Risk factors for perioperative respiratory failure following Mandibular Distraction Osteogenesis (MDO) for micrognathia: A retrospective cohort study
Rosaline Zhang, Lawrence Lin, Ian Hoppe, Scott Bartlett, Jesse Taylor, Kate Magoon, Jordan Swanson.
Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
BACKGROUND: The frequency of respiratory events in the perioperative period, and optimal duration of intubation during early mandibular distraction osteogenesis (MDO) activation, are poorly understood. This study assesses potential risk factors associated with perioperative respiratory events, particularly the need for reintubation, following MDO surgery. METHODS: A retrospective review was conducted for infants (less than 1 year of age) undergoing MDO for tongue-based airway obstruction between November 2010 and December 2017. Univariate and multivariate analysis of sentinel events and outcomes was performed. RESULTS: Ninety infants (median age 35 days) were included in the study (50% syndromic, 52% male). 27 subjects (30%) experienced a respiratory event requiring intervention prior to discharge, including 14 subjects who failed initial extubation. 33% of subjects extubated earlier than post-operative day 5 (POD5) failed extubation, compared to 9% of subjects extubated on POD5 or later (p=0.005). Respiratory events occurred more frequently when extubation was attempted at distraction lengths of 5mm or less (42%,16/38) compared to >5mm (21%,11/52; p=0.032.) Logistic regression modeling showed that syndromic status (odds ratio, OR 14.8) and secondary airway anomaly (OR 6.1) were significant predictors for respiratory events, while greater length of distraction at time of extubation was protective (OR 0.8) (p<0.05). A subset of the cohort (32 subjects successfully extubated, 6 subjects failing initial extubation) had pre-operative and pre-extubation lateral radiographs of sufficient quality allowing measurement of narrowest airway diameter with fidelity. Pre-operatively, there was no significant difference between the two groups in airway diameter (successful 3±3mm vs failed 2mm+3mm, p=0.849). However, there was a significant difference between the two groups with regards to both pre-extubation airway diameter (successful 9±2mm vs failed 4±3mm, p=0.002) and change in airway diameter from pre-operative (successful 6±3mm vs failed 2±2mm p=0.005).
CONCLUSIONS: Post-operative intubation of at least 5 days, with associated mean distraction of 5mm appears to be associated with successful extubation trial following MDO surgery. Patients with congenital syndromes and secondary airway anomalies are more likely to experience perioperative respiratory events, and this group of patients merits increased attention at extubation.
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