Neonates with younger gestational age and lower birth weight are more likely to fail extubation and to require earlier surgical airway intervention, according to an April 28 presentation by University of Texas Medical School, Houston, researchers at the American Society of Pediatric Otolaryngology program at the Combined Otolaryngology Spring Meeting.
Stacey L. Smith, MD, a resident physician in the university’s Department of Otolaryngology-Head and Neck Surgery, also offered COSM participants a treatment algorithm for the management of neonatal failed extubation.
Although advances in the management of neonates have increased survival rates, comorbid factors such as bronchopulmonary disease can contribute to the need for prolonged intubation time and can lead to upper airway injury, including vocal cord paralysis, laryngeal edema, granular tissue formation, and subglottic stenosis, Dr. Smith said.
She told COSM participants that indications for neonatal tracheostomies have shifted from airway obstruction to prolonged intubation. Unfortunately, recommendations for management of failed extubation are inconsistent.
The researchers’ goal in the study were to determine the causes of failed extubation in the neonatal intensive care unit (NICU), identify the population most likely to fail extubation, and recommend an algorithm for airway intervention.
Reasons for Failed Extubation
Headed by Kevin D. Pereira, MD, MS, Professor and Director of Pediatric Otolaryngology, the research team identified all premature infants with a gestational age of under 37 weeks who were admitted to the NICU between January 1998 and December 2006, and who underwent direct laryngoscopy and bronchoscopy (DLB) in the operating room for failed extubation. Data were collected on weight, gestational age, comorbid conditions, number of failed extubations, findings at endoscopy, and whether or not a tracheostomy was performed. The patients were divided into two groups: Group A were those who underwent tracheostomy and Group B did not undergo tracheostomy.
The 50 Group A (tracheostomy) children studied had an average gestational age of 30 weeks and an average birth weight of 1457 grams. This compared to the 13 infants in Group B (no tracheostomy), who had an average gestational age of 34.5 weeks and an average birth weight of 2309 grams. In Group A, 50% of the infants had laryngopharyngeal reflux (LPR), 56% had chronic lung disease, and 96% had comorbidities such as chromosomal abnormality, cerebral palsy, congenital heart disease, patent ductus arteriosis, and other conditions. In Group B, 61.5% had LPR, 38.5% had chronic lung disease, and 92.3% had comorbidities.
The Group A infants were intubated for an average of 88.7 days, compared with 43.2 days for the Group B children. There were 2.69 average failed extubation attempts in the Group A babies, compared with 1.33 in the Group B infants. The average number of DLBs was 1.82 for Group A and 1.17 for Group B. In addition, DLB findings indicated abnormal airways in 92.7% of Group A and 90.9% of Group B. Subglottic stenosis or edema was seen in 44% of Group A and 23.1% of Group B.
Overall, we found that Group A had double the number of days of ventilated, failed extubations and incidence of subglottic compromise when compared to Group B, Dr. Smith said. The majority of our neonates overall who underwent direct endoscopy for failed extubation eventually had tracheostomy, specifically 80.1 percent.
Based on their findings, the researchers recommended that after the second failure of extubation, physicians do a detailed head and neck examination and flexible endoscopy. They said a third extubation trial should be preceded by optimizing pulmonary function, vigorously treating for gastroesophageal reflux, decongesting the nose, removing all nasal and oral tubes prior to extubation, and providing intravenous dexamethasone 48 hours before extubation and 24 hours after.
After a third failure at extubation, they recommended endoscopy in the OR and surgical intervention, depending on the findings.
Risk Factors
The researchers concluded that neonates with chronic lung disease, gestational age of 30 weeks or less, and very low birth weight are twice as likely to have subglottic edema and fail extubation when compared to older and larger infants with similar comorbidities.
Multiple attempts at extubation are unlikely to yield positive results in this group and could make a case for earlier airway intervention, Dr. Smith said.
On the other hand, older infants with higher birth weights could benefit from additional attempts at extubation unless the severity of laryngotracheal obstruction dictates otherwise, according to the research team.
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