Prevalence and Risk Factors for Upper Airway Obstruction after Pediatric Cardiac Surgery

Abstract

Objective: To determine the incidence of and risk factors for extrathoracic upper airway obstruction after pediatric cardiac surgery.Study Design: A retrospective chart review was performed on 213 patients less than 18 years of age who recovered from cardiac surgery in our multidisciplinary intensive care unit in 2012.Clinically significant upper airway obstruction was defined before performing the chart review as post-extubation stridor with at least one of the following: greater than two corticosteroid doses, receiving helium-oxygen therapy, or re-intubation. Multivariate logistic regression analysis was performed to determine independent risk factors for this complication.Results: Thirty-five patients (16%) with extrathoracic upper airway obstruction were identified.On bivariate analysis, patients with upper airway obstruction had greater surgical complexity, higher vasoactive medication requirements, and longer postoperative durations of endotracheal intubation. They were also more difficult to calm while on mechanical ventilation, as indicated by higher narcotic infusion doses and greater likelihood to receive dexmedetomidine or vecuronium. On multivariable analysis, adjunctive use of dexmedetomedine or vecuronium (odds ratio: 4.4, 95% confidence intervals: 1.8-10.5) remained independently associated with upper airway obstruction. Conclusion:Extrathoracic upper airway obstruction is relatively common following pediatric cardiac surgery, especially in children who are difficult to calm while endotracheally intubated.Postoperative upper airway obstruction could represent an important outcome measure in future studies of optimal sedation practices in this patient population.2

Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals

“…The analysis considered many factors (eg, prematurity, genetic syndromes, diaphragmatic paralysis, cardiopulmonary bypass, procedure complexity, extracorporeal life support, delayed sternal closure, postoperative infections, and duration of mechanical ventilation) that have been reported as risk factors in previous analyses. 4,5,7–9,21,22 None of these variables were independently associated with extubation failure in this large multicenter dataset of neonates who underwent cardiac surgery. Some of the aforementioned risk factors, especially those identified in single-center studies, may be unique to those institutions.…”

Complex effects of high-flow nasal cannula therapy on hemodynamics in the pediatric patient after cardiac surgery

“…In this situation, HFNC therapy helps to decrease afterload by providing positive pressure and by abating sympathetic nervous system activity via unloading of respiratory and cardiovascular work [5, 12]. Second, an upper airway obstruction (UAO) is relatively common after pediatric cardiac surgery and has been implicated as an important contributor to extubation failure in this population [14–16]. UAO increases negative swings of intrathoracic pressure and increases WOB, thereby imposing an undue burden on a recovering myocardium and further complicating LCOS; HFNC therapy could alleviate the WOB and large negative swings of intrathoracic pressure.…”

Tracheostomy Following Surgery for Congenital Heart Disease

“…Surgical complications including recurrent laryngeal nerve injury, diaphragmatic paralysis, and persistent chylothorax have been associated with tracheostomy. [8][9][10][11][12] In the population with CHD, there is often residual cardiac disease that exacerbates an underlying pulmonary process. 9 Without a clear indication for tracheostomy, prolonged mechanical ventilation and multiple extubation failures usually occur.…”