Assessment of socioeconomic disadvantage in laryngotracheoplasty outcomes among pediatric patients

OBJECTIVES

To determine whether socioeconomic disadvantage impacts outcomes after pediatric laryngotracheoplasty.

STUDY DESIGN

Case series with chart review.

METHODS

All laryngotracheoplasty procedures at a tertiary children's hospital between 2010 and 2019 were included. Primary zip code determined Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure, and children were grouped based on less or more community disadvantage. Primary outcomes included complication and decannulation rates.

RESULTS

Eighty-four procedures were included with 69% (58/84) double-stage and 31% (26/84) single-stage reconstructions. Median age at surgery was 3.2 (IQR 2.2-4.9) years, 56% (47/84) were male, and median gestational age was 25 (IQR 24-28) weeks. Children from more disadvantaged communities represented 67% (56/84) of surgeries and were more likely to have higher grade stenosis (89% vs. 64%, P = .02). Postoperative airway complications (20% vs. 18%, P = .99), non-airway complications (14% vs. 18%, P = .75), and total length of stay (7 vs. 6 days, P = .26) were not impacted by ADI grouping. While children from higher community disadvantage were just as likely to be decannulated after double stage surgeries (76% vs. 76%, P = .99), it more often took longer than six months to achieve (90% vs. 61%, P = .04).

CONCLUSIONS

Community disadvantage is associated with higher grade airway stenosis and longer times to successful decannulation in children requiring expansion airway surgery. Encouragingly, ADI grouping did not impact complication and decannulation rates. Continued work is needed to understand how socioeconomic metrics influence pediatric open airway surgery.

Pediatric Airway Surgeries in COVID 19 Era

To outline a set of recommendations on the management of pediatric cases who requiring airway surgery in the context of COVID 19 pandemic. A set of recommendations have been prepared based on National and International published scientific literature and recent updates on COVID 19. These has been implemented in our tertiary care centre. Due to the evolving nature of COVID 19 and existing knowledge gaps, these recommendations may have to be revised periodically. The incidence of COVID 19 is very low (1-5%) in the pediatric age group with relatively good prognosis. Pediatric airway surgeries should be restricted to emergency cases only. The decision of postponement of the surgical cases should be taken by the team of senior pediatric airway surgeons. Flexible laryngoscopy should be avoided. Foreign body cases should undergo a computed tomography scan to avoid diagnostic bronchoscopies. All the measures should be taken to prevent direct contact of aerosol so powered instruments should not be used unless mandatory. Protective draping method should be adopted to prevent aerosol exposure. As paediatric airway surgeries are aerosol generating procedure where the risk of contracting COVID 19 by the surgeons and support staff is very high, we suggest recommendations to prevent the contact with infected aerosol. We assure these recommendations are easy to follow and can impact good quality outcome during this pandemic crisis.

Pediatric airway surgery under spontaneous respiration using high-flow nasal oxygen

OBJECTIVES

In pediatric airway surgery, SponTaneous Respiration using IntraVEnous anesthesia and Hi-flow nasal oxygen (STRIVE Hi) has not been well explored. Here, we report our experience of using STRIVE Hi in endoscopic evaluations and surgeries of the pediatric airway.

METHODS

This retrospective review was based on 45 airway procedures conducted under STRIVE Hi, performed by a single surgeon at a single institute from May 2017 to September 2018. After induction of anesthesia, continuous infusion with propofol and remifentanil was provided to ensure an adequate level of anesthesia and supply of humidified oxygen via a nasal cannula. Monitoring was conducted using a transcutaneous CO₂ sensor and a pulse oximeter, and the oxygen reserve and bispectral indexes were measured. No muscle relaxant was administered.

RESULTS

The median age of the patients was 16.0 months (range: 1-215 months) and the median weight was 10.2 kg (range: 2.4-38.5 kg). The median duration of spontaneous respiration was min 40 (range: 10-140 min). The airway procedures included diagnostic microlaryngoscopy, tracheocutaneous fistula excision, balloon dilation, supraglottoplasty, laryngeal cleft repair, injection laryngoplasty, papilloma excision, and subglottic cyst removal. During these procedures, STRIVE Hi facilitated evaluation of dynamic obstruction of the airway and the immediate outcome of surgical treatment and provided a good surgical view. Intubation and the termination of spontaneous respiration were required in only five patients.

CONCLUSIONS

STRIVE Hi is an effective and feasible anesthesia option in pediatric airway surgery. It provides unobstructed surgical access and is applicable to a wide range of procedures.

Rigid dilatation of pediatric laryngotracheal stenosis as an adequate alternative to balloon dilatation

INTRODUCTION

Endoscopic balloon dilation (EBD) is the mainstay of endoscopic therapy for laryngotracheal stenosis (LTS), although there is no evidence that it achieves better results than traditional rigid laryngeal dilators. Rigid bougie dilators are less expensive and easier to use, and confer the advantage of providing tactile information about the stenosis to the surgeon. We analyzed the outcome of endoscopic rigid bougie dilatation of LTS in a large series of children and compared it to the reported results of EBD in the same setting.

PATIENTS AND METHODS

All cases of pediatric LTS treated by endoscopic rigid dilatation in a tertiary referral center between 2006 and 2015 were retrospectively studied. They were divided into a primary dilatation group (PDG) and a post-reconstruction dilatation group (PRG). The PDG children had no history of reconstructive airway surgery, and dilatation was the major treatment approach. The PRG children underwent dilatations after airway reconstruction surgery as part of routine postoperative management. A successful primary outcome was defined as improvement of dyspnea and achievement of a functional airway without reconstructive laryngotracheal surgery or need for a tracheostomy at final follow-up.

RESULTS

Sixty-two children (68 cases, mean age 5.1 years, range 0.7-17.2) underwent 156 endoscopic rigid dilatations. Successful outcome was achieved in 48 cases (70.6%), 73.0% in the PDG and 67.7% in the PRG. There were no procedure-related adverse events.

CONCLUSIONS

Endoscopic rigid dilatation is a relatively inexpensive and efficacious tool in endoscopic management of pediatric LTS. Its success rates are in the same range as those of EBD.