Interrater Reliability of Point-of-Care Ultrasound for Predicting Post-Extubation Stridor in Pediatrics

Post-extubation stridor (PES) is a serious complication in pediatric patients following endotracheal intubation and is linked to laryngeal edema. Prior studies suggest that the laryngeal air column width difference (LACWD), measured by point-of-care ultrasound (POCUS), may predict PES. There is a critical need to evaluate whether such techniques can be reliably reproduced among typical providers in the pediatric critical care setting. We aimed to assess the predictive value of LACWD for PES, examine its correlation with endotracheal tube (ETT) cuff pressure, and determine whether LACWD can be measured consistently by multiple POCUS-trained providers.

We conducted a prospective observational study of 51 mechanically ventilated pediatric patients aged 0-18 years. LACWD was measured using bedside POCUS. A subset underwent duplicate scans by different providers to assess interrater reliability. PES was defined by the presence of inspiratory stridor. Intra- and interrater reliability were evaluated using intraclass correlation coefficients (ICCs).

PES occurred in 14% of patients. There was no significant difference in LACWD between PES and non-PES groups. LACWD showed no correlation with ETT cuff pressure. Intrarater reliability for LACWD measurements was excellent (ICC >0.95), but interrater reliability was poor (ICC = 0.27 for LACWD).

LACWD did not reliably predict PES and showed poor interrater reliability, raising concerns about its practical utility in pediatrics. While POCUS remains an appealing non-invasive tool, our study demonstrates that the current technique lacks the reproducibility required for clinical application across providers. Future advancements may improve feasibility, but current methods are not yet suitable for routine bedside use.