Peri-Extubation Dexamethasone to Prevent Post-extubation Airway Obstruction in Critically Ill Children: A Systematic Review of Randomized Trials Across Heterogeneous Populations, Regimens, and Outcomes.

Peri-extubation dexamethasone is used to prevent post-extubation upper airway obstruction in critically ill children, but pediatric randomized trials differ substantially in population selection, dosing, timing, and outcome definitions. We systematically reviewed randomized controlled trials evaluating peri-extubation dexamethasone in mechanically ventilated children. PubMed/MEDLINE, Scopus, and Web of Science were searched from inception to June 22, 2026. Nine trials randomized 1,063 children, with 949 included in reported analyses. Because comparator architecture, dexamethasone exposure, extubation context, outcome constructs, and follow-up windows were not clinically comparable, findings were synthesized narratively rather than pooled. Among placebo-controlled trials with interpretable pairwise binary airway outcomes, no trial provided statistically significant evidence of a reduction in the principal airway obstruction outcome. A 24-hour versus 6-hour regimen comparison reported less clinically significant airway obstruction with the 24-hour regimen, but the groups also differed in pre-extubation dose count and cumulative exposure, preventing attribution to timing alone. A low-dose versus high-dose trial did not establish non-inferiority of the lower-dose regimen. Reintubation outcomes showed no consistent treatment effect and were limited by imprecision and variable attribution. Adverse event ascertainment was limited. Seven trials raised some concerns, and two were at high overall risk of bias. Current randomized evidence does not define a single optimal peri-extubation dexamethasone regimen. Standardized eligibility criteria, explicit reporting of actual pre-extubation exposure, consistent airway outcome definitions, and prospective attribution of reintubation are needed before an optimal prophylactic strategy can be established.