A retrospective observational study of acquired subglottic stenosis using low‐pressure, high‐volume cuffed endotracheal tubes

Abstract

Summary Introduction The safety of cuffed endotracheal tubes in the neonatal and critically ill pediatric population continues to be questioned due to the theoretical risk of acquired subglottic stenosis. The incidence of acquired subglottic stenosis in the high‐risk mixed surgical and medical critically ill pediatric cohort using high‐volume, low‐pressure cuffed endotracheal tube policy has not yet been described. The aim of our study was to describe and evaluate the use and complication rate of cuffed ETT's in our unit over a 5‐year period. Methods We defined clinically significant subglottic stenosis as a positive stenotic finding of endotracheal tube‐related pathology on a microlaryngoscopy within 6 months of invasive ventilation. All patients admitted through our pediatric critical care unit from January 10, 2012 to January 25, 2017 were matched against our theater management system database for the same period. We reviewed all matching patients’ baseline demographics, comorbidities, intubation/endotracheal tube history, and subsequent surgical management. Results Of 5309 pediatric critical care unit admissions (61% ventilated) and 1251 microlaryngoscopies, 23 children had endoscopic findings of clinically significant endotracheal tube‐related pathology, reflecting 0.68% of all intubated patients. Eight patients developed acquired subglottic stenosis. All those requiring major surgical correction were ex‐premature neonates initially intubated with uncuffed tubes in an external neonatal intensive care. No patient initially intubated with a cuffed endotracheal tube developed subglottic stenosis requiring surgical correction. Conclusion We report no single case of acquired subglottic stenosis in our cohort that required major surgical correction from a cuffed endotracheal tube during a 5‐year period. The introduction of a policy of appropriate placement and maintenance of low‐pressure, high‐volume cuffed endotracheal tubes in the pediatric critical care unit was not associated with an increased rate of endotracheal tube‐related subglottic trauma.

A clinical study on laryngotracheal injuries following endotracheal intubation

“…The laryngeal injuries can be mucosal injuries like vocal cord erythema, edema, granulations or ulcerations to a more permanent sequelae like vocal cord palsy, arytenoids dislocation and subglottic stenosis. 6,11,[16][17][18][19][20][21][22][23][24][25][26][27][28] In addition, the tracheal injuries can be granulations in the initial stages to tracheal stenosis in the later stages. 29 In the present study, LTI observed were subglottic stenosis, granulation tissue in posterior commissure, vocal cord fixation and granulation tissue in the tracheal wall.…”

“…[8][9][10] With the advent of high-volume low pressure cuffed tubes, patient can be ventilated through the endotracheal tube for up to 3 weeks. 3,11 The presence of endotracheal tube in direct contact with larynx and trachea can provoke injuries to its mucosa and submucosal layer which in turn can lead to ulcerations, granulation tissue and stenosis. 12 These injuries may be temporary in the beginning which can become a permanent sequelae later.…”

Cuffed tracheal tubes: guilty now proven innocent

“…Risk factors for developing subglottic stenosis are: multiple intubation; incorrectly sized tracheal tube; low birth weight; underlying clinical condition and duration of mechanical ventilation, rather than the type of tube used . A recent retrospective study of 5309 children admitted to critical care, of whom 3361 were ventilated with a high‐pressure low‐volume cuffed tube, reported only eight patients with acquired subglottic stenosis . Five of these patients required major airway correction surgery and all had been born prematurely, initially intubated with uncuffed tubes in an external neonatal intensive care unit.…”

Post-intubation subglottic stenosis: aetiology at the cellular and molecular level

“…GERD has been associated with SGS in both adults and children [19,20]. In children, SGS is most commonly associated with pre-term infants and/or low birth rate [21,22].…”