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Predictive value of bronchoscopy after infant cardiac surgery: a prospective study
1Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Airway narrowing is common after infant heart surgery but has poor predictive value for extubation failure. Preoperative ventilation need is the strongest predictor of extubation failure in these infants.
Area of Science:
- Pediatric Cardiology
- Thoracic Surgery
- Respiratory Medicine
Background:
- Infant cardiac surgery frequently leads to tracheobronchial narrowing.
- Airway complications can impact post-operative recovery and outcomes.
Purpose of the Study:
- To investigate the association between airway narrowing and extubation failure (EF) in infants following cardiac surgery.
- To identify predictors of EF in this vulnerable population.
Main Methods:
- A prospective cohort study involving infants (≤6 months) undergoing cardiac surgery.
- Flexible bronchoscopy (FB) was used for standardized airway evaluation post-operatively.
- Extubation failure was defined as the need for mechanical ventilation within 48 hours of primary extubation.
Main Results:
- Significant airway narrowing was observed in 50% of patients who underwent FB.
- 19% of all patients developed extubation failure.
- Narrowed airway calibre showed 50% sensitivity and 50% specificity for EF. Preoperative ventilation need was the strongest predictor of EF (OR 6.5).
Conclusions:
- Airway narrowing is frequently identified on FB after infant cardiac surgery.
- Bronchoscopic assessment of airway narrowing has limited sensitivity and specificity for predicting EF.
- Inter-rater reliability for expert assessment of tracheobronchial narrowing is poor to moderate.
Background And Aims:
Airway evaluation following infant cardiac surgery often reveals evidence of tracheobronchial narrowing. We studied the association between airway narrowing and extubation failure (EF) in this population.
Methods:
Prospective cohort study of infants (age ≤6 months) from March-September 2009. Flexible bronchoscopy (FB) evaluations were obtained using a standardised protocol after operative intervention. The primary endpoint was the development of extubation failure (EF; defined as the need for invasive mechanical ventilation ≤48 h after primary extubation) and several secondary endpoints.
Results:
Fifty-three patients were evaluated at a median age of 81 [interquartile range (IQR) 13-164] days and weight of 4.2 (IQR 3.2-6.0) kg; 13 (25 %) of the patients had single ventricle palliations and two subsequently underwent heart transplantation. Significant airway narrowing was noted in 15 of 30 [50 %, 95 % confidence interval (CI) 31-69 %] patients who underwent FB; ten of the 53 patients (19 %, 95 %CI 10-32 %) subsequently developed EF. Narrowed airway calibre on bronchoscopy had a sensitivity and specificity of 50 % (95 %CI 28-71 %) and 50 % (95 %CI 28-71 %), respectively, for EF. The single greatest predictor of EF by univariate analysis was the need for preoperative ventilation [odds ratio (OR) 6.5, 95 %CI 1.3-33.2, p = 0.03]. Patients with EF had a greater likelihood of intensive care readmission (OR 4.8, 95 %CI 1.1-21, p < 0.04) during the same hospital admission.
Conclusions:
Airway narrowing on FB is noted frequently after infant cardiac surgery. Overall assessment and presence of narrowing on bronchoscopy had poor sensitivity and specificity for EF in our cohort. Expert assessment of tracheobronchial narrowing on FB has poor to moderate inter-rater reliability.
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