Acute Laryngeal Injury in Patients Undergoing Airway Screening at a Long-Term Acute Care Hospital

BACKGROUND/OBJECTIVES

Acute laryngeal injury (ALgI) is an identified complication of prolonged intubation. Its evolution into mature stenosis and factors affecting decannulation are unclear. This retrospective review aims to characterize the incidence and characteristics of ALgI development and decannulation.

METHODS

Retrospective study of post-intubated patients with a tracheostomy seen for screening evaluation at a single long-term acute care hospital (LTACH) from 2019 to 2022.

RESULTS

Patients were followed for an average of 115 days after extubation. Forty-nine of 119 adult patients had ALgI. Those with ALgI were more likely female (61% vs. 35.7%, p = 0.006) with higher body mass index (BMI; 32.9 vs. 28.1, p = 0.03) and lower height (166 vs. 171.1 cm, p = 0.01). Decannulation rates in patients with ALgI were 69.4% compared to 84.3% in patients without ALgI (p = 0.053). Patients with ALgI were scoped more quickly post-extubation (28.8 vs. 36.6 days, p = 0.04), but time to decannulation did not differ (66.6 vs. 81.2 days, p = 0.74). Lower CCI (4.03 vs 6.93) and lack of tobacco use (41.2% vs 73.3%) were associated with successful decannulation (p = 0.038, p = 0.0008). Patients with ALgI treated conservatively (observation or medical management) were decannulated up to 71 days post-extubation. Further decannulations only occurred with surgical intervention.

CONCLUSIONS

Female gender, higher BMI, and shorter height are associated with ALgI among patients undergoing a LTACH screening evaluation. CCI and tobacco have a negative association with decannulation success. Among the ALgI cohort, no patient treated conservatively was decannulated after 71 days.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Role of Prolonged Intubation in Vocal Fold Motion Impairment in Critically Ill Patients

OBJECTIVE

COVID-19 upsurge in orotracheal intubation (OTI) has opened a new opportunity for studying associated complications. Vocal fold motion impairment (VFMI) is a known complication of OTI. The present study sought to determine the impact of OTI and prolonged OTI on the risk of developing VFMI; to identify both risk and protective factors associated with it.

STUDY DESIGN

Retrospective cohort study.

SETTING

Multicenter.

METHODS

Medical charts were reviewed for all patients that received invasive mechanical ventilation with a subsequent flexible laryngoscopic assessment between March 2020 and March 2022. The main outcomes were the presence of VFMI, including immobility (VFI) and hypomobility (VFH).

RESULTS

A total of 155 patients were included, 119 (76.8%) COVID-19 and 36 (23.2%) non-COVID-19 patients; overall 82 (52.9%) were diagnosed with VFMI. Eighty (52.3%) patients underwent a tracheostomy. The median (IQR) intubation duration was 18 (11-24.25) days, while the median (IQR) time to tracheostomy was 22 (16-29). In the adjusted model, we observed there was a 68% increased risk for VFMI from day 21 of intubation (RR: 1.68; 95% CI 1.07-2.65; P = 0.025).

CONCLUSIONS

VFMI is a frequent complication in severely ill patients that undergo intubation. A prolonged OTI was associated with an increased risk of VFMI, highlighting the importance of timely tracheostomy. Further research is needed to confirm these findings in other subsets of critically ill patients.

Tracheal ulcer development from high volume, low-pressure cuffed endotracheal tubes

INTRODUCTION

Iatrogenic injury to the larynx, particularly the vocal cords from prolonged intubation, has been well-studied; however, tracheal injuries are rarely reported. This study investigates the effectiveness of cuffed, high-volume, low-pressure endotracheal tubes in preventing the development of tracheal ulcers in intubated subjects.

METHODS

A retrospective, IRB-approved review was performed on 1355 subjects who underwent percutaneous tracheostomy from 2002 to 2018. The presence and severity of tracheal ulcers were collected using documentation and photos during percutaneous tracheostomy placement. Primary outcome measures included: the length of time on a ventilator until tracheostomy (LOVT), length of hospitalization (LOH), and mortality in relationship to the severity of the tracheal injury. Data was reported as n (%) and median (IQR). The differences in means between groups were analyzed by ANOVA and Chi-square test with an alpha of 0.05.

RESULTS

206 subjects met the inclusion criteria; 65 subjects had an absence of tracheal injury, and 141 subjects developed tracheal ulcers. Subjects with tracheal ulcers were grouped by the following severity scale: no ulcer; mild ulcer (minimal mucosal erosion with exudate); moderate ulcer (mucosal erosion); and severe (tracheal ring exposure). There were no statistically significant differences in age (p = 0.99), gender (p = 0.83), BMI (p = 0.44), LOH (p = 0.88), LOVT (p = 0.93), and mortality (p = 0.306) between subjects with differing severity of ulcers. The average annual incidence of clinically significant ulcers (moderate and severe) was 2.2 %.

CONCLUSIONS

The lack of statistical correlation between the duration of intubation and tracheal ulcer severity, along with a low annual incidence of tracheal ulcers, supports the improved safety of high-volume, low-pressure cylindrical, cuffed endotracheal tubes. This study is among the first to specifically focus on injuries at the level of the cuff and tip of endotracheal tubes with implications in preventive measures and potential product design changes.

Acute Cricoarytenoid Joint Fixation Following Routine Intubation: A Case Report

Prolonged intubation is a common cause of injury to the posterior larynx often resulting in cricoarytenoid joint (CAJ) fixation and posterior glottic stenosis (PGS). We present a case of respiratory failure due to acute bilateral CAJ fixation and PGS following only 2 days of intubation for routine cardiac surgery. A tracheostomy was placed due to critical airway obstruction. Clinicians should remain vigilant for laryngeal injury presenting as CAJ fixation and PGS. Prompt surgical consultation is advised as early intervention is associated with reduced morbidity.

Multidisciplinary management of laryngeal pathology identified in patients with COVID-19 following trans-laryngeal intubation and tracheostomy

Background

COVID-19 disease often requires invasive ventilatory support. Trans-laryngeal intubation of the trachea may cause laryngeal injury, possibly compounded by coronavirus infection. Fibreoptic Endoscopic Evaluation of Swallowing (FEES) provides anatomical and functional assessment of the larynx, guiding multidisciplinary management. Our aims were to observe the nature of laryngeal abnormalities in patients with COVID-19 following prolonged trans-laryngeal intubation and tracheostomy, and to describe their impact on functional laryngeal outcomes, such as tracheostomy weaning.

Methods

A retrospective observational cohort analysis was undertaken between March and December 2020, at a UK tertiary hospital. The Speech and Language Therapy team assessed patients recovering from COVID-19 with voice/swallowing problems identified following trans-laryngeal intubation or tracheostomy using FEES. Laryngeal pathology, treatments, and outcomes relating to tracheostomy and oral feeding were noted.

Results

Twenty-five FEES performed on 16 patients identified a median of 3 (IQR 2-4) laryngeal abnormalities, with 63% considered clinically significant. Most common pathologies were: oedema (n = 12, 75%); abnormal movement (n = 12, 75%); atypical lesions (n = 11, 69%); and erythema (n = 6, 38%). FEES influenced management: identifying silent aspiration (88% of patients who aspirated (n = 8)), airway patency issues impacting tracheostomy weaning (n = 8, 50%), targeted dysphagia therapy (n = 7, 44%); ENT referral (n = 6, 38%) and reflux management (n = 5, 31%).

Conclusions

FEES is beneficial in identifying occult pathologies and guiding management for laryngeal recovery. In our cohort, the incidence of laryngeal pathology was higher than a non-COVID-19 cohort with similar characteristics. We recommend multidisciplinary investigation and management of patients recovering from COVID-19 who required prolonged trans-laryngeal intubation and/or tracheostomy to optimise laryngeal recovery.

Complicated Laryngotracheal Stenosis Occurring Early after COVID-19 Intubation

Background: Airway stenosis is a known complication of prolonged intubation in hospitalized patients. With the high rate of intubations in patients with COVID-19 pneumonia, laryngotracheal stenosis (LTS) is a complication of COVID-19 that drastically reduces quality of life for patients who may remain tracheostomy-dependent. Methods: Patient medical history, laryngoscopy, and CT imaging were obtained from medical records. Results: We report four cases of complicated LTS following intubation after COVID-19 pneumonia and explore the current literature in a narrative review. Four patients developed LTS following intubation from COVID-19 pneumonia. Three patients remain tracheostomy-dependent, and the fourth required a heroic operative schedule to avoid tracheostomy. Conclusion: Intubation for COVID-19 pneumonia can result in severe LTS, which may persist despite endoscopic intervention.

Outcomes following traumatic inhalational airway injury - Predictors of mortality and effect of procedural intervention

OBJECTIVE

Study outcomes, predictors of mortality, and effects of procedural interventions on patients following traumatic inhalational airway injury.

STUDY

Design: Retrospective study.

SETTING

National Trauma Data Bank METHODS: Patients over the age of eighteen admitted between 2008 and 2016 to NTDB-participating sites were included. In-hospital mortality and length of stay were the primary outcomes.

RESULTS

The final study cohort included 13,351 patients. History of active smoking was negatively associated with in-house mortality with an OR of 0.33 (0.25-0.44). History of alcohol use, and presence of significant medical co-morbidities were positively associated with in-house mortality with OR of 5.28 (4.32-6.46) 2.74 (19.4-3.86) respectively. There was little to no association between procedural interventions and in-house mortality. Intubation, laryngobronchoscopy, and tracheostomy had OR of 0.90 (0.67-1.20), 1.02 (0.79-1.30), and 0.94 (0.58-1.51), respectively. However, procedural intervention did affect both the median hospital and ICU lengths of stay of patients. Median hospital and ICU length of stay were shorter for patients receiving endotracheal intubation. Median hospital length of stay was longer for patients undergoing bronchoscopy and laryngoscopy, but median ICU length of stay was shorter for patients undergoing bronchoscopy and laryngoscopy. Patients receiving a tracheostomy have both significantly increased median hospital and ICU lengths of stay.

CONCLUSIONS

Active smoking was associated with decreased odds of in-hospital mortality, while presence of pre-existing medical comorbidities and history of alcohol use disorder was associated with increased odds of in-hospital mortality. Procedural intervention had little to no association with in-hospital mortality but did affect overall hospital and ICU LOS.

Laryngeal Injury and Upper Airway Symptoms After Endotracheal Intubation During Surgery: A Systematic Review and Meta-analysis

Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval [CI], 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.

Prevalence, Pathophysiology, Diagnostic Modalities, and Treatment Options for Dysphagia in Critically Ill Patients

Postextubation dysphagia may impose a substantial burden on intensive care unit patients and healthcare systems. Approximately 517,000 patients survive mechanical ventilation during critical care annually. Reports of postextubation dysphagia prevalence are highly variable ranging between 3% and 93%. Of great concern is aspiration leading to the development of aspiration pneumonia when patients resume oral feeding. Screening for aspiration with a water swallow test has been reported to be positive for 12% of patients in the intensive care unit after extubation. This review aims to increase awareness of postextubation dysphagia and provide an updated overview of the current knowledge regarding prevalence, pathophysiology, diagnostic modalities, and treatment options.

Laryngotracheal injuries after intubation in pediatric seizure patients: A case series and a review of the literature

Acute management of seizures may require intubation with an endotracheal tube (ETT) in addition to benzodiazepine administration. Although necessary for management at times, intubation can lead to laryngotracheal injury as has been reported at length in both the adult and pediatric populations. A review of the literature shows no prior reports of laryngotracheal injuries following intubation in actively seizing pediatric patients. We share our experience with two pediatric patients who had laryngotracheal injuries after being emergently intubated with large ETT's during management of their seizures. We describe two unique cases in the pediatric seizure population associated with laryngotracheal injuries with the goal of emphasizing appropriate ETT sizing for intubation.

Aetiopathogenesis of Laryngotracheal Stenosis: A Retrospective Review

Background. Airway stenosis is a technically challenging pathology to deal with. Various aetiologies can lead to the stenosis; however, trauma, mostly related to intubation, is the commonest so far. This study retrospectively evaluates various aetiological factors resulting in airway stenosis and the associated patient-related factors. Objectives. The objectives of this study were to evaluate the common patient-related factors, aetiology, site, and mode of presentation of airway stenosis and to evaluate the duration of intubation resulting in airway stenosis. Materials and methods. This was a retrospective study carried out at the Department of ENT-HNS, Institute of Medicine, Nepal. Record files from January 2014 to January 2019 of all cases with endoscopic diagnosis of airway stenosis were evaluated. Demographic data, site, severity, aetiology, time, and mode of presentation were noted. The severity of stenosis was graded based on Cotton–Meyer (CM) classification. Results. A total of 33 cases were included in the study. The trachea and the subglottis were the frequent sites to be involved. Intubation-related trauma was the commonest aetiology with a shortest duration of intubation of only 4 days resulting in development of the stenosis. The other aetiologies were congenital, trauma, inflammation, and idiopathic. Conclusion. Trauma, mostly related to intubation, is still the commonest cause for the development of airway stenosis. Along with the duration of intubation, there are several other factors that can affect the development of stenosis. A prospective study with a large population is required to draw a definite conclusion.

Classification of tracheal stenosis in children based on computational aerodynamics

Tracheal stenosis is a health condition in which local narrowing of the upper trachea can cause breathing difficulties and increased incidence of infection, among other symptoms. Occurring most commonly due to intubation of infants, tracheal stenosis often requires corrective surgery. It is challenging to determine the most effective surgical strategy for a given patient as current clinical methods used to assess tracheal stenosis are simplistic and subjective, and are not rigorously based on aerodynamic considerations. This paper summarizes a non-invasive approach based on computational fluid dynamics (CFD) and medical imaging to establish relationships between trachea anatomy and inspiration performance. Though patient-specific CFD analysis has gained recent popularity, an objective of this study is to computationally formulate dimensionless analytical correlations between anatomy and performance that are applicable to any member of a class of patients and that can be interpreted within the context of the Myer-Cotton stenotic airway classification system. These correlations can provide aerodynamics-based insight for the development of more robust stenosis evaluation methods and may allow for time-efficient assessment of corrective surgical strategies.

Association between clinical risk factors and severity of dysphagia after extubation based on a videofluoroscopic swallowing study

BACKGROUND/AIMS

This study aimed to evaluate the correlation between clinical risk factors of post-extubation dysphagia (PED) and the severity of impaired pharyngeal swallowing function assessed via videofluoroscopic swallowing studies (VFSSs).

METHODS

This study was a retrospective review of medical records. Of 116 patients who were admitted to the intensive care unit and underwent VFSS, 32 who had non-neurologic disorders and experienced prolonged intubation (for more than 48 hours) were diagnosed with PED. The severity of PED was evaluated by using a functional dysphagia scale (FDS) and a penetration aspiration scale (PAS), on the basis of VFSS.

RESULTS

The Simplified Acute Physiology Score 3 and total FDS score were positively correlated (r = 0.40, p = 0.02). Intubation duration was positively correlated with total PAS and FDS scores (r = 0.62, p < 0.001; r = 0.65, p < 0.001, respectively). The amounts of residue in the valleculae (RV) and pyriform sinuses (RP) were associated with intubation duration (r = 0.58, p < 0.001; r = 0.57, p < 0.001, respectively). Multivariate regression analysis revealed that intubation duration was significantly associated with the total FDS score, RV and RP subscales of the FDS, and total PAS score.

CONCLUSION

The severity of impaired swallowing function, particularly the amount of residue in the pharyngeal recesses assessed via VFSS, was strongly associated with both severity of medical illness and intubation duration. Intubation duration could be a prognostic factor for assessing impaired swallowing function on the basis of VFSS.

A closed claims analysis of vocal cord injuries related to endotracheal intubation between 2004 and 2015

STUDY OBJECTIVE

To provide a contemporary medicolegal analysis of claims brought against anesthesiologists for injuries related to endotracheal intubation.

DESIGN

A retrospective study of closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2004 and 2015.

SETTING

Closed claims that occurred in any surgical specialty in which the patient was undergoing general anesthesia and anesthesiology was named as the primary responsible service.

PATIENTS

Twenty claims were identified for analysis in 7 surgical specialties. Patient ages ranged from 45 to 76. Data regarding patient comorbidities and case history were obtained when available.

INTERVENTIONS

None.

MEASUREMENTS

Data collected includes patient demographics such as age, outcome severity, alleged complication, plaintiff allegations, contributing factors to the injury, the surgical specialty in which the injury occurred, and the ultimate result of the claim (dismissed/denied/settled).

MAIN RESULTS

Out of 20 claims, settlement payments were made in 10% of claims with a mean payment amount of $7669. Mean patient age was 55.6 years. Within severity of injuries, 65% of claims were classified as "Permanent Minor." The most common contributing factor in claims was "Technical Knowledge/Performance" and the most common plaintiff allegation was "Trauma from endotracheal tube placement." Bilateral vocal cord paralysis, unilateral (left-sided) vocal cord paralysis, and laryngeal nerve injury were the top alleged complications. The surgical specialty in which claims most often resulted was orthopedic surgery.

CONCLUSIONS

Injuries related to endotracheal intubation remain an ongoing challenge to anesthesiologists. Their etiology is often multifactorial and was found in this study to stem most commonly from technical errors and patient co-morbidities. A detailed discussion of risks with patients during the consent process, careful documentation of such discussion, and prompt referral to specialists when needed are critical. Understanding the patterns related to injuries during intubation is essential in order to develop strategies for improved patient safety and outcomes.

Type I Posterior Glottic Stenosis: Natural History and In-Office Management

Objectives:

To review the natural history of type I posterior glottic stenosis (PGS-I) and its treatment outcomes through a case presentation and demonstrate the feasibility of in-office management of PGS-I.

Methods:

The case of a middle-aged woman who developed PGS-I after prolonged intubation is presented. A review of the literature on management and treatment outcomes of PGS-I is also performed.

Results:

Initially presenting with a large granuloma that failed conservative management, the patient deferred surgical intervention and developed unilateral vocal fold hypomobility with posterior glottic synechia. The adhesion was successfully ablated in the office with potassium-titanyl-phosphate (KTP) laser; however, vocal fold hypomobility persisted after treatment.

Conclusions:

This case illustrates the natural history of the development of PGS-I, demonstrates the feasibility of office-based management of this condition, and provides further evidence that lysis of PGS-I synechia does not uniformly lead to restoration of normal laryngeal function and mobility.

Glottic Stenosis: An Anatomic Analysis and New Treatment With a Self-Retaining Interarytenoid Spring

Introduction:

Endotracheal (ET) intubation is a common cause of acquired glottic stenosis. Severe cases often require an irreversible arytenoidectomy/cordectomy, which typically results in poor voice quality. Adult human cadaver larynges were studied to gain insights about ET tube–induced posterior glottic injuries, hoping to create a less invasive remedy.

Study Design:

Human cadaver investigation and case reports.

Methods:

Microlaryngeal assessments were done on 10 human cadaver larynges (5 men, 5 women) with and without ET tubes. After supracricoid soft tissue resection, measurements were obtained, including the distance between the outer diameter of the ET tube and the medial aspect of the cricoarytenoid joint facet. Additionally, measurements of the circumferential arc of differently sized ET tubes were made alongside both cricoarytenoid joint capsules. This information was used to design a silastic stent that would function as a self-retaining interarytenoid spring to treat posterior glottic stenosis in 5 patients. Four of 5 patients included in the clinical study were tracheotomy dependent, primarily because of glottic stenosis. The human surgical technique is described in detail.

Results:

The shortest distance between the outer diameter of the ET tube to the medial cricoid facet averaged 5.02 mm in men and 3.62 mm in women. On the basis of the diameter of the intralaryngeal component of the initially round stent, and the position of the cricoarytenoid joint facets, the interarytenoid spring would have a subtended arc between 110° and 175°. These data helped fashion parameters for modifying a conventional T-tube to form a new self-retaining silastic interarytenoid spring. The first 5 human cases have been successful, allowing effective tracheotomy tube decannulation and excellent voice quality.

Conclusions:

The anatomic investigation herein provided key insights into ET tube–induced glottic stenosis and facilitated a new straightforward procedure to surgically improve the airway yet preserve excellent vocal function in patients with acquired glottic stenosis. Level of Evidence: NA

Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review

OBJECTIVES

To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the ICU.

DATA SOURCES

PubMed, Embase, CINAHL, and Cochrane Library from database inception to September 2017.

STUDY SELECTION

Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed postextubation laryngeal examinations with either direct or indirect visualization.

DATA EXTRACTION

Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration's criteria.

DATA SYNTHESIS

Nine studies (seven cohorts, two cross-sectional) representing 775 patients met eligibility criteria. The mean (SD; 95% CI) duration of intubation was 8.2 days (6.0 d; 7.7-8.7 d). A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13-31% of patients across studies. The most frequently occurring clinical symptoms reported post extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies.

CONCLUSIONS

Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.

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

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.

Image-Based 3-Dimensional Characterization of Laryngotracheal Stenosis in Children

Objectives

Describe a technique for the description and classification of laryngotracheal stenosis in children using 3-dimensional reconstructions of the airway from computed tomography (CT) scans.

Study Design

Cross-sectional.

Setting

Academic tertiary care children’s hospital.

Subjects and Methods

Three-dimensional models of the subglottic airway lumen were created using CT scans from 54 children undergoing imaging for indications other than airway disease. The base lumen models were deformed in software to simulate subglottic airway segments with 0%, 25%, 50%, and 75% stenoses for each subject. Statistical analysis of the airway geometry was performed using metrics extracted from the lumen centerlines. The centerline analysis was used to develop a system for subglottic stenosis assessment and classification from patient-specific airway imaging.

Results

The scaled hydraulic diameter gradient metric derived from intersectional changes in the lumen can be used to accurately classify and quantitate subglottic stenosis in the airway based on CT scan imaging. Classification is most accurate in the clinically relevant 25% to 75% range of stenosis.

Conclusions

Laryngotracheal stenosis is a complex diagnosis requiring an understanding of the airway lumen configuration, anatomical distortions of the airway framework, and alterations of respiratory aerodynamics. Using image-based airway models, we have developed a metric that accurately captures subglottis patency. While not intended to replace endoscopic evaluation and existing staging systems for laryngotracheal stenosis, further development of these techniques will facilitate future studies of upper airway computational fluid dynamics and the clinical evaluation of airway disease.

The occurrence of pressure damage in the oral cavity caused by endotracheal tubes

The aim of this observational study was to investigate the occurrence of pressure damage caused by endotracheal tubes (ETT) when the tube is repositioned from one corner of the mouth to the other every third day. For the assessment of oral condition and the eventual damage caused by ETT, a modified version of the Oral Assessment Guide (OAG) was used. The oral condition was assessed once per day in all adult patients who were orally intubated with a tube for over 24 hours. Thirty-eight patients were included in the study. Most patients ( n = 33, 86.8%) had no pressure damage. Five patients (13.2%) had pressure damage on the oral mucosa and lip caused by endotracheal tubes. The group with damage to the oral mucosa was treated with noradrenaline, had bleeding problems and clotting disorders and had significantly more intubated and study days. The assessment of the oral mucosa according to the OAG reflected the worsening oral condition in the group with pressure damage. Endotracheal tubes may need to be repositioned more often than every third day to avoid pressure damage in patients with a high risk of complications, and individually tailored care may need to be implemented.

"Post intubation Laryngeal injuries in a pediatric intensive care unit of tertiary hospital in India: A Fibreoptic endoscopic study"

STUDY OBJECTIVES

To identify acute laryngeal injuries among pediatric patients intubated for more than 48hours, and to correlate these injuries with clinical variables.

SETTING

Pediatric Intensive Care Unit (PICU) of a tertiary level hospital in India.

PATIENTS AND METHODS

Prospective, observational study. Thirty-four children meeting the inclusion and exclusion criteria were recruited into the study after obtaining informed consent from the parents. A bedside, flexible, fiberoptic laryngoscopy was done within the first 24hours of extubation. Laryngeal injuries were documented and graded. Individual types of laryngeal injuries were correlated to the duration of intubation, size of the tube, the experience of the intubator and the patient's demographics. A repeat endoscopy was done in the outpatient department, 3-4 weeks after extubation, and findings noted.

RESULTS

97% had acute laryngeal injury, of which 88% were significant. Erythema was the most common form of injury. Duration of intubation, with a mean of 4.5 days, showed a trend towards significance (p=0.06) for association with subglottic narrowing. Laryngeal injuries were similar with both cuffed and uncuffed tubes. Age of the subject, size of the tube and skill level of the intubator did not correlate with the laryngeal injuries. 18% required intervention for post-extubation laryngeal lesions. Three (10%) children had post-extubation stridor, and of these, two needed surgical intervention (6%).

CONCLUSION

Post-extubation laryngeal injuries are not uncommon. Fiberoptic endoscopy is an inexpensive and cost-effective tool for bedside evaluation of post-intubation status in pediatric larynx. Early diagnosis of post-intubation laryngeal injuries in children can prevent long term sequelae. Hence, post-extubation fiberoptic laryngoscopy should be done routinely in pediatric population.

Predictors of Posterior Glottic Stenosis: A Multi-Institutional Case-Control Study

OBJECTIVE

To assess intrinsic and extrinsic risk factors in the development of posterior glottic stenosis (PGS) in intubated patients.

METHODS

Patients diagnosed with PGS between September 2012 and May 2014 at 3 tertiary care university hospitals were included. Patient demographics, comorbidities, duration of intubation, endotracheal tube (ETT) size, and indication for intubation were recorded. Patients with PGS were compared to control patients represented by patients intubated in intensive care units (ICU).

RESULTS

Thirty-six PGS patients were identified. After exclusion, 28 PGS patients (14 male, 14 female) and 112 (65 male, 47 female) controls were studied. Multivariate analysis demonstrated ischemia (P < .05), diabetes (P < .01), and length of intubation (P < .01) were significant risk factors for the development of PGS. Fourteen of 14 (100%) males were intubated with a size 8 or larger ETT compared to 47 of 65 (72.3%) male controls (P < .05). Posterior glottic stenosis (P < .01), length of intubation (P < .001), and obstructive sleep apnea (P < .05) were significant risk factors for tracheostomy.

CONCLUSION

Duration of intubation, ischemia, diabetes mellitus, and large ETT size (8 or greater) in males were significant risk factors for the development of PGS. Reducing the use of size 8 ETTs and earlier planned tracheostomy in high-risk patients may reduce the incidence of PGS and improve ICU safety.

Laryngotracheal stenosis in critically ill patients

CONCLUSIONS

Prolonged artificial pulmonary ventilation by tracheostomy tube (>30 days) doubled the risk of stenosis (relative risk, RR = 2.04, p = 0.002). Critically ill patients with repeated tracheotomies were more than six times likely to experience stenosis (RR = 6.44, p< 0.001) than other critically ill patients.

OBJECTIVE

In this retrospective study, we describe the occurrence of laryngotracheal stenosis (LTS) in critically ill patients after elective tracheostomy who had undergone treatment for LTS at the Na Homolce Hospital in Prague, Czech Republic.

METHODS

We studied 28 patients who were diagnosed with symptomatic LTS. Basic major demographic data, duration of mechanical ventilation, onset of tracheal stenosis after decannulation, and tracheostomy type (percutaneous dilatational or surgical tracheostomy) were recorded. The number of patients requiring repeated tracheostomies was also recorded.

RESULTS

Neither the demographic data nor the type of tracheostomy represented statistically significant risk factors. The risk factors for LTS were prolonged artificial pulmonary ventilation using the tracheostomy tube (p = 0.005) and repeated tracheostomy (p< 0.001). The mean onset of stenosis symptoms was 53.7 days (range 2-300 days), with a median of 58 days. Stenosis involved the trachea in 20 patients, subglottis in five cases, and glottis and subglottis in three cases. Seven patients (25%) underwent a tracheal resection and primary end-to-end reconstruction. One patient underwent laryngotracheoplasty with dilatation. The procedure was endoscopic in 18 patients (64.3%). Two patients (7.1%) received permanent tracheostomies.

Laryngeal injury from prolonged intubation: a prospective analysis of contributing factors

OBJECTIVES/HYPOTHESIS

The factors leading to laryngeal injury due to intubation are not fully understood. This study sought to determine if duration of intubation, size of endotracheal tube, and/or type of endotracheal tube impact the degree of vocal fold immobility and other laryngeal injury upon extubation.

STUDY DESIGN

Prospective study.

METHODS

Sixty-one adult patients intubated for more than 48 hours were examined by recorded flexible nasolaryngoscopy shortly after extubation.

RESULTS

Forty-one percent of patients had some degree of vocal fold immobility. However, neither the duration of intubation (range, 2-28 days; mean, 9.1 days), the size of endotracheal tube (range, 6 to 8), nor the type of endotracheal tube significantly affected the degree of laryngeal injury including vocal fold immobility. Additionally, none of the collected demographic information (age, gender, height, weight) significantly affected the degree of laryngeal injury.

CONCLUSIONS

In this cohort, duration of intubation, type of endotracheal tube, and size of endotracheal tube do not significantly correlate to the incidence of vocal fold mobility and degree of laryngeal injury noted after prolonged intubation.