Postoperative care following single-stage laryngotracheoplasty

Single-stage laryngotracheoplasty (SSLTP) provides a method of correcting mild-to-moderate laryngotracheal stenosis while avoiding the risks of prolonged laryngeal stenting. Pediatric patients are orally intubated for 5 to 7 days postoperatively to ensure an adequate airway while edema resolves and healing begins. During this period, continuous neuromuscular blockade has been advocated in infants and young children to avoid endotracheal tube trauma to the fresh graft and potentially life-threatening accidental decannulation. Pulmonary atelectasis is the most common morbidity associated with prolonged neuromuscular blockade. Neuromuscular weakness also may follow prolonged paralysis and prolong hospitalization. This paper compares the postoperative course of 17 patients who underwent 18 SSLTP procedures by the senior author. The first 8 patients received continuous neuromuscular blockade in the early postoperative period. To reduce perceived morbidity, the last 9 patients were managed with a protocol that incorporated daily 4- to 8-hour "interruptions" of paralysis. Seven patients tolerated this protocol modification. As a group, these patients had less postoperative pulmonary atelectasis prior to extubation (p < .05) and were extubated sooner than patients receiving continuous neuromuscular blockade (p<.05) without compromising the surgical success of the procedure. Intermittent paralysis permitted for more accurate assessment of pain control and protected against accidental drug accumulation. Although self-extubation did not occur, diligent nursing care with adequate sedation and analgesia is necessary to avoid the risk of accidental extubation.