Impending Airway Research Articles

Airway management in trauma

Trauma has assumed epidemic proportion. 10% of global road accident deaths occur in India. Hypoxia and airway mismanagement are known to contribute up to 34% of pre-hospital deaths in these patients. A high degree of suspicion for actual or impending airway obstruction should be assumed in all trauma patients. Objective signs of airway compromise include agitation, obtundation, cyanosis, abnormal breath sound and deviated trachea. If time permits, one should carry out a brief airway assessment prior to undertaking definitive airway management in these patients. Simple techniques for establishing and maintaining airway patency include jaw thrust maneuver and/or use of oro- and nas-opharyngeal airways. All attempts must be made to perform definitive airway management whenever airway is compromised that is not amenable to simple strategies. The selection of airway device and route- oral or -nasal, for tracheal intubation should be based on nature of patient injury, experience and skill level.

The emergency control of traumatic maxillofacial haemorrhage

Maxillofacial trauma is common and may lead to haemorrhage that is associated with actual or impending airway compromise. This study briefly discusses the aetiology of midfacial haemorrhage and describes a simple effective technique of midface splintage for haemorrhage control, which may be applied in the prehospital and emergency environments. This technique has been used successfully by the London Helicopter Emergency Medical Service.

Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider

Our goal is to review the recent year's novel and relevant literature on the practice of sedation/anesthesia in the nonoperating room setting. Risk factors and outcomes were evaluated related to locations, providers, and anesthetic regimens. Administration of sedation/anesthesia for patients undergoing uncomfortable or painful interventions outside the operating room is an expanding practice involving a wide variety of practitioners. With a growing emphasis on cost, efficiency, and patient satisfaction, propofol alone or in combination with other sedatives/analgesics has become popular for procedural sedation among nonanesthesiologists. Although major adverse events are rare in this setting, potentially risky complications, such as respiratory depression and desaturation, still occur and their importance cannot be neglected. In this context, the American Society of Anesthesiologists Closed Claims and the Pediatric Sedation Research Consortium databases convey some valuable data. The bulk of reported complications are related to anesthetic drug-induced respiratory depression or airway obstruction leading to hypoxemia or hypoventilation. There are several new studies highlighting the importance of capnography in detecting impending airway or respiratory adverse events. The current incidence of complications associated with sedation in the nonoperating room environment remains irresolute. Although there are many studies on sedation practices in the out-of-operating room setting, high-quality studies are lacking. There are no data comparing practice outcomes between different practitioners and specialties.

Complex Salvage of a Failed Pharyngoesophageal Reconstruction with Impending Airway Disaster

Complex Salvage of a Failed Pharyngoesophageal Reconstruction with Impending Airway Disaster

Airway Collapse or Closure via the Soft Palate as Mechanism of Obstruction in Sedated Patients?

Although it is possible to produce or induce differential inspiratory and expiratory obstruction at the level of the soft palate, this was not relevant to the circumstances of our study. Our purpose was to define evolution of vulnerability to upper airway collapse along the pathway from wakefulness through conscious sedation and unconscious sedation to anesthesia. Our methods are standard tools for determining upper airway collapsibility. The pharyngeal critical pressure, which is associated with occlusion (inspiratory and expiratory—assessed over a sequence of five consecutive inspiratory efforts), quantifies this.1The intramuscular genioglossus electromyogram not only provides direct information regarding activation of the major upper airway dilator muscle but also reflects activation of the other upper airway muscles.2It is evident from our findings that this evolution is an alinear process with a disproportionate increase in collapsibility occurring proximate to loss of consciousness and coincident with a precipitate decrease in the upper airway muscle activation in response to application of negative pressure to the upper airway.3These findings hold independent of the precise site of upper airway obstruction, presence of a catheter in the upper airway, or whether or not the mouth is taped.Nevertheless, the velopharynx is the most common primary site of upper airway obstruction during both anesthesia4,5and sleep;6,7hence, Dr. Kempen is on firm ground with his suggestion that the soft palate might be important! Indeed, as has been our previous experience in anesthetized subjects with and without sleep apnea,5,8–10the primary site of collapse was velopharyngeal in a substantial majority of subjects during our recent study. Seven of our subjects collapsed at this site. Retrolingual collapse was observed in two (subjects 2 and 5). As Dr. Kempen surmises, the site of collapse was determined manometrically according to methods previously described.5Commonly, it is velopharyngeal obstruction that causes hypopneas and accompanying arousals during sleep. Similarly, velopharyngeal collapse is a common site of obstruction during anesthesia and postanesthetic recovery, accounting for the usefulness of the nasopharyngeal airway in these situations. Unlike infants or other mammals, adults are not obligate nasal breathers, so that oral breathing represents an alternative route when the velopharynx is occluded. However, as Dr. Kempen points out in citing Drummond,11recourse to oral breathing during anesthesia may well indicate impending airway difficulty, regardless of phase of respiration.*West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. david.hillman@health.wa.gov.au

Fatal airway obstruction following arterial trauma during internal jugular venous cannulation

Central venous cannulations are commonly performed in the intensive care unit. However, these may be associated with severe mechanical or bleeding complications. Here, we describe a patient who died following severe and rapid airway obstruction secondary to an arterial trauma during internal jugular vein cannulation. This case report highlights the importance of prompt recognition of arterial trauma so that it can be repaired surgically instead of sheath removal. The prompt diagnosis of an impending airway obstruction and obtaining early airway access cannot be overemphasized. Finally, we discuss the risk factors associated with this complication and what we could have possibly done to prevent this outcome.

Obstructive sleep apnoea syndrome in children and anaesthesia

Obstructive sleep apnoea syndrome (OSAS) is a common medical disorder among adults, which is increasingly being recognized in children too. It is a breathing disorder characterized by upper airway obstruction with or without intermittent complete obstruction that disrupts normal breathing during sleep. Anatomical and neuromuscular disorders are mainly responsible for this disorder. This disorder leads to a state of chronic hypoxemia, which has significant cardiac, pulmonary and central nervous system implications. Diagnosis of OSAS is based on thorough history and clinical examination along with appropriate sleep studies including polysomnography. The mainstay of treatment of paediatric OSAS is adenotonsillectomy. Good anaesthetic practice in Paediatric patients with OSAS revolves around good and ideal airway management. Early detection of airway obstruction, intense monitoring to warn of impending airway problems and appropriate and early intervention of airway compromise are good anaesthetic practices. Coexisting medical problems should be adequately addressed and safe analgesic techniques in the perioperative period go towards improving outcomes in patients with paediatric OSAS.

Antiretroviral-induced toxic epidermal necrolysis in a patient positive for human immunodeficiency virus

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two variants on a spectrum of severe systemic hypersensitivity characterized by blistering maculopapular lesions and desquamation of the skin and mucus membranes. Although several causative agents, including infections, have been reported for SJS/TEN, medications remain the most common cause. We report the case of a 42-year-old man with human immunodeficiency virus (HIV) who developed TEN 4 months after starting treatment with darunavir and abacavir. The patient presented with upper body lesions, oral mucosal ulcerations, and impending airway compromise. He was intubated and admitted to the burns unit. Score for Toxic Epidermal Necrolysis (SCORTEN) was 5, with > 90% predicted mortality. However, after intravenous immunoglobulin and supportive treatment, the patient made a remarkable recovery. Abacavir and darunavir may be associated with SJS/TEN. TEN should be considered a risk for patients with HIV and should be monitored for cutaneous eruptions for several months after changes in treatment regimen.

Fetal death due to upper airway compromise complicated by thyroid storm in a mother with uncontrolled Graves' disease: a case report

IntroductionWe report an unusual case of upper airway compromise complicated by thyroid storm in a pregnant woman with Graves' disease, ending with the in utero death of the fetus. This complication might have developed due to upper airway edema as a result of poorly controlled hyperthyroidism.Case presentationA 41-year-old Turkish woman at 27 weeks' gestation suffering from Graves' disease was referred to our emergency department with a diagnosis of respiratory arrest. She was unconscious and had been intubated. Her laboratory results were compatible with thyrotoxicosis. The patient had suffered from respiratory difficulty for a long time and had stopped using her antithyroid medications after the first trimester of pregnancy. One day before, she had visited an obstetrician because her respiratory distress had increased. At that time, her fetus was still alive. She was given oxygen therapy and then sent home. With a presumptive diagnosis of thyroid storm, she was admitted to the intensive care unit and treated with aggressive medical therapy. The baby was found to be no longer alive and was delivered vaginally after labor induction. The mother was discharged 10 days later with maintenance therapy.ConclusionHyperthyroidism during pregnancy warrants very close attention and should almost always be treated with appropriate antithyroid medications. Maternal respiratory distress in such patients can be an early sign of impending upper airway compromise and thyroid storm, which can endanger the mother and fetus unless prompt and aggressive therapy is initiated.

Diagnosis and management of a neonatal intralingual cyst of foregut origin

Congenital intralingual cysts of foregut origin are extremely rare. These cysts have the potential to compromise the fetal airway at the time of delivery. We present a case of a 37-week fetus with an intralingual cyst identified by antenatal ultrasound and subsequently further delineated by MRI. Information acquired from the imaging allowed for controlled delivery with necessary precautions to manage an impending airway obstruction. Excision of the cyst occurred at day 8 of life. We have reviewed the literature as it pertains to our case as well as the role of imaging in managing fetal oral cavity cysts.

Gunshot facial injury: a multi-disciplinary management

ABSTRACTGunshot facial injury may be frightening and overwhelming. We present a case report of a male employee who was shot in the face during an armed robbery attack on a bank. He sustained severe injuries to the eyes, as well as fractures involving the orbital, maxillary and mandibular bones, with impending airway compromise. He bled profusely and was resuscitated and stabilized. Anaesthesia management included initial local anaesthesia for emergency tracheostomy and then a general anaesthetic for emergency ophthalmology and maxillofacial surgeries in a one-staged operation all on the same day lasting six hours.

P035: Continuing Trends in Awake Tracheotomy Airway Intervention

P035: Continuing Trends in Awake Tracheotomy Airway Intervention

Urgent awake tracheotomy for impending airway obstruction

Awake tracheotomy is performed for patients with impending airway obstruction. Few studies to date have addressed the issues surrounding awake tracheotomy. We sought to review the indications, complications, and outcome of awake tracheotomy for urgent airway control. We conducted a retrospective review of patients who underwent awake tracheotomy over a 4-year period from 2001 to 2004 at an urban tertiary medical center. Data were obtained from inpatient records and operative charts. We obtained data on 54 men and 19 women, with a mean age of 61 years. The majority of patients presented with hoarseness, dyspnea, and stridor. Twenty patients had obstruction from head and neck cancers. Nonmalignant causes included deep neck infections (n = 18), bilateral vocal cord paralysis (n = 17), trauma (n = 9), and laryngeal edema (n = 6). Other causes include laryngeal cyst, subglottic stenosis, and vocal cord granuloma. Six (8.2%) patients experienced complications, including postoperative hemorrhage, pneumothorax, and chest and wound infections. There were no long-term complications or deaths. Awake tracheotomy is efficacious and safe and has a low complication rate. Awake tracheotomy should be performed for impending airway obstruction and in a timely manner before complete obstruction occurs.

Carcinosarcoma Of The Parotid: Parapharyngeal Extension With Facial Nerve Palsy and Airway Obstruction

Objective: We report an extremely rare case of carcinosarcoma of the parotid with parapharyngeal extension presenting with facial nerve palsy and airway obstruction. The patient succumbed to the disease despite surgery performed. Here, we discuss the pecularities of the histopathology, immunohistochemistry, radiology and the surgical aspects of this condition. Case report: An elderly lady with a rapidly progressing large parapharyngeal mass presented with facial nerve palsy and impending airway compromise. Fine needle aspiration cytology showed presence of sarcomatous components. Distant metastasis was excluded. Subsequently, surgical removal of the mass was performed and carcinosarcoma of the parotid gland was diagnosed. The epithelial component was predominately composed of squamous cell carcinoma whereas chondrosarcoma was the predominant stromal component.

Anesthesia in a child with fibrodysplasia ossificans progressiva

We describe the anesthesia management of a 12-year-old girl, diagnosed with fibrodysplasia ossificans progressiva (FOP), who presented with a submandibular abscess. FOP is a rare, inherited disorder with heterotopic bone formation and progressive musculoskeletal disability. This disability ultimately confines patients to a wheelchair. Minor trauma following dental treatment may lead to ankylosis of the jaw. Subsequent to this disability, which resulted in poor dental hygiene, our patient developed a dental abscess. This spread along the mandibular margin and under the tongue. She presented with an impending airway compromise in an already difficult situation. The options for airway management in a child with limited mouth opening are discussed.

Acute Infectious Upper Airway Obstructions in Children

There are numerous causes of acquired acute upper airway obstructions in children but most are secondary to infections, foreign bodies, and trauma. Recognizing impending airway obstructions is important because cardiopulmonary arrest rarely is a sudden event but rather follows a progressive deterioration in respiratory function. From an anatomic perspective, acute obstructions may present in the pharyngeal or laryngeal regions. In the pharynx, fascial layers create several potential peritonsillar, parapharyngeal, and retropharyngeal spaces that may accommodate abscess formation. Within the larynx and lower airways, small changes in radius dramatically affect the resistance to flow as described by Poiseuille's law, allowing for small amounts of inflammation to cause significant obstruction. The clinical presentation of acute upper airway obstruction will depend on the degree and location of the obstruction. Therapy is aimed primarily at maintaining a patent airway and prescribing appropriate antimicrobials.

Urgent Surgical Airway Intervention: A 3 Year County Hospital Experience

To review the indications, complications, and outcomes of patients undergoing urgent surgical airway intervention. The inpatient and outpatient charts of patients who underwent awake tracheostomy or were converted from cricothyrostomy to tracheostomy at our institutional-affiliated County Hospital over a 3 year period were reviewed. Ninety patients underwent awake tracheotomy, and seven were converted from cricothyrostomy to tracheostomy. Indications for awake tracheotomy included impending airway obstruction from malignancy of the aerodigestive tract or that causing extrinsic compression of the airway in 72 (80%) patients, neck abscess in 4 (4.4%), subglottic stenosis in 3 (3.3%), and a variety of other etiologies in 11 (12.2%). Thirty-eight (42%) patients were noted to have stridor. On fiberoptic laryngoscopy, 66 (80%) patients had moderate or severe airway obstruction, whereas 17 (20%) had mild or no obstruction. Of the 72 patients with squamous cell carcinoma, only 6 (8%) have been subsequently decannulated. Among the remainder, 13 of 18 (72%) have been decannulated. Complications occurred in seven (7.8%) patients after awake tracheotomy, none with untoward sequelae. Three severe complications occurred among the seven patients converted from cricothyrostomy to tracheostomy: anoxic brain injury in each, leading to death in two. Awake tracheostomy should be considered in any patient with impending or ongoing airway obstruction or with potential for difficult intubation. This should be performed in a timely manner before an emergent situation arises because the complications of emergency surgical airway can be devastating.

Upper Airway Obstruction

General management guidelines For upper airway obstruction: (Do & Dont’s) • Child nursed in parent’s lap. • Avoid/minimise noxious stimulus. Do not – Inspect the orapharynx/Laryngoscopy – Send to radiology for X-ray – Insert IV line/take ABG • Humidified oxygen should be administered in non threatening manner (flow by O2) • In severe conditions intubation should be done in controlled settings (with facilities of emergency tracheostomy preferably in the PICU) in the presence of anaesthetist/pediatric intensevist using inhalation anaesthesia and using ET tube one size smaller than recommended for age. Danger sings of impending airway obstruction/ indication for intubation • Agitation • Inadequate respiratory effort • Fatigue • Diminished air entry / gasping • Drowsiness respiration • Cyanosis • Expiratory / absence of stridor • Tachycardia • Tachypnoea with severe retractions • Poor skeletal muscle tone

Infectious Mononucleosis and Corticosteroids

Although many studies have examined the effects of systemic corticosteroid therapy (SCT) on the clinical course of infectious mononucleosis (IM), few have evaluated the influence of these studies on treatment patterns and outcomes. The purpose of this study was to review current therapeutic strategies and outcomes in uncomplicated and complicated IM. Retrospective case series. Tertiary care center. We identified 206 immunocompetent patients with IM diagnosed during the previous 5 years. Patient information, including age, sex, history and physical findings at presentation, pertinent laboratory data, management practices, and treatment outcomes, were analyzed. Systemic corticosteroid therapy was used in 44.7% of patients. Evaluation of treatment indications for SCT revealed that 8.0% of the study population qualified by traditional criteria for the use of corticosteroids; 92.0% of patients received SCT for other indications. Factors associated with the observed increase in corticosteroid use included a history of repeat visits, inpatient admission, and otolaryngology consultation. Diagnosis was made on the basis of a positive heterophil antibody test (monospot test) with appropriate clinical findings (97.5% of patients) or by the presence of lymphocytosis with appropriate clinical findings (2.4% of patients). Systemic corticosteroid therapy was not positively associated with fever, decreased oral intake, tonsillar hypertrophy, or duration of symptoms. No significant differences in incidence of disease complications, rates of hospital admission, or length of hospital stay were noted between the steroid and nonsteroid treatment groups. Despite consistent and uniform acceptance in the medical literature that SCT in the setting of IM should be reserved for patients with impending airway obstruction, corticosteroids continue to be used on a much broader scale at this tertiary care institution. This observation suggests that clinicians see value in SCT for treatment of IM beyond the classically accepted reasons. Moreover, despite previous reports of possible adverse consequences of SCT in IM, our review failed to demonstrate any such trend.

Malignant Cervical Teratoma in an Adult Presenting with Impending Airway Obstruction

Extragonadal teratomas and germ cell tumours are uncommon. Most teratomas of the head and neck present in the paediatric age group. Occurrence of such tumours in an adult is extremely rare and, to date, less than 40 cases have been reported in the literature. We report a case of a young man presenting with impending airway obstruction secondary to a malignant teratoma of the neck.