Life-threatening Airway Obstruction Research Articles

Necrotizing Tracheitis Secondary to Corynebacterium Species Presenting With Central Airway Obstruction

Pseudomembranous necrotizing tracheitis is a rare cause of life-threatening central airway obstruction. Patients present with hoarseness, cough, dyspnea, wheezing, stridor, and occasionally with respiratory failure. Diagnosis requires a high index of suspicion, and should be confirmed with a comprehensive bronchoscopy and biopsy. For patients with signs and symptoms of airway obstruction, a therapeutic rigid bronchoscopy with mechanical debridement is recommended. We present a rare case of necrotizing tracheitis secondary to Corynebacterium species, which caused life-threatening airway obstruction in an adult.

Urgent Tracheal Resection and Reconstruction Assisted by Temporary Cardiopulmonary Bypass: a Case Report

Severe tracheal stenosis can not only cause critical medical problems such as severe shortness of breath, hypoxia, and even orthopnea, but also impose overwhelming challenges on the physicians, particularly the anesthesiologist. Life-threatening airway obstruction can make the patient's gas exchange extremely difficult.Though several options could be offered regarding the treatment of tracheal stenosis, normally, tracheal resection and following reconstruction is the first choice for severe airway stenosis. Successful surgical intervention relies on the close communication and cooperation between surgeons and anesthesiologists. In these cases, airway management is the top issue for the anesthesiologist, and the level of difficulty varies with stenosis location, severity of stenosis, and surgical technique. Extracorporeal membrane oxygenation (ECMO), or cardiopulmonary bypass (CPB), is rarely utilized for the surgery, but for those impossible airways due to nearly complete tracheal obstruction, ECMO or CPB could be the final choice for anesthesiologists. Here we report a case of successful urgent airway management for tracheal resection and reconstruction assisted by temporary CPB.

Life threatening airway obstruction secondary to a large probable parathyroid cyst

Life threatening airway obstruction secondary to a large probable parathyroid cyst

Outcomes after ecallantide treatment of laryngeal hereditary angioedema attacks

BackgroundHereditary angioedema (HAE) is a rare disorder associated with episodic attacks of well-demarcated angioedema. Attacks that affect the larynx can result in life-threatening airway obstruction. ObjectivesTo examine efficacy and safety of ecallantide treatment for laryngeal HAE attacks. MethodsData were combined from 4 clinical studies (EDEMA2, EDEMA3, EDEMA4, and DX-88/19) evaluating 30 mg of subcutaneous ecallantide for treatment of acute HAE attacks. Efficacy was assessed using 2 validated, HAE-specific, patient-reported outcome measures. The change in Mean Symptom Complex Severity (MSCS) score indicates change in symptom severity; a negative score indicates improvement. The calculated minimally important difference (MID) for change in severity is −0.30. The Treatment Outcome Score (TOS) measures treatment response. A positive score indicates improvement; the calculated MID is 30. ResultsOverall, 98 patients received ecallantide for 220 laryngeal attacks. The mean ± SD change in MSCS score was −1.1 ± 0.73 and −1.6 ± 0.68 at 4 and 24 hours, respectively. The mean ± SD TOS was 73.5 ± 35.8 and 85.5 ± 27.8 at 4 and 24 hours, respectively. Median time to significant improvement was 185 minutes (95% confidence interval, 167-226). One attack required intubation. Four treatment-emergent serious adverse events were reported, including 2 HAE attacks that resulted in hospitalization and 2 anaphylactic reactions. One of these reactions required treatment with epinephrine, but both patients recovered fully. There were no deaths. ConclusionIn this large attack series, ecallantide was effective for treatment of laryngeal HAE attacks. There is a risk of hypersensitivity, including anaphylaxis, consistent with product labeling. As such, ecallantide should be administered under the supervision of a health care professional. Trial Registrationclinicaltrials.gov Identifiers: not applicable for EDEMA2 (trial was conducted before implementation of registration requirements); NCT00262080 for EDEMA3, NCT00457015 for EDEMA4, and NCT00456508 for DX-88/19.

Angiographic embolization for hemorrhage control after dental implantation

Dental implantation in the mandibular anterior region is considered a safe and reliable surgical procedure. On the other hand, several articles have reported that inadvertent hemorrhage of the sublingual artery can result in life-threatening airway obstruction. Surgical ligation under intubation or tracheostomy is the most widely used approach for controlling mouth floor bleeding in this highly vascular region. Nonetheless, surgically exploring the bleeding focus is difficult because of anatomical distortion followed by widespread edema and swelling. Since swelling of the mouth floor advances quickly, timely management is essential for favorable postoperative outcome. This paper reports a case of immediate hemorrhage control with angiographic embolization to perform rapid hemostasis before the ongoing swelling causes airway obstruction. Less invasive, angiographic embolization can prevent neurovascular damage during a surgical exploration of injured vascular structures on the mouth floor.

Successful Treatment with a Combination of Electrocautery Using Wire Snares and Gefitinib in Patients with <i>EGFR</i>-mutant Lung Cancer and Central Airway Obstruction

One-third of lung cancer patients present with life-threatening central airway obstruction (CAO). Two elderly patients were referred to our institution with symptoms caused by CAO. In each case, thoracic computed tomography and a bronchoscopic examination revealed a tumor obstructing the central airway. The tumors were resected endoscopically, and the patients' respiratory and performance status remarkably improved. Both patients were diagnosed with an advanced stage of lung adenocarcinoma harboring epidermal growth factor receptor (EGFR) mutations. They received gefitinib monotherapy, with partial responses sustained for more than 12 months. Combination therapy with endoscopic tumor resection and gefitinib is beneficial in patients with EGFR-mutant lung cancer and CAO.

Giant Retropharyngeal Abscess in a Nigerian Adult Following Fish Bone Throat Injury

Retropharyngeal abscess (RPA) is an uncommon disease entity that typically occurs in children under 5 years of age, which has the potential to cause upper airway obstruction. Upper respiratory tract infection is the most common predisposing factor to RPA in children while cervical spine tuberculosis and trauma are the major aetiological factors in the adult. We report a case of a 21-year-old Nigerian farmer with giant retropharyngeal abscess following fish bone throat injury causing life-threatening upper airway obstruction. The patient responded well to emergency tracheostomy, intraoral surgical drainage and empirical antibiotic therapy. We highlight the diagnostic and therapeutic challenges of managing such a patient.

Airway Trauma in a High Patient Volume Academic Cardiac Electrophysiology Laboratory Center

Providing anesthesia and managing airways in the electrophysiology suite can be challenging because of its unique setting outside of the conventional operating room. We report our experience of several cases of reported airway trauma including tongue and pharyngeal hematoma and vocal cord paralysis in this setting. We analyzed all of the reported airway trauma cases between December 2009 and January 2011 in our cardiac electrophysiology laboratories and compared these cases with those without airway trauma. Data from 87 cases, including 16 cases with reported airway trauma (trauma group) and 71 cases without reported airway trauma from the same patient population pool at the same period (control group), were collected via review of medical records. Airway trauma was reported for 16 patients (0.7%) in 14 months among 2434 anesthetic cases. None of these patients had life-threatening airway obstruction. The avoidance of muscle relaxants during induction in patients with a body mass index less than 30 was found to be a significant risk factor for airway trauma (P = 0.04; odds ratio, 10; 95% confidence interval, 1.1-482). Tongue or soft tissue bite occurred in 2 cases where soft bite block was not used during cardioversion. No statistically significant difference was found between the trauma and the control groups for preprocedure anticoagulation, anticoagulation during the procedure, or reversal of heparin at the end of the procedure. The overall incidence of reported airway trauma was 0.7% in our study population. Tongue injury was the most common airway trauma. The cause seems to have been multifactorial; however, airway management without muscle relaxant emerged as a potential risk factor. Intubation with muscle relaxant is recommended, as is placing a soft bite block and ensuring no soft tissue is between the teeth before cardioversion.

Anesthetic implications of infants with mandibular hypoplasia treated with mandibular distraction osteogenesis

To document the incidence of difficult intubation following mandibular distraction osteogenesis (MDO) in children with severe mandibular hypoplasia. Syndromes associated with significant mandibular hypoplasia, especially Pierre Robin sequence, provide a challenge in airway management both in and out of the operating room. Mandibular advancement using mandibular distraction osteogenesis devices has been used in infants in an attempt to reduce the incidence of acute life-threatening airway obstruction. Whether MDO also reduces the incidence of difficult intubation has not been adequately described. A retrospective chart review of 51 infants with upper airway obstruction secondary to mandibular hypoplasia who required MDO between January 2002 and 2012. The primary outcome was the incidence of difficult or failed intubation. Secondary outcomes were the relationship between syndrome type and the incidence of difficult intubation. Fifty-one PRS infants were identified. Twenty-eight patients had isolated PRS, six had syndromic PRS, seven had Treacher Collins syndrome, and 10 had another coexisting syndrome. Prior to mandibular distraction osteogenesis (MDO), the incidence of difficult intubation was 71%, with the highest incidence in patients with Treacher Collins syndrome (100%), sPRS syndrome (100%), and PRS (65%). Following MDO, the incidence of difficult intubation was 8.3%. The difference was statistically significant for all patients (Kruskal-Wallis rank test P = 0.0001) those with isolated PRS (P = 0.0001), syndromic PRS (P = 0.0023), and other syndromes (P = 0.0002), but not for Treacher Collins syndrome (P = 0.21). Three patients had pre existing tracheostomies. In a select group of infants with severe upper airway obstruction who have failed nonsurgical airway interventions, mandibular distraction osteogenesis reduces the incidence of difficult mask ventilation and difficult intubation. We were not able to compare the improvement in airway management to a comparable group of PRS infants who did not undergo surgical intervention. The improvement in laryngeal view was most marked for infants with isolated PRS but no significant benefit was demonstrated in infants with TCS.

Life Threatening Airway Obstruction by Mediastinal Masses

Life Threatening Airway Obstruction by Mediastinal Masses

Management of Deep Vein Thrombosis of the Upper Extremity

Case 1: A 34-year-old previously healthy male office manager was admitted with acute onset of heaviness, pain, and functional impairment of his right arm. The arm was cyanotic and massively swollen (Figure 1). For the past weeks, he reported transient paresthesia of his right arm during overhead activities and was unable to perform repetitive or strenuous arm exercise. He had a fracture of the right clavicle after a ski accident 5 years previously. The fracture was managed conservatively. There was no personal or family history of thrombosis. Conventional phlebography confirmed axillary and subclavian vein thrombosis (Figure 2, top), and treatment with intravenous unfractionated heparin was started. Figure 1. Clinical presentation of case 1 with massive swelling and cyanosis of the right arm (left). One day after pharmacomechanical thrombolysis, signs of thrombosis have markedly improved (right). Figure 2. Baseline digital subtraction venogram from case 1 with extensive filling defects in the axillary subclavian veins (top). Control venogram after 15 hours of pharmacomechanical thrombectomy confirmed resolution of filling defects and restored venous flow (middle). Positional venography obtained during abduction of the right arm confirmed the venous thoracic outlet syndrome with residual stenosis of the subclavian vein at the costoclavicular junction (white arrow, bottom). Case 2: A 55-year-old man with lung cancer presented with swelling, heaviness, and pain in his left arm 1 week after completion of chemotherapy administered via a left-sided indwelling central venous catheter. Axillary and subclavian vein thrombosis was confirmed by ultrasonography. Low-molecular-weight heparin (LMWH) was initiated, and the catheter was removed 3 days later because it was no longer functional. At 1 week, pain and functional impairment had not improved, and the circumference of the left upper arm had increased by 2 cm. Case 3: A 65-year-old woman with metastatic ovarian cancer presented with swelling of the face and both arms, headache, …

Management of Plastic Bronchitis With Topical Tissue-type Plasminogen Activator

Plastic bronchitis or cast bronchitis is a rare disease of unclear etiology characterized by formation of airway casts that can lead to life-threatening airway obstruction. There is currently limited data regarding optimal treatment of plastic bronchitis. Several therapies have been suggested, but recurrences are common and mortality remains high. We report the case of a 6-year-old boy with refractory eosinophilic bronchial casts, unresponsive to low-dose systemic corticosteroids, inhaled corticosteroids, azithromycin, and dornase alfa, who was treated successfully and safely with direct instillation of tissue-type plasminogen activator (tPA) to the obstructing casts during flexible bronchoscopy and inhaled tPA. Our case illustrates that the current therapy for plastic bronchitis remains inadequate. To our knowledge, this case is the first to show that direct instillation of tPA can be used safely for treatment of this disease. The use of tPA via direct administration into the airways during bronchoscopy and via a nebulizer appeared to be a safe and effective therapy for plastic bronchitis and should be considered early in the course of the disease to prevent complications of severe airway obstruction.

Hodgkin Disease of the Trachea

Endobronchial Hodgkin disease (HD) is very rare. We report the case of a women who presented with life-threatening airway obstruction. She was diagnosed with HD 4 years earlier and was in remission after treatment with a combination of chemotherapy and radiation. Bronchoscopy showed a polypoid mass obstructing the tracheal lumen almost completely. The mass was resected using an electrocautery snare loop, providing immediate relief of symptoms. Pathology and staging investigations revealed HD isolated to the trachea. This presentation and treatment is extremely unique for HD.

Kyste laryngé congénital : une cause rare de stridor chez le nouveau-né

Laryngeal cyst is a rare but generally benign lesion in the larynx. It may cause stridor and life-threatening airway obstruction in early infancy. We report the case of a neonate who developed respiratory distress 24h after birth in relation with materno-fetal infection. Airway obstruction was then suspected because of stridor. A laryngeal mass was discovered at the time of intubation. The infant experienced a nosocomial infection and died on day 14 of life before any surgical treatment. Autopsy concluded in an epiglottic congenital laryngeal cyst.

Angioedema-Induced By Angiotensin Converting Enzyme Inhibitors

Angioedema is a known allergic reaction to many medications. Angiotensin Converting Enzyme Inhibitors (ACE-I) have been reported to cause such an adverse event, however, the mechanism of action is not clear enough. ACE-I induced angioedema is often misdiagnosed, although it could develop to a life-threatening situation. It is believed that it is caused by bradykinin induced activation of vascular bradykinin B2 receptors. Studies have reported an incidence of angioedema of 1 in 1000 during the first week of use, and 1 to 42,000 subsequently. Life threatening airway obstruction requiring intubation has been reported in up to 22% of angioedema cases caused by ACE inhibitors, with an overall mortality rate of 11%.

Initial assessment and management of pediatric trauma patients

Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS® sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the “bigger picture.” Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.

Massive macroglossia developing fast and immediately after endotracheal extubation

We report an unusual case of massive macroglossia that developed very rapidly after neurosurgery in the park bench position with neck flexion. A few minutes after endotracheal extubation, massive macroglossia was noticed with marked protrusion of the tongue from the oral cavity. The patient's hospital stay was prolonged due to difficulty in speaking and eating. Macroglossia is a rare complication; however, it may cause life-threatening airway obstruction. It is important to be prepared for managing post-operative macroglossia and keep in mind that it may develop rapidly, especially after prolonged surgery performed with sustained neck flexion. The patient should be informed of the risk of macroglossia and the associated problems prior to the operation.

Primary anaplastic large cell lymphoma of trachea with subcutaneous emphysema and progressive dyspnea

Primary anaplastic large cell lymphoma of the trachea is a rare tumor. Common complaints are dyspnea and cough that could mimic a partially refractory asthma in some cases. We report a 16-year-old female with an anaplastic large cell lymphoma (null cell type) in which tracheal involvement was presented with life-threatening airway obstruction and subcutaneous emphysema. After debulking the tumor by endobronchial curettage, the patient was treated with chemotherapy followed by local radiotherapy. She had no evidence of local or distant recurrence after 25 months. Primary anaplastic large cell lymphoma of the trachea is a rare life-threatening disease. Nevertheless, this condition has a good prognosis if diagnosed immediately and treated with chemotherapy and radiotherapy.

Threatening Airway Obstruction by Mediastinal Masses: The Experience of a Medical Intensive Care Unit

Objective: Life-threatening airway obstruction is a dreaded complication of mediastinal masses. The acute management is difficult and catastrophic outcomes have been reported. We describe our experience in a Medical Intensive Care Unit (ICU) and discuss the management options. Design: Retrospective observational study. Setting: 1,600-bed tertiary-care hospital. Patients and Participants: 13 patients were treated between January 1996 and February 2010. Interventions: All patients were mechanically ventilated. Three received emergent chemotherapy, 10 underwent airway stenting and 2 underwent surgery. Measurements and Results: The median age was 51 years (range 13 to 64). In 5 patients (36%), the diagnosis was only made after ICU admission. Two had benign pathologies (retrosternal goitre and bronchogenic cyst) and 3 had lymphoma. The remaining 8 had metastatic mediastinal lymphadenopathy. All were successfully weaned off the ventilator (range 0 to 5 days). All patients with benign pathologies and lymphoma were still alive with a mean follow-up of 2.8 years (range 1 to 7 years). All patients with metastatic disease died, with a mean survival of 3.8 months (range 1 to 9 months). Conclusion: In the management of life-threatening airway obstruction by mediastinal masses, we reported the heterogeneous nature of this group of conditions. Therefore in the intensive care setting, a definitive diagnosis needs to be established urgently, as treatment and prognosis are highly dependent on the underlying etiology. We propose categorising patients into subgroups and combining various therapeutic modalities.

Life-Threatening Upper Airway Obstruction Due to Isolated Hypermobile Tongue

Isolated hypermobile tongue is extremely rare. We present a case of isolated hypermobile tongue that caused several life-threatening airway obstructions during sleep. The tongue could reach to the nasopharynx and clear and moisten the nasopharynx by its movement.