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Sequential Balloon Dilation and Triamcinolone Injection in Premature Infant to Treat Glottic and Subglottic Injury

Contributors: Sanjay Parikh

Sequential Balloon Dilation and Triamcinolone Injection in Premature Infant to Treat Glottic and Subglottic Injury.  This video with narration shows a marked improvement in neonatal airway edema and successful extubation after three interventions of triamcinolone injection and balloon dilation.

DOI# http://dx.doi.org/10.17797/w2iwnogofq

Author Recruited by: Sanjay Parikh, MD. FACS

A premature infant was unable to extubate on multiple occasions due to stridor. A 3-0 endotracheal tube was in place and she was 3 weeks of age when our consult team met her. She was born at 35 weeks gestational age and required intubation on day of life 3. Laryngoscopy and bronchoscopy was performed to evaluate the etiology of stridor when extubated. The first endoscopy revealed glottic and subglottic injury likely due to the presence of the endotracheal tube. Balloon dilation to 5 mm was performed as well as triamcinalone injection. The patient remained intubated. At repeat bronchoscopy one week later, the findings in the subglottis had improved, but there was persistent glottic edema preventing safe extubation. Balloon dilation and triamcinalone injection were performed again and the patient remained intubated with 3-0 endotracheal tube. The third endoscopy one week later demonstrated significant improvement. Although dilation was not needed, triamcinalone was injected at the level of the glottis and subglottis, the endotracheal tube replaced, and the patient was successfully extubated 3 days later. The patient required no subsequent intervention.
A premature infant was unable to extubate on multiple occasions due to stridor. A 3-0 endotracheal tube was in place and she was 3 weeks of age when our consult team met her. She was born at 35 weeks gestational age and required intubation on day of life 3. Operative evaluation was necessary.
Unstable from a cardiovascular standpoint to undergo general anesthia, or acute infectious process (i.e. pneumonia, upper respiratory viral infection, tracheitis). The airway evaluation should be done in the operating with an anesthesiologist comfortable with spontaneous ventilation sedation.
Microdirect suspension laryngoscopy equipment using the neonatal sized Parsons laryngoscope and the pediatric sized Lindholm laryngoscope. An initial evaluation is typically performed with a 4 mm 0-degree endoscope, and other endoscopes available and frequently used are 2.7 mm 0-degree endoscope, and 30-degree angled endoscopes. Bronchoscopy instrument sets are available to secure airway if needed. An operative microscope is in the room and available for intervention as needed. The anesthesia team topically anesthetizes the larynx, and then the table is rotated 90 degrees toward the surgeon. Visualization is aided with Lindholm laryngeal distention forceps, which are placed in the ventricle to retract the false vocal folds.
The patient is evaluated by the ICU team to assess cardiovascular stability and safety of undergoing general anesthesia. In this instance, multiple extubation trials were attempted without success. Ideally, flexible laryngoscopy is performed during an extubation trial to assess the dynamic airway including vocal fold mobility.
Laryngoscopy and bronchoscopy was performed to evaluate the etiology of stridor. The first endoscopy revealed glottic and subglottic injury likely due to the presence of the endotracheal tube. Balloon dilation to 5 mm was performed as well as triamcinalone injection The balloon dilation was done 3 times, each holding for 30-60 seconds, or until the patient desaturated. The triamcinolone formulation used was Kenalog�®-40 (Triamcinolone Acetonide Injectable Suspension, USP, 40 mg per 1 mL; 1 mL vial). An oro-tracheal injector was used that fits a 1 mL syringe. 0.1 mL was injected into each side. The patient remained intubated postoperatively. At repeat bronchoscopy one week later, the findings in the subglottis had improved, but there was persistent glottic edema preventing safe extubation. Balloon dilation and triamcinalone injection were performed again (with same dose) and the patient remained intubated with 3-0 endotracheal tube. The third endoscopy one week later demonstrated significant improvement. Although dilation was not needed, triamcinalone was injected at the level of the glottis and subglottis, the endotracheal tube replaced, and the patient was successfully extubated 3 days later. The patient required no subsequent intervention.
The advantage of this treatment plan is that it can be done endoscopically through laryngoscopy and bronchoscopy. Treatment alternatives include continued intubation with observation and medical treatment with systemic steroids, laryngotracheal reconstruction, or tracheotomy.
The risks incurred include multiple brief anesthetics or continued stenosis resulting in need for intubation. The maximum recommended volume of injected triamcinolone (40mg / 1 mL) is 0.2 mL.
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