Objective: Multi-dose dexamethasone pretreatment prevents postextubation airway obstruction (PEAO), however, its optimal dose in children is not known. We planned to compare effect of 24h pretreatment of low dose (LD) (0.25mg/kg/dose) versus high dose (HD) (0.5mg/kg/dose) dexamethasone for prevention of PEAO. Design: Stratified (for age and intubation duration) randomized open-label non-inferiority trial. Setting: 15-bed Pediatric Intensive Care Unit in a tertiary care teaching hospital of a lower-middle income country. Patients: Children (3mo-12yrs) intubated for ≥48h and planned for first extubation over 26 months (Feb’17 to Mar’19). Children with preexisting upper airway conditions, chronic respiratory diseases, steroid or IVIG therapy in last 7 days, gastrointestinal bleeding, hypertension and hyperglycemia were excluded. Interventions: Low dose (n=144) or high dose (n=143) dexamethasone (q6h) for 6 doses. Extubation was planned after 5th dose. Measurements and Main Results: Patients were monitored for PEAO (Westley’s Croup Score >4) for 24 hours. 238 patients were included in per-protocol analysis. 78 patients (33%) developed PEAO; both groups were similar (LD, 41/121, 34% vs HD, 37/117, 32% p=0.71). Risk difference of LD vs HD touches the non-inferiority margin of 0.12 and hence the overall result is non-significant. Incidence of reintubation was also similar (LD, 10/121, 8.3% vs HD, 9/117, 7.7%; p=0.87). Intubation for more than 7 days was an independent risk factor for development of PEAO. Conclusions: Multi-dose 24-hour pretreatment with low dose dexamethasone is not inferior to high dose in preventing PEAO and reintubation among unselected patients in the studied clinical setting. Multi-centric trials with larger sample size among children at high risk of developing PEAO are needed.

Objectives: To describe clinico-virological profile, treatment details, intensive care needs, and outcome of infants with acute viral bronchiolitis (AVB). Methodology: In this prospective study, 173 infants with AVB admitted to Pediatric emergency and Pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India during November 2019 to February 2020 were enrolled. The data collection included clinical features, viruses detected, complications, intensive care needs, treatment, and outcome. Multivariate analysis was performed to determine independent predictors for PICU admission. Results: Patients had rapid breathing (98.8%), cough (98.3%), and fever (74%). On examination, tachypnea (98.8%), chest retractions (93.6%), respiratory failure (84.4%), wheezing (49.7%), and crepitations (23.1%) were observed. RSV and rhinovirus were predominant isolates. Complications were noted in 25% cases as encephalopathy (17.3%), transaminitis (14.3%), shock (13.9%), AKI (7.5%), myocarditis (6.4%), MODS (5.8%), and ARDS (4.6%). More than one-third cases required PICU admission requiring nasal cannula oxygen (11%), continuous positive airway pressure (51.4%), high flow nasal canula (14.5%), and mechanical ventilation (23.1%); nebulization (74%); antibiotics (35.9%); and vasoactive drugs (13.9%). The mortality was 8.1%. Underlying comorbidity; chest retractions, respiratory failure, and low oxygen saturation at admission; presence of shock; and need of mechanical ventilation were independent predictors of PICU admission. Isolation of virus or co-infection were not associated with disease severity, intensive care needs, and outcome. Conclusion: Among infants with AVB, RSV and rhinovirus were predominant; >1/3rd required PICU admission; and comorbidity; chest retractions, respiratory failure, low oxygen saturation; shock; and need of mechanical ventilation independently predicted PICU admission.