Airway Management In Patients Research Articles

Die Larynxmaske – Schritt für Schritt

Laryngeal masks are supraglottic airway devices developed in the early 1980s. Today, they are frequently used in clinical routine to provide airway access for mechanical ventilation in patients undergoing surgery with a short duration. Moreover, the they have also become integral part of difficult airway management in patients who cannot be intubated by the use of conventional laryngoscopy. Relevant advances have been made to simplify their positioning and improve tightness with the aim to allow for the use of higher airway pressures during mechanical ventilation thereby reducing the risk of gastric insufflation and pulmonary aspiration. Focusing on this goal, several different prototypes have been developed and introduced in clinical practice until today. However, even these new developed laryngeal masks still do not provide reliable protection against pulmonary aspiration until today. Consequently, their use In critical care medicine is still limited to rescue situations with intubation failure. In this review some of the most popular lanryngeal masks are presented, indications for their use are outlined and their handling is described.

Use of a Tracheal Tube as a Nasally Inserted Supraglottic Airway in a Case of Near-Fatal Airway Obstruction Caused by Epiglottitis

Airway management is critical during near-fatal obstruction of the upper airway in epiglottitis; however, this is challenging because of the sitting posture and agitated mental status of the patient. Moreover, there is currently no established protocol for safe airway management in patients with epiglottitis. Here, we describe the use of a conventional tracheal tube as a nasolaryngeal airway to maintain airway patency at the site of airway narrowing in the supine position, which enabled alleviation of imminent airway obstruction in a patient with epiglottitis. For definitive airway establishment, tracheostomy was then safely performed in the supine position.

Confirmed cardiac output on emergency medical services arrival as confounding by indication: an observational study of prehospital airway management in patients with out-of-hospital cardiac arrest

ObjectivesMany registry studies on patients with out-of-hospital cardiac arrest (OHCA) have reported that conventional bag-valve-mask (BVM) ventilation is independently associated with favourable outcomes. This study aimed to compare the data...

A data review of airway management in patients with oral cavity or oropharyngeal cancer: a single-institution experience

BackgroundOral cavity and oropharyngeal cancer impose significant threat to airway management. Head and neck radiotherapy (HNRT) may further increase the difficulty of tracheal intubation. We hypothesized that a history of HNRT would be associated with a high rate of difficult tracheal intubation.MethodsAdult patients with a history of HNRT were identified. Non-HNRT controls were case-matched by age, sex and body mass index. The tracheal intubation status between the two patient groups (treated vs. untreated with HNRT) was compared. The t test was used to evaluate differences in continuous variables between the 2 groups. Fisher’s exact test or a chi-square test was used to test for associations between radiation status and patient characteristics that may be associated with difficult tracheal intubation. Odds ratio and its confidence interval were used to assess the effect of radiation status on intubation status.ResultsThe final cohort of 472 matched patients in age, sex and body mass index consisted of 236 patients who had HNRT before surgery and 236 who had upfront surgery without HNRT. The percentage of patients who had restricted neck range of motion in the HNRT group was significantly higher than in the control group (22.3% vs. 11.0%; p = 0.001). The proportion of patients with trismus (p = 0.11) or difficult tracheal intubation (p = 0.73) did not differ significantly between the 2 groups. 12.7% patients in the study had difficult tracheal intubation. Patients who had mallampati scores of 3 or 4 had significantly higher rate of difficult tracheal intubation than did patients with mallampati scores of 1 or 2 (17.8% vs. 8.7%; p = 0.004). Multivariate logistic regression model showed no difference between HNRT and intubation status after adjusting neck range of motion and mallampati score (OR = 0.91, 95% CI: 0.510 to1.612).ConclusionsPrevious treatment with HNRT was not associated with additional risk of difficult tracheal intubation. Mallampati score may be a sensitive measurement for difficult tracheal intubation in this patient population.

Procedural Challenges During Intubation in Patients With Oropharyngeal Masses: A Prospective Observational Study.

In patients who undergo surgery for oropharyngeal masses, intubation is almost always successful. However, technical aspects of airway management, including bag mask ventilation and oxygenation, may still be difficult. Although rates of airway difficulty and intubation success in these patients have been studied, these data may not reflect difficulty with individual components of the intubation process. We hypothesized that rates of complications with individual elements of the intubation process would not be reflected in the rate of eventual intubation success. To test our hypothesis, we observed the process of airway management and resulting complications with oxygenation and bag mask ventilation in patients with oropharyngeal masses undergoing otorhinolaryngology procedures under general anesthesia. Forty-four patients with oropharyngeal masses scheduled for surgery were observed during the process of airway management. Observers recorded the number of airway devices used, the overall number of intubation attempts, the number and type of manual maneuvers required during bag mask ventilation, and the incidence of oxygen desaturation. The eventual intubation success rate was also recorded. All 44 patients (100%; 95% CI, 92%-100%) were successfully intubated. Thirty-six (81.8%) of 44 patients were intubated asleep and 8 (18.2%) of 44 were intubated awake using flexible fiberoptic bronchoscopy. Thirty-one (86.1%) of 36 patients who were intubated asleep received bag mask ventilation before intubation, while the other 5 patients underwent a rapid sequence induction. Twenty-seven (61.4%) of 44 patients (95% CI, 45%-75%) had ≥1 complication during airway management. Ten (23%) of 44 patients (95% CI, 11%-37%) required ≥3 attempts to intubate, 21 (68%) of 31 patients (95% CI, 49%-83%) had difficult mask ventilation, and 15 patients (34%; 95% CI, 20%-50%) experienced desaturation (oxygen saturation measured by pulse oximetry, <95%). We found that, although all patients were successfully intubated, clinicians frequently encountered complications with both intubation and mask ventilation. These complications required frequent use of additional manual maneuvers during mask ventilation and a high incidence of oxygen desaturation. The difficulty of airway management in patients with oropharyngeal masses may not be effectively assessed by success rate alone.

How to Incorporate Bariatric Training Into Your Fellowship Program.

How to Incorporate Bariatric Training Into Your Fellowship Program.

Airway management in patients with mucopolysaccharidoses: The progression toward difficult intubation.

Patients with mucopolysaccharidoses (MPS) have physical changes to their airways over time. Due to the natural progression of their disease, these patients become more difficult to intubate as they get older. The aims of this study were to evaluate the difficulty of airway management in MPS patients over time, and to evaluate the effect of bone marrow transplant and/or enzyme replacement therapy on airway difficulty. A retrospective review of MPS patients presenting for surgery from January 2012 to May 2018 was performed. Patients were assigned to groups based on their ages at the time of surgery, number of intubation attempts, equipment used for intubation, difficulty of mask ventilation, and difficulty of laryngeal mask airway placement. The same designations were applied to patients with a history of a bone marrow transplant (BMT) and/or enzyme replacement therapy, and they were compared to patients of similar ages who had received no treatment. Logistic regression was used to determine the odds of difficult intubation. One hundred and twenty-eight anesthetic records were reviewed. In 27 cases, the patient had a BMT and in 54 cases, the patient had received enzyme replacement therapy. Adults (18years and older) had the highest likelihood of difficult intubation (OR 13.44, CI 1.45-124.86, P=0.022). Mask ventilation and laryngeal mask airway placement were not significantly more difficult in any age groups. Bone marrow transplant did not improve airway management. A history of enzyme replacement therapy was associated with an increased risk of difficult intubation in patients under the age of 12. As patients with MPS get older, there is a progression toward difficult intubation. Mask ventilation and laryngeal mask airway placement does not become more difficult with age. Bone marrow transplantation did not affect airway difficulty in our population, while enzyme replacement therapy was associated with difficult intubations in younger patients.

The Laryngeal mask - step by step

Laryngeal masks are supraglottic airway devices developed in the early 1980s. Today, they are frequently used in clinical routine to provide airway access for mechanical ventilation in patients undergoing surgery with a short duration. Moreover, the they have also become integral part of difficult airway management in patients who cannot be intubated by the use of conventional laryngoscopy.Relevant advances have been made to simplify their positioning and improve tightness with the aim to allow for the use of higher airway pressures during mechanical ventilation thereby reducing the risk of gastric insufflation and pulmonary aspiration. Focusing on this goal, several different prototypes have been developed and introduced in clinical practice until today. However, even these new developed laryngeal masks still do not provide reliable protection against pulmonary aspiration until today. Consequently, their use In critical care medicine is still limited to rescue situations with intubation failure.In this review some of the most popular lanryngeal masks are presented, indications for their use are outlined and their handling is described.

Perioperative airway management of patients with cervical trauma

Perioperative airway management of patients with cervical trauma

Perioperative airway management in patients with maxillofacial and cervical venous malformation involving isthmus faucium area

Data of patients with maxillofacial and jugular venous malformations involving isthmus faucium area from January 2012 to July 2016 were collected.Patients were questioned about the medical history before operation, and the airway was adequately evaluated.The patients diagnosed as having non-difficult airways were endotracheally tubed using fast induction of anesthesia.Tracheal intubation was performed using fast induction of anesthesia combined with topical anesthesia after visual laryngoscopy in the patients assessed as having difficult airways.Endotracheal intubation was guided with a visual hard endoscope or a fibrobronchoscope in the patients with difficulty in opening mouth after multiple treatments.Postoperative airway management was as follows: the tracheal tube was removed after extubation, the tracheal tube was retained for 24-48 h, or preventive tracheotomy was performed.Oxygen was inhaled by mask.A total of 157 patients were included in this study, 55 patients diagnosed as having difficult airways, and among the 55 patients, 87% cases were intubated after visual laryngoscopy and 13% cases received tracheotomy.There were 10 patients with difficulty in opening mouth after multiple treatments and 5 cases underwent tracheotomy in the outer hospital.Sixteen patients presented with a transient increase in airway pressure during intraoperative injection of anhydrous ethanol.There were 106 cases in whom the tracheal tube was removed immediately after emergence, and among them, 32.1% cases needed tongue traction and 2.8% cases underwent emergency tracheotomy after extubation.Thirty-eight patients needed to retain the tracheal tube for 24-48 h after operation, and among them, 37% cases needed tongue traction and 3% cases required emergency tracheotomy after extubation.Thirteen cases underwent preventive tracheotomy.The preoperative visit and assessment are especially important, appropriate airway management strategies should be developed, vital signs should be closely observed during operation, and the timing of extubation should be grasped for this type of patients, and the SpO2 and airway pressure should be mainly observed during operation especially for the patients who underwent anhydrous ethanol ablation. Key words: Vascular malformation; Airway management

Application of simple respirator combined with respiratory function training in airway management of patients with cerebral apoplexy after tracheotomy

Objective To observe the application effect of simple respirator combined with respiratory function training in airway management of patients with cerebral apoplexy after tracheotomy. Methods Totally 93 patients with stroke tracheotomy from May 2017 to April 2018 were randomly divided into the intervention group (45 cases) and thecontrol group (48 cases). The control group was treated with routine nursing after tracheotomy, and the intervention group was trained by simple ventilator combined with breathing function on the basis of the control group.The incidence of pulmonary infection during the tracheal cannula in two groups was observed, the total retention time of the trachea cannula, the incidence of blood oxygen saturation < 94% from 24 h to 48 h, the number of cases of catheterization, and the incidence of pulmonary infection were observed. Results In the intervention group and the control group, the pulmonary infection rate was 6.67% (3/45) in the intervention group, which was lower than the control group. The lung infection rate was 20.83% (10/48). The significance of learning (χ2=3.89, P=0.04); the total indwelling time of tracheal intubation in the intervention group (25.73±6.51) d was shorter than that in the control group (28.28±4.79) d, the difference was statistically significant (t=-2.16, P=0.03); within the intervention group and the control group, within 24-48 hours, the oxygen saturation of the intervention group was <0.94 (6.6% (3/45), and the incidence of pulmonary infection was 2.22% (1/45). The incidence rate of re-intubation was 0 (0/45), which was lower than 22.92% (11/48), 14.58% (7/48), and 10.42% (5/48) of the control group. The difference was statistically significant (χ2= 4.80, 4.51, 4.75, P= 0.03, 0.03, 0.03). Conclusions The simple breathing apparatus combined with respiratory function training can effectively improve the respiratory function of the patients, reduce the occurrence of pulmonary infection and re tube after the tracheal tubing and tubing, shorten the retention time of the trachea cannula, reduce the patient's pain and economic burden, and reduce the risk of nursing. It is scientific and effective. Airway management measures should be widely applied in clinical practice. Key words: Stroke; Tracheotomy; Simple respirator; Respiratory function training; Nursing care

Guidewire-assisted fiberoptic bronchoscope-guided tracheal intubation: A novel airway management in an invasive thyroid malignancy.

Sir, Airway management in patients with tracheal stenosis secondary to invasive tumors, especially when they present with signs of airway obstruction, is a challenging task. Though the primary airway management of choice is not well-defined, airway management in invasive thyroid malignancy can be dealt with a wide range of choices.[1] Here we report such a case, managed successfully by awake guide-wire-assisted fiberoptic bronchoscope (FOB)-guided intubation. A 35-year-old female presented with history of progressively increasing swelling in the region of thyroid for the past 20 years. As it was associated with difficulty in breathing on exertion and lying supine for a past few days, she sought medical help. The swelling was hard in consistency with palpable lower border. Contrast-enhanced computed tomography neck examination revealed a 5 × 4 × 5 cm mass in the right thyroid lobe with tracheal invasion resulting in significant luminal compromise of trachea with tracheal shift toward the left side [Figure 1a and b]. Preoperative FOB examination [Figure 1c] showed a fleshy mass, 4 cm below the level of glottis occupying more than 90% cross-sectional area of the trachea. Our preoperative plan was to perform awake FOB-guided nasotracheal intubation with the help of Cook's polytetrafluoroethylene guidewire. On the day of surgery, she was positioned in 75° semi-recumbent position. Oxygen was supplemented through nasal prongs. Intravenous dexmedetomidine was infused to maintain optimal level of sedation. Awake nasal fiberoptic was performed with spray-as-you-go (SAYGO) technique. Beyond 4 cm from the glottis, tracheal invasion by the tumor mass was noted. Cook's guidewire was passed beyond the tracheal mass. This was followed by the railroading of FOB over it. Once the tracheal carina was identified, the preloaded endotracheal tube (ETT) was railroaded across the tracheal narrowing. The position of ETT was confirmed by FOB. Subsequently, general anesthesia was induced. After completion of total thyroidectomy, sleeve resection of trachea and primary anastomosis was done. She was extubated at the end of surgery and postoperative course was uneventful.Figure 1: (a and b) Sagittal and coronal section of CT showing the invasive thyroid malignant lesion; (c) Fibreoptic bronchoscopy showing the extent of tracheal invasionAirway obstruction by a thyroid tumor may result from extrinsic compression or intrinsic obstruction by tracheal invasion. By context- sensitive airway management principle, airway intervention in such cases depends on the degree of tracheal narrowing, available airway equipments, and anesthesiologist's expertise.[2] We had chosen awake FOB-guided intubation as a primary choice as we anticipated difficulty in ventilation, intubation, and front of neck surgical airway intervention. Preservation of spontaneous ventilation is the safest option in any compromised airway situation.[3] Cook's guidewire was used to negotiate into the narrow space between the mass and the tracheal wall. Railroading the ETT preloaded FOB over the Cook's guidewire prevented unintentional injury to the tumor mass thus ensuring atraumatic passage of the ETT. If the guidewire was not in place beyond the mass, simple FOB-guided intubation would increase the chances of airway edema while passing the FOB/ETT and injury to the tumor mass causing torrential bleeding into the trachea. Placement of Cook's guidewire had in fact facilitated the spontaneous ventilation effectively (as FOB would have totally occupied the narrow space through which the patient was breathing). Also, the presence of the guidewire beyond the tumor mass can help the anesthesiologist quickly railroad the ETT over it and secure the airway in the event of accidental bleeding from the mass during airway management. Rigid bronchoscope was kept ready as a rescue plan if there were events of airway collapse and bleeding from the tumor mass. Preserving spontaneous ventilation is the key to airway management in cases where tracheal lumen is narrowed by infiltrating tumor mass. Cook's guidewire can act as a useful and alternative airway adjuvant in facilitating spontaneous ventilation in such scenarios. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

GlideScope versus D-blade for tracheal intubation in cervical spine patients: A randomised controlled trial.

Background and Aims:Airway management in patients with cervical spine pathology is challenging. The aim of the study was to evaluate GlideScope (GVL) and D blade of C-MAC (CMAC-D) using manual inline axial stabilisation (MIAS) for tracheal intubation in patients with cervical spine injury/pathology.Methods:This is a randomised, single-blind, hospital-based study. After obtaining informed consent, 54 patients with cervical spine pathology/injury were grouped into GVL group or CMAC-D group, (n = 27 each) based on computer-generated random number table. Preoperative airway difficulty score (ADS) was calculated. The primary outcome of the study was intubation difficulty score (IDS) and the secondary outcomes included total time taken to secure airway, failure to intubate, haemodynamic parameters and adverse events. Data was represented in the form of number (%) or mean and standard deviation and median and interquartile range as appropriate. Chi square test was used for analysing IDS.Results:The mean ± SD of IDS of the CMAC-D and GVL groups were 0.04 ± 0.2 (0.04–0.11) and 0.19 ± 0.40 (0.03–0.34), respectively, (P value = 0.096). The number (%) of patients with IDS > 0 was 1 (3.7) in CMAC-D and 5 (18.5) in GVL group, (P value = 0.192). Demographic data, ADS, Cormack–Lehane grading, success rate, time of tracheal intubation, type of surgeries, haemodynamic parameters and post-operative complications were similar in both the groups.Conclusion:Both GVL and CMAC-D with MIAS are equally efficacious in tracheal intubation in cervical spine injury/pathology patients without other difficult airway management criteria.

Anesthetic consideration for airway management of patients undergoing endoscopic fibrin glue treatment of tracheobronchial rupture: a case series of three patients

Tracheobronchial ruptures are very severe and life-threatening injuries. The origin of such airway damage is trauma or an iatrogenic event. Last year, we operated on three different cases of tracheal ruptures using endobronchial suture with three different airway management. We exposed the description of three different techniques to manage the airway during an endoscopic suture of tracheobronchial rupture with fibrin glue (laryngeal mask, orotracheal tube positioned distally the lesion, one lung ventilation with a small size single tube). Using this kind of technique, we have obtained a protective ventilation on tracheal rupture, a rapid healing, and fast recovery of spontaneous breathing.

NATIONAL TREND OF MORTALITY AND MORBIDITY AMONG HOSPITALIZED PATIENTS WITH ANGIOEDEMA

SESSION TITLE: Allergy and Airway SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Angioedema refers to abrupt nonpitting swelling of the skin or mucous membranes that can involve the upper respiratory and gastrointestinal tracts. Episodes can be triggered by medications, foods, or even sun exposure, although most cases remain idiopathic. Hospital admission data in the United States indicates rising incidence in all-cause angioedema during the past several decades. This study attempts to estimate trends in disease severity, and associated healthcare costs in patients hospitalized with angioedema from 2005 to 2014. METHODS: This is a retrospective cohort study using the 2005-2014 National Inpatient Sample. The inclusion criteria were patients over the age of 18. Elective admissions were excluded. The primary outcome was the temporal change of hospitalizations for all-cause angioedema based on validated ICD9-CM codes. In the secondary analysis, we examined the trend of in-hospital mortality, morbidities and resource utilization for angioedema. The in-hospital morbidities included anaphylactic shock, requirement for mechanical ventilation requiring ICU admission. Adjusted odds ratios (aOR) were calculated based on multivariate logistic analysis adjusted for age, gender, race, Charlson Comorbidity Index and specific comorbidities (urticaria, allergies and asthma). Hospitalization charges were adjusted for inflation and analyzed using poisson regression analysis. Analysis was performed by using Stata, version 14.2. RESULTS: 224.3 million patients were included in this study. There was a increasing trend in the incidence of angioedema requiring hospitalization from 2005 (4.8/10000 admissions) to 2014 (7.2/10000 admissions in 2014, aOR 1.05, p<0.0001). Among patients admitted for angioedema, the in-hospital mortality rate remained stable (0.45% in 2005 vs 0.49% in 2014, aOR 0.98, p=0.667). However, there was an increasing trend in anaphylactic shock (1.01% in 2005 vs 1.77% in 2014, aOR 1.08, p=0.002), mechanical ventilation (7.01% in 2005 vs 17.97% in 2014, aOR 1.12, p<0.0001) and ICU admission (7.01% in 2005 vs 18.07% in 2014, aOR 1.12, p<0.0001). There was an increase in total hospital charges annually despite adjustment for inflation (crude charge $10537.34 in 2005 vs. $26184.79 in 2014, p<0.001). CONCLUSIONS: The incidence of angioedema requiring hospitalization increased significantly from 2005 to 2014, with increasing morbidities including anaphylactic shock, requirement of intubation and mechanical ventilation despite unchanged mortality rate. This accompanied with an increasing burden in the US health system with lengthier hospital stay and higher hospital charges. CLINICAL IMPLICATIONS: Our study demonstrated a steady increasing trend of incidence and severity of angioedema despite similar mortality rate. Airway management of patients with angioedema may be quite challenging, and the overall increasing severity of angioedema carries a heavier burden in the healthcare system. DISCLOSURES: No relevant relationships by Di Pan, source=Web Response No relevant relationships by tal shachi, source=Web Response No relevant relationships by Avinash Singh, source=Web Response No relevant relationships by Yumeng Wen, source=Web Response

FIRST PASS SUCCESS DURING AIRWAY MANAGEMENT BY CRITICAL CARE PHYSICIANS OUTSIDE OF AN ICU

SESSION TITLE: Critical Care 1 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: There is limited data available regarding the airway management of patients by critical care doctors outside of an intensive care unit (OICU) or emergency department. Our goal is to describe the population of patients intubated by critical care physicians OICU at our institution and to see if the rate of first pass success (FPS) is different from inside of an ICU (IICU). We hypothesized that at our large academic medical center, the rate of FPS during intubations done by critical care providers would be lower OICU than IICU. METHODS: We performed a retrospective cohort study of all intubations done by the critical care service at Montefiore Medical Center between July 1st, 2016 and May 1st, 2017. Intubation notes and associated patient data were identified using clinical looking glass (CLG) (Clinical Analytics®, NY, NY). For patients who had multiple intubations performed, only the first intubation was included. Patient characteristics were compared with chi-square testing for categorical variables and either a t-test or Wilcoxon rank-sum test for continuous and discrete variables, respectively. To compare FPS between patients intubated IICU and OICU we performed logistic regression with adjustment for age, gender, diagnosis of obstructive sleep apnea (OSA), body mass index (BMI), method of intubation, operator rank as non-attending and operator background as non-anesthesia trained. RESULTS: 762 intubations (384 OICU, 378 IICU) met inclusion criteria and were examined in the final analysis. Patients who were intubated OICU were found to be older (67.8 vs. 62.8 years; p < 0.001), have equal likelihood of a diagnosis of OSA (12.2% vs. 14.0%; p = 0.47), have similar BMI (33.8 vs. 29.7; p = 0.48) and have higher Charlson co-morbidity index (median 5 vs. 4; p = 0.01). Patients OICU were more likely to be intubated for circulatory arrest (27.6% vs. 7.14%; p < 0.001) and have higher mortality within 24 hours of the intubation (14.6% vs. 5.56%; p < 0.001). OICU intubations were more likely to be done by a trainee (88.8% vs. 77.8%; p < 0.001) and less likely to be done by a physician with anesthesia training (4.2% vs. 9.5%; p <0.001). Unadjusted FPS was not different between patients OICU and IICU (73.7% vs. 71.4%; p = 0.48, odds ratio (OR), 1.12, [95% CI, 0.82-1.54]). After multivariate adjustment, FPS was also not different between the 2 patient groups (OR, 1.10; 95% CI, 0.79-1.54). CONCLUSIONS: At our institution we found that patients intubated by the critical care service OICU were more likely to be older and have higher co-morbidity than those patients intubated IICU. The rate of first pass success was not different between the two groups. CLINICAL IMPLICATIONS: Critically ill patients can be intubated by critical care specialists irrespective of hospital location. DISCLOSURES: No relevant relationships by Lewis Eisen, source=Web Response No relevant relationships by Nader Esfahani, source=Admin input No relevant relationships by Daniel Fein, source=Web Response No relevant relationships by Fiore Mastroianni, source=Web Response No relevant relationships by Ariel Shiloh, source=Web Response

Airway management in a patient with bullous pemphigoid.

Airway management in patients with pemphigoid lesions has anaesthetic implications. We report a case of a 23 years old female with bullous pemphigoid who presented with laryngeal stenosis and critical airway narrowing. The airway was initially managed with jet ventilation. Anaesthesia was maintained with propofol infusion and ventilation was performed by introducing a size 10 French gauge suction catheter through the stenotic laryngeal orifice. Thirty minutes into anaesthesia, she developed subcutaneous emphysema and decreased air entry on right side of the chest but remained hemodynamically stable. The airway was further managed by tracheostomy. This case report highlights complications that can occur during the anaesthetic management of such cases.

A Meta-Analysis of the Influencing Factors for Tracheostomy after Cervical Spinal Cord Injury.

Background Traumatic cervical spinal cord injury (CSCI) is a common disease that has high complication, disability, and mortality rates and a poor prognosis. Tracheostomy is an important supportive therapy for patients with CSCI. However, a consensus on the predictive factors for tracheostomy after CSCI has not been reached. Objective This meta-analysis study assessed the influencing factors for tracheostomy after CSCI. Methods We searched for relevant studies on the influencing factors for tracheostomy after CSCI. The extracted data were analyzed using RevMan 5.3 software. We calculated the odds ratio (OR) or mean difference (MD) and 95% confidence intervals (CIs). Results Sixteen eligible studies containing 9697 patients with CSCI were selected. The pooled OR (MD) and 95% CI of the influencing factors were as follows: age (mean ± SD): -0.98 (-4.00 to 2.03), advanced age: 1.93 (0.80 to 4.63), sex (male): 1.29 (1.12 to 1.49), American Spinal Injury Association Impairment Scale (AIS) A grade: 7.79 (5.28 to 11.50), AIS B grade: 1.15 (1.13 to 2.02), AIS C grade: 0.28 (0.20 to 0.41), AIS D grade: 0.04 (0.02 to 0.09), neurological level of injury (upper CSCI): 2.36 (1.51 to 3.68), injury severity score (ISS): 8.97 (8.11 to 9.82), Glasgow Coma Scale (GCS) score ≤8: 6.03 (2.19 to 16.61), thoracic injury: 1.78 (1.55 to 2.04), brain injury: 0.96 (0.55 to 1.69), respiratory complications: 5.97 (4.03 to 8.86), smoking history: 1.45 (0.99 to 2.13), traffic accident injury: 1.27 (0.92 to 1.74), and fall injury: 0.72 (0.52 to 1.01). Conclusions The current evidence shows that male sex, AIS A grade, AIS B grade, neurological level of injury (upper CSCI), high ISS, GCS≤8, thoracic injury, and respiratory complications are risk factors for tracheostomy after CSCI, and AIS C grade and AIS D grade are protective factors. This study will allow us to use these factors for tracheostomy decisions and ultimately optimize airway management in patients with CSCI.

Algorithm for Airway Management in Patients With Pierre Robin Sequence

Airway management in neonates with Pierre Robin sequence (PRS) can be challenging. The goal was to describe the algorithm developed by the authors over the past 8 years. A retrospective case series analyzing airway management in neonates with PRS admitted to the neonatal intensive care unit at a tertiary care pediatric hospital was performed. The utility of the proposed algorithm for airway management incorporating more consistent use of polysomnography (PSG), and airway assessment was assessed. A total of 31 neonates with PRS (12 men, 19 women) with a mean gestational age of 38.2 weeks were analyzed. Thirteen (41.9%) patients had a named syndrome, chromosomal abnormality, or global delay. Twenty (64.5%) patients had pre-intervention PSG, and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) ≥ 10 events/hour was identified in 19 (95.0%). Mandibular distraction osteogenesis was performed in 18 (58.1%) patients, and improved the AHI on post-operative PSGs. Direct assessment of the upper and lower airways was performed in 19 patients, and 13 (68.4%) were found to have secondary airway pathology. Presence of a concomitant syndrome was significantly associated with need for tracheostomy. The algorithm differs from previous ones in that it relies on rigorous pre- and post-intervention PSG (including with a nasopharyngeal airway), as well as that it allows flexibility between treatment options given the whole-patient clinical scenario and endoscopic findings. Results from these studies may be integrated to stratify patients into those who are most likely to benefit from conservative interventions or surgical procedures.

Submental Intubation: an Underutilized Technique for Airway Management in Patients With Panfacial Trauma.

To evaluate submental intubation compared with secure airways of patients who have sustained significant maxillofacial trauma. Patient series of 3 patients who underwent submental intubation prior to open reduction internal fixation of fractures associated with the mid and lower face. All of these patients were initially orally intubated, and then converted to submental intubation prior to the reparative procedure. Detailed description of the procedure is discussed in each patient. All the patients received appropriate reduction of facial fractures following submental intubation with no intraoperative complications. Two of the 3 patients were extubated immediately postoperatively and 1 was extubated on the second postoperative day. None of the patients had any complications associated with submental intubation. Submental intubation is a safe and expedient technique to divert the airway in patients who require operative repair of panfacial injuries. This procedure is preferable over tracheostomy in selected patients of maxillofacial trauma without indication for prolonged ventilation support.