Post-extubation Stridor Research Articles

Complicaciones de la Ventilación Mecánica en niños

La ventilación mecánica (VM) puede salvar la vida del niño con insuficiencia respiratoria, pero sus complicaciones pueden incrementar la morbimortalidad. Decidimos realizar un estudio para evaluar la frecuencia de las complicaciones de la VM. Durante un periodo de 17 meses, todos los pacientes admitidos a la UCI del Instituto de Salud del Niño y sometidos a VM fueron evaluados prospectivamente. Se registró edad, diagnóstico(s), estado nutricional, tamaño del tubo endotraqueal (TET), duración de la VM, parámetros ventilatorios y complicaciones: intubación endobronquial (lE), obstrucción del TET, atelectasias, barotrauma (BT), infección respiratoria y estridor postextubación. La edad promedio fue 37 meses (<1 día - 19 años). La duración promedio de la VM fue de 5.7 días. En los niños que presentaron alguna complicación, el tiempo de VM fue significativamente mayor (p< 0.05). Se registró 228 complicaciones en 142 (31.6%) pacientes; 97 (21.6%) pacientes fueron malnutridos; ellos tuvieron una mortalidad significativamente mayor (p< 0.001, chi cuadrado, corrección de Yates). Se observó lE en 47 (10.5%) pacientes; BT en 66 (14.7%): infección en 46 (10.2%); atelectasia en 44 (9.8%); estridor postextubación en 10 (2.2%) y obstrucción del TET en 4 (0.9%). Ocho pacientes fallecieron por causas relacionadas a alguna complicación. La edad menor de 1 mes se asoció a mayor frecuencia de atelectasias e lE (p< 0.001 y 0.003, respectivamente); y la enfermedad pulmonar focal se asoció a mayor frecuencia de BT, infección y atelectasia (p< 0.001). El enfisema pulmonar intersticial (EPI) fue la forma más común de barotrauma. Conclusiones: 1) Las complicaciones de la VM se incrementan conforme aumenta la duración de su empleo; 2) La mayoría de las muertes por VM son prevenibles; 3) Los neonatos y niños con enfermedades pulmonares focales tienen mayor riesgo de complicaciones; 4) El EPI es la forma más común de barotrauma en niños.

Management of Post extubation stridor following Total thyroidectomy due to bilateral recurrent laryngeal nerve damage - a case report

Recurrent laryngeal nerve(RLN) damage during total thyroidectomy is rare and estimated to occur in upto 14% of cases. Damage to RLN may be unilateral or bilateral. Bilateral RLN injury results in dysfunction of both vocal cords ;which remain in midline during inspiration. After extubation ,biphasic stridor ,respiratory distress and aphonia occurs due to unopposed adduction of vocal cords and closure of glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Deliberate intraoperative identification and preservation of the recurrent laryngeal nerve minimizes the risk of injury. Post operative visualization of vocal cord movements should also be performed as patients may be asymptomatic at first .Laryngeal electromyography EMG may be useful to distinguish vocal cord paralysis from injury to the cricoarytenoid joint secondary to intubation, and it may yield prognostic information. We report a case of post extubation stridor following total thyroidectomy probably due to accidental bilateral RLN damage and the management of the same after tracheal extubation

Obstructive Fibrinous Tracheal Pseudomembrane: A Rare Condition in Postextubation Stridor

Obstructive fibrinous tracheal pseudomembrane (OFTP) is an airway complication that occurs after endotracheal intubation. It originates from superficial mucosal abrasion and desquamation of necrotic tracheal epithelium at the site of cuff pressure. This condition is a rare cause of postextubation stridor. We present a case of postextubation stridor secondary to OFTP, resulting in clinical features of upper airway obstruction > 8 h after extubation. The case features complete obstruction at the tip of the endotracheal tube from OFTP.

Laryngeal ultrasonography versus cuff leak test in predicting postextubation stridor.

Introduction: Although cuff leak test has been proposed as a simple method of predicting the occurrence of postextubation stridor, cut-off point of cuff-leak volume substantially differs between previous studies. In addition, laryngeal ultrasonography including measurement of air column width could predict postextubation stridor. The aim of the present study was to evaluate the value of laryngeal ultrasonography versus cuff leak test in predicting postextubation stridor. Methods: In a prospective study, all patients intubated for a minimum of 24 h for acute respiratory failure, airway protection and other causes were included. Patients were evaluated for postextubation stridor and need for reintubation after extubation. The cuff leak volume was defined as a difference between expiratory tidal volumes with the cuff inflated and deflated. Laryngeal air column width was defined as the width of air passed through the vocal cords as determined by laryngeal ultrasonography. The air-column width difference was the width difference between balloon-cuff inflation and deflation. Results: Forty one intubated patients with the mean age of 57.16±20.07 years were included. Postextubation stridor was observed in 4 patients (9.75%). Cuff leak test (cut off point: 249 mL) showed sensitivity and specificity of 75% and 59%, respectively. In addition, laryngeal ultrasonography (cut off point for air column width: 10.95 mm) resulted in sensitivity and specificity of 50% and 54%, respectively. Positive predictive value of both methods were <20%. Conclusion: Both cuff leak test and laryngeal ultrasonography have low positive predictive value and sensitivity in predicting postextubation stridor and should be used with caution in this regard.

Safety and reliability of the sealing cuff pressure of the Microcuff pediatric tracheal tube for prevention of post-extubation morbidity in children: A comparative study.

Objectives:The objective of this study is to evaluate the efficacy and safety of sealing pressure as an inflation technique of the Microcuff pediatric tracheal cuffed tube.Materials and Methods:A total of 60 children were enrolled in this study. After induction of anesthesia and intubation with Microcuff pediatric tracheal tube, patients were randomly assigned, to one of the three groups. Control group (n = 20) the cuff was inflated to a cuff pressure of 20 cm H2O; sealing group (n = 20) the cuff was inflated to prevent the air leak at peak airway pressure of 20 cm H2O and the finger group (n = 20) the cuff was inflated to a suitable pressure using the finger estimation. Tracheal leak, incidence and severity of post-extubation cough, stridor, sore throat and hoarseness were recorded.Results:The cuff pressure as well as the volume of air to fill the cuff was significantly low in the sealing group when compared with the control group (P < 0.001); however, their values were significantly high in the finger group compared with both the control and the sealing group (P < 0.001). The incidence and severity of sore throat were significantly high in the finger group compared with both the control and the sealing group (P = 0.0009 and P = 0.0026). Three patients in the control group developed air leak around the endotracheal tube cuff. The incidence and severity of other complications were similar in the three groups.Conclusion:In pediatric N2O, free general anesthesia using Microcuff pediatric tracheal tub, sealing cuff pressure is safer than finger palpation technique regarding post-extubation morbidities and more reliable than recommended safe pressure in prevention of the air leak.

Local facial cutaneous vasoconstriction: an unusual complication of inhaled racemic epinephrine in a neonate

A term infant treated for post-extubation stridor with nebulized racemic epinephrine developed localized facial blanching due to cutaneous absorption of the aerosolized vasoconstrictor. Local application of heat restored circulation to the afflicted area. This complication of a commonly used medication is not previously reported in the medical literature and has the potential for severe sequelae.

English

Introduction Major head and neck surgeries especially in difficult airway patients have a great hazard for post-operative laryngo-pharyngeal oedema and airway obstruction. In this prospective study, mannitol was administrated intra-operatively in an attempt to reduce airway oedema and hence post-extubation airway collapse and obstruction. Materials and methods Two hundred patients undergoing maxillofacial and radical neck surgeries were randomly allocated into the following two equal groups: (1) Group M: in which 0.25 gm /kg mannitol was given after intubation and 30 minutes before the end of surgery. (2) Group C: in which similar volume of the infused mannitol but lactated Ringer was given in the same time points. Cuff-air leak test, flexible fiberoptic laryngoscopic assessment of the upper airway before extubation, post-extubation clinical evaluation of upper airway obstruction and incidence of post-extubation stridor have been conducted to evaluate airway oedema. Results The total mean cuff-leak volume was significantly higher in Group M than in the Group C. The incidence of moderate upper airway lesion was statistically significant lower in mannitol group than in control group. The incidence of post-extubation stridor (after failed cuff-leak test was 4/17 (24%) in the mannitol group and 6/26 (23%) in the control group after passed cuff-leak test it was 2/83 (0.02%) in the mannitol group and 4/74 (.05%) in the control group). Conclusion Pre-emptive use of mannitol in maxillo-facial and radical neck surgeries is effective and nearly side effect free to reduce airway oedema and post-extubation airway obstruction.

Obstructive Fibrinous Tracheal Pseudomembrane: A Rare Condition in Postextubation Stridor

Obstructive fibrinous tracheal pseudomembrane (OFTP) is an airway complication that occurs after endotracheal intubation. It originates from superficial mucosal abrasion and desquamation of necrotic tracheal epithelium at the site of cuff pressure. This condition is a rare cause of postextubation stridor. We present a case of postextubation stridor secondary to OFTP, resulting in clinical features of upper airway obstruction > 8 h after extubation. The case features complete obstruction at the tip of the endotracheal tube from OFTP.

Do Clinical Parameters Predict First Planned Extubation Outcome in the Pediatric Intensive Care Unit?

There is absence of evidence-based guidelines to determine extubation readiness in the pediatric intensive care unit (PICU). Evaluate our practice of determining extubation readiness based on physician judgment of preextubation ventilator settings, blood gas analysis, and other factors potentially affecting extubation outcome. Prospective cohort study from August 2010 to April 2012. Academic, multidisciplinary PICU. A total of 319 PICU patients undergoing first planned extubation attempt. None. Determine the extubation success rate and evaluate factors potentially affecting extubation outcome. The PICU length of stay (LOS) and cost were also recorded. Subgroup analysis was performed based on days of mechanical ventilation (MV). A total of 319 consecutive patients underwent first planned extubation attempt with a 91% success rate. Factors associated with extubation failure were the length of MV (P < .0001, odds ratio [OR] 2.20); age (P = .02, OR 0.54); preextubation steroids (P = .04, OR 2.40); and postextubation stridor (P < .01, OR 3.40). Ventilator settings and blood gas results had no association with extubation outcome with 1 exception, ventilator rates ≤ 8 were associated with extubation failure in patients with ≤1 day of MV. Extubation failure was associated with prolonged PICU LOS and excess cost, with failures staying 14 days longer (P < .0001) and costing 3.2 time more (P < .0001) than successes. Physician judgment to determine extubation readiness led to a first planned extubation success rate of 91%. Age and the length of MV were primary risk factors for failed extubation. In patients with ≤1 day of MV, our findings suggest that confidence in extubation readiness following weaning to low ventilator rates may not be justified. Furthermore, reliance on preextubation ventilator settings and blood gas results to determine extubation readiness may lead to unnecessary prolongation of MV, thereby increasing the PICU LOS and excess cost. These findings are hypothesis generating and require further study for confirmation.

Defining sedation-related adverse events in the pediatric intensive care unit

BackgroundClinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry. ObjectivesTo perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial. MethodsIn Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates. ResultsWe reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy. ConclusionsConcise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.

Inspiratory Stridor after Tracheal Intubation with a MicroCuff® Tracheal Tube in Three Young Infants

ncuffed tracheal tubes (TTs) have been the stan-dard for tracheal intubation in infants and children for decades until the recent introduction of the Microc uff (Kim-berley-clark, Roswell, GA) cuffed TT. e vidence suggests that the incidence of perioperative airway events after use of these new TTs is small,

Intra-individual Variation of the Cuff-Leak Test as a Predictor of Post-Extubation Stridor

This was an evaluation of intra-individual variation of the cuff-leak test (ΔCLT) immediately post-intubation and pre-extubation, as a predictor of post-extubation stridor. Prospective, clinical investigation in the ICU of a non-university hospital. CLTs were performed immediately after intubation (T0) and before extubation (T1) to evaluate the differences in cuff leak (ΔCLT = CL(T1) - CL(T0)). We included 104 mechanically ventilated subjects in the study over a 12-month period. The incidence of post-extubation stridor was 6.7%. Stridor was more common in females of short stature. ΔCLT was considered as significant when CL(T1) - CL(T0) was negative. The sensitivity and the specificity of the test were 86% and 48%, respectively. When we tested the pre-extubation CLT alone with a threshold of 130 mL as a predictor of post-extubation stridor, the sensitivity and the specificity of the test were 86% and 76%, respectively. The intra-individual variation of CLT immediately post-intubation and pre-extubation does not improve the accuracy of a standard pre-extubation CLT to predict post-extubation stridor. Moreover, the standard pre-extubation CLT did not appear in our study to be an ideal test to detect post-extubation stridor. Larger studies should be performed before generalizing these preliminary results.

The Cuff Leak Test: Does It “Leak” Any Information?

Post-extubation stridor and upper-airway obstruction are multifactorial in etiology and can occur as a result of laryngotracheal edema, intubation trauma, excessive cuff pressure with mucosal ulceration, and prolonged intubation with secondary inflammation and granuloma formation.[1][1] Cuff leak

Iatrogenic tracheal flap mimicking tracheal stenosis with resultant stridor

To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor. We report a case of iatrogenic tracheal mucosal tear secondary to violent movement during intubation. The patient presented with post-extubation stridor that worsened over three days. Initial evidence suggested tracheal stenosis. Computed tomography scans revealed a mucosal tear at the level of the seventh cervical to second thoracic vertebrae. The tear was caused by forceful inflow of air as breathing became more and more difficult, resulting in a false tract. A tracheostomy changed the direction of airflow, bypassing the tear. The inflated tracheostomy tube cuff acted as a stent to keep the flap in place as healing occurred. Iatrogenic laryngotracheal injuries are common, especially when endotracheal intubation is performed under unfavourable emergency conditions. A tracheal mucosal tear is a rare entity which is almost always undiagnosed. However, a tracheal mucosal flap may be suspected when changes in patient position alter the nature and severity of the resultant stridor and/or respiratory distress. In such cases, an inflated tracheostomy tube cuff should be kept in place for an adequate period, to act as a stent and help keep the flap in place while healing occurs.

Prospective evaluation of sedation-related adverse events in pediatric patients ventilated for acute respiratory failure*

Sedation-related adverse events in critically ill pediatric patients lack reproducible operational definitions and reference standards. Understanding these adverse events is essential to improving the quality of patient care and for developing prevention strategies in critically ill children. The purpose of this study was to test operational definitions and estimate the rate and site-to-site heterogeneity of sedation-related adverse events. Prospective cohort study. Twenty-two pediatric intensive care units in the United States enrolling baseline patients into a prerandomization phase of a multicenter trial on sedation management. Pediatric patients intubated and mechanically ventilated for acute respiratory failure. Analysis of adverse event data using consistent operational definitions from a Web-based data management system. There were 594 sedation-related adverse events reported in 308 subjects, for a rate of 1.9 adverse events per subject and 16.6 adverse events per 100 pediatric intensive care unit days. Fifty-four percent of subjects had at least one adverse event. Seven (1%) adverse events were classified as severe, 347 (58%) as moderate, and 240 (40%) as mild. Agitation (30% of subjects, 41% of events) and pain (27% of subjects, 29% of events) were the most frequently reported events. Eight percent of subjects (n = 24) experienced 54 episodes of clinically significant iatrogenic withdrawal. Unplanned endotracheal tube extubation occurred at a rate of 0.82 per 100 ventilator days, and 32 subjects experienced postextubation stridor. Adverse events with moderate intraclass correlation coefficients included: Inadequate sedation management (intraclass correlation coefficient = 0.130), clinically significant iatrogenic withdrawal (intraclass correlation coefficient = 0.088), inadequate pain management (intraclass correlation coefficient = 0.080), and postextubation stridor (intraclass correlation coefficient = 0.078). Operational definitions for sedation-related adverse events were consistently applied across multiple pediatric intensive care units. Adverse event rates were different from what has been previously reported in single-center studies. Many adverse events have moderate intraclass correlation coefficients, signaling site-to-site heterogeneity.

Use of Video Laryngoscopy and Camera Phones to Communicate Progression of Laryngeal Edema in Assessing for Extubation

Video laryngoscopy has demonstrated utility in airway management. For the present case series, we report the use of video laryngoscopy to evaluate the airway of critically ill, mechanically ventilated patients, as a means to reduce the risk of immediate postextubation stridor by assessing the degree of laryngeal edema. We also describe the use of cellular phone cameras to document and communicate airway edema in using video laryngoscopy for the patients' medical records. We found video laryngoscopy to be an effective method of assessing airway edema, and cellular phone cameras were useful for recording and documenting video laryngoscopy images for patients' medical records.

Cuff leak tests: analysis of diagnostic accuracy in observational cohorts of patients with acute respiratory failure

Cuff leak tests provide clinicians with information about upper airway narrowing and may help predict weaning success. However, most clinical trials reporting this measurement are small, and the utility of this test remains uncertain. We identified all clinical studies using cuff leak tests in the PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials databases using multiple search terms, including &lt;em&gt;cuff leak test, laryngeal edema, extubation&lt;/em&gt;, and &lt;em&gt;stridor&lt;/em&gt;, and abstracted quantitative information on cuff leaks and outcomes (stridor and reintubation). We reviewed six studies which included 958 patients with acute respiratory failure in intensive care units. Eighty-two patients (8.5%) had postextubation stridor. The weighted mean cuff leak was 119 (&amp;plusmn;51) mls in the patients with stridor and 313 (&amp;plusmn;24) mls in patients without stridor (P&amp;lt;0.01). Sixty-six patients required reintubation. The presence of stridor had a sensitivity of 0.60 (95% CI 0.48-0.72), a specificity of 0.96 (95% CI 0.94-0.97), and a positive likelihood ratio of 13.4 (95% CI 6.9-25.7) for predicting reintubation. No single clinical parameter consistently predicted stridor. Patients with postextubation stridor have smaller cuff leak volumes than patients who do not have stridor and are more likely to require reintubation. Cuff leak measurements can improve decision making with extubation protocols.

Cuff leak tests: analysis of diagnostic accuracy in observational cohorts of patients with acute respiratory failure

Cuff leak tests provide clinicians with information about upper airway narrowing and may help predict weaning success. However, most clinical trials reporting this measurement are small, and the utility of this test remains uncertain. We identified all clinical studies using cuff leak tests in the PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials databases using multiple search terms, including cuff leak test, laryngeal edema, extubation, and stridor, and abstracted quantitative information on cuff leaks and outcomes (stridor and reintubation). We reviewed six studies which included 958 patients with acute respiratory failure in intensive care units. Eighty-two patients (8.5%) had postextubation stridor. The weighted mean cuff leak was 119 (±51) mls in the patients with stridor and 313 (±24) mls in patients without stridor (P&lt;0.01). Sixty-six patients required reintubation. The presence of stridor had a sensitivity of 0.60 (95% CI 0.48-0.72), a specificity of 0.96 (95% CI 0.94-0.97), and a positive likelihood ratio of 13.4 (95% CI 6.9-25.7) for predicting reintubation. No single clinical parameter consistently predicted stridor. Patients with postextubation stridor have smaller cuff leak volumes than patients who do not have stridor and are more likely to require reintubation. Cuff leak measurements can improve decision making with extubation protocols.

Postextubation stridor in a child with asymptomatic trifid epiglottis with polydactyly – A rare case report

Abstract Trifid epiglottis is an extremely rare congenital laryngeal anomaly. Trifid anomaly of epiglottis has not been described in literature. In the embryo, epiglottis, hypothalamus, and digital buds develop synchronously. Some disturbances during this stage may account for the concurrence of trifid epiglottis and polysyndactyly. We report a trifid epiglottis in a 6 year old child with congenital bilateral polydactyly of hand and foot who was asymptomatic and developed postexubation mild stridor after general anesthesia for excision of the extra digit which was managed conservatively.

Nebulized 0.5, 2.5 and 5 ml l-epinephrine for post-extubation stridor in children: a prospective, randomized, double-blind clinical trial

Nebulized L-epinephrine has been recommended for the treatment of viral croup. However, the few studies assessing its effect on post-extubation stridor (PES) have shown conflicting results. We compared the efficacy and safety of nebulized L-epinephrine at three different doses for the treatment of PES. We conducted a prospective, randomized, double-blind trial including all consecutive children with a PES score of ≥4 (Westley score). The primary efficacy outcome was change in PES score at 40 min. A reduction of ≥2 points in stridor score was defined as clinically significant. A total of 96 patients were randomly assigned to receive one of three doses of nebulized L-epinephrine upon achieving a PES score of 4 or more following extubation. Stridor score and vital signs were recorded before treatment, and at 20, 40, 60 and 180 min after nebulization. Baseline characteristics were similar among all study groups. No significant difference was detected among the treatments based on change in Westley score by intent-to-treat analysis. In addition, the difference in the number of patients who clinically improved among the treatment groups was not significant (p = 0.54). Patients receiving 5 ml nebulized epinephrine had a significant increase of systolic and diastolic blood pressure at 40 and 180 min. Nebulized L-epinephrine at doses of 0.5, 2.5 and 5 ml demonstrated a lack of dose response in effect on PES and a modestly clinically significant increase in undesired side effects (heart rate and blood pressure) at higher doses.