Charles A. Elmaraghy

Effects of nasal continuous positive airway pressure and cannula use in the neonatal intensive care unit setting.

OBJECTIVE To investigate the effects of nasal continuous positive airway pressure (CPAP) and cannula use in the neonatal intensive care unit. DESIGN Cross-sectional study. SETTING Tertiary care childrens hospital. PATIENTS One hundred patients (200 nasal cavities), younger than 1 year, who received at least 7 days of nasal CPAP (n = 91) or cannula supplementation (n = 9) in the neonatal intensive care unit. INTERVENTIONS External nasal examination and anterior nasal endoscopy with photographic documentation. MAIN OUTCOME MEASURES The incidence and characteristics of internal and external nasal findings of patients with nasal CPAP or cannula use. RESULTS Nasal complications were seen in 12 of the 91 patients (13.2%) with at least 7 days of nasal CPAP exposure, while no complications were seen in the 9 patients with nasal cannula use alone. The external nasal finding of columellar necrosis, seen in 5 patients (5.5%), occurred as early as 10 days after nasal CPAP use. Incidence of intranasal findings attributed to CPAP use, in the 182 nostrils examined, included ulceration in 6 nasal cavities (3.3%), granulation in 3 nasal cavities (1.6%), and vestibular stenosis in 4 nasal cavities (2.2%). Intranasal complications were seen as early as 8 to 9 days after nasal CPAP administration. Nasal complications from CPAP were associated with lower Apgar scores at 1 (P = .02) and 5 (P = .06) minutes. CONCLUSIONS External or internal complications of nasal CPAP can be relatively frequent (13.2%) and can occur early, and patients with lower Apgar scores may be at higher risk. Close surveillance for potential complications should be considered during nasal CPAP use.

Guidelines to decrease unanticipated hospital admission following adenotonsillectomy in the pediatric population

INTRODUCTION Tonsillectomy has become one of the most commonly performed surgical procedures in the pediatric-aged patient. Many of these children are diagnosed with obstructive sleep apnea (OSA). Although polysomnography is considered the gold standard, many practioners rely on the clinical examination and parental history. Nationwide Childrens Hospital recently instituted pediatric adenotonsillectomy guidelines for hospital admission to help determine which patients should be done in main hospital OR vs. outpatient surgery facility. The main goal was to decrease unanticipated admissions. The secondary goal was to determine areas for practice improvement. METHODS Using databases for the hospital, operating room, and otolaryngology, all cases with CPT codes 42820, 42830, 42825, 42826, and 42821 were evaluated from October 2009 to August 2012 in the main operating room and 2 outpatient surgery centers. Data for each unanticipated admission were reviewed to determine whether the criteria were met according to the developed guidelines. Fishers exact test was applied to the unplanned admission rate before and after the institution of the guidelines. Non-paired t-test and a Fishers exact test were used for comparison of the demographic data between the two groups. RESULTS Following the institution of the pediatric adenotonsillectomy guidelines, the number of unanticipated admissions decreased from an absolute number of 88 to 43. This represents a decrease from 2.38% to 1.44% (p=0.008). Forty-two percent of the unanticipated admissions prior to establishing guidelines were in patients who would have met criteria for admission based on the guidelines. This decreased to 30% after establishing the guidelines. CONCLUSION We found that the institution of pediatric adenotonsillectomy guidelines for patients undergoing adenotonsillectomy significantly decreased the rate of unanticipated admission. However, there was still a significant percentage (30%) of unanticipated admissions due to non-compliance with the guidelines demonstrating the need for ongoing practice improvement.

The relationship between head and neck position and endotracheal tube intracuff pressure in the pediatric population

Over the past few years, there has been a change in clinical practice with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in pediatric patients. These changes have led to concerns regarding unsafe intracuff pressures in pediatric patients, which may result in postoperative morbidity. To avoid these issues, it is generally suggested that the intracuff pressure be maintained at ≤30 cmH2O. The current study prospectively assesses the changes in intracuff pressure related to alterations in head and neck position in pediatric patients.

Effect of cuffed and uncuffed endotracheal tubes on the oropharyngeal oxygen and volatile anesthetic agent concentration in children.

BACKGROUND Over the past 5 years, there has been a change in the clinical practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in infants and children. As the trachea is sealed, one advantage is to eliminate the contamination of the oropharynx with oxygen which should be advantageous during adenotonsillectomy where there is a risk of airway fire. The current study prospectively assesses the oropharyngeal oxygen and volatile anesthetic agent concentration during adenotonsillectomy in infants and children. METHODS Following the induction of general anesthesia in patients scheduled for adenoidectomy, tonsillectomy or adenotonsillectomy, the trachea was intubated. The use of a cuffed or uncuffed ETT and the use of spontaneous (SV) or positive pressure ventilation (PPV) were at the discretion of the anesthesia team. The oxygen concentration was kept at 100% oxygen until the study was completed. Following placement of the mouth gag, the otolaryngolist placed into the oropharynx a small bore catheter, which was attached to a standard anesthesia gas monitoring device which sampled the gas at 150mL/min. The concentration of the oxygen and the concentration of the anesthetic agent in the oropharynx were measured for 5 breaths. RESULTS The cohort for the study included 200 patients ranging in age from 1 to 18 years. With the use of a cuffed ETT and either SV or PPV, the oxygen concentration in the oropharynx was 20-21% and the volatile agent concentration was 0% in all 118 patients. With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The mean oxygen concentration was 71% during PPV with an uncuffed ETT and 65% during SV with an uncuffed ETT. In these patients, the oropharyngeal oxygenation concentration exceeded 30% in 73 of the 82 patients (89%). The oropharyngeal oxygen and agent concentration was greater when the leak around the uncuffed ETT was ≥10cmH(2)O versus less than 10cmH(2)O and when the leak around the uncuffed ETT was ≥15cmH(2)O versus less than 15cmH(2)O. CONCLUSIONS With the use of an uncuffed ETT and the administration of 100% oxygen, there was significant contamination of the oropharynx noted during both PPV and SV. The oropharyngeal concentration of oxygen is high enough to support combustion in the majority of patients. The use of a cuffed ETT eliminates oropharyngeal contamination with oxygen during the administration of anesthesia and may be useful in limiting the incidence of an airway fire.

Endoscopic Management of Blunt Pediatric Laryngeal Trauma

Objectives: Blunt laryngeal trauma in the pediatric population is an uncommon but unique entity that can be potentially life-threatening. Given the infrequency of these events, its management can pose a clinical dilemma. The authors review the evaluation and treatment of blunt pediatric laryngeal trauma. Methods: We present a case report and a review of the literature. Results: We describe the case of a 3-year-old boy who presented with laryngeal injury following blunt trauma. The patient sustained endolaryngeal hematomas and mucosal lacerations with exposed cartilage. After mucosal approximation, the patient was successfully managed in a critical care setting without a tracheostomy. Conclusions: With an appropriate and thorough evaluation of the pediatric patient, endoscopic management without a surgical airway may be considered as a viable alternative for blunt laryngeal trauma.

A technique to measure the intracuff pressure continuously: an in vivo demonstration of its accuracy.

A major concern with the use of cuffed endotracheal tubes (cETT) in children is hyperinflation of the cuff which may compromise tracheal mucosal perfusion. To measure the intracuff pressure (CP), we devised a method using the transducer of an invasive pressure monitoring device. The objective of the study was to test the accuracy and validity of this device for instantaneous and continuous CP monitoring.

Identification of biofilms in post-tympanostomy tube otorrhea

Otitis media is a common problem in the pediatric population. Despite antibiotic therapy, post‐tympanostomy otorrhea can be difficult to treat. Biofilms have been shown to play a role in chronic and recurrent otitis media and are implicated in otorrhea. This study investigated both the microbial composition and the presence of biofilm fragments rich in extracellular DNA (eDNA) and the bacterial DNA‐binding protein, integration host factor (IHF), in post‐tympanostomy tube otorrhea.

Voice related quality of life in pediatric patients with a history of prematurity

OBJECTIVE To determine incidence of dysphonia in patients with history of prematurity and evaluate the correlation between dysphonia and risk factors unique to premature infants. The aim of this study is to determine parent-perceived vocal quality in patients with history of prematurity and whether duration of intubation, number of intubations, and incidence of patent ductus arteriosus repair were correlated with these perceptions. METHODS Cohort study of premature patients presenting to outpatient clinics from January 2010 to January 2013 in tertiary care center. Patients gestational age ≤37 weeks at birth without history of tracheostomy or known vocal fold pathology were eligible. A volunteer sample was obtained from patients presenting in Otolaryngology clinics from January 2010 to January 2013 whose parents agreed to complete surveys. Outcomes were assessed via parental completion of pediatric voice outcomes score (pVOS) and pediatric voice-related quality of life (pVRQOL) instruments. The primary outcome assessed was the incidence of dysphonia in infants with a history of prematurity without known vocal pathology. Additionally, patient factors associated with dysphonia were evaluated. The hypothesis tested was formulated prior to data collection. RESULTS Sixty-nine participants were included. Mean age at follow-up was 28 (3-197) months. Mean gestational age was 29 (23-37) weeks. Mean intubation duration was 3 (0-22) weeks and median number of intubations was 1 (range 0-5). Voice outcome scores varied widely with pVRQOL scores demonstrating a mean of 89.2±18.1 (25-100) and pVOS with a mean of 11.4±2.2 (0-13). Univariate analysis utilized Spearman correlation coefficients for continuous variables and Wilcoxon Two-sample test for categorical groups. Significance was set at p<0.05. All significant univariate associations were placed in a multivariate model. Duration of intubation ≥4 weeks was the only factor which correlated with dysphonia on multivariate analysis (p=0.0028, OR=6.4, 95% CI=1.9-21.6). CONCLUSIONS The data suggest that prolonged intubation is associated with poorer long term parent-perceived voice quality in premature patients. Further study is required to correlate parent perceptions with objective vocal quality data and physical findings of vocal pathology. These data may increase the clinicians suspicion for and evaluation of dysphonia in this population.

Pain management following myringotomy and tube placement: Intranasal dexmedetomidine versus intranasal fentanyl

PURPOSE Despite the brevity of the procedure, bilateral myringotomy and tympanostomy tube placement (BMT) can result in significant postoperative pain and discomfort. As the procedure is frequently performed without intravenous access, non-parenteral routes of administration are frequently used for analgesia. The current study prospectively compares the efficacy of intranasal (IN) dexmedetomidine with IN fentanyl for children undergoing BMT. METHODS This prospective, double-blinded, randomized clinical trial included pediatric patients undergoing BMT. The patients were randomized to receive either IN dexmedetomidine (1 μg/kg) or fentanyl (2 μg/kg) after the induction of general anesthesia with sevoflurane. All patients received rectal acetaminophen (40 mg/kg) and the first 50 patients also received premedication with oral midazolam. Postoperative pain and recovery were assessed using pediatric pain and recovery scales, and any adverse effects were monitored for. RESULTS The study cohort included 100 patients who ranged in age from 1 to 7.7 years and in weight from 8.6 to 37.4 kg. They were divided into 4 groups with 25 patients in each group: (1) midazolam premedication+IN dexmedetomidine; (2) midazolam premedication+IN fentanyl; (3) no premedication+IN dexmedetomidine; and (4) no premedication+IN fentanyl. Pain scores were comparable when comparing groups 2, 3 and 4, but were higher in group 1 (midazolam premedication with IN dexmedetomidine). There was no difference in total time in the post-anesthesia care unit (PACU) or time from arrival in the PACU until hospital discharge between the 4 groups. The heart rate (HR) was significantly lower in group 3 when compared to the other groups at several different times after arrival to the PACU. No clinically significant difference was noted in blood pressure. CONCLUSION Following BMT, when no premedication is administered, there was no clinical advantage when comparing IN dexmedetomidine (1 μg/kg) to IN fentanyl (2 μg/kg). The addition of oral midazolam as a premedication worsened the outcome measures particularly for children receiving IN dexmedetomidine.

Cuffed Endotracheal Tubes in Infants and Children A Technique to Ensure an Acceptable Intracuff Pressure

Background. Over the past 5 to 10 years, there has been a change in the clinical practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in infants and children. When such tubes are used in clinical practice, it is imperative to ensure that the intracuff pressure is ≤30 cm H2O. To date, there are limited data regarding techniques to ensure this practice. Methods. Following endotracheal intubation with a cuffed ETT, a stethoscope was placed in the sternal notch and continuous positive airway pressure of 20 to 25 cm H2O held. The fresh gas flow was increased as needed to achieve a gradual rise of the airway pressure. Using a syringe, air was added to the cuff until no air escape or leak was heard. The intracuff pressure was checked using a handheld manometer (Posey Cufflator Endotracheal Tube Inflator and Manometer, JT Posey Company, Arcadia, CA). Results. The cohort for the study included 200 patients ranging in age from 6 months to 18 years...