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Early extubation following major tracheal surgery in select children
International Journal of Pediatric Otorhinolaryngology (2006) 70, 253—258
www.elsevier.com/locate/ijporl
Early extubation following major tracheal surgery in select children Seth M. Brown a, Joshua D. Rosenberg a, Sanjay R. Parikh a,b,* a
Department of Otolaryngology, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, 3rd Floor, Bronx, NY 10467, USA b The Children’s Hospital at Montefiore, Bronx, NY, USA Received 2 May 2005; accepted 22 June 2005
KEYWORDS Tracheoplasty; Tracheal resection; Cricotracheal resection; Stenting; Extubation
Summary Major airway surgery in children has traditionally consisted of a period of endotracheal intubation after the procedure for a period of 1—2 weeks to ensure stability of the repair. Recent literature has supported a trend toward decreasing this time period to prevent the consequences of leaving a foreign body in the airway and the morbidity associated with the use of sedation and narcotics in children. We present a series of five select children from our institution that underwent major tracheal surgery and were successfully extubated early in their postoperative course; four on postoperative day number 1. This demonstrates the feasibility of this approach in select patients. # 2005 Elsevier Ireland Ltd. All rights reserved.
1. Introduction In the mid-1960s, McDonald and Stocks reintroduced long term endotracheal intubation in neonates [1]. This popularized practice led to an increase in the incidence of subglottic stenosis. Fearon and Cotton, after experimenting on primates, reported in 1974 the division of the cricoid and anterior trachea with interposition of a cartilage graft for subglottic stenosis in two children [2]. Originally a two-staged procedure, the following two decades brought about a vast interest in pediatric airway surgery and the development of the single-staged LTR * Corresponding author. Tel.: +1 718 920 2991; fax: +1 718 920 8112. E-mail address: [email protected] (S.R. Parikh).
(SSLTR) [3—12]. In addition to the advantage of decannulating the patient much sooner, this procedure avoids the use of an in-dwelling stent, often left for a month or longer. The replacement of the stent in SSLTR is an endotracheal tube, usually left in place for 7—10 days when an anterior graft is used and 12—14 days with a posterior graft [13]. Recently, interest has turned toward cricotracheal resection in children [14—17]. This procedure has enabled a number of patients, who may not have been successfully treated with a SSLTR secondary to severe disease, to be decannulated. Much like laryngotracheal reconstruction (LTR), this procedure can consist of a two-staged procedure with stenting or a single-staged procedure with the use of an endotracheal tube as a stent for 7—10 days [16].
0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.06.014
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Controversy exists about the role of stenting after major airway surgery. Thomas and Stevens looked at different materials of stents in acute laryngeal injuries in dogs in the mid-1970s. They concluded that using a stent of any material results in a much higher frequency of ulceration, granulation tissue formation, and infection [18]. Olson has argued against stents as well. His report nearly 25 years ago mentions that the success of a laryngeal repair occurs in spite of a stent rather then because of one [19]. Albert et al. demonstrated in rabbits that even when a stent is sutured into place, thus preventing tube slipping, squamous metaplasia of the respiratory epithelium can occur in as little as 1 week’s time [20]. Smith et al. studied phonation in patients with LTRs and came to the conclusion that stents can cause scarring of the vocal fold mucosa and impair arytenoid mobility [21]. Zalzal reviewed a specific device, the Aboulker stent in 1988 and found complications in 10 out of 18 patients including: infection, granulation tissue, stent migration, and stent breakage [22]. Jewett et al. studied stenting versus nonstenting of rabbits after SSLTR and found that in stented animals there was a trend toward increasing mucosal edema and granulation tissue [23]. Despite these reports, it has been suggested that stents are beneficial to the tissues as they are healing, as they play a role in preventing scar contracture, thus avoiding the complication of a decrease in size of the reconstructed tracheal lumen [24]. Recent studies however, have demonstrated that the use of a stent may not offer a clinically beneficial advantage. For instance, it has been reported that in tracheal resection, edema at the anastomosis site does not usually occur and therefore postoperative airway protection may be unnecessary [14]. The Great Ormond Street Group reported in 28 patients that duration of intubation following SSLTR had no effect on extubation complications or final outcome [11]. In 2001 Hartley et al. conducted a retrospective study comparing duration of endotracheal tube stenting in 101 patients with SSLTR finding no significant correlation, with similar stage of disease, between duration of stenting and the need for reintubation or tracheotomy. The authors concluded that long stenting periods do not give an additional benefit [7]. These studies suggest that major airway surgery may not require long term intubation or stenting.
2. Materials and methods Medical records of five patients with a mean age of 7 years who underwent major tracheal surgery between July 2002 and June 2003 were reviewed.
S.M. Brown et al.
3. Results 3.1. Case 1 A 4-year-old boy with a history of bronchopulmonary dysplasia and reactive airway disease was referred for possible decannulation. The patient was born at 25 weeks gestation requiring intubation secondary to respiratory distress syndrome. A tracheotomy was performed before the patient left the neonatal intensive care unit. The patient’s workup included a bronchoscopy that revealed a Myer—Cotton grade II stenosis between tracheal rings 3 and 5 [25]. Of note, the previous tracheotomy had been performed in the sixth tracheal space. Tracheoplasty was thus performed with the existing tracheal stoma being extended superiorly to the third tracheal space, facilitating removal of an occluding suprastomal granuloma. A thyroid alar cartilage free graft was fashioned into the opening in the anterior trachea and sutured into place using 4.0 monocryl sutures. Total operative time was 4.5 h. Postoperatively the patient was transferred to the pediatric intensive care unit intubated. The patient was placed on intravenous dexamethasone, cefazolin, famotidine, and inhaled fluticasone. The patient was extubated 16 h postoperatively and subsequently developed stridor and tachypnea that responded to treatment with racemic epinephrine and a helium—oxygen mixture by mask. He was successfully weaned off the helium—oxygen mixture on postoperative day 8 with oxygen saturation rates above 94% on room air. The patient was transferred from the pediatric intensive care unit on postoperative day 9 and weaned off steroids. He was discharged home on postoperative day 14. At 1-year follow-up he was well without signs or symptoms of upper airway obstruction.
3.2. Case 2 A 2-month-old boy was admitted to the hospital for Kawasaki’s disease. During treatment with aspirin the patient suffered a massive lower gastrointestinal hemorrhage necessitating endotracheal intubation for 3 weeks. The patient was extubated successfully and subsequently discharged home. Two days later he presented with progressive stridor and respiratory distress. Despite treatment with racemic epinephrine, intravenous dexamethasone, and a helium—oxygen mixture by mask, his respiratory status continued to deteriorate. Rigid bronchoscopy at this time revealed a grade III stenosis. After the procedure the patient was left intubated with a 3.5 endotracheal tube and started on high dose dexamethasone, ranitidine, and ampicillin/sulbac-
Early extubation following major tracheal surgery in select children
tam. Bronchoscopy 4 days later demonstrated significant improvement in the patient’s tracheal stenosis and he was successfully extubated. However, the patient redeveloped stridor within 3 days. Repeat bronchoscopy again demonstrated a grade III stenosis. Segmental tracheal resection with endto-end anastomosis was thus undertaken in conjunction with the cardiothoracic surgery service. Intraoperatively tracheal rings 3—5 were noted to be stenotic and resected in a total operative time of 7 h. Postoperatively the patient was placed on intravenous dexamethasone, ranitidine, clindamycin, and cephradine. The patient was extubated the following day, approximately 18 h after leaving the operating room. By postoperative day 2 the patient was saturating well on room air and able to tolerate oral feeding. The intravenous dexamethasone was discontinued and inhaled budesonide was started on postoperative day 5. The patient was discharged on postoperative day 14. Although mild inspiratory stridor was noted at 3 months and a grade I stenosis was seen at the second tracheal space on subsequent bronchoscopy, the patient was breathing without effort and eating well. Since, the patient has been asymptomatic with 15 months of follow-up.
3.3. Case 3 A 4-year-old girl with velocardiofacial syndrome, Pierre Robin sequence, and tracheal stenosis was being followed for airway management and ear disease. The patient’s medical history was also significant for reactive airway disease, recurrent pneumonia, and chronic serous otitis media. A tracheotomy was performed while the patient was an infant secondary to airway obstruction due to the Robin sequence. The patient’s past surgical history also included a cleft palate repair at the age of two and a gastrostomy tube. Prior to the patient’s airway reconstruction, under the same anesthesia, an umbilical hernia repair was performed by general surgery. Intraoperative bronchoscopy revealed a grade II suprastomal tracheal stenosis. The stenotic scar tissue was exposed via extension of the tracheal stoma superiorly and excised. A free graft was harvested from the left alar of the thyroid cartilage and sutured into place using 4.0 monocryl sutures. There were no significant intraoperative complications in a total operative time of 4.5 h. Postoperatively, along with her chronic medications, she was placed on intravenous dexamethasone, ranitidine, and cefazolin. She was extubated 20 h later and was stable on room air. The dexamethasone was discontinued on postoperative day 3. The remainder of her hospital course was unremarkable and she was dis-
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charged home on postoperative day 4. One year postoperatively the patient had no signs or symptoms of upper airway obstruction.
3.4. Case 4 A 14-year-old boy with a history of accidental lye ingestion at age 9 and reactive airway disease was referred for evaluation and treatment of worsening respiratory symptoms. Since his injury the patient had undergone a gastrostomy tube placement and greater than 60 esophageal dilatations. At the time of referral the patient’s feeding tube had been removed and he was tolerating a regular diet. Bronchoscopy done shortly after revealed a grade III tracheal stenosis. Subsequently, segmental cricotracheal resection with end-to-end anastamosis was performed in conjunction with cardiothoracic surgery. Intraoperatively the anterior cricoid cartilage and tracheal rings 1—3 were resected. There were no intraoperative complications in a total operative time of 8 h. Along with his chronic medications the patient was started on intravenous dexamethasone, pantoprazole, cefazolin, and enoxaparin. He was extubated approximately 19 h postoperatively and placed on humidified oxygen. The intravenous dexamethasone was discontinued on postoperative day 1. The patient was weaned from oxygen and discharged home on postoperative day 7. At 20 months follow-up the patient still noted some limitation with strenuous exercise but marked improvement in his overall work of breathing.
3.5. Case 5 An institutionalized 13-year-old girl with chromosome 8 deletion was being followed for a tracheotomy which was performed at the age of 5 for intractable seizures. The child also had a history of pulmonic stenosis that was repaired at the age of 9 months, marked developmental delay, and cerebral palsy. Past surgical history also included a gastrostomy tube. The patient had failed several decannulation attempts and bronchoscopy revealed grade II tracheal stenosis superior to the tracheotomy. As a result, the child underwent elective tracheoplasty with thyroid alar cartilage graft augmentation. Intraoperatively, the tracheotomy site was extended superiorly 5 mm revealing severe fibrosis and scarring of the two immediately superior tracheal rings. This area was excised and the tracheal defect was augmented with a free cartilage graft fashioned from the left thyroid alar. The graft was sutured into place using 4.0 monocryl sutures. There were no intraoperative complications and the total operative time was approximately 4 h. Post-
21 months–—asymptomatic None 4 days
None 19 h
II
Cricotracheal resection Tracheoplasty III
None 20 h Tracheoplasty II 4 years
14 years
13 years
3
4
5
Velocardiofacial syndrome, Robin sequence Esophageal strictures, reactive airway disease Chromosome 8 deletion, pulmonic stenosis, developmental delay, cerebral palsy, seizure disorder
Tracheal resection 2 months 2
Kawasaki’s disease
III
18 h
1 year–—asymptomatic
Stridor, tachypnea–—resolved with heliox and racemic epinephrine None 4 years 1
Broncho-pulmonary dysplasia, reactive airway disease
II
Tracheoplasty
16 h
Follow-up Post-extubation complications Time to extubation Procedure Myer—Cotton grade Age
Comorbidities
operatively the patient was transferred to the pediatric intensive care unit intubated and placed on intravenous famotidine and cefazolin along with her chronic medications. On postoperative day 2 dexamethasone was added to her regiment. She was extubated on day 4 without complications and placed on humidified room air. Intravenous dexamethasone was discontinued on postoperative day 6 and she was discharged the following day. At 21 months follow-up the patient was well without signs or symptoms of upper airway obstruction (Table 1).
4. Discussion
Case
Case reports Table 1
20 months–—mild limitations
S.M. Brown et al.
1 month–—inspiratory stridor, 25% stenosis on bronchoscopy, 15 months–—asymptomatic 1 year–—asymptomatic
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The role of intubation and stenting after major tracheal surgery in children is unclear. In our study four out of five patients were extubated successfully within 24 h. The fifth patient was kept intubated until postoperative day 4, not because of postoperative complications but secondary to the patient’s associated comorbidities; chromosome 8 deletion, cerebral palsy, and severe neurological compromise. It has been mentioned that extubation should be guided by measuring leak pressures. This is based on one study that found patients without a leak of at least 20 cm H2O were twice as likely to fail initial extubation [9]. This may be a reasonable approach but in our patients this criteria was not used for extubation. Reports have been made that longer periods of stenting are necessary in patients with more severe stenosis [6]. However, in our study, three patients had grade II stenosis and two grade III; both patients with grade III being extubated in the initial 24 h. It is important to note that both of our grade III patients underwent resections and not procedures requiring a grafting technique. Furthermore, four out of our five patients underwent tracheal reconstruction without laryngoplasty and thus extrapolating our results to major laryngeal surgery, where stenting may have a more important role, would be inappropriate. Several reports in the literature have appeared over the past 15 years demonstrating successful results in patients stented for short periods of time. Lusk et al. published a report of 19 patients in 1991 with SSLTRs with an average duration of endotracheal tube stenting of less than 5 days, including successfully extubating five patients on postoperative day 0 or 1 [3]. There has also been several reports in the recent literature of extubating select patients on the first postoperative day following a cricotracheal resection [14,17]. More recently, Younis and Lazar reported that 19 of 21 patients under-
Early extubation following major tracheal surgery in select children
going SSLTR who were extubated in the OR did not require any immediate airway intervention [26]. Despite these results, still larger studies are necessary as failures could result in devastating complications. Potential problems include the need for reintubation, carrying with it the risk of disrupting a fresh surgical site, as well as the difficulty recognizing an airway emergency in time to prevent hypoxia. Postoperative complications such as graft migration and restenosis of the airway are theoretical problems that could also exist with early extubation. It must be mentioned that there are many times when early extubation would not be indicated and therefore proper patient selection is important. For instance, in one report, adult patients were extubated in a matter of hours following major tracheal surgery and 10 out of 23 required reintubation [27]. One particular case where early extubation may not be ideal is when both anterior and posterior grafts are used, as this reconstruction is much less stable secondary to the cricoid ring being split in two places [7]. In addition, early extubation may be limited by an anastomosis site in close relationship to the glottis, thus causing edema of the vocal folds in the early postoperative period [14]. Patients with decreased pulmonary function may also require longer periods of intubation and therefore may actually be better handled by a two-staged approach. Other factors thought to play a role in extubation failure include: confounding airway problems such as tracheomalacia, the use of a posterior cartilage graft, patients with a high degree of stenosis, young children who require more than 48 h of sedation, and patients less than 4 years of age [9]. The need for removal of the endotracheal tube is well summarized by Cotton who remarks that since most cases of subglottic stenosis are originally incited by an endotracheal tube, ideally no stent should be used [13]. Stenting postoperatively with an endotracheal tube, in addition to having some of the same complications as traditional stents, also carries with it another collection of problems. For example, particularly in younger children, intubation may require high doses of sedatives, narcotics, and paralytic agents. This can lead to issues such as pneumonia, pulmonary atelectasis, and opiate addiction. Some groups have already begun to limit the postoperative intubation time in order to decrease postoperative problems associated with prolonged intubation and paralysis [4]. The goal in airway reconstruction continues to be to create a safe, stable airway, avoiding complications, in the shortest period of time [6]. There is no doubt that a reduction in long term intubation can reduce postoperative morbidities including infec-
257
tion and narcotic addiction. As airway surgery continues to evolve, the trend may continue toward decreased stenting and earlier extubation.
5. Conclusions The function of stenting and prolonged intubation after major pediatric tracheal surgery is indistinct. Current trends in the literature suggest that stenting may not prevent restenosis of airway lesions. Our initial experience with early extubation in select patients undergoing major tracheal surgery has been positive with no need for post-extubation airway intervention and successful decannulation.
References [1] I.H. McDonald, J.G. Stocks, Prolonged nasotracheal intubation a review of its development in a paediatric hospital, Br. J. Anaesth. 37 (1965) 161—172. [2] B. Fearon, R. Cotton, Surgical correction of subglottic stenosis of the larynx in infants and children, Ann. Otol. 83 (1974) 428—431. [3] R.P. Lusk, S. Gray, H.R. Muntz, Single-stage laryngotracheal reconstruction, Arch. Otolaryngol. Head Neck Surg. 117 (1991) 171—173. [4] A.B. Seid, S.M. Pransky, D.B. Kearns, One-staged laryngotracheoplasty, Arch. Otolaryngol. Head Neck Surg. 117 (1991) 408—410. [5] R.T. Cotton, Pediatric laryngotracheal reconstruction, Oper. Tech. Otolaryngol. Head Neck Surg. 3 (1992) 165—172. [6] R.T. Cotton, C.M. Myer, D.M. O’Connor, Innovations in pediatric laryngotracheal reconstruction, J. Pediatr. Surg. 27 (1992) 196—200. [7] B.E. Hartley, L.M. Gustafson, J.H. Liu, C.J. Hartnick, R.T. Cotton, Duration of stenting in single-staged larygotracheal reconstruction with anterior costal cartilage grafts, Ann. Otol. Rhinol. Laryngol. 110 (2001) 413—416. [8] R.T. Cotton, C.M. Myer, D.M. O’Connor, M.E. Smith, Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the single-stage approach, Laryngoscope 105 (1995) 818—821. [9] L.M. Gustafson, B.E.J. Hartley, J.H. Liu, D.T. Link, J. Chadwell, C. Koebbe, C.M. Myer, R.T. Cotton, Single-stage laryngotracheal reconstruction in children: a review of 200 cases, Otolaryngol. Head Neck Surg. 123 (2000) 430—434. [10] R.F. Yellon, M. Parameswaran, B.W. Brandom, Decreasing morbidity following laryngotracheal reconstruction in children, Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 145—154. [11] C.T. McQueen, N.L. Shapiro, S. Leighton, X.G. Guo, D.M. Albert, Single-stage laryngotracheal reconstruction. The Great Ormond Street experience and guidelines for patient selection, Arch. Otolaryngol. Head Neck Surg. 125 (1999) 320—322. [12] J.S. Rhee, R.J. Toohill, Single-staged adult laryngotracheal reconstruction with stenting, Laryngoscope 111 (2001) 165— 768. [13] R.T. Cotton, Update on the pediatric airway. Management of subglottic stenosis, Otolaryngol. Clin. N. Am. 33 (2000) 111— 130.
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[14] Y. Stern, M.E. Gerber, D.L. Walner, R.T. Cotton, Partial cricotracheal resection with primary anastomosis in the pediatric age group, Ann. Otol. Rhinol. Laryngol. 106 (1997) 891—896. [15] P. Monnier, F. Lang, M. Savary, Cricotracheal resection for pediatric subglottic stenosis, Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S283—S286. [16] M.J. Rutter, B.E. Hartley, R.T. Cotton, Cricotracheal resection in children, Arch. Otolaryngol. Head Neck Surg. 127 (2001) 289—292. [17] J.M. Triglia, R. Nicollas, S. Roman, Primary cricotracheal resection in children: indications, technique and outcome, Int. J. Pediatr. Otorhinolaryngol. 58 (2001) 17—25. [18] G.K. Thomas, M.H. Stevens, Stenting in experimental laryngeal injuries, Arch. Otolaryngol. 101 (1975) 217— 221. [19] N.R. Olson, Wound healing by primary tension in the larynx, in: Proceedings of the Symposium on Reconstruction of the Larynx and Trachea, Milwaukee, April 1—2, 1977, Otolaryngol. Clin. N. Am. 12 1979 735—740. [20] D.M. Albert, R.T. Cotton, P. Conn, Effect of laryngeal stenting in a rabbit model, Ann. Otol. Rhinol. Laryngol. 99 (1990) 108—111.
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[21] M.E. Smith, A.J. Mortelliti, R.T. Cotton, C.M. Myer, Phonation and swallowing considerations in pediatric laryngotracheal reconstruction, Ann. Otol. Rhinol. Laryngol. 101 (1992) 731—738. [22] G.H. Zalzal, Use of stents in laryngotracheal reconstruction in children: indications, technical considerations, and complications, Laryngoscope 98 (1998) 849—854. [23] B.S. Jewett, R.D. Cook, K.L. Johnson, T.C. Logan, W.M. Shockley, Effect of stenting after laryngotracheal reconstruction in a subglottic stenosis model, Otolaryngol. Head Neck Surg. 122 (2000) 488—494. [24] A. Willner, S.A. Gereau, R.J. Ruben, Reconstruction of the pediatric airway with an open stented tracheotomy tube, Int. J. Pediatr. Otorhinolaryngol. 28 (1994) 205—211. [25] C.M. Myer, D.M. O’Connor, R.T. Cotton, Proposed grading system for subglottic stenosis based on endotracheal tube sizes, Ann. Otol. Rhinol. Laryngol. 103 (1994) 319—323. [26] R.T. Younis, R.H. Lazar, Laryngotracheal reconstruction without stenting, Otolaryngol. Head Neck Surg. 116 (1997) 358—362. [27] M. Wolf, Y. Shapira, Y.P. Talmi, I. Novikov, J. Kronenberg, A. Yellin, Laryngotracheal anastomosis: primary and revised procedures, Laryngoscope 111 (2001) 622—627.
www.elsevier.com/locate/ijporl
Early extubation following major tracheal surgery in select children Seth M. Brown a, Joshua D. Rosenberg a, Sanjay R. Parikh a,b,* a
Department of Otolaryngology, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, 3rd Floor, Bronx, NY 10467, USA b The Children’s Hospital at Montefiore, Bronx, NY, USA Received 2 May 2005; accepted 22 June 2005
KEYWORDS Tracheoplasty; Tracheal resection; Cricotracheal resection; Stenting; Extubation
Summary Major airway surgery in children has traditionally consisted of a period of endotracheal intubation after the procedure for a period of 1—2 weeks to ensure stability of the repair. Recent literature has supported a trend toward decreasing this time period to prevent the consequences of leaving a foreign body in the airway and the morbidity associated with the use of sedation and narcotics in children. We present a series of five select children from our institution that underwent major tracheal surgery and were successfully extubated early in their postoperative course; four on postoperative day number 1. This demonstrates the feasibility of this approach in select patients. # 2005 Elsevier Ireland Ltd. All rights reserved.
1. Introduction In the mid-1960s, McDonald and Stocks reintroduced long term endotracheal intubation in neonates [1]. This popularized practice led to an increase in the incidence of subglottic stenosis. Fearon and Cotton, after experimenting on primates, reported in 1974 the division of the cricoid and anterior trachea with interposition of a cartilage graft for subglottic stenosis in two children [2]. Originally a two-staged procedure, the following two decades brought about a vast interest in pediatric airway surgery and the development of the single-staged LTR * Corresponding author. Tel.: +1 718 920 2991; fax: +1 718 920 8112. E-mail address: [email protected] (S.R. Parikh).
(SSLTR) [3—12]. In addition to the advantage of decannulating the patient much sooner, this procedure avoids the use of an in-dwelling stent, often left for a month or longer. The replacement of the stent in SSLTR is an endotracheal tube, usually left in place for 7—10 days when an anterior graft is used and 12—14 days with a posterior graft [13]. Recently, interest has turned toward cricotracheal resection in children [14—17]. This procedure has enabled a number of patients, who may not have been successfully treated with a SSLTR secondary to severe disease, to be decannulated. Much like laryngotracheal reconstruction (LTR), this procedure can consist of a two-staged procedure with stenting or a single-staged procedure with the use of an endotracheal tube as a stent for 7—10 days [16].
0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2005.06.014
254
Controversy exists about the role of stenting after major airway surgery. Thomas and Stevens looked at different materials of stents in acute laryngeal injuries in dogs in the mid-1970s. They concluded that using a stent of any material results in a much higher frequency of ulceration, granulation tissue formation, and infection [18]. Olson has argued against stents as well. His report nearly 25 years ago mentions that the success of a laryngeal repair occurs in spite of a stent rather then because of one [19]. Albert et al. demonstrated in rabbits that even when a stent is sutured into place, thus preventing tube slipping, squamous metaplasia of the respiratory epithelium can occur in as little as 1 week’s time [20]. Smith et al. studied phonation in patients with LTRs and came to the conclusion that stents can cause scarring of the vocal fold mucosa and impair arytenoid mobility [21]. Zalzal reviewed a specific device, the Aboulker stent in 1988 and found complications in 10 out of 18 patients including: infection, granulation tissue, stent migration, and stent breakage [22]. Jewett et al. studied stenting versus nonstenting of rabbits after SSLTR and found that in stented animals there was a trend toward increasing mucosal edema and granulation tissue [23]. Despite these reports, it has been suggested that stents are beneficial to the tissues as they are healing, as they play a role in preventing scar contracture, thus avoiding the complication of a decrease in size of the reconstructed tracheal lumen [24]. Recent studies however, have demonstrated that the use of a stent may not offer a clinically beneficial advantage. For instance, it has been reported that in tracheal resection, edema at the anastomosis site does not usually occur and therefore postoperative airway protection may be unnecessary [14]. The Great Ormond Street Group reported in 28 patients that duration of intubation following SSLTR had no effect on extubation complications or final outcome [11]. In 2001 Hartley et al. conducted a retrospective study comparing duration of endotracheal tube stenting in 101 patients with SSLTR finding no significant correlation, with similar stage of disease, between duration of stenting and the need for reintubation or tracheotomy. The authors concluded that long stenting periods do not give an additional benefit [7]. These studies suggest that major airway surgery may not require long term intubation or stenting.
2. Materials and methods Medical records of five patients with a mean age of 7 years who underwent major tracheal surgery between July 2002 and June 2003 were reviewed.
S.M. Brown et al.
3. Results 3.1. Case 1 A 4-year-old boy with a history of bronchopulmonary dysplasia and reactive airway disease was referred for possible decannulation. The patient was born at 25 weeks gestation requiring intubation secondary to respiratory distress syndrome. A tracheotomy was performed before the patient left the neonatal intensive care unit. The patient’s workup included a bronchoscopy that revealed a Myer—Cotton grade II stenosis between tracheal rings 3 and 5 [25]. Of note, the previous tracheotomy had been performed in the sixth tracheal space. Tracheoplasty was thus performed with the existing tracheal stoma being extended superiorly to the third tracheal space, facilitating removal of an occluding suprastomal granuloma. A thyroid alar cartilage free graft was fashioned into the opening in the anterior trachea and sutured into place using 4.0 monocryl sutures. Total operative time was 4.5 h. Postoperatively the patient was transferred to the pediatric intensive care unit intubated. The patient was placed on intravenous dexamethasone, cefazolin, famotidine, and inhaled fluticasone. The patient was extubated 16 h postoperatively and subsequently developed stridor and tachypnea that responded to treatment with racemic epinephrine and a helium—oxygen mixture by mask. He was successfully weaned off the helium—oxygen mixture on postoperative day 8 with oxygen saturation rates above 94% on room air. The patient was transferred from the pediatric intensive care unit on postoperative day 9 and weaned off steroids. He was discharged home on postoperative day 14. At 1-year follow-up he was well without signs or symptoms of upper airway obstruction.
3.2. Case 2 A 2-month-old boy was admitted to the hospital for Kawasaki’s disease. During treatment with aspirin the patient suffered a massive lower gastrointestinal hemorrhage necessitating endotracheal intubation for 3 weeks. The patient was extubated successfully and subsequently discharged home. Two days later he presented with progressive stridor and respiratory distress. Despite treatment with racemic epinephrine, intravenous dexamethasone, and a helium—oxygen mixture by mask, his respiratory status continued to deteriorate. Rigid bronchoscopy at this time revealed a grade III stenosis. After the procedure the patient was left intubated with a 3.5 endotracheal tube and started on high dose dexamethasone, ranitidine, and ampicillin/sulbac-
Early extubation following major tracheal surgery in select children
tam. Bronchoscopy 4 days later demonstrated significant improvement in the patient’s tracheal stenosis and he was successfully extubated. However, the patient redeveloped stridor within 3 days. Repeat bronchoscopy again demonstrated a grade III stenosis. Segmental tracheal resection with endto-end anastomosis was thus undertaken in conjunction with the cardiothoracic surgery service. Intraoperatively tracheal rings 3—5 were noted to be stenotic and resected in a total operative time of 7 h. Postoperatively the patient was placed on intravenous dexamethasone, ranitidine, clindamycin, and cephradine. The patient was extubated the following day, approximately 18 h after leaving the operating room. By postoperative day 2 the patient was saturating well on room air and able to tolerate oral feeding. The intravenous dexamethasone was discontinued and inhaled budesonide was started on postoperative day 5. The patient was discharged on postoperative day 14. Although mild inspiratory stridor was noted at 3 months and a grade I stenosis was seen at the second tracheal space on subsequent bronchoscopy, the patient was breathing without effort and eating well. Since, the patient has been asymptomatic with 15 months of follow-up.
3.3. Case 3 A 4-year-old girl with velocardiofacial syndrome, Pierre Robin sequence, and tracheal stenosis was being followed for airway management and ear disease. The patient’s medical history was also significant for reactive airway disease, recurrent pneumonia, and chronic serous otitis media. A tracheotomy was performed while the patient was an infant secondary to airway obstruction due to the Robin sequence. The patient’s past surgical history also included a cleft palate repair at the age of two and a gastrostomy tube. Prior to the patient’s airway reconstruction, under the same anesthesia, an umbilical hernia repair was performed by general surgery. Intraoperative bronchoscopy revealed a grade II suprastomal tracheal stenosis. The stenotic scar tissue was exposed via extension of the tracheal stoma superiorly and excised. A free graft was harvested from the left alar of the thyroid cartilage and sutured into place using 4.0 monocryl sutures. There were no significant intraoperative complications in a total operative time of 4.5 h. Postoperatively, along with her chronic medications, she was placed on intravenous dexamethasone, ranitidine, and cefazolin. She was extubated 20 h later and was stable on room air. The dexamethasone was discontinued on postoperative day 3. The remainder of her hospital course was unremarkable and she was dis-
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charged home on postoperative day 4. One year postoperatively the patient had no signs or symptoms of upper airway obstruction.
3.4. Case 4 A 14-year-old boy with a history of accidental lye ingestion at age 9 and reactive airway disease was referred for evaluation and treatment of worsening respiratory symptoms. Since his injury the patient had undergone a gastrostomy tube placement and greater than 60 esophageal dilatations. At the time of referral the patient’s feeding tube had been removed and he was tolerating a regular diet. Bronchoscopy done shortly after revealed a grade III tracheal stenosis. Subsequently, segmental cricotracheal resection with end-to-end anastamosis was performed in conjunction with cardiothoracic surgery. Intraoperatively the anterior cricoid cartilage and tracheal rings 1—3 were resected. There were no intraoperative complications in a total operative time of 8 h. Along with his chronic medications the patient was started on intravenous dexamethasone, pantoprazole, cefazolin, and enoxaparin. He was extubated approximately 19 h postoperatively and placed on humidified oxygen. The intravenous dexamethasone was discontinued on postoperative day 1. The patient was weaned from oxygen and discharged home on postoperative day 7. At 20 months follow-up the patient still noted some limitation with strenuous exercise but marked improvement in his overall work of breathing.
3.5. Case 5 An institutionalized 13-year-old girl with chromosome 8 deletion was being followed for a tracheotomy which was performed at the age of 5 for intractable seizures. The child also had a history of pulmonic stenosis that was repaired at the age of 9 months, marked developmental delay, and cerebral palsy. Past surgical history also included a gastrostomy tube. The patient had failed several decannulation attempts and bronchoscopy revealed grade II tracheal stenosis superior to the tracheotomy. As a result, the child underwent elective tracheoplasty with thyroid alar cartilage graft augmentation. Intraoperatively, the tracheotomy site was extended superiorly 5 mm revealing severe fibrosis and scarring of the two immediately superior tracheal rings. This area was excised and the tracheal defect was augmented with a free cartilage graft fashioned from the left thyroid alar. The graft was sutured into place using 4.0 monocryl sutures. There were no intraoperative complications and the total operative time was approximately 4 h. Post-
21 months–—asymptomatic None 4 days
None 19 h
II
Cricotracheal resection Tracheoplasty III
None 20 h Tracheoplasty II 4 years
14 years
13 years
3
4
5
Velocardiofacial syndrome, Robin sequence Esophageal strictures, reactive airway disease Chromosome 8 deletion, pulmonic stenosis, developmental delay, cerebral palsy, seizure disorder
Tracheal resection 2 months 2
Kawasaki’s disease
III
18 h
1 year–—asymptomatic
Stridor, tachypnea–—resolved with heliox and racemic epinephrine None 4 years 1
Broncho-pulmonary dysplasia, reactive airway disease
II
Tracheoplasty
16 h
Follow-up Post-extubation complications Time to extubation Procedure Myer—Cotton grade Age
Comorbidities
operatively the patient was transferred to the pediatric intensive care unit intubated and placed on intravenous famotidine and cefazolin along with her chronic medications. On postoperative day 2 dexamethasone was added to her regiment. She was extubated on day 4 without complications and placed on humidified room air. Intravenous dexamethasone was discontinued on postoperative day 6 and she was discharged the following day. At 21 months follow-up the patient was well without signs or symptoms of upper airway obstruction (Table 1).
4. Discussion
Case
Case reports Table 1
20 months–—mild limitations
S.M. Brown et al.
1 month–—inspiratory stridor, 25% stenosis on bronchoscopy, 15 months–—asymptomatic 1 year–—asymptomatic
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The role of intubation and stenting after major tracheal surgery in children is unclear. In our study four out of five patients were extubated successfully within 24 h. The fifth patient was kept intubated until postoperative day 4, not because of postoperative complications but secondary to the patient’s associated comorbidities; chromosome 8 deletion, cerebral palsy, and severe neurological compromise. It has been mentioned that extubation should be guided by measuring leak pressures. This is based on one study that found patients without a leak of at least 20 cm H2O were twice as likely to fail initial extubation [9]. This may be a reasonable approach but in our patients this criteria was not used for extubation. Reports have been made that longer periods of stenting are necessary in patients with more severe stenosis [6]. However, in our study, three patients had grade II stenosis and two grade III; both patients with grade III being extubated in the initial 24 h. It is important to note that both of our grade III patients underwent resections and not procedures requiring a grafting technique. Furthermore, four out of our five patients underwent tracheal reconstruction without laryngoplasty and thus extrapolating our results to major laryngeal surgery, where stenting may have a more important role, would be inappropriate. Several reports in the literature have appeared over the past 15 years demonstrating successful results in patients stented for short periods of time. Lusk et al. published a report of 19 patients in 1991 with SSLTRs with an average duration of endotracheal tube stenting of less than 5 days, including successfully extubating five patients on postoperative day 0 or 1 [3]. There has also been several reports in the recent literature of extubating select patients on the first postoperative day following a cricotracheal resection [14,17]. More recently, Younis and Lazar reported that 19 of 21 patients under-
Early extubation following major tracheal surgery in select children
going SSLTR who were extubated in the OR did not require any immediate airway intervention [26]. Despite these results, still larger studies are necessary as failures could result in devastating complications. Potential problems include the need for reintubation, carrying with it the risk of disrupting a fresh surgical site, as well as the difficulty recognizing an airway emergency in time to prevent hypoxia. Postoperative complications such as graft migration and restenosis of the airway are theoretical problems that could also exist with early extubation. It must be mentioned that there are many times when early extubation would not be indicated and therefore proper patient selection is important. For instance, in one report, adult patients were extubated in a matter of hours following major tracheal surgery and 10 out of 23 required reintubation [27]. One particular case where early extubation may not be ideal is when both anterior and posterior grafts are used, as this reconstruction is much less stable secondary to the cricoid ring being split in two places [7]. In addition, early extubation may be limited by an anastomosis site in close relationship to the glottis, thus causing edema of the vocal folds in the early postoperative period [14]. Patients with decreased pulmonary function may also require longer periods of intubation and therefore may actually be better handled by a two-staged approach. Other factors thought to play a role in extubation failure include: confounding airway problems such as tracheomalacia, the use of a posterior cartilage graft, patients with a high degree of stenosis, young children who require more than 48 h of sedation, and patients less than 4 years of age [9]. The need for removal of the endotracheal tube is well summarized by Cotton who remarks that since most cases of subglottic stenosis are originally incited by an endotracheal tube, ideally no stent should be used [13]. Stenting postoperatively with an endotracheal tube, in addition to having some of the same complications as traditional stents, also carries with it another collection of problems. For example, particularly in younger children, intubation may require high doses of sedatives, narcotics, and paralytic agents. This can lead to issues such as pneumonia, pulmonary atelectasis, and opiate addiction. Some groups have already begun to limit the postoperative intubation time in order to decrease postoperative problems associated with prolonged intubation and paralysis [4]. The goal in airway reconstruction continues to be to create a safe, stable airway, avoiding complications, in the shortest period of time [6]. There is no doubt that a reduction in long term intubation can reduce postoperative morbidities including infec-
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tion and narcotic addiction. As airway surgery continues to evolve, the trend may continue toward decreased stenting and earlier extubation.
5. Conclusions The function of stenting and prolonged intubation after major pediatric tracheal surgery is indistinct. Current trends in the literature suggest that stenting may not prevent restenosis of airway lesions. Our initial experience with early extubation in select patients undergoing major tracheal surgery has been positive with no need for post-extubation airway intervention and successful decannulation.
References [1] I.H. McDonald, J.G. Stocks, Prolonged nasotracheal intubation a review of its development in a paediatric hospital, Br. J. Anaesth. 37 (1965) 161—172. [2] B. Fearon, R. Cotton, Surgical correction of subglottic stenosis of the larynx in infants and children, Ann. Otol. 83 (1974) 428—431. [3] R.P. Lusk, S. Gray, H.R. Muntz, Single-stage laryngotracheal reconstruction, Arch. Otolaryngol. Head Neck Surg. 117 (1991) 171—173. [4] A.B. Seid, S.M. Pransky, D.B. Kearns, One-staged laryngotracheoplasty, Arch. Otolaryngol. Head Neck Surg. 117 (1991) 408—410. [5] R.T. Cotton, Pediatric laryngotracheal reconstruction, Oper. Tech. Otolaryngol. Head Neck Surg. 3 (1992) 165—172. [6] R.T. Cotton, C.M. Myer, D.M. O’Connor, Innovations in pediatric laryngotracheal reconstruction, J. Pediatr. Surg. 27 (1992) 196—200. [7] B.E. Hartley, L.M. Gustafson, J.H. Liu, C.J. Hartnick, R.T. Cotton, Duration of stenting in single-staged larygotracheal reconstruction with anterior costal cartilage grafts, Ann. Otol. Rhinol. Laryngol. 110 (2001) 413—416. [8] R.T. Cotton, C.M. Myer, D.M. O’Connor, M.E. Smith, Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the single-stage approach, Laryngoscope 105 (1995) 818—821. [9] L.M. Gustafson, B.E.J. Hartley, J.H. Liu, D.T. Link, J. Chadwell, C. Koebbe, C.M. Myer, R.T. Cotton, Single-stage laryngotracheal reconstruction in children: a review of 200 cases, Otolaryngol. Head Neck Surg. 123 (2000) 430—434. [10] R.F. Yellon, M. Parameswaran, B.W. Brandom, Decreasing morbidity following laryngotracheal reconstruction in children, Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 145—154. [11] C.T. McQueen, N.L. Shapiro, S. Leighton, X.G. Guo, D.M. Albert, Single-stage laryngotracheal reconstruction. The Great Ormond Street experience and guidelines for patient selection, Arch. Otolaryngol. Head Neck Surg. 125 (1999) 320—322. [12] J.S. Rhee, R.J. Toohill, Single-staged adult laryngotracheal reconstruction with stenting, Laryngoscope 111 (2001) 165— 768. [13] R.T. Cotton, Update on the pediatric airway. Management of subglottic stenosis, Otolaryngol. Clin. N. Am. 33 (2000) 111— 130.
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[14] Y. Stern, M.E. Gerber, D.L. Walner, R.T. Cotton, Partial cricotracheal resection with primary anastomosis in the pediatric age group, Ann. Otol. Rhinol. Laryngol. 106 (1997) 891—896. [15] P. Monnier, F. Lang, M. Savary, Cricotracheal resection for pediatric subglottic stenosis, Int. J. Pediatr. Otorhinolaryngol. 49 (1999) S283—S286. [16] M.J. Rutter, B.E. Hartley, R.T. Cotton, Cricotracheal resection in children, Arch. Otolaryngol. Head Neck Surg. 127 (2001) 289—292. [17] J.M. Triglia, R. Nicollas, S. Roman, Primary cricotracheal resection in children: indications, technique and outcome, Int. J. Pediatr. Otorhinolaryngol. 58 (2001) 17—25. [18] G.K. Thomas, M.H. Stevens, Stenting in experimental laryngeal injuries, Arch. Otolaryngol. 101 (1975) 217— 221. [19] N.R. Olson, Wound healing by primary tension in the larynx, in: Proceedings of the Symposium on Reconstruction of the Larynx and Trachea, Milwaukee, April 1—2, 1977, Otolaryngol. Clin. N. Am. 12 1979 735—740. [20] D.M. Albert, R.T. Cotton, P. Conn, Effect of laryngeal stenting in a rabbit model, Ann. Otol. Rhinol. Laryngol. 99 (1990) 108—111.
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