Time after supraglottoplasty of initial need for ICU-level care stratified by initial intervention needed (N = 223). One patient intubated at 11 h postoperatively met the ICU requirement at 4 h because of elevated oxygen requirement at that time.
Albergotti WG, Sturm JJ, Stapleton AS, Simons JP, Mehta DK, Chi DH. Predictors of Intensive Care Unit Stay After Pediatric Supraglottoplasty. JAMA Otolaryngol Head Neck Surg. 2015;141(8):704-709. doi:10.1001/jamaoto.2015.1033
Supraglottoplasty is a common procedure performed without evidence-based postoperative management plans. Patients are routinely admitted to the intensive care unit (ICU) postoperatively, but this may not be necessary in all cases.
To determine (1) whether routine admission to the ICU after supraglottoplasty is warranted in all patients who undergo this procedure and (2) which factors predict requirement for ICU-level care.
Design, Setting, and Participants
Retrospective case series and analysis of immediate postoperative outcomes of all children aged 1 month to 18 years who underwent supraglottoplasty at 1 tertiary-care children’s hospital from January 1, 2008, through January 31, 2014. Exclusion criteria included preoperative admission to the ICU, preoperative need for positive-pressure ventilation, history of major airway reconstruction, or any concomitant other major procedure.
Main Outcomes and Measures
Need for ICU-level care as defined by need for intubation, positive-pressure ventilation, multiple doses of racemic epinephrine, or oxygen via nasal cannula at greater than 4 L/min within the first 24 hours.
Of 223 patients identified, 25 (11.2%) met our criteria for ICU-level care. Nine patients required intubation. Twenty of the 25 patients met ICU criteria within 4 hours of surgery. Univariate analysis was performed on 38 risk factors. Risk factors for ICU requirement that remained statistically significant on multivariable analysis (P < .05) included surgical duration longer than 30 minutes (odds ratio [OR], 4.48 [95% CI, 1.51-13.19]; P = .007), nonwhite race (OR, 4.42 [95% CI, 1.54-12.66]; P = .006), and a preoperative diagnosis of gastroesophageal reflux disease (OR, 0.10 [95% CI, 0.09-0.36]; P < .001).
Conclusions and Relevance
Our study suggests that most children undergoing supraglottoplasty do not require ICU-level care postoperatively. Those who require ICU-level care are likely to be identified within the first 4 hours after surgery. Consideration for routine ICU admission should be given to those with longer surgical duration and those of nonwhite race.
Laryngomalacia is the most common cause of stridor in newborns.1 Whereas its etiology is still unknown, laryngomalacia is hypothesized to be caused by incomplete neurologic development of the larynx leading to prolapse of the supraglottic structures during inspiration and typically presents with inspiratory stridor with feeding difficulties.2,3 Most cases improve over time with observation or with medical therapy alone, although a subset of patients with severe laryngomalacia characterized by stridor with cyanosis, apnea, failure to thrive, poor weight gain, or aspiration will require surgical intervention.4
Supraglottoplasty was initially described in 1987 and has become the mainstay for surgical management of children with severe laryngomalacia.5 There are numerous endoscopic methods of supraglottoplasty, but it most commonly involves a division of the aryepiglottic folds and/or trimming of the arytenoid mucosa.6 While supraglottoplasty generally has a low morbidity, concerns for airway compromise remain in these patients postoperatively because of airway edema, aspiration, or decompensation of the patient. Most physicians observe patients postoperatively in the intensive care unit (ICU) or on a surgical floor with continuous pulse oximetry whereas others routinely keep patients intubated.2
In our clinical practice, most patients undergoing supraglottoplasty are admitted to the ICU postoperatively for airway monitoring. We have observed that the majority of these patients have no airway concerns overnight and are frequently discharged from the ICU on postoperative day 1. A recent report by Fordham and colleagues7 suggested that most patients undergoing supraglottoplasty can be admitted to a surgical floor postoperatively and found an ICU transfer rate of only 1.5% after supraglottoplasty in patients with severe laryngomalacia. Furthermore, in this era of need for increased cost savings in health care it is important to critically evaluate the use of health care resources and allocate them appropriately.
The primary goal of this study was to determine the likelihood that patients undergoing supraglottoplasty would require ICU-level care and, if so, how soon after surgery this becomes evident. Our secondary goal was to determine whether there are any factors, either patient related or surgery related, that predict the need for ICU-level care.
Institutional review board approval was obtained for this retrospective case series. Informed consent was waived because of the retrospective nature of the study. Records were queried for patients who underwent supraglottoplasty at the Children’s Hospital of Pittsburgh of UPMC between January 1, 2008, and January 31, 2014. Patients were identified through a search using common Current Procedural Terminology codes for supraglottoplasty.
Supraglottoplasty in our institution is performed by multiple surgeons using various methods. Most surgeons use a spontaneous ventilation technique with cold knife dissection to divide the aryepiglottic folds and/or trim excess arytenoid mucosa. Additional techniques include the use of bovie electrocautery and carbon dioxide laser. Most surgeons routinely admit patients to the ICU postoperatively. Patients undergoing supraglottoplasty receive a single intraoperative dose of systemic corticosteroids as a matter of routine but do not generally receive inhaled or systemic corticosteroids in the postoperative period. The patient’s preoperative antireflux regimen is continued immediately postoperatively or is started if the patient is not receiving antireflux medications preoperatively. Antibiotics are not routinely used. We included all methods of supraglottoplasty and postoperative management in this analysis.
The study exclusion criteria were as follows: preoperative admission to the ICU, preoperative need for positive-pressure ventilation, a history of major airway reconstruction, or any other major concomitant airway procedure (patients undergoing tonsillectomy and/or adenoidectomy and injection laryngoplasty for type I laryngeal cleft were included in the study population). Patients were also excluded if preoperative or postoperative records were absent.
Medical records were reviewed for demographic characteristics, medical histories, symptoms, medication use, physical and endoscopic examination findings, intraoperative factors, and postoperative hospital course.
Included patients’ postoperative courses were queried for need for intubation, positive-pressure ventilation, multiple doses of racemic epinephrine, or oxygen via nasal cannula at greater than 4 L/min within the first 24 hours postoperatively, or ICU transfer if not admitted to the ICU. Any of these requirements were considered to necessitate ICU-level care. The time course of these events in the postoperative period was documented and ICU-level care was considered to be warranted at the time of first occurrence.
Statistical analysis was performed using STATA IC, version 13.1 (StataCorp). Univariate analysis of binomial categorical variables was performed using the Pearson χ2 method, and the Fisher exact 2-sided method was used for categorical variables with fewer than 5 observations in 1 category. P < .05 was considered statistically significant.
Multivariable analysis was performed using stepwise selection criteria initially including all variables that were judged to be significant on univariate analysis (P < .05). We ran a backward stepwise multivariable logistic regression analysis allowing variables to remain in the model with P < .10 to arrive at a final model. Patients were excluded from multivariable analysis if any analyzed variables were missing data.
A total of 266 patients were initially identified who underwent supraglottoplasty during the inclusion period. Forty-three patients were excluded: 1 patient with need for preoperative positive-pressure ventilation, 3 patients with a history of laryngotracheal reconstruction, 5 patients with absent records, 26 patients who were in the ICU preoperatively, and 8 patients undergoing a concomitant other major surgery. Ultimately, 223 patients were included.
Demographic characteristics of the included patients are given in Table 1. Most patients were white and younger than 1 year (median, 7.1 months). There were slightly more males than females in our series.
Most patients presented with observed stridor (85.1%). All patients were classified as having severe laryngomalacia by history, with 17.4% of patients having a history of cyanotic episodes, 46.3% a history of apnea, 19.1% failure to thrive, and 27.6% poor weight gain. Aspiration and penetration, respectively, were noted in 23.0% and 38.4% of patients who underwent either flexible endoscopic evaluation of swallowing (FEES) or modified barium swallow (MBS) for swallowing evaluation. At least 1 cardiac, pulmonary, neurologic, or genetic comorbidity was present in 24.7% of patients.
The majority of the supraglottoplasties were performed using a cold knife technique. Of the 223 patients, 205 (91.9%) were admitted to the ICU postoperatively as a matter of routine while the remaining patients were admitted to a pediatric surgical floor for observation. One hundred fifty-nine patients (71.0%) underwent a bedside swallow evaluation prior to resuming oral intake.
Twenty-five of the 223 patients (11.2%) ultimately met our ascribed ICU-level criteria (Figure). Nine patients (4.0%) required reintubation. Seven of these underwent reintubation while still in the operative suite. One patient was reintubated at 11 hours postoperatively, and the other was reintubated at 22 hours postoperatively for what was later determined to be a respiratory syncytial bronchiolitis. The patient intubated at 11 hours postoperatively had an 8-L supplemental oxygen requirement at 4 hours, which is when he initially met our ascribed ICU criteria.
The other 16 patients met ICU criteria due to requirement of positive-pressure ventilation (4 patients), supplemental oxygen requirement greater than 4 L/min (6 patients), or need for multiple doses of racemic epinephrine (6 patients) (Figure). There were no transfers to the ICU among patients admitted to the surgical floor postoperatively. Among the 25 patients requiring ICU-level care, the mean (range) time to meeting these requirements was 2.66 (0-22) hours. Twenty (80.0%) of these patients met these criteria within 4 hours postoperatively.
The mean (range) ICU length of stay for patients admitted to the ICU was 1.12 (1-4) days among those not meeting ICU-level care criteria and 4.36 (1-38) days among those meeting ICU-level care criteria (P < .001). Among both groups, 189 (84.8%) patients were discharged from the hospital by postoperative day 2.
Univariate analysis using either the χ2 or Fisher exact method (Table 2) yielded the following factors that were significantly associated with ICU-level care requirement: nonwhite race (29.7% vs 7.8%; P < .001), preoperative diagnosis of gastroesophageal reflux disease (GERD) (8.8% vs 26.9%; P = .006), duration of surgery longer than 30 minutes (18.9% vs 5.6%; P = .002), bilateral trimming of aryepiglottic folds as compared with unilateral trimming or no trimming (20.3% vs 3.7% and 8.8%, respectively; P = .03), use of microscope during procedure (29.6% vs 8.7%; P = .001), and arterial oxygen saturation nadir less than 90% during procedure (21.9% vs 9.4%; P = .04).
Multivariable analysis revealed nonwhite race (odds ratio [OR], 4.42 [95% CI, 1.54-12.66]; P = .006) and duration of surgery greater than 30 minutes (OR, 4.48 [95% CI, 1.51-13.19]; P = .007) to be independent risk factors for need for ICU-level care postoperatively. A diagnosis of GERD preoperatively was protective against need for ICU-level care (OR, 0.10 [95% CI, 0.09-0.36]; P < .001).
Laryngomalacia is the most common cause of stridor in the newborn, and although it is concerning for the caregiver, most cases can be managed conservatively. However, patients with failure to thrive, cyanotic or apparent life-threatening episodes, or respiratory compromise, as well as children with feeding difficulties, poor weight gain, or sleep-disordered breathing for whom medical therapy has failed, should be considered for surgical intervention with supraglottoplasty.6 Supraglottoplasty has been shown to have a greater than 80% success rate at improving respiratory symptoms, GERD, and growth rate and is considered a well-tolerated and successful procedure.8- 10
While there have been a number of studies evaluating long-term success and complications of supraglottoplasty, we were only able to identify 1 previous study that has evaluated short-term airway complications.7,11 The study by Fordham et al7 suggested that most children undergoing supraglottoplasty could be observed on the pediatric floor with a 1.5% rate of need for ICU transfer after supraglottoplasty and recommended that routine ICU monitoring is not necessary. Supraglottoplasty has a risk of respiratory compromise secondary to airway edema from the procedure. There is also a theoretical risk of postoperative dysphagia and aspiration, although it has been shown that aspiration after supraglottoplasty is usually present preoperatively as well and can improve after supraglottoplasty.2
The primary goal of this study was to determine the likelihood that patients undergoing supraglottoplasty would require ICU-level care. In our clinical practice, we admit most children who undergo supraglottoplasty to the ICU prophylactically for airway monitoring. While this practice is borne out of risk for airway compromise after supraglottoplasty, this study suggests that approximately 90% of these patients do not require such intensive monitoring. Our ascribed criteria of need for ICU monitoring are fairly conservative, and it is likely that most of these patients would do well with routine pulse oximetry on a monitored floor.
Furthermore, we found that 80% of incidents of airway compromise occurred within 4 hours postoperatively and that 7 of 9 patients who required intubation experienced failure immediately postoperatively. This suggests that patients could be observed in the postanesthesia care unit for a period postoperatively before an automatic ICU admission.
Despite our conservative criteria, 13 patients (5.8%) required either intubation or positive-pressure ventilation postoperatively. This group of patients would require ICU-level care in any circumstance. While the requirement of ICU-level care was evident for most of these patients immediately postoperatively, 2 patients required intubation at 11 and 22 hours postoperatively. Therefore, monitored surgical floors must be capable of managing this possibility. It is necessary that patients be admitted to an inpatient floor or a 23-hour observation unit postoperatively rather than discharged to home for this reason. It is evident that even with good technique, supraglottoplasty can result in airway compromise.
Our secondary goal for this study was to determine whether there are any factors, either patient related or procedure related, that predict the need for ICU-level care. On univariate analysis, we found prolonged surgical duration (>30 minutes), arterial oxygen saturation nadir less than 90% during the procedure, bilateral trimming of the arytenoid mucosa, use of the operating microscope, and nonwhite race to be positively associated with need for ICU admission. Using a multivariable model, we were further able to demonstrate independent risk factors for decompensation including prolonged surgical duration and nonwhite race. A preoperative diagnosis of GERD was found to have a protective effect.
Most of the risk factors identified on univariate analysis are surgical technique–related factors rather than patient-related factors. Prolonged surgical duration, arterial oxygen desaturations during the procedure, bilateral trimming of the arytenoids, and use of the operating microscope are likely related to a more complicated surgical procedure or more severe laryngomalacia. On multivariable analysis, surgical duration longer than 30 minutes remained significant, again likely related to the complexity of the procedure or residual anesthetic effect.
Among patient factors, nonwhite race was also positively associated with need for ICU observation after supraglottoplasty on multivariate analysis. This was a surprising finding in our analysis. Review of the literature reveals scant data on laryngomalacia in nonwhite patients. It has been proposed in a small population series that nonwhite children may be at a higher risk of laryngomalacia, particularly if delivered preterm.12 Our data set does not reveal an association between prematurity and race, suggesting that other factors are likely at play. More evaluation is certainly needed prospectively to further elucidate the relationship between race and the need for ICU admission postoperatively after supraglottoplasty.
We found that a diagnosis of GERD was protective against immediate postoperative complications. The association between laryngomalacia and GERD is well reported within the literature and has been previously associated with severity of disease.6,13,14 In our study, there was no difference in GERD diagnosis rate according to severity of disease as graded endoscopically. As expected, patients with a diagnosis of GERD were significantly more likely to be receiving antireflux medications preoperatively (82% vs 12%) and it may be that these medications had a protective effect that led to fewer immediate postoperative complications. It is plausible that those without a diagnosis of GERD in reality had GERD and were left untreated, leading to worse complications. Regardless, we would recommend that antireflux measures be instituted in the perioperative period.
We did not identify any effect of comorbidity on immediate outcomes after supraglottoplasty. The effect of comorbidity on outcomes after supraglottoplasty is somewhat controversial, with most reports suggesting that patients with comorbid conditions such as congenital syndromes or neurologic or pulmonary disease have poorer long-term outcomes,15,16 although a series by Day et al17 in 2012 suggested no effect. Our data suggest that these patients are at similar risk to the general population in terms of immediate postoperative complications.
Although a full cost analysis is beyond the scope of this article, substantial savings could be achieved by limiting ICU admissions. The standard daily charge for a surgical floor admission in our hospital is $1017.10, and daily ICU charge, $2190.86. This is in addition to the cost to the family of more stringent visitation and overnight policies in the ICU, as well as the increased risk of hospital-acquired infections.18
Our study is limited by the diversity of surgical techniques and surgeons and by its retrospective nature. Further evaluation is encouraged in a prospective manner. In addition, unlike the series by Fordham et al,7 our series does include patients previously admitted to the hospital and may be skewed toward a more severe phenotype of laryngomalacia. Of note, there are differences in the rates of immediate outcomes between our series and the series by Fordham et al.7 Future larger, prospective studies will help further determine which factors best predict the need for ICU admission postoperatively after supraglottoplasty.
Our results suggest that patients with severe laryngomalacia undergoing supraglottoplasty can be safely observed on a pediatric surgical floor postoperatively. For most children who develop respiratory difficulties postoperatively, these will be evident within the first 4 hours after surgery. Nonwhite race and surgical duration longer than 30 minutes are risk factors for need for ICU-level care, whereas a diagnosis of GERD is protective. Further study should be performed prospectively to confirm these findings.
Submitted for Publication: March 8, 2015; final revision received April 9, 2015; accepted April 22, 2015.
Corresponding Author: William G. Albergotti, MD, Department of Otolaryngology, University of Pittsburgh Medical Center, Eye and Ear Institute, 200 Lothrop St, Ste 500, Pittsburgh, PA 15213 (firstname.lastname@example.org).
Published Online: June 11, 2015. doi:10.1001/jamaoto.2015.1033.
Author Contributions: Dr Albergotti had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Albergotti, Stapleton, Simons, Mehta, Chi.
Acquisition, analysis, or interpretation of data: Albergotti, Sturm, Stapleton, Simons, Chi.
Drafting of the manuscript: Albergotti.
Critical revision of the manuscript for important intellectual content: Sturm, Simons, Mehta, Chi.
Statistical analysis: Albergotti.
Administrative, technical, or material support: Stapleton, Chi.
Study supervision: Simons, Mehta, Chi.
Conflict of Interest Disclosures: None reported.
Funding/Support: This project was supported by the National Institutes of Health through grant UL1-TR-000005.
Role of the Funder/Sponsor: The National Institutes of Health assisted with analysis and interpretation of the data but had no role in the design and conduct of the study; collection and management of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Previous Presentation: This study was presented at the American Society of Pediatric Otolaryngology at the Combined Otolaryngology Spring Meetings; April 25, 2015; Boston, Massachusetts.