Post-extubation Stridor Research Articles

Risk factors associated with post-extubation stridor in the trauma intensive care unit

BackgroundPost-extubation stridor is an uncommon complication in medical intensive care units (ICUs) but has not been well studied in trauma patients. We sought to determine the incidence of reintubation due to stridor in trauma patients and describe associated risk factors. MethodsA retrospective review of all intubated trauma patients was performed. Data collected included presence of stridor, demographic data, and details of intubation and extubation. ResultsOf all trauma patients reintubated, 31% were for stridor. Although female gender, age less than 18, blunt mechanism, and duration of intubation 5 days or more were associated with reintubation for stridor, endotracheal tube diameter was not. Mortality was not increased with reintubation. ConclusionsTrauma ICU patients are reintubated for stridor at a higher rate than medical ICU patients. Age, gender, blunt mechanism, and duration of intubation are risk factors for this complication.

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

Study objectivesTo identify acute laryngeal injuries among pediatric patients intubated for more than 48hours, and to correlate these injuries with clinical variables. SettingPediatric Intensive Care Unit (PICU) of a tertiary level hospital in India. Patients and MethodsProspective, 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. Results97% 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%). ConclusionPost-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.

Cuff-leak test combined with interventional bronchoscopy benefits early extubation for patients who received tarp surgery.

This study explored the performance characteristics of a cuff-leak test (CLT) combined with interventional fiberoptic bronchoscopy (FBS) for evaluating whether early nasoendotracheal extubation was possible for patients who had received transoral atlantoaxial reduction plate (TARP) internal fixation surgery. 318 patients who underwent surgery were retrospectively analyzed (between January 2006 and December 2012). Extubation was performed by conventional approach (CA group, until December 2008) and improved approach (IA group, from January 2009) including CLT and an interventional FBS procedure. The extubation success within 1-3days after surgery, incidence of postextubation stridor and tracheal reintubation were examined. More IA-treated patients experienced extubation during the first 2days than those CA-treated, median extubation time was 3 (2, 3) days in the CA group and 2 (1, 2) days in the IA group (all P<0.01). The incidence of stridor and reintubation was 5.69 and 0.57% in IA and 11.98 and 4.93% in CA, respectively (both P<0.05). For the CLT-positive patients in the IA group that remained intubated until day 3-4, interventional FBS was applied for safe extubation and achieved 100% success. Early extubation through IA is safe and interventional FBS assists successful extubation for CLT-positive patients who underwent TARP surgery.

Post extubation stridor due to bilateral vocal cord palsy following button battery ingestion – A rare and forgotten complication of button battery ingestion in children

We report a patient who developed bilateral vocal cord palsy following button battery ingestion. A two and half year old girl presented with a history of button battery ingestion. Rigid oesophagoscopy was performed within 3 hours. Patient developed post extubation stridor with respiratory distress. Bilateral vocal cord palsy is a rare complication of button battery ingestion which can lead to an airway catastrophe. Decision on timing of extubation is crucial to avoid immediate post-operative respiratory distress. Expedited removal of lodged button battery, increased vigilance for possible complications and long term follow up is of utmost importance.

Diagnosis of Post-extubation Stridor: Easier with Technology Support?

Diagnosis of Post-extubation Stridor: Easier with Technology Support?

Should Reinke edema be considered a contributing factor to post-extubation failure?

We read with interest the recently published review in Critical Care about post-extubation laryngeal edema and stridor by Pluijms et al. [1]. The review considers in detail the risk factors for post-extubation respiratory failure and describes a post-extubation algorithm for its prevention and reduction. We recently published a case report describing the occurrence of post-extubation stridor leading to post-extubation respiratory failure in a woman with a previously undiagnosed Reinke edema (RE) [2]. RE is a progressive laryngeal soft-tissue swelling. The condition typically manifests in female gender as hoarseness and as a gradually deepening voice in patients with a history of smoking, vocal cord abuse, and/or gastroesophageal reflux. Other case reports of RE complicating airway management already exist [3]. Our patient did not undergo prolonged intubation or difficult airway instrumentation. However, she presented risk factors for RE (i.e. female gender and smoking history). Notably, female gender has been reported in different studies investigating risk factors for complications following extubation which have been summarized in the review by Pluijms et al. [1]. Since our patient did not present stridor before intubation, the additional laryngeal edema due to airway management, which would have not been responsible for post-extubation failure in normal conditions, contributed to reaching the critical obstruction of airways. We believe, in accordance with other authors [4], that RE may be considered an important, underdiagnosed concomitant cause of post-extubation stridor. RE may explain why, in certain patients, a minor grade of laryngeal edema could lead to a clinically relevant reduction of airway space and post-extubation stridor. Clinical signs and risk factors for RE should be systematically assessed when clinicians deal with risks of post-extubation failure. In our opinion, when risk factors for RE are associated with difficult airway management and/or prolonged intubation, a conservative approach consisting of otolaryngology consultation, fiberoptic examination, or a neck computed tomography scan may be undertaken for a safe airway assessment and detection of a potentially critical obstruction.

Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review.

Endotracheal intubation is frequently complicated by laryngeal edema, which may present as postextubation stridor or respiratory difficulty or both. Ultimately, postextubation laryngeal edema may result in respiratory failure with subsequent reintubation. Risk factors for postextubation laryngeal edema include female gender, large tube size, and prolonged intubation. Although patients at low risk for postextubation respiratory insufficiency due to laryngeal edema can be identified by the cuff leak test or laryngeal ultrasound, no reliable test for the identification of high-risk patients is currently available. If applied in a timely manner, intravenous or nebulized corticosteroids can prevent postextubation laryngeal edema; however, the inability to identify high-risk patients prevents the targeted pretreatment of these patients. Therefore, the decision to start corticosteroids should be made on an individual basis and on the basis of the outcome of the cuff leak test and additional risk factors. The preferential treatment of postextubation laryngeal edema consists of intravenous or nebulized corticosteroids combined with nebulized epinephrine, although no data on the optimal treatment algorithm are available. In the presence of respiratory failure, reintubation should be performed without delay. Application of noninvasive ventilation or inhalation of a helium/oxygen mixture is not indicated since it does not improve outcome and increases the delay to intubation.

Stridor in Neonates After Using the Microcuff® and Uncuffed Tracheal Tubes: A Retrospective Review.

We conducted a retrospective chart review to determine the frequency of stridor and contributing factors after the use of Microcuff® and uncuffed tracheal tubes (TTs) in neonates. All neonates in our neonatal intensive care unit whose airways were intubated between May 2011 and June 2012 were included. Data were collected from the neonatal intensive care unit database and from the electronic anesthesia record. Extracted data included postmenstrual age (PMA) at birth, birth weight, TT size and type, duration of tracheal intubation, and number of reintubations. The use of racemic epinephrine, heliox, and/or dexamethasone postextubation was considered diagnostic of stridor. Of the 324 neonates whose data were reviewed, 27 (8.3%) developed postextubation stridor. Neonates who developed stridor were more premature (PMA at birth, 29.9 ± 5.8 vs 33.0 ± 4.8 weeks, P = 0.001), had a lower birth weight (1.56 ± 1.07 vs 2.02 ± 0.96 kg, P = 0.005), greater duration of intubation (median: 20 vs 3 days, P < 0.0001), and multiple reintubations (median: 2 vs 0, P < 0.0001). The frequency of stridor was 17.2% after using Microcuff TT and 7.5% after using uncuffed TTs (Fisher exact test, 2-sided P = 0.08 [95% confidence interval for difference in proportions: -9.4% to 28.7%]). In a multivariable logistic regression model, after adjusting for PMA, birth weight, duration of intubation, and number of reintubations, the use of a Microcuff TT was associated with increased odds of stridor (adjusted odds ratio = 9.27 [95% confidence interval: 1.88-45.67], P = 0.006). The use of the Microcuff TT is associated with increased odds of postextubation stridor in neonates compared with the use of uncuffed TT.

A Two-Group Trial of a Terminal Ventilator Withdrawal Algorithm: Pilot Testing.

Terminal ventilator withdrawal entails cessation of mechanical ventilation to allow a natural death. There is little empirical evidence to guide the conduct of this procedure. If the process is not well conducted, patients undergoing terminal ventilator withdrawal are at high risk for experiencing significant respiratory distress. Our aim was to (1) establish the feasibility of a nurse-led algorithmic approach; (2) determine differences in patient comfort between groups; and (3) determine differences in the use of opioids and benzodiazepines. A prospective, two-group, repeated measures, observation design was used with nurses from one medical intensive care unit (MICU) conducting the algorithm and nurses from a second MICU providing unstandardized usual care. Patient respiratory comfort/distress was measured with the Respiratory Distress Observation Scale (RDOS). Nurses and respiratory therapists were trained to follow the algorithm in one-hour educational sessions; fidelity to the algorithm was subsequently confirmed. Fourteen patients evenly distributed by ethnicity and gender were enrolled, eight in the control MICU and six in the intervention unit. No significant differences in age, consciousness, illness severity, or baseline RDOS were found. All control patients underwent a one-step terminal extubation process. There were no incidences of post-extubation stridor in the intervention group, whereas three (38%) control patients experienced stridor. Patients in the intervention group had greater respiratory comfort compared with control patients (p<0.05). Differences in medication use were found with lorazepam favored in the control unit; morphine is recommended in the algorithm. Feasibility and proof of concept for the nurse-led algorithm were established.

Postextubation stridor in neonates and children undergoing cardiac surgery: two year of institutional experience

Introduction. To describe risk factors associated with respiratory distress after extubation in the pediatric cardiac intensive care unit. Methods. A retrospective observational study was performed involving patients (n1⁄4514) undergoing pediatric cardiac surgery at a single university hospital from January 1, 2011 to December 31, 2012, excluding deaths. The patients were under 8 years of age. The study approved by the local Institutional Review Board. Clinical characteristics, surgical data, and intensive care unit outcome were obtained from medical records. Extubation criteria mainly were based on the clinical judgement of the surgeon, anesthesiologist and pediatric cardiolog. Extubation criteria included neurologic status to ensure airway protection, hemodynamic statu with minimal inotropic support (dopamine r 5 m/kg/min, no milrinone, no adrenaline), minimal ventilator setting (FiO2 o 0.5, peak inspiratory pressure r25 cmH2O) and appropriate arterial blood gases. Continous variables compared using Mann-Whitney U tests and categorical variables were compared using One-way Anova and chi-square when appropriate. Logistic regression models were used to determine variables impacting respiratory distress after extubation. Results. The patients were categorized into two groups according to postoperative stridor: Group PES (n1⁄4104) and group non-PES (n1⁄4410). Median age in group PES was smaller than group nonPES (9.5 14.5 months and 20.38 21.82 months, respectively, po0.005) and weight in group PES was less than group non-PES (5.7 3.5 kg and 8.9 5.6 kg, respectively, po0.005)]. Compared to preoperative intubation (24% and 4.4%, respectively, po0.005), with sydrome (22.1% and 10.2%, respectively, po0.005) and required cardiopulmonary bypass (67.1% and 32.9%, respectively, po0.009) were significantly higher in group PES. Multivariate logistic regression revealed that age (95% CI 0.971.03, p40.38) is not predictor of PES, however weight (95% CI 0.76-0.98, Po0.03), with syndrome (95% CI 1.46-4.89, po0.01), preoperative intubation (95% CI 2.18-9.12, po0.005) and required cardiopulmonary bypass (95% CI 1.16-3.76, po0.014) predictors of PES. Discussion. Our study resulted that post-operative post-extubation stridor is observed more frequently on new born and children who were undergone cardiopulmoner by pass and having syndrome associated with preoperative endotracheal intubation history. This study also proves that body weight has a more important effect on post-extubation stridor than age contrary to popular belief.

Paediatric resuscitation: Always breathe carefully.

Paediatric resuscitation: Always breathe carefully.

Double-blind, placebo-controlled pilot randomized trial of methylprednisolone infusion in pediatric acute respiratory distress syndrome.

Low-dose methylprednisolone therapy in adults with early acute respiratory distress syndrome reduces systemic inflammation, duration of mechanical ventilation, and ICU length of stay. We report a pilot randomized trial of glucocorticoid treatment in early pediatric acute respiratory distress syndrome. Double-blind, placebo-controlled randomized clinical trial. Le Bonheur Children's Hospital, Memphis, TN. Children (0-18 yr) with acute respiratory distress syndrome undergoing mechanical ventilation. Patients were randomly assigned to steroid or placebo groups within 72 hours of intubation. IV methylprednisolone administered as loading dose (2 mg/kg) and continuous infusions (1 mg/kg/d) on days 1-7 and then tapered over days 8-14. Both groups were ventilated according to the Acute Respiratory Distress Syndrome Network protocol modified for children. Daily surveillance was performed for adverse effects. Thirty-five patients were randomized to the steroid (n = 17, no death) and placebo groups (n = 18, two deaths). No differences occurred in length of mechanical ventilation, ICU stay, hospital stay, or mortality between the two groups. At baseline, higher plateau pressures (p = 0.006) and lower Pediatric Logistic Organ Dysfunction scores (p = 0.04) occurred in the steroid group; other characteristics were similar. Despite higher plateau pressures on days 1 (p = 0.006) and 2 (p = 0.025) due to poorer lung compliance in the steroid group, they had lower PaCO2 values on days 2 (p = 0.009) and 3 (p = 0.014), higher pH values on day 2 (p = 0.018), and higher PaO2/FIO2 ratios on days 8 (p = 0.047) and 9 (p = 0.002) compared with the placebo group. Fewer patients in the steroid group required treatment for postextubation stridor (p = 0.04) or supplemental oxygen at ICU transfer (p = 0.012). Steroid therapy was not associated with detectable adverse effects. This study demonstrates the feasibility of administering low-dose glucocorticoid therapy and measuring clinically relevant outcomes in pediatric acute respiratory distress syndrome. Changes in oxygenation and/or ventilation are consistent with early acute respiratory distress syndrome pathophysiology and results of similar clinical trials in adults. We propose and design a larger randomized trial to define the role of glucocorticoid therapy in pediatric acute respiratory distress syndrome.

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Protocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown. To determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care. Cluster randomized trial conducted in 31 US pediatric intensive care units (PICUs). A total of 2449 children (mean age, 4.7 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge. Intervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care. The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal. Duration of mechanical ventilation was not different between the 2 groups (intervention: median, 6.5 [IQR, 4.1-11.2] days; control: median, 6.5 [IQR, 3.7-12.1] days). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups. Intervention patients experienced more postextubation stridor (7% vs 4%; P = .03) and fewer stage 2 or worse immobility-related pressure ulcers (<1% vs 2%; P = .001). In exploratory analyses, intervention patients had fewer days of opioid administration (median, 9 [IQR, 5-15] days vs 10 [IQR, 4-21] days; P = .01), were exposed to fewer sedative classes (median, 2 [IQR, 2-3] classes vs 3 [IQR, 2-4] classes; P < .001), and were more often awake and calm while intubated (median, 86% [IQR, 67%-100%] of days vs 75% [IQR, 50%-100%] of days; P = .004) than control patients, respectively; however, intervention patients had more days with any report of a pain score ≥ 4 (median, 50% [IQR, 27%-67%] of days vs 23% [IQR, 0%-46%] of days; P < .001) and any report of agitation (median, 60% [IQR, 33%-80%] vs 40% [IQR, 13%-67%]; P = .003), respectively. Among children undergoing mechanical ventilation for acute respiratory failure, the use of a sedation protocol compared with usual care did not reduce the duration of mechanical ventilation. Exploratory analyses of secondary outcomes suggest a complex relationship among wakefulness, pain, and agitation. clinicaltrials.gov Identifier: NCT00814099.

An Algorithmic Approach to Terminal Ventilator Withdrawal: Pilot Testing (FR416-D)

•Describe a terminal ventilator withdrawal algorithm.•Describe the outcomes of a pilot clinical trial of a terminal ventilator withdrawal algorithm. Terminal ventilator withdrawal entails the cessation of invasive mechanical ventilation to allow a natural death. There is little empirical evidence to guide the conduct of this common procedure. If the process is not well conducted, patients undergoing ventilator withdrawal are at very high risk for experiencing significant respiratory distress. (1) To establish the feasibility of a nurse-led algorithmic approach; (2) To demonstrate that the algorithm ensured greater patient comfort compared with usual care; and (3) To determine differences in the use of opioids and benzodiazepines. A two-group, repeated measures observation design was used with one medical ICU (MICU) conducting the algorithm and a second MICU providing usual care. Patient respiratory comfort/distress was measured with the Respiratory Distress Observation Scale (RDOS). The algorithm guided three process decisions: (1) premedication, (2) withdrawal method, and (3) extubation decisions. MICU nurses and respiratory therapists from the intervention unit were trained to follow the algorithm in educational sessions of 1-hour duration; fidelity to the algorithm was subsequently confirmed. Fourteen patients evenly distributed by ethnicity and gender were enrolled, with 8 in the control ICU and 6 in the intervention unit. No significant differences in age, gender, ethnicity, consciousness, illness severity, or baseline RDOS were found. All patients in the control unit underwent a one-step terminal extubation process. There were no incidences of postextubation stridor in the intervention group, and three (38%) control patients experienced stridor. Patients in the intervention group had greater respiratory comfort compared with the patients in the control group (p <.05). Differences in medication use were found with the control unit favoring benzodiazepines, while the algorithm promotes morphine. Feasibility and proof of concept were established in this pilot study. A powered, randomized controlled trial is planned.

Cuff leak test and laryngeal survey for predicting post-extubation stridor.

Background and Aims:Evidence for the predictive value of the cuff leak test (CLT) for post-extubation stridor (PES) is conflicting. We evaluated the association and accuracy of CLT alone or combined with other laryngeal parameters with PES.Methods:Fifty-one mechanically ventilated adult patients in a medical-surgical intensive care unit were tested prior to extubation using; CLT, laryngeal ultrasound and indirect laryngoscopy. Biometric, laryngeal and endotracheal tube (ETT) parameters were recorded.Results:PES incidence was 4%. CLT demonstrated ‘no leak’ in 20% of patients. Laryngeal oedema was present in 10% of the patients on indirect laryngoscopy, and 71% of the patients had a Grades 1-3 indirect laryngoscopic view. Mean air column width on laryngeal ultrasound was 0.66 ± 0.15 cm (cuff deflated), mean ratio of ETT to laryngeal diameter was 0.48 ± 0.07, and the calculated CLT and laryngeal survey composite was 0.86 ± 1.25 (range 0-5). CLT and the CLT and Laryngeal survey composite measure were not associated with or predict PES. Age, sex, peri-extubation steroid use, intubation duration and body mass index were not associated with PES.Conclusion:Even including ultrasonographic and indirect laryngoscopic examination of the airway, no single aspect of the CLT or combination with laryngeal parameters accurately predicts PES.

Laryngeal air column width ratio in predicting post extubation stridor.

Aim:Correlation of upper air column width ratio in postextubation stridor patients.Materials and Methods:A prospective observational study was conducted in a tertiary hospital between January and December 2013. Patients who were admitted in Intensive Care Unit and intubated for >24 h were included (72 patients). The upper airway air column width ratio (air column width before extubation/air column width after intubation) was calculated and compared in patient with or without postextubation stridor.Results:The incidence of stridor was 6.9% (5/72). The duration of mechanical ventilation was 5.60 ± 1.14 days and 3.91 ± 1.45 days in stridor and nonstridor group respectively. In all 5 patients who had stridor, the upper airway air column width ratio was 0.8 or less.Conclusion:Air column width ratio of 0.8 or less may be helpful in predicting postextubation stridor, which should be confirmed by large observational studies.

Risk factors for post-extubation stridor in children: the role of orotracheal cannula.

ObjectiveTo determine the risk factors associated with stridor, with special attention to the role of the cuffed orotracheal cannula.MethodsProspective analysis of all the intubated patients submitted to mechanical ventilator support from January 2008 to April 2011. The relevant factors for stridor collected were age, weight, size and type of airway tube, diagnosis, and duration of mechanical ventilation. The effects of variables on stridor were evaluated using uni- and multivariate logistic regression models.ResultsA total of 136 patients were included. Mean age was 1.4 year (3 days to 17 years). The mean duration of mechanical ventilation was 73.5 hours. Fifty-six patients (41.2%) presented with stridor after extubation. The total reintubation rate was 19.6% and 12.5 in patients with and without stridor, respectively. The duration of mechanical ventilation (>72 hours) was associated with a greater risk for stridor (odds ratio of 8.60; 95% confidence interval of 2.98-24.82; p<0.001). The presence of the cuffed orotracheal cannula was not associated with stridor (odds ratio of 98; 95% confidence interval of 0.46-2.06; p=0.953).ConclusionThe main risk factor for stridor after extubation in our population was duration of mechanical ventilation. The presence of the cuffed orotracheal cannula was not associated with increased risk for stridor, reinforcing the use of the cuffed orotracheal cannula in children with respiratory distress.

Prevalence and Risk Factors for Upper Airway Obstruction after Pediatric Cardiac Surgery

To determine the prevalence of and risk factors for extrathoracic upper-airway obstruction after pediatric cardiac surgery. A retrospective chart review was performed on 213 patients younger than 18years of age who recovered from cardiac surgery in our multidisciplinary intensive care unit in 2012. Clinically significant upper-airway obstruction was defined as postextubation stridor with at least one of the following: receiving more than 2 corticosteroid doses, receiving helium-oxygen therapy, or reintubation. Multivariate logistic regression analysis was performed to determine independent risk factors for this complication. Thirty-five patients (16%) with extrathoracic upper-airway obstruction were identified. On bivariate analysis, patients with upper-airway obstruction had greater surgical complexity, greater vasoactive medication requirements, and longer postoperative durations of endotracheal intubation. They also were more difficult to calm while on mechanical ventilation, as indicated by greater infusion doses of narcotics and greater likelihood to receive dexmedetomidine or vecuronium. On multivariable analysis, adjunctive use of dexmedetomedine or vecuronium (OR 3.4, 95% CI 1.4-8) remained independently associated with upper-airway obstruction. Extrathoracic upper-airway obstruction is relatively common after pediatric cardiac surgery, especially in children who are difficult to calm during endotracheal intubation. Postoperative upper-airway obstruction could be an important outcome measure in future studies of sedation practices in this patient population.

PO-0913 A Review Of Cuffed Vs. Uncuffed Endotracheal Tubes In Children

Background and aims The use of cuffed endotracheal tubes in paediatric patients is still a controversial topic. This paper aims to investigate whether cuffed or uncuffed tubes should be used in children under the age of 8 based on the literature that is currently available on this topic. Currently there are no guidelines on this topic. Methods literature review. Results The results of the first four studies reviewed all show significant results in favour of use of a cuffed endotracheal tube and a change in current practice. None of the studies reviewed showed that patients were more likely to suffer injury as a result of using a cuffed tube. This is important as the review covers a variety of patients including those undergoing elective operations, burn patients and those who are critically ill. All of the studies reviewed demonstrated potential benefits of introducing cuffed tubes into practice as they reduced exchange rate, air leaks and the costs associated with the anaesthetic gases used; without a significant increase in the rates of post-extubation stridor or failed extubation. Conclusion In conclusion cuffed tubes are shown to decrease the need for multiple intubations, reduce costs and are not shown to increase adverse effects in children of all ages.

ABSTRACT 433

Background and aims: Sparse data available on the use ofnoninvasive ventilation (NIV) in infants and children.Clinical application of high flow nasal cannula therapy(HFNC) in young children has been increased in the recent years. Aims: To analyse the clinical profile of critically ill children receiving NIV and their outcome. Methods: Retrospective review of all children managed with NIV over 3 years in PICU. Data of children who received HFNC therapy over a period of one year was analyzed. Results: A total of 419 children were managed with NIV. Females formed the majority (60%). 24 neonates and 101 infants. 333 (80%) were managed with Nasopharyngeal (NPCPAP); 86 (20%) with mask NIV. Common primary diagnoses include respiratory failure due to Pneumonia, CHD, Sepsis and bronchiolitis. In 44 (11%) children, NIV was used as a modality to wean from invasive or for post extubation stridor. Primary outcome was failed NIV which lead to intubation. Totally, 49 (12%) children failed NIV; of which 36 were on NPCPAP. 51 (12%) children died or taken in a terminally ill state. HFNC used in 381 children over one year. Majority (273; 72%) of them were young infants (1-24months). There were 31 (8%) newborn. Common diagnoses include respiratory distress due to pneumonia (83;22%), Sepsis(60;16%), Dengue (38;10%), Post surgical (37;10%), CHD (34;9%), bronchiolitis (31;8%) and others (88;25%). Of the total 381, 42 (11%) failed HFNC and 34 children needed intubation. Conclusions: NIV is a feasible stratergy to avoid intubation if used appropriately and early during the respiratory distress. In our cohort, only 12% failed NIV and 11% high flow therapy.