CLINICAL INVESTIGATION

Pre-Extubation Ultrasound Measurement of

In Situ Cuffed Endotracheal Tube Laryngeal Air
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Column Width Difference: Single-Center Pilot

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Study of Relationship With Post-Extubation

Stridor in Subjects Younger Than 5 Years Old
Luke Burton, MD1
OBJECTIVES: Post-extubation stridor (PES) is difficult to predict before extu- Jeremy Loberger, MD1
bation. We therefore evaluated the potential diagnostic performance of pre-
Mark Baker, MD2
extubation laryngeal air column width difference (LACWD) measurement, as
assessed by intensivist-performed point-of-care laryngeal ultrasound, in relation Priya Prabhakaran, MD1
to clinically important PES. Vidit Bhargava, MBBS, MD1
DESIGN: Prospective observational cohort study.
SETTING: Single quaternary care PICU (July 19, 2021, to October 31, 2022).
PATIENTS: Included subjects were younger than 5 years old, intubated with a
cuffed endotracheal tube, requiring invasive mechanical ventilation for greater
than 24 hours, and nearing extubation. Subjects at high risk for supraglottic airway
obstruction were excluded.
INTERVENTIONS: Laryngeal ultrasound with measurement of laryngeal air
column width with the endotracheal tube cuff inflated and deflated. Clinically
important PES was defined as a high-pitched inspiratory respiratory noise sus-
pected to be from a subglottic focus necessitating received medical intervention
or reintubation.
MEASUREMENTS AND MAIN RESULTS: Among 53 enrolled subjects, 18
of 53 (34%) experienced PES and three of 53 (6%) were reintubated because
of severe subglottic upper airway obstruction. Median LACWD was significantly
lower in the stridor group compared with the nonstridor group (∆ 0.41 mm; 95%
CI, 0.37–0.48; p < 0.001). The area under the receiver operating characteristic
curve for LACWD as a diagnosis of PES was 0.94 (95% CI, 0.89–1.00; p <
0.001). The LACWD cutoff for PES was less than or equal to 0.47 mm, which
yielded a diagnostic sensitivity of 91.4% and specificity of 88.9%. In this popu-
lation, the pre-to-post-test change in probability of PES for LACWD less than or
equal to 0.47 mm is 0.34 to 0.81.
CONCLUSIONS: Pre-extubation LACWD is a novel, noninvasive assessment
that can be performed and interpreted by the intensivist at the bedside. There
is, however, diagnostic uncertainty in the use of this measurement for identifying
those at-risk of PES and larger validation studies are needed.
KEYWORDS: airway obstruction; extubation failure; intensive care unit liberation;
pediatric critical care; point-of-care ultrasound
Copyright © 2023 by the Society of

P
Critical Care Medicine and the World
ediatric extubation failure is associated with increased duration of in- Federation of Pediatric Intensive and
vasive mechanical ventilation, ICU length of stay, and mortality (1, 2). Critical Care Societies
Upper airway obstruction (UAO) is the primary etiology of extubation DOI: 10.1097/PCC.0000000000003377

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RESEARCH IN CONTEXT
• Post-extubation stridor (PES) is a common and
significant problem in pediatrics.
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• Cuff leak testing lacks sensitivity and specificity
in pediatric patients for identification of potential
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development of PES. Laryngeal ultrasound is a
promising predictive tool.
• This clinical investigation evaluated the fea-
sibility and potential diagnostic performance
of intensivist-performed, laryngeal ultrasound
measurement of laryngeal air column width
difference (LACWD) in relation to subsequent
PES.
failure among children, causing 41–51% of pediatric
extubation failure in two single-center reports (3, 4).
Post-extubation UAO is difficult to predict as the prox-
imal airway cannot be reliably assessed before extuba-
tion with the endotracheal tube (ETT) in place (5, 6).
While UAO can occur along the entire airway axis, most
attention is focused on subglottic UAO, manifesting as
stridor because it is treatable before and after extubation
(7–9). Clinical assessment of the subglottic airway be-
fore extubation traditionally relies on the airway leak
test (ALT) which is neither sensitive (27–55%) nor spe-
cific (35–81%) for identifying post-extubation UAO in
pediatric patients (10). Treatment of patients at high risk
for subglottic UAO with glucocorticoids can decrease
post-extubation stridor (PES) (8, 9). At the same time,
the administration of glucocorticoids can be spared in
patients at low risk for developing PES. Therefore, there
is a need to develop and evaluate other bedside tests fo-
cusing on feasibility, reproducibility, and diagnostic ac-
curacy for this important outcome.
Laryngeal ultrasound can visualize the column of
air passing through the vocal cords. The width of this
column of air is referred to as laryngeal air column
width (LACW). This measurement has been studied
as a tool for identifying potential PES in adults. In a
2001–2002 pilot study of 51 adults, LACW meas-
ured with the ETT balloon cuff deflated had “poten-
tial ability to predict PES in intubated patients” (11).
Subsequent laryngeal ultrasound studies in adults
have demonstrated varying test characteristics in the
prediction of PES (12–15). In a PICU population, a
Pediatric Critical Care Medicine
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Clinical Investigation
2015–2017 study of 400 patients found that LACW dif-
ference (LACWD) had better sensitivity (93% vs. 61%)
and specificity (86% vs. 53%) than the ALT, regarding
identification of PES (16). LACWD was used instead
of the LACW measurement because the absolute value
of the air column width varies in children depending
on age and size. The LACWD measures the difference
between a patient’s LACW with the balloon cuff of the
ETT inflated and deflated and is comparable in chil-
dren, from patient to patient. In this study, we aimed to
evaluate the feasibility and the diagnostic performance
of LACWD measured by an intensivist using point-of-
care laryngeal ultrasound.
METHODS
Study Setting, Design, and Ethics
This prospective, observational cohort study was per-
formed in the PICU at a quaternary care children’s
hospital. The study, under the title “Laryngeal ultra-
sound and air column width as a predictor of post
extubation stridor,” was approved by the University of
Alabama at Birmingham Institutional Review Board
(IRB-300006847) on May 28, 2021. Informed consent
was obtained from legal guardians at the time of en-
rollment. All procedures were followed in accordance
with the ethical standards of the IRB on human exper-
imentation and with the Helsinki Declaration of 1975.
Between July 19, 2021, and October 31, 2022, we
screened for enrollment all patients in our PICU, every
day. Inclusion criteria were as follows: younger than 5
years old, invasive mechanical ventilation for greater
than or equal to 24 hours with a cuffed ETT, and eli-
gibility for spontaneous breathing trials based on the
institutional eligibility screen. We restricted the pop-
ulation to younger than 5 years old because this age
group is at greater risk of post-extubation UAO or
PES, and the LACWD ultrasound measurement is
only capable of evaluating the subglottic airway (3, 17).
Exclusion criteria included a predisposition to supra-
glottic airway obstruction (i.e., severe traumatic brain
injury, hypoxic-ischemic encephalopathy, craniofacial
syndromes, midface hypoplasia), known supraglottic
obstruction, surgical intervention to the airway dur-
ing admission, presence of an uncuffed ETT, and the
presence of a device obstructing laryngeal ultrasound
performance (e.g., cervical collar). The clinical team
was blinded to the results of the laryngeal ultrasound.
www.pccmjournal.org     223
 Burton et al
Laryngeal Ultrasound Procedure
The principal investigator (L.B.) performed all ultra-
sound studies. Having no previous training in diag-
nostic airway point-of-care ultrasound, the principal
investigator gained proficiency in performing laryn-
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geal ultrasound after completing and reviewing 25
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ultrasonographer within the division of pediatric
critical care (V.B.) over the course of 3 months. Each
image and measurement was compared with published
images and descriptions of LACW (11, 16).
The LACW represents the functional airway size de-
termined using ultrasound. It is the width of the air
column passing through the vocal cords. On an ul-
trasound image, it is depicted with a hyperechoic line
at the air-tissue interface with reverberation artifacts
beneath (Fig. 1). The air column appears rectangular
when the ETT cuff is inflated. The air column becomes
trapezoid in shape, and the width increases as it con-
forms to the subglottic area, which is the narrowest part
of the airway when the cuff is deflated. Laryngeal ultra-
sound was performed as originally described by Ding
et al (11). The scans were done within 6 hours before a
planned extubation attempt. Patients were positioned
supine with the neck in a neutral to a hyperextended
position. A high-frequency, linear ultrasound probe
was used with a laryngeal preset applied with 2.5 cm
of depth, optimal gain, and a frequency of 12 MHz.
The probe was placed over the cricothyroid membrane
in a transverse plane of cut to facilitate visualization
of the appropriate field of view. For quality control,
we ensured that the image included the vocal cords,
Figure 1. Ultrasound image at the level of cricoid cartilage (CC) showing (arrow) air column width. Note the rectangular shape of
air column (left) with cuff inflated and trapezoid shape (right) with cuff deflated. Probe placement is depicted in the center. A-M = air
mucosal interface, TG = thyroid gland.
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cricoid cartilage, and a clear air-mucosal interface. The
laryngeal air column was depicted as the width of air
passing through the vocal cords. Three separate clips of
the images in the appropriate field of view were saved
with the ETT balloon cuff inflated. The patients’ res-
piratory therapist (RT) then completely deflated the
balloon cuff. The same field of view was reimaged, and
three more clips were stored. LACW was measured
along the most superficial hyperechoic line depict-
ing the air-tissue interface, as described above, with
the ETT cuff inflated and deflated. The average of the
three measurements was taken. LACWD (LACWcuff
–LACWcuff inflated) was calculated. The LACWdeflated
deflated
is greater than LACWinflated since deflation of the cuff
creates a larger column of air through the vocal cords.
A smaller LACWD suggests airway narrowing, pre-
sumably from soft tissue edema, and a higher likeli-
hood of developing PES. While the cuff was deflated,
the RT performed an ALT by attaching a self-inflating
bag with a positive end-expiratory pressure valve to
the ETT and delivering a pressure of 25 cm H2O. The
neck was auscultated to evaluate for the presence or
absence of a leak. Based on auscultation, the result was
recorded as either leak present or leak absent. The RT
then reinflated the balloon cuff of the ETT to the pre-
vious level.
Extubation Timing and Post-Extubation Stridor
Definition
The timing of extubation was determined by the clin-
ical team, which was blinded to the results of the la-
ryngeal ultrasound. After extubation, the clinical team
March 2024 • Volume 25 • Number 3

evaluated subjects for the presence of stridor. The
principal investigator did not enroll or perform any ul-
trasound studies while serving in a clinical role to min-
imize conflict of interest. PES, for the purposes of this
study, was defined as a high-pitched inspiratory res-
piratory noise suspected to be from a subglottic focus
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and received medical intervention (i.e., racemic epi-
nephrine, glucocorticoids, or heliox). The study team
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had no role in determining the presence of stridor or
the need for intervention.
The following data were collected from the medical
record of each subject: age, height, weight, sex, primary
diagnosis, ETT size, length of invasive mechanical ven-
tilation for the screened ventilator encounter, neuro-
logic or pulmonary comorbidity, ETT cuff pressure, the
presence or absence of glucocorticoids administered in
the 24 hours before extubation, history of difficult in-
tubation, the laryngoscopic view grade as reported by
the clinician performing intubation, and the number
of intubation attempts. Neurologic and pulmonary co-
morbidity was defined as any coexisting, neurologic
or pulmonary condition not otherwise encompassed
by the primary admission diagnosis. ETT cuff pres-
sure was measured by the RT at the time of extubation
and reported as less than 20 mm Hg, 20–30 mm Hg, or
greater than 30 mm Hg.
Statistical Methods
The 2015–2017 PICU study of 400 patients found that
mean LACWD among those with stridor was 50%
smaller than patients without stridor (16). For a power
of 80% and α level of 0.05, a sample size of 17 patients
in each group, with and without stridor, would allow a
t-test to detect a difference of 25% of the mean LACWD
value between the two groups with an expected sd of
25% of the mean.
We report the mean observed to estimated ETT
inner diameter ratio in the results, a measure of appro-
priate ETT size selection. The predicted ETT inner di-
ameter was calculated using the equation: (age in yr/4)
+ 3.5 for cuffed ETTs. All results were rounded to the
nearest 0.5 mm inner diameter. For infants younger
than 6 months old, 3.0 mm was predicted, whereas
3.5 mm was predicted for infants 7–12 months old. The
ratio of actual to expected ETT size is reported.
Descriptive statistics included counts/percentages
for categorical variables, medians with interquartile
ranges (IQRs) for nonparametric continuous variables
Pediatric Critical Care Medicine
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Clinical Investigation
and means with sds for parametric continuous variables.
As appropriate, the stridor and nonstridor groups were
compared using the two-sample t tests, the Kruskal-
Wallis test, and chi-square tests. Correction was made
to the p value for multiple comparisons. The bivariate
Pearson’s correlation coefficient was used to evaluate
test-retest reliability between the repeated measures
of LACWD. In the “diagnostic test” evaluation, we
used receiver operating characteristic (ROC) curves to
evaluate the potential utility of LACWD in its identi-
fication of subsequent PES and extubation failure. A
cutoff for LACWD was determined with priority for a
balance between maximal sensitivity and specificity. A
STrengthening the Reporting of Observational Studies
in Epidemiology (STROBE) statement was completed
and can be found in the supplemental content (http://
links.lww.com/PCC/C436).
RESULTS
During the study period, our PICU had 588 patients
needing mechanical ventilation, with 199 patients eli-
gible for enrollment. Fifty-three patients were included
in the study (Fig. 2). The mean interval from laryngeal
ultrasound to extubation was 2.54 ± 1.97 hours. The
mean duration of the laryngeal ultrasonography scan
was 73 ± 14 seconds. Repeated measures of the LACWD
were correlated, reflecting acceptable test-retest relia-
bility (Pearson’s correlation coefficient 0.983; p = 0.01).
No patient decompensations, unplanned tube move-
ments, or extubations were associated with the study
protocol. None of the subjects received any additional
sedation for the laryngeal ultrasound. Additionally,
images of sufficient quality to measure LACW were
obtained in 100% of the subjects enrolled.
Descriptive statistics of the 53 patients are shown in
Table 1. On inspection of the data, PES was observed
in 18 of 53 patients (34%). Of note, median (IQR)
LACWD was lower in PES patients vs. those with
no stridor, even using the p value for multiple com-
parisons (p < 0.004) (PES, 0.37 mm [0.23–0.46 mm]
vs. no stridor, 0.78 mm [0.56–1.07 mm]; p < 0.001).
None of the other comparisons reached this level of
significance.
The ROC curve analysis evaluated the diagnostic
utility of LACWD as a potential identifier of subse-
quent PES (Fig. 3). It yielded an area under the ROC
curve (AUROC) of 0.94 (95% CI, 0.89–1.00; p < 0.001).
The AUROC-determined cutoff value for LACWD for
www.pccmjournal.org     225
 Burton et al

were three of 53 patients

(6%) with this outcome, or
pre-test probability of extu-
bation failure in our pop-
ulation was 0.06. Figure 3
shows the AUROC anal-
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ysis, with area 0.91 (95% CI,

0.81–1.00). The AUROC-
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determined diagnostic
cutoff value in LACWD
for extubation failure was
0.32 mm, which provides a
sensitivity of 88.0%, speci-
ficity of 66.7%, positive pre-
dictive value of 13.7%, and
negative predictive value of
98.9%. The pre-to-post-test
change in probability of
extubation failure is 0.06 to
0.14 for LACWD less than
or equal to 0.32 mm.

Figure 2. Consort diagram of enrollment.
diagnosis of was 0.47 mm, which provides a sensitivity
of 91.4%, specificity of 88.9%, positive predictive value
80.9%, and negative predictive value 95.4%. The sim-
ilar analysis for absence of leak on the ALT and PES
provides sensitivity 44.4% and specificity 77.1%, with
positive predictive value 50% and negative predictive
value 73%. In our population, the pre-test probability
of PES was 18 of 53, or 0.34. That is, the pre-to-post-
test change in probability of PES is 0.34 to 0.81 for
LACWD less than or equal to 0.47 mm, and 0.34 to
0.50 for absence of air leak on ALT.
Among the 53 cases in our study, with respect to the
AUROC-determined cutoff point for PES less than or
equal to 0.47 mm, LACWD was measured above the
cutoff in 34 patients and below in 19. Of the 34 patients
with LACWD above the cutoff, 2 (6%) had PES. Among
the 19 cases with LACWD measured below the cutoff,
16 (84%) had PES.
Extubation failure due to subglottic UAO was
evaluated as an exploratory outcome (Table 2). There
DISCUSSION
In this single-center pilot
study of pre-extubation ul-
trasound measurement of
in situ cuffed ETT LACWD
in subjects younger than 5 years old, we have two main
observations. First, point-of-care ultrasound assess-
ment of the larynx is feasible by PICU personnel after
a short period of training. Second, we have hypothesis-
generating data regarding the diagnostic utility of
AT THE BEDSIDE
• LACWD in pre-extubation subjects younger
than 5 years old is a skill that is feasible and
easy to learn with equipment already available
in most PICUs.
• As a potential pre-extubation diagnostic test of
subsequent PES, LACWD may be suited to as
part of a pre-extubation readiness testing bundle.
• Our hypothesis-generating data suggests that
a LACWD cutoff around 0.47 mm needs valida-
tion in other studies.

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 Clinical Investigation

TABLE 1.
Study Population Description by Variable
Variable Whole Cohort Stridor No Stridor

Subjects, n (%) 53 18 (34) 35 (66)

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Age (mo), median (IQR) 10 (1.9–3.5) 4.5 (1.4–17.3) 18 (4–34)

Weight (kg), median (IQR) 9 (4.7–12.4) 6.5 (4.5–10.1) 10.4 (5.1–14.2)
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Male sex (%) 33 (62) 9 (50) 24 (69)

Diagnosis category (%)
 Pulmonary 27 (51) 9 (50) 18 (52)
 Neurologic 11 (21) 6 (33) 5 (14)
 Airway 2 (4) 1 (6) 1 (3)
 Other 13 (24) 2 (11) 11 (31)
Length of ventilation (hr), median (IQR) 91 (54–168) 69.3 (38.8–115) 120 (65.5–172)
Mean observed: expected ETT inner diameter ± sd 1.04 ± 0.12 1.1 ± 0.14 1 ± 0.09
Neurologic comorbidity (%) 19 (36) 6 (33) 13 (37)
Pulmonary comorbidity (%) 31 (59) 11 (61) 20 (57)
ETT cuff pressure at scan time (%)
 Low 13 (25) 4 (22) 9 (27)
 Recommended 39 (75) 14 (78) 25 (73)
Steroids 24 hr pre-extubation (%) 32 (60) 13 (72) 19 (54)
Laryngeal air column width difference (mm), median (IQR) 0.37 (0.23–0.46) 0.78 (0.56–1.07)
Air leak (%)
 Present 10 (56) 27 (77)
 Absent 8 (44) 8 (23)

ETT = endotracheal tube, IQR = interquartile range.

LACWD in identifying subsequent risk of PES. Taken
together, these data may help to develop work toward a
pre-extubation bundle of assessment.
Laryngeal ultrasound is well-suited to pediatric
patients. The lack of maturity of thyroid, cricoid and
laryngeal cartilages, and bony structures, in addition
to the low depth of penetration required to visualize
airway structures allows easy acquisition of high-
resolution images. In our experience, the laryngeal
ultrasound skills involved in this study were readily
acquired over a three-week period of training. Our
patients younger than five years old tolerated the pro-
cedure without difficulty, the need for additional se-
dation, or adverse or unexpected events. However, the
upper limit of the 95% CI for no adverse events in 53
patients is 6%, and so such events should be expected
with wider experience. That said, the intensivist-
performed point-of-care diagnostic evaluation could
be performed very quickly and close to the time of
extubation. The measurement was also reproducible.
These features, if incorporated into a protocol for
extubation, would allow clinicians to make decisions
with the most current information at the bedside.
Furthermore, avoiding additional sedation also pro-
motes the possibility of timely extubation.
Our LACWD data are hypothesis-generating and so,
at this stage, are preliminary to diagnostic testing of po-
tential PES. For example, we measured LACWD in our
53 patients, then used an AUROC analysis to identify a
cutoff that was optimal for the diagnosis of subsequent
PES, or extubation failure. As expected, the LACWD
cutoff value yielded for extubation failure (0.32 mm)
was lower than the value for PES (0.47 mm). However,
we have not validated these cutoffs in a population sep-
arate to the one in which we have generated the cutoff.
Also, at present, all we have is the diagnostic uncertainty
evident in the change in pre-to-post-test probability of
PES (0.34–0.81), and of extubation failure (0.06–0.14),
and the question is whether such performance would
influence practice. Here, we should discuss the prior

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 Burton et al
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Figure 3. Receiver operating characteristic (ROC) curve. A, Laryngeal air column width difference (LACWD) as a predictor for post-
extubation stridor. B, LACWD as a predictor for extubation failure. AUROC = area under the receiver operating characteristic curve.
pediatric study of LACWD (16). Of note, this popula-
tion of 400 cases, 0–18 years old, included 400 patients
with a pre-test probability of PES 44 of 400 (0.11). The
authors’ hypothesis-generating data for the diagnosis of
PES identified a LACWD cutoff of 0.80 mm, which is
higher that the cutoff of 0.47 mm in our younger than
5-year-old population. Using this higher cutoff across
the whole pediatric age range, the change in pre-to-
post-test probability of PES (0.11–0.44) considerable di-
agnostic uncertainty is evident, which is no better than
tossing-a-coin. Taken together, there are two points
that will need to be clarified in future study: 1) what are
the normal expected measurements in LACWD by age
and 2) what degree of diagnostic certainty in change in
pre-to-post-test probability of PES at the time of extu-
bation would influence practitioners responsible for
decision-making.
In 2022, there were two key reports on pediatric ven-
tilation liberation (5, 18). The Pediatric Acute Lung
Injury and Sepsis Investigators (PALISI) network clin-
ical practice guideline (CPG) suggests “using the ALT,
in children with cuffed ETT, as part of the extubation
readiness bundle, to assess the risk for the development
of post-extubation UAO” (strength of recommenda-
tion, conditional; certainty of evidence, very low) (5).
However, there are concerns regarding the diagnostic
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accuracy and low sensitivity of the ALT in young chil-
dren. In our study, we did not quantify air leak as origi-
nally defined in 1996 (19); instead, we used a pragmatic
“yes or no” approach to applied pressure of 25 cm H2O,
which is also described in the PALISI network CPG (5).
Our pilot study in subjects younger than 5 years old
shows considerable diagnostic uncertainty of using ab-
sent air leak on ALT for subsequent development of PES;
the pre-to-post-test change in probability of PES is 0.34–
0.50, again no better than a coin-flip. Taking this infor-
mation together with our LACWD findings, we wonder
about an alternative approach to airway assessment at
the time of extubation. Perhaps a tiered approach could
be used in patient evaluation and intervention.
Recent evidence supports the early administration
of glucocorticoids to prevent post-extubation UAO
(8, 9). A pragmatic approach based on our results in
subjects younger than 5 years old could be, at the time
of extubation readiness, as follows. First, use laryngeal
ultrasound to measure LACWD. If the measurement
falls above the cutoff value reported above, then con-
sider that there is no utility in waiting for a cuff leak
before extubation or treating with steroids. However,
if the LACWD is below the threshold value, then this
finding could be indication for delaying extubation ir-
respective of the presence of air leak and administering
March 2024 • Volume 25 • Number 3

TABLE 2.
Description of Variables
Variable
n 3
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Age (mo), median (IQR)
Weight (kg), median (IQR)
ywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 04/12/2024
Male sex
Diagnosis category
 Pulmonary
 Neurologic
 Airway
 Other
Length of ventilation (hr), median (IQR)
Median observed: expected ETT inner diameter ± (sd)
Neurologic comorbidity
Pulmonary comorbidity
ETT cuff pressure at scan time
 Low
 Recommended
Steroids 24 hr before extubation
Laryngeal air column width difference (mm), median (IQR)
Air leak
 Present
 Absent
ETT = endotracheal tube, IQR = interquartile range.
glucocorticoids. However, these assumptions—not
least the threshold in LACWD—need testing in future
work.
There are limitations in our study. It was powered
for clinically significant UAO, but clinicians are not
consistent in making this diagnosis (3, 6, 20). Often,
obstruction is at multiple levels leading to serial airway
resistance, which added together increases overall re-
sistance and increased risk of extubation failure (3).
Therefore, a more clinically relevant outcome is extu-
bation failure due to subglottic UAO, which is a rare
event and our study was underpowered for this out-
come. The ability to predict who will require reintu-
bation due to subglottic UAO is a research priority in
pediatric ventilation liberation (5). Regarding poten-
tial limits to the laryngeal ultrasound measurement,
the difference in LACWD between the groups with and
without PES is of the order of the axial resolution of the
12 MHz ultrasound transducer (0.06 mm). However,
Pediatric Critical Care Medicine
Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Clinical Investigation
Extubation Failure Extubation Success
50
2 (0.9–3) 13 (1.9–31.3)
4.7 (3.8–4.9) 9.3 (5–12.5)
2 31
2 25
1 10
0 2
0 13
73 (54–79) 100.5 (52.3–169)
1.2 (1–1.2) 1 (1–1.2)
1 18
3 28
1 12
2 37
3 29
0.30 (0.1–0.37) 0.6 (0.45–0.94)
1 36
2 14
this technical limitation can induce unwanted errors,
but we mitigated against this potential problem by tak-
ing three measurements and demonstrating that there
was excellent test-retest reliability in LACW measure-
ment. Other limitations are the single-center design
and the lack of inter-rater reliability due to a single
ultrasonographer. Additionally, this test is only valid
for subjects with cuffed ETT as the LACWD value
relies on inflated and deflated LACW measurements.
In conclusion, measurement of LACWD in patients
being considered for extubation is a novel, feasible point-
of-care laryngeal ultrasound technique that can be learned
and applied by PICU practitioners. However, there re-
mains diagnostic uncertainty in the utility of LACWD as a
test of PES. Therefore, future multicenter studies will need
to focus on: 1) investigation of normal LACWD meas-
urement by age; 2) diagnostic utility of LACWD below
threshold in relation to PES and/or to subglottic UAO-
mediated extubation failure; and 3) a tiered approach to
www.pccmjournal.org     229
 Burton et al
extubation readiness including ALT, LACWD measure-
ment, and intervention with glucocorticoids.
ACKNOWLEDGMENTS
We thank Dr. James Odum, MD for article review and
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suggestions during the revision process. We also ac-
knowledge and thank the Respiratory Therapists in the
ywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 04/12/2024
PICU at Children’s of Alabama for their assistance with
and enthusiasm for the study protocol. We also appre-
ciate the trust and willing participation of the subjects
and their families in this study.
1 Department of Pediatrics, Division of Critical Care Medicine,
University of Alabama at Birmingham, Birmingham, AL.
2 Department of Pediatrics, Division of Emergency Medicine,
University of Alabama at Birmingham, Birmingham, AL.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s website
(http://journals.lww.com/pccmjournal).
All authors participated in study design, drafting, and revision of
the article.
The authors have disclosed that they do not have any potential
conflicts of interest.
For information regarding this article, E-mail: wlburton@uabmc.
edu
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March 2024 • Volume 25 • Number 3