Airway Management Challenges Research Articles

Complete bronchial stricture and airway management challenges

Objective The purpose of this report is to demonstrate a unique case of severe bronchial stricture and discuss the associated diagnostic and airway management challenges. Study design The design was that of a case report. Methods A review of the literature was made. Results A 15-year-old adolescent boy with a history of renal transplantation 1 year prior presented with a 10-day history of progressive cough and shortness of breath necessitating ventilator support. Chest radiograph and computed tomography showed complete whiteout of the left lung with some areas of hyperinflation of the left upper lobe. Subsequent flexible and rigid bronchoscopy noted a narrowed left mainstem bronchus with no evidence of an intact lumen. After failed attempts at medical treatment and dilation, the patient underwent a left pneumonectomy. He was ultimately discharged home in good condition. Discussion Bronchial strictures are rare phenomenon with oftentimes unclear etiologies. Atresia of bronchi is even rarer, usually occurring in young males, and may go undiagnosed for 30 years until clinical symptoms occur. Treatment of narrowed segments may involve medical treatment of infectious agents, stent placement, dilation, and sleeve resection. Treatment of atresia or severe stricture may necessitate resection of the lung distal to the affected region. Conclusion Bronchial strictures and atresias may go undiagnosed for years before pulmonary symptoms occur. Computed tomography and bronchoscopy with biopsies represent the mainstays of diagnosis. Regional lung hyperinflation and peribronchial translucency may hint at bronchial atresia. Treatment paradigms vary from dilation and stent placement to resection of the affected areas. In the absence of a clear etiology for lung whiteout, severe bronchial stricture or atresia should be considered as a possibility.

Mandibular distraction osteogenesis to relieve Pierre Robin airway obstruction

Children with Pierre Robin sequence can present challenging airway management issues. We describe a neonate with a life-threatening airway obstruction secondary to severe micrognathia and glossoptosis. When the patient was 9 days old, bilateral distraction osteogenesis was performed to lengthen the mandible by 17 mm. The patient was subsequently extubated without further airway or swallowing difficulties.

Two babies, one heart, and no airway

The medical literature on conjoined twins is replete with descriptions of the complexity of surgical separations. However, airway management, although quite challenging, is neglected in literature. We present experience with conjoined twins united anteriorly at the thorax and abdomen sharing one six-chambered heart. Laryngoscopy and intubation recommendations, bronchoscopy techniques, and tracheotomy strategies are outlined for the face-to-face twins. Difficult, unique case report at tertiary care medical center. Conjoined thoraco-omphalopagus twins were successfully intubated at birth using the rigid Seldinger-assisted videotelescopic intubation (SAVI) technique. Flexible airway endoscopy allows for timely management of ventilator-dependent conjoined twins. Tracheotomy was later performed with the twins in the upright position with heads slightly rotated. Meticulous attention to detail, monitoring and vigilance are mandatory. Successful management of conjoined twins relies on close communication and cooperation of all members of the multidisciplinary team. Conjoined thoraco-omphalopagus twins united anteriorly require a challenging airway management strategy. A three-dimensional perspective is utilized for intubation and tracheotomy. The SAVI technique is helpful for difficult intubations in the emergent twin airways.

Two Babies, One Heart, and No Airway

The medical literature on conjoined twins is replete with descriptions of the complexity of surgical separations. However, airway management, although quite challenging, is neglected in literature. We present experience with conjoined twins united anteriorly at the thorax and abdomen sharing one six-chambered heart. Laryngoscopy and intubation recommendations, bronchoscopy techniques, and tracheotomy strategies are outlined for the face-to-face twins. Difficult, unique case report at tertiary care medical center. Conjoined thoraco-omphalopagus twins were successfully intubated at birth using the rigid Seldinger-assisted videotelescopic intubation (SAVI) technique. Flexible airway endoscopy allows for timely management of ventilator-dependent conjoined twins. Tracheotomy was later performed with the twins in the upright position with heads slightly rotated. Meticulous attention to detail, monitoring and vigilance are mandatory. Successful management of conjoined twins relies on close communication and cooperation of all members of the multidisciplinary team. Conjoined thoraco-omphalopagus twins united anteriorly require a challenging airway management strategy. A three-dimensional perspective is utilized for intubation and tracheotomy. The SAVI technique is helpful for difficult intubations in the emergent twin airways.

Elective extracorporeal support for complex tracheal reconstruction in neonates

Background Congenital obstructive anomalies of the trachea present unique challenges in reconstruction and perioperative airway management. Complications include anastomotic breakdown, leak and granulation formation related to the complexity of the repair, and difficulties with perioperative airway management. We describe our technique of elective intraoperative and postoperative extracorporeal support to improve surgical exposure and postoperative healing. Methods We have performed complex tracheal reconstructions in 4 newborns (2.2 to 4.3 kg) for long segment tracheal stenosis and complete tracheal rings, diagnosed with bronchoscopy and computerized tomography. Three of the 4 infants had other significant anomalies including complex congenital heart disease, hydrocephalus, encephalomalacia, left lung agenesis, facial anomalies, vertebral anomalies, and hand and hip anomalies. The repairs were performed through a median sternotomy using an extracorporeal membrane oxygenation circuit for support. Venoarterial support was used for the sliding tracheoplasty reconstruction. Extracorporeal membrane oxygenation was converted to venovenous for postoperative “airway rest.” After diuresis, the lungs were reexpanded and the 4 patients were ventilated and removed from extracorporeal membrane oxygenation at 4, 5, 8, and 9 days postoperatively. Bronchoscopy was performed to evaluate the airway. Results All patients had excellent healing of the trachea without granulation tissue. There were no complications of extracorporeal membrane oxygenation support or bleeding issues. All 4 patients survived the surgery and immediate postoperative period with 2 late deaths. The child with congenital heart disease expired after 8 weeks after having hepatorenal failure develop. The child with Goldenhar’s syndrome and a single left lung died after 5 months in the hospital. The other 2 patients survived. Two of the infants required late tracheostomy for facial and laryngeal anomalies. Conclusions Extracorporeal membrane oxygenation provides an excellent environment for complex tracheal reconstruction and promotes postoperative healing by minimizing trauma to the reconstructed airway.

Anesthesia and airway management of pediatric patients with Smith-Lemli-Opitz syndrome.

SMITH-LEMLI-OPITZ syndrome (SLOS) is an autosomal recessive disorder with an incidence of between 1 in 26,500 pregnancies in Canada and 1 in 50,000 pregnancies in the United States. The syndrome results from an inborn error of cholesterol biosynthesis involving a deficiency of 3β-hydroxysterol Δ 7 -reductase, the enzyme that catalyzes the reduction of 7-dehydrocholesterol to cholesterol. As a result, patients with SLOS have abnormal embryonic development, high plasma concentrations of 7-dehydrocholesterol, and usually decreased plasma concentrations of cholesterol. This biochemical defect is associated with a broad spectrum of clinical manifestations with potentially profound anesthetic implications. Patients with SLOS cans have severe growth failure, congenital anomalies affecting most organ systems, early death, developmental delay, and self-injurious and ritualistic behavior. Of special concern to anesthesiologists are the typical dysmorphic facial features, including micrognathia, cleft palate, and a small and abnormally hard tongue, which can present a challenge in airway management of patients with SLOS. The broad spectrum of congenital anomalies and potential increase in lifespan with dietary cholesterol replacement therapy make it very likely that diagnostic and therapeutic interventions requirign anesthesia will be needed in patients with SLOS. However, since the discovery of the biochemical defect in SLOS, little has been reported on the anesthetic management of these patients. In this report, we describe the administration of 20 anesthetics in 14 patients with confirmed biochemical diagnosis of SLOS. Our focus was on airway management, and because of previous reports of difficult intubations in some of our patients, we chose to use fiberoptic laryngoscopy as the initial technique to achieve tracheal intubation.

Airway Management of the Severely Retrognathic Child: Use of the Laryngeal Mask Airway

Successful airway management of an infant or child with moderate to severe retrognathia first requires recognition of a potential problem. If the child cannot be intubated in a standard fashion, the use of a laryngeal mask airway (LMA) should be considered. We describe two cases wherein a toddler and an infant with severe retrognathia failed multiple attempts at traditional intubation. Both had an anterior larynx and hypoplasia of the mandible. In both cases, a subsequent LMA was successfully placed. The severely retrognathic newborn or child presents to the physician a unique challenge in airway management. Techniques to manage this difficult pediatric airway are different from those used in the adult. Otolaryngologists should be aware of this intubation technique and include it in their armamentarium of airway-management strategies. The LMA is not recommended as the technique of choice for securing a difficult airway, but it is an effective alternative when indicated, and it might be life-saving.

Anesthesia for tracheal and endobronchial interventions

Tracheal and endobronchial interventions constitute a wide variety of procedures offering unique challenges in perioperative airway management and ventilatory support. Elective or emergent anesthetic management is individualized according to underlying airway pathology, coexisting disease, and patient age. This review explores recent literature and reports on relevant advances in anesthetic care.

Etomidate-Facilitated Intubation in the Prehospital Setting

Environmental conditions, limited resources, and safety concerns can lead to airway management challenges in the prehospital setting. Few emergency medical services organizations have implemented the emergency department gold standard of rapid sequence intubation. Some have used an induction agent alone (facilitated intubation). These authors compared success rates for facilitated intubation before and after introduction of an etomidate protocol …

Airway management in the emergency department

Summary Some of the greatest challenges in airway management occur in the ED. Limited pre-intubation assessment and complicating clinical conditions mandate that these patients be viewed as difficult intubations. It is more important to know well one or two approaches for each stage of a difficult airway algorithm than to know many approaches superficially. Besides the requisite intubation skills to manage these airways, the airway equipment necessary to implement these skills must be immediately available. Expertise alone cannot make up for the lack of the right equipment. Even the most skilled intubator will eventually encounter the patient who defies intubation; practicing in the ED ensures an increased frequency of this occurrence. The ability to establish a surgical airway is an absolute requirement of all practitioners committed to safe and responsible airway management.

Thyroid disease

In summary, disease of the thyroid gland is common. Anaesthetists will be required to manage patients with hypothyroidism and hyperthyroidism and those requiring thyroidectomy. Since anaesthesia for thyroidectomy provides many challenges of airway management, the anaesthetist should pay particular attention to preoperative assessment of the airway and should be able to deal with acute airway complications in the perioperative phase.

AIRWAY MANAGEMENT OF SURGICAL PATIENTS WITH HEAD AND NECK MALIGNANCIES

Few situations present greater potential for airway management challenges than head and neck oncologic surgery. Such patients often present to the operating room with conditions that make mask ventilation and tracheal intubation potentially or obviously difficult following the induction of general anesthesia. 21 Frequently, the surgical procedures are lengthy, especially those involving plastic reconstruction of a large defect. The surgical team usually requires complete and easy access to the operative site, which is either the airway itself or an area near it. 20 The anesthesiologist may not be able to position him or herself near the patient's head, 30 yet, the surgical team expects the timely establishment of general anesthesia in the patient, a quiet operative field free of bulky equipment, and the patient's smooth emergence from anesthesia at the end of the operation. 20 This article describes a concise and safe approach for securing and managing the airways of patients undergoing surgical therapy for head and neck cancer. The approach is based on current airway management principles and techniques and emphasizes the prevention of airway problems associated with this type of surgery. 58

An airway management dilemma - gross swelling of the airway associated with haemorrhagic varicella in an adult

We describe a fatal case of haemorrhagic chickenpox in a previously healthy adult. Haemorrhagic complications of chickenpox are rare in immunocompetent adults, and the case is particularly interesting since the coagulopathy was associated with gross swelling of the head and neck, thus presenting a potentially challenging airway management problem.

An airway management dilemma - gross swelling of the airway associated with haemorrhagic varicella in an adult

We describe a fatal case of haemorrhagic chickenpox in a previously healthy adult. Haemorrhagic complications of chickenpox are rare in immunocompetent adults, and the case is particularly interesting since the coagulopathy was associated with gross swelling of the head and neck, thus presenting a potentially challenging airway management problem.