Airway Anatomy Research Articles

DeepCOVIDNet-CXR: deep learning strategies for identifying COVID-19 on enhanced chest X-rays.

COVID-19 is one of the recent major epidemics, which accelerates its mortality and prevalence worldwide. Most literature on chest X-ray-based COVID-19 analysis has focused on multi-case classification (COVID-19, pneumonia, and normal) by the advantages of Deep Learning. However, the limited number of chest X-rays with COVID-19 is a prominent deficiency for clinical relevance. This study aims at evaluating COVID-19 identification performances using adaptive histogram equalization (AHE) to feed the ConvNet architectures with reliable lung anatomy of airways. We experimented with balanced small- and large-scale COVID-19 databases using left lung, right lung, and complete chest X-rays with various AHE parameters. On multiple strategies, we applied transfer learning on four ConvNet architectures (MobileNet, DarkNet19, VGG16, and AlexNet). Whereas DarkNet19 reached the highest multi-case identification performance with an accuracy rate of 98.26 % on the small-scale dataset, VGG16 achieved the best generalization performance with an accuracy rate of 95.04 % on the large-scale dataset. Our study is one of the pioneering approaches that analyses 3615 COVID-19 cases and specifies the most responsible AHE parameters for ConvNet architectures in the multi-case classification.

Delayed 3D IR FLASH for airway imaging in children: more than myocardial fibrosis assessment

BackgroundTo investigate the ability of a delayed respiratory-navigated, electrocardiographically-gated three-dimensional inversion recovery-prepared flash low angle shot (3D IR FLASH) sequence to evaluate the lower airways in children undergoing routine cardiovascular magnetic resonance (CMR). MethodsThis retrospective study included pediatric patients (0-18 years) who underwent clinical CMR where a delayed 3D IR FLASH sequence was performed between July 2020 and April 2021. The airway image quality and extent of lower airway visibility was graded by two blinded readers using a four-point ordinal scale (0-3). Lower airway anatomical variants and abnormalities were recorded. Results180 patients were included with a median age of 11.7 (4.6-15.3) years. 51/180 (28%) were under general anesthesia (GA). Overall, the median grading of airway image quality was 3 (2-3) and extent of lower airway visibility was 3 (3-3). Interrater agreement was almost perfect (κ = 0.867 and κ = 0.956, respectively). Image quality correlated with extent of lower airway visibility (r = 0.62, p < 0.01). Delayed 3D IR FLASH was able to characterize the segmental bronchi in 137/180 (76%) and lobar bronchi in 172/180 (96%) of patients. Lower airway abnormalities were identified in 37/180 (21%) of patients and in 33/129 (26%) with congenital heart disease (CHD). Identified abnormalities included tracheobronchial branching anomalies in 6/180 (3%), abnormal tracheobronchial situs in 6/180 (3%), and extrinsic vascular compression in 25/180 (14%). ConclusionsDelayed 3D IR FLASH has excellent performance for evaluation of the lower airway anatomy and can simultaneously assess for myocardial late gadolinium enhancement. Lower airway abnormalities are not infrequently seen in children undergoing routine CMR for CHD.

Bending the rules: A novel approach to laryngeal surgery in a body donor study.

Transoral laser microsurgery, the standard surgical approach for early-stage laryngeal cancer, necessitates an unobstructed line of sight to the operating field. However, achieving adequate laryngeal exposure can be challenging, potentially compromising treatment outcomes. We developed a 3D-printed curved laryngoscope (sMAC), designed to match the upper airway anatomy. In a user study (n = 15) with a human body donor we compared the sMAC system to conventional microlaryngoscopy regarding laryngeal exposure and accessibility in a difficult exposure scenario. All 15 participants achieved complete glottic exposure and successfully manipulated laryngeal landmarks using the sMAC system. Only four participants achieved partial exposure using microlaryngoscopy. Positioning of the sMAC system was significantly faster (p = 0.023). A vocal cord resection was conducted successfully (n = 2) using the sMAC system. The sMAC system effectively addresses challenges associated with transoral laryngeal surgery. Ongoing development aims to overcome current limitations of the system and prepare first clinical trials.

Retrospective analysis of the upper airway anatomy and Sella turcica morphology across different skeletal malocclusions: a computerized technique

ObjectiveThis study aimed to investigate the normal volumetric space and variations in the measurements of different landmarks in adults with different skeletal relations of the maxilla and the mandible based on CBCT data. The study also analyses these landmarks to locate any correlations.BackgroundNumerous studies in orthodontics have found a relationship between orthodontic treatment and changes in the anatomy and function of the airway. Severe changes in airway morphology can cause breathing difficulties, lower quality of life, and even result in life-threatening conditions such as obstructive sleep apnoea. Consequently, orthodontic diagnosis and treatment planning require a thorough understanding of the airway space and its function.MethodsThe present retrospective study was conducted using CBCT records of 120 adult patients, containing 40 samples of each skeletal class (20 males and 20 females). The boundaries were defined for the 3 major regions: the nasopharynx, the oropharynx, and the hypopharynx. Various measurements were recorded across these regions, as well as selective cephalometric landmarks. The obtained data was used to calculate average and standard deviation, while regression analysis was used to evaluate correlations and t-test was used to test statistical significance of gender differences.ResultsThe results demonstrate that skeletal Class III individuals exhibit a reduced airway volume in the nasopharynx compared to other groups, whereas skeletal Class II individuals displayed a diminished airway volume in the hypopharynx. A strong correlation was observed for Sella turcica parameters. There were no significant differences in skeletal parameters across genders. Nasopharynx cavity volume demonstrated significant differences between skeletal Class I–Class III as well as between skeletal Class II–Class III. Hypopharynx cavity volume also demonstrated significant differences between skeletal Class I–Class II and between skeletal Class II–Class III.ConclusionThe major findings are the presence of a reduced nasopharyngeal volume in skeletal Class III malocclusions while skeletal Class II individuals displayed a diminished hypopharyngeal volume, making these critical areas to consider during the diagnostic and orthodontic treatment planning stages. This study also revealed a consistent correlation between Sella turcica parameters across various facial skeletal profiles, with skeletal Class II patients exhibiting a distinct pattern and skeletal Class I and Class III demonstrating an average relationship.

Lung Isolation Techniques for Challenging Airway Scenarios: A Narrative Review

Lung isolation is a critical aspect of patient management during thoracic cancer surgeries. While conventional techniques are well established for patients with normal airway anatomy, anatomical alterations in the upper or lower airways, especially due to cancer, can pose significant challenges. This review thoroughly examines the available lung isolation techniques for challenging airway scenarios, aiming to guide clinicians in selecting the most appropriate approach for each patient. Here, we explore the intricacies and nuances of one-lung ventilation in patients with altered airway anatomy. A comprehensive literature search was conducted using PubMed from January 2000 to May 2024, and additional references were identified through manual review. A tailored approach using available techniques is warranted in difficult airway scenarios, especially in patients with complex anatomical variations. The techniques such as a single-lumen endotracheal tube with bronchial blocker and a double-lumen tube insertion using a video laryngoscope or paediatric fibre-optic bronchoscope are discussed in difficult upper airway abnormalities. In some of the lower airway abnormalities, diverse lung isolation techniques mentioned in the literature are described.

High-flow nasal cannula in Spanish Pediatric Intensive Care Services: A national web survey about its use and indications

ObjectiveTo describe the high-flow nasal cannula (HFNC) indications in the Spanish pediatric critical care units (PICUs). DesignDescriptive cross-sectional observational study. SettingElectronic survey among members of the Spanish Society of Pediatric Intensive Care (SECIP). It was sent weekly from April 10, 2023, to May 21, 2023. ParticipantsAll SECIP members. InterventionsNone. Main variables of interestThe questions focused on workplace, years of experience, use or non-use of HFNC, justification and expectations regarding its application, starting point within each center, clinical criteria for indication, existence of clinical guidelines, evaluation during its use, and criteria and mode of withdrawal. ResultsTwo hundred and two participants, 176 were from Spain. Of these, 87/176 had over ten years of experience. One hundred sixty two use HFNC and 66/162 have HFNC clinical guidelines. Acute bronchiolitis (138/162) and respiratory assistance after extubation (106/56) are the two main indications. For 62/162 HFNC may reduce therapeutic escalation. Neuromuscular diseases (105/162) and anatomical airway diseases (135/162) are the two main contraindications. The reasons to do not use HFNC were the absence of evidence about it effectiveness (8/14) and its inadequate cost/effectiveness balance (8/14). ConclusionsA majority of Spanish pediatric intensivists use HFNC. Its application and withdrawal appears to be primarily based on clinical experience. Besides, those who use HFNC are aware of its limitations and the lack of evidence in some cases. It is necessary to develop single-center and multicenter studies to elucidate the effectiveness of this therapy in the context of critically ill children.

Sedation for GI Endoscopy in the Morbidly Obese: Challenges and Possible Solutions.

With the increasing prevalence of obesity and morbid obesity, this subgroup's contribution to patients presenting for elective procedures requiring sedation is significant. Gastrointestinal (GI) procedures clearly form the largest group of such procedures. These procedures may be intended to treat obesity such as the insertion of an intragastric balloon or one or more unrelated procedures such as a screening colonoscopy and (or) diagnostic/therapeutic endoscopy. Regardless of the procedure, these patients pose significant challenges in terms of choice of sedatives, dosing, airway management, ventilation, and oxygenation. An understanding of dissimilarity in the handling of different groups of medications used by an anesthesia provider and alterations in airway anatomy is critical for providing safe sedation. Administration of sedative medications and conduct of anesthesia requires dose modifications and airway adjuncts. In this review, we discuss the above issues in detail, with a particular focus on GI endoscopy.

Cardiopulmonary crisis caused by bronchial blocker malposition in a patient with aberrant tracheal anatomy: a case report

BackgroundDouble-lumen tubes (DLTs) and bronchial blockers (BBs) can be used to establish one-lung ventilation (OLV) for thoracic surgery. BBs are a good alternative when DLTs are not suitable or patients have difficult airways. However, BBs are more prone to malposition, leading to adverse events.Case presentationWe present a 68-year-old male patient who was scheduled for thoracoscopic left lower lobectomy. The patient was not expected to have airway malformation preoperatively. When the DLT could not be inserted into the bronchus after general anesthesia induction, we used a BB to perform OLV. During surgery, malposition of the BB resulted in the development of an “incomplete balloon valve”, leading to a cardiopulmonary crisis.ConclusionsPreviewing chest computed tomography scans to assess the airway anatomy before thoracic surgery is essential. Three-dimensional reconstruction of the airway can provide a more intuitive assessment of airway anatomy. During OLV with BBs, we should pay attention to balloon malposition to prevent cardiopulmonary crises.

The metabolic cost of breathing for exercise ventilations: effects of age and sex.

Given that there are both sex-based structural differences in the respiratory system and age-associated declines in pulmonary function, the purpose of this study was to assess the effects of age and sex on the metabolic cost of breathing (V̇o2RM) for exercise ventilations in healthy younger and older males and females. Forty healthy participants (10 young males 24 ± 3 yr; 10 young females 24 ± 3 yr; 10 older males 63 ± 3 yr, 10 older females 63 ± 6 yr) mimicked their exercise breathing patterns (voluntary hyperpnea) in the absence of exercise across a range of exercise intensities. At peak exercise, V̇o2RM represented a significantly greater fraction of peak oxygen consumption (V̇o2peak) in young females, 12.7 ± 4.0%, compared with young males, 10.7 ± 3.0% (P = 0.027), whereas V̇o2RM represented 13.5 ± 2.3% of V̇o2peak in older females and 13.2 ± 3.3% in older males. At relative ventilations, there was a main effect of age, with older males consuming a significantly greater fraction of V̇o2RM (6.6 ± 1.9%) than the younger males (4.4 ± 1.3%; P = 0.012), and older females consuming a significantly greater fraction of V̇o2RM (6.9 ± 2.5%) than the younger females (5.1 ± 1.4%; P = 0.004) at 65% V̇emax. Furthermore, both younger and older males had significantly better respiratory muscle efficiency than their female counterparts at peak exercise (P = 0.011; P = 0.015). Similarly, younger participants were significantly more efficient than older participants (6.5 ± 1.5% vs. 5.5 ± 2.0%; P = 0.001). Normal age-related changes in respiratory function, in addition to sex-based differences in airway anatomy, appear to influence the ventilatory responses and the cost incurred to breathe during exercise.NEW & NOTEWORTHY Here we show that at moderate and high-intensity exercise, older individuals incur a higher cost to breathe than their younger counterparts. However, as individuals age, the sex difference in the cost of breathing narrows. Collectively, our findings suggest that the normative age-related changes in respiratory structure and function, and sex differences in airway anatomy, appear to influence the ventilatory responses to exercise and the oxygen cost to breathe.

Analysis of the difference of therapeutic effect and predictive factors between postural and non-postural OSA after modified uvulopalatopharyngoplasty

Objective:To analyze the factors influencing the outcome of uvulopalatopharyngoplasty in positional obstructive sleep apnea（POSA） and non-positional OSA（NPOSA） patients, and to explore the differences between the two groups. Methods:The data of 101 patients with obstructive sleep apnea who received treatment from November 2020 to November 2023 were retrospectively analyzed. Among them, 45 positional patients（POSA group） and 56 non-positional patients（NPOSA group）, who underwent overnight polysomnography were included. The upper airway（UA） anatomy was evaluated by three-dimensional computer tomography（3D-CT）. All patients received revised uvulopalatopharyngoplasty with uvula preservation and were followed using polysomnography for at least three months postoperatively. Results:The overall effective rate was 55.45%. The surgical success rate in POSA undergoing UPPP was higher than NPOSA（POSA 30/45, 66.7% versus NPOSA 26/56, 46.4%, P=0.042）. The H-UPPP effect of POSA was negatively correlated with the minimum lateral airway of the Velopharyngeal airway（r=-0.505, P<0.001）, the minimum lateral airway of the glossopharyngeal airway（r=-0.474, P=0.001） and the minimum cross-sectional area（r=-0.394, P=0.007）. Logistic analysis showed that minimal lateral airway of the glossopharynxgeum（mLAT）（OR 0.873; 95%CI 0.798-0.955, P=0.003） was a significant predictor for surgical outcomes among POSA patients. In NPOSA, age（OR 0.936; 95%CI 0.879-0.998, P=0.042） was a significant predictor for surgical outcomes. Conclusion:The effect of H-UPPP was higher in POSA than in NPOSA. The width of glossopharyngeal mLAT was an important predictor of POSA efficacy. Age was a predictor of NPOSA efficacy.

Awake 160-Slice Computed Tomography for Upper Airway Evaluation in 17 Dogs.

This study investigated using a 160-slice multidetector computed tomography (CT) scanner for conscious image acquisition in dogs with upper airway disease, and describes findings in dogs that had previously undergone soft palate surgery. Seventeen client-owned dogs with upper airway disease were retrospectively reviewed, and classified into three groups: group I, "untreated brachycephalic obstructive airway syndrome (BOAS) patients"; group II, "previously treated BOAS patients"; and group III, "patients with respiratory disease other than BOAS". Data included signalment, clinical history, direct laryngoscopy and endoscopy findings, previous surgeries and CT findings. CT scans in group I revealed overlong and thickened soft palates in all dogs, and signs of laryngeal collapse in four dogs. Patients in group II exhibited normal soft palate lengths, while patients in group III displayed various findings such as nasopharyngeal narrowing and tracheal collapse. Upper airway examinations under general anaesthesia confirmed most CT findings. This study demonstrates the feasibility and value of conscious CT scanning for assessing upper airway diseases in dogs, providing valuable diagnostic information while eliminating the need for chemical immobilisation, thus reducing patient stress and cost. These findings offer new insight into upper airway anatomy in awake patients, especially in brachycephalic breeds, and lay a foundation for future research.

Challenges of Anesthetic Management in Pediatric Patients with Hernia Inguinalis Lateralis Dextra Reponibilis: A Case Report

Introduction: Hernia inguinalis lateralis dextra reponibilis (HILD repr.) is a common condition in infants and children, but anesthetic management in these pediatric patients requires special attention. Children's unique physiological and pharmacological characteristics, potential comorbidities, and risk of postoperative pain demand a careful and integrated approach. Case presentation: This case report presents comprehensive anesthetic management of a 6-month-old male infant who underwent elective herniorrhaphy for HILD repr. The anesthesia procedure involved induction with sevoflurane and fentanyl, maintenance of anesthesia with sevoflurane, and multimodal pain management with paracetamol and bupivacaine. The surgery was successful without complications, and the patient recovered well. Conclusion: This case highlights the importance of implementing modern anesthetic practices in pediatric patients with HILD repr., including selection of appropriate anesthetic agents, close monitoring, and multimodal pain management. Specific challenges such as unique airway anatomy, variability in drug pharmacokinetics, and risk of perioperative complications are also highlighted. The successful anesthetic management of this case highlights the importance of an individualized approach and close monitoring to optimize clinical outcomes and minimize complications in pediatric patients with HILD repr.

208 Head and Neck Surgical Oncology Handover Audit Using ‘RAAAIDDSS’ Method

Abstract Background Patient handover is vital in ensuring patient safety and quality of patient care, in line with Royal College of Surgeons Guidance of Safe Handover (2007). ‘RAAAIDDSSS’ method stands for resection (surgery), airway, anticoagulant, antibiotics, intake, drain, Doppler, serology, scans, structure (plans). It shows comprehensive clinical updates for planning best management, ensuring smooth flow of activity and reducing morbidity. This method is ideal as our surgical patients often have altered airway anatomy and airway plans and consequently variable feeding routes. Aim To audit the compliance of RAAAIDDSSS method. Method This is a prospective audit in Head and Neck Surgery Department of University College London Hospital (UCLH), done within 4 weeks across June-July 2023, with sample (n=100) for first cycle and (n=81) for second cycle. The format was implemented in handover sheet and case presentation was run according to this method. Results First cycle showed good compliance to RAAAIDDSSS handover method. The least compliant component is ‘structure’ which showed only 62%. Results were presented in grand ward round. Second cycle showed significant improvement. Almost all components showed 100% compliance, except for the ‘intake’, which was 90%. Overall shows positive compliance to this handover method. Conclusions UCLH Head and Neck Surgery has strict compliance with the RAAIDDSSS method. This audit brings significant positive impacts and changes to clinical practice in terms of patient safety, service efficiency and quality of patient care. This audit also holds valuable clinical value and opens doors for further audits as well as project expansion regionally and nationally.

A child with congenital hypothyroidism posted for emergency surgery- anaesthesia challenges

Paediatric cases pose considerable anaesthetic challenges and are more challenging if they are posted for emergency surgeries with associated comorbidities like congenital hypothyroidism. Few reported cases of anaesthesia management of congenital hypothyroid cases are there in the literature. Challenges are due to the difficult airway, associated congenital anomalies and increased sensitivity to anaesthetic drugs. Knowledge of pathophysiology, preoperative optimization and proper selection and planning of anaesthesia techniques are essential for successful anaesthesia management of children with congenital hypothyroidism for emergency surgeries. Congenital hypothyroidism in a child poses significant challenges for anaesthesiologists because of altered physiology, airway anatomy and difficult airway and drug metabolism.

BranchLabelNet: Anatomical Human Airway Labeling Approach using a Dividing-and-Grouping Multi-Label Classification.

Anatomical airway labeling is crucial for precisely identifying airways displaying symptoms such as constriction, increased wall thickness, and modified branching patterns, facilitating the diagnosis and treatment of pulmonary ailments. This study introduces an innovative airway labeling methodology, BranchLabelNet, which accounts for the fractal nature of airways and inherent hierarchical branch nomenclature. In developing this methodology, branch-related parameters, including position vectors, generation levels, branch lengths, areas, perimeters, and more, are extracted from a dataset of 1000 chest computed tomography (CT) images. To effectively manage this intricate branch data, we employ an n-ary tree structure that captures the complicated relationships within the airway tree. Subsequently, we employ a divide-and-group deep learning approach for multi-label classification, streamlining the anatomical airway branch labeling process. Additionally, we address the challenge of class imbalance in the dataset by incorporating the Tomek Links algorithm to maintain model reliability and accuracy. Our proposed airway labeling method provides robust branch designations and achieves an impressive average classification accuracy of 95.94% across fivefold cross-validation. This approach is adaptable for addressing similar complexities in general multi-label classification problems within biomedical systems.

Difficult airway due to acute necrotizing mediastinitis: a case report

Descending necrotizing mediastinitis (DNM) due to odontogenic or oropharyngeal infections can change the airway anatomy and cause difficult intubation. A 56-year-old female patient, who was followed up for dental abscess, was taken to emergency surgery due to DNM. The patient with widespread edema on the face could only be intubated with a gamma elastic bougie. it should be kept in mind that patients with oropharyngeal infection and mediastinitis may have intubation difficulties and tendency to airway trauma, and it is important to use airway instruments carefully in these patients.

Post-extubation laryngitis in children: diagnosis, management and follow-up

ObjectivesTo describe the occurrence of post-extubation laryngitis, analyze its one-year evolution, and correlate laryngeal lesions with clinical outcomes. MethodsRetrospective study including children up to 13 years old at a tertiary hospital between March 2020 and March 2022 with diagnosis of post-extubation laryngitis confirmed by endoscopic examination. Exclusion criteria were prior history of intubation or anatomical airway abnormalities. Medical records were reviewed to characterize patients, underlying diagnosis, laryngeal lesions, treatment, and outcomes at 12-month follow-up. ResultsThe study included 38 endoscopically confirmed post-extubation laryngitis cases, corresponding to 86.4% of suspected cases. The mean age was 13.24 months, and 60.5% were male. Acute respiratory failure was the leading cause of intubation. Initial treatment was clinical, and initial diagnosis was defined by nasopharynoglaryngoscopy and/or Microlaryngoscopy and Bronchoscopy (MLB) findings. Initial diagnostic MLB was performed in 65.7% of the patients. Approximately half (53%) of the patients exhibited moderate or severe laryngeal lesions. When compared to mild cases, these patients experienced a higher rate of extubation failures (mean of 1.95 vs. 0.72, p = 0.0013), underwent more endoscopic procedures, and faced worse outcomes, such as the increased need for tracheostomy (p = 0.0001) and the development of laryngeal stenosis (p = 0.0450). Tracheostomy was performed in 14 (36.8%) children. Patients undergoing tracheostomy presented more extubation failures and longer intubation periods. Eight (21%) developed laryngeal stenosis, and 17 (58.6%) had complete resolution on follow-up. ConclusionPost-extubation laryngitis is a frequent diagnosis among patients with clinical symptoms or failed extubation. The severity of laryngeal lesions was linked to a less favorable prognosis observed at one-year follow-up. Otolaryngological evaluation, follow-up protocols, and increased access to therapeutic resources are essential to manage these children properly. Level of evidenceLevel 4.

Double lumen endobronchial tube intubation: lessons learned from anatomy

BackgroundDouble lumen endobronchial tubes (DLTs) are frequently used to employ single lung ventilation strategies during thoracic surgical procedures. Placement of these tubes can be challenging even for experienced clinicians. We hypothesized that airway anatomy, particularly of the glottis and proximal trachea, significantly impacts the ease or difficulty in placement of these tubes.MethodsImages from 24 randomly selected Positron Emission Tomography – Computed Tomography (PET-CT) scans were evaluated for several anatomic aspects of the upper airway, including size and angulation of the glottis and proximal tracheal using calibrated CT measurements and an online digital protractor. The anatomic issues identified were confirmed in cadaveric anatomic models.ResultsProximal tracheal diameter measurements in PET-CT scans demonstrated a mean ± standard deviation of 20.4 ± 2.5 mm in 12 males and 15.5 ± 0.98 mm in 12 females (p < 0.001), and both were large enough to accommodate 39 French and 37 French DLTs in males and females, respectively. Subsequent measurements of the posterior angulation of the proximal trachea revealed a mean angle of 40.8 ± 5.7 degrees with no sex differences. By combining the 24 individual posterior tracheal angles with the 16 angled distal tip measurements DLTs (mean angle 24.9 ± 2.1 degrees), we created a series of 384 patient intubation angle scenarios. This data clearly showed that DLT rotation to a full 180 degrees decreased the mean intubation angle between the DLT and the proximal trachea from a mean of 66.6 ± 5.9 to only 15.8 ± 5.9 degrees.ConclusionsRotation of DLTs a full 180 instead of the recommended 90 degrees facilitates DLT intubations.

Pediatric Tracheostomy Year in Review.

Tracheostomized children have higher mortality compared to adults due to smaller airway anatomy and greater medical complexity and are at high risk for life-threatening complications. Following new tracheostomy placement, caregivers are required to successfully complete extensive training before discharge home. Training for tracheostomy emergencies such as tube obstruction and accidental decannulation is challenging without real-life, hands-on experience, but simulation training has shown promising effects on improving caregiver knowledge and comfort in preparing for emergency situations. Readmissions and emergency department visits are common following discharge, with many due to respiratory illness. Inhaled antibiotics are frequently prescribed to treat bacterial respiratory infection. However, guidelines for standardized management of tracheostomy-related respiratory illness are not available. Although standardized decannulation protocols are utilized, evidence-based guidelines are lacking, and the role of routine polysomnogram prior to decannulation is unresolved. Several knowledge gaps in management of pediatric tracheostomy present the opportunity for future research to improve patient outcomes.

Association Between Soft Tissue Measures From Computed Tomography and Upper Airway Collapsibility on Drug-Induced Sleep Endoscopy.

Positive airway pressure (PAP) titration during drug-induced sleep endoscopy (DISE) provides objective measures of upper airway collapsibility. While skeletal measurements relate to collapsibility measures on DISE, the influence of soft tissue dimensions on upper airway collapsibility is not known. We analyzed the relationship of measures of upper airway soft tissue volumes, specifically soft palate, pharyngeal lateral walls, and tongue, with metrics of collapsibility. Cross-sectional analysis from a prospective cohort. Academic medical center. Patients seeking PAP alternative therapies for obstructive sleep apnea (OSA) underwent standardized supine computed tomography (CT) acquisition and DISE protocols. The CT analysis primarily focused on soft tissue volumes and, secondarily, on airway and skeletal volumetric measures. DISE with PAP administration (DISE-PAP) enabled the determination of the pressure at which inspiratory airflow first commenced (pharyngeal critical pressure, PcritA) and the pressure at which inspiratory flow limitation was abolished (pharyngeal opening pressure, PhOP). Both unadjusted and adjusted correlation analyses were performed to understand the relationship between upper airway anatomy and either PcritA or PhOP. One hundred thirty-nine subjects completed both CT and DISE-PAP. On average, patients were male (70.5%), white (84.2%), middle-aged (56.6 ± 13.5 years), and overweight (29.6 ± 4.7 kg/m2), with moderate-severe apnea-hypopnea index (29.7 ± 21.3 events/h). Adjusted for age, sex, body mass index, and skeletal volumes, soft palate, and lateral pharyngeal wall volumes were not associated with PhOP or PcritA, but a larger tongue was associated with more positive PhOP (⍴ = 0.20, P = .02), and more positive PcritA (⍴ = 0.16, P = .07). Exploratory analyses revealed smaller minimum cross-sectional retropalatal area and intramandibular volume were also associated with increased collapsibility measures. After controlling for clinical factors and skeletal volume, greater tongue volume was associated with more severe collapsibility during DISE. These results, in concert with previous work, suggest that greater tongue volume in a smaller skeletal dimensions contribute to the severity of airway collapsibility, a key driver of OSA pathogenesis.