(A938) Operative Airway Evaluation for Chronically Intubated Infants with Extubation Failures Associated with High Downsizing Rates

Introduction: Chronic respiratory failure in infants often necessitates long-term intubation in which endotracheal sizes are guided by the Neonatal Resuscitation Program (NRP). Large tube sizes may predispose the airway to iatrogenic laryngotracheal injury and extubation failure. Our objective is to characterize laryngeal findings for infants with prolonged intubation undergoing operative airway evaluation.

Methods: Retrospective review at a tertiary level children’s hospital of intubated infants 6 months and younger undergoing airway endoscopy (DLB) from November 2021 to December 2024.

Results: 55 patients (51% male, median age 3.3 months [IQR 1.5 - 4.3] at time of surgery) met inclusion criteria. The majority were born prematurely (67%) at mean gestational age 31 weeks and had bronchopulmonary dysplasia (55%). Mean duration of intubation was 63 + 54 days. In patients with 3.0 and 3.5mm endotracheal tubes (ETT), prevalence of subglottic stenosis was high and did not differ (59% vs. 56%, respectively, p=0.81). In patients >2kg, 56% of patients with 3.5 ETT required downsizing to size 3.0 compared to 12% of patients with 3.0 ETT (p < 0.01) due to operative findings. After downsizing, 67% of patients achieved extubation.

Conclusions: Subglottic stenosis is prevalent in young infants requiring long-term intubation for chronic respiratory failure. In patients >2kg, endotracheal tube sizes 0.5mm smaller than NRP recommendations are associated with fewer ETT downsizing events and may be more suitable for long-term ventilation needs in infants younger than 6 months of age.