A European Multicenter Outcome Study of Perioperative Airway Management Policies following Midface Surgery in Syndromic Craniosynostosis

Abstract

Background: Perioperative airway management following midface advancements in children with Apert and Crouzon-Pfeiffer syndromes can be challenging, and protocols often differ. This study examined airway management following midface advancements and postoperative respiratory complications.

Methods: A multicenter, retrospective cohort study was performed to obtain information about the timing of extubation, perioperative airway management, and respiratory complications after monobloc or Le Fort III procedures.

Results: A total of 275 patients (monobloc surgery, n = 129; Le Fort III surgery, n = 146) were included. Sixty-two patients received immediate extubation and 162 received delayed extubation; 42 had long-term tracheostomies, and 9 had perioperative short-term tracheostomies. In most centers, short-term tracheostomies were reserved for selected cases. Patients with delayed extubation remained intubated for 3 days (interquartile range, 2 to 5 days). The rate of no or only oxygen support after extubation was comparable between immediate and delayed extubation groups (58 of 62 patients [94%] and 137 of 162 patients [85%], respectively). However, the immediate extubation group developed fewer cases of postoperative pneumonia than did the delayed group (0 of 62 [0%] versus 24 of 161 [15%]; P = 0.001). Immediate extubation also appeared safe in moderate to severe obstructive sleep apnea, as 19 of 20 patients (95%) required either no or only oxygen support after extubation. The odds of developing intubation-related complications increased by 21% with every extra day of intubation.

Conclusions: Immediate extubation following midface advancements was found to be a safe option, as it was not associated with respiratory insufficiency but did lead to fewer complications. Immediate extubation should be considered routine management in patients with no or mild obstructive sleep apnea, and should be the aim in moderate to severe obstructive sleep apnea cases after careful assessment.

Clinical question/level of evidence: Therapeutic, III.

Fig. 1.

Bar chart showing absolute numbers of patients per perioperative airway management strategy and medical center location. IEX, immediate extubation; DEX, delayed extubation; STT, short-term tracheostomy; LTT, long-term tracheostomy; SP, Spain; NETH, the Netherlands; SWE, Sweden; UK, United Kingdom; GER, Germany; POL, Poland; FRA, France.

Fig. 2.

Stacked bar chart showing distribution of perioperative airway management strategies by medical center location. IEX, immediate extubation; DEX, delayed extubation; STT, short-term tracheostomy; LTT, long-term tracheostomy; SP, Spain; NETH, the Netherlands; SWE, Sweden; UK, United Kingdom; GER, Germany; POL, Poland; FRA, France.

Fig. 3.

Boxplots show the number of days (median and IQR) of intubation in patients with delayed extubation (above) and mechanical ventilation in patients with a long-term tracheostomy (below) by medical center location. The colored dots show the distribution of patients and outliers per medical center. SP, Spain; UK, United Kingdom; NETH, the Netherlands; SWE, Sweden; POL, Poland; FRA, France; GER, Germany.