Airway Management Strategies Research Articles

Prehospital Airway Management.

The prehospital emergency airway management is a key moderating factor for patient survival and mortality rates. There has been much debate around the optimum method of prehospital emergency airway management. This commentary critically appraises a recent systematic review which assesses the harms and benefits of three different airway management strategies for a range of emergency clinical scenarios.

Apneic Technique in Laryngotracheal Surgery.

BackgroundApneic oxygenation can be applied to select laryngotracheal procedures to improve operative visualization and avoid potential complications associated with intubation and jet ventilation. Aims/objectivesThe authors sought to determine if apneic oxygenation using a high-flow nasal cannula could be used as a safe alternative airway management strategy for the duration of select laryngotracheal procedures.MethodsSingle institution, multi-site retrospective review of 38 adult (>18 years old) patients undergoing apneic oxygenation in the setting of various laryngotracheal procedures from January 2017 through January 2018. Humidified oxygen was delivered via a high-flow nasal cannula. The data was collected and analyzed using SAS version 9.4 (SAS Institute, Cary, NC).ResultsTwenty-four women and 14 men, mean age 60.0 years (SD 16.1; 36-89) and 70.1 years (SD 7.2; 56-81), respectively, underwent a mean total apneic time of 23.9 minutes (13-40). A statistically significant correlation existed between apneic time and minimum oxygen saturation (Pearson correlation coefficient 0.38; p=0.018). Twenty-one patients resumed spontaneous ventilation without the need for jet ventilation, mask ventilation, or placement of a definitive airway during the procedure. Conclusions and significanceApneic oxygenation allows for extended periods of operating without the need for the placement of an endotracheal tube in patients undergoing general anesthesia for select laryngotracheal procedures.

Airway management for one lung ventilation during COVID-19 pandemic: a survey within Italian anesthesiologists

BackgroundAirway management for thoracic surgery represents a high risk setting for SARS-CoV-2 infection diffusion due to complex and invasive airway instrumentation and techniques.ResultsAn 18-item questionnaire was submitted to the 56 members of the Thoracic subcommittee of the SIAARTI Cardio-Thoraco-Vascular Research Group to provide a snapshot of current situation and national variability of devices and procedures for airway management during the COVID-19 pandemic. The response rate was 64%. Eighty-three percent of anesthetists declared that they modified their airway management strategies. The Hospital Management considered necessary to provide a complete level 3 personal protective equipment for thoracic anesthetists only in 47% of cases. Double-lumen tube and bronchial blocker were preferred by 53% and 22% of responders to achieve one-lung ventilation respectively. Over 90% of responders considered the videolaryngoscope with separate screen and rapid sequence induction/intubation useful to minimize the infection risk. Thirty-nine percent of participants considered mandatory the bronchoscopic check of airway devices. Vivasight-DL was considered comfortable by more than 50% of responders while protective box and plastic drape were judged as uncomfortable by most of anesthetists.ConclusionsThe survey reveals many changes in the clinical practice due to SARS-CoV-2 outbreak. A certain diffusion of new devices such as the VivaSight-DL and barrier enclosure systems emerged too. Finally, we found that most of Italian hospitals did not recognize thoracic anesthesia as a high-risk specialty for risk of virus diffusion.

Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document

Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. NAEMSP recommends: Based on the skill of the clinician and available resources, BVM, SGA, or ETI may be considered as airway management strategies in OHCA. Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest. EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation. Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.

Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document

Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends: The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors. Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions. Management of immediately life-threatening injuries should take priority over advanced airway insertion. Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium. EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.

Airway management in penetrating thoracic trauma.

Penetrating thoracic trauma accounts for 20-25% of all deaths due to trauma in the first four decades of life. About 33% of deaths from thoracic trauma occur due to penetrating trauma. In an autopsy study that enrolled 1178 trauma patients, 82% of the patients with tracheobronchial injuries died at the incidence site. In another study, 30% of those who could be transferred to the hospital died. This review aimed to revisit penetrating thoracic trauma with respect to complications and the strategies for airway management. While the risk of death in injuries with a sharp object is normally 1-8%, it reaches 25-28% when the cardiac box is included, and still, most of the patients are lost before they can come to the hospital. The consequences and management of penetrating thoracic trauma are mainly dependent on the extent of the injury to internal organs, as well as on the skill of the clinicians, airway obstruction, respiratory failure, and bleeding. Chest computed tomography (CT) is better than chest radiography in diagnosing the main bronchus or lobe/segment rupture. However, with the use of multi-channel multi-detector CT, the sensitivity of CT imaging has increased to 94% in the diagnosis of tracheobronchial injuries. While standard orotracheal intubation is sufficient in 75% of the patients, flexible bronchoscopy, intubation through the open wound or tracheostomy is required for airway provision in the rest. Clinical suspicion is the first diagnostic tool in a patient with penetrating airway trauma, and early treatment with multidisciplinary teamwork is life-saving.

Airway management in patients with obesity.

Airway management in patients with obesity remains a complex and evolving topic that is becoming more pertinent given the increasing prevalence of obesity and bariatric surgery worldwide. Obesity is associated with increased morbidity and mortality secondary to anesthetic complications, especially related to airway management. Preoperative assessment is especially vital for the bariatric patient so that potential predictors for a difficult airway can be identified. There are several airway management strategies and techniques for the bariatric population that may help reduce postoperative pulmonary complications. This review aims to discuss assessment of the airway, ideal patient positioning, intubation techniques and devices, apneic oxygenation, optimal ventilation strategies, and extubation and post-anesthesia care.

REGIONAL ANESTHESIA IN SPINAL SURGERY: COULD IT BE THE SOLUTION FOR DIFFICULT INTUBATION.

This article includes two topics - anesthesia for spinal surgery and difficult airway, both of them are linked with the same topic, which is regional anesthesia. In recent years, regional anesthesia for spinal surgery has gained a great popularity, where neuraxial blocks are the first choice. Regional anesthesia seems to have benefits against general anesthesia due to lower rate of perioperative and postoperative complications, lower cost and length of stay. This is more evident in elderly population or patients with comorbidities. On the other hand, difficult airway is the life threatening condition and requires increased attention. There are many methods and tools for managing difficult airways, but there are few supporters of regional anesthesia as an option or solution in these cases. Of course, special attention is required during regional anesthesia in a patient with difficult airway, the decision must be correct, and an anesthesiologist must have a preformulated strategy for airway management. However, does not the same happen even when we apply general anesthesia?

Outcomes of Early versus Late Endotracheal Intubation in Patients with Initial Non-Shockable Rhythm Cardiopulmonary Arrest in the Emergency Department.

Background Sudden cardiac arrest is a critical condition in the emergency department (ED). Currently, there is no considerable evidence supporting the best time to complete advanced airway management (AAM) with endotracheal intubation in cardiac arrest patients presented with initial non-shockable cardiac rhythm. Objectives To compare survival to hospital discharge and discharge with favorable neurological outcome between the ED cardiac arrest patients who have received AAM with endotracheal intubation within 2 minutes (early AAM group) and those over 2 minutes (late AAM group) after the start of chest compression in ED. Methods We conducted a retrospective cohort study involving the ED cardiac arrest patients who presented with initial non-shockable rhythm in ED. Multivariable logistic regression analysis was used to evaluate the independent effect of early AAM on outcomes. The outcomes included the survival to hospital discharge and discharge with favorable neurological outcome. Results There were 416 eligible participants: 209 in the early AAM group and 207 participants in the late AAM group. The early AAM group showed higher survival to hospital discharge compared with the late AAM group, but no statistically significant difference (adjusted odds ratio (aOR): 1.28, 95% confidence interval (CI): 0.59 -2.76, p = 0.524). Discharge with favorable neurological outcome is also higher in the early AAM group (aOR: 1.68, 95% CI, 0.52 -5.45, p = 0.387). Conclusion This study did not demonstrate a significant improvement of survival to hospital discharge and discharge with favorable neurological outcome in the ED cardiac arrest patients with initial non-shockable cardiac arrest who underwent early AAM within two minutes. More research is needed on the timing of AAM and on airway management strategies to improve survival.

Anesthetic considerations in children with asthma.

Due to the high prevalence of asthma and general airway reactivity, anesthesiologists frequently encounter children with asthma or asthma-like symptoms. This review focuses on the epidemiology, the underlying pathophysiology, and perioperative management of children with airway reactivity, including controlled and uncontrolled asthma. It spans from preoperative optimization to optimized intraoperative management, airway management, and ventilation strategies. There are three leading causes for bronchospasm (1) mechanical (eg, airway manipulation), (2) non-immunological anaphylaxis (anaphylactoid reaction), and (3) immunological anaphylaxis. Children with increased airway reactivity may benefit from a premedication with beta-2 agonists, non-invasive airway management, and deep removal of airway devices. While desflurane should be avoided in pediatric anesthesia due to an increased risk of bronchospasm, other volatile agents are potent bronchodilators. Propofol is superior in blunting airway reflexes and, therefore, well suited for anesthesia induction in children with increased airway reactivity.

Design of a novel clinical trial of prehospital pediatric airway management.

Emergency Medical Services personnel are often the first to intervene in the care of critically ill children. Airway management is a fundamental step in prehospital resuscitation, yet there is significant variation in current prehospital airway management practices. Our objective is to present a methodologic approach to determine the optimal strategy for prehospital pediatric airway management. We describe the conceptual premise for the Pediatric Prehospital Airway Resuscitation Trial, a novel Bayesian adaptive sequential platform trial. We developed an innovative design to enable comparison of the three predominant prehospital pediatric airway techniques (bag-mask-ventilation, supraglottic airway insertion, and endotracheal intubation) in three distinct disease groups (cardiac arrest, major trauma, and other respiratory failure). We used a Bayesian statistical approach to provide flexible modeling that can adapt based on prespecified rules according to accumulating trial data with patient enrollment continuing until stopping rules are met. The approach also allows the comparison of multiple interventions in sequence across the different disease states. This Bayesian hierarchical model will be the primary analysis method for the Pediatric Prehospital Airway Resuscitation Trial. The model integrates information across subgroups, a technique known as "borrowing" to generate accurate global and subgroup-specific estimates of treatment effects and enables comparisons of airway intervention arms within the overarching trial. We will use this Bayesian hierarchical linear model that adjusts for subgroup to estimate treatment effects within each subgroup. The model will predict a patient-centered score of 30-day intensive care unit-free survival using arm, subgroup, and emergency medical services agency as predictors. The novel approach of Pediatric Prehospital Airway Resuscitation Trial will provide a feasible method to determine the optimal strategy for prehospital pediatric airway management and may transform the design of future prehospital resuscitation trials.

El-Ganzouri multivariate risk index based airway management in head and neck cancer patients: A retrospective analysis of 1000 patients in a tertiary care center.

Background and Aims:Intubation in head and neck carcinoma (HNC) is difficult due to many reasons. Various guidelines recommend strategies for airway management in such anticipated difficult airway cases. However, literature is limited on airway management planning as per the level of difficulty based on airway assessment in these patients. EL-Ganzouri risk index (EGRI) has been proposed to aid in making airway management plan in HNC cases by some authors. This retrospective study was conducted to look at the data related to the pre-anesthetic airway assessment and the airway management plan executed by the anesthesiologists in 1000 patients of HNC in the previous nearly four years in order to determine how the choices made conformed to EGRI scores.Material and Methods:Records of all the patients with oral cancer posted for surgery over four years from January 2014 to December 2017 were retrospectively analyzed for preoperative airway assessment using El Ganzouri risk index assessment (EGRI), the intraoperative technique for nasotracheal intubation, airway management plan, and any intraoperative complications.Results:The risk of predicted airway difficulty was low (EGRI <4) in 38 patients and was high in the rest. The EGRI score was higher in the FOB group [4-9] as compared to DL [2-3] and VL [1-6]. The patients with EGRI >7 were intubated awake and those with EGRI <7 were intubated under general anesthesia (79.8%). Overall, the technique of choice for intubation was fibreoptic bronchoscopy (54%) followed by video laryngoscopy (42.6%).Conclusion:The airway management plan used in a tertiary care cancer center conformed to the approach suggested by the multivariate El Ganzouri risk index (EGRI). EGRI appears to be a useful means to ascertain the appropriate strategies for intubation in head and neck cancer patients.

Tracheostomy in Mechanically Ventilated Patients With SARS-CoV-2-ARDS: Focus on Tracheomalacia.

The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. The aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence. This retrospective, single-center study was performed in an Italian teaching hospital. All adult subjects admitted to the ICU between February 24, 2020, and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, whereas information regarding airway management was collected daily. A total of 151 subjects were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 40%. A tracheostomy was performed in 73 (48%), open surgical technique in 54 (74%), and percutaneous Ciaglia technique in 19 (26%). Subjects who had a tracheostomy performed had, compared to the other subjects, a longer duration of mechanical ventilation and longer ICU and hospital stay. Tracheomalacia was diagnosed in 8 (5%). The factors associated with tracheomalacia were female sex, obesity, and tracheostomy. In our population, approximately 50% of subjects with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized subjects had a longer ICU and hospital stay. In our population, 5% were diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature, and the underlying mechanisms are not fully understood.

Optimisation of airway management strategies: a prospective before-and-after study on events related to airway management

BackgroundPoor medical outcomes often result from series of minor events. The present study assessed events related to airway management to determine whether targeted changes to departmental strategies for airway management can reduce the incidence. MethodsThis prospective before-and-after study was performed with ethics committee approval and written informed consent from patients. Major and minor events related to airway management were prospectively recorded for 9 weeks. After implementation of changes to departmental strategies for airway management, events were again prospectively recorded over 9 weeks. Primary outcome was number of cases with events. Secondary outcomes were various predefined events. ResultsAt study baseline, 3668 cases and at follow-up 3786 cases were assessed. Cases with events decreased from 566 (15.4%) to 433 (11.4%) (risk ratio [RR]=0.74; 95% confidence interval [CI], 0.66–0.83; P<0.01). As secondary outcomes, the following events decreased: Cormack–Lehane grade 3 or 4 (4.3–2.9%; RR=0.67; 95% CI, 0.52–0.85; P<0.01); difficult bag-mask ventilation (3.8–2.7%; RR=0.69; 95% CI, 0.54–0.89; P<0.01); hypoxaemia (3.8–2.9%; RR=0.75; 95% CI, 0.59–0.96; P=0.03); unplanned use of special equipment (3.2–2.0%; RR=0.62; (95% CI, 0.47–0.83; P<0.01); oesophageal intubation (1.3–0.8%; RR=0.61; 95% CI, 0.39–0.96; P=0.03); bleeding (0.8–0.2%; RR=0.30; 95% CI, 0.14–0.63; P<0.01); insufficient spontaneous breathing (0.3–0.0%; RR=0.09; 95% CI, 0.01–0.68; P<0.01); communication errors (0.1–0.0%; RR=0; 95% CI, 0–NA; P=0.03). ConclusionsImplementation of changes to departmental strategies for airway management significantly reduced cases with events related to airway management. Analysis of events and implementation of strategies that specifically target identified issues might be key to improving airway management. Clinical trial registrationNCT02743767.

Identification of patients for a delayed extubation strategy versus elective tracheostomy for postoperative airway management in major oral cancer surgery: A prospective observational study in seven hundred and twenty patients

ObjectivesTracheostomy (TT) and delayed extubation (DE) are two approaches to postoperative airway management in patients after major oral cancer surgery. We planned a study to determine the safety of overnight intubation followed by extubation the next morning (DE) compared to elective TT and to identify factors that were associated with a safe DE (maintenance of a patent airway). Material and methodsWe conducted a prospective observational study in a tertiary referral cancer care center. We included adult patients undergoing elective major oral cancer surgery under general anesthesia with tracheal intubation. The decision regarding postoperative airway management using either TT or DE was made according to the usual practice at our center. ResultsWe screened a total of 4477 patients, 720 patients were included. DE was performed in 417 patients (58.4%) and TT in 303 patients (42.4%). On multivariable analysis, T1-T2 tumor stage, absence of extensive resection, primary closure or reconstruction using fasciocutaneous flap, absence of preoperative radiation, no neck dissection or unilateral neck dissection and shorter duration of anesthesia were independent predictors for a safe DE. Overall complications (4.3% versus 22.5%, p = 0.00) and airway complications (1.7% versus 8.7%, p = 0.00) were lower in the DE compared to the TT group respectively. DE was associated with a shorter hospital stay (7.2 ± 3.7 versus 11.5 ± 7.2 days, p = 0.00), time to oral intake and speech compared to TT. ConclusionsA DE strategy after major oral cancer surgery is a safe alternative to TT in a select group of patients.

Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study

BackgroundOut-of-hospital cardiac arrest (OHCA) in children is associated with a low survival rate. Conclusions in the literature are conflicting regarding the best way to handle ventilation. The purpose of this study was to assess the impact of two airway management strategies, endotracheal intubation (ETI) vs. supraglottic procedure, during cardiopulmonary resuscitation (CPR) on 30-day survival in paediatric OHCA. MethodsThis was a retrospective, observational, multicentre, registry-based study conducted from July 2011 to March 2018. All paediatric OHCA patients under 18 years of age and managed by a mobile intensive care unit were included. The primary endpoint was 30-day survival in a weighted population (based on propensity scores). ResultsOf 1579 children, 1355 (85.8%) received ETI and 224 (14.2%) received supraglottic ventilation during CPR. We observe a lower 30-day survival in the ETI group compared to the supraglottic group (7.7% vs. 14.3%, absolute difference, 6.6 percentage points; 95% confidence interval [CI], 2.3–12.0; propensity-adjusted odds ratio [paOR], 0.39; 95% CI, 0.25–0.62; p < 0.001), and also a poorer neurological outcome (paOR, 0.32; 95% CI, 0.19–0.54; p < 0.001). However, we did not identify any significant association between airway management strategy and return of spontaneous circulation (paOR, 1.15; 95% CI, 0.80–1.65; p = 0.46). ConclusionsThe findings of this large cohort study suggest that ETI in paediatric OHCA, although performed by trained physicians, is associated with a worse outcome, regardless of traumatic or non-traumatic aetiology.

Impact of COVID-19 pandemic on out-of-hospital cardiac arrest system-of-care: A systematic review and meta-analysis

Introduction: COVID-19 pandemic overwhelmed healthcare systems and diverted resources allocated for other conditions. This systematic review and meta-analysis aimed to analyse how the pandemic impacted the system-of-care of out-of-hospital cardiac arrest. Methods: We searched PubMed and Embase up to May 31, 2021, for studies comparing out-of-hospital cardiac arrests that occurred during the COVID-19 pandemic versus a non-pandemic period. Survival at hospital discharge or at 30 days was the primary outcome. Results: We included 24 studies for a total of 75,952 patients. Out-of-hospital cardiac arrests during COVID-19 pandemic had lower survival (19 studies; 603/11,666 [5.2%] vs. 1320/17,174 [7.7%]; OR =0.54; 95% CI, 0.44–0.65; P = 0.001) and return of spontaneous circulation (4370/24353 [18%] vs. 7401/34510 [21%]; OR =0.64; 95% CI, 0.55–0.75; P < 0.001) compared with non-pandemic periods. Ambulance response times (10.1 vs 9.0 minutes, MD =1.01; 95% CI, 0.59–1.42; P < 0.001) and non-shockable rhythms (18,242/21,665 [84%] vs. 19,971/24,817 [81%]; OR =1.27; 95% CI, 1.10–1.46; P < 0.001) increased. Use of supraglottic airways devices increased (2853/7645 [37%] vs. 2043/17521 [12%]; OR =1.97; 95% CI, 1.42–2.74; P < 0.001). Conclusions: The COVID-19 pandemic affected the system-of-care of out-of-hospital cardiac arrest, and patients had worse short-term outcomes compared to pre-pandemic periods. Advanced airway management strategy shifted from endotracheal intubation to supraglottic airway devices. Review registration: PROSPERO CRD42021250339.

Approach to Difficult Airway Management

According to the 2013 American Society of Anesthesiology Practice Guidelines for Management of the Difficult Airway, a term “difficult airway” refers to clinical situations in which a likelihood of 1) difficulty with patient cooperation or consent, 2) difficult mask ventilation, 3) difficult supraglottic airway placement, 4) difficult laryngoscopy, 5) difficult intubation, and/or 6) difficult surgical airway is high. Several considerations are important when approaching each individual clinical scenario. An airway management plan should include patient-specific and situation-specific factors that take into account findings of bedside airway evaluation, prior history of intubations, the acuity of the situation requiring intubation, and the level of airway obstruction. The following module provides an overview of these factors along with a brief introduction to specific clinical situations in which some airway management strategies are more suitable.1,2 This review contains 10 figures, 7 tables and 32 references Key words: Difficult airway, intubation, LEMON score, High-Flow Nasal Cannula Oxygenation, THRIVE

Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses

PurposeTo investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. Study designA retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. ResultsAntenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d – 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. ConclusionThis series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.

Complex Airway Management in Patients with Tracheal Cartilaginous Sleeves.

A tracheal cartilaginous sleeve (TCS) is a rare anomaly characterized by anterior fusion of tracheal cartilages. TCS is associated with syndromic craniosynostoses including Apert, Crouzon and Pfeiffer syndromes and FGFR2, FGFR3, and TWIST1 variants. This study presents a 30-year review of patients with syndromic craniosynostosis and TCS and describes diagnostic methods, genetic variants, surgical interventions, and long-term outcomes. Retrospective, single-institution review. This review included patients with syndromic craniosynostosis and TCS treated at Seattle Children's Hospital from 1990 to 2020. Tracheostomy, genetic variants, and additional surgery were primary measures. Fisher's exact test compared need for tracheostomy in patients with proposed high-risk (FGFR2 p.W290 or FGFR2 p.C342) versus low-risk genetic variants. Thirty patients with TCS were identified. Average age at diagnosis was 12 months (range 2-weeks to 7.9-years; standard deviation 19.8 months). Syndromes included Pfeiffer (37%), Apert (37%), and Crouzon (26%). Severe obstructive sleep apnea was present in 76% of patients. Tracheostomy was performed in 17 patients (57%); five were successfully decannulated. Additional interventions included adenotonsillectomy (57%), nasal (20%), laryngeal (17%), and craniofacial skeletal surgery (87%). All patients with Pfeiffer syndrome and FGFR2 p.W290C variants and 83% of patients with FGFR2 p.C342 variants required tracheostomy, differing from other variants (P=.02, odds ratio 33, 95% confidence interval 1.56-697.96). One patient (3%) died. TCS contributes to multilevel airway obstruction in patients with syndromic craniosynostosis. Genetic testing in patients with FGFR2-related syndromic craniosynostoses may identify those at risk of TCS and facilitate early intervention. A better understanding of this patient population may foster individualized airway management strategies and improve outcomes. 4 Laryngoscope, 132:215-221, 2022.