Impending Airway Obstruction Research Articles

Difficult Airway Society guidelines

Anaesthesia is to be congratulated for publishing the Difficult Airway Society (DAS) Guidelines (Anaesthesia 2004; 59: 675–94), which I am sure will result in a reduction in anaesthesia-related morbidity and mortality. However, I was amazed to read that rejection was considered, presumably on the basis of concerns raised in the accompanying editorial by Chambers (Anaesthesia 2004; 59: 631–3). Comment has been encouraged. Chambers challenges the assertion that failed intubation is the leading cause of anaesthetic mortality and suggests that the DAS guidelines may actually cause more problems than they solve. I agree that contemporaneous data is lacking and that this would be extremely difficult to obtain for such a rare event. All the more reason therefore to rely on expert opinion. In my hospital, over the last 5 years, there have been two anaesthesia-related deaths, one in theatre and one in the Intensive Care Unit (ITU), both due to failed intubation. This is a very approximate incidence of 1 in 100 000 general anaesthetics and 1 in 1000 ITU admissions. In my experience therefore failed intubation is the leading cause of anaesthesia-related mortality, entirely justifying a robust approach to prevention. Chambers seems particularly concerned about the place of surgical cricothyroidotomy. The guidelines make it absolutely clear that this is the last resort, is only to be used in the ‘can’t intubate, can't ventilate' (CICV) situation and that cannula cricothyroidotomy with high-pressure ventilation is an equally valid alternative in plan D. ‘Very difficult ventilation’ is not an indication per se and trainees are not ‘encouraged to proceed to cricothyroidotomy’ in this situation alone. It is precisely because junior trainees, or even senior consultants, may not be able to differentiate between ‘impossible’ and ‘only just sufficient’ ventilation that the emphasis is on the prevention of hypoxia, which can be more objectively recognised. There is no place for a definitive level of peripheral blood oxygen saturation (Spo2) at which cricothyroidotomy is indicated, as the risk of hypoxic damage will be relative to the rate of desaturation and individual patient resistance. This requires clinical judgement, but if there is doubt, I welcome a guideline that gives a definitive solution to a potentially lethal problem. In my hospital, it is most unlikely that the first of our two cases could have been salvaged by cricothyroidotomy, because of a massive neck haematoma. By the time tracheostomy was achieved, the patient was dead. The ITU case had been intentionally extubated but could not be re-intubated at the first attempt. He might have been salvaged by cricothyroidotomy, but the patient suffered an early cardiac arrest due to his underlying condition and a transiently unrecordable Spo2, despite some ventilation being possible with a bag and mask. I have successfully performed a surgical cricothyroidotomy in a patient with extensive facial trauma, increasing oedema and impending airway obstruction. I, too, have over 20 years experience in anaesthesia and, up to that point, had never experienced a CICV situation. It all went wrong very quickly, despite careful thought and preparation. I am convinced that the patient is alive and well today because I had trained myself for this eventuality. This is why DAS believes that cricothyroidotomy of one type or another should be a core skill for all anaesthetists. The modest chance of resolvable morbidity that Chambers is so concerned about is likely to be far outweighed by the high risk of unresolvable hypoxic brain damage or mortality. A patient should never die from failed intubation, but only after failed cricothyroidotomy.

Tongue base abscess requiring emergent tracheotomy: A complication of volumetric RFA

Objectives: A case of a near-obstructing tongue base abscess secondary to radiofrequency volumetric tongue-base reduction is presented. Methods: Case report and review of the literature. Results: A 39-year-old woman presented with severe odynophagia, “hot-potato” voice, and increasing respiratory difficulty 8 days following a radiofrequency volumetric tongue-base reduction procedure. Examination revealed marked fullness of her tongue base with vallecular effacement, significant narrowing of the oropharyngeal airway, and exquisite tenderness to palpation over the tongue base and neck. CT scan revealed a large, rim-enhancing tongue base fluid collection measuring 3.3 × 5.2 × 3.8 cm. The diagnosis was felt to be consistent with an abscess, and due to the large size of the lesion and impending airway obstruction, the patient was taken to the operating room for emergent tracheotomy and drainage of the abscess. Conclusion: The complication of tongue base abscess secondary to radiofrequency ablation procedures has been well described in the literature, however, this is the first reported case of a tongue-base abscess requiring emergent tracheotomy. Clinical complication avoidance strategies for tongue-base RFA, which have been previously recommended, should be followed closely in an attempt to minimize the risk of this potentially life-threatening complication.

Dexamethasone for the Treatment of Infectious Mononucleosis

Emergency Medicine| July 01 2004 Dexamethasone for the Treatment of Infectious Mononucleosis AAP Grand Rounds (2004) 12 (1): 8–9. https://doi.org/10.1542/gr.12-1-8 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Dexamethasone for the Treatment of Infectious Mononucleosis. AAP Grand Rounds July 2004; 12 (1): 8–9. https://doi.org/10.1542/gr.12-1-8 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: dexamethasone, infectious mononucleosis Source: Roy M, Bailey B, Amre DK, et al. Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double blind, placebo–controlled, clinical trial. Arch Pediatr Adolesc Med. 2004;158:250–254. Pharyngeal pain from infectious mononucleosis (IM) can be severe and may persist for up to 14 days.1 Although corticosteroids have been used for treatment of upper airway obstruction caused by IM, 2–,3 their effectiveness in ameliorating throat pain is unknown. Researchers from the Hôpital Ste-Justine, Montréal, Quebec, conducted a randomized, double-blind, placebo-controlled trial in the emergency department to investigate whether routine corticosteroid treatment would relieve the sore throat associated with IM in patients between the ages of 8 to 18 years. Because a monotest was not available 24 hours a day to confirm the diagnosis, patients were enrolled if they had clinical symptoms suggestive of IM. Clinical diagnosis was based on the presence of sore throat, odynophagia, respiratory distress, fatigue, and fever. Epstein-Barr virus antibody levels, monotest, and bacterial throat cultures were performed on each patient to reach a final diagnosis of IM or another cause of pharyngitis. Patients were randomized to receive a single oral dose of dexamethasone (0.3 mg/kg, maximum 15 mg) or a placebo. To assess throat pain, visual analog pain scores (VAS) were recorded by patients at 0 hours, 12 hours, 24 hours, 48 hours, 72 hours, and on day 7. The primary outcome measure was an improvement of 20 mm from baseline on the VAS. A total of 40 patients were enrolled in the study, with 33 ultimately having confirmed IM, either by monotest or viral antibody testing (16 of 20 in the dexamethasone group and 17 of 20 in the placebo group). There was no difference between the treatment and placebo group in the frequency of use of other pain medications including acetaminophen. Hospitalization rates were also similar between the 2 groups (3 placebo patients and 1 dexamethasone patient), although the hospitalized dexamethasone-treated patient had a prolonged hospitalization, complicated by sepsis. A significantly greater proportion of patients given dexamethasone had a 20 mm improvement in VAS at 12 hours (12/20, 60%) when compared to the placebo treatment group (5/19, 26%). At 24 hours, 11 of 20 patients (55%) in the dexamethasone group showed improved pain relief compared to 6 of 20 patients (30%) in the placebo group, a difference that did not achieve statistical significance. At all other time measurements, the improvements in VAS were similar. The authors conclude that a single oral dose of dexamethasone may not provide lasting pain relief. Treatment of severe throat pain associated with IM is a clinical challenge because non-prescription analgesics like acetaminophen and non-steroidal anti-inflammatory medications often fail to provide sufficient analgesia. Dexamethasone is recommended for treatment of IM in the AAP’s 2003 Red Book, but only for significant complications including impending upper airway obstruction, massive splenomegaly, myocarditis, hemolytic anemia, or hemophagocytic syndrome.4 Corticosteroids have been studied in other pharyngeal infections and have... You do not currently have access to this content.

The paediatric upper airway: anaesthetic aspects and conclusions

Paediatric airway problems are among the most challenging clinicians will face throughout their career. Clinicians unaccustomed to dealing with children tend to approach paediatric airway problems with a disproportionate amount of fear that is often engendered by inexperience, and this fear can interfere with performance. Understanding the differences between the infant upper airway and the airway in older children is important to properly manage the airway. Airway manoeuvres and the important tools used for airway management, such as the laryngeal mask airway, the fibreoptic bronchoscope and the new intubating fibreoptic stylets for managing the difficult paediatric airway, have been elucidated in the literature. Planning, preparation, and teamwork are essential, and must include an awareness of problems that might occur in the recovery period. Special clinical situations such as management of the child with impending airway obstruction are discussed.

Anaesthetic dilemma: spinal anaesthesia in an eclamptic patient with mild thrombocytopenia and an “impossible” airway

We present our anaesthetic management of a 27-year-old woman with antepartum eclampsia, mild thrombocytopenia, difficult airway and clinical evidence of impending upper airway obstruction. She required urgent delivery by caesarean section, which was conducted uneventfully under spinal anaesthesia. We discuss the management conundrums presented by this case and why we chose spinal anaesthesia over other anaesthetic options.

Idiopathic fibrosclerosis presenting as angioedema and upper airway obstruction

Rationale Retroperitoneal fibrosis is uncommon condition of mostly unknown etiology. The clinical presentations are variable from constitutional symptoms to rare association of other fibroinflammatory diseases such as sclerosing cholangitis, mediastinal fibrosis and parotid gland. With such a broad array of presenting symptoms, the early stage of the disease can mimic several other conditions. In this report, we describe an idiopathic fibrosclerotic patient who came into the hospital for prolonged fever, fatigue, weight loss and abdominal pain then later found to have facial and neck edema with trimus. Upon the investigations of abdominal CT-scan and retrograde pyelography revealing bilateral hydronephrosis with UPJ obstruction and hypodensity lesion between posterior bladder and anterior rectum together with nasopharynx MRI demonstrating infiltrative lesions involving right parapharyngeal, parotid and were submandibular spaces, subsequently, the diagnosis of retroperitoneal and mediastinal fibrosis made. Nasopharynx, oropharynx and submandibular biopsy also showed chronic inflammation with fibrosis and loose connective fibrous tissue, respectively. Other investigations revealed ANA of 1:40 titer, alkaline phosphatase of 393 u/L, hypoalbuminemia of 2.4 mg/dL. The rest of laboratory examination including ANCA, cryoglobulin test and anti HIV were negative. Endotracheal tube was placed to prevent obstruction. High dose of oral corticosteroid and tamoxifen were started. Systemic steroid was tapered down to 0.5 mg/kg/day in 8 weeks. At a follow up of 4 month, she continues to do well. Conclusion In summary, Idiopathic fibrosclerosis can present as angioedema and impending airway obstruction accompanying with constitutional and urinary symptoms will lead us to recognize retroperitoneal fibrosis as well.

Unusual local complications of Vipera palaestinae bite

Background. Vipera palaestinae is the commonest venomous snake in Israel. V. palaestinae-specific antivenom is indicated for both systemic effects and marked progressive local signs. In our experience, clinicians are often not aware of the morbidity associated with the local effect of the venom and consequently do not administer the antivenom in envenomations with local effects only. Objective. To describe unusual local complications of inadequately treated V. palaestinae envenomation. Case series. Three cases of V. palaestinae bites involving distal parts of the limbs are reported. Within 36–48 h tense swelling progressed to the trunk. Swelling involved the neck in two patients and was severe enough to cause dysphagia and to suggest impending upper airway obstruction. In the third patient, the swelling led to urine retention necessitating introduction of urinary catheter. V. palaestinae antivenom administration resulted in regression of swelling in two patients and in allergic reaction in the third. Conclusion. Inadequately treated swelling caused by V. palaestinae envenomation may involve the trunk even when the site of the bite is remote. In some cases this may pose a threat to the function of vital structures such as the upper airways, call for unnecessary interventions and prolong hospitalization. It is recommended that V. palaestinae antivenom be administered whenever there is marked and progressive swelling even in the absence of systemic signs.

Palliative thyroidectomy for malignant lymphoma of the thyroid.

Current treatment of malignant lymphoma of the thyroid consists of chemotherapy and external beam radiation. The diagnosis can routinely be made by fine-needle aspiration, obviating the need for surgery. However, a significant number of patients present with symptoms of obstruction, necessitating thyroidectomy for palliation. To determine the outcomes of patients with malignant thyroid lymphoma after palliative thyroidectomy, we reviewed our experience. Between 1980 and 2001, 27 patients with thyroid lymphoma and symptoms or signs of airway and/or esophageal obstruction were evaluated at 1 of 3 academic institutions. The mean age of the patients was 66 +/- 3 years, and the majority was female. Patients presented with symptoms of dyspnea/stridor (30%), dysphagia/pain (30%), or impending airway obstruction (40%). All underwent palliative surgery. In addition to surgery, 10 patients had combined chemo- and radiotherapy, 10 had radiotherapy alone, and 4 had only chemotherapy. Symptom-free survival after palliative surgery was determined by Kaplan-Meier analysis. The mean actuarial symptom-free survival of patients with symptomatic, malignant thyroid lymphoma was 10 years (95% confidence interval, 7.67 to 12.33 years). Patients with malignant lymphoma of the thyroid can present with obstructive symptoms requiring palliative intervention. In this group of patients, thyroidectomy can be associated with good long-term palliation and low morbidity.

Poststreptococcal glomerulonephritis presenting as impending airway obstruction

The presence of poststreptococcal glomerulonephritis in the pediatric patient remains a diagnostic challenge to the emergency physician. The variability of both patient presentation and laboratory parameters often obscures the diagnosis. We describe a child who presented to the emergency department with subglottic edema and the possibility of impending airway compromise. The child was admitted to the hospital under close observation, and several days later, the diagnosis of poststreptococcal glomerulonephritis was made. [Campagna DP, Wallace DR. Poststreptococcal glomerulonephritis presenting as impending airway obstruction. Ann Emerg Med. October 2001;38:450-452.]

Detection of obstructive sleep apnea by analysis of phase angle using the forced oscillation signal

Pharyngeal collapse in patients with obstructive sleep apnea syndrome (OSAS) is linked to decreased upper airway muscle activity. We hypothesised that decreased muscle activity causes decreased stiffness of the upper airway wall and assumed that a decrease in wall stiffness would result in a change point (CP) of the morphology of phase angle time series φ(t) obtained by forced oscillation technique (FOT). We developed an algorithm to detect CPs in φ(t) and investigated φ(t) data measured in parallel to all-night polysomnography in seven patients. A total of 2724 CPs were detected by algorithm. The CPs were marked on the polysomnograms and compared with polysomnogram scoring performed jointly by three sleep expert physicians. A total of 791 (67%) of the 1172 handscored respiratory events showed a CP in φ(t) within a time interval of 8 sec before and 6 sec after the marked onset. A total of 672 (57%) respiratory events were detected at an earlier time by algorithm, and 119 (10%) were algorithmically detected later. The average detection time by the CP algorithm was 4.0±1.1 sec earlier than the manual scoring. We conjecture that a CP in φ(t) indicates a change in upper airway collapsibility and that φ(t) might be a potentially useful parameter for detection of impending upper airway obstruction.

Acute supraglottitis in adults: Early indicators of airway obstruction

Purpose: To show that cardinal signs of upper airway obstruction are characteristically absent in the early phases of potentially fatal supraglottitis. Patients and Methods: The hospital records of 9 previously healthy adults who died from autopsy-proven supraglottitis within 12 hours after sudden onset of severe sore throat. Results: Six patients who were discharged from the emergency room with a diagnosis of pharyngitis died at home within 4 hours after dismissal. Three patients suspected of supraglottitis were admitted and treated medically; by the time signs of respiratory obstruction appeared, attempts at airway intervention failed. None of the 9 patients presented with symptoms or signs of respiratory distress, but all gave a history of fulminant sore throat associated with chills and fever. In all patients, the pulse rate was above 100 per minute. Conclusion: In the early phases of acute supraglottitis, the most reliable indicator of impending airway obstruction is a rapidly developing severe sore throat. Dyspnea, tachypnea, retractions, stridor, and cyanosis are manifestations of advanced stages of the infection and should not be awaited to determine the need for airway intervention.

Type I hereditary angio-oedema. Variability of clinical presentation and course within two large kindreds.

Hereditary angio-oedema (C1-inhibitor deficiency) is a disease with protean manifestations which is often misdiagnosed initially. The purpose of this study was to delineate the clinical spectrum and course of this potentially life-threatening disease. Ten members of two unrelated affected kindreds were repeatedly hospitalized in our service with attacks of angio-oedema. Among the 271 members of the two kindreds 69 were identified who reported typical attacks. Detailed information on the clinical course and laboratory data (C1-inhibitor concentration and activity, C4 concentration) were obtained from 59 of the 69 affected subjects. C1-inhibitor concentration and activity were low in all affected patients. The disease had become manifest by age 30 years in 98%. Most patients suffered from attacks of subcutaneous swellings and abdominal pain, and half of the patients have had attacks affecting the airways. The frequency of attacks ranged from less than one to over 26 per year. Forty-two per cent had to be hospitalized at least once. Four have died of acute airway obstruction. Thirty-eight attacks in 10 patients hospitalized in our service were all treated successfully with fresh frozen plasma or with C1-inhibitor concentrate. Trauma, stress, insect stings and foodstuff were triggering factors, but the majority of attacks occurred without an identifiable trigger. Oral contraceptives and pregnancy led to worsening of symptoms. Nonetheless, all 36 pregnancies reported were carried to term. Twenty-five patients were on continuous treatment with attenuated androgens or tranexamic acid, but only seven were free of attacks in the year preceding the survey. Hereditary angio-oedema is an autosomal dominant disease with great variability of clinical expression and severity, even within a single kindred. It often goes unrecognized over years, and it may lead to death if, in case of impending airway obstruction, specific therapy is not instituted.

Changing indications for tracheostomy in maxillofacial trauma

Purpose: Tracheostomy is one of the most common surgical procedures, but not always without complications. The purpose of this article was to reevaluate the indications of maintaining the airway with the use of tracheostomy. Materials and Methods: A total of 399 patients with maxillofacial trauma, who were treated in the Maxillofacial Surgery Department from 1985 to 1992, were evaluated for the type of fracture and air-way problems. Results: Out of the 399 patients evaluated, 13 needed a tracheostomy. Of these, 6 had had a cricothyroidotomy on arrival, 3 required tracheostomy because of impending airway obstruction, 3 because of respiratory distress, and 1 due to difficulty in intubation. Conclusions: The results of this study indicated that surgically securing the airway by tracheostomy should be revised compared to other available methods. In the era of rigid fixation of fractures and the possibility of leaving the patient with an open mouth, it is unnecsssary to carry out tracheostomy for securing the airway as frequently as in the past.

Herpes simplex dissemination following glucocorticoids for upper airway obstruction in an adolescent girl

A previously healthy adolescent female suddenly developed a severe febrile pharyngitis and impending upper airway obstruction. Her Monospot test was positive, and her throat culture grew group A beta-hemolytic streptococcus. After treatment with antibiotics and glucocorticoids, she developed a fulminant course dominated by disseminated intravascular coagulation and hepatic necrosis. At autopsy, herpes simplex virus type-1 was cultured from lung, liver, and spleen tissue. We believe this is the first report of disseminated herpes simplex infection after steroid use for upper airway obstruction.

Spontaneous regression of a symptomatic laryngopyocoele

A laryngopyocoele is a rarely encountered neck mass which may cause respiratory obstruction. Spontaneous regression of an established symptomatic laryngopyocoele is an even more unusual situation, since most of the reported cases require immediate intervention for impending airway obstruction. A case of a laryngopyocoele showing spontaneous regression after antibiotic therapy is presented and the clinical aspects are reviewed.

Fine-needle aspiration biopsy: Application to pediatric head and neck masses : Mobley D.L.; Wakely P.E. Jr.; Frable M.A.S.LARYNGOSCOPE (1991) 101/5 (469–472)

Hospital records from 1974 through 1983 contained the cases of 20 patients over 18 years old admitted with supraglottitis (epiglottitis). Most patients presented with pharyngitis and odynophagia, and were diagnosed by laryngoscopy and neck radiographs. Four patients required tracheostomies, and one was nasotracheally intubated because of impending airway obstruction. Visualization of the hypopharynx was often necessary for diagnosis and in accordance with previously reported cases, did not precipitate airway obstruction. Adults without respiratory distress can be treated in the intensive care unit with inhaled mist, antibiotics, and corticosteroids, and such patients usually recover in a few days. Tracheostomy is being supplanted by nasotracheal intubation as the preferred means of securing an endangered airway.

Airway Compromise as a Result of Retropharyngeal Hematoma Following Cervical Spine Injury

Mechanical airway obstruction secondary to prevertebral hematoma following cervical spine injury is a life-threatening emergency. We present eight cases of mechanical airway obstruction from prevertebral hematomas in patients with cervical spine injury. They are combined with 13 previously reported cases to produce a study population of 21 patients. Although it is a rare complication of cervical spine injury, swelling significant enough to cause airway obstruction should be anticipated in all patients, regardless of age, severity of trauma, or lack of symptoms. To date, this phenomenon has not been reported in injuries below C6. Additionally, because symptoms may take hours to develop, initial cervical radiographs may not show evidence of retropharyngeal swelling and impending airway obstruction.

Indications for and Techniques of Tracheotomy

Although the operation has been practiced for centuries, the modern technique of tracheotomy was introduced and popularized in the beginning of the 20th century. The initial indication for tracheotomy was limited to impending airway obstruction resulting from trauma, but current indications are broader. Tracheotomy is one of four methods available to intubate the trachea and is associated with physiologic changes that are dependent on the duration of tracheotomy. Although surgical in nature, it is employed to relieve or prevent airway obstruction and to offer ventilatory support. Tracheotomy may be performed as an elective or an emergency procedure. Ideally, it is done in a controlled situation. However, when performed in an emergency setting, variations of the procedure, such as minitracheotomy or cricothyroidotomy, may be temporarily substituted. Preferably, tracheotomy is performed in an operating room; however, it may be carried out successfully in an intensive care unit as well.

Branchial anomaly in a newborn presenting as stridor

A male patient presented at day 3 of life with a small anterior neck mass and mild intermittent upper airway obstruction. Despite intravenous antibiotics, the patient rapidly progressed to impending airway obstruction requiring surgical intervention. The clinical, radiographic, and histologic findings of this extremely rare case of a third branchial anomaly will be presented. The embryologic basis for the connection to the aerodigestive tract and the access provided to gram negative enteric organisms in newborns will be discussed.

Iatrogenic Retropharyngeal Emphysema

To the Editor .—I am writing this letter concerning the article by Breznick and Saporito 1 on Iatrogenic Retropharyngeal Emphysema With Impending Airway Obstruction. There is a very simple method of eliminating air in tissue. Of course, air is 80% nitrogen. Nitrogen is inert. Oxygen is picked up by the bloodstream very rapidly, and the nitrogen remains a problem. Nature abhors spaces and will then begin to fill those spaces with tissue fluids that can become infected quite rapidly. Although nitrogen is inert, it can be eliminated fairly rapidly. This treatment was not mentioned under the Management Aspects section of the article. Because nitrogen is inert, the only way to eliminate nitrogen is to create as large a partial pressure difference between the nitrogen in the tissue and the nitrogen in the blood. Then, according to the general gas laws, the nitrogen gas will flow to the area of lower