Management Of Upper Airway Obstruction Research Articles

Role of Nasopharyngeal Airway in Management of Craniofacial Syndrome-Associated Upper Airway Obstruction in Children.

Upper airway obstruction (UAO) management in children, particularly those with associated anatomical mid-face structural differences, poses a significant challenge. This study describes using a nasopharyngeal airway (NPA) in managing infants with severe upper airway obstruction. Infants discharged home from Queensland Children's Hospital with an NPA insitu for the management of upper airway obstruction were retrospectively evaluated for clinical and demographic parameters, underlying diagnoses and respiratory support, including NPA insertion details and comorbidities. Sixty-seven children (24 male) were included with a median age at NPA insertion of 24 (IQR 7-59) days and a median duration of NPA use of 229.1 (IQR 151.50-297.75) days. Fifty-two (77.6%) had Pierre Robin sequence. Other diagnoses included CHARGE syndrome, Treacher Collins syndrome, Stickler syndrome, Crouzon syndrome, Bohring-Opitz syndrome, isolated cleft palate, Beckwith-Wiedemann syndrome, Chromosome 3 deletion and VACTERL association. Four infants required tracheostomy, and no complications related to NPA use were reported. Those with oximetry and polysomnography data showed improving indices following NPA insertion [pre NPA median (IQR) SpO2: 95.9% (94.73-97.73), AHI: 51.40 (44.50-69.45), OAHI 65.9 (56.45-73.35) and TcCO2 (mmHg) 65.70 (61.95-67.30) vs. post-NPA median (IQR) SpO2: 97.1% (96.19-97.9), AHI: 12.20 (11.25-24.35), OAHI 10.20 (6.12-5.62) and TcCO2 (mmHg) 52.40 (47.90-58.40)]. Our findings highlight the effectiveness and safety of NPA as a noninvasive management option for severe upper airway obstruction in children, particularly in those with anatomical midface structural differences. Further research and larger studies are warranted to confirm these findings and optimise management strategies for these patients.

Conservative Airway Management Successful in Majority of Infants With Pierre-Robin Sequence at Queensland Children's Hospital: A Retrospective Review.

Pierre-Robin Sequence (PRS) is a congenital abnormality characterized by micrognathia, glossoptosis, and variable severity upper airway obstruction. Clear management algorithms are lacking, particularly the indications for surgical versus nonsurgical intervention. The authors reviewed the management of these children in Queensland. All children diagnosed with PRS at Queensland Children's Hospital from April 2014 to October 2019 were identified (n=45), and their charts were retrospectively reviewed. Three management patterns emerged: prone/lateral positioning, nasopharyngeal airway (NPA) use, and surgery (tracheostomy or mandibular distraction). Most children (n=30; 67%) were managed successfully nonsurgically with an NPA (median age of insertion 0.25 mo, median duration 5.0 mo). Of these, 12 patients (40%) also required supplemental oxygen. The median age of NPA cessation was 5.5 months, with oxygen therapy ceasing at a median 8.25 months, upon which no further support was required. The remaining majority (n=13; 29%) of children were managed without an NPA, using positioning alone (10/13; 77%) or positioning combined with supplemental oxygen (1/13), CPAP (1/13), or both adjunct measures (1/13). Only 2 patients underwent surgical intervention. Feeding supplementation using nasogastric tube was necessary in 78% of patients for a median duration of 4 months. Cleft palate co-existed in all but one patient. Management of upper airway obstruction in PRS children is variable between units. Over a 5-year period, 96% of children with PRS were successfully managed without surgical intervention at the Queensland Children's Hospital. These findings contrast with some other literature and may suggest that more careful consideration of surgical intervention in PRS patients is prudent.

Current Trends in Orthognathic Surgery.

Orthognathic surgery has evolved significantly over the past century. Osteotomies of the midface and mandible are contemporaneously used to perform independent or coordinated movements to address functional and aesthetic problems. Specific advances in the past twenty years include increasing fidelity with computer-assisted planning, the use of patient-specific fixation, expanding indications for management of upper airway obstruction, and shifts in orthodontic-surgical paradigms. This review article serves to highlight the contemporary practice of orthognathic surgery.

Is Continuous Positive Airway Pressure All There Is? Alternative Perioperative Treatments for Obstructive Sleep Apnea

Is Continuous Positive Airway Pressure All There Is? Alternative Perioperative Treatments for Obstructive Sleep Apnea

Preoperative tracheotomy in the treatment of upper airway obstruction of patients with advanced stage supraglottic carcinoma

BackgroundPreoperative tracheotomy is an effective option that secures upper airway patency in laryngeal carcinoma patients suffering from upper airway obstruction, but the influence of this treatment on oncologic outcomes of laryngeal carcinoma remains controversial. The purpose of this study was to determine the impact of preoperative tracheotomy on overall survival in supraglottic carcinoma patients with tumor obstruction of the upper airway, and explore the potential causes. Materials and methodsThis retrospective study collected 243 consecutive patients with advanced stage supraglottic carcinoma from 2005 to 2010. Preoperative tracheotomy in the management of upper airway obstruction in patients with supraglottic carcinoma was analyzed. ResultsThe mean age was 60.9 years at diagnosis, with men accounting for 98.4% of all patients. Thirty nine (16.0%) patients presenting with tumor obstruction of the upper airway required preoperative tracheotomy. T4 stage patients had higher rate of tracheotomy than those of patients with T3 stage (36.8% vs 12.2%). Patients with upper airway obstruction presented with greater tumor area compared with patients without (13.7 cm2 vs 9.0 cm2). The optimal cutoff value of tumor area for tracheotomy and OS rate were both at 10 cm2. Supraglottic patients with upper airway obstruction receiving preoperative tracheotomy had poorer OS rate compared with patients without. T stage and tumor area were correlated with upper airway obstruction, and these two variables were independent predictors of OS rate in supraglottic carcinoma patients. ConclusionsAdvanced stage supraglottic carcinoma patients with upper airway obstruction undergoing preoperative tracheotomy experienced worse overall survival. Advanced T stage and greater tumor size were associated with upper airway obstruction, indicating that the negative influence of tumor obstruction on survival may be cause by these two preoperative variables. Therefore, preoperative tracheotomy acts only as an alternative procedure, and is not a prognostic agent.

Predicting Failure of Conservative Airway Management in Robin Sequence

PURPOSE: While initial management of upper airway obstruction in Robin sequence is traditionally conservative, early identification of patients who failed in this approach would avoid the deleterious effects of prolonged upper airway obstruction and hospitalization. The purpose of the current study was to evaluate patient factors, clinical data, and polysomnographic (PSG) results in hospitalized infants with Robin sequence who were either discharged after successful conservative airway measures (Group 1) or required surgical airway intervention after a protracted hospital course (Group 2). We hypothesized that differences between these two groups may expedite early operative airway procedures in appropriate patients without an initial prolonged and, ultimately, unsuccessful period of conservative management. METHODS: A retrospective review was conducted among infants diagnosed with RS who underwent primary airway management at a single institution from 1994 to 2020. Patient demographics, nutritional and respiratory status, laboratory values, and PSG results were recorded. Airway management was classified as conservative or surgical, and recorded variables were compared between the groups. Unpaired t-test/Wilcoxon-Mann-Whitney test was used to compare continuous data and Chi square test/Fisher exact test for categorical data. To assess the ability of PSG variables to predict failure of conservative management, we performed receiver operator characteristic (ROC) curve analysis. Accuracy was graded based on the area under the curve (AUC) defined as “poor” (AUC 0.60–0.70), “fair” (AUC 0.70–0.80), “good” (AUC 0.80–0.90), and “excellent” (AUC 0.90–1.00). Optimal cut-points were calculated using the Youden index (J) method. RESULTS: In total, 122 infants with Robin sequence were analyzed. Conservative airway measures were successful in 61 patients (Group 1), while 61 infants failed this approach after a mean period of 23 days and required a surgical airway procedure (Group 2). Lower 5-minute Apgar scores and associated pulmonary, CNS, and reflux disease were seen more frequently in Group 2 patients. A significantly smaller proportion of patients in Group 2 also demonstrated adequate oral intake compared with Group 1 patients (5% versus 28%, P < 0.001). The surgically managed patients required greater respiratory support or intubation, as well as higher levels of maximum CO2 (67.8 versus 51.4 mm Hg, P < 0.001) and maximum HCO3 (32.7 versus 28 mmol/L, P = 0.001). PSG results in Group 2 patients documented a higher percentage of time with O2 saturation < 90% (10.4% versus 1.1%, P = 0.005) and overall higher apnea-hypopnea index (AHI) (59.7 versus 20.6 events/hour, P < 0.001). Good predictors for failure of conservative airway management (AUC range: 0.80–0.85) included AHI, obstructive AHI (OAHI) REM, OAHI non-REM, and maximum ETCO2 (asleep). Cut points most predictive for failure of conservative management by ROC curve analysis included: AHI > 16.9, OAHI REM > 25.9, OAHI non-REM > 23.6, and maximum ETCO2 > 49 mm Hg. CONCLUSIONS: The current study identified patient factors and PSG results in infants with RS that were associated with persistent upper airway obstruction despite weeks of conservative airway management. Our data may expedite earlier definitive treatment of these critical patients that is essential to reducing risk for known complications such as hypertension, metabolic syndrome, and neurocognitive dysfunction.

Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19).

The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. However, the fear of provoking laryngospasm may cause avoidance of deep or sedated extubation techniques which could reduce coughing and infection risk. This fear may be alleviated with clear understanding of the mechanisms and effective management of post-extubation airway obstruction including laryngospasm. We review the dynamic function of the larynx from the vantage point of head-and-neck surgery, highlighting two key concepts:1. The larynx is a complex organ that may occlude reflexively at levels other than the true vocal folds;2. The widely held belief that positive-pressure ventilation by mask can “break” laryngospasm is not supported by the otorhinolaryngology literature.We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.

Implement of flexible bronchoscopy in diagnosis and management of pediatric upper airway obstruction

Acute upper airway obstruction is a very common urgent situation in pediatric emergency.It includes several types of disease, mostly classified as infectious and noninfectious.Children are dying with delayed diagnosis and airway clear.Except traditional techniques and rigid bronchoscopy, flexible bronchoscopy would be a very convenient and handable way in diagnosis and management of upper airway obstruction in children.Herence, we presented etiologies of upper airway obstruction and how could flexible bronchoscopy reveal and(or) manage them. Key words: Children; Upper airway obstruction; Flexible bronchoscopy; Diagnosis; Management

The role of adenotonsillectomy in the treatment of primary nocturnal enuresis in children: A systematic review

Primary nocturnal enuresis (PNE) is a challenging condition for physicians, patients and families. Although the etiology remains unclear, sleep-disordered breathing (SDB) and sleep apnea have been suggested to play an important role. Recent research has suggested a potential therapeutic benefit of adenotonsillectomy (T&A) and surgical management of upper airway obstruction in the treatment of PNE. The aim was to conduct a systematic review of relevant literature to determine the effectiveness of T&A in treating children aged 2-19 years with PNE. This was a systematic review using a comprehensive electronic search strategy that included PubMed, Embase, CINAHL, Cochrane Library, conference proceedings, and the gray literature up to July 2015. We included all studies of children aged 2-19 years with PNE and SDB who underwent T&A. The primary outcome was resolution of PNE following surgery. Observational studies and randomized trials were reviewed. Risk of bias assessment and meta-analyses of included studies were performed. We screened 3254 citations; following title and abstract screening, 42 studies were selected for full-text screening by two independent reviewers. We included 18 studies (890 patients) in our final analysis. All studies were observational and only one included a control group. Meta-analysis of proportions of all (18) studies revealed a pooled complete resolution rate of 51% (43-60%), with significant heterogeneity among studies (I2=82.2%). Partial resolution was seen in 20% (14-27%), with similar heterogeneity to the complete resolution group. Sensitivity analysis including only studies with a low risk of bias and with patients ≥5 years (n=244 patients) yielded a complete resolution rate of 43% (36-49%) with minimal heterogeneity (I2=0%; figure). In our systematic review, T&A resulted in improvement of nocturnal enuresis in more than 60% of patients, with complete resolution rates in excess of 50%. Findings were persistent on meta-analysis focused only on studies including older patients (≥5 years) and those with short follow-up after surgery (≤3 months), which imply a higher cure rate than would be expected based on natural history alone. The limitations of this review include the lack of controlled trials, the overall quality of the evidence reviewed and the heterogeneity between included studies. The role for systematic investigation and treatment of sleep disorders in patients with PNE should be scrutinized further, since a near 50% complete resolution rate for PNE may be expected with T&A in some settings.

Surgical versus nonsurgical interventions to relieve upper airway obstruction in children with Pierre Robin sequence.

Newborns with Pierre Robin sequence (PRS) often experience chronic intermittent hypoxemia/hypoventilation associated with airway obstruction. The heterogeneity of the severity of upper airway obstruction makes management a challenge; the optimal intervention in individual cases is not clear. To investigate the prevalence of surgical/nonsurgical interventions for PRS at two children's hospitals. Patient characteristics and outcomes were examined. The present retrospective chart review identified 139 patients with PRS born between 2000 and 2010. Demographic information, mode of airway management, associated anomalies and syndromes, polysomnography results, length of intensive care unit and hospital stay, complications and deaths were extracted. Interventions included prone positioning (alone [61%]), tongue-lip adhesion (45%), nasopharyngeal intubation (28%), continuous positive airway pressure (20%), tracheostomy (19%) and mandibular distraction osteogenesis (5%). Tracheostomies were more prevalent in syndromic patients (P=0.03). Patients who underwent tracheostomy had a lower birth weight (P=0.03) compared with newborns with other interventions. Patients who underwent surgical interventions had longer intensive care unit stays (P<0.001). No intervention was associated with a statistically significant likelihood of requiring a subsequent intervention. Thirty percent of patients underwent polysomnography, with a higher proportion of these using continuous positive airway pressure (n=15) (P<0.01). In the present descriptive study, patients with syndromic PRS or low birth weight underwent early intervention, which included a tracheostomy. Objective measures of airway obstruction were underutilized. Decision making regarding evaluation and management of upper airway obstruction in this population remains clinician and resource dependent. Reporting data obtained from a large cohort of PRS patients is important to compare experiences and motivate future studies investigating this complex condition.

A 10 year retrospective review on the management of upper airway obstruction in children with pierre robin sequence: the success of the nasopharyngeal airway

Introduction Pierre Robin Sequence (PRS) is a congenital anomaly presenting with micrognathia, glossoptosis and a cleft palate. Although significant upper airway obstruction is common, especially during sleep, there isn9t a general consensus about its management. In most centres, mandibular distraction surgery or insertion of tracheostomy is the recommended management for children with PRS not responding to conservative management such as positioning. The objective of this study was to present our experience with the use of nasopharyngeal airway in these patients as a possible alternative to surgery by retrospectively reviewing its use in our department over the last 10 years. Methods This study was conducted jointly between the respiratory and otolaryngology departments. Only the children with all three characteristics of this condition have been included. The data collected included the method of airway management and oximetry data pre and post intervention. Results Data was collected on 104 Pierre Robin patients referred to us from 2000 to 2010. Most of patients (64/104) were less than 4 weeks of age at referral. In this referred group, the airway symptoms were managed conservatively in 27 (25.9%), with nasopharyngeal airway (NPA) in 63 (60.6%) and tracheostomy in 14 (13.4%) patients. The duration of NPA use varied from 3 weeks to 27 months, the average being 7.9 months. There was an objective improvement on oximetry in all 63 patients with NPA. NPA did not improve symptoms subjectively or objectively in 14 patients who underwent a tracheostomy. There were no NPA related complications in this study. In this study 86.5% (90/104) PRS patients were successfully managed either conservatively or with the help of nasopharyngeal airway for few months. Conclusion In majority of children (86.5%), the airway obstruction can be managed by conservative measures or nasopharyngeal airway for few months. A small number of children need to be managed with a tracheostomy. Although oximetry studies are not the most accurate tool to diagnose obstruction in itself, they were accurate enough to show objective improvement post insertion of NPA.

The successful use of the nasopharyngeal airway in Pierre Robin sequence: an 11-year experience

IntroductionPierre Robin sequence (PRS) is a congenital anomaly presenting with micrognathia, glossoptosis and a cleft palate. This study describes a decade's experience of the management of upper airway obstruction (UAO)...

Diagnosis and Management of Upper Airway Obstruction Due to Lingual Hematoma: Report of a Case

The tongue is a highly vascular structure with a propensity for brisk hemorrhage as a result of trauma. Hemorrhage within the tongue can result in lingual hematoma formation and subsequent upper airway compromise. Such cases require rapid identification and management to ensure optimal patient outcomes. We describe the management of an expanding lingual hematoma via extraoral ligation of the lingual artery.

S216: Surgical Management of Upper Airway Obstruction and Sleep Apnea

S216: Surgical Management of Upper Airway Obstruction and Sleep Apnea

Non-invasive ventilation in children with upper airway obstruction

The aim of this paper is to highlight our experience with the use of non-invasive positive pressure ventilation (NIPPV) in children, neonates and pre-term infants with upper airway obstruction. This was a retrospective review of our recent experience in using NIPPV for the management of upper airway obstruction in paediatric patients. NIPPV was successful in preventing tracheostomy in patients with significant laryngo-tracheomalacia as well as being used to optimise the timing of surgery in subglottic stenosis. Furthermore, it proved beneficial in stabilising the airway after aryepiglottoplasty and also had a role in the management of obstructive sleep apnoea. The use of NIPPV in children with upper airway obstruction can be a safe and effective alternative to invasive mechanical ventilation. NIPPV can potentially be beneficial in avoiding prolonged invasive ventilation, avoiding tracheostomy, stabilizing the airway after extubation or decannulation, and management of obstructive sleep apnoea.

S236: Advanced Surgical Management of Obstructive Sleep Apnea

The awareness of the deleterious effects of obstructive sleep apnea (OSA) has increased over the past decade. Known symptoms of OSA include hypersomnolence, and cardiovascular and neurological diseases. Increased awareness of these conditions has led to an increase in the diagnosis and treatment options for patients with OSA. Conventional nonsurgical treatment options may be unacceptable or intolerable to some patients. In these situations, surgical management may be a viable option. Phase I surgery for OSA involves the surgical management of upper airway obstruction that does not involve maxillomandibular advancement surgery (phase II). A variety of solitary and combined surgical procedures have been developed to address upper airway obstruction. This lecture will review several commonly used techniques and emphasize, either alone or in combination, the latest advanced OSA surgery techniques, such as nasal reconstruction (internal and external nasal valve reconstruction, septoplasty, etc) hyoid advancement, elliptical genioglossus advancement, soft palate surgery (UPPP, LAUP, etc), and maxillomandibular advancements. Oral and maxillofacial surgeons managing the surgical obstructive sleep apnea patient will learn the latest advanced techniques in upper airway obstruction surgery. Emphasis will be on the correct diagnosis, treatment planning, indications, and latest research in these techniques for the surgical management of OSA.

S331: Advanced Surgical Management of Obstructive Sleep Apnea

The awareness of the deleterious effects of obstructive sleep apnea (OSA) has increased over the past decade. Known symptoms of OSA include hypersomnolence, and cardiovascular and neurological diseases. Increased awareness of these conditions has led to an increase in the diagnosis and treatment options for patients with OSA. Conventional nonsurgical treatment options may be unacceptable or intolerable to some patients. In these situations, surgical management may be a viable option.Phase I surgery for OSA involves the surgical management of upper airway obstruction that does not involve maxillomandibular advancement surgery (phase II). A variety of solitary and combined surgical procedures have been developed to address upper airway obstruction. This lecture will review several commonly used techniques and emphasize, either alone or in combination, the latest advanced OSA surgery techniques, such as nasal reconstruction (internal and external nasal valve reconstruction, septoplasty, etc) hyoid advancement, elliptical genioglossus advancement, soft palate surgery (UPPP, LAUP, etc), and maxillomandibular advancements.Oral and maxillofacial surgeons managing the surgical obstructive sleep apnea patient will learn the latest advanced techniques in upper airway obstruction surgery. Emphasis will be on the correct diagnosis, treatment planning, indications, and latest research in these techniques for the surgical management of OSA. The awareness of the deleterious effects of obstructive sleep apnea (OSA) has increased over the past decade. Known symptoms of OSA include hypersomnolence, and cardiovascular and neurological diseases. Increased awareness of these conditions has led to an increase in the diagnosis and treatment options for patients with OSA. Conventional nonsurgical treatment options may be unacceptable or intolerable to some patients. In these situations, surgical management may be a viable option. Phase I surgery for OSA involves the surgical management of upper airway obstruction that does not involve maxillomandibular advancement surgery (phase II). A variety of solitary and combined surgical procedures have been developed to address upper airway obstruction. This lecture will review several commonly used techniques and emphasize, either alone or in combination, the latest advanced OSA surgery techniques, such as nasal reconstruction (internal and external nasal valve reconstruction, septoplasty, etc) hyoid advancement, elliptical genioglossus advancement, soft palate surgery (UPPP, LAUP, etc), and maxillomandibular advancements. Oral and maxillofacial surgeons managing the surgical obstructive sleep apnea patient will learn the latest advanced techniques in upper airway obstruction surgery. Emphasis will be on the correct diagnosis, treatment planning, indications, and latest research in these techniques for the surgical management of OSA.

S224: Surgical Management of Upper Airway Obstruction in Sleep Apnea

Sleep apnea problems can cause disruption of the performance of normal life activities as well as create major medical and life threatening conditions. Although central and pulmonary factors can cause sleep apnea, the most common areas contributing to this condition involve obstruction(s) in the upper airway; from the nostrils and lips to the trachea.

S226: Surgical Management of Upper Airway Obstruction in Sleep Apnea

Sleep apnea problems can cause disruption of the performance of normal life activities as well as create major medical and life threatening conditions. Although central and pulmonary factors can cause sleep apnea, the most common areas contributing to this condition involve obstruction(s) in the upper airway; from the nostrils and lips to the trachea.

Mandibular Lengthening in Micrognathic Infants With the Internal Distraction Device

Mandibular distraction osteogenesis can play an important role in the management of upper airway obstruction in infants with Pierre Robin sequence. These infants are characterizedbymicrognathia,glossoptosis,andupperairwayobstruction. 1-3 Asmall jawwitharelativelylargetongueresultsinretropositioningofthetonguebaseagainst theposteriorpharyngealwall. 4 Mandibularlengtheningthroughdistractionosteogenesisrelievesupper airway obstruction by moving the tongue base anteriorly with its muscular attachments to the mandible. 4 Distraction osteogenesis provides an alternative to tracheotomy in managing upper airway obstruction and allows earlier decannulation in infants with Pierre Robin sequence who previously have undergone tracheotomy. Pierre Robin sequence is often associated with Stickler and velocardiofacialsyndromes.Thus,pediatricophthalmologic,pediatriccardiologic,andgeneticevaluations are imperative in addition to cleft palate management. 5 We use distraction osteogenesis techniques in the management of mandibular, maxillary, cranial vault, and cranioorbital bony deficiencies. We use internal microdistractors in the management of mandibular deficiencies in neonates and infants with nonsyndromic Pierre Robin sequence, as well as in syndromes with mandibulofacial dysostosis such as Nager, Treacher Collins, and Goldenhar syndromes.