Factors to Consider When Treating Pediatric Airway Reconstruction

Can a multidisciplinary and international consensus be reached on the factors affecting outcomes and complications for pediatric airway reconstruction?

Bottom Line:
The list provides a framework for communication and clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient.

Background: Historical measures of success on open airway reconstructive procedures, based primarily on the ability to maintain a patent airway or to decannulate a patient following surgery, have shifted over time, and despite an improved understanding of complex airway reconstruction and the long-term results of our interventions, outcome measures following laryngeal and tracheal surgery have become progressively more disparate.

Study design: Thirty-three pediatric airway experts recruited between June 2016 and October 2017 from eight countries in North and South America, Europe, and Australia, representing otolaryngology, pulmonology, general surgery, and cardiothoracic surgery.

Setting: Department of Otorhinolaryngology and Mayo Clinic Children’s Center, Rochester, Minn.

Synopsis: Consensus was reached in 20 open operations of the larynx, trachea, and bronchi (single-stage laryngotracheoplasty; double-stage laryngotracheoplasty; open cricoid split; patch tracheoplasty; single-stage tracheal resection; double-stage tracheal resection; single-stage partial cricotracheal resection; double-stage partial cricotracheal resection; single-stage extended cricotracheal resection; double-stage extended cricotracheal resection; cervical slide tracheoplasty; thoracic slide tracheoplasty; slide bronchoplasty; vocal cord lateralization; laryngeal web repair; open arytenoidectomy; open epiglottic petiole resuspension; open tracheal stent placement; open t-tube placement; tracheal homograft).

Consensus was reached on three endoscopic operations (balloon dilation; endoscopic cricoid split; endoscopic posterior graft laryngotracheoplasty). A total of 16 operation details items reached consensus (graft used: yes/no; graft location: anterior, posterior, both, box graft; graft type/source; stent: yes/no; stent duration; stent type; endotracheal tube duration (single-stage operation); keel type; antibiotic use: therapeutic; single or double stage; airway levels repaired; use of cardiopulmonary bypass or ECMO; initial vs. revision surgery; adjunct procedures required; indication for surgery; length of stay), and one item (duration of follow-up) reached near consensus.

Seven airway items (airway sizing; distance from vocal folds to stenosis; severity of stenosis; length of stenosis; vocal fold immobility: neurologic; cricoarytenoid joint status; static vs. dynamic obstruction) reached consensus and four (location of stenosis; suprastomal collapse: yes/no; vocal fold immobility; congenital vs. acquired vs. combined stenosis) reached near consensus. Four airway-related comorbidity items (airway compression; tracheomalacia presence/severity; bronchomalacia presence/severity; secondary airway lesions) reached consensus and eight (tongue base obstruction; sleep apnea; CPAP dependence; active/reactive larynx; mucosal inflammation/edema; tracheostomy; TEF history; indication for tracheostomy) reached near consensus. Six other patient factors (aspiration status; need for mechanical ventilation immediately prior; documented GERD; CHARGE; 22q11/VCFS; Pierre Robin) reached consensus, and 10 (nutrition status; multidisciplinary team management: yes/no; bronchiectasis; pulmonary hypertension; chronic lung disease; cardiac disease; eosinophilic esophagitis; esophageal stricture; oral feeding status; Wegener’s) reached near consensus.

Eight general outcome measures reached consensus (mortality; need for revision; number of subsequent open procedures; number of subsequent endoscopic procedures; number of dilations; need for adjunctive procedures; long-term patency; quality of life), and two (parent/caregiver satisfaction; patient satisfaction) reached near consensus.

Limitations included level 5 Delphi method evidence, and few cardiovascular surgeons and no participants from African or Asian countries on the panel.

Citation: Balakrishnan K, Sidell DR, Bauman NM, et al. Outcome measures for pediatric laryngotracheal reconstruction: international consensus statement. Laryngoscope. Published August 27, 2018 online ahead of print. doi: 10.1002/lary.27445.