Pediatric Otolaryngologist Prematurely Removes Ventilator Support

This case involves a six-month-old infant who was diagnosed with group B strep meningitis. Due to respiratory distress, the patient required intubation and a tracheotomy. For several months, the patient received constant nursing home care while a ventilator assisted his breathing. The patient underwent a direct laryngoscopy, bronchoscopy, and balloon dilation to correct subglottic stenosis. Immediately after surgery, the patient was quickly weaned off of the ventilator after depending on the machine for an extended period of time. The patient was discharged the same day as the surgery to a pediatric long-term care facility. Upon arrival, his mother noticed that he was having significant trouble breathing. The child was rushed back to the emergency room and was intubated. The patient died three days later due to cardiac and respiratory arrest.

Question(s) For Expert Witness

1. Is there any way to prevent subglottic stenosis from developing?

Expert Witness Response E-000660

Acquired subglottic stenosis (SGS) is often caused by endotracheal intubation. Mechanical trauma from an endotracheal tube, as it passes through or remains for long periods in the narrowed neonatal airway, can lead to mucosal edema and hyperemia. These conditions then can progress to pressure necrosis of the mucosa. These changes have been reported in the literature to occur within a few hours of intubation and may progress to expose the perichondrium of the cricoid cartilage. Infection of the perichondrium can result in a subglottic scar, which can be hastened if an oversized endotracheal tube is used. It is important to always check for an air leak after placing an endotracheal tube because of the risk of necrosis of the mucosa, which can occur even in short surgical procedures.