Postintubation airway injury in the pediatric intensive care unit
Lesiones de la vía aérea postintubación en la unidad de terapia intensiva pediátrica
Otilia E. Blain
, Celeste C. Patiño González, Enrique J. Romero Manteola
Corresponding author
Pediatric Surgery Department, Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina
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Blain, Celeste C. Patiño González, Enrique J. Romero Manteola" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Otilia E." "apellidos" => "Blain" "email" => array:1 [ 0 => "otiliablain@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Celeste C." "apellidos" => "Patiño González" "email" => array:1 [ 0 => "celestecarolina@hotmail.com" ] ] 2 => array:3 [ "nombre" => "Enrique J." "apellidos" => "Romero Manteola" "email" => array:1 [ 0 => "eromeromanteola@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Pediatric Surgery Department, Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones de la vía aérea postintubación en la unidad de terapia intensiva pediátrica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1261 "Ancho" => 2509 "Tamanyo" => 123739 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Distribution of patients with or without endoscopy according to days of intubation (p < 0.05; chi square test).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Advances in airway techniques including endotracheal intubation (ETI) and mechanical ventilation have increased the survival of critically ill patients. Nevertheless, the presence of an endotracheal tube (ETT) in the airway may cause laryngotracheal injury increasing morbidity and mortality during the recovery period of the patient.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Airway injury caused by endotracheal intubation (ETI) is a common event affecting the larynx and trachea. The pathophysiology that leads to the development of this type of injury consists of an ischemic process followed by ulceration of the respiratory mucosa in the areas in contact with the ETT. Exposure of the cartilage and perichondritis results in proliferation of granulation tissue and finally a retractile scar.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Reports on intubation injury in pediatrics date back to 1970 when the flexible bronchoscope was developed.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Currently, the most appropriate diagnostic tools to evaluate the larynx, trachea, and bronchi of infants and children are the flexible fiber-optic laryngoscope and the rigid bronchoscope.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several factors that may be involved in the development of airway injuries after intubation have been studied; however, the results were not sufficient to draw robust conclusions and there is no universal consensus regarding their classification.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The primary aim of our study was to determine the incidence of airway injury and identify predisposing factors for developing these lesions in patients who required ETI in the pediatric intensive care unit (PICU) at our center. Secondary aims were to evaluate the reasons to request airway endoscopy examination and to determine the tracheostomy rate in intubated patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data collection</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective, observational, and descriptive study was conducted.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All patients from one month to 18 years of age who required ETI and mechanical ventilation in the PICU of the Hospital de Niños de la Santísima Trinidad in the city of Córdoba, Argentina, between May 2015 and April 2019 were included. This large, tertiary center does not provide services to newborns less than 30 days of life.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients who were already intubated on admission, those with a history of ETI or previously diagnosed airway pathology, and those who had undergone tracheostomy prior to hospital admission were excluded from the study.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patient data were obtained from the medical records and were entered in a spreadsheet using Microsoft Excel 2017.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Two groups were defined: intubated patients (IP) and intubated patients who underwent airway endoscopy (PAE). The first group included all children who required ETI and the second group children who required ETI and underwent airway endoscopy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables and definitions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patient age was calculated in months. The duration of ETI was measured in days, including the days on which the patient was intubated and extubated.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The indications for diagnostic and/or therapeutic upper airway endoscopy were:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Suspected airway burn:</span> burns in the face or nasal vibrissae or a history of burns in a closed space with dysphonia, laryngeal stridor, or cough with carbonaceous sputum.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Difficult airway:</span> due to a history of difficult intubation, or craniofacial/cervicothoracic and/or other syndromes associated with a difficult airway in order to understand their challenging anatomy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">The indications for diagnostic and/or therapeutic lower airway endoscopy were:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Post-extubation stridor:</span> the presence of inspiratory noise without other symptoms following extubation, refractory to medical treatment (inhaled steroids or adrenaline, intravenous dexamethasone, and/or support with continuous positive airway pressure).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Extubation failure:</span> need to reposition the ETT into the patient’s airway within 48 hours after extubation in patients with clinical signs of respiratory distress in the absence of underlying diseases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Persistent atelectasis:</span> pulmonary tissue collapse for at least three weeks confirmed by chest X-rays.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Suspected foreign body aspiration:</span> patients with a history of, or signs and/or symptoms consistent with a foreign body in the airway.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Broncho-alveolar lavage:</span> due to suspected pulmonary disease to assess the type and extension of inflammation and/or the pathogenic organism involved.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Suspected tracheo-esophageal fistula:</span> in patients who underwent surgery for esophageal atresia with compatible symptoms.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Based on the endoscopic diagnosis, the following conditions were determined:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Acute airway injury:</span> laryngeal mucosal injury, diagnosed immediately or within seven days after extubation, categorized according to the classification of acute laryngeal injuries.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vocal cord paralysis:</span> lack of motility in one or both vocal cords during respiratory phases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Subglottic stenosis:</span> concentric scar tissue at the cricoid cartilage reducing the lumen.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Posterior glottic stenosis:</span> scar tissue reducing the glottic lumen.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Tracheal stenosis:</span> reduced tracheal diameter due to scar retraction.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Procedures</span><p id="par0140" class="elsevierStylePara elsevierViewall">ETI procedures were performed by specialists or fellows in pediatric intensive care according to the institutional protocol.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Endoscopic airway assessment was done with the patient connected to a multiparametric monitor. Flexible fiber-optic laryngoscopy was performed when the patient was awake and/or rigid bronchoscopy when the patient was sedated, entering through the nasal and/or oral cavity, after applying lidocaine 2% solution to the larynx. All procedures were performed by otolaryngologists and pediatric surgeons from the airway unit. Digital images were obtained during the procedures.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical aspects</span><p id="par0150" class="elsevierStylePara elsevierViewall">The research protocol was approved by the Scientific Committee of the Department for Research and Development at our hospital (protocol N° 14/21).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0155" class="elsevierStylePara elsevierViewall">Descriptive parameters, means, and standard deviation were calculated for continuous variables and frequency, distribution, and percentages for categorical variables, with a 95% confidence interval as appropriate.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The results are presented in tables and graphs. The student’s T test was used to compare means and the Chi Square test for correlation between variables. A significance level of 0.05 or less was used.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using Microsoft Excel 2017 and InfoStat 2017.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Demographic features</span><p id="par0170" class="elsevierStylePara elsevierViewall">During the study period, 1854 patients underwent ETI (IP group) of whom 136 required endoscopic airway evaluation (PAE group). After applying the exclusion criteria, 90 patients were included in the PAE group (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Demographic data of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Overall, 58.8% of the patients in the IP group were male, with an M/F ratio of 1.43:1. In the PAE group, 65.5% were male, with an M/F ratio of 1.54:1 (p = 0.2).</p><p id="par0185" class="elsevierStylePara elsevierViewall">Mean age was 35.6 months in the IP and 27.3 months in the PAE group (p = 0.04).</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Endotracheal intubation</span><p id="par0190" class="elsevierStylePara elsevierViewall">The mean duration of intubation was 7.2 days in the IP and 23.5 days in the PAE group (p = 0.001) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">Endoscopy showed laryngeal lesions in 2.03% of the children who were intubated for 7 days or less (95% CI: 1.39–2.93) and in 12.08% of the patients who remained intubated for 8 days or more (95% CI: 9.56–15.17; OR: 6).</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Indications for airway endoscopy</span><p id="par0200" class="elsevierStylePara elsevierViewall">The main indications for airway endoscopy in the PAE group were post-extubation stridor in 38 (42%), extubation failure in 31 (34%), suspected airway burn in six (7%), and persistent atelectasis in five children (5%).</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Endoscopic diagnosis</span><p id="par0205" class="elsevierStylePara elsevierViewall">In the PAE group, 88 patients (97.8%) were assessed by bronchoscopy. Lesions were found in 80% of all the studies.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Of the endoscopies that showed alterations, 76.4% (55 patients) were considered to be ETI related and in 23.6% (17 patients) the findings were unrelated to ETI. Overall, the incidence of ETI-related injury was 3% in the IP group.</p><p id="par0215" class="elsevierStylePara elsevierViewall">The most frequent ETI-related endoscopic diagnosis was acute airway injury in 43% of the patients who had injuries (17 mild, 4 moderate, 10 severe), followed by subglottic stenosis in 26.4% (5 grade I, 5 grade II, and 9 grade III). Tracheal stenosis and posterior glottic stenosis were seen in two patients each and only one had vocal cord paralysis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">Among the non-ETI-related injury, airway malacia was observed in 12 patients, a foreign body in three, vascular compression in one, and an airway burn by direct fire in another patient (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Correlation between indications for airway endoscopy and endoscopic diagnosis</span><p id="par0225" class="elsevierStylePara elsevierViewall">Among the children in whom endoscopy was indicated, all of those who had post-extubation stridor or extubation failure had some type of airway injury (p < 0.05) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Tracheostomy</span><p id="par0230" class="elsevierStylePara elsevierViewall">The rate of patients who required tracheostomy in the PICU was 3.34%, 43.5% of whom had ETI-related injury. In the remaining 56.5%, the indication for tracheostomy was related to the underlying disease, consisting of neurologic disorders, polytrauma, airway malacia, and a difficult airway. In patients with ETI-related injury, tracheostomy was required for 58% of the patients who had acute airway injury; 19 had subglottic stenosis, two had posterior glottic stenosis and tracheal stenosis, respectively, and one had vocal cord paralysis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0235" class="elsevierStylePara elsevierViewall">In this study we assessed the incidence of airway injury after ETI observed on endoscopy in patients in the PICU. Currently, studies about this type of lesions are limited to the analysis of a specific type of injury, but no data are available on post-ETI injury in general.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,15,16</span></a> By evaluating all types of injury, we tried to determine the variables involved in the pathophysiology with the aim to optimize different ETI-related practices and thereby reduce patient morbidity.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Multiple factors are involved in the development of laryngotracheal injuries in critically ill children, including patient characteristics, intubation technique, type of ETT used, and the duration of intubation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5,9,17</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">In our study, age less than 27 months was found to be a significant risk factor for the development of airway injury. In this age group, ETI may be difficult due to the immature laryngotracheal anatomy with an anterior tilt and small caliber of the lariynx.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> This latter condition may lead to miscalculation at the moment of determining the optimal size of the ETT leading to injuries in different locations and of variable severity.</p><p id="par0250" class="elsevierStylePara elsevierViewall">A history of prolonged intubation – i.e. 7 days or longer –, also plays an important role in the development of lesions. Patients who remained intubated for more than 7 days had a six-fold higher risk of developing airway injury. The exposure time to the decubitus of the ETT may increase the odds of developing inflammation and ulceration.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,17</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Based on the above, we propose evaluating the possibility of early extubation with endoscopic examination of the airway and/or even early tracheostomy in children that are intubated for more than 7 days, as we consider this may reduce the incidence of ETI-related injury in the PICU.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5,17,19</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">When evaluating all the ETI-related laryngotracheal injuries, we observed a wide range of clinical presentations, of which extubation failure and stridor were the most common conditions leading to the indication of airway endoscopy in the PICU. Some authors propose diagnostic endoscopic evaluation when these conditions persist, while others discourage using the procedure because of its invasiveness.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> Nevertheless, we believe that endoscopic airway visualization is crucial to assess ETI-related injury associated with post-extubation signs and/or symptoms. Early indication of endoscopy may lead to prompt diagnosis and adequate treatment reducing the risk of developing severe tracheobronchial sequelae.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Currently, optimal timing for tracheostomy in the intubated patient remains a matter of controversy and the decision is often individualized based on the characteristics of the child and the protocol of the center.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In our series, the tracheostomy rate in intubated patients was higher than that reported by other centers.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> This finding may be explained by the fact that our hospital is the main tertiary referral center in the region caring for patients with neurosurgical disorders, congenital heart disease, trauma, among others. In addition, it is the reference hospital for the management of complex airway and/or respiratory diseases in the region.</p><p id="par0270" class="elsevierStylePara elsevierViewall">We consider that endoscopic evaluation prior to tracheostomy is mandatory, since it allows for accurate diagnosis and initiation of appropriate treatment.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">One of the limitations of our study is its retrospective nature that restricts the sensitivity of detecting airway findings as endoscopy was neither randomized nor systematically performed. Also, some of the factors involved in the airway injury, such as type and size of the ETT and the intubation technique used could not be assessed as they were not recorded.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,18,19</span></a> Different authors state that the main factors involved in the development of laryngotracheal injuries are related to the features of the ETT used, while others support the role of the intubation technique and the context in which it is performed (scheduled vs. emergency).<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,24,25</span></a> We believe that the development of these injuries is a multifactorial phenomenon and that the elimination of each of these factors involved may decrease morbidity in the children who require ETI.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusion</span><p id="par0280" class="elsevierStylePara elsevierViewall">In pediatric patients, post-intubation airway injury has a wide range of presentation. Endoscopic visualization is crucial in their assessment as the severity of symptoms may not always correlate with the degree and/or extension of the airway injury. Early indication of endoscopy will lead to a prompt diagnosis and adequate treatment reducing morbidity in these critically ill patients.</p><p id="par0285" class="elsevierStylePara elsevierViewall">We found that the incidence of ETI-related injury in the PICU was 3%, and age younger than 27 months and intubation for more than 7 days were observed to be predisposing factors.</p><p id="par0290" class="elsevierStylePara elsevierViewall">The main indications for endoscopy were extubation failure and stridor, which were related to the presence of injury. The tracheostomy rate was 3.34%.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0295" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Declaration of interest</span><p id="par0300" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres2023502" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1732281" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1732280" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2023501" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1732279" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Data collection" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Variables and definitions" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Procedures" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical aspects" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Demographic features" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Endotracheal intubation" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Indications for airway endoscopy" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Endoscopic diagnosis" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Correlation between indications for airway endoscopy and endoscopic diagnosis" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Tracheostomy" ] ] ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0090" "titulo" => "Declaration of interest" ] 12 => array:2 [ "identificador" => "xack706712" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-09-16" "fechaAceptado" => "2022-12-28" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1732281" "palabras" => array:5 [ 0 => "Airway" 1 => "Bronchoscopy" 2 => "Endotracheal intubation" 3 => "Laryngostenosis" 4 => "Pediatrics" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1732280" "palabras" => array:1 [ 0 => "Endotracheal intubation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1732279" "palabras" => array:5 [ 0 => "Airway" 1 => "Bronchoscopy" 2 => "Endontratracheal intubation" 3 => "Laryngostenosis" 4 => "Pediatrics" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Airway injury caused by endotracheal intubation (ETI) is a common event in children who require ETI in the pediatric intensive care unit (PICU). The main aim of our study was to determine the incidence and the predisposing factors for the development of airway injury in PICU patients who need ETI. Secondary objectives were to evaluate the reasons for the request of airway endoscopy examination and the tracheostomy rate in this population.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">A retrospective, observational, descriptive study was conducted evaluating 1854 patients who were intubated in the PICU of a tertiary-care center between May 2015 and April 2019.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The mean age of all intubated patients was 35.6 months and of those who required endoscopy 27.3 months (p = 0.04). Mean length of intubation was 7.2 days for all intubated patients and 23.5 days for those who required endoscopy (p = 0.0001). Extubation failure and stridor were significantly associated with the finding of airway injury (p = 0.0001 and p = 0.0006, respectively).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The incidence rate of ETI-related injury was 3%. Age younger than 27 months and intubation for more than 7 days were predisposing factors for the development of injury.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The main indications for endoscopy were extubation failure and stridor, both related to the presence of injury. Tracheostomy rate in the PICU was 3.34%.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Las lesiones de la vía aérea por intubación endotraqueal (IET) son procesos patológicos causados por el trauma de los tejidos durante dicha condición. El principal objetivo fue determinar la incidencia y los factores predisponentes para el desarrollo de lesión de la vía aérea en pacientes que requirieron IET en la Unidad de Terapia Intensiva Pediátrica (UTIP). Los objetivos secundarios fueron evaluar las indicaciones de endoscopía y el porcentaje de pacientes traqueostomizados en dicha población.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo, observacional y descriptivo, de 1854 pacientes intubados en un centro de tercer nivel de complejidad entre Mayo de 2015 y Abril de 2019.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La media de edad de los pacientes intubados fue de 35,6 meses y la de los que requirieron endoscopía de la vía aérea fue de 27,3 meses (p = 0,04). El promedio de días de intubación de los pacientes intubados fue de 7,2 días y el de los que requirieron endoscopía fue de 23,5 días (p = 0,0001). El fallo de extubación programada y el estridor se relacionaron con la presencia lesión (p = 0,0001 y p = 0,0006, respectivamente).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">La incidencia de lesiones asociadas a la IET fue del 3%. La edad menor a 27 meses y la intubación por más de 7 días fueron los factores predisponentes para el desarrollo de lesiones.</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Las principales indicaciones de endoscopía fueron el fallo de extubación programada y el estridor; ambas se relacionaron con la presencia de lesión. El porcentaje de traqueostomías realizadas en la UTIP fue del 3,34%.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3093 "Ancho" => 3176 "Tamanyo" => 483548 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: IP: Intubated patients; PAE: Patients whit airway endoscopy; ETT: endotracheal tube; AAI: acute airway injury; SS: subglottic stenosis; TS: tracheal stenosis; PGS: posterior glottic stenosis; VCP: vocal cord paralysis).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1261 "Ancho" => 2509 "Tamanyo" => 123739 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Distribution of patients with or without endoscopy according to days of intubation (p < 0.05; chi square test).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1181 "Ancho" => 1676 "Tamanyo" => 81650 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ETI-related injury according to days of endotracheal intubation (p = 0,01; chi square test).</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: <span class="elsevierStyleItalic">(ETI):</span> endotracheal intubation; <span class="elsevierStyleItalic">(AAI):</span> acute airway injury; <span class="elsevierStyleItalic">(SS):</span> subglottic stenosis; (<span class="elsevierStyleItalic">TS):</span> tracheal stenosis; (<span class="elsevierStyleItalic">PGS):</span> posterior glottic stenosis; <span class="elsevierStyleItalic">(VCP):</span> vocal cord paralysis.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">p value < 0.005 was considered significant in bold.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">d</span>Chi Square test.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IP (n = 1854) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PAE (n = 90) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age at admission – Range<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.6 (1−226) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.3 (1−178) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">0.04</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male gender – n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">993 (58.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (65.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnosis – n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Respiratory disease</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1115 (60.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 (72.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Post-surgical</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">175 (9.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Accidents</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">163 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Neurological disorders</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">141 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Congenital heart disease</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Infectious disease</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic"><span class="elsevierStyleHsp" style=""></span>Others</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">228 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3359373.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Months.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Foreign body aspiration, trauma, burns.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">T test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">p value < 0.005 was considered significant in bold.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical features \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without injury \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With injury \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Upper Airway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspected airway burn \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4142 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficult airway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">--- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lower airway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-extubation stridor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">0.0001</span></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extubation failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">0.0023</span></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Persistent atelectasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">0.1797</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspected foreign body aspiration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">--- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Broncho-alveolar lavage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">--- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspected tracheo-esophageal fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">0</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">---</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3359372.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Correlation between airway endoscopy indications and endoscopic diagnosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post intubation Laryngeal injuries in a pediatric intensive care unit of tertiary hospital in India: a fibreoptic endoscopic study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B. 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