Distorted Airway Anatomy Research Articles

Difficult airway following inhalational burn injury in a child

Airway management in a burn victim poses special challenges for the anaesthesiologist not only during the acute phase but also after delayed consequences have set in resulting in difficulty in airway management. We report a 5-year-old boy who was admitted to the Department of Paediatrics with biphasic stridor 2 months following inhalational burn injury. He presented with complaints of difficulty in swallowing solid food, hoarseness of voice for the past 1 month and occasional difficulty in breathing for the past 10 days. Laryngoscopy using a #2 Macintosh blade revealed pharyngeal stenosis with grossly distorted airway anatomy. The patient was finally intubated after great difficulty with a 3.5 mm internal diameter endotracheal tube using a fibrescope.

Awake nasotracheal intubation with a 300-mm working length fiberscope: a prospective observational feasibility trial

BackgroundAwake fiberoptic tracheal intubation is an established method of securing difficult airways, but there are some reservations about its use because many practitioners find it technically complicated, time-consuming, and unpleasant for patients. Our main goal was to test the safety and efficacy of a 300-mm working length fiberscope (video rhino-laryngoscope) when used for awake nasotracheal intubation in difficult airway cases. MethodsThis was a prospective, single-center study involving adult patients, having an ASA physical status between I and IV, with laryngopharyngeal pathology causing distorted airway anatomy. Awake nasotracheal intubation, using topical anesthesia and light sedation, was performed using a 300 mm long and 2.9 mm diameter fiberscope equipped with a lubricated reinforced endotracheal tube. The primary outcomes were the success and duration of the procedure. Patients’ periprocedural satisfaction and other incidents were recorded. ResultsWe successfully intubated all 25 patients included in this study. The mean ±SD duration of the procedure, starting from the passage of the intubating tube through one of the nostrils until the endotracheal intubation, was 76 ± 36 seconds. Most of the patients showed no discomfort during the procedure with statistical significance between the No reaction Group with the Slight grimacing Group (95%CI 0.13, 0.53, p = 0.047) and the Heavy grimacing Group (95%CI 0.05, 0.83, p = 0.003). The mean ±SD satisfaction score 24 hours post-intervention was 1.8 ± 0.86 – mild discomfort. No significant incidents occurred. ConclusionsOur study showed that a 300-mm working length flexible endoscope is fast, safe, and well-tolerated for nasotracheal awake intubation under challenging airways.

Airway Manoeuvres during Anaesthetic Management of Adult Acquired Tracheo-Oesophageal Fistula

Regardless of aetiology, acquired tracheo-oesophageal fistula (TEF) is a life-threatening condition due to the risk of pulmonary soiling and sepsis. Distorted airway anatomy below the glottis makes airway management challenging. We present the anaesthetic management for TEF repair in an adult male who developed fistula following organophosphorus poisoning. Maintaining optimum position of the endotracheal tube (ETT) during cross-field ventilation and ETT repositioning is crucial. For better understanding of the anaesthetic management for this relatively rare surgery, we have described airway management sequentially to coincide with different phases of surgical interventions.

Anesthetic management of a patient presenting with huge neck lymphatic cyst

Lymphatic cyst in the cervical region presents a great challenge to the anesthesiologist. The anesthetic difficulties are because of the extension of the cyst, difficult airway, postoperative respiratory obstruction, and coexisting anomalies. The management of such patients depends on direct communication between the surgeon and anesthesiologist. We hereby present a case of a 53-year-old male presenting with lymphatic cyst of the cervicothoracic region with dysphagia and dyspnea, posted for direct laryngoscopy and biopsy under general anesthesia. Awake fiberoptic intubation was done in this patient successfully in spite of totally distorted airway anatomy.

3D printing for airway disease.

It has been 30 years since the first commercial three-dimensional (3D) printer was available on market. The technological advancement of 3D printing has far exceeded its implementation in medicine. The application of 3D printing technology has the potential of playing a major role within interventional pulmonology; specifically, in the management of complex airway disease. Tailoring management to the patient-specific anatomical malformation caused by benign or malignant disease is a major challenge faced by interventional pulmonologists. Such cases often require adjunctive therapeutic procedures with thermal therapies followed by dilation and airway stenting to maintain the patency of the airway. Airway-stent size matching is one key to reducing stent-related complications. A major barrier to matching is the expansion of the stent in two dimensions (fixed sizes in length and diameter) within the deformed airway. Additional challenges are created by the subjective oversizing of the stent to reduce the likelihood of migration. Improper sizing adversely affects the stability of the stent. The stent-airway mismatch can be complicated by airway erosion, perforation, or the formation of granulation tissue. Stents can migrate, fracture, obstruct, or become infected. The use of patient-specific 3D printed airway stents may be able to reduce the stent airway mismatch. These stents allow more precise stent-airway sizing and minimizes high-pressure points on distorted airway anatomy. In theory, this should reduce the incidence of the well-known complications of factory manufactured stents. In this article, the authors present the brief history of 3D printed stents, their consideration in select patients, processing steps for development, and future direction.

Airway management in patients with deep neck infections: A retrospective analysis.

Securing the airway in patients undergoing surgical intervention to control a deep neck infection (DNI) is challenging for anesthesiologists due to the distorted airway anatomy, limited mouth opening, tissue edema, and immobility. It is critical to assess the risk of a potential difficult airway and prepare the most appropriate airway management method.We reviewed our anesthetic experiences managing patients with DNIs, focusing on the need for video-laryngoscope or awake fiberoptic intubation beyond a standard intubation from the anesthesiologist's perspective.When patients had infections in the masticatory space, mouth of floor, oropharyngeal mucosal space, or laryngopharynx, their airways tended to be managed using methods requiring more effort by the anesthesiologists, and more extensive equipment preparation, compared with use of a standard laryngoscope. The degree to which the main lesion influenced the airway anatomy, especially at the level of epiglottis and aryepiglottic fold was related to the airway management method selected.When managing the airways of patients undergoing surgery for DNIs under general anesthesia, anesthesiologists should use imaging with computed tomography to evaluate the preoperative airway status and a comprehensive understanding of radiological findings, comorbidities, and patients’ symptoms is needed.

Awake Fiberoptic Nasotracheal Intubation in an Elderly Patient With Distorted Airway Anatomy [Hava Yolu Anatomisi Degisen Yasli Hastada Uyanik Fiberoptik Nazotrakeal Entubasyon

Patients with head and neck cancer can undergo several surgical operations varying from local excision to radical dissection. These operations may cause changes in the anatomy of the airway. Difficult airway is a multifactorial condition that is affected by anatomical features of the patient, clinical conditions and experiences and skills of the physician leading the airway management. Difficult airway is encountered more frequently in elderly patients and in case of distorted airway anatomy due to reasons like head and neck surgery or trauma. The aim of this case report is to share our experience on awake fiberoptic intubation in a 71-year-old female patient with maxillary sinus tumor with distorted airway anatomy due to multiple head and neck surgeries. When the patient compliance is achieved, awake fiberoptic intubation technique is an alternative method which has high success rate without destroying patient comfort.

Morquio syndrome with acute cord compression: An anesthetic challenge

Morquio syndrome with skeletal and extraskeletal manifestations is an anesthetic challenge. Airway management in children with Morquio syndrome can pose added risks of atlantoaxial instability, spinal cord compression, and distorted airway anatomy, leading to difficult mask ventilation and intubation. We report the anesthetic management of a 4-year-old child with Morquio syndrome who presented with acute cord compression and underwent emergency decompression of the stenotic spinal canal at the craniovertebral junction. Thorough preoperative evaluation, meticulous planning, and vigilant monitoring in the perioperative period are essential for safe anesthetic management.

Evaluation of rigid bronchoscopy-guided percutaneous dilational tracheostomy. A pilot study.

Rigid bronchoscopy-guided (RBG) percutaneous tracheostomy has been used in patients with morbid obesity, prior neck surgery, distorted airway anatomy, and uncorrected coagulopathy where standard percutaneous dilational tracheostomy (PDT) is relatively contraindicated. This study aims to describe a standardized approach to incorporate RBG-PDT in clinical practice. Retrospective case series of patients who underwent RBG-PDT from 2008 to 2012 at Beth Israel Deaconess Medical Center. Patient medical records were reviewed for demographics, comorbid conditions, American Society of Anesthesiologists classification, indication for tracheostomy, duration of procedure, and periprocedural complications. A total of 35 patients underwent RBG-PDT, including 24 men, with a mean age of 66 years (±11 yr; range, 42-88 yr). The mean body mass index was 34 kg/m(2). The mean procedure time was 32 (±10) minutes, with a median of 33 minutes. The most common indication for tracheostomy was failure to wean from mechanical ventilation, followed by tracheal stenosis and tracheobronchomalacia. The most common indications for RBG-PDT were complex airway, obesity, and coagulopathy. There were no periprocedural complications of consequence, or mortality associated with the procedure. RBG-PDT is safe and effective in a population of high-risk patients who are otherwise not considered good candidates for standard PDT.

Successful nasotracheal intubation in a patient with distorted airway anatomy by combined use of flexible fiberoptic bronchoscope and trachway

Nasotracheal intubation for airway anatomy distorted patients is often frustrating. Here, we describe a redo oral cancer patient who received awake nasotracheal intubation under flexible fiberoptic bronchoscopy (FFB) guidance with assistance of the Trachway ® intubating stylet. After repeated failures of locating the epiglottis or vocal cords with the FFB, we put Trachway stylet into the oropharynx to assist identifying glottic structures. With the assistance of Trachway, glottic structures and the tip of FFB were identified, and fiberoptic intubation was achieved without complications. Therefore, this feasible application may be applied to patients with distorted airway who requires nasotracheal intubation.

Airway management of recovered pediatric patients with severe head and neck burns: a review

There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

Wire-guided (Seldinger technique) intubation through a face mask in urgent, difficult and grossly distorted airways

We report two cases of successful urgent intubation using a Seldinger technique for airway management through an anesthesia facemask, while maintaining ventilation in patients with difficult airways and grossly distorted airway anatomy. In both cases, conventional airway management techniques were predicted to be difficult or impossible, and a high likelihood for a surgical airway was present. This technique was chosen as it allows tracheal tube placement through the nares during spontaneous ventilation with the airway stented open and oxygen delivery with either continuous positive airway pressure and/or pressure support ventilation. This unhurried technique may allow intubation when other techniques are unsuitable, while maintaining control of the airway.

Airway Management in a Patient With Treacher Collins Syndrome Requiring Emergent Cesarean Section

To the Editor: Treacher Collins syndrome also referred to as mandibulofacial dysostosis, is characterized by maxillary, zygomatic, and mandibular hypoplasia and known to be associated with difficult intubation. We report the airway management in a patient with Treacher Collins syndrome requiring emergent cesarean delivery owing to cord prolapse. The patient did not have either a preoperative assessment, or a clinical history in the hospital, and therefore no anesthetic strategy had been considered beforehand. Because there was no time to perform regional anesthesia because of the cord prolapse, the patient received general anesthesia. Taking into account that exclusive reliance on direct laryngoscopy was a high-risk strategy (mouth opening 2 cm; unable to protrude the lower incisors past the upper incisors; Mallampati class 4), we decided to insert a LMA-Fastrach™ (which was inserted on the first attempt) and the patient breathed spontaneously thereafter. No blind intubation through the LMA could be achieved because of resistance, despite of applying Chandy's maneuver (1). As backup in the event the LMA could not be satisfactorily inserted, or that ventilation could not be achieved, we were prepared to perform jet ventilation leaving emergent tracheostomy as the last option. Both weaning and LMA-Fastrach removal were uneventful. Craniofacial abnormalities often affect airway management making mask ventilation and tracheal intubation difficult or even impossible to achieve if there are also temporomandibular joint abnormalities. Airway morphology may change as patients mature or as a result of surgical interventions (2). The difficulty in intubation increases as the patient with Treacher Collins syndrome ages and requires reevaluation of the airway prior to each anesthetic (3). Different strategies including use of the classical laryngeal mask airway (LMA), [which is not always successful (4)] and the Bullard laryngoscope (5) have been described for airway management in patients with Treacher Collins syndrome. Ferson et al. (6) reported the use of LMA-Fastrach as a conduit for blind intubation in 254 patients with difficult-to-manage airways and showed a success rate for this device of 75.5% on the first attempt and 96.5% within five attempts, reaching the success rate 100% with the added use of a fiberoptic bronchoscope. However, in patients with distorted airway anatomy related to previous surgeries, Ferson et al. electively used a fiberoptic guided intubation (6), although it should be noted that none of these patients had Treacher Collins syndrome. A new device that has been successfully used to intubate the tracheas of patients with difficult airways (none with Treacher Collins syndrome) is the LMA-CTrach (7). Nevertheless, there is no published evidence that any of these new devices (including the LMA-Fastrach) are successful in adult patients with craniofacial abnormalities as Treacher Collins syndrome. In such patients, a previous preoperative assessment together with a complete clinical history (including records of previous surgeries or anesthetics) and even a reevaluation of the airway are advised to best plan anesthetic strategy and airway management. Paloma Morillas, MD Inocencia Fornet, MD, PhD Isabel De Miguel, MD Francisco J. Palacio, MD, PhD Marïa A. López, MD Department of Anesthesia and Intensive Care Medicine La Paz University Hospital Madrid, Spain [email protected]

The effectiveness of ARNDT endobronchial blockers in paediatric scoliosis surgery

Introduction: Although described for paediatric thoracic surgery (1), there is little data on the use of the Arndt endobronchial blocker in paediatric spinal deformity surgery. We present its successful application in these patients.Methods: Thirteen patients undergoing surgical correction of scoliosis involving a lateral thoracotomy anterior approach were suitable for lung isolation using an Arndt endobronchial blocker. Placement was via an armoured tracheal tube; the endobronchial blockers were 5 or 9 FG with low‐volume low‐pressure cuffs (spherical or elliptical balloons). Placement was by a paediatric anaesthetist trained in paediatric bronchoscopy and required a 2.2 or a 2.8 mm paediatric fibreoptic bronchoscope.Results: Patient ages ranged from 18 months to 18 years and weights from 9 kg to 71 kg. All had idiopathic or congenital scoliosis; one patient underwent a VEPTR procedure. In all 13 patients, placement was easily and promptly achieved with no incorrect placements, displacements (including after patient repositioning), or failures to isolate one lung. Median time of insertion was 5 min (with checks), speed of insertion increasing as experience improved. Inflation times for the blocker balloon ranged from 1.5 h to 5 h. There was no airway trauma; direct bronchial inspection revealed local erythema only. Saturations were supported with 5 cm CPAP to the isolated lung and one‐lung ventilation was well tolerated in all but one patient with acceptable airway pressures (<35 cm water); this one patient required partial lung inflation (blocker in place, balloon not inflated) to maintain adequate saturations and airway pressures. The surgical field was excellent in all cases.Discussion: Complex paediatric spinal surgery may require lung collapse to improve spinal access, and is traditionally achieved using a double‐lumen tracheal tube. Difficulties can arise as the children are often small for age with potentially distorted airway anatomy and there are a limited number of double lumen tube sizes. This can lead to inadequate isolation, a poor surgical field, endobronchial cuff herniation or obstruction of left upper lobe (tube too small or too long). The careful use of the Arndt endobronchial blocker avoids all these problems and enables easy reliable and safe isolation. Potential complications include malposition, migration, and direct airway trauma, allied to the usual complications of one lung anaesthesia. In our series, there were no complications relating to its use and insertion was quick and straightforward.Conclusions: Lung isolation with the Arndt endobronchial blocker is both safe and very effective in paediatric spinal deformity surgery.Reference 1 Wald SH, Mahajan A, Kaplan MB et al. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2005; 94: 92–94.