DEFINITION
|
Definition of PEL: Inflammation of the larynx associated to tracheal intubation that manifests as stridor and/or dysphonia and/or effortful breathing beginning hours or days following extubation associated or not to failed extubation |
X (100%) |
|
X |
X |
Most appropriate terminology: Post extubation laryngitis |
X (76.5%) |
|
X |
X |
SYMPTOMS
|
Stridor is the most important symptom |
X (70.6%) |
|
X |
X |
Dysphonia and retractions were the second and third most common symptoms |
|
X (58%) |
X |
X |
24 h to 48 h is the maximum expectation time for spontaneous resolution of symptoms before demanding endoscopic evaluation |
X (70.5%) |
|
X |
X |
DIAGNOSIS
|
Diagnosis must be confirmed by endoscopic examination |
X (82.4%) |
|
X |
X |
FNL is the first endoscopy procedure that should be performed in patients with PEL |
X (100%) |
|
X |
|
3.2 or 3.4 mm FNL are the most used for bedside examination |
X (100%) |
|
X |
|
FNL as a bedside examination |
|
X (66.7%) |
X |
|
Sedation is not needed for bedside FNL |
X (83.3%) |
|
X |
|
Use of topical anesthetics for bedside FNL |
|
X (50%) |
X |
|
The main limitation of FNL is the evaluation of the subglottis |
X (100%) |
|
X |
|
FNL allows evaluation of severe acquired laryngeal lesion (cricoid exposure, granulation tissue, subglottic stenosis) |
|
X (66%) |
X |
|
RISK FACTORS AND PRECAUTIONS
|
Specific length of intubation in PICU |
|
X (60%) |
X |
|
Specific length of intubation in the NICU |
|
X (68%) |
X |
|
Previous intubation history is considered a risk factor for PEL |
X (88.2%) |
|
X |
X |
GERD is considered a risk factor for PEL |
X (70.6%) |
|
X |
X |
Neuropathy as a condition influencing the occurrence of PEL |
X (76.5%) |
|
X |
X |
Cardiopathy, post-operative cardiac surgery, and sepsis as conditions influencing the occurrence of PEL |
|
X (61.7%) |
X |
X |
Comfort scale is considered important |
X (81.8%) |
|
X |
X |
Care should be taken particularly during endotracheal aspiration |
X (100%) |
|
X |
X |
CLINICAL TREATMENT
|
Systemic corticosteroids are part of the clinical treatment if no contra indication |
X (76.5%) |
|
X |
X |
Dexamethasone is the most used systemic corticosteroid |
X (70.5%) |
|
X |
X |
Minimal clinical treatment with systemic corticosteroid is 48 h |
X (94.1%) |
|
X |
X |
Maximum clinical treatment with maximum dose of systemic corticosteroid is 72 h |
|
X (47%) |
X |
X |
Minimum dose of dexamethasone |
|
X (58.8%) |
X |
X |
Maximum dose of dexamethasone |
|
X (23.5%) |
X |
X |
The endoscopic aspect of the lesions, described by the otolaryngologist, influences the choice of dose and duration of corticosteroid therapy |
X (94.1%) |
|
X |
X |
Proton pump inhibitors are part of the clinical treatment |
X (70.6%) |
|
X |
X |
PPI dosage varies from 1-2 mg/kg |
|
X (52.9%) |
X |
X |
Nebulized adrenaline is part of clinical treatment |
X (94.1%) |
|
X |
X |
Use of non-invasive ventilation is beneficial and useful |
X (100%) |
|
X |
X |
Inadequate sedation levels, inappropriate masks, craniofacial deformities, nasal lesions and inexperienced physiotherapy teams are considered the causes for NIV failure |
X (94,1%) |
|
X |
X |
High flow nasal cannula is a useful tool in treating PEL |
X (70.6%) |
|
X |
X |
ENDOSCOPIC TREATMENT
|
Indications for MLB: following two failed extubations, severe acute laryngeals lesions seen on FNL and/or persistent stridor and dysphonia 72 h after extubation and medical treatment |
X (100%) |
|
X |
X |
Circumferential mucosal ulceration, ulceration with exposed cartilage, SGS and interarytenoid lesions are considered severe aspects of PEL |
X (100%) |
|
X |
|
Intra or perilesional infiltration of triamcinolone is used for severe lesions |
X (100%) |
|
X |
|
Airway calibration with endotracheal tube is routine during MLB |
X (100%) |
|
X |
|
When dilation is indicated for acute SGS balloon is the instrument of choice |
X (100%) |
|
X |
|
Mytomicin C is not used |
X (100%) |
|
X |
|
After MLB intubated patients will be extubated 24-72 h |
X (100%) |
|
X |
X |
A smaller uncuffed tube is the choice following MLB |
X (83.3%) |
|
X |
|
Laryngeal rest and appropriate sedation until extubation are recommended |
X (100%) |
|
X |
X |
Corticosteroid and antibiotic ointment applied around the tube is beneficial in treatment of PEL |
X (100%) |
|
X |
|
Systemic corticosteroids and PPI are recommended following MLB for PEL |
X (94.1%/70.6%) |
|
X |
|
Tracheal secretion culture is not part of the routine |
X (94.1%) |
|
X |
|
Tracheal secretion cultures are indicated when secondary infection is suspected, in cases of poor outcome and/or severe lesions are encountered in endoscopy |
X (93.7%) |
|
X |
|
FOLLOW-UP
|
The ENT surgeon is responsible for tracheostomy indication |
X (88.2%) |
|
X |
X |
The ENT surgeon should be involved in the tracheostomy follow-up |
X (100%) |
|
X |
X |
Discharge from the PICU and NICU is a pediatric decision. ENT reevaluation is demanded only if stridor or dysphonia |
X (70%) |
|
X |
|
PEL patients should have peripheral venous access during entire ICU and ward stay while symptomatic |
X (76.4%) |
|
X |
X |
Discharge from hospital only after ENT evaluation |
X (75%) |
|
X |
X |
ENT reevaluation in outpatient setting after 1‒3 weeks regardless of symptoms |
X (83.3%) |
|
X |
|
Need of MLB in follow-up of PEL |
|
X (50%) |
X |
|
Outpatient follow-up should be from 4-8 weeks |
X (83.3%) |
|
X |
|