Subglottic Ulceration and Healing following Endotracheal Intubation in the Neonate: A Morphometric Study

In neonates, acquired subglottic stenosis is the most serious long-term complication of endotracheal intubation and is due primarily to posttraumatic fibrosis of the infant larynx. We have examined 78 larynges, 75 of which were intubated, from infants ranging in gestation from 22 to 40 weeks, and who survived from a few hours to up to 300 days. Each larynx was morphometrically assessed for the extent of acute injury, indicated by the percentage of epithelial loss, and healing, indicated by the percentage of a subglottic ulcer covered by metaplastic squamous epithelium. Results show that acute injury is almost invariable, and up to 100% of the subglottic epithelium may be lost within a few hours of intubation, but that progression of injury is relatively short-lived. Ulcer healing starts after a few days, rapidly progresses from day 10, and in the majority of cases is complete after 30 days. This study suggests that long-standing acute injury in the subglottis is the exception rather than the rule, even with the endotracheal tube remaining in place.

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Long term pathological sequelae of neonatal endotracheal intubation

The Journal of Laryngology & Otology ◽

10.1017/s0022215100109521 ◽

1989 ◽

Vol 103 (6) ◽

pp. 622-625 ◽

Cited By ~ 19

Author(s):

S. J. Gould ◽

J. Graham

Keyword(s):

Endotracheal Intubation ◽

Cricoid Cartilage ◽

Subglottic Stenosis ◽

Corrective Surgery ◽

Pathological Changes ◽

Laryngeal Cartilages ◽

Quality Of Voice

AbstractIn neonates, acquired subglottic stenosis (SGS) is the most serious long term complication of endotracheal intubation. In this case report, we describe the pathological changes in the larynx of a child who died two years after successful treatment, involving corrective surgery, for neonatally acquired SGS. Stenosis, due to dense fibrous connective tissue, was still present at death. However, there was evidence that there had been growth of the laryngeal cartilages. Disruption of the laryngeal cartilages was present anteriorly due to the antecedent surgery but major cricoid cartilage injury secondary to intubation was not seen. The crico-arytenoid joints demonstrated ankylosis and to this was attributed the abnormal quality of voice noted in the child at follow-up. The pathological changes are considered in relation to the pathology of endotracheal intubation and pathogenesis of acquired subglottic stenosis.

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Treatment of Iatrogenic Subglottic Stenosis by Therapeutic Fibreoptic Bronchoscopy

Journal of Armed Forces Medical College Bangladesh ◽

10.3329/jafmc.v13i2.41379 ◽

2019 ◽

Vol 13 (2) ◽

pp. 64-68

Author(s):

Nurun Nahar Fatema Begum ◽

Jesmin Sultana ◽

Md Ferdousur Rahman Sarker ◽

Sabina Yasmeen ◽

Maj Bijoy Kumar Das ◽

...

Keyword(s):

Endotracheal Tube ◽

Endotracheal Intubation ◽

Young Infant ◽

Invasive Procedure ◽

Armed Forces ◽

Subglottic Stenosis ◽

Fibreoptic Bronchoscopy ◽

Tracheal Mucosa ◽

Common Procedure ◽

Cuffed Endotracheal Tube

Endotracheal intubation is a common procedure in intensive care unit. It still qualifies as an invasive procedure. Prolonged endotracheal intubation or intubation with cuffed endotracheal tube in a newborn or young infant is a risk factor for the development of subglottic stenosis. It usually presents with stridor in childhood. The most likely mechanism of subglottic stenosis is an injury of tracheal mucosa, with secondary scar healing that consequently leads to the development of some degree of subglottic stenosis. Depending on the degree of subglottic stenosis, patients may be asymptomatic for a long time or symptoms can occur within several weeks. The incidence of stenosis is very low if intubation lasts less than a week. Sometimes the patient may develop severe subglottic stenosis after short-term endotracheal intubation. Intubation with cuffed endotracheal tube in newborn results in pressure necrosis and sloughing followed by subglottic stenosis. This article presents a case of a patient (Baby A) who had intubation with cuffed tube which landed to airway problem and stenosis and was managed successfully by taking help from an expert pediatric pulmonologist of a neighbouring country. Journal of Armed Forces Medical College Bangladesh Vol.13(2) 2017: 64-68

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Review of Intubation in Severe Laryngotracheobronchitis

PEDIATRICS ◽

10.1542/peds.87.6.847 ◽

1991 ◽

Vol 87 (6) ◽

pp. 847-853

Author(s):

Julie McEniery ◽

Jonathan Gillis ◽

Henry Kilham ◽

Bruce Benjamin

Keyword(s):

Airway Obstruction ◽

Endotracheal Tube ◽

Cardiac Disease ◽

Nasotracheal Intubation ◽

Subglottic Stenosis ◽

Endoscopic Evaluation ◽

Artificial Airway ◽

Low Incidence ◽

Severe Airway Obstruction

Of 208 children who required relief of severe airway obstruction due to laryngotracheobronchitis by an artificial airway (nasotracheal intubation or tracheostomy) during a 10-year-period, 181 (87%) were intubated and later extubated. Twenty-seven children (13%) had tracheostomies performed. The tracheostomies were for severe subglottic narrowing precluding the passage of an adequate size endotracheal tube in 10 children, and for severe endotracheal tube trauma in 17 children. Five children developed acquired subglottic stenosis (2.4% of 208) and 1 of these has a retained tracheostomy. One child died of cardiac disease. The remaining 202 children had no long-term complications of laryngotracheobronchitis, intubation, or tracheostomy. It is concluded that nasotracheal intubation is a satisfactory artificial airway for laryngotracheobronchitis. Endoscopic evaluation in a selected group of these children will identify those with significant intubation trauma or severe subglottic narrowing in whom continued intubation may cause permanent subglottic damage. The low incidence of acquired subglottic stenosis in this series supports the practice of selective endoscopy and tracheostomy.

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Modified Endotracheal Tube for Prevention of Posterior Commissure Stenosis in Long-Term Endotracheal Intubation: A Preliminary Canine Study

Otolaryngology ◽

10.1177/019459988709700616 ◽

1987 ◽

Vol 97 (6) ◽

pp. 594-599

Author(s):

Isaac Eliachar ◽

Jay Roberts ◽

Eric Olsen ◽

Hector Munoz-Ramirez ◽

Bruce Sebek ◽

...

Keyword(s):

Endotracheal Tube ◽

Endotracheal Intubation ◽

Posterior Commissure ◽

Canine Study

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Modified Endotracheal Tube for Prevention of Posterior Commissure Stenosis in Long-term Endotracheal Intubation

Survey of Anesthesiology ◽

10.1097/00132586-198808000-00012 ◽

1988 ◽

Vol XXXII (4) ◽

pp. 224

Author(s):

I. ELIACHAR ◽

J. ROBERTS ◽

E. OLSEN ◽

H. MUNOZ-RAMIREZ ◽

B. SEBEK ◽

...

Keyword(s):

Endotracheal Tube ◽

Endotracheal Intubation ◽

Posterior Commissure

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Treatment of Acquired Subglottic Stenosis

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348947308200613 ◽

1973 ◽

Vol 82 (6) ◽

pp. 822-826 ◽

Cited By ~ 20

Author(s):

Lyle G. Waggoner ◽

Walter M. Belenky ◽

Charles E. Clark

Keyword(s):

Cardiac Surgery ◽

Endotracheal Tube ◽

Triamcinolone Acetonide ◽

Endotracheal Intubation ◽

Conservative Management ◽

Subglottic Stenosis ◽

Assisted Respiration

Four children, who had undergone major cardiac surgery, were treated for severe subglottic stenosis following prolonged endotracheal intubation and assisted respiration. Following removal of the endotracheal tube, all required tracheotomy after varying lengths of time. An adequate airway and good voice was obtained in each with injections of triamcinolone acetonide suspension combined with hyaluronidase, and gentle dilatations. This treatment greatly reduced the needed time of tracheotomy maintenance from that required with the previously recommended conservative management consisting of dilatations only. It also avoided the use of alloplastic stents which frequently resulted in a deformed larynx and poor voice.

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Incidence of and Risk Factors for Airway Complications Following Endotracheal Intubation for Bronchiolitis

Otolaryngology ◽

10.1016/j.otohns.2007.03.041 ◽

2007 ◽

Vol 137 (3) ◽

pp. 394-399 ◽

Cited By ~ 18

Author(s):

Jeffrey Jorgensen ◽

Julie L. Wei ◽

Kevin J. Sykes ◽

Stephen A. Klem ◽

Robert A. Weatherly ◽

...

Keyword(s):

Risk Factors ◽

Endotracheal Intubation ◽

Study Design ◽

Average Duration ◽

Average Length ◽

Subglottic Stenosis ◽

Airway Complications ◽

The Mean

OBJECTIVE: To identify risk factors predisposing to postextubation complications and the incidence of subglottic stenosis following endotracheal intubation for bronchiolitis. STUDY DESIGN AND SETTING: A review of 144 consecutive infants and children intubated for bronchiolitis between 2000 and 2005 at a regional children's hospital. RESULTS: The mean age at diagnosis was 6.4 months. Follow-up data were available in 93 patients (64.6%), and average length of follow-up was 9.3 months. One hundred and three patients (71.5%) had positive RSV detection. Average duration of intubation was 5.5 days. Twenty-six patients (18.1%) required reintubation during the same admission. Children intubated for less than 3 days and those greater than 12 months of age were more likely to experience postextubation difficulties. Approximately 40% of patients experienced postextubation difficulties. Subglottic pathology was found on endoscopy in 6 patients (4%). There were no cases of long-term subglottic stenosis. CONCLUSION: Immediate postextubation complications are common after bronchiolitis, especially in patients intubated for less than 3 days and greater than 12 months of age. We found no evidence of long-term subglottic stenosis in this population.

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