Airway Management In Patients Research Articles

Airway management for patients with tracheal stenosis and severe scar contracture of the face and neck via bronchoscopy: a case report

Both anaesthesiologists and surgeons experience challenges in managing airway stenosis and scar contracture in the face and neck. Herein, we report the case of a 38-year-old woman (BMI 23.1 kg/m2, third-degree burns covering 40% of her body, an American Society of Anaesthesiologists physical status III) with an unusual case of airway constriction. This patient had a predictable difficult airway (mouth opening of 2 cm, bilateral nostril scar hyperplasia, Mallampatti score III, scarring of the head and neck, and severe tracheal stenosis). Tracheal stenosis measuring 5.5 mm in width as observed 8 cm below the glottis, and the bronchoscope could not pass through it. After two failed attempts at laryngeal mask insertion, we decided to instead insert a custom-made tracheal tube under the guidance of a fiberoptic bronchoscope. The operation was successful, and the patient was transferred to the intensive care unit (ICU).

Application of Laryngeal Mask Airway in Airway Management of Patients with A Tracheal Stenosis – A Case Report

Tracheal stenosis is a severe condition that significantly affects patients’ quality of life, with airway reconstruction surgery being the primary treatment. Airway management is critical during general anesthesia, especially when the airway is the surgical site. This report presents clinical concepts and cases of the successful use of laryngeal masks as a supraglottic airway for intraoperative tracheal management in patients with tracheal stenosis. As a transitional device for airway management, a laryngeal mask can provide adequate ventilation and oxygenation and should be incorporated into airway control protocols for individuals with tracheal stenosis.

Efficacy of tracheostomy for respiratory management in patients with advanced oral cancer

BackgroundMany studies have been reported on tracheostomy to prevent upper airway obstruction after surgery. Among these, the scoring system proposed by Cameron et al. quantifies various factors that influence postoperative respiratory failure. This system provides a basis for surgeons to decide whether to perform an elective tracheostomy. In this study, the authors applied the Cameron scoring system retrospectively to patients undergoing severe oral cancer surgery to reevaluate the indications for elective tracheostomy and to investigate its clinical efficacy in airway management. In this study, a sample of 20 patients who underwent oral cancer surgery was selected and divided into two groups: 10 underwent tracheostomy and 10 did not. The Cameron scoring scores for each patient were extracted, to verify whether elective tracheostomy was performed in accordance with the threshold scores. Differences in scores and significant clinical impact factors between the two groups were analyzed and compared.ResultThe 10 patients who underwent tracheostomy had an average Cameron score of 6.4, all scoring above the recommended threshold of 5 for tracheostomy. For the 10 patients who did not undergo tracheostomy, the average score was 2.5, with 8 out of these 10 patients scoring below 5. Significant clinical impact factors observed included the location and size of the tumor, the performance of mandibulectomy and neck dissection, and the type of reconstruction surgery.ConclusionIn planning surgery for oral cancer patients, it is essential to consider the use of elective tracheostomy based on preoperative assessment of the risk of postoperative airway obstruction using tools like the Cameron scoring system, and patients’ condition. Research confirms that elective tracheostomy effectively enhances airway management in patients with severe oral cancer.

Impact of Radiotherapy on Endotracheal Intubation Quality Metrics in Patients with Esophageal Cancer: A Challenge for Advanced Airway Management?

(1) Background: Currently, no data are available in the literature investigating the influence of radiotherapy (RT) on endotracheal intubation success in patients with esophageal cancer. This study aims to evaluate the impact of RT on endotracheal intubation quality metrics in patients with esophageal cancer. (2) Methods: Patients with esophageal cancer who underwent RT followed by surgery between 2012 and 2023 at the University Hospital Heidelberg, Germany, were retrospectively analyzed. (3) Results: Fifty-five patients, predominantly males 65.5% with a mean age of 64 years, were enrolled. Overall, 81.8% of the patients had an ASA class of III, followed by 27.2% ASA II. The mean prescribed cumulative total dose to the primary tumor and lymph node metastasis was 48.2 Gy with a mean single dose of 1.8 Gy. The mean laryngeal total dose was 40.0 Gy. Direct laryngoscopy was performed in 80.0% of cases, followed by 12.1% videolaryngoscopy, and 7.2% required fiberoptic intubation. Overall, 96.4% of patients were successfully intubated on the first attempt. (4) Conclusions: It has been demonstrated that post-RT effects can increase the risk of airway management difficulties and complications. The results of our study did not indicate any evidence of impaired advanced airway management in patients with esophageal cancer who had undergone RT.

Difficult airway management in patients with laryngeal tumor: Case series and systematic review

Airway management in patients with laryngeal tumor presents significant challenges and risks. SEEKflex (Safe Easy Endotracheal Kit-flexible) is a modified introducer developed by our team for the intubation in severe COVID-19 patients. Here, we present 4 cases where SEEKflex facilitated tracheal intubation in patients with laryngeal tumors underwent surgeries and achieved a definitive airway. A systematic review of MEDLINE, EMBASE, CINAHL, and Web of Science databases was also performed using the keywords such as “laryngeal tumor”, “airway management” and “anesthesia” to identify the reports on airway management techniques for patients with laryngeal tumors. 14 papers involving 17 patients were retrieved. All the cases reported positive patient outcomes, though there were instances of intubation failure after general anesthesia. Despite increased availability of basic airway management techniques and various types of intubation tools, challenges persist, especially in patients with pre-existing severe airway obstruction. SEEKflex provides a simple and rapid solution for intubating patients with laryngeal tumors, which ensures a clear airway for patient safety.

Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM).

There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting. An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012-June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors. It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.

AB192. SOH24AB_149. Emergent airway management in patients with subglottic lesions: a case series

AB192. SOH24AB_149. Emergent airway management in patients with subglottic lesions: a case series

Comparison of Modified Mallampati Classification in Supine and Sitting Positions to Predict Difficult Tracheal Intubation in Diabetic Patients.

Airway management of patients with long-standing diabetes poses a major challenge for anaesthesiologists due to stiff joint syndrome affecting the atlanto-occipital joint. In certain cases requiring immobilization, the Mallampati test must often be performed in the supine position for obvious reasons. Hence, we determined the diagnostic precision (sensitivity and specificity) of the modified Mallampati test in sitting and supine positions among the diabetic population in predicting difficult tracheal intubation. A single-center prospective observational study on adult diabetic patients undergoing general anesthesia and orotracheal intubation was carried out. An observer recorded the modified Mallampati in the sitting posture during the pre-anesthetic examination. The Mallampati in the supine position was determined while in the operating room, and the difficulty of intubation was noted, and diagnostic precision was calculated. The main objective was to predict a difficult airway by calculating the sensitivity, specificity, positive predictive value, and negative predictive value. Out of the 150 participants, Mallampati grading in a sitting position was correctly able to identify 42.5% of difficult intubation cases, whereas it was 97.5% with Mallampati in the supine position. Mallampati grading in the sitting position was able to correctly identify 89.1% of easy intubation cases, which was 63.6% with Mallampati in the supine position. The correlation of Mallampati in the supine position with CL grading was statistically significant (P < 0.001). Among diabetic patients, the modified Mallampati test in the supine position can be considered a more accurate and sensitive predictor of difficult intubation than the sitting posture.

Airway Management for Emergency Spinal Epidural Hematoma Evacuation With Awake Spine Surgery: Case Report and Literature Review.

Postoperative spinal epidural hematomas (pSEHs) are a rare complication of microdiscectomy surgery. The hematoma may be unnoticed intraoperatively, but timely treatment may prevent permanent neurologic impairment. Airway management in patients with a full stomach is generally performed with rapid sequence intubation and general anesthesia. Awake spine surgery without intravenous analgesia or sedation may be beneficial in patients with a full stomach who are at higher risk for pulmonary aspiration with general anesthesia due to a loss of non-per-oral (NPO) status. The authors propose that it can also be performed in cases of urgent/emergent postsurgical epidural hematoma evacuation. We present the airway management of a 41-year-old man who underwent a minimally invasive microdiscectomy with normal strength immediately after surgery but developed progressive weakness with right foot dorsiflexion, right extensor hallucis longus muscle weakness, and progressive right lower extremity ascending numbness over the course of the first 2 hours after surgery due to an epidural hematoma. The patient underwent urgent awake epidural hematoma evacuation with a spinal anesthetic. Afterward, the patient recovered neurological function and was discharged the following morning. pSEHs are a rare complication of microdiscectomy surgery. The purpose of this article is to describe the novel use of awake spine surgery in emergent epidural hematoma evacuation and demonstrate its feasibility. In emergencies, when a patient is not NPO, awake spine surgery can safely be performed with no sedation, ensuring the patient can protect their airway and avoid the risk of aspiration.

Incidence and Predictors of Difficult Intubation in Patients Undergoing Thyroid Surgery

Introduction: Thyroid enlargement is considered a risk factor for challenging direct laryngoscopy and intubation. Airway management in patients with thyroid swelling presents unique challenges, requiring thorough preparation for potential difficult airways. Although airway management in the overall population has been thoroughly researched, there is a scarcity of literature specifically addressing airway management in individuals who have thyroid enlargement. Aim: To evaluate the incidence of difficult intubation in patients undergoing thyroid surgery, utilising the Intubation Difficulty Score (IDS). Materials and Methods: This cross-sectional observational study was conducted among 258 patients in the Department of Anaesthesiology, Government TD Medical College, Alappuzha, Kerala, India. Various parameters including Modified Mallampati score, neck circumference, Body Mass Index (BMI), inter-incisor distance, retrognathia, neck extension, thyromental distance, tracheal deviation, and tracheal compression were assessed for all patients with thyroid swelling. The incidence of difficult endotracheal intubation was analysed using the IDS and the time taken for successful intubation was recorded. Data were presented as mean±standard deviation (SD), frequencies, and percentages. The association between variables was analysed using the Chi-square test. Results: Thyroid disorders were more common in females 220 (85.3%) than in males 38 (14.7%). The variables such as BMI, Mallampati score, thyromental distance, inter-incisor distance, and neck mobility were not found to be associated with difficult intubation. However, increased neck circumference (&gt;43 cm) was statistically significant (p-value=0.007) in relation to difficult intubation. According to IDS, 94.2% of patients had easy intubation, while 5.8% experienced difficult intubation. In terms of intubation times, 72.5% of patients were intubated within 10-15 seconds, 24.4% within 16-20 seconds, and 3.1% took longer than 20 seconds. Conclusion: Thyroid surgery itself is not an independent predictive factor for difficult intubation. Among the predictive factors in the study population, a neck circumference greater than 43 cm was found to be associated with difficult endotracheal intubation during thyroid surgery

Submental intubation in patients with maxillofacial fractures: case report and literature review

Background: Conventional orotracheal and nasotracheal intubation can be challenging in patients requiring fixation of fractures of the maxillofacial skeleton. The proximity of the surgical site for maxillofacial procedures to the airway predisposes patients with maxillofacial pathologies to anaesthetic complications like dislodged endotracheal (ET) tubes and inadvertent extubation. The need for maxillomandibular fixation (MMF) as part of fracture management precludes the use of orotracheal intubation. In patients with nasal bone fractures, nasotracheal intubation may not be feasible, and the complications associated with tracheostomy make it a last resort for securing access to the airway. The purpose of this article is to highlight the usefulness of submental intubation in the management of patients with maxillofacial fractures.Case presentation: We present our initial experience with the submental route of intubation and illustrate the procedure with a case of a patient with midface fractures successfully managed using submental intubation. A literature review of alternative airway routes to conventional orotracheal and nasotracheal intubation is also included.Discussion: Edentulous spaces, retromolar intubation, submental intubation, submandibular intubation, and tracheostomy have been used as alternatives to conventional endotracheal intubation. Each route has its associated advantages, disadvantages, and limitations.The submental approach is fast, easy to learn, and associated with minimal complications.Conclusion:Submental intubation is a safe option for airway management in patients with maxillofacial fractures.

Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study.

Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]). Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS). Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020. A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry. None. We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822). Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.

Utility of a clinical risk scale to predict the requirement of advanced airway management in patients with a diagnosis of deep neck abscess

ObjectivesTo analyze the clinical utility of a clinical risk scale to predict the need for advanced airway management in patients with deep neck abscess. MethodsObservational, analytical, cross-sectional study. Patients over 18 years old, both genders, with surgical management of a deep neck abscess, between January 1st, 2015 to December 31th, 2021, who were applied the clinical risk scale (https://7-414-5-19.shinyapps.io/ClinicalRiskScore/). The sensitivity, specificity, and predictive values of the scale were calculated based on the identified clinical outcomes. A p<0.05 was considered significant. ResultsA sample of 213 patients was obtained, 121 (56.8%) men, of whom 50 (23.5%) required advanced airway management. Dyspnea was the variable with the most statistical weight in our study, (p=0.001) as well as the multiple spaces involvement, (p=0.001) the presence of air corpuscles, (p=0.001) compromise of the retropharyngeal space (p=0.001) and age greater than 55 years (p=0.001). Taking these data into account, were found for the clinical risk scale a sensitivity of 97% and a specificity of 65% (p=0.001, 95% CI 0.856–0.984). ConclusionsThe clinical risk scale developed to predict advanced airway management in patients with a diagnosis of deep neck abscess may be applicable in our environment with high sensitivity and specificity. Level of evidenceIV.

Changing trend of airway management in patients with temporomandibular joint ankylosis; A 9 year retrospective appraisal in Sokoto, Northwest Nigeria

Study objectiveTemporomandibular joint ankylosis (TMJA) presents a serious airway management challenge as rigid laryngoscopy is not possible. Administration of anesthesia to these patients requires flexible fibreoptic bronchoscope, trained personnel and monitoring facilities. These equipment and trained personnel are not readily available in resource limited countries. The main objective of this article is to report the changing trends of airway management in patients with TMJA in our centre over the last 9 years. DesignThis was a retrospective study conducted from January 2014 to December 2022. The period of review was grouped into 3 yearly periods (2014–2016, 2017–2019 and 2020–2022). SettingDepartment of Oral and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital and Noma Children Hospital, Sokoto, Nigeria. Patients A total of 117 patients were studied. Data retrieved include gender, age, etiology of ankylosis, duration of ankylosis, type of airway management and complications. Interventions Type of airway management. Conducted includeBlind nasal tracheal intubation, awake flexible fibreoptics, sleeping flexible fibreoptics and tracheostomy. MeasurementsAnesthetic chart, age, duration and laterality of TMJA. Main resultsA total of 117 TMJA patients (56 males and 61females) were recruited into the study. Age ranged from 5 to 40 years. Mean ± SD 16.5(7.85). Bulk of the patients were between age 1–30 years. During the 2014–2016 review, tracheostomy was the main airway management procedure in 20 (17.1%) patients, while only 1 (0.8%) case of blind nasal tracheal intubation was observed. In the 2020–2022 review, most of the airway management was awake fibre-optics in 48 (41.0%) patients and sleeping fibre-optics in 27 (23.1%) patients. Only 2 (1.7%) cases of death was observed in the tracheostomy subjects. ConclusionAirway management in TMJA patients have evolved over the years in our centre. Surgical airway management which has many shortcomings is no longer encouraged because of improved facilities and personnel.

Oropharyngeal Hemorrhage and Difficult Airway Management: A Decision Not to Intubate

BackgroundBleeding in the upper airways is an important cause of airway-related death. A higher incidence of airway management failure and complications after intubation attempts in the emergency department (ED) had been suggested. Airway management of patients with active oropharyngeal hemorrhage may be challenging, leading the clinician to modify the approach. Case ReportA 57-year-old woman presented to the ED with oropharyngeal hemorrhage after an extensive invasive dental procedure. She was on long-term warfarin therapy due to aortic and mitral valve replacement, which she suspended 5 days prior and restarted the day after the procedure. Besides the active bleeding, swelling, and hematoma of the face, the patient had other signs of “difficult airway,” so there were serious questions on when and how to manage the airway. Several strategies to address the airway were considered, the main point being an early versus later intubation. As the patient remained clinically stable, she was conservatively managed with local hemostasis and coagulopathy reversal. The patient was transferred to the intensive care unit, where she remained stable and was successfully discharged after restart on warfarin. Why Should an Emergency Physician Be Aware of This?When faced with an oropharyngeal hemorrhage, emergency physicians may be compelled to secure and protect the airway. This could be achieved by planning several strategies. Nevertheless, in selected patients, and considering the circumstances, not addressing the airway is a reasonable and justifiable alternative.

Effectiveness of Training: Airway Management of Tracheostomized Pediatric Patients by Pediatric Residents and Anesthesiology Residents.

To evaluate the effect of training on increasing baseline knowledge of pediatrics and anesthesia residents about airway management of pediatric patients with tracheostomy. It is a prospective, descriptive, before and after survey study. A questionnaire was conducted to measure the baseline knowledge of pediatrics and anesthesia residents about airway management in patients with pediatric tracheotomy. The same questionnaire was repeated after the education. Of the 63 participants, 42 were pediatric residents and 21 were anesthesiology residents. While the number of participants who answered the cuff part, inner cannula part, obturator part and balloon part of the tracheostomy tube correctly before the training was 27, 4, 10, and 12, respectively, these numbers increased to 53, 52, 57, and 55 after the training. There was a statistically significant improvement after the training in the correct response of the cuff, inner cannula, obturator, and balloon sections. A statistically significant improvement was observed in the answers received after the training for all 7 questions regarding the clinical scenario of accidental decannulation and tracheostomy bleeding compared to the pre-training. There was a statistical improvement in part where the participants rated themselves. In conclusion, training increases the ability of healthcare professionals to cope with life-threatening complications related to pediatric tracheotomy. A standardized education program on pediatric tracheostomy should be included in the routine programs of associated departments such as emergency medicine, anesthesia, and pediatrics residencies.

A comparative evaluation of LMA® Gastro™ versus Gastro Laryngeal Tube for airway management in patients undergoing endoscopic retrograde cholangiopancreatography under general anesthesia: A randomized control study

BackgroundEndoscopic Retrograde Cholangio-Pancreatography is fraught with anesthetic challenges. Various anesthesia techniques have been studied, ranging from sedation to general anesthesia with tracheal intubation or specialized supra-glottic airway devices. MethodsThis randomized control trial included 70 patients undergoing endoscopic retrograde cholangio-pancreatography under general anesthesia and divided equally into two groups, LMA® Gastro™ or Gastro-Laryngeal tube. The primary objective was to compare the 1st time success rate and the secondary outcomes included, ease of insertion, number of attempts, oropharyngeal leak pressure, occurrence of adverse events; hemodynamic and ventilatory parameters. They were also compared in terms gastroenterologist's feedback about the device. ResultsThe first-time success rate for LMA® Gastro™ group was 88.5% and for Gastro-Laryngeal tube group was 77.1% (p value = 0.10). The mean difference for ease of insertion (p value = 0.001), oropharyngeal leak pressure (p value < 0.0001), peak airway pressure (p value < 0.0001) at different time intervals were significant for LMA® Gastro™ group. Hemodynamic response in terms of mean arterial pressure at 0 min (p value = 0.021) and gastroenterologist's feedback (p value < 0.0001) for Gastro-Laryngeal tube group was shown to be statistically significant. The mean difference between two groups for number of attempts, complications, hemodynamic response, end tidal volume, EtCO2 and recovery time were statistically insignificant (p value > 0.05). There was no desaturation in both the groups. ConclusionTo conclude, LMA® Gastro™ had performed better in terms of an airway device and ventilatory efficiency even in anticipated difficult airway, on the other hand, Gastro-Laryngeal tube is more conducive for the insertion and maneuvering of a gastro-endoscope.

Manual jet ventilation to rescue a patient with pinhole tracheal stenosis: A case report

Airway management of patients with tracheal stenosis is highly challenging and even establishing a surgical airway may be difficult in these patients. A 24 year old female developed pinhole tracheal restenosis after undergoing tracheal web resection and reconstruction. After other modes of ventilation had failed, we used the Manual jet ventilator endotracheal tube assembly as a rescue device and performed intermittent low-frequency jet ventilation until a definitive surgical airway could be established.: Central airway obstruction in severe tracheal stenosis can cause life-threatening hypoxia. Jet ventilation through the pin hole opening buys some time for the surgeon to secure the airway.

Airway Management of a Patient with Montgomery T-tube in situ undergoing Neurosurgery

This article stipulates the airway management in a patient requiring cranial debridement and cranioplasty with a Montgomery T-tube (MTT) in situ. Anesthetic techniques that have been previously described for surgeries with MTT in situ which can be managed by applying a laryngeal mask or intubating a trachea tube easily. The airway management of patients with an MTT in situ, requiring a supine position with the head rightly tilted and flexed, has not yet been addressed. In this article, we explored some possible approaches to cope with this arising problem. We present how we managed to intubate a double-lumen endotracheal tube onto the superior tracheal limb of the T-tube since the 5.0 mm ID tracheal tube (equivalent to a 6.9 mm ED) could not pass through the tube readily. This technique could possibly be considered for patients in similar clinical scenarios.

Airway Management In Patients With Traumatic Cervical Spine Injury For Emergency Surgery: A Case Series

Airway Management In Patients With Traumatic Cervical Spine Injury For Emergency Surgery: A Case Series