Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series

Imaizumi, Mitsuyoshi; Suyama, Kazuhide; Goto, Aya; Hosoya, Mitsuaki; Murono, Shigeyuki

doi:10.1016/j.bjorl.2023.101290

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Brazilian Journal of Otorhinolaryngology

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Sumário

ORIGINAL ARTICLE • Braz. j. otorhinolaryngol. 89 (5) • 2023 • https://doi.org/10.1016/j.bjorl.2023.101290 copy

Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series^☆ ☆ Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

Medical advances have resulted in increased survival rates of neurologically impaired children who may require mechanical ventilation and subsequent tracheostomy as a surgical airway. However, at present, there is no definite consensus regarding the timing and methods for placement of a surgical airway in a neurologically impaired intubated child who needs to be cared for over a long-term period. We therefore created a flowchart for the selection of a surgical airway for Neurologically Impaired Pediatric Patients (NIPPs).

Methods:

The flowchart includes information on the patients’ backgrounds, such as intubation period, prognosis related to reversibility, and history of aspiration pneumonia. To evaluate the importance of the flowchart, first we conducted a survey of pediatricians regarding selection of a surgical airway, and we also evaluated the appropriateness of the flowchart among pediatricians and caregivers through questionnaire surveys which include satisfaction with the decision-making process, and postoperative course after discharge.

Results:

A total of 21 NIPPs with intubation underwent surgery and a total of 24 participants (14 pediatricians and 10 caregivers) completed the survey. The answers regarding the importance of the flowchart showed that eleven pediatricians had experience selecting of surgical airways, nine of whom had had experiences in which they had to make a difficult decision. The answers regarding the appropriateness of the flowchart revealed that all pediatricians and caregivers were satisfied with the decision-making process and postoperative course after discharge using the flowchart.

Conclusions:

The present study demonstrated the effectiveness of our flowchart for selecting an appropriate surgical airway in NIPP. By referring to our flowchart, pediatricians and caregivers are likely to be able to select an appropriate surgical airway, leading to increased satisfaction with the decision-making process and postoperative course.

Level of Evidence:

Keywords
Flowchart; Surgical airway; Tracheostomy; Neurologically impaired pediatric patient; Aspiration prevention surgery

Highlights

Survival rate of severely impaired children requiring tracheostomy is increasing.

Appropriate surgical airway selection in intubated children is difficult.

We designed a flowchart for surgical airway selection in intubated pediatric patients.

Effectiveness of the flowchart for selecting a surgical airway was demonstrated.

Pediatricians and caregivers will be able to select an appropriate surgical airway.

Case	Age, yr	Sex	Height, cm	Weight, kg	Primary disease	Reason for intubation	Preoperative intubation period, days	Primary disease	Past history of AP or high risk of AP	Permission for elimination of VF	Selected surgery	Operation time, min	Bleeding, g	Patient outcome
1	2	F	84	13.5	Acute encephalopathy	Dysfunction of respiratory center	25	–	+	–	TwPT	44	0	Transferred to hospital
2	0	F	58.6	5.3	Severe perinatal asphyxia	Aspiration pneumonia	23	–	+	–	TwPT	55	0	Home-based care
3	2	F	73	9.5	Acute encephalopathy	Dysfunction of respiratory center	68	–	–	N/A	TwPT	53	0	Home-based care
4	2	M	78	9.2	Double outlet right ventricle	Congestive heart failure	358	+	–	N/A	TwTT	120	0	Home-based care
5	12	F	138.7	31	Aicardi syndrome	Aspiration pneumonia	19	–	+	–	TwPT	76	0	Transferred to hospital
6	16	M	118	16	Cerebral palsy	Status dystonicus	26	–	+	+	APS	194	10	Home-based care
7	0	M	68	7	Acute encephalopathy	Dysfunction of respiratory center	37	–	+	+	APS	214	0	Home-based care
8	0	F	57.5	3.6	Pfeiffer syndrome	Upper airway obstruction	28	–	+	–	TwPT	84	0	Died 237 days after the procedure
9	1	F	78	7.9	Hypoxicischemic encephalopathy	Dysfunction of respiratory center	8	–	+	+	APS	220	0	Home-based care
10	0	F	54.5	3.7	Trisomy 13	Respiratory failure	30	–	–	N/A	TwPT	75	0	Home-based care
11	6	F	110	15	Muscular dystrophy	Respiratory failure	25	+	–	N/A	TwTT	51	0	Home-based care
12	1	F	66	6.3	Severe perinatal asphyxia	Respiratory failure	138	–	–	N/A	TwPT	92	10	Died 144 days after the procedure
13	6	M	123	29	Acute encephalopathy	Respiratory failure	12	+	–	N/A	TwTT	66	0	Home-based care
14	1	M	72.5	7	Severe perinatal asphyxia	Dysfunction of respiratory center	71	–	–	N/A	TwPT	41	0	Transferred to hospital
15	2	F	85	12.1	Acute encephalopathy	Dysfunction of respiratory center	34	–	+	–	TwPT	54	0	Home-based care
16	0	F	58.5	4.9	Trisomy 13	Dysfunction of respiratory center	84	–	–	N/A	TwPT	83	0	Died 113 days after the procedure
17	3	M	91.6	13.9	Trisomy 18	Dysfunction of respiratory center	30	–	+	–	TwPT	92	5	Died 44 days after the procedure
18	0	M	70	7	Hypoxicischemic encephalopathy	Dysfunction of respiratory center	32	–	–	N/A	TwPT	80	0	Hospitalized for 198 days after the procedure
19	0	M	63.4	9.9	Infantile epilepsy	Dysfunction of respiratory center	69	+	–	N/A	TwTT	62	5	Transferred to hospital
20	1	F	75	8	Unilateral megalencephaly	Dysfunction of respiratory center	22	–	+	–	TwPT	72	0	Hospitalized for 142 days after the procedure
21	8	M	120	30	Acute encephalitis with refractory, repetitive partial seizures	Respiratory depression	40	+	–	N/A	TwTT	64	0	Hospitalized for 97 days after the procedure

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] *Corresponding author. E-mail:ima-mitu@fmu.ac.jp (M. Imaizumi).

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Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series☆ ☆ Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.

Abstract

Objective:

Methods:

Results:

Conclusions:

Level of Evidence:

Highlights

Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series^☆ ☆ Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.