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. 2021 Oct 1;22(10):e502-e512.
doi: 10.1097/PCC.0000000000002724.

Subglottic Post-Extubation Upper Airway Obstruction Is Associated With Long-Term Airway Morbidity in Children

Jack Green  1 , Patrick A Ross  2   3 , Christopher J L Newth  2   3 , Robinder G Khemani  2   3
Affiliations

Subglottic Post-Extubation Upper Airway Obstruction Is Associated With Long-Term Airway Morbidity in Children

Jack Green et al. Pediatr Crit Care Med. .

Abstract

Objectives: Post-extubation upper airway obstruction is the most common cause of extubation failure in children, but there are few data regarding long-term morbidity. We aim to describe the frequency of long-term airway sequelae in intubated children and determine the association with post-extubation upper airway obstruction.

Design: Retrospective, post hoc analysis of previously identified prospective cohort of children in the pediatric/cardiothoracic ICU at Children's Hospital Los Angeles from July 2012 to April 2015. A single provider blinded to the upper airway obstruction classification reviewed the electronic medical records of all patients in the parent study, before and after the index extubation (extubation during parent study), to identify pre-index and post-index upper airway disease. Primary outcomes were prevalence of newly diagnosed airway anomalies following index extubation.

Setting: Single center, tertiary, 391-bed children's hospital.

Patients: From the parent study, 327 children younger than 18 years (intubated for at least 12 hr) were included if they received subsequent care (regardless of specialty) after the index extubation.

Interventions: None.

Measurements and main results: New airway anomalies were identified in 40 of 327 children (12.2%). Patients labeled with subglottic upper airway obstruction at the index extubation were more likely to be diagnosed with new airway anomalies on subsequent follow-up, receive long-term Otolaryngology follow-up, or receive airway surgery (all p ≤ 0.006). In multivariable modeling, upper airway obstruction as the primary reason for initial intubation (odds ratio, 3.71; CI, 1.50-9.19), reintubation during the index ICU admission (odds ratio, 4.44; CI, 1.67-11.80), pre-index airway anomaly (odds ratio, 3.31; CI, 1.36-8.01), and post-extubation subglottic upper airway obstruction (odds ratio, 3.50; CI, 1.46-8.34) remained independently associated with the diagnosis of new airway anomalies.

Conclusions: Post-extubation subglottic upper airway obstruction is associated with a three-fold greater odds of long-term airway morbidity. These patients may represent an at-risk population that should be monitored closely after leaving the ICU.

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Conflict of interest statement

Drs. Green, Newth, and Khemani received support for article research from the National Institutes of Health (NIH). Dr. Newth’s institution received funding from the NIH; he received funding from Philips Research North America and Nihon Kohden OrangeMed. Dr. Khemani’s institution received funding from the NIH, the National Institute of Child Health and Human Development, and Securisyn Medical; he received funding from Nihon Kohden OrangeMed. Dr. Ross has disclosed that he does not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
(a) Case of a one-month-old male with aortic arch hypoplasia and cleft lip post-cardiac surgery. He was found to have tool-assessed subglottic UAO after index study extubation and taken to the OR for bronchoscopy with findings showing a considerable amount of arytenoid edema with prolapse into the glottic airway causing obstruction. He ultimately required tracheostomy. (b) Case of a six-week-old female with hypoplastic left heart syndrome post-cardiac surgery, also found to have tool-assessed subglottic UAO after index study extubation. Initial workup for stridor included multiple bedside flexible laryngoscopies with no significant pathology. Eight months later, she was taken to the OR for formal bronchoscopy with findings showing glottic band at the inferior border of the posterior aspect of the true vocal folds, which is thick and narrowing the airway to about a 4 mm diameter, requiring band excision. figure 1A – small arrow represents left vocal fold granuloma, large arrow represents arytenoid edema with prolapse; figure 1B – arrow represents very thick glottic band causing airway narrowing
Figure 1.
Figure 1.
(a) Case of a one-month-old male with aortic arch hypoplasia and cleft lip post-cardiac surgery. He was found to have tool-assessed subglottic UAO after index study extubation and taken to the OR for bronchoscopy with findings showing a considerable amount of arytenoid edema with prolapse into the glottic airway causing obstruction. He ultimately required tracheostomy. (b) Case of a six-week-old female with hypoplastic left heart syndrome post-cardiac surgery, also found to have tool-assessed subglottic UAO after index study extubation. Initial workup for stridor included multiple bedside flexible laryngoscopies with no significant pathology. Eight months later, she was taken to the OR for formal bronchoscopy with findings showing glottic band at the inferior border of the posterior aspect of the true vocal folds, which is thick and narrowing the airway to about a 4 mm diameter, requiring band excision. figure 1A – small arrow represents left vocal fold granuloma, large arrow represents arytenoid edema with prolapse; figure 1B – arrow represents very thick glottic band causing airway narrowing
Figure 2.
Figure 2.
STARD (Standards for Reporting of Diagnostic Accuracy Studies) flow diagram
See this image and copyright information in PMC

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