Difficult Airway Management In Patient Research Articles

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.

Difficult Airway Management in Pediatric Patient with Neck Contracture

Background: A specific airway evaluation and physical examination should be performed in all pediatric patients undergoing anesthesia. Pediatric difficult airway problems can occur due to congenital, inflammation, trauma, or malignant disorders. Laryngeal mask airway (LMA) is an alternative breathing device for difficult airway cases. Case: We reported a 5-year-old girl, 12 kg of weight, with a diagnosis of Colli region contracture planned for contracture release. Physical examination revealed glasgow coma scale score 15, with a pulse of 98 beats per minute, a breath rate of 22 times per minute and SpO2 of 98% on the room air. In the airway evaluation, it was found that the lower mouth was pulled down by the contracture tissue, 2-fingers-wide of mouth opening, the mallampati score was difficult to evaluate, there was no obstruction and neck motion was limited due to contractures. In this report, intubation via video laryngoscope was failed due to the severely restricted neck motion caused by the contracture. The use of LMA became an alternative difficult airway management in this patient after failed intubation with a video laryngoscope. Conclusion: Preoperative evaluation for assessing and evaluating difficult airway in pediatric patients greatly determines the success of airway management. The use of airway devices such as LMA is still very helpful in cases of pediatric difficult airway.

Superior Laryngeal Nerve Block for Intubation in Patients With COVID-19.

Coronaviruses are thought to primarily spread via respiratory droplets and close or direct contact. Transmission is also possible through prolonged exposure to high concentrations of virally infected aerosols in a relatively closed environment.1 Once generated, these aerosols reportedly remain suspended in the air for up to 3 hours.2 Certain clinical procedures such as intubation and extubation are particularly known to generate potentially contagious aerosols that could infect medical personnel.3 Canelli et al4 recently invented an “aerosol box,” a barrier that can be easily fabricated, to reduce the risk of viral transmission and infection via exposure to contaminated aerosols for clinicians performing intubation- and extubation-related procedures. This barrier consists of a transparent plastic cube that encases the patient's head, with 2 circular ports through which clinicians can insert their hands to manage the airway with minimal exposure. However, this box restricts hand mobility and requires prior training before use in actual clinical procedures.5Ponnappan et al6 analyzed their preliminary experience using the aerosol box during 30 endotracheal intubations performed by anesthesiologists at the Institute of Liver and Biliary Sciences, New Delhi. The mean experience of the anesthesiologists involved in that study was 5.3 years after completion of anesthesia training. Successful intubation was achieved in 38.1% of cases during the first attempt. A second attempt was required in 28.6% of cases, and removal of the aerosol box was required in 28.6% of cases because of poor vision and/or inadequate space to facilitate proper airway management. In difficult intubation cases in which it was necessary to intubate while spontaneous ventilation was maintained, success rates while using the aerosol box would have likely decreased significantly.Reducing coughing during intubation could contribute to a reduction in viral transmission and exposure among health care workers. Coughing can be reduced by several techniques such as the administration of nebulized lidocaine to anesthetize the airway or intravenous boluses of opioid agonists for cough suppression, among others. In our hospital, we use moderate sedation with midazolam and fentanyl for patients with suspected difficult intubation or airway management. Once the patient is adequately sedated, a bilateral superior laryngeal nerve (SLN) block (SLNB) can be performed to further reduce coughing during intubation, because the block effectively prevents contraction of the cricothyroid muscle. The block can be performed percutaneously without ultrasound guidance (Figure). Therefore, even when the need for emergent intubation unexpectedly becomes apparent, it can be performed relatively easily and quickly. The SLN provides sensation to the upper part of the larynx (and lower part of the pharynx).7–10 SLNB has been used to facilitate awake endotracheal intubations during endoscopic laryngeal surgeries.11,12 Alessandri et al13 reported that SLNB reduced cough and discomfort during awake fiber-optic intubations. However, this block can be associated with potential complications, including intravascular injection and nerve damage. Nevertheless, we believe that cough suppression via bilateral SLNB can be a useful approach for reducing aerosol generation during airway management (ie, intubation). It must be mentioned that appropriate personal protective equipment still remains necessary for adequate protection at all times, particularly during this pandemic.We do not have any experience intubating patients infected with SARS-CoV-2, the virus that causes the novel coronavirus disease 2019 (COVID-19). However, we are of the opinion that SLNB is likely to be effective in reducing coughing and aerosol generation during difficult airway management in patients with COVID-19.

Airway Management of Retrosternal Goiters in 22 Cases in a Tertiary Referral Center.

BackgroundThe present study aimed to investigate the incidence and extent of difficult airway management in patients with massive retrosternal goiter.DesignAn 8-year retrospective analysis was performed to identify patients who underwent massive retrosternal thyroidectomy. A total of 22 cases were identified as giant retrosternal goiter, followed by a review of each patient’s preoperative computerized tomography imaging.InterventionsThere were no cases of failed intubation. Twenty patients underwent uneventful tracheal intubation using direct laryngoscopy or Glidescope. Thirteen patients received a muscle relaxant intravenously, and two patients were induced with sevoflurane. Five patients underwent awake tracheal intubation, including awake fiberoptic intubation in three patients. Before entering the operating theatre, the remaining two patients underwent oral tracheal intubation with Glidescope in the emergency department.ResultsTwo patients had tracheal intubation before they entered the operating theatre. Once entering vocal cords, tracheal intubation can pass beyond the site of the tracheal obstruction without difficulty. One patient died because of serious perioperative bleeding owing to the adhesion between the retrosternal goiter and large vessel within the thoracic cavity. One patient experienced dyspnea after extubation and was intubated again.ConclusionIntravenous induction of muscle relaxant using laryngoscopy or Glidescope is feasible in patients with massive benign retrosternal goiter. The incidence of difficult intubation and postoperative tracheomalacia is likely too rare. Furthermore, perioperative bleeding and postoperative airway complication seem frequent.

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.

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.

Difficult Airway Management in Patients Submitted to General Anesthesia. Is it a Matter of Devices or Predictive Scores?

Background: Incidence of difficult tracheal intubation in elective surgery population varies in a wide range, with estimated pooled frequency of 6.8%. Unanticipated difficult intubation has been reported in 1.5 8.5% of all general anesthesia. Among devices providing indirect laryngoscopy, Truview EVO2 ® offers advantages in terms of glottic exposure, short training, and low cost. Methods: Retrospective review of unexpected difficult intubation among 24.500 patients scheduled for elective surgery under general anesthesia over a 44 months period. Direct laryngoscopy was first performed in all patients, thus, in case of any difficulty encountered, an alternative device was utilized. Incidence and characteristics of difficult intubation are reported. Preoperative airway evaluation parameters have been correlated with intubation difficulty. Results: Difficult tracheal intubation (DTI) was observed in 0.4% (90 patients). Truview laryngoscope has been used in 59 of 90 patients and succeeded in achieving intubation in 75% of cases. Among risk factors for difficult intubation, neither Mallampati class nor Body Mass Index (BMI) were shown to have high predictive value. An El-Ganzouri Risk Index (EGRI) score of 3 has been estimated to represent the cut-off value between easy and difficult intubation. Conclusion: Truview laryngoscope represents a useful tool in case of unexpected difficult intubation, and could be eventually introduced in a difficult airway management algorithm without burden on Unit costs and staff training. DTI predictive scores have been applied in clinical practice but still lack in cut-off values validation. As in our experience the risk score failed in predicting difficult airway, we speculate that the Anesthesiologist’s confidence with one or more alternative intubation devices could obviate the need for predictive scores. patient airway occurs, exposes the patient to the risk of complications basically related to hypoxia. Its incidence has been reported around 1-4% of patients with normal airway and, more recently, in a range of 1.5 8.5% of all general anesthesia [2,3]. Management of unanticipated difficult airways has been standardized in various algorithms, with an increasing need in updating related to development of novel devices [4].

Difficult Airway Management In Patients With Severe Post Burn Contracture of Neck

Severe post-burn contracture (PBC) of the neck represents a challenge to the plastic surgeon as well as the anaesthesiologist. As mortality and morbidity are directly related to the ability to deliver oxygen to the patient, the airway must be managed with particular care in these patients. A burn scar contracture causes insufficient neck extension, resulting in difficult intubation that can be life-threatening [1].

Difficult Airway Management in Patients Undergoing Cardiac Surgery

Difficult Airway Management in Patients Undergoing Cardiac Surgery

Using Proseal LMA and I-gel for difficult airway management in patient with diffuse tracheal stenosis and pulmonary artery sling

Pulmonary artery sling (PAS) is a rare congenital anomaly frequently accompanied by focal or long-segment tracheal stenosis. We presented a 34-year-old female patient with severe long-segment tracheal stenosis associated with PAS which was assessed with Multi Slice Computed Tomography (MSCT) consisting of axial, three dimensional and virtual bronchoscopic images of the airway. This case report discussed the management of her difficult airway condition during surgical cholecystectomy and thyroidectomy by using proseal- LMA and I-gel, respectively (Fig. 4, Ref. 10).

Dexmedetomidine premedication for fiberoptic intubation in patients of temporomandibular joint ankylosis: A randomized clinical trial

Background:Fiberoptic intubation is the gold standard technique for difficult airway management in patients of temporomandibular joint. This study was aimed to evaluate the clinical efficacy and safety of dexmedetomidine as premedication with propofol infusion for fiberoptic intubation.Methods:Consent was obtained from 46 adult patients of temporomandibular joint ankylosis, scheduled for gap arthroplasty. They were enrolled for thisdouble-blind, randomized, prospective clinical trial with two treatment groups – Group D and Group P, of 23 patients each. Group D patients had received premedication of dexmedetomidine 1 μg/kg infused over 10 min followed by sedative propofol infusion and the control Group P patients were given only propofol infusion to achieve sedation. Condition achieved at endoscopy, intubating conditions, hemodynamic changes and postoperative events were evaluated as primary outcome.Results:The fiberoptic intubation was successful with satisfactory endoscopic and intubating condition in all patients. Dexmedetomidine premedication has provided satisfactory conditions for fiberoptic intubation and attenuated the hemodynamic response of fiberoptic intubation than the propofol group.Conclusion:Fiberoptic intubation was found to be easier with dexmedetomidine premedication along with sedative infusion of propofol with complete amnesia of the procedure, hemodynamic stability and preservation of patent airway.

Difficult airway management in patients with sleep apnea syndrome: A prospective study

Difficult airway management in patients with sleep apnea syndrome: A prospective study