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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Post-intubation stridor is a common problem in the pediatric intensive care setting &#40;over 44&#37; in the current article by Schweiger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> Yet the incidence of airway complications associated with intubation is relatively low&#46; A recent prospective study reported an incidence of post-intubation subglottic stenosis in children was 11&#46;38&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> The challenge is identifying which children are at particular risk of developing airway compromise&#44; or alternatively identifying those at low risk of airway compromise&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk factors for the development of airway complications related to intubation are well known&#46; The size of the endotracheal tube relative to the size of the airway remains the single most important variable&#44; but the duration of intubation&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#8211;5</span></a> whether the intubation was traumatic or not&#44; the number of intubations&#44; agitation&#44; nasal vs&#46; oral intubation&#44; the composition of the endotracheal tube&#44; and factors predisposing to inflammation &#40;e&#46;g&#46;&#44; gastroesophageal reflux&#44; viral infection&#41; are all factors to consider as well&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> A new prospective study even implied that undersedation might be a risk factor for the development of subglottic stenosis in intubated children&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> The key concept is that the appropriate size of the endotracheal tube is not the age-appropriate tube&#44; but rather the child-appropriate endotracheal tube&#46; While ideally having an endotracheal tube with a leak pressure of less than 20<span class="elsevierStyleHsp" style=""></span>cm of water will minimize the risk of iatrogenic airway trauma&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#44;9</span></a> in some children the ventilatory needs are such that the risk of post-intubation airway compromise has to be tolerated &#8211; in such children&#44; the smallest endotracheal tube that will provide adequate ventilation is a better management guideline&#46; An alternative approach is the use of a smaller-diameter cuffed endotracheal tube&#46; This will carry a lower risk of iatrogenic laryngeal trauma&#44; but attention needs to be paid to cuff pressure to prevent the formation of tracheal stenosis&#46; Although some studies demonstrated that the use of cuffed tubes in pediatric population may not increase respiratory complications&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10&#8211;12</span></a> robust evidence is still lacking&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> The group at highest risk of cuff-related tracheal stenosis are agitated teenagers who have sustained a brain injury&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the current study the incidence of post-intubation stridor and the development of subglottic stenosis &#40;SGS&#59; 9&#46;62&#37;&#41; are relatively high in comparison to many other studies&#46; This would appear to be a consequence of the indications for intubation rather than the subsequent management&#46; This is a relatively young cohort of patients &#40;median age 2&#46;7 months&#41;&#44; 63&#46;1&#37; of whom were intubated for bronchiolitis&#46; Moreover&#44; intubation and viral infection are synergistic in the development of subglottic stenosis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The potential airway complications of intubation include the development of glottic and subglottic granulation&#44; cricoid ulceration&#44; posterior glottic stenosis&#44; cricoarytenoid joint fixation&#44; SGS&#44; and tracheal stenosis&#46; The stenosis may initially be soft and immature&#44; and may be reversible&#44; or may progress to cicatricial scar formation and a fixed stenosis&#46; The signs and symptoms of airway compromise may be overt or covert&#46; The most noticeable is stridor&#44; typically inspiratory or biphasic&#46; Biphasic stridor is typically seen with a fixed stenosis&#44; while inspiratory stridor is more typically seen with a dynamic collapse &#40;laryngomalacia&#44; vocal cord paralysis&#44; glottic granulation&#41;&#46; Stridor should not be confused with an expiratory wheeze&#46; While stridor is the sign that draws the most attention&#44; retractions &#40;whether suprasternal&#44; intercostal or subcostal&#41; are a much better indicator of the severity of an obstruction&#46; In a child with stridor but no retractions&#44; the airway is unlikely to be significantly compromised&#46; However&#44; a child with a severe stenosis may have minimal stridor&#44; yet have marked retractions&#46; Other symptoms may include a hoarse voice&#44; apneas&#44; and cyanosis&#46; Symptoms are typically worse when agitated&#44; or during exertion &#40;primarily when feeding in a baby&#41;&#46; With the development of stenosis in the airway&#44; symptoms are typically progressive&#44; and may evolve over a period of weeks&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a child with post extubation stridor&#44; it is not mandatory to investigate&#44; as often the stridor is mild and transient&#46; However&#44; if the stridor is severe&#44; late onset&#44; or progressive&#44; then investigation is warranted&#46; The single most valuable non-invasive investigation&#44; if available&#44; is an awake transnasal flexible laryngoscopy&#46; This is fast&#44; low risk&#44; does not involve sedation&#44; and provides valuable information about the upper airway&#44; from the nasal aperture to the vocal cords&#46; This is best done with the child sitting up or being supported in an upright position&#46; For dynamic laryngeal problems&#44; including laryngomalacia and vocal cord movement impairment&#44; it is invaluable&#44; and it may also provide valuable information about laryngeal granulation and subglottic stenosis&#46; However&#44; it requires the right equipment and personnel&#44; typically an otolaryngologist&#46; If the child is symptomatic&#44; and there is little evidence to be seen on flexible laryngoscopy&#44; this implies a more distal pathology&#44; and a bronchoscopy under general anesthesia is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> Other investigations include imaging of the airway &#40;airway films&#44; CT scan&#44; <span class="elsevierStyleItalic">etc</span>&#46;&#41;&#44; and in older stable children&#44; pulmonary function tests may be of value&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">However&#44; the gold standard for airway evaluation currently is microlaryngoscopy and bronchoscopy with a rigid Hopkins rod endoscope &#40;whether through a ventilating bronchoscope or with the telescope alone&#41;&#46; The optics are superb&#44; and for evaluation of laryngeal and tracheal pathology&#44; especially SGS and posterior glottic stenosis&#44; it remains the recommended investigation in a significantly symptomatic child&#46; Flexible bronchoscopy has some advantages evaluating airway dynamics and malacia&#44; and accessing the peripheral bronchial tree&#46; However&#44; flexible bronchoscopy is not a reliable tool for evaluation of the posterior glottis &#40;e&#46;g&#46;&#44; evaluating for posterior glottic stenosis or a laryngeal cleft&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Management of a child with post-extubation stridor may be expectant in most cases&#44; especially if the stridor is mild&#46; The underlying cause of stridor is tissue reaction at the interface of the endotracheal tube and the laryngeal or tracheal mucosa&#44; and removal of the inciting cause is key to tissue recovery&#46; However&#44; following extubation&#44; there may be reactive edema of damaged mucosa&#44; and obstruction &#40;with resultant stridor and retractions&#41; may become transiently worse over the first 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h before improving&#46; Over this time&#44; supportive measures to prevent the need for re-intubation are recommended&#44; including the use of racemic epinephrine&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> steroids&#44; heliox&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> positive airway pressure&#44; or nebulized steroids&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> If re-intubation is required&#44; a smaller tube may be used to maintain a leak&#44; and steroid antibiotic combination drops may be placed down the tube to help with granulation and swelling&#46; Re-intubation through a different route also is of value &#8211; swapping an oral tube to a nasal tube&#44; for example&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A child failing extubation&#44; or in whom stridor is still present after 72<span class="elsevierStyleHsp" style=""></span>h&#44; in whom stridor occurs after 72<span class="elsevierStyleHsp" style=""></span>h&#44; or in whom obstruction is getting progressively worse&#44; evaluation should be performed in the operating room&#44; for consideration of intervention&#46; Interventions may be endoscopic&#44; open&#44; or serve to bypass the obstruction&#46; A tracheotomy serves to bypass the obstruction&#44; but may not prevent the need for later endoscopic or open intervention to achieve decannulation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Endoscopic management may be as simple as removing granulation tissue&#46; However&#44; if stenosis is present&#44; whether from soft tissue edema or from scar tissue&#44; then other endoscopic interventions may be considered&#46; The key is patient selection&#46; If the mucosa is very &#8220;unhealthy&#8221; then it may be better to place a tracheotomy and wait until the larynx is quiescent&#44; and then consider intervention&#46; If there is stenosis present&#44; then considering the cartilaginous &#8220;exoskeleton&#8221; of the laryngotracheal complex is helpful in planning interventions&#46; If the outer cartilaginous framework of the airway is intact&#44; and there is intraluminal scar&#44; then endoscopic interventions such as steroid injections&#44; scar division&#44; and balloon dilation may be effective&#46; But if the cartilaginous structure is compromised&#44; whether congenitally narrow&#44; such as an elliptical cricoid causing subglottic stenosis&#44; or there is mucosal ulceration exposing damaged cartilage&#44; then endoscopic procedures may be ineffective&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">If open surgery is required&#44; whether to prevent the need for a tracheotomy or to allow removal of a tracheotomy&#44; there are three main classes of procedure to assist with stenosis&#44; namely expansion surgery&#44; resection surgery&#44; and the slide tracheoplasty&#46; Expansion surgery&#44; or laryngotracheal reconstruction &#40;LTR&#41;&#44; involves placing cartilage grafts to expand a stenotic segment of the airway&#46; This may be done for posterior glottic stenosis&#44; SGS&#44; or tracheal stenosis&#44; and the grafts may be placed in the anterior cricoid&#44; anterior trachea&#44; or posterior cricoid&#46; Costal cartilage is the graft material of choice&#46; Resection surgery &#40;tracheal resection or cricotracheal resection &#91;CTR&#93;&#41; involves removing a scarred segment of the airway&#44; and anastomosing healthy tissue to healthy tissue&#46; CTR is an operation for treating SGS&#44; and for severe stenosis has better outcomes than LTR&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> However&#44; it is a more challenging operation&#44; with a higher risk of post-operative complications&#46; The slide tracheoplasty is an operation for treating tracheal stenosis&#44; and expands the size of the stenosis by transecting the airway and overlapping the stenotic segments&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">These various potential interventions are time dependent &#8211; it is more challenging dealing with a fixed&#44; thick cicatricial scar than a soft tissue stenosis&#44; and medical management and endoscopic interventions &#8211; if implemented early enough &#8211; may prevent the need for more complex invasive surgery&#46; Therefore early identification of patients at risk for the development of SGS is of value&#46; This study examines one clinical indicator&#44; namely post-extubation stridor&#44; and relates this to findings on transnasal flexible laryngoscopy&#44; and in the more symptomatic cases&#44; the findings on bronchoscopy&#46; For children with stridor present 72<span class="elsevierStyleHsp" style=""></span>h after extubation&#44; the positive predictive value was 40&#37;&#44; and the negative predictive value was 96&#37;&#46; This does suggest that bronchoscopic evaluation in an operating room is not required in children who do not have stridor 72<span class="elsevierStyleHsp" style=""></span>h following extubation&#46; However&#44; the presence of stridor 72<span class="elsevierStyleHsp" style=""></span>h after extubation does suggest that consideration should be given to formal evaluation of the airway in an operating room setting&#44; as subglottic stenosis may be present in 40&#37; of cases&#44; and be potentially amenable to endoscopic intervention&#46; In this series&#44; 18 patients had SGS&#44; eight requiring open reconstruction&#44; but with a further eight only requiring endoscopic intervention &#40;usually balloon dilation&#41;&#46; Of the remaining two patients&#44; one died of sepsis&#44; and one did not require intervention&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion&#44; post-extubation stridor is common&#44; while intubation related SGS is comparatively rare&#46; There are few current guidelines to suggest which patients warrant further evaluation&#46; The study by Schweiger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> is valuable in suggesting that if stridor is persistent after 72<span class="elsevierStyleHsp" style=""></span>h&#44; then evaluation for possible SGS&#44; and appropriate early intervention&#44; may prevent the need for complex subsequent airway reconstruction in a significant number of children&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">Dr&#46; Rutter is a consultant for Tracoe and Bryan Medical&#46; He has a patent for a balloon dilator that is licensed by Bryan Medical&#44; for which he receives royalties&#46; He developed a suprastomal stent marketed by Boston Medical Products that he has declined royalties on&#46; Dr&#46; Kuo has no disclosures&#46;</p></span></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rutter M&#44; Kuo IC&#46; Predicting and managing the development of subglottic stenosis following intubation in children&#46; J Pediatr &#40;Rio J&#41;&#46; 2020&#59;96&#58;1&#8211;3&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">See paper by Schweiger et al&#46; in pages 39&#8211;45&#46;</p>"
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Editorial
Predicting and managing the development of subglottic stenosis following intubation in children
Previsão e manejo do desenvolvimento da estenose subglótica após a intubação em crianças
Michael Ruttera,
Corresponding author
Mike.Rutter@cchmc.org

Corresponding author.
, I-Chun Kuoa,b
a Cincinnati Children's Hospital Medical Center, Division of Pediatric Otolaryngology, Aerodigestive and Esophageal Center, Cincinnati, United States
b Chang Gung Memorial Hospital, Department of Otolaryngology-Head & Neck Surgery, Kwei-Shan, Taiwan
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The size of the endotracheal tube relative to the size of the airway remains the single most important variable&#44; but the duration of intubation&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#8211;5</span></a> whether the intubation was traumatic or not&#44; the number of intubations&#44; agitation&#44; nasal vs&#46; oral intubation&#44; the composition of the endotracheal tube&#44; and factors predisposing to inflammation &#40;e&#46;g&#46;&#44; gastroesophageal reflux&#44; viral infection&#41; are all factors to consider as well&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> A new prospective study even implied that undersedation might be a risk factor for the development of subglottic stenosis in intubated children&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> The key concept is that the appropriate size of the endotracheal tube is not the age-appropriate tube&#44; but rather the child-appropriate endotracheal tube&#46; While ideally having an endotracheal tube with a leak pressure of less than 20<span class="elsevierStyleHsp" style=""></span>cm of water will minimize the risk of iatrogenic airway trauma&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#44;9</span></a> in some children the ventilatory needs are such that the risk of post-intubation airway compromise has to be tolerated &#8211; in such children&#44; the smallest endotracheal tube that will provide adequate ventilation is a better management guideline&#46; An alternative approach is the use of a smaller-diameter cuffed endotracheal tube&#46; This will carry a lower risk of iatrogenic laryngeal trauma&#44; but attention needs to be paid to cuff pressure to prevent the formation of tracheal stenosis&#46; Although some studies demonstrated that the use of cuffed tubes in pediatric population may not increase respiratory complications&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10&#8211;12</span></a> robust evidence is still lacking&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> The group at highest risk of cuff-related tracheal stenosis are agitated teenagers who have sustained a brain injury&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the current study the incidence of post-intubation stridor and the development of subglottic stenosis &#40;SGS&#59; 9&#46;62&#37;&#41; are relatively high in comparison to many other studies&#46; This would appear to be a consequence of the indications for intubation rather than the subsequent management&#46; This is a relatively young cohort of patients &#40;median age 2&#46;7 months&#41;&#44; 63&#46;1&#37; of whom were intubated for bronchiolitis&#46; Moreover&#44; intubation and viral infection are synergistic in the development of subglottic stenosis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The potential airway complications of intubation include the development of glottic and subglottic granulation&#44; cricoid ulceration&#44; posterior glottic stenosis&#44; cricoarytenoid joint fixation&#44; SGS&#44; and tracheal stenosis&#46; The stenosis may initially be soft and immature&#44; and may be reversible&#44; or may progress to cicatricial scar formation and a fixed stenosis&#46; The signs and symptoms of airway compromise may be overt or covert&#46; The most noticeable is stridor&#44; typically inspiratory or biphasic&#46; Biphasic stridor is typically seen with a fixed stenosis&#44; while inspiratory stridor is more typically seen with a dynamic collapse &#40;laryngomalacia&#44; vocal cord paralysis&#44; glottic granulation&#41;&#46; Stridor should not be confused with an expiratory wheeze&#46; While stridor is the sign that draws the most attention&#44; retractions &#40;whether suprasternal&#44; intercostal or subcostal&#41; are a much better indicator of the severity of an obstruction&#46; In a child with stridor but no retractions&#44; the airway is unlikely to be significantly compromised&#46; However&#44; a child with a severe stenosis may have minimal stridor&#44; yet have marked retractions&#46; Other symptoms may include a hoarse voice&#44; apneas&#44; and cyanosis&#46; Symptoms are typically worse when agitated&#44; or during exertion &#40;primarily when feeding in a baby&#41;&#46; With the development of stenosis in the airway&#44; symptoms are typically progressive&#44; and may evolve over a period of weeks&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a child with post extubation stridor&#44; it is not mandatory to investigate&#44; as often the stridor is mild and transient&#46; However&#44; if the stridor is severe&#44; late onset&#44; or progressive&#44; then investigation is warranted&#46; The single most valuable non-invasive investigation&#44; if available&#44; is an awake transnasal flexible laryngoscopy&#46; This is fast&#44; low risk&#44; does not involve sedation&#44; and provides valuable information about the upper airway&#44; from the nasal aperture to the vocal cords&#46; This is best done with the child sitting up or being supported in an upright position&#46; For dynamic laryngeal problems&#44; including laryngomalacia and vocal cord movement impairment&#44; it is invaluable&#44; and it may also provide valuable information about laryngeal granulation and subglottic stenosis&#46; However&#44; it requires the right equipment and personnel&#44; typically an otolaryngologist&#46; If the child is symptomatic&#44; and there is little evidence to be seen on flexible laryngoscopy&#44; this implies a more distal pathology&#44; and a bronchoscopy under general anesthesia is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> Other investigations include imaging of the airway &#40;airway films&#44; CT scan&#44; <span class="elsevierStyleItalic">etc</span>&#46;&#41;&#44; and in older stable children&#44; pulmonary function tests may be of value&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">However&#44; the gold standard for airway evaluation currently is microlaryngoscopy and bronchoscopy with a rigid Hopkins rod endoscope &#40;whether through a ventilating bronchoscope or with the telescope alone&#41;&#46; The optics are superb&#44; and for evaluation of laryngeal and tracheal pathology&#44; especially SGS and posterior glottic stenosis&#44; it remains the recommended investigation in a significantly symptomatic child&#46; Flexible bronchoscopy has some advantages evaluating airway dynamics and malacia&#44; and accessing the peripheral bronchial tree&#46; However&#44; flexible bronchoscopy is not a reliable tool for evaluation of the posterior glottis &#40;e&#46;g&#46;&#44; evaluating for posterior glottic stenosis or a laryngeal cleft&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Management of a child with post-extubation stridor may be expectant in most cases&#44; especially if the stridor is mild&#46; The underlying cause of stridor is tissue reaction at the interface of the endotracheal tube and the laryngeal or tracheal mucosa&#44; and removal of the inciting cause is key to tissue recovery&#46; However&#44; following extubation&#44; there may be reactive edema of damaged mucosa&#44; and obstruction &#40;with resultant stridor and retractions&#41; may become transiently worse over the first 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h before improving&#46; Over this time&#44; supportive measures to prevent the need for re-intubation are recommended&#44; including the use of racemic epinephrine&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> steroids&#44; heliox&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> positive airway pressure&#44; or nebulized steroids&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> If re-intubation is required&#44; a smaller tube may be used to maintain a leak&#44; and steroid antibiotic combination drops may be placed down the tube to help with granulation and swelling&#46; Re-intubation through a different route also is of value &#8211; swapping an oral tube to a nasal tube&#44; for example&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A child failing extubation&#44; or in whom stridor is still present after 72<span class="elsevierStyleHsp" style=""></span>h&#44; in whom stridor occurs after 72<span class="elsevierStyleHsp" style=""></span>h&#44; or in whom obstruction is getting progressively worse&#44; evaluation should be performed in the operating room&#44; for consideration of intervention&#46; Interventions may be endoscopic&#44; open&#44; or serve to bypass the obstruction&#46; A tracheotomy serves to bypass the obstruction&#44; but may not prevent the need for later endoscopic or open intervention to achieve decannulation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Endoscopic management may be as simple as removing granulation tissue&#46; However&#44; if stenosis is present&#44; whether from soft tissue edema or from scar tissue&#44; then other endoscopic interventions may be considered&#46; The key is patient selection&#46; If the mucosa is very &#8220;unhealthy&#8221; then it may be better to place a tracheotomy and wait until the larynx is quiescent&#44; and then consider intervention&#46; If there is stenosis present&#44; then considering the cartilaginous &#8220;exoskeleton&#8221; of the laryngotracheal complex is helpful in planning interventions&#46; If the outer cartilaginous framework of the airway is intact&#44; and there is intraluminal scar&#44; then endoscopic interventions such as steroid injections&#44; scar division&#44; and balloon dilation may be effective&#46; But if the cartilaginous structure is compromised&#44; whether congenitally narrow&#44; such as an elliptical cricoid causing subglottic stenosis&#44; or there is mucosal ulceration exposing damaged cartilage&#44; then endoscopic procedures may be ineffective&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">If open surgery is required&#44; whether to prevent the need for a tracheotomy or to allow removal of a tracheotomy&#44; there are three main classes of procedure to assist with stenosis&#44; namely expansion surgery&#44; resection surgery&#44; and the slide tracheoplasty&#46; Expansion surgery&#44; or laryngotracheal reconstruction &#40;LTR&#41;&#44; involves placing cartilage grafts to expand a stenotic segment of the airway&#46; This may be done for posterior glottic stenosis&#44; SGS&#44; or tracheal stenosis&#44; and the grafts may be placed in the anterior cricoid&#44; anterior trachea&#44; or posterior cricoid&#46; Costal cartilage is the graft material of choice&#46; Resection surgery &#40;tracheal resection or cricotracheal resection &#91;CTR&#93;&#41; involves removing a scarred segment of the airway&#44; and anastomosing healthy tissue to healthy tissue&#46; CTR is an operation for treating SGS&#44; and for severe stenosis has better outcomes than LTR&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> However&#44; it is a more challenging operation&#44; with a higher risk of post-operative complications&#46; The slide tracheoplasty is an operation for treating tracheal stenosis&#44; and expands the size of the stenosis by transecting the airway and overlapping the stenotic segments&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">These various potential interventions are time dependent &#8211; it is more challenging dealing with a fixed&#44; thick cicatricial scar than a soft tissue stenosis&#44; and medical management and endoscopic interventions &#8211; if implemented early enough &#8211; may prevent the need for more complex invasive surgery&#46; Therefore early identification of patients at risk for the development of SGS is of value&#46; This study examines one clinical indicator&#44; namely post-extubation stridor&#44; and relates this to findings on transnasal flexible laryngoscopy&#44; and in the more symptomatic cases&#44; the findings on bronchoscopy&#46; For children with stridor present 72<span class="elsevierStyleHsp" style=""></span>h after extubation&#44; the positive predictive value was 40&#37;&#44; and the negative predictive value was 96&#37;&#46; This does suggest that bronchoscopic evaluation in an operating room is not required in children who do not have stridor 72<span class="elsevierStyleHsp" style=""></span>h following extubation&#46; However&#44; the presence of stridor 72<span class="elsevierStyleHsp" style=""></span>h after extubation does suggest that consideration should be given to formal evaluation of the airway in an operating room setting&#44; as subglottic stenosis may be present in 40&#37; of cases&#44; and be potentially amenable to endoscopic intervention&#46; In this series&#44; 18 patients had SGS&#44; eight requiring open reconstruction&#44; but with a further eight only requiring endoscopic intervention &#40;usually balloon dilation&#41;&#46; Of the remaining two patients&#44; one died of sepsis&#44; and one did not require intervention&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion&#44; post-extubation stridor is common&#44; while intubation related SGS is comparatively rare&#46; There are few current guidelines to suggest which patients warrant further evaluation&#46; The study by Schweiger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> is valuable in suggesting that if stridor is persistent after 72<span class="elsevierStyleHsp" style=""></span>h&#44; then evaluation for possible SGS&#44; and appropriate early intervention&#44; may prevent the need for complex subsequent airway reconstruction in a significant number of children&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">Dr&#46; Rutter is a consultant for Tracoe and Bryan Medical&#46; He has a patent for a balloon dilator that is licensed by Bryan Medical&#44; for which he receives royalties&#46; He developed a suprastomal stent marketed by Boston Medical Products that he has declined royalties on&#46; Dr&#46; Kuo has no disclosures&#46;</p></span></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rutter M&#44; Kuo IC&#46; Predicting and managing the development of subglottic stenosis following intubation in children&#46; J Pediatr &#40;Rio J&#41;&#46; 2020&#59;96&#58;1&#8211;3&#46;</p>"
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        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">See paper by Schweiger et al&#46; in pages 39&#8211;45&#46;</p>"
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Article information
ISSN: 00217557
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