that many publication records as much as them, but I will try my best. So my disclosures, the guidelines were supported by the NIH and also by Indiana University. Today I will talk about why about abstraction is important and then how we can predict it and how we can prevent it and a little bit about treatment. So let's take a case. You have a four-year-old patient that is recovering from septic shock, unlawful in sitting, passed SPT. The RT comes and says that the leak pressure is 30. Would you consider this patient a high risk for upper airway obstruction and would you give this patient steroids? So why we care about upper airway obstruction in pediatric population? This study is done in 2003. We need to replicate it, but it looks at extubation failure. Why pediatric patient fail extubation? As you can see, the most common reason for extubation failure is upper airway obstruction and it is associated also with long, other than the short-term morbidities or mortality, it's also associated with long-term morbidities. As you can see, they are 14% acquired tracheostomy. It's very important when we talk about upper airway obstruction to recognize the two areas that patient can have upper airway obstruction. You can have the subraglottic and you can have the subglottic. Why is that important? Robby is not here, but there's a lot of studies that made it in the recommendation from Robby's work and the CHLA group work. As you can see, who we call upper airway obstruction, they may be 50 and 50. They can have subraglottic versus subglottic. If you look in the right side, the patients with subglottic upper airway obstruction, they have higher morbidities. They require a lot of treatments and their extubation failure is about 23%. Compare them to patients with a subraglottic upper air obstruction. These patients actually don't require as much treatments and their extubation failure is about half. The guidelines came out with recommendation regarding how we predict and how we treat upper airway obstruction and this is a nice graph for the bundle itself. It starts with identification of patients that they might require steroids before extubation and I will come to this later in the slides. The first question is what's the utility of using a leak pressure in predicting upper airway obstruction? With this, we came with a recommendation that for patients with cuffed endotracheal tube, we suggest using leak pressure to predict upper airway obstruction. Now for uncuffed tube, the performance of the test is not great and we need to have an alternative method to predict upper airway obstruction. For the recommendation, we use eight observational studies and the summary of the evidence is look at extubation failure versus upper airway obstruction using uncuffed versus cuffed tube. As you can see, the performance of the test do much better, especially predicting upper airway obstruction in cuffed ET tubes. Now how we practice? The international, again, you know, survey showed that most of us will check a leak pressure but interestingly we don't differentiate between cuffed and uncuffed tube. Most people just check it and deal with it the same way. Now do we have a better way? If we say that the leak pressure doesn't perform great predicting extubation failure, especially for uncuffed tubes, there is more people are using BOCUS to look for risk for both extubation slider or upper airway obstruction and also extubation failure. And you can see it from the area under the curve, actually they perform quite well, 94 and 91 percent. When I talk about upper airway obstruction, you know, this is outside the guidelines, but I like to think about prevention of upper airway obstruction starting even earlier. When you try to intubate a patient, what size ET tube do you use? How many attempts do you use? So I think if you are part of the Near 4 Kids, this is a great initiative, but if you are not, maybe you should join. And during the invasive mechanical ventilation course, how do you manage the cuffed tube? You don't want to cause secondary injury. The same thing also from the abandon guideline, make sure the patient has appropriate sedation deleter management so you don't have a patient that is agitated and keep irritating the subglottic area. Now we'll come to the steroids question, but before to come to that, we classify also patients with risk for upper airway obstruction to high and standard, because leak pressure is maybe one thing, but there's other factors that can put a patient in a higher risk for upper airway obstruction, mainly if a patient had multiple intubation attempts or traumatic intubation or if somebody used a large size tube and caused injury. Now regarding steroids, the recommendation suggests using corticosteroids at least six hours before extubation for patients at higher risk for upper airway obstruction. This came from analysis of eight RCTs. These RCTs had about 900 patients and all of these articles used dexamethasone. So there will be a question, what about methylbenzalone and other steroids, but most of these articles use dexamethasone. If you look at the meta-analysis for reintubation, dexamethasone is better, but you can see that it crossed one here, but for upper airway obstruction actually it favors steroids and it doesn't cross one, so it performs very well. So after that we did the network meta-analysis, because the question is if I'm using steroid, how much steroid I will use and how early. So if you can see here on the right side, this network meta-analysis result, high early rank first and it comes after that low early, but if you are trying to use a steroid less than six hours, use a high dose, which is at least 0.5 milligram per kilo per dose. So you saw that multiple of the analysis says that the test and the steroids, they do better with preventing and predicting upper airway obstruction, but not extubation failure. And we need to understand that extubation failure is multifactorial. It's imbalance between respiratory load and respiratory capacity, and many of our patients will fail extubation for multiple reasons. Going back to the great work from Rob Bekemani, and you know looking at a fraction of re-intubation, look at patients with no subglottic upper airway obstruction. Patients who are weak, who has PI max less than 30, they have a higher extubation failure. Now look at the right side, patients with subglottic upper airway obstruction, if they are weak, there is about 5.6 times risk for them to have extubation failure. So it's not just a leak pressure to predict extubation failure, there is other factors, and that's why when we talk in the guideline about the bundle, is different factors can affect your extubation failure risk. Now you know the guideline came with this bundle, and the bundle not only include evaluation of upper airway obstruction and giving steroids, screening for ART, and how long do you do the ART, and if you pass the ART, what do you extubate the patient to? Do you extubate them to conventional oxygen therapy or to some forms of non-invasive respiratory support? And for steroids, it's come first. When you think that you want to extubate a patient 12 to 24 hours, you need to assess them, are they at risk for upper airway obstruction, and you need to introduce the steroids early to prevent upper airway obstruction. Now treatment for upper airway obstruction or stridor, we didn't discuss it too much in the guidelines, but it's another mess that we need to handle as a community because there is variation. When you think about a patient that develop upper airway obstruction, you give them some form of steroids or racemic AP, then you support them with Heliox, high flow, non-invasive respiratory support, but we don't have a standardization of how we do it. This is how we did it in one of the studies, but there is no standardization in the management for upper airway obstruction. I think one thing that also came from CHLA group that we need to differentiate the supraglottic versus subglottic, and it can be easy to identify by doing a jaw thrust maneuver. So you don't need to give steroids for patients that just have a flabby airway because they have traumatic brain injury. You might need to give them some other stuff with manipulation of their airway or you need to give them some non-invasive respiratory support to overcome the upper airway obstruction. With that, I will finish my presentation and hopefully I convinced you that upper airway obstruction is very important in pediatrics, and hopefully you start to timely identify patients with upper airway obstruction and give them steroids in an appropriate fashion too. Thank you very much.

upper airway obstruction

pediatric extubation failure

leak pressure

dexamethasone

preventive measures