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Published on: August 2, 2024
Subglottic Post-Extubation Upper Airway Obstruction Is Associated With Long-Term Airway Morbidity in Children
Jack Green1, Patrick A Ross2,3, Christopher J L Newth2,3
1Department of Pediatrics, Division of Pediatric Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
Insights
Post-extubation upper airway obstruction in children significantly increases the risk of long-term airway problems. Close monitoring after intensive care unit (ICU) discharge is crucial for these at-risk pediatric patients.
Area of Science:
- Pediatric critical care medicine
- Otolaryngology
- Respiratory medicine
Background:
- Post-extubation upper airway obstruction is a common cause of extubation failure in children.
- Limited data exist on the long-term morbidity associated with this condition.
Purpose of the Study:
- To determine the frequency of long-term airway sequelae in intubated children.
- To investigate the association between post-extubation upper airway obstruction and subsequent airway morbidity.
Main Methods:
- Retrospective analysis of a prospective cohort of 327 children intubated for at least 12 hours.
- Electronic medical records were reviewed to identify pre- and post-extubation airway disease by a blinded provider.
- Primary outcome was the prevalence of newly diagnosed airway anomalies after extubation.
Main Results:
- Newly diagnosed airway anomalies occurred in 12.2% of children.
- Subglottic upper airway obstruction post-extubation was linked to higher rates of new airway anomalies, otolaryngology follow-up, and airway surgery (p ≤ 0.006).
- Independent predictors of new airway anomalies included upper airway obstruction as the reason for intubation, reintubation, pre-index airway anomaly, and post-extubation subglottic upper airway obstruction.
Conclusions:
- Post-extubation subglottic upper airway obstruction is associated with a threefold increased risk of long-term airway morbidity.
- Children experiencing post-extubation upper airway obstruction represent a high-risk group requiring vigilant monitoring post-ICU discharge.
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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