Literature Review: A Roundup of Important Recent Studies

Citation: Friedman NR, Perkins JN, McNair B, Mitchell RB. Current practice patterns for sleep-disordered breathing in children. Laryngoscope. 2013;123:1055-1058.

—Reviewed by Amy Eckner

Length of Intubation, Number of Sedation Doses Affect Subglottic Stenosis Risk in Children

Do the length of endotracheal intubation and other risk factors increase the incidence of subglottic stenosis (SGS) in children?

Background: As the use of mechanical ventilation in children has increased, so, too, has the incidence of SGS. However, risk factors for the development of laryngeal lesion after intubation remain unclear. To the study authors’ knowledge, this is the first prospective research protocol evaluating the incidence of post-intubation SGS in children by carrying out flexible fiberoptic laryngoscopy (FFL) in all study patients. Previous studies have reported findings on neonates, and previous incidence in literature is variable.

Study design: Prospective research protocol.

Setting: Intensive care unit, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil.

Synopsis: The study included 142 children, from birth to younger than 5 years, who were admitted and required endotracheal intubation for more than 24 hours. Participants underwent FFL within the first eight hours after extubation. Examinations were performed at the pediatric ICU (PICU) bedside, without sedation, and patients were positioned across the bed with no neck hyperextention. All PICU intubation procedures, except those that were urgent, followed the protocol of fast intubation sequence, use of midazolam, fentanyl and rocuronium. Patients were monitored daily for repositioning of endotracheal tube, number of reintubations and the need to maintain or increase sedation. The evaluation was based on parameters that included respiratory response, physical movement, blood pressure, heart rate and muscle tone, but without an objective scale. Eighty-four patients had normal examinations or mild lesions, while 58 had moderate or severe lesions. The incidence of SGS in the sample was 11.3 percent (16 patients); of those, two had grade I SGS, five had grade II SGS, six had grade III SGS and three had grade IV SGS. For every additional five days of intubation, the risk of SGS increased by 50.3 percent; for each additional sedation dose per day, the risk increased by 12 percent. A limitation of this study is the lack of application of existing validated scales for patient agitation.

Bottom line: The study found a higher overall incidence of SGS compared with most previous studies. The length of intubation and additional sedative doses were found to be critical factors for SGS development.