise meet extubation criteria.7 For patients who fail the cuff leak test but are otherwise ready for extubation, the guidelines recommend administering systemic steroids at least 4 hours before extubation attempt.
Current evidence suggests that up to a fifth of patients undertaking a planned extubation on the intensive care unit fail the procedure, requiring reintubation within the next 72h.1 Extubation failure is associated with an increased duration of mechanical ventilation, ICU stay, high tracheostomy rate and overall increase in mortality.1 While some of these events may be unpredictable, all patients can still be evaluated for risk of failure and should be optimised for their trial of extubation. Multiple meta-analyses report that prophylactic corticosteroids administered prior to planned extubation significantly reduce the incidence of post-extubation stridor and significantly decrease the need for subsequent reintubation in adults. As such, corticosteroids should be strongly considered during optimisation. The benefit of corticosteroids appears to be most pronounced in patients with identifiable risk factors for laryngeal oedema (e.g. prolonged intubation, female sex, or positive cuff leak test).1 2 The benefit appears negligible in low-risk patients, therefore broad prescribing seems inappropriate and individualised therapy likely to be superior.8 The optimal timing, regime and dosing of steroids prior to extubation attempt remain areas of ongoing inquiry. Steroids appear to have maximal clinical effectiveness when administered at least 4–12 h prior to extubation, not immediately beforehand.3 4 There is no clear endpoint for therapy prior to extubation attempt (such as return of airflow during cuff deflation). The evidence reviewed indicates that methylprednisolone and dexamethasone are the agents with the greatest efficacy, although clarity on dosing strategy is lacking.11 Commonly used schedules include methylprednisolone 20 mg IV every 6 h OR dexamethasone 5 mg IV every 6h leading up to extubation (roughly equivalent to 30mg Prednisolone / 150mg hydrocortisone). There is no good evidence to support multiple dosing regimens over a single dose 6h prior to attempt. Older trials suggest that a multiple-dose course of steroids (e.g. four doses of dexamethasone 5 mg over 24 hours) may confer more sustained protection against airway oedema and stridor.5 However, a recent network meta-analysis found no significant difference in reintubation rates between a single-dose steroid prophylaxis and a multi-dose regimen.10 In practice, many clinicians use multiple doses for high-risk cases, but a one-time dose of steroid before extubation appears to be an equally effective and evidence-based approach. In regards to safety, short courses of corticosteroids in this context appear to be well tolerated. None of the larger trials reviewed report a significant increase in infectious complications, bleeding, or other steroid-related adverse events attributable to prophylactic use.3 5 6 The typical duration of therapy is only 24–48 hours, which likely minimises the risk of side effects. Nonetheless, formal data on safety are limited, as most studies did not rigorously track longer term adverse events or complications potentially attributable to steroid use. Clinicians should remain vigilant for transient hyperglycaemia, delirium and/or risk of worsening infection, but these risks must be weighed against the clinical benefits of successful liberation from mechanical ventilation. Overall, the evidence supports a targeted strategy. This approach is now favoured within international guidelines - the American Thoracic Society / American College of Chest Physicians (ATS/ACCP) ventilator liberation guidelines suggest performing a cuff leak test in mechanically ventilated adults who otherwise meet extubation criteria.7 For patients who fail the cuff leak test but are otherwise ready for extubation, the guidelines recommend administering systemic steroids at least 4 hours before extubation attempt.
Bottom Line:
Systemic corticosteroids given >4h prior to extubation attempt can significantly reduce the risk of subsequent reintubation in adult patients at high risk of post-extubation airway oedema / failure. Dexamethasone (5mg IV) or methylprednisolone (20mg IV) appear to be optimal regimes and a single well-timed dose or a short multi-dose schedule are both acceptable.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Kuriyama et al.. Prophylactic Corticosteroids for Prevention of Postextubation Stridor and Reintubation in Adults: A Systematic Review and Meta-analysis.
- Feng et al. . Comparative efficacies of various corticosteroids for preventing postextubation stridor and reintubation: a systematic review and network meta-analysis.
- Jaber S, Jung B, Chanques G, et al.. Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials.
- Ahn C, Na MK, Choi KS, et al. . Comparison between Multiple Doses and Single-Dose Steroids in Preventing the Incidence of Reintubation after Extubation among Critically Ill Patients: A Network Meta-Anal
- Torrini F, Gendreau S, Morel J, et al. . Prediction of extubation outcome in critically ill patients: a systematic review and meta-analysis
- Darmon JY, Rauss A, Dreyfuss D, et al. . Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study.
- Francois B, Bellissant E, Gissot V, et al. . 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial.
- McCaffrey J, Farrell C, Whiting P, et al. . Corticosteroids to prevent extubation failure: a systematic review and meta-analysis.
- Lee CH, Peng MJ, Wu CL.. Dexamethasone to prevent postextubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study.
- Fan T, Wang G, Mao B, et al.. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials.
- Girard TD, Alhazzani W, Kress JP, et al. . An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Venti