What is it about?
Subglottic edema is the most common cause of pediatric extubation failure, but few studies have confirmed risk factors to help with prevention. Using a novel objective tool which is strongly associated with both treatment for upper airway obstruction (UAO) and reintubation, we identified that risk factors for subglottic UAO differ based on whether the endotracheal tube was cuffed or uncuffed. For cuffed tubes, low cuff leak volume or high preextubation leak pressure, poor sedation, and preexisting UAO were associated with subglottic UAO. For uncuffed endotracheal tubes, age (1 mo to 5 yr) was the only risk factor associated with subglottic UAO. The presence or absence of a leak preextubation (regardless of pressure) was not associated with subglottic UAO for uncuffed endotracheal tubes. There is no difference in the rate of subglottic UAO between cuffed and uncuffed endotracheal tubes, even when matching for age.
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Why is it important?
These findings contradict a common practice in pediatric intensive care units in which practitioners delay extubation to administer corticosteroids to patients who do not have an extubation leak. This practice is not warranted if the endotracheal tube is uncuffed because leak pressure has no bearing on post extubation UAO. If the tube is cuffed and there is no leak (at a pressure of 25 cmH20), then there is roughly a 20% chance the patient will need a treatment for UAO. Future research is needed to determine whether this high risk group would benefit from prophylactic corticosteroids.
Perspectives
I believe this is a very important publication because post-extubation UAO is the most common complication of pediatric mechanical ventilation. We have described a way to improve the diagnosis with a new tool. We have identified that about half of the cases of post-extuabtion UAO are likely supra-glottic, and these cases warrant different treatment and prevention strategies than subglottic UAO. Finally, we have been able to clarify the importance of extubation leak pressures: identifying that they are only relevent for children with cuffed endotracheal tubes. We hope this can change current practice, and forms a line of new investigation for prevention strategies.
Dr Robinder G Khemani
Children's Hospital Los Angeles
Read the Original
This page is a summary of: Evaluating Risk Factors for Pediatric Post-extubation Upper Airway Obstruction Using a Physiology-based Tool, American Review of Respiratory Disease, January 2016, American Thoracic Society,
DOI: 10.1164/rccm.201506-1064oc.
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