Endotracheal Tube and Neonate

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Endotracheal Tube and Neonate
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Archives of Otolaryngology -- headneck surgery.
vol.117 No.8,Augest 1991

• 100 with a leak pressure of less than 20 cm H2O
  --successfully extubated
• 100 with a leak of greater than 30 cm H2O
  --failure
• 60 with a leak pressure in the range of 21 to 30
  cm H2O --successfully extubated

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Archives of Otolaryngology -- headneck surgery.
119(8)815-9, 1993 Aug.

• Risk factors for acquired laryngotracheal
  stenosis in newborn infants are poorly known.
• The size of the endotracheal tube appears to be a
  major risk factor for acquired laryngotracheal
  stenosis in the neonate.

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Pediatric Pulmonology. 7(2)116-20, 1989

• 37 month period
• flexible fiberoptic bronchoscopies in 77 neonates
• Bronchoscopy has been found valuable in the
  management of emergency situations such as
  suspected tube blockage or malposition and
  difficult intubations.

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AANA Journal. 66(3)299-303, 1998 Jun.

• The traditional age-base(AB) formula(age in
  year16) divided by 4
• Using the Broselow pediatric resuscitation tape.
• The AB formula is reliable and easily applied.
• Age is not available, the Broselow pediatric
  resuscitation tape allows reliable.

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(No Transcript)
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Anesthesia Analgesia. 97(6)1857-1858, 2003

• ETT allow small air leak at peak inflation
  pressure of 20-30 cm H2O.
• Inspiratory and expiratory tidal volume(ITV and
  ETV)
• 10-15 ml/kg tidal volume and an appropriate RR
• Apply PEEP of 4-5cm and increase gradually(1-2cm
  H2O at a time) until the PIP to 25 cm H2O(PEEPlt10
  cm H2O)
• A difference of 10 tidal volume but less than
  5ml between the ITV and ETV? suitability of the
  ETT.
• No further increase in the difference between the
  ITV and ETV, the ETT is deemed an oversized one.

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• Endotracheal Intubation
• and
• Tracheal Stenosis

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Textbook-Millers Anesthesia
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• Uncuffed endotracheal tubes have been used in
  children younger than 6 8 years
• Gas leak in the peak inflation pressure1520
  cmH2O (2030 cmH2O)
• If no leak is detected in the pressure of 40
  cmH2O, shift to smaller size.
• Cuff pressures that afford good (but not perfect)
  protection (20 to 25 mm Hg) are just below the
  perfusion pressure of the tracheal mucosa (25 to
  35 mm Hg).

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• Laryngotracheal Stenosis

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• The most common cause ischemia secondary to
  intubation.
• Sites
• Adult glottis, posterior site
• Children subglottis

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Risk factors

• GE reflux,
• Bacterial colonization,
• Systemic illness
• Malnutrition
• Hypoxia, Anemia
• Movement

• Cuff pressure
• Tube size
• Tube shape
• Intubation duration
• Repeated intubation

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Normal Subglottic Area
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elliptical congenital subglottic stenosis (SGS)
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Spiral subglottic stenosis
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4-month-old infant with acquired grade III
subglottic stenosis from intubation
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Literature Search

• 12 incidence of laryngeal stenosis in patients
  with tracheal intubation for 11 days or longer, a
  5 incidence between 6-10 days of intubation, and
  a 2 incidence with less than 6 days intubation.
• Whited RE. Laryngeal dysfunction following
  prolonged intubation. Ann Otol Rhinol Laryngol
  197988474-8

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• 19 of the patients who had translaryngeal
  intubation developed significant stenosis, which
  was defined as gtgt10 reduction in the air column
  diameter, with stenosis occurring either at the
  subglottic area or the cuff.
• Stauffer JL, Olson DE, Petty TL. Complications
  and consequences of endotracheal intubation and
  tracheotomy a prospective study of 150
  critically ill adult patients. Am J Med
  19817065-76

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• Almost all patients who undergo translaryngeal
  intubation suffer some degree of stenosis
• Heffner JE. Timing of tracheotomy in
  ventilator-dependent patients. Clin Chest Med
  199112611-25

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• Histologic study demonstrated
• Focal or complete loss of mucosal epithelium in
  contact with the orotracheal tube for even one
  hour.
• The ischemic nature of the necrosis.
• That perichondritis of the vocal process is
  increasingly frequent after 48 hours of
  intubation.
• The infestation of the ulcer site by
  microorganisms is common after 24 hours of
  intubation.
• ( 15 min 176 hrs of intubation duration )
• William H. Donnelly. Histopathology of
  endotracheal
• Intubation. An Autopsy study of 99 cases. Arch
  Path.
• 881969.

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• Contencin P, Narcy P. Size of endotracheal tube
  and neonatal
• acquired subglottic stenosis. Arch Otolaryngol
  Head Neck Surg.
• 1993 Aug119(8)815-9

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• In the 1970s and 1980s, estimates of the
  incidence of subglottic stenosis were in the
  range of 0.9 8.3 of intubated neonates.
• All studies published after 1983 reported an
  incidence of neonatal subglottic stenosis as lt
  4.0, and all studies published after 1990
  reported an incidence as lt 0.63.
• The current incidence of neonatal subglottic
  stenosis is likely between 0.0 2.0.
• Walner, David L. Loewen, Mark S. Kimura,
  Robert E. Neonatal Subglottic Stenosis-Incidence
  and Trends. Laryngoscope. 111(1)48-51, January
  2001