History Of Tracheostomy Research Articles

Determining the epidemiological status of patients with tracheal stenosis

Introduction: Tracheal stenosis is a rare, but serious complication that often occurs following tracheal intubation or tracheostomy. This study aimed to evaluate the causes, symptoms, and complications of therapeutic methods in patients with treated tracheal stenosis Analysis. Material and methods: In this descriptive retrospective study, patients who had undergone tracheal stenosis were evaluated for its cause, the cause of endotracheal intubation, the duration of intubation, types of treatment, length of hospital stay, and postoperative complications.80 patients were included in the study. Result and Discussion: The most common cause of tracheal stenosis was endotracheal intubation (57.5%). Among 41 patients with a history of tracheostomy, 34 patients underwent late tracheostomy and 7 patients underwent early tracheostomy. Recurrence of stenosis was the most common complication of tracheal stenosis treatment (surgery), respectively. Conclusion: The prolonged endotracheal intubation is the most common cause of endotracheal stenosis, therefore, early tracheostomy is recommended to be done on patients with predicted long-term endotracheal intubation.

Tracheal resection in post COVID-19 patients is associated with high reintervention rate and early restenosis.

A remarkable increase in the number of patients presenting with tracheal complications after prolonged endotracheal intubation and mechanical ventilation for the management of the severe COVID-19 - associated respiratory failure has been observed. In this study, we assessed the postoperative outcomes of tracheal resection in COVID-19 patients. We conducted a retrospective study in which all patients with a history of prolonged invasive mechanical ventilation due to COVID-19 infection, who were treated with tracheal resection and reconstruction, were included. The primary objective was in-hospital mortality and postoperative reintervention rate. The secondary objective was the time to tracheal restenosis. During the 16-month study period, 11 COVID-19 patients with tracheal complications underwent tracheal resection with end-to-end anastomosis. Mean patient age was 51.5 ± 9 years, and the majority were male (9 patients). Eight patients were referred for management of post-intubation tracheal stenosis and 3 for tracheoesophageal fistula. Eight patients had a history of tracheostomy during the COVID-19 infection hospitalization. There was one in-hospital death (9.1%) due to septicemia in the Intensive Care Unit, approximately two months after the operation. Postoperatively, 32 reinterventions were required for tracheal restenosis due to granulation tissue formation. The risk for reintervention was higher during the first 3 months after the index operation. Four patients developed tracheal restenosis (36.4%) and two of them required endotracheal stent placement during the follow up period. Tracheal resection and reconstruction after COVID-19 infection is associated with a high reintervention rate postoperatively. Such patients require close follow up in expert interventional pulmonology units and physicians should be on high alert for the early diagnosis and optimal management of tracheal restenosis.

Endoscopic percutaneous repair of laryngeal cleft.

The aim of this study was to describe a novel surgical technique of endoscopic percutaneous repair in pediatric patients with type 1, type 2 and type 3 laryngeal cleft (LC). A retrospective study involving 12 patients with LC was performed at a tertiary pediatric hospital between February 2021 and June 2022. Endoscopic percutaneous repair was performed in all the patients. Information such as demographics, comorbidities, history of tracheostomy and the open approach for the repair, type of cleft and complications were analyzed. Twelve patients were diagnosed with LC. The median age of the patients at the time of surgery was 8.50 months (interquartile range, 49.50 months). Seven patients had tracheomalacia, four patients had subglottic stenosis, three patients had laryngomalacia. No surgical complications occurred in the 10 patients who underwent the primary procedure. For two patients who underwent a secondary procedure, endoscopic percutaneous repair failed again to heal the cleft. During the follow-up period after surgery, none of the patients had stridor, recurrent pneumonia, feeding difficulties, or dyspnea. Follow-up modified barium swallow postoperatively demonstrated no aspiration in 10 patients. Only the 2 patients with a secondary procedure had intermittent cough while taking large gulps of water. The cure rate of endoscopic percutaneous repairer was 83.3% (95% confidence interval: 73.9%-92.8%). Endoscopic percutaneous repair should be considered as an alternative to the open transcervical approach and the traditional endoscopic approach for type 1, type 2 and type 3 LC.

The Continuing Search for the Right Balance

Anesthesiologists are currently viewed as airway experts. Interestingly, advanced airway management were initially primarily performed to resuscitate victims of drowning and patients afflicted with diphtheria infection by non-anesthesiologists.1,2 In 1878, the first elective use of endotracheal intubation for anesthesia was performed by Dr. William Macewen, a Scottish surgeon, using an awake, digital blind intubation technique.1The invention of the Macintosh and Magill laryngoscope blades as well as the introduction of curare in the 1940’s facilitated tracheal intubation such that it already became a routine component of anesthetic management for major surgeries.2 Advancements involving flexible fiberoptic cables paved the way for flexible fiberoptic bronchoscope in the late 1960’s.3 Later on, the need for a wider angle of view to address difficult intubation cases gave birth to a variety of videolaryngoscopes in the 2000s.As early as 2004, there were already reports combining airway equipment to facilitate intubation.4 However, it was not until 2011 that Boet et al. coined the term “multimodal airway approach”.5 Since then, this practice has been explored further by anesthesiologists and is now included as an option in the American Society of Anesthesiologists difficult airway algorithm for both adult and pediatric patients.6The second article in this special issue described how a non-traditional combination of advanced airway equipment easily circumvented the difficulty posed by the initial sole airway equipment technique. Meanwhile, the third article incorporated a twist in the multimodal airway approach by employing two different techniques at different stages of the surgery.These two articles are particularly encouraging since an awake intubation for anticipated difficult airway is hardly applicable for the pediatric population. In addition, the combination described in the second article is reproducible in other parts of the country. The COVID-19 pandemic already created a rapid paradigm shift favoring the acceptance and availability of videolaryngoscopes in routine practice.7-9 Bonfils intubating fiberscope does not have a steep learning curve.10 It also requires less maintenance compared to a fiberoptic bronchoscope.Synergism is a pharmacologic principle that has long been used by anesthesiologists in maintaining homeostasis through the provision of “balanced anesthesia” and “multimodal analgesia”.11,12 The time has come to extend this concept to nonpharmacologic entities as well.As the field of anesthesiology continues to expand in coverage and complexity, the search continues for the perfect complement that will provide the right balance encompassing all elements.
 
 Evangeline K. Villa, MDDepartment of Anesthesiology College of Medicine and Philippine General HospitalUniversity of the Philippines Manila 
 REFERENCES1. Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history oftracheostomy and tracheal intubation, from the Bronze Age to theSpace Age. Intensive Care Med. 2008 Feb;34(2):222-8. doi: 10.1007/s00134-007-0931-5.2. Doyle J. A brief history of clinical airway management. Rev Mex Anest.2009;32(Suppl: 1):164-167.3. Pieters BM, Eindhoven GB, Acott C, van Zundert AAJ. Pioneers oflaryngoscopy: indirect, direct and video laryngoscopy. Anaesth IntensiveCare. 2015 Jul;43 Suppl:4-11. doi: 10.1177/0310057X150430S103.4. John Doyle D. GlideScope-assisted fiberoptic intubation: a new airwayteaching method (letter). Anesthesiology. 2004 Nov; 101(5):1252.doi: 10.1097/00000542-200411000-00046.5. Boet S, Dylan Bould M, Diemunsch PA. Combined rigidvideolaryngoscopy-flexible bronchoscopy for intubation. Korean JAnesthesiol. 2011 May;60(5):381-2. doi: 10.4097/kjae.2011.60.5.381.6. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M,Dutton RP, et al. 2022 American Society of Anesthesiologists PracticeGuidelines for Management of the Difficult Airway. Anesthesiology.2022 Jan 1;136(1):31-81. doi: 10.1097/ALN.0000000000004002.7. Davies M, Hodzovic I. Videolaryngoscopy post COVID-19. TrendsAnaesth Crit Care. 2021 Feb;36:49–51. doi: 10.1016/j.tacc.2020.09.0068. De Jong A, Pardo E, Rolle A, Bodin-Lario S, Pouzeratte Y, JaberS. Airway management for COVID-19: a move towards universalvideolaryngoscope? Lancet Respir Med. 2020 Jun;8(6):555. doi:10.1016/S2213-2600(20)30221-6.9. Saoraya J, Musikatavorn K, Sereeyotin J. Low-cost Videolaryngoscopein Response to COVID-19 Pandemic. West J Emerg Med. 2020 May22;21(4):817-818. doi: 10.5811/westjem.2020.5.47831.10. Falcetta S, Pecora L, Orsetti G, Gentili P, Rossi A, Gabbanelli V, et al.The Bonfils fiberscope: a clinical evaluation of its learning curve andefficacy in difficult airway management. Minerva Anestesiol. 2012Feb;78(2):176-84.11. Lundy JS. Balanced anesthesia. Minnesota Med J. 1926; 9:399-404.12. Kehlet H, Dahl JB. The value of "multimodal" or "balanced analgesia"in postoperative pain treatment. Anesth Analg. 1993 Nov; 77(5):1048-56. doi: 10.1213/00000539-199311000-00030.

Gram-negative multidrug-resistant organisms were dominant in neurorehabilitation ward patients in a general hospital in southwest China

This study aimed to investigate the prevalence of and risk factors for multidrug-resistant organism (MDRO) infection in the rehabilitation ward of a general hospital in Southwest China. We analyzed rehabilitation patients with nosocomial infections caused by MDROs from June 2016 to June 2020. MDRO infection pathogens and associated antibiotic resistance were calculated. Possible risk factors for MDRO-related infection in the neurorehabilitation ward were analyzed using chi-square, and logistic regression. A total of 112 strains of MDRO were found positive from 96 patients. The MDRO test-positive rate was 16.70% (96/575). Ninety-five MDRO strains were detected in sputum, of which 84.82% (95/112) were gram-negative bacteria. Acinetobacter baumannii (A. Baumannii), Pseudomonas aeruginosa (P. aeruginosa), and Klebsiella pneumonia (K. pneumonia) were the most frequently isolated MDRO strains. The logistic regression model and multifactorial analysis showed that long-term (≥ 7 days) antibiotic use (OR 6.901), history of tracheotomy (OR 4.458), and a low albumin level (< 40 g/L) (OR 2.749) were independent risk factors for the development of MDRO infection in patients in the rehabilitation ward (all P < 0.05). Gram-negative MRDOs were dominant in rehabilitation ward patients. Low albumin, history of a tracheostomy, and long-term use of antibiotics were independent risk factors for MRDO infection and are worthy of attention.

Clinical Characteristics and Risk Factors for Pulmonary Infection in Emergency ICU Patients.

Background Pulmonary infection in the emergency ICUs increases patient morbidity, hospital stay, treatment costs, and the risk of related adverse events. Methods This study included 695 patients admitted to our emergency ICU between December 2019 and March 2021. Medical records of emergency ICU patients were reviewed to collect their clinical data, including antibiotic use, history of tracheostomy, history of mechanical ventilation, presence or absence of underlying disease, history of smoking, alcohol consumption, age, gender, and history of shock. Bacterial cultures were performed. The incidence, main clinical features, main pathogens, and risk factors of pulmonary infection in emergency ICU were analyzed. Results In this study, 69 of the 695 emergency ICU patients (9.93%) developed pulmonary infection. The main clinical features of patients with pulmonary infection included cough and expectoration (97.10%), shortness of breath and chest tightness (95.65%), leukocyte elevation (69.57%), confusion (31.88%), drowsiness (28.99%), persistent fever (27.54%), and nausea and vomiting (10.14%). The main pathogenic bacteria in those with pulmonary infection included Klebsiella pneumoniae (62.32%), Pseudomonas aeruginosa (49.28%), Streptococcus pneumoniae (21.74%), Staphylococcus aureus (39.13%), Candida albicans (7.25%), Pneumococcus pneumoniae (15.95%), Pseudomonas aeruginosa (24.64%), and lung diplococcus inflammatory (13.04%). Univariate analysis showed that there were no significant differences in the occurrence of pulmonary infection with regard to sex, smoking, and alcohol consumption, but there were significant differences with regard to age, basic disease, invasive surgery, and shock. Logistic regression analysis confirmed that age ≥ 80 years, invasive surgery, shock, and basic diseases ≥ 2 were important risk factors for pulmonary infection in emergency ICU patients. Conclusion Considering the clinical features and risk factors for pulmonary infection in the emergency ICU, preventive and control measures are required to minimize its occurrence and ensure good outcomes.

Utilizing Pulmonary Function Parameters to Predict Dysphagia in Individuals With Cervical Spinal Cord Injuries.

Objective To utilize pulmonary function parameters as predictive factors for dysphagia in individuals with cervical spinal cord injuries (CSCIs).MethodsMedical records of 78 individuals with CSCIs were retrospectively reviewed. The pulmonary function was evaluated using spirometry and peak flow meter, whereas the swallowing function was assessed using a videofluoroscopic swallowing study. Participants were divided into the non-penetration-aspiration group (score 1 on the Penetration-Aspiration Scale [PAS]) and penetration-aspiration group (scores 2–8 on the PAS). Individuals with pharyngeal residue grade scores >1 were included in the pharyngeal residue group.ResultsThe mean age was significantly higher in the penetration-aspiration and pharyngeal residue groups. In this study, individuals with clinical features, such as advanced age, history of tracheostomy, anterior surgical approach, and higher neurological level of injury, had significantly more penetration-aspiration or pharyngeal residue. Individuals in the penetration-aspiration group had significantly lower peak cough flow (PCF) levels. Individuals in the pharyngeal residue group had a significantly lower forced expiratory volume in 1 second (FEV1). According to the receiver operating characteristic curve analysis of PCF and FEV1 on the PAS, the cutoff value was 140 L/min and 37.5% of the predicted value, respectively.ConclusionLow PCF and FEV1 values may predict the risk of dysphagia in individuals with CSCIs. In these individuals, active evaluation of swallowing is recommended to confirm dysphagia.

Long-term respiratory and developmental outcomes in children with bronchopulmonary dysplasia and history of tracheostomy

ObjectiveThe long-term morbidity among children with severe bronchopulmonary dysplasia who require tracheostomy (tBPD) relative to those without tracheostomy (sBPD) is not well characterized. We compared childhood lung function and neurodevelopmental outcomes in tBPD and sBPD.Study designRetrospective case-control study of N = 49 tBPD and N = 280 sBPD subjects in Boston Children’s Hospital Preterm Lung Patient Registry and medical record. We compared NICU course, childhood spirometry, and neurodevelopmental testing.ResulttBPD subjects were more likely than sBPD to be Black, have pulmonary hypertension, and have subglottic stenosis. tBPD subjects had lower maximal childhood FEV1 % predicted (β = −0.14) and FEV1/FVC (β = −0.08); spirometry curves were more likely to suggest fixed extrathoracic obstruction. tBPD subjects had greater cognitive and motor delays <24 months, and greater cognitive delays >24 months.ConclusionCompared to subjects with sBPD who did not require tracheostomy, tBPD subjects suffer from increased long-term impairment in respiratory function and neurodevelopment.

Ephemeral history of the three-bladed tracheostomy dilator

Tracheostomy remains a topical surgical procedure. The history of tracheostomy is marked by the development of various instruments, including the three-bladed tracheostomy dilator from the middle of the 19th century. The purpose of this historical note is to recall the use of this unusual instrument.

Postintubation Multisegmental Tracheal Stenosis: A 24-Year Experience

Management of multisegmental tracheal stenosis is challenging. In this 24-year longitudinal single-center study, we present an algorithmic treatment approach. A retrospective analysis of 2167 patients with postintubation tracheal stenosis indicated 83 (3.83%) patients with multisegmental tracheal stenosis. Patients were assigned to 4 management groups according to the length, location, and severity of stenoses; tracheal infection/mucositis; laryngeal function; symptoms; general condition; and comorbid diseases. Type 1 (n= 13): 1-stage resection of both strictures, Type 2 (n= 6): 2-stage resection of both strictures, Type 3 (n= 40): resection of 1 stricture and nonresectional management of the other, Type 4 (n= 24): nonresectional management of both strictures. Outcomes were categorized as Good, Acceptable, or Poor. Univariate analyses for factors predictive of recurrence and outcome were performed. Follow-ups were completed in 70 (84.34%) patients (median, 22.5 months). Outcome was assessed as Good in 56 (82.35%), Acceptable in 10 (14.71%), Poor in 2 (2.94%), and mortality in 2 (2.94%) patients. The median length of airway resection was 46, 67.5, and 40 mm in Types 1-3, respectively. Only 11 (13.25%) patients had no history of tracheostomy or tracheal surgery. By univariate analysis, a shorter intubation period was associated with Good outcome (P= .017). No factors predictive of recurrence or outcome were ascertained. Multisegmental tracheal stenosis, generally caused by performing an inappropriate tracheostomy, is an iatrogenic disease that can be prevented. Although resection of both strictures may be feasible and is associated with Good results, in the majority of cases, a combination of surgical resection and non-resectional methods are sufficient to achieve Good results.

Tracheal A-Frame Deformities Following Airway Reconstruction.

Airway reconstruction for subglottic and tracheal stenosis is often successful in achieving tracheostomy decannulation and improving airway symptoms. However, one common reason for late failure is development of a tracheal A-frame deformity, which can necessitate additional surgery. Although knowledge of this deformity exists, the incidence and risk factors have not been reported. This study seeks to determine the incidence of A-frame following airway reconstruction and define factors that correlate with development of this deformity. Retrospective case series. Patients under 21 years of age undergoing open airway reconstruction at our institution between January 2005-December 2006 were retrospectively reviewed. Demographic data, comorbidities, airway history/reconstruction type, and follow-up airway findings were examined using multivariable logistic regression. Kaplan-Meier curves were used to examine time to A-frame repair. Two hundred patients underwent airway reconstruction and 69 (34.5%) developed an A-frame deformity. History of tracheostomy was the most significant contributor to A-frame development (P < .0001). Double- versus single-stage procedures were not associated with increased odds of A-frame development (P = .94), however, patients undergoing resection procedures as opposed to laryngotracheal reconstruction (LTR) with cartilage grafts had a significantly lower chance of developing this deformity (P = .004). Of the patients with an A-frame, 27 (39%) required further surgical intervention. Approximately one-third of patients undergoing airway reconstruction developed a tracheal A-frame deformity, with a significantly higher rate among patients with a history of tracheostomy and those undergoing LTR. Patients should be followed long term to assess for the development of an A-frame. IV Laryngoscope, 131:E1363-E1368, 2021.

Management of A‐Frame Tracheal Deformity in Children With Endoscopic Resection Tracheoplasty

Tracheal A-frame deformity is a known consequence of tracheostomy that may lead to obstruction after decannulation. The goal of this study is to demonstrate the feasibility and success of endoscopic carbon dioxide (CO2 ) laser-assisted tracheoplasty of tracheal A-frame deformity in children. Retrospective case series of symptomatic children with tracheal A-frame deformity with no other site of airway obstruction (2016-2018). All patients underwent CO2 -laser assisted endoscopic resection tracheoplasty. Eight patients (six male) were included with a median age of 15.4 (IQR 12.3-17.9) years. Patients had a median of two previous open airway surgeries (IQR 1-2.5) and all patients had a history of tracheostomy with successful decannulation. Tracheal A-frame deformity presented as dyspnea on exertion for all patients (n = 8, 100%). Obstructive sleep apnea was confirmed for all patients who underwent polysomnography (4/4, 100%). Median interval from decannulation to development of symptoms was 8.7 years (IQR 5.8-9.3). All patients sized with an age-appropriate endotracheal tube despite the deformity. Endoscopic A-frame tracheoplasty was successful for 7/8 (87.5%) patients and was performed with overnight observation for these patients (8/8, 100%). Unilateral A-frame tracheoplasty was performed successfully for five patients (62.5%), bilateral A-frame tracheoplasty was performed successfully for two patients (25.0%), and one patient (12.5%) did not have complete resolution of symptoms after bilateral A-frame tracheoplasty due to multi-level airway obstruction. CO2 laser-assisted tracheoplasty is an innovative endoscopic technique to relieve symptoms of airway obstruction for selected patients with tracheal A-frame deformity although avoiding the morbidity and hospital stay duration associated with tracheal resection. 4 Laryngoscope, 131:E719-E723, 2021.

Correlation of Aggressivity Papilloma Recurrent Respiratory Tract With Human Papillomavirus Types 6 And 11

Background : Recurrent respiratory tract papilloma (PSPB) is a viral disease that correlated with an airway exophthalmia lesion. Papilloma is primarily caused by human papillomavirus (HPV) types 6 and 11 which are classified as low-risk HPV. Reports indicate that patients with the HPV-11 experience more aggressive course of the disease than HPV-6. Patients are often diagnosed at a younger age, the longer duration, require more frequent surgery and rare diseases of the disease when compared with those caused by HPV-6.Objectives : To investigate the correlation of aggressiveness of PSPB with HPV-6 and 11.Methods : Fifteen samples were conducted in the Outpatient Unit of Otorhinolaryngology and the Lotus Inpatient Installation of Dr. Soetomo General Hospital from December 2012 to March 2013 then determine the disease aggressiveness. PCR examination was done at the Tropical Disease Institute of Universitas Airlangga. Aggressive correlation of disease with HPV type was tested using Chi-Square.Results : Fifteen patients were enrolled that divided; the male was 10 and female was 5. The mean annual number of operations was 2.8 ± 1.27 and 9 patients reported more than 3 surgeries each year. 10 patients had distal papilloma and 11 patients had a history of tracheostomy. PSPB was found in 12 patients, HPV-11 was 9 patients and HPV-6 was 6 patients. Chi-square test results showed no significant results with p = 0.525.Conclusion : There was no correlation between PSPB aggression with HPV-6 and 11

2852. Epidemiology of Emerging Carbapenemase-Producing Organisms (CPO) in Chicago, Illinois, 2013–2018

BackgroundEmerging CPO in the Chicago area poses clinical and infection control challenges across the spectrum of care. Since November 2013, CPO are reportable to the Illinois’ Extensively Drug-resistant Organism (XDRO) registry. We examined trends in mechanism of resistance (MOR) among CPO reported through December 2018.MethodsMOR reported into the XDRO registry were identified by clinical laboratories performing molecular methods on routine clinical cultures, by public health laboratories during point prevalence surveys (PPS) in response to clusters and as part of a project to assess CPO prevalence in high-risk Chicago area healthcare settings. Chicago patients with known MOR other than Klebsiella pneumoniae carbapenemase (KPC) are investigated by Chicago Department of Public Health (CDPH) to implement containment strategies and identify risk factors within 6 months of culture date.ResultsMOR was identified in 40% (1,216/3,587) of CPO-positive specimens collected from unique Chicago patients; 87% were KPC, 7% New Delhi metallo-β-lactamase (NDM), 5% Verona integron-mediated metallo-β-lactamase (VIM), 0.6% OXA-48-type carbapenemases, and 0.01% Imipenemase metallo-β-lactamase (IMP) (figure). Since 2017, 15 patients with CPO expressed more than one MOR; 14 were identified during PPS at ventilator capable skilled nursing facilities (vSNF) or long-term acute care hospitals (LTACH), and one was hospitalized in India. Among 156 patients with non-KPC CPO, the median age was 64 years (range, 20–97), 107 (69%) were identified from rectal screening and 49 (31%) were from clinical specimens, most of which were urine 23 (47%) or blood 6 (12%). Among 134 patients with risk factor history, 64% had history of tracheostomy (Table 1). Among 113 patients without documented travel outside of the United States, all stayed overnight at an Illinois healthcare facility; 62% stayed in a vSNF and 24% in an LTACH within 6 months of identification (Table 2).ConclusionWe have increasingly detected non-KPC CPO in Chicago; however, estimates of prevalence are limited by lack of systematic surveillance and molecular testing. The high proportion of CPO patients without travel who stayed in vSNF or LTACH underscores the need for infection control training and surveillance in these settings. Disclosures All Authors: No reported Disclosures.

Prevalence of voice disturbances in pediatric airway patients: Are we missing anything?

ObjectiveTo report on the prevalence of voice disturbances in pediatric airway patients. MethodsConsecutive patients seen in a specialized Center for Airway Disorders at a tertiary children's hospital from February 2017 to September 2017 were included. Patients' families were invited to complete a pediatric voice health handicap index (pVHI) questionnaire. Patients underwent evaluation including flexible laryngoscopy and/or direct laryngoscopy and bronchoscopy. Results146 patients were included. Of these children, 73 patients (50.3%) presented with swallowing difficulty and 44 patients (30.3%) presented with respiratory complaints. Only 9 patients (6.2%) reported hoarseness initially. The median age at referral was 2.7 years of age (interquartile range: 1.4-4.3). The mean total pVHI score was 9.5 (± 12.9). Sixty-seven patients (45.9%) had abnormal pVHI findings of score > 4. Six patients (4.1%) had pVHI > 40. The mean pVHI score was 26.0 (± 21.1) among 12 patients with a history of tracheostomy, 12.0 (± 14.3) among 30 patients with laryngeal cleft, and 9.0 (± 9.9) among 19 patients with laryngomalacia. ConclusionVoice disturbances are not uncommon in pediatric patients evaluated for airway disorders. Although patients may present with primary concerns for breathing or swallowing difficulties, many of these patients may need further work-up and treatment for dysphonia.

Decompression for Chiari malformation type II in individuals with myelomeningocele in the National Spina Bifida Patient Registry.

OBJECTIVEThe purpose of this study was to determine the rate of decompression for Chiari malformation type II in individuals with myelomeningocele in the National Spina Bifida Patient Registry (NSBPR). In addition, the authors explored the variation in rates of Chiari II decompression across NSBPR institutions, examined the relationship between Chiari II decompression and functional lesion level of the myelomeningocele, age, and need for tracheostomy, and they evaluated for temporal trends in rates of Chiari II decompression.METHODSThe authors queried the NSBPR to identify all individuals with myelomeningocele between 2009 and 2015. Among these patients, they identified individuals who had undergone at least 1 Chiari II decompression as well as those who had undergone tracheostomy. For each participating NSBPR institution, the authors calculated the proportion of patients enrolled at that site who underwent Chiari II decompression. Logistic regression was performed to analyze the relationship between Chiari II decompression, functional lesion level, age at decompression, and history of tracheostomy.RESULTSOf 4448 individuals with myelomeningocele identified from 26 institutions, 407 (9.15%) had undergone at least 1 Chiari II decompression. Fifty-one patients had undergone tracheostomy. Logistic regression demonstrated a statistically significant relationship between Chiari II decompression and functional lesion level of the myelomeningocele, with a more rostral lesion level associated with a higher likelihood of posterior fossa decompression. Similarly, children born before 2005 and those with history of tracheostomy had a significantly higher likelihood of Chiari II decompression. There was no association between functional lesion level and need for tracheostomy. However, among those children who underwent Chiari II decompression, the likelihood of also undergoing tracheostomy increased significantly with younger age at decompression.CONCLUSIONSThe rate of Chiari II decompression in patients with myelomeningocele in the NSBPR is consistent with that in previously published literature. There is a significant relationship between Chiari II decompression and functional lesion level of the myelomeningocele, which has not previously been reported. Younger children who undergo Chiari II decompression are more likely to have undergone tracheostomy. There appears to be a shift away from Chiari II decompression, as children born before 2005 were more likely to undergo Chiari II decompression than those born in 2005 or later.

Inclusion of the Acute Care Surgeon in the Difficult Airway Protocol: A Nine-Year Experience

An emergency surgical airway is a lifesaving intervention required in the event of airway loss or respiratory failure when conventional endotracheal intubation cannot be performed. The Acute Care Surgery/Trauma Service is a critical component in the angioedema/difficult airway protocol at our institution. We conducted a retrospective review (2007-2016) to analyze the role our service has in managing patients requiring an emergency surgical airway. Cases were analyzed for preexisting conditions, hospital location of procedure, techniques, complications, and mortality. Our protocol involves early coordination between anesthesia and the Acute Care Surgery/Trauma Service for patients with a potentially difficult airway. If anesthesia is unable to intubate the patient, a surgical airway is performed. Patients are preemptively taken to the operating room (OR) if stable for transport. There were 43 surgical airways performed during the study period. All patients had a failed attempt with oral endotracheal intubation. The most common factors associated with these patients were history of tracheostomy, angioedema, or difficult anatomy. Nineteen (44%) of the surgical airways were performed in the OR. Three deaths (7%) occurred from cardiac or respiratory arrest despite the emergency procedure. No immediate deaths occurred in the patients taken to the OR. Early coordination in patients with a difficult airway is another hospital resource that the acute care surgeon can provide to improve patient outcomes.

Obstructive sleep apnea in the irradiated head and neck cancer patient.

To assess the prevalence of obstructive sleep apnea (OSA) in head and neck cancer (HNSCC) patients treated with radiation therapy. Prospective case series without comparison group. Patients who underwent radiation therapy for oropharyngeal or laryngeal squamous cell carcinoma completed a 3-night home sleep test (HST), Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, and University of Washington Quality of Life questionnaire. Exclusion criteria included oncologic surgical procedures, active disease, history of tracheotomy, history of OSA, or completion of radiation therapy within the last 3 months. Sixteen HNSCC patients completed the HST, with 50% (8) demonstrating objective evidence of OSA ranging from mild to severe (range 5.6-38.8, median 13.9). Median age was 61.6 years, with a median body mass index (BMI) of 29.8, and 13 of the subjects were male. There were no differences in age, BMI, median radiation dose, tumor primary site or stage, human papilloma virus status, or comorbidity status between the OSA and non-OSA groups. Self-reported questionnaire scores were no different between the two groups. OSA patients had a nonsignificant shorter time interval between the completion of radiation and the HST date (1.8 vs. 3.4 years, P = 0.065) and higher rate of gastrostomy tube placement during radiation (62.5% vs. 12.5%, P = 0.059). The results of this preliminary study suggest that the prevalence of OSA is increased in the head and neck irradiated patient when compared to the general population. Self-report of sleep symptoms alone may be unreliable to determine risk of OSA in the HNSCC population. 4. Laryngoscope, 127:2673-2677, 2017.

Open airway reconstruction in adults: Outcomes and prognostic factors

PurposeThe purpose was to assess the success of open tracheal resection and re-anastomosis for non-malignant tracheal stenosis in adults. Successful operations were defined as T-tube or tracheostomy-free status by 6months post-operatively. Materials and methodsRetrospective chart review was performed and data were recorded in a de-identified manner. The primary outcome was T-tube or tracheostomy-free status by 6months following tracheal resection. Clinical and demographic characteristics were evaluated as potential prognostic variables. ResultsThirty-two patients met inclusion criteria, with a median age of 46. Seven patients underwent tracheal resection with primary closure, without stenting. Successful tracheal resection was defined as tracheostomy or T-tube free by 6months post-operation, and this was possible in 21 patients (66%). Eighty-two percent of patients with cricoid cartilage-sparing tracheal resection had a successful outcome, versus 30% of patients who underwent cricoid cartilage resection (HR 5.02, 95% CI 1.46–17.3; p=0.011). Patients with a history of tracheostomy-dependence were four times more likely to remain tube-dependent at 6months (HR 4.15, 95% CI 1.56–10.86; p=0.004). ConclusionsTracheal stenosis remains a very difficult problem to treat. In our series, we confirm that patients with cricoid involvement or with a history of tracheostomy were more likely to be tube dependent at 6-months post-operation.

The Role of Systemic Steroids in Postintubation Tracheal Stenosis: A Randomized Clinical Trial

Most patients with postintubation tracheal stenosis are not ideal candidates for airway resection at presentation and their airways must be temporarily kept open by repeated bronchoscopic dilation (RBD). Meanwhile, some sufficiently recover by RBD without further airway resection requirement. We hypothesized whether systemic corticosteroids could lengthen RBD intervals, decrease the number of patients who eventually need airway resection, and shorten the required length of airway resection. Between February 2009 and November 2012, a randomized double-blind clinical trial with a 1:1 ratio (corticosteroids group [group C], prednisolone 15 mg/day; placebo group [group P]) was conducted on 120 patients without tracheostomy or T tube and in no ideal situation for airway resection at presentation, whose precipitating injury had occurred recently. All underwent RBD until they became asymptomatic or prepared for airway resection. Asymptomatic patients received the capsules (prednisolone or placebo) for 6 months; others discontinued them before surgery. Those requiring RBD at short intervals underwent tracheostomy or T tube placement and were then excluded. Follow-up terminated 6 months after airway resection or capsule discontinuation. There were 105 patients (72 male; 50 in group C), aged 15 to 64 years, who completed their follow-up. There was no significant difference between the two groups in age, sex, history of tracheostomy, intubation cause and duration, time interval between intubation and initial bronchoscopy, length of stenosis, and subglottic involvement. Our study showed a trend for RBD with longer intervals (22 days), and fewer operations, 17% (28 of 50 versus 40 of 55) in group C, although statistically insignificant. Furthermore, the required airway resection length became significantly shorter (5.3 mm) in group C. Early low-dose systemic corticosteroids can bebeneficial in postintubation tracheal stenosis management.