Emanuele Rossetti Alessandro Germani Alfredo Onofri Sergio Bottero Non-invasive ventilation with balloon dilatation of severe subglottic stenosis in a 10-month infant Accepted: 10 October 2010 Published online: 11 November 2010 Ó Copyright jointly held by Springer and ESICM 2010 Dear Editors, We report the case of a 10-month infant who underwent II–III liver lobe split orthotopic transplantation (OLT), with congenital biliary atresia and Kasai portoenterostomy on his 75th day of life. In the following 10 pediatric intensive care unit (PICU) post- orthotopic liver transplantation (OLT) days, he was still intubated (diameter 4,5 cuffed tube) and showed conges- tive pulmonary oedema, severe malnutrition, hypotonic status and a large abdomen hosting the graft, leading us to assess the diuretic therapy, early parenteral nutrition and enteral feeding. On the 11th and 13th days, we extubated him twice unsuccessfully: on both occasions, he rapidly started wheezing and devel- oped hypercapnic respiratory failure, necessitating re-intubation. Fiber optic laryngoscopy (FOL) was deci- ded upon, revealing a Myer–Cotton I subglottic stenosis (SGSI) (Fig. 1) [1]. The patient was once again ex- tubated, and treatment consisting of non-invasive mask pressure support ventilation (NIV), corticosteroids and vasoconstrictors aerosol, endovenous corticosteroids and respiratory physiokinesis was initiated. One week later he was breathing spontaneously without respiratory efforts and com- plete enteral feeding; he was discharged to the ward on the 20th postoperative day. Unfortunately, a sudden intestinal occlusion occurred on the 24th post- operative day, and he underwent laparotomy: he was intubated using a smaller (diameter 3.5 mm), uncuffed tube that was removed after 18 h in the PICU. The patient was moved to the ward 4 days later. In the follow- ing 3 days expiratory efforts, tirage, wheezing and hypercapnic acidosis reappeared gradually, leading us to perform an emergency intubation with a 2,5-mm uncuffed tube through an evident very narrow SGSIII \ 1.0 cm of thickness (Fig. 1). He was admitted once again to the PICU and 12 h later we dilated the SGSIII using a progressive wider tube intu- bation from 2.5 to 4.0 of diameter. After 48 h of deep sedation to pre- vent vertical up-and-down movements of the tube through the lesion, the SGSIII was successfully treated by balloon dilation (BD) in the PICU [2]. With oxygen delivered by assisted mask ventilation (AV), a 7.0-mm angioplasty balloon catheter was inserted into the SGSIII under direct FOL; this was inflated with a pressure of 7 atm by using a 60-ml syringe with an attached pressure gauge until the patient’s SpO 2 dropped to 90%, at which point the airway was reassessed using AV. During the following 5 days, NIV and medical therapy resulted in complete respiratory com- fort, improved nutritional status and discharge of the patient to the ward. In selected SGS, NIV may repre- sent a valuable tool to treat obstructive symptoms, improving the breathing pattern and reducing respi- ratory efforts in younger infants with severe upper airway obstruction [3, 4]. In our case, BD allowed controlled radial dilation with a minimal muco- sal trauma, breaking the fibrin bridges inside the lesion and establishing a clear alternative to open surgery with acquired SGS in this infant. Our clinical practice did not pro- long the infant’s length of stay in the PICU. Furthermore, according to the higher incidence of nosocomial pneumonia in tracheostomized patients and increased ward mortality in adult patients discharged from the ICU with tracheostomy [5], our approach may help avoid more potential complications in our pedi- atric patients. Studies in children are not yet available. Fig. 1 Grade of Myer-Cotton subglottic stenosis Intensive Care Med (2011) 37:364–365 DOI 10.1007/s00134-010-2069-0 CORRESPONDENCE