A comprehensive scoring system in correlation with perioperative airway management for neonatal Pierre Robin Sequence
December
A comprehensive scoring system in correlation with perioperative airway management for neonatal Pierre Robin Sequence
Ning Yin 0 1 2
Lei Fang 0 2
Xiaohua Shi 2
Hongqiang Huang 2
Li Zhang 2
0 School of Medicine, Southeast University , Nanjing , China , 4 Department of Anesthesiology, Nanjing Children's Hospital Affiliated to Nanjing Medical University , Nanjing , China
1 Department of Anesthesiology, Sir Run Run Hospital Affiliated to Nanjing Medical University , Nanjing , China , 2 Department of Anesthesiology, Zhongda Hospital Affiliated to Southeast University , Nanjing , China
2 Editor: Christos Papadelis, Boston Children's Hospital / Harvard Medical School , UNITED STATES
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Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: Our study was funded by the
departmental resource to the recipient Dr. Ning Yin.
This is a neutral fund that subtracts 2% of the
annual departmental income, in order to support
unbiased research cost. The funders and
organization had no role and no conflict of interest
in study design, data collection and analysis,
Purpose
To evaluate a comprehensive scoring system which combines clinical manifestations of
Pierre Robin Sequence (PRS) including severity of breathing difficulties, body weight and preoperative Cormack-Lehane grade, for its correlation with perioperative PRS airway management decision.
Design
Findings
Forty PRS children were retrospectively recruited after surgery. Specialists examined all
subjects and scored for clinical manifestations (1Â - 4Â), weight gain (1Â- 4Â), dyspnea scores
(1Â- 4Â), and Cormack-Lehane grade (1Â- 4Â). The correlation of the integrated scores and
the necessity of endotracheal intubation or laryngeal mask application were analyzed. In
addition, the score correlation with postoperative dyspnea and/or low pulse oxygen
saturation (SPO2) levels after extubation was determined.
In our study every individual patient had a score from 0Â to 16Â, while the higher in the num
bers represented higher risk of breathing difficulty. All patients with comprehensive scores
<10 points underwent endotracheal intubation successfully. Patients scoring 10±12 points
had an intubation success rate of 47%, whereas all patients scored >13 points required a
laryngeal mask assisted airway management and were considered to have difficult airways.
Dyspnea after extubation and postoperative low SPO2 occurred among patients who scored
over 10 points.
decision to publish, or preparation of this
manuscript.
Competing interests: The authors have declared
that no competing interests exist.
Conclusion
In PRS patients, preoperative weight gaining status and severity of dyspnea in combination
with Cormack-Lehane classification provide a scoring system that could help to optimize
airway management decisions such as endotracheal intubation or laryngeal mask airway
placement and has the potential to predict postoperative dyspnea or low SPO2 levels.
Introduction
The Pierre Robin Sequence (PRS) was first described in 1923, by a French stomatologist.
Infants with PRS are characterized by mandibular hypotrophy (micrognathia) and glossoptosis
(abnormal posterior placement of the tongue), which result in serious airway obstruction and
feeding difficulties. Other clinical features may also include a soft or high-arched cleft palate,
and a typical "bird face" appearance due to the shortened length of the lower jaw [
1, 2
]. This is
a neonatal disease with an occurrence around 1:8500 to 14,000 at births. It is estimated that
around 70% of PRS patient with mild airway obstruction could be successfully managed by
supine positioning. However, from moderate to severe PRS patients that fail to respond to
conservative treatment, additional interventions are necessary. In the most severe cases, a
tracheostomy may be ultimately necessary to establish an efficient and permanent airway. Tongue
posterior placement, which occurs due to mandibular dysplasia, cleft palate, and large size of
the tongue, prevents the infant from effective fetal swallowing [3]. Thus, PRS children often
show signs of feeding difficulties, such as extended feeding times, reduced nutritional uptake,
and even requirement of feeding by gavage (oral or nasal) [
4, 5
]. Eventually, PRS children may
develop poor nutritional status, inability of gaining weight, and slow growth.
PRS children require anesthesia for a variety of procedures, including tongue-lip adhesion,
distraction osteogenesis (DO) of the mandible, and even tracheostomy. These therapies will
help to alleviate the breath difficulty and delayed neurodevelopment caused by hypoxia from
upper respiratory tract obstructions [
6, 7
]. However, the clinical features of PRS challenge
both anesthesiologists and the surgeons due to the high risk of airway obstruction and difficult
intubation. The deformations may cause intraoperative and postoperative complications due
to PRS pati (...truncated)