Post-Extubation Laryngitis (PEL), or post-intubation laryngitis, consists of an inflammation of the larynx caused by an endotracheal tube and noticeably diagnosed after its removal. It’s a potentially severe complication of endotracheal intubation with variable incidence, between 2.4% and 40%, depending on the studied population and criteria established.1–4 Damage to the columnar pseudostratified epithelium begins soon after intubation and can result in injuries of varying severity.5 Severe cases can culminate in extubation failures, in which reintubation increases morbidity and mortality.6

Survival rates in Pediatric Intensive Care Units (PICUs) have increased dramatically in recent decades and the advance of pediatric airway management seems to be a contributing factor. Endotracheal intubation is widely used in increasingly younger, premature, and low birth weight patients.7 While intubation is necessary, it may lead to temporary or permanent airway damage, such as laryngeal edema, granulation tissue formation, vocal fold paralysis, Subglottic Stenosis (SGS), glottic or tracheal stenosis.8

In 1969, Lindholm correlated endotracheal intubation with laryngeal and tracheal injuries, proposing that the inadequate size of the endotracheal tube was the main factor for developing subsequent glottic lesions.9,10 Studies indicate that the main risk factors include intubation lasting over 24 h, an inappropriate size of the endotracheal tube, traumatic intubation often performed by unqualified professionals or those in training, the need for reintubation or tube exchange, and concurrent respiratory tract infections.7,11

Post-extubation laryngitis impacts respiratory outcomes, which can range from a self-limited condition without sequelae to severe airway involvement leading to morbidities. The need for a tracheostomy potentially impairs an individual's quality of life and may lead to rehospitalizations.7

Upon clinical suspicion, the diagnosis requires endoscopic confirmation. Flexible bedside Nasopharyngolaryngoscopy (NPL) is the initial exam due to low cost and risk and good diagnostic accuracy.12 Microlaryngoscopy and Bronchoscopy (MLB) under general anesthesia can also be performed with a more accurate evaluation of the posterior glottis, subglottis and trachea, allowing for therapeutic procedures simultaneously.13

Exam findings can be analyzed using internationally validated classifications to define the degree of airway involvement and estimate the prognosis and respiratory outcome.8,9,13,14

Understanding these patients' epidemiological conditions and clinical variables contributes to more effective strategies to prevent and treat acquired laryngeal lesions.2,7,10,11,15

A care flow of patients by the pediatric otolaryngology team within the PICU at the Hospital de Clínicas affiliated with the Universidade Estadual de Campinas (HC Unicamp) has been established in the past seven years. Since early 2020, all attended cases have been documented and recorded in a specific spreadsheet with data relating to patients' characteristics, underlying pathologies, endoscopic findings, and treatments instituted.

This study aims to describe the occurrence of endoscopically confirmed PEL in children who presented symptoms after extubation and/or extubation failure in a tertiary public university hospital, analyze its one-year evolution, and correlate laryngeal lesions with clinical outcomes.

This study included 38 endoscopically confirmed PEL cases (NPL and/or MLB) over 2 years. Sixty-six requests for otolaryngology evaluation in children with post-extubation stridor, dysphonia, and/or extubation failure were reviewed. Fifteen had previous intubation history, and seven lacked endoscopic assessment (Fig. 1). Among 44 with suspected PEL who underwent NPL/MLB without prior intubation, 38 were confirmed PEL and included for analysis.

Figure 1.

Summary of case selection, endoscopic evaluation performed, severity classification and need for tracheostomy. *Three patients classified as mild PEL by NPL showed normal MLB. ETI, Endotracheal Intubation; MLB, Microlaryngoscopy and Bronchoscopy; TRACH, Tracheostomy; SGS, Subglottic Stenosis; NPL, Nasopharyngolaryngoscopy; DX, Diagnosis; EVAL, Evaluation; HC, Hospital de Clínicas; PEL, Post-Extubation Laryngitis.

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Acute respiratory failure was the primary indication for intubation in 68.4% of cases, followed by neurological causes (23.7%) and intubation for procedure/surgery/transport (7.9%). Males were majority (60.5%), and comorbidities were present in 42.1% of cases.

The mean age of the patients was 13.24 months (median = 6, Standard Deviation [SD = 23.27]), with ages ranging from 1 to 115 months. The mean duration until the first extubation was 6.32 days (median = 5, SD = 8.22), ranging from 0 to 47 days. Patients remained intubated for a mean total duration of 18.68 days (median = 12, SD = 18.54), ranging from 1 to 84 days. The mean number of extubation failures was 1.37 (median = 1, SD = 1.17), ranging from 0 to 4 failures. Finally, the mean length of hospital stay was 57.71 days (median = 35, SD = 90.82), ranging from 8 to 565 days. Overall, while average ventilation durations and hospital stays were under three weeks, there was wide variability across patients, with some remaining intubated for up to 12 weeks and hospitalized for over 1.5 years.

Among clinically suspected cases, the occurrence of confirmed post-extubation laryngitis was 86.4% (38/44). Before evaluation by the otolaryngology airway team, clinical interventions by the PICU staff included: proton pump inhibitors, intravenous corticosteroids, inhaled epinephrine, and/or non-invasive ventilation as indicated.

The present study revealed a high occurrence (86.4%) of confirmed PEL among PICU patients with clinical suspicion. Although respiratory symptoms are paramount in practice to raise suspicion, endoscopic confirmation is more specific, particularly in moderate to severe cases, as other authors show.19 Proper management of these cases under MLB can mitigate morbidity from acute and chronic laryngeal injuries after extubation.9,20–23 Also, continuous follow-up has proven essential, as seen by the need for further MLBs and even treatment of ongoing laryngeal stenosis in cases of PEL, even those considered mild, as described in one of the described cases.

Acute respiratory failure accounted for 68.4% (n = 26) of cases as the primary cause of orotracheal intubation. Jorgensen et al. reported a 40% prevalence of airway complications after extubation in children with acute bronchiolitis.2 As a common PICU admission reason requiring invasive ventilation, acute respiratory failure results from lung parenchyma diseases, airway obstruction, or neuromuscular dysfunction.24 Respiratory tract infection during intubation may raise the risk for PEL.11 Careful endotracheal intubation and extubation of children with known airway inflammation may reduce PEL.12,25

Patients with comorbidities exhibited more severe laryngeal injuries after extubation, higher tracheostomy need, and lower 12-month resolution compared to previously healthy individuals. Comorbidities are particularly relevant when it comes to airway healing and inflammation. Experienced airway surgeons have recognized this and have even been included in a modified classification of laryngeal stenosis, given its impact on surgical outcomes and prognosis.26

Although nasopharyngolaryngoscopy in the PICU may lack accuracy, needing additional MLBs,13 in the current study, NPL sufficiently served as the initial examination, avoiding diagnostic laryngoscopy in 13 (34.21%) mild cases. Otolaryngologists working in the PICU should be trained to perform these first-line examinations and indicate the need for further MLB, depending on the progression of symptoms or inconclusive findings on NPL.

Brazil has 51 university hospitals but only nine pediatric otolaryngology specialty training programs. Those are located in the country's southern, southeastern, and central-western regions and offer 1–3 positions per academic year.27,28 Airway management experience is still critical, particularly knowledge of other contributing factors to airway dynamics and airway healing in small children. Identifying and treating acute laryngeal lesions due to PEL and tracheostomy indications differ enormously from those for adult patients. This should be addressed in the training of pediatric otolaryngologists.29

Over half (65.79%) of patients developing PEL required at least one MLB. This substantial demand justifies the reformulation of logistics to establish dedicated specialized airway teams and operating room availability for these patients.

Laryngeal injury severity correlates with adverse outcomes in post-extubation laryngitis.8 Our findings align with the literature, showing moderate/severe cases are associated with more tracheostomies, endoscopic procedures, extubation failures, and subglottic stenosis. This is helpful information when addressing parental and PICU staff expectations.

Laryngeal stenosis occurred in 21% of cases with PEL. A prior study showed a 29.8% stenosis rate in patients with laryngeal findings after intubation.30 Other descriptions of these rates typically include all admissions or all intubated patients, not discriminating the cases with PEL.

The high tracheostomy rate (36.84%) most probably reflects the degree of laryngeal injury and the patient’s general condition severity. Although tracheostomies were associated with worse outcomes, these patients were also the most severe cases of PEL with the most comorbidities and pre-tracheostomy procedures; this data may be biased.

Prolonged hospitalization increases healthcare costs, making managing this condition essential for cost reduction.31,32 Determining if earlier tracheostomies could abbreviate hospitalizations remains unanswered, given the multifactorial nature of indication of ventilatory support needs and development of acute laryngeal lesions. Nevertheless, tracheostomies also represent additional airway damage and morbidity.33,34 Thus, our airway team advocates airway evaluation and case-to-case discussion before deciding whether to perform a tracheostomy.

A multidisciplinary approach is essential in PEL management, as endorsed by a recent expert-bases opinion on PEL diagnosis/treatment in Brazil.17 However, many PICUs lack multidisciplinary teams or protocols for pediatric airway management, leading to suboptimal care for Post-Extubation Laryngitis (PEL). This results in failures to diagnose at-risk children or identify those who may develop airway obstruction post-discharge.

There is also an insufficient understanding of PEL pathophysiology and evolution into untreated airway obstruction even weeks after intubation.26 Not recognizing PEL symptoms and progression leads to discharging stridorous patients without follow-up. Unfortunately, these patients often return to emergency services weeks later in respiratory distress with established laryngeal stenosis, now facing risks of difficult intubation.

One-third of children awaited definite diagnoses or surgeries after hospital discharge due to long waiting lists for procedures requiring general anesthesia. Strategies to reduce these waiting lists are needed, although patients' comorbidities may also limit definitive treatment and decannulation.

Limitations include the retrospective nature of this study. Also, the small sample size and 23.68% loss to follow-up limit outcome assessment. Prospective studies and better strategies to track discharged PICU patients could help understand post-intubation needs and burdens. This includes monitoring possible ongoing laryngeal stenosis after PEL, not just in tracheostomy patients but also to allow better follow-ups for all.

We emphasize the importance of implementing otolaryngological evaluation and follow-up protocols and expanding access to therapeutic resources required to manage these children adequately.

Post-extubation laryngitis is commonly confirmed upon suspicion. The severity of laryngeal lesions was linked to poorer one-year outcomes. Although NPL is a useful diagnostic tool, the need for examination under general anesthesia through MLB is high. A third of patients needed a tracheostomy and a fifth developed laryngeal stenosis. Otolaryngological evaluation, follow-up, and therapy access are crucial for managing intubation sequelae in children.

The authors have no funding or financial relationships.

The authors declare no conflicts of interest.