Post-extubation stridor after prolonged intubation in the pediatric intensive care unit (PICU): a prospective observational cohort study

Veder, L.L.; Joosten, K.F.; Schlink, K; Timmerman, M.K.; Hoeve, L.J.; Schroeff, Marc P. van der; Pullens, Bas

doi:10.1007/s00405-020-05877-0

Cited by 24 publications

(31 citation statements)

References 29 publications

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“…The serial mWCS was also similar in two groups during the first 48 h after extubation. The rate of PEAO (15%) in the index study was within the range of the documented rates of PEAO among critically ill children (18-40%) (20,23,(27)(28)(29). However, the rate of PEAO in index study was lower than the reported rates of Unplanned extubation, n (%) 9 ( 12 PEAO in the recent studies from our unit (32.8-34%) (21,23).…”

Section: Discussionsupporting

confidence: 59%

Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial

et al. 2021

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Background: The data on long-term nasotracheal intubation among mechanically ventilated critically ill children is limited. The purpose of this study was to compare the rate of post-extubation airway obstruction (PEAO) with nasotracheal and orotracheal intubation.Methods: This open-label randomized controlled trial was conducted in PICU of a tertiary care and teaching hospital in North India from January-December 2020 involving intubated children aged 3 months−12 years. After written informed consent, children were randomized into nasotracheal and orotracheal intubation groups. Post-extubation, modified Westley's croup score (mWCS) was used at 10-timepoints (0-min, 30 min, 1, 2, 3, 6, 12, 24, 36, and 48-h after extubation) to monitor for PEAO. The primary outcome was the rate of PEAO; and secondary outcomes were time taken for intubation, number of intubation attempts, complications during intubation, unplanned extubation, repeated intubations, tube malposition/displacement, endotracheal tube blockade, ventilator associated pneumonia, skin trauma, extubation failure/re-intubation, duration of PICU stay, and mortality.Results: Seventy children were randomized into nasotracheal (n = 30) and orotracheal (n = 40) groups. Both the groups were similar in baseline characteristics. The rate of PEAO was similar between nasotracheal and orotracheal groups (10 vs. 20%, p = 0.14). The maximum mWCS and mWCS at 10-timepoints were similar in two groups. The time taken for intubation was significantly longer (85 vs. 48 s, p < 0.001) in nasotracheal group, whereas other secondary outcomes were similar in two groups.Conclusion: The rate of PEAO was not different between nasotracheal and orotracheal groups.Clinical Trial Registration:http://ctri.nic.in, Identifier: CTRI/2020/01/022988.

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Section: Discussionsupporting

confidence: 59%

Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial

et al. 2021

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“…Patients' co-morbidities (prematurity, cardiopulmonary defects) and hypoxia status play a role in the tissue healing process, which may increase the propensity for the development of chronic intubation-related laryngeal lesions ( 1 , 2 ). Various risk factors contributing to the development of laryngeal lesions in children are: patient-factors (prematurity, cardiopulmonary comorbidities), intubation technique (in emergency, inexperienced team), endotracheal tube (large size, cuffed tube), longer duration of intubation, infection and inadequate patient sedation ( 3 – 7 ).…”

Section: Introductionmentioning

confidence: 99%

Intubation Related Laryngeal Injuries in Pediatric Population

2021

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Introduction: Laryngeal intubation related lesions (LIRL) in pediatric patients cause extreme morbidity in both elective and emergency settings. It has a wide range of presentations from minor laryngeal edema to a life-threatening airway obstruction. We report here our units' experience with LIRL in neonates, infants, and small children.Material and Methods: This is a retrospective monocentric cohort study between January 2013 and April 2019.Results: Thirty-nine patients with intubation lesions were included in the study. We looked at the lesions type, characteristics, management, and outcome. Half the patients were premature and having comorbidities. Main LIRL were subglottic stenosis (31%), ulcers (26%), granulations (18%), retention cysts (18%), posterior glottic stenosis (13%), and vocal cords edema (5%). Unfavorable lesions causing airway stenosis were associated with an intubation duration of over 1 week and were an important factor in causing airway stenosis (p < 0.05). The endoscopic treatment performed for these lesions was lesion and anatomical site-specific. Tracheostomy was needed in five patients, and was avoided in another two. Seven patients (18%) received open surgery prior to their decannulation.Conclusions: LIRL management is challenging and stressful in the pediatric population and optimal treatment could avoid extreme morbidity in them. Intubation duration and associated comorbidities are important factors in deciding the severity of these lesions. Protocols to prevent the formation of these lesions are critical.

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“…On the contrary, in a study investigating the incidence of stridor in infants with an average age of 1.0 month (range 0–201), stridor was identified in 18.7% of infants, among which the majority resolved with oxygen therapy or medication. But 10.7% of the infants presenting with stridor required re-intubation ( 28 ). However, previous intubation was not an exclusion criterion in this study and 70% of infants needed a tube exchange, which could explain the much higher percentage of stridor.…”

Section: Discussionmentioning

confidence: 99%

Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis

et al. 2022

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BackgroundEndotracheal intubation is a common procedure in Neonatal Intensive Care. While cuffed endotracheal tubes (ETT) are the standard of care in adults and children, their use in infants is controversial. The aim of this study was to compare the incidence of post-extubation stridor between uncuffed and cuffed ETTs in infants. We further evaluated the safety of cuffed ETTs in infants with a bodyweight between 2 and 3 kg and performed baseline analysis on development of subglottic stenosis.MethodsIn this retrospective study, we screened all infants admitted to two NICUs of the Medical University of Vienna between 2012 and 2019.The study cohort was screened twice: In the first screening we selected all infants who underwent the first intubation when attaining a bodyweight >2 kg (but <6 kg) to analyze the incidence of post-extubation stridor and only considered the first intubation of each included infant. Post-extubation stridor was defined as the administration of either epinephrine aerosol or any corticosteroid within 6 h post-extubation. In the second screening we searched for all infants diagnosed with acquired severe subglottic stenosis during the study period regardless their bodyweight and numbers of intubations.ResultsA total of 389 infants received at least one intubation during the study period. After excluding infants who underwent the first intubation below a bodyweight of 2 kg, 271 infants remained for final analysis with an average gestational age of 38.7 weeks at the time of intubation. Among those, 92 (33.9%) were intubated with a cuffed and 179 (66.1%) with an uncuffed ETT. Seven infants (2.6%) developed a clinically significant stridor: five of those were intubated with a cuffed and two with an uncuffed ETT (71.4 vs. 28.6%, p = 0.053). All of them had a bodyweight >3 kg at the time of intubation. Infants who developed subglottic stenosis were more often intubated with an uncuffed ETT.ConclusionIn this study, no difference in the incidence of post-extubation stridor between cuffed and uncuffed ETTs in infants with a bodyweight from 2 to 6 kg could be found. The use of uncuffed ETTs does not exhibit higher risk for the acquired subglottic stenosis in this cohort.

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Post-extubation stridor after prolonged intubation in the pediatric intensive care unit (PICU): a prospective observational cohort study

Cited by 24 publications

References 29 publications

Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial

Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial

Intubation Related Laryngeal Injuries in Pediatric Population

Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis

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