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The surgical safety of paediatric patients can begin from the neonatal period, with collaborative work with paediatric and neonatal colleagues.  Neonatal intensive care made incredible strides throughout the 20th century, with huge increases in the survival of premature babies.  Evolving understanding and techniques to support and protect premature lung function were key to this.  This included intubation, ventilation and the administration of surfactant.  Prolonged ventilation with endotracheal tubes, often for several weeks or months had some unexpected consequences.  The subglottic airway, with its complete cartilaginous ring became prone to damage to its airway mucosa.  A combination of pressure from the tube, infection and the delicate nature of this tissue in neonates contributed to a number of these children developing scar tissue within the airway, particularly in the subglottis, with evolving stenosis.  They would often fail extubation with progressive respiratory deterioration and would often end up with a tracheostomy.  In the 1970s this was reaching a peak.   Many children would outgrow their chronic lung disease and oxygen dependence but be dependent on a tracheostomy due to the stenosis of their airway. 

There were innovative and creative solutions to this problem.  In the 1970s a British surgeon, Robin Cotton, was completing his ENT fellowship in Toronto and was increasingly interested in the problem of airway stenosis in ex-premature infants.  He developed laryngotracheal reconstruction.  This was a game changer for airway stenosis.  The operation involved splitting the airway which was stenosed above the level of the tracheostomy.  The novel solution to expand the airway was to use the infant鈥檚 own native rib cartilage which could be shaped and placed in the airway around a stent.  The stent could then be removed after several weeks, and an expanded airway would then allow removal of the tracheostomy in a life changing intervention for the child and family. 

The technique was popularized throughout the world in the 80s and 90s and evolutions occurred.  A 鈥渟ingle stage鈥� technique was pioneered, with the tracheostomy being removed at the time of reconstruction with rib graft, to be followed by a period of intubation on intensive care, and then extubation without the need for the tracheostomy. 

The next progression was the evolution of endoscopic management of airway stenosis.  With progression in the quality of endoscopes and endoscopic instruments it was identified that intervention at the early stage or even in more established stenosis could result in a wider airway.  This became a progressively more accepted technique for trying to widen the airway to prevent the need for tracheostomy, or as a technique to try and improve the airway so the tracheostomy could be removed.  Despite popularity, the evidence for this was lacking.  NICE commissioned the Airway Intervention Register, a prospective database to record the use of endoscopic balloon dilation in the treatment of airway stenosis.  I was one of the designers of this and was the clinical lead and chair.  We captured the largest prospective cohort of paediatric patients in the literature with this procedure and demonstrated that it was both a safe and effective treatment.  This evidence was part of the NICE intervention procedures guidance which resulted in the procedure being taken out of special arrangement and into the accepted standard of care for airway stenosis. 

While endoscopic and open techniques of airway reconstruction offer patients a way forward, increasing the safety of airway management in neonatal intensive care has resulted in a much-reduced incidence of airway damage.  Led by progressive interventions from the British Association of Perinatal Medicine and neonatal intensive care units around the UK, techniques have been put in place which result in shorter periods of intubation, and less harm when intubation is required.  Non-invasive ventilation with pressure and oxygen administered by masks as opposed to endotracheal tubes can support ventilation.  When surfactant needs to be administered it can be done via less invasive methods with a thin catheter which is temporarily placed in the airway, with no need in some cases for intubation.  If intubation is required, the standards around this are carefully monitored.   Neonatologists receive careful training and the appropriate level of intubator is available on units where this is required.  When an endotracheal tube is in place, careful monitoring and audit is in place.  This has resulted in less unplanned extubations, which are associated with higher rates of airway damage from emergency re-intubations. 

There is still an ongoing need for endoscopic airway and open airway management by ENT surgeons, but the efforts of the neonatal team at the initial stages of perinatal care are resulting in safer airway care for this vulnerable group of patients.