Expert opinion on factors associated with severe laryngeal injury after intubation in the pediatric population: a worldwide survey study

Purpose: To minimize post-intubation laryngeal injury it is important to identify the factors that contribute to the development of these lesions. Previous literature has been inconsistent. This survey aims to investigate experts’ opinions on the various factors associated with severe laryngeal injury following intubation in the pediatric population and to determine whether these opinions influence the treatment of patients with one or more of these factors. Methods: A multiple-choice questionnaire with the possibility to provide open text answers was developed and sent by email, WhatsApp and Siilo to members of the scientific societies of anesthesiology, pediatric intensive care, emergency medicine and ear nose throat surgeons worldwide. Responses were analyzed thematically. Results: A total of 363 physicians worldwide responded to the survey, mainly anesthesiologists (31%), intensivists (35%) and ENT surgeons (29%). The majority of the respondents (69%) had over 10 years of experience in pediatric airway management. Overall, factors with the highest agreement (> 80% of respondents) were ‘traumatic intubation’, ‘multiple intubation attempts’, ‘the use of oversized tubes’, ‘skill level of the intubator’, ‘repeated intubations’ and ‘period of intubation’, specifically in small (weight < 2 kg, age < 1 year) children. The factors ‘use of muscle relaxants’ and ‘biological sex’ were not considered relevant. In accordance with their daily practice, physicians from different specialties reported varying factors as being relevant. These assumptions influence their routine decisions regarding intubation and extubation procedures. Conclusions: Although not extensively supported by literature, the majority of the experts indicate that factors such as ‘traumatic intubation’, ‘multiple intubation attempts’, ‘oversized tubes’, ‘skill level of the intubator’, ‘repeated intubations’ and ‘period of intubation’ are the most relevant factors in the development of post-intubation severe laryngeal injury in the pediatric population. Physicians from different specialisms also highlight specialism specific factors they consider most significant which influence their day-to-day clinical practice.