Airway Anatomy Research Articles

Successful airway management of twin coincidental supraglottic and thyroid masses with difficult fiber optic intubation: a case report

BackgroundAberrant airway anatomy in cases of laryngeal carcinomas makes airway management a herculean task for the anesthesiologist. What can further compound the situation is an external compression by thyroid mass.Case presentationWe present a case report of successful airway management by awake nasal fiberoptic intubation in a 65-year-old male who was found to have compressive symptoms due to thyroid swelling in addition to supraglottic obstructive mass. Although a detailed airway examination and indirect laryngoscope did assist in planning the procedure, but what lay inside could only be dealt with by having an in-depth orientation of airway anatomy, practical know-how to fiberoptic scope, and swift reflexes to prevent an adverse event.ConclusionFrom our experience, fiberoptic intubation can only be optimally utilized if emphasis is laid on planning and preparation for the procedure which are key elements in making any difficult airway management successful.

Management of cesarean delivery in a parturient with osteogenesis imperfecta：A case report

Osteogenesis imperfecta (OI) is characterized by bone fragility, defects in the teeth, blue sclera, and deficits in hearing and vision [1,2]. Because of an anticipated difficult airway and back anatomy, there is a high risk of choosing either general or spinal anesthesia, especially in critically ill obstetric patients. It is still controversy about the anesthesia method in patients with OI. Ultrasound-guided transversus abdominis plane block (TAPB) has been used for analgesia after cesarean section, but rarely for anesthesia in this operation [3-5]. We describe a critically parturient with OI who underwent cesarean section under ultrasound guided TAPB with spontaneous breathing general anesthesia. The patient's vital signs have remained stable during the operation, and a live female infant was delivered successfully by cesarean section. The mother and daughter were safe at last. Written informed consent was provided by the patient for publication of this report with photos.created.

Tetraplegic obstructive sleep apnoea patients dilate the airway similarly to able-bodied obstructive sleep apnoea patients

Context/objective: Obstructive sleep apnoea (OSA) develops soon after cervical spinal cord injury (SCI) at rates higher than the general population, but the mechanisms are not understood. This study aimed to determine whether OSA in SCI is associated with altered pharyngeal muscle dilatory mechanics during quiet breathing, as has been observed in the non-SCI injured with obstructive sleep apnoea. Design: Cross sectional imaging study. Setting: Medical research institute. Participants: Eight cervical SCI patients with OSA were recruited and compared to 13 able-bodied OSA patients and 12 able-bodied healthy controls of similar age and BMI. Interventions and outcome measures: 3T MRI scans of upper airway anatomy and tagged-MRI to characterize airway muscle motion during quiet breathing were collected for analysis. Results: Considerable variation in the patterns of inspiratory airway muscle motion was observed in the SCI group, with some participants exhibiting large inspiratory airway dilatory motions, and others exhibiting counterproductive narrowing during inspiration. These patterns were not dissimilar to those observed in the able-bodied OSA participants. The increase in airway cross-sectional area of able-bodied control participants was proportional to increase in BMI, and a similar, but not significant, relationship was present in all groups. Conclusion: Despite the limited sample size, these data suggest that SCI OSA patients have heterogeneous pharyngeal dilator muscle responses to the negative pressures occurring during inspiration but, as a group, appear to be more similar to able-bodied OSA patients than healthy controls of similar age and BMI. This may reflect altered pharyngeal pressure reflex responses in at least some people with SCI.

A Novel 3-Dimensional Printing Fabrication Approach for the Production of Pediatric Airway Models.

BACKGROUND:Pediatric airway models currently available for use in education or simulation do not replicate anatomy or tissue responses to procedures. Emphasis on mass production with sturdy but homogeneous materials and low-fidelity casting techniques diminishes these models’ abilities to realistically represent the unique characteristics of the pediatric airway, particularly in the infant and younger age ranges. Newer fabrication technologies, including 3-dimensional (3D) printing and castable tissue-like silicones, open new approaches to the simulation of pediatric airways with greater anatomical fidelity and utility for procedure training.METHODS:After ethics approval, available/archived computerized tomography data sets of patients under the age of 2 years were reviewed to identify those suitable for designing new models. A single 21-month-old subject was selected for 3D reconstruction. Manual thresholding was then performed to produce 3D models of selected regions and tissue types within the dataset, which were either directly 3D-printed or later cast in 3D-printed molds with a variety of tissue-like silicones. A series of testing mannequins derived using this multimodal approach were then further refined following direct clinician feedback to develop a series of pediatric airway model prototypes.RESULTS:The initial prototype consisted of separate skeletal (skull, mandible, vertebrae) and soft-tissue (nasal mucosa, pharynx, larynx, gingivae, tongue, functional temporomandibular joint [TMJ] “sleeve,” skin) modules. The first iterations of these modules were generated using both single-material and multimaterial 3D printing techniques to achieve the haptic properties of real human tissues. After direct clinical feedback, subsequent prototypes relied on a combination of 3D printing for osseous elements and casting of soft-tissue components from 3D-printed molds, which refined the haptic properties of the nasal, oropharyngeal, laryngeal, and airway tissues, and improved the range of movement required for airway management procedures. This approach of modification based on clinical feedback resulted in superior functional performance.CONCLUSIONS:Our hybrid manufacturing approach, merging 3D-printed components and 3D-printed molds for silicone casting, allows a more accurate representation of both the anatomy and functional characteristics of the pediatric airway for model production. Further, it allows for the direct translation of anatomy derived from real patient medical imaging into a functional airway management simulator, and our modular design allows for modification of individual elements to easily vary anatomical configurations, haptic qualities of components or exchange components to replicate pathology.

Management of tracheo-oesophageal fistula in adults.

Tracheo-oesophageal fistula (TOF) is a pathological connection between the trachea and the oesophagus that is associated with various underlying conditions including malignancies, infections, inhalation injuries and traumatic damage. As the condition spans multiple organ systems with varying aetiologies and acuities, TOF poses unique diagnostic and management challenges to pulmonologists, gastroenterologists and thoracic surgeons alike. Although stents have been a cornerstone in the management of TOF, there exists a large gap in our understanding of their efficacy and precise methodology, making stenting procedure both art and science. TOFs relating to underlying oesophageal or tracheal malignancies require advanced understanding of the airway and digestive tract anatomy, dimensions of the fistula, stent characteristics and types, and the interplay between the oesophageal stent and the airway stent if dual stenting procedure is elected. In this review article, we review the most up-to-date data on risk factors, clinical manifestations, diagnostic approaches, management methods and prognosis. Consequently, this article serves to evaluate current therapeutic strategies and the future directions in the areas of 3D-printed stents, over-the-scope clipping systems, tissue matrices and atrial septal closure devices.

The effect of airway motion and breathing phase during imaging on CFD simulations of respiratory airflow

RationaleComputational fluid dynamics (CFD) simulations of respiratory airflow can quantify clinically useful information that cannot be obtained directly, such as the work of breathing (WOB), resistance to airflow, and pressure loss. However, patient-specific CFD simulations are often based on medical imaging that does not capture airway motion and thus may not represent true physiology, directly affecting those measurements. ObjectivesTo quantify the variation of respiratory airflow metrics obtained from static models of airway anatomy at several respiratory phases, temporally averaged airway anatomies, and dynamic models that incorporate physiological motion. MethodsNeonatal airway images were acquired during free-breathing using 3D high-resolution MRI and reconstructed at several respiratory phases in two healthy subjects and two with airway disease (tracheomalacia). For each subject, five static (end expiration, peak inspiration, end inspiration, peak expiration, averaged) and one dynamic CFD simulations were performed. WOB, airway resistance, and pressure loss across the trachea were obtained for each static simulation and compared with the dynamic simulation results. ResultsLarge differences were found in the airflow variables between the static simulations at various respiratory phases and the dynamic simulation. Depending on the static airway model used, WOB, resistance, and pressure loss varied up to 237%, 200%, and 94% compared to the dynamic simulation respectively. ConclusionsChanges in tracheal size and shape throughout the breathing cycle directly affect respiratory airflow dynamics and breathing effort. Simulations incorporating realistic airway wall dynamics most closely represent airway physiology; if limited to static simulations, the airway geometry must be obtained during the respiratory phase of interest for a given pathology.

Teaching Review on Approach of Esophageal Intubation as Complications in Emergency Airway Management

Background: Intubation is daily process in hospitals, it’s insertion of tube to secure an airway, nonemergent intubation is done in well controlled circumstances, while emergent intubation is not. Most emergency intubated are cardiac or respiratory arrest patients. Intubation helps to secure airway for patient breathing, also could protect from aspiration. Most common complications are: esophagus intubation and hypotension. This research will be divided into two main topics, emergency intubation as a whole, and unrecognized esophagus intubation as a complication. Emergency intubation discuss: knowledge about the procedure, equipment needed, airway assessment, preoxygenation, difficulties and risks, outcomes. While Unrecognized esophagus intubation will be discussed as complication in ER settings, point to clear: Epidemiology, tools of detection, equipment, human and environmental bias and consideration for cardiac arrest patients. Finishing with a conclusion and recommendation. Therefore, we aim to look into the common pitfalls that both medical students and new physicians face in the recognition, diagnosis, and Emergency Airway Management. Targeted Population: Airway cardiorespiratory arrest patients who are requiring urgent management in the ED, with emergency physicians for teaching approach protocol. Aim of the Study: Appropriate for assessment and priorities for Airway cardiorespiratory arrest patients by training protocol to emergency physicians. Based on patients’ causes of Airway injuries. Methods: Collection of all possible available data about the Esophageal Intubation as Complications in the Emergency department. By many research questions to achieve these aims so a midline literature search was performed with the keywords “critical care”, “emergency medicine”, “principals of airway management”, “Esophageal Intubation as Complications”. Literature search included an overview of recent definition, causes and recent therapeutic strategies. Results: All studies introduced that the initial diagnosis of Esophageal Intubation as Complications is a lifesaving conditions that face patients of the emergency and critical care departments. Conclusion: Intubation in emergency settings require a good preparation, available equipment (e.g. ready cart for all time), and supportive anatomical airway of the patient. Following a checklist will improve outcomes, prevent malpractice and complications. Preoxygenation and RSI play major roles for successful intubations with decrease risk of complications. Follow procedure steps, and expect difficult intubation for any patient, so consider LEMON mnemonic to evaluate risk of difficulty, and after 3 attempts try a different technique or equipment. More training and education are essential to decrease congenital and equipotential mistakes/errors.

Orofacial clefts: treatment based on a multidisciplinary approach

Orofacial clefts: treatment based on a multidisciplinary approach

Impact of upper airway configuration on CPAP titration assessed by CT during Müller's maneuver in OSA patients

PurposeContinuous positive airway pressure (CPAP) is the current gold-standard treatment for moderate to severe obstructive sleep apnea (OSA), and upper airway anatomy plays an increasingly important role in evaluating the efficacy of CPAP therapy. The aim of this observational study was to investigate the influence of upper airway anatomy on CPAP titration in OSA patients assessed by computed tomography (CT) during Müller's maneuver. MethodsConsecutive patients under investigation for OSA by undergoing polysomnography and CT scan of the upper airway while awake were enrolled. Successful full-night manual titration was performed to determine the optimal CPAP pressure level for OSA patients in supine position using a nasal mask. ResultsA total of 157 subjects (134 males and 23 females) were included. Both apnea–hypopnea index (AHI) and LaSO2 significantly correlated with CPAP titration level, upper airway length (UAL), distance from mandibular plane to hyoid bone (MPH), and neck circumference (all p < 0.05). There were significant positive correlations between CPAP titration level and UAL (r = 0.348, p = 0.000) and MPH (r = 0.313, p = 0.002). Stepwise multiple linear regression analyses were performed to evaluate the independent predictors of AHI, LaSO2, and CPAP titration level. CPAP titration level was identified as an independent explanatory variable for AHI and LaSO2 after adjustment for confounders. Multiple linear regression analyses also indicated that body mass index (BMI) and UAL were independently associated with CPAP titration level (all p < 0.05). ConclusionsUpper airway abnormalities combined with anthropometric parameters play important roles in CPAP titration for OSA patients, providing additional insight into the factors influencing OSA treatment strategies. UAL and BMI should be taken into consideration when choosing CPAP titration level to improve CPAP compliance.

Airway emergency management in a pediatric hospital before and during the COVID-19 pandemic

ObjectiveChildren's hospitals frequently care for infants with various life-threatening airway anomalies. Management of these infants can be challenging given unique airway anatomy and potential malformations. Airway emergency management must be immediate and precise, often demanding specialized equipment and/or expertise. We developed a Neonatal-Infant Emergency Airway Program to improve medical responses, communication, equipment usage and outcomes for all infants requiring emergent airway interventions in our neonatal and infant intensive care unit (NICU). Patients and methodsAll patients admitted to our quaternary NICU from 2008 to 2019 were included in this study. Our program consisted of a multidisciplinary airway response team, pager system, and emergency equipment cart. Respiratory therapists present at each emergency event recorded specialist response times, equipment utilization, and outcomes. A multidisciplinary oversite committee reviewed each incident. ResultsSince 2008, there were 159 airway emergency events in our NICU (~12 per year). Mean specialist response times decreased from 5.9 ± 4.9 min (2008–2012, mean ± SD) to 4.3 ± 2.2 min (2016–2019, p = 0.12), and the number of incidents with response times >5 min decreased from 28.8 ± 17.8% (2008–2012) to 9.3 ± 11.4% (2016–2019, p = 0.04 by linear regression). As our program became more standardized, we noted better equipment availability and subspecialist communication. Few emergency situations (n = 9, 6%) required operating room management. There were 3 patient deaths (2%). ConclusionsOur airway safety program, including readily available specialists and equipment, facilitated effective resolution of airway emergencies in our NICU and multidisciplinary involvement enabled rapid and effective changes in response to COVID-19 regulations. A similar program could be implemented in other centers.

REFRACTORY SIROLIMUS-INDUCED PULMONARY ALVEOLAR PROTEINOSIS IN A PATIENT WITH LUNG TRANSPLANT

SESSION TITLE: Fellows Transplantation Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary alveolar proteinosis (PAP) is a rare disease with accumulation of proteins and lipids within the alveolar macrophages with considerable morbidity and mortality [1]. PAP etiologies include a primary autoimmune process due to anti-granulocyte macrophage colony stimulating factor (GM-CSF) antibodies while secondary causes include medications, infection, toxic inhalations, or hematological disorders [1]. Sirolimus, an immunosuppressant used in organ transplantation, is a rare cause of reversible PAP [2-6]. We present a patient who worsened despite discontinuation of sirolimus, regional lung lavage and inhaled GM-CSF. CASE PRESENTATION: A 57 year old female underwent bilateral lung transplant for idiopathic pulmonary fibrosis, complicated by acute rejection, bilateral pulmonary embolism, pulmonary artery stenosis requiring stenting, and bilateral airway anastomotic stenosis requiring a left mainstem stent. She presented with hypoxia five years post-transplant on sirolimus and prednisone. Chest CT demonstrated new unilateral ground glass opacities with bilateral septal thickening. Bronchoalveolar lavage (BAL) had milky fluid return, concerning for PAP. Sirolimus was discontinued and cyclosporine started. A segmental large volume BAL of the right upper lobe failed to improve hypoxia or shortness of breath and whole lung lavage was impractical due to bilateral anastomotic stenosis. She had resultant renal failure secondary to cyclosporine while off sirolimus for 3 months. Oxygen requirement and imaging failed to improve. Her anti-GM-CSF antibody test was negative and other causes of secondary PAP were ruled out. Salvage inhaled GM-CSF (sargramostim) was begun for progressive hypoxemic respiratory failure. VV-ECMO and whole lung lavage were offered but the patient declined. After four cycles of inhaled GM-CSF, her condition deteriorated and she passed away on POD 2492. Autopsy confirmed severe PAP. DISCUSSION: Sirolimus is a rare cause of secondary PAP. Typically sirolimus-induced PAP improves with medication discontinuation and potentially whole lung lavage. In this case, whole lung lavage was deemed impractical due to airway anatomy. She did not improve with sirolimus discontinuation or inhaled GM-CSF. Further research into the mechanism related to sirolimus induced PAP is necessary as this medication is widely used in complex patients with solid organ transplants. CONCLUSIONS: Sirolimus is implicated in drug induced PAP with expected reversibility when the medication is discontinued. This refractory case highlights the need for better understanding and treatment options in complex solid organ transplant patients. Reference #1: 1.Borie, R., et al., Pulmonary alveolar proteinosis. European Respiratory Review, 2011. 20(120): p. 98-107. 2.Mattewal, A.S., et al., Pulmonary alveolar proteinosis: a rare pulmonary toxicity of sirolimus in lung transplant patients. Chest, 2009. 136(4): p. 23S. 3.Pedroso, S.L., et al., Pulmonary alveolar proteinosis – a rare pulmonary toxicity of sirolimus. Transplant International, 2007. 20(3): p. 291-296. 4.Kadikoy, H., et al., Pulmonary alveolar proteinosis in a kidney transplant: a rare complication of sirolimus. Nephrology Dialysis Transplantation, 2010. 25(8): p. 2795-2798. 5.Garrean, S., et al., Sirolimus-associated interstitial pneumonitis in solid organ transplant recipients. Clinical transplantation, 2005. 19(5): p. 698-703. 6.Dhawan, K., A. Pope-Harman, and N. Sood, PULMONARY ALVEOLAR PROTEINOSIS SECONDARY TO SIROLIMUS IN A RENAL TRANSPLANT PATIENT. CHEST, 2009. 136(4): p. 34S. DISCLOSURES: No relevant relationships by Brian Boer, source=Web Response no disclosure on file for Heather Strah; No relevant relationships by Grant Turner, source=Web Response No relevant relationships by Navin Victor, source=Web Response

Dimensional compatibility of balloon-tipped bronchial blockers with the pediatric airway anatomy using different recommendations for age-related size selection.

Age-related recommendations for size selection of bronchial blocker devices are based on a few dated anatomical autopsy and radiological studies determining lower airway dimensions in children. These recommendations are based on anterior-posterior internal bronchial diameters, which are smaller than the more relevant lateral internal bronchial diameters. Outer diameters of bronchial blocker balloons inflated with the maximum recommended volume of air were compared to age-related lateral internal bronchial diameters of left and right proximal mainstem bronchi using five different recommendations for age-related size selection of bronchial blocker equipment in children published in the literature. The ratio of outer bronchial blocker diameters inflated with the maximal recommended volume of air to the median lateral internal diameters of the proximal mainstem bronchus ranged from 71.4% to 181.8% for the left side and from 61.7% to 162.6% for the right side. There were many settings where the blocker diameters did not reach the median lateral internal diameters of the proximal mainstem bronchus. This was more often observed for the right than for the left side (37 vs 22 settings). This analysis demonstrates that irrespective of the recommendation for size selection used, neither the two balloon-tipped vascular catheters included nor the Arndt endobronchial blockers are ideal for lung isolation in children are compared with the age-related relevant dimensions of pediatric airway anatomy. A redesign of bronchial blocker equipment with age-related anatomically based high-volume, low-pressure blocker balloons made from ultrathin membranes and with smaller catheters would be desirable.

Gaps in Training: Misunderstandings of Airway Management in Medical Students and Internal Medicine Residents.

(1) Evaluate baseline airway knowledge of medical students (MSs) and internal medicine (IM) residents. (2) Improve MS and IM resident understanding of airway anatomy, general tracheostomy and laryngectomy care, and management of airway emergencies. A before-and-after survey study was carried out over a single academic year. MS and IM resident knowledge was evaluated before and after an educational, grand rounds-style lecture reviewing airway anatomy, tracheostomy tube components, tracheostomy and laryngectomy care, and clinical vignettes. The primary outcome measure was change in pre- and postlecture survey scores. Prelecture surveys were completed by 90 participants, and 83 completed a postlecture assessment. Postlecture scores were statistically improved for all questions on the assessment (P < .001). Level of training did not confer an improved pre- or postlecture survey score. While the majority of participants in our study had previously cared for patients with a tracheostomy or laryngectomy, less than half were able to correctly address basic airway emergencies. Senior IM residents were no more proficient than MSs in addressing airway emergencies. The lack of formal airway training places patients at risk with routine care and in emergencies, demonstrating the need for formal airway education for early medical trainees. Our data demonstrate a serious gap in MS and IM resident knowledge with respect to emergent airway care in patients with tracheostomies and laryngectomies. An interdepartmental collaborative curriculum offers a realistic and potentially life-saving solution for medical trainees.

Correlations to Estimate the Key Anatomical Dimensions of Pediatric Nasal Airways using Minimally Invasive Measurements of Intranasal Pressure Gradient.

Background: Understanding the morphology of nasal airways is important in determining the nasal airway deposition of inhaled aerosol. Moreover, objective assessment of the anatomy of human nasal airways is useful to develop a database of reference or normal values as a resource to investigate anatomical abnormalities of airways. Current methods for the objective assessment of the nasal airways are either limited to very few dimensions or can only be performed by specialized researchers. Thus, the main objective of this study was to determine the correlations between the intranasal pressure gradient (Δp) and the key anatomical dimensions of the pediatric nasal airways, which could in turn allow the extrapolation of nasal airway morphology based on simple minimally invasive measurements of pressure. Methods: The anatomical data and Δp were obtained from in vitro studies with nasal airway models of 11 infants ages 3-18 months and 13 children ages 4-14 years old. Key anatomical dimensions were identified based on both rhinology and aerosol dosimetry literature. These anatomic data, including the volume, V, surface area, As, length, L, and the minimum cross-sectional area of the replicas, Amin, were then analyzed for correlation with Δp and flow parameters, using Bernoulli's principle and dimensional analysis. Results: Strong correlations were found between Δp and As/L for children, and between Δp and V/As for infants. Additional pressure gradient correlations were developed with Amin, V/As, , and L. Conclusions: The correlations identified between anatomic data and Δp have clinical implications in pediatric rhinology, suggesting that certain aspects of airway anatomy in infants and children can be predicted through the measurement of Δp. The airway dimensions, predicted using Δp measurement, may be used in tandem with aerosol nasal deposition correlations that account for nasal airway dimensions.

Difficult airways: a 3D printing study with virtual fibreoptic endoscopy

Head and neck cancer patients present unique airway challenges, and oropharyngeal, laryngeal, and hypopharyngeal tumours considerably distort and narrow the anatomy of the airway. We describe the use of 3D augmented reality software combined with 3D printed models to assess the anatomy of difficult airways and to assist in the formulation of the most optimal airway management strategy in such patients. The reported patients had computed tomograms (CT) of the neck prior to their anaesthetic and surgical management. DICOM files of the respective scans were imported to 3D rendering software (OsiriX, Pixmeo). We constructed volume rendered models for initial assessment of the airway then generated serial surface rendered models to create a virtual endoscopic path of the airway to simulate the fibreoptic approach. To further facilitate the study of difficult airways we have subsequently printed 3D models of those that were most difficult using rapid prototyping. Head and neck tumours significantly distort the airway. Thorough study of the relevant anatomy prior to airway management for operating reasons enhances communication between the surgeon and anaesthetist, and aids selection of the most appropriate intubation approach. In conclusion, this paper highlights a useful and novel pre-assessment strategy that allows a virtual, visual, 3-dimensional assessment of the airway anatomy combined with 3D modelling and 3D printing. This enables the airway specialist, anaesthetist, and head and neck surgeon to anticipate any critical steps and adjust the plan accordingly.

A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation

One-lung ventilation (OLV) in children remains a niche practice with few studies to guide best practices. The objective of this study was to describe lower airway anatomy relevant to establishment of OLV in young children. Retrospective, observational study using pre-existing studies in the electronic health record. Single institution, academic medical center, tertiary-care hospital. Pediatric patients <8 years old. None. Chest computed tomographic scans of 111 children 4 days to 8 years of age were reviewed. Measurements were taken from the thyroid isthmus to the carina, carina to first lobar branch on the left and right,diameter of the trachea at the carina, and diameter of the left and right mainstem bronchi. Dimensions were correlated with the outer diameter of endotracheal tubes and bronchial blockers. The left mainstem bronchus is consistently smaller than the right. Lung isolation using a mainstem technique on the left should use an endotracheal tube a half size smaller than would be used for tracheal intubation. The length from the carina to the first lobar branch on the left is consistently 3 times longer than on the right. Further, age-delineated bronchial diameters suggest that the clinician should transition from a 5F to a 7F Arndt bronchial blocker at 3-to-4 years of age. A more detailed and accurate understanding of pediatric lower airway anatomy may assist the clinician in successfully performing OLV in young children.

Management of a Difficult Airway Scenario in a Case of Hurler’s Syndrome with a D-Blade Video Laryngoscope

AbstractHurler’s syndrome is a rare genetic disease characterized by progressive multiorgan accumulation of glycosaminoglycans. It is associated with progressive craniofacial, skeletal, and cardiac involvement, which increases the risk of anesthesia. Patients with Hurler’s syndrome could present as the worst airway management problem an anesthesiologist could deal with due to abnormal upper airway anatomy and limited neck manipulation, owing to the atlantoaxial instability. We report a case of difficult airway scenario of a child with Hurler’s syndrome, leading to an apparent cannot ventilate cannot intubate scenario, which was managed successfully with the help of a C-MAC video laryngoscope with unique D-blade. In Hurler’s syndrome, C-MAC with D-blade is an excellent tool in establishing an airway in a pediatric difficult airway scenario. Moreover, D-blade C-MAC could be considered as the primary tool for establishing an airway in pediatric patients with Hurler’s syndrome.

Drug-induced sleep endoscopy findings in surgically-naïve obese vs non-obese children

ObjectiveTo determine if drug-induced sleep endoscopy (DISE) findings are different in obese versus non-obese pediatric patients with obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB). MethodsProspective, observational cohort study from June 2017 to June 2018 at a tertiary academic pediatric medical center that included surgically-naïve children ages 2–12 with diagnoses of OSA or sleep-disordered breathing. Subjects with a known diagnosis of craniofacial syndromes, genetic disorders, prior adenoidectomy or tonsillectomy, or chronic tonsillitis as the indication for surgery were excluded. Two groups were assessed for patterns of obstruction based on DISE videos at each anatomic airway level using a previously published DISE scoring system. The groups included obese subjects (BMI ≥ 95th percentile) and non-obese controls (BMI <85th percentile). Each video was graded by two blinded, fellowship-trained Pediatric Otolaryngologists. ResultsFifty-one patients were included, 26 non-obese and 25 obese. Based on anatomic airway level, there was no statistically significant difference in airway obstruction at the velum (p = 0.134), adenoid (p = 0.592), lateral pharyngeal walls (p = 0.867), tongue base (p = 0.977), or supraglottis (p = 0.428) between obese and non-obese children. ConclusionOur prospective study did not associate severity of obstruction with obesity status based on anatomic airway levels. Further studies are needed to elucidate the etiology of the high rate of persistent obstructive sleep apnea in obese children.

In Response.

In Response.

Exercise as a treatment for sleep apnea

Citation:Lee-Iannotti JK, Parish JM. Exercise as a treatment for sleep apnea. J Clin Sleep Med. 2020;16(7):1005–1006.