Postoperative Airway Research Articles

Management of Complications Associated With Gorham-Stout Disease: Case Report and Review of the Literature

This case report describes the course of a patient diagnosed with Gorham-Stout Disease and reviews known complications and treatment options for this rare condition. An emphasis is placed on potential multi-systemic complications that may occur including surgical complications, obstructive sleep apnea, post-operative airway obstruction, respiratory failure and cardiac arrest.

Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea.

Obstructive sleep apnea (OSA) is an under-recognized condition that results in morbidity and mortality. Postoperative complications, including medical emergency team activation (META), are disproportionally increased among surgical patients at risk for OSA. A systematic approach is needed to improve provider recognition and treatment, but protocols that demonstrate improvement in META are lacking. As part of a multidisciplinary quality improvement project, DOISNORE50 (DIS), a sleep apnea questionnaire and proactive safety measure, was algorithmically applied to all perioperative patients. Consecutive sleep screening was conducted among perioperative patients. Of the 49,567 surgical navigation center patients, 11,932 had previous diagnosis of OSA. Of the 37,572 (96%) patients screened with DIS, 25,171 (66.9%) were Low Risk (DIS < 4), 9,211 (24.5%) were At Risk (DIS ≥ 4), and 3,190 (8.5%) were High Risk (DIS ≥ 6) for OSA, respectively. High Risk patients received same-day sleep consultation. On the day of surgery, patients with Known OSA, At Risk, and High Risk for OSA received an "OSA Precaution Band." An electronic chart reminder alerted admission providers to order postoperative continuous positive airway pressure (CPAP) machine and sleep consult for patients High Risk for OSA. Implementation of a comprehensive program was associated with increased sleep consultation, sleep testing, and inpatient CPAP use (P < .001). For every 1,000 surgical patients screened, 30 fewer META, including rapid responses, reintubation, code blues, and code strokes, were observed. However, inpatient sleep consultation and inpatient CPAP use were not independently associated with reduced META. In the subgroup of patients hospitalized longer than 3 days, inpatient CPAP use was independently associated with reduced META. In this single-center, institution-wide, multidisciplinary-approach, quality improvement project, a comprehensive OSA screening process and treatment algorithm with appropriate postoperative inpatient CPAP therapy and inpatient sleep consultations was associated with increased CPAP use and reduced META. Further prospective studies are needed to assess cost, feasibility, and generalizability of these findings. Namen AM, Forest D, Saha AK, etal. Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):1953-1965.

Unexpected Beneficial Effect of Dexamethasone Administration after Septoplasty Procedure: As Prospective Cohort Audit

Background and Objectives: Septoplasty is one of the most common surgical procedures in specialty of otorhinolaryngology. Therefore, there are frequent thoughts regarding this procedure to improve its conditions from different aspects, indications, time of surgery, techniques, safety measures, and postoperative care. One of big issues regarding this procedure is the post-operative sequel and complications namely post-operative pain, oro-facial edema, air way obstruction, epistaxis, nausea and vomiting, nasal obstruction, atrophic rhinitis, induction of allergic rhinitis, septal perforation and synachia formation. Therefore, this study was conducted prospectively to confirm the effect of intravenous administration of dexamethasone on outcomes of this procedure as compared to the effect of oral administration of ketoprofen as well as paracetamol after septoplasty procedure. Patients and Methods: Two- thousands and two- hundred thirteen patients aged from 4 years to 65 years presented at ENT department-Althowra central teaching hospital as well as Altarahom private clinic-elbyda city-Libya at period in between September 2005 to January 2022 as cases of DNS with variable patterns of septal deformities for septoplasty. Five hundred thirty- one patients were received oral paracetamol who represent group-A, 753 received oral ketoprofen that constitutes group-B, while remaining 929 were administrated by intravenous dexamethasone and classified as group-C. As prospective analytic study, three groups compared in relation to significant postoperative complications risk namely post-operative pain, oro-facial edema, airway obstruction, epistaxis, nausea and vomiting, nasal obstruction, atrophic rhinitis, induction of allergic rhinitis, septal perforation and synachia formation. In addition, these groups compared for any significant difference regarding the period of postoperative hospitalization, which can be used, as objective indicator to measure the postoperative morbidity rate. Results: Dexamethasone as well as ketoprofen administration caused significant improvement in pain intensity as compared to paracetamol group. On the other hand there was significant reduction in the incidence of post-operative oro-facial edema, air way obstruction, epistaxis, nausea and vomiting, nasal obstruction, atrophic rhinitis, induction of allergic rhinitis, septal perforation and synachia formation among group-B and C as compared to group-A. Conclusion: Dexamethasone can be considered as potent analgesic drug after septoplasty procedure and in same time, it plays significant role in the improvement of outcomes of this common procedure as compared to the other commonly used non-steroidal anti-inflammatory drugs.

Comparing S-Guide® and Gliderite® Times to Assist Video laryngoscopic Intubation in Patients with Simulated Difficult Airways: A Single-Blinded Randomized Prospective Study.

Objective:Gliderite®, one of the first stylets designed specifically to assist tracheal intubation with non-channeled curved blades video laryngoscopes, can cause injury. The S-Guide® is a new, malleable, intubating guide allowing oxygenation. Its soft tip is designed to prevent trauma. We aimed to compare the duration of tracheal intubation with S-Guide compared to Gliderite using a C-MAC® D-Blade® video laryngoscope in patients with simulated difficult airways. Methods:We performed a single-blinded prospective randomized study, with 50 adult patients requiring orotracheal intubation under general anaestheesia in Lausanne University Hospital. A cervical collar was fitted around the patient’s neck to simulate difficult intubation conditions. Exclusion criteria were American Society of Anesthesiologists (ASA) >3, BMI > 35 kg m2, known or at risk of difficult intubation, and risk of aspiration of gastric content. We recorded T1: time of identification of the glottis; T2: time to inflate the cuff, and T3: total intubation time (capnography curve appearance). Secondary outcomes were the presence of arytenoid contact during intubation and postoperative airway discomfort.Results:There were no significant differences between T1 and T2 (seconds) while using the S-Guide or Gliderite, respectively: 14.6 [9.6-18.6] vs 16.5 [11.0-20.6]; P = .368 and 43.3 [33.2-49.3] vs 46.3 [35.6-61.5], P = .308. T3 was significantly shorter in the S-Guide group: 58.1 [50.2-61.8] vs 65.3 [57.6-78.7], P = .044. Fewer arytenoid contact occurred during intubation using the S-Guide (P = .032), without difference in postoperative airway discomfort.Conclusion:S-Guide-assisted tracheal intubation, with a C-MAC D-Blade in simulated difficult airways, allows successful and faster intubation than with the Gliderite Stylet.

Combination Therapy of High-flow Nasal Cannula and Upper-body Elevation for Postoperative Sleep-disordered Breathing: Randomized Crossover Trial.

The low acceptance rate of continuous positive airway pressure therapy in postoperative patients with untreated obstructive sleep apnea (OSA) indicates the necessity for development of an alternative postoperative airway management strategy. The authors considered whether the combination of high-flow nasal cannula and upper-body elevation could improve postoperative OSA. This nonblinded randomized crossover study performed at a single university hospital investigated the effect on a modified apnea hypopnea index, based exclusively on the airflow signal without arterial oxygen saturation criteria (flow-based apnea hypopnea index, primary outcome), of high-flow nasal cannula (20 l · min-1 with 40% oxygen concentration) with and without upper-body elevation in patients with moderate to severe OSA. Preoperative sleep studies were performed at home (control, no head-of-bed elevation) and in hospital (30-degree head-of-bed elevation). On the first and second postoperative nights, high-flow nasal cannula was applied with or without 30-degree head-of-bed elevation, assigned in random order to 23 eligible participants. Twenty-two of the 23 (96%) accepted high-flow nasal cannula. Four participants resigned from the study. Control flow-based apnea hypopnea index (mean ± SD, 60 ± 12 events · h-1; n = 19) was reduced by 15 (95% CI, 6 to 30) events · h-1 with head-of-bed elevation alone (P = 0.002), 10.9 (95% CI, 1 to 21) events · h-1 with high-flow nasal cannula alone (P = 0.028), and 23 (95% CI, 13 to 32) events · h-1 with combined head-of-bed elevation and high-flow nasal cannula (P < 0.001). Compared to sole high-flow nasal cannula, additional intervention with head-of-bed elevation significantly decreased flow-based apnea hypopnea index by 12 events · h-1 (95% CI, 2 to 21; P = 0.022). High-flow nasal cannula, alone or in combination with head-of-bed elevation, also improved overnight oxygenation. No harmful events were observed. The combination of high-flow nasal cannula and upper-body elevation reduced OSA severity and nocturnal hypoxemia, suggesting a role for it as an alternate postoperative airway management strategy.

Recognising and managing postoperative airway complications: a patient safety quality improvement project

Within our institution, surgery that may cause postoperative airway complications is frequently performed by several surgical specialties. A strategy to improve awareness and management of these associated complications was developed after several clinical incidents involving delayed recognition of postoperative anterior neck haematomas (ANHs), including a cardiac arrest in a patient who had deteriorated over several hours after right partial glossectomy and selective neck dissection.

Application of computational fluid dynamics for the analysis of postoperative airway changes in oral cancer patients

Application of computational fluid dynamics for the analysis of postoperative airway changes in oral cancer patients

Mandibular Distraction in Neonatal Pierre Robin Sequence: Is Immediate Extubation Both Feasible and Safe?

The timing of extubation following placement of mandibular distractors in the setting of Pierre Robin sequence is variable across institutional algorithms. Postoperative maintenance of intubation allows for an improvement in airway dimension and tongue positioning before extubation, theoretically decreasing the impact of postoperative airway edema. Maintenance of intubation, however, is not without risk. The authors analyze their institutional experience with neonatal mandibular distraction followed by immediate extubation to assess feasibility and safety profiles. A 4-year retrospective review of patients diagnosed with Pierre Robin sequence who underwent mandibular distraction within the first 3 months of life was performed. Patients intubated preoperatively were excluded. Fifty-two patients met inclusion criteria. Thirty-eight patients (73 percent) were extubated immediately, whereas 14 patients (27 percent) remained intubated. No differences between these groups were found when comorbidities, cleft pathology, preoperative respiratory support, or grade of view on direct laryngoscopy were analyzed. Case duration greater than 120 minutes, operation start time after 3 pm, and the subjective designation of a difficult airway by the anesthesiologist were associated with maintaining intubation (p < 0.05). Eight patients (21 percent) in the extubated group required an increase in respiratory support in the postoperative interval. Four of these patients (11 percent) required reintubation. Increased postoperative respiratory support was more likely in patients with certain comorbidities and higher preoperative respiratory support requirements (p < 0.05). The authors' data suggest that immediate extubation following neonatal mandibular distraction is feasible in patients who are not intubated preoperatively. Careful consideration should be given to patients who require significant respiratory support preoperatively and in those with certain comorbidities. Therapeutic, III.

P80. ANALYSIS OF ROUTINE INTENSIVE CARE UNIT ADMISSION FOLLOWING PALATOPLASTY IN PATIENTS WITH ROBIN SEQUENCE

PURPOSE: Management of neonatal upper airway obstruction (UAO) in patients with Robin Sequence (RS) may impact the need for intensive care unit (ICU) care following primary palatoplasty (PP) later in life. The current study investigated the necessity for ICU admission after PP in patients with RS, based upon prior upper airway management. METHODS: We conducted a review of patients with RS who underwent PP between 2006-2020. Patient demographics, perioperative characteristics, ICU admission, and postoperative airway and non-airway complications were compared, based on prior airway management, as determined by multidisciplinary team evaluation and consensus. RESULTS: Fifty-eight patients were included. Median [IQR] age at PP was 12.9 [10.8,15.6] months. Three groups were compared: Conservative (n=30), tongue-lip adhesion (TLA) (n=14) and mandibular distraction osteogenesis (MDO) (n=14). While ICU admission (conservative, 33.3%; TLA, 78.6%; MDO, 78.6%; p=0.002) and overall airway-related complications were significantly higher in patients with prior TLA and MDO (conservative, 26.7%; TLA, 64.3%; MDO, 57.1%; p=0.034), rates of major post-PP airway events (prolonged intubation >4h, unexpected ventilatory support via pre-existing tracheostomy, or reintubation) that would have required ICU care were low and insignificant between groups (0-14.3%; p>0.05); post-hoc analysis documented significant differences only in overall airway events between TLA vs. conservative airway groups (64.3% vs. 26.7%; p=0.02). CONCLUSION: ICU care after PP in patients with RS may not be necessary for infants who had appropriate management of neonatal UAO, potentially preserving resources for patients with greater need. Special attention may be prudent for post-PP patients who underwent neonatal TLA.

Bronchial Suturing Techniques After Lung Transplant: A Single Surgeon Analysis

<h3>Purpose</h3> In lung transplantation (LTx) postoperative airway complications can increase morbidity and mortality. Current literature offers little analysis examining a single surgeon's work. We assessed postoperative bronchial complication rates, treatments, and survival outcomes in LTx performed by a single surgeon and stratified data by suturing technique. <h3>Methods</h3> A single surgeon's LTx (n=444) were analyzed from 901 total LTx done between Feb 2012- March 2021. Continuous suturing (CS) and intermittent suturing (IS) techniques were compared. CS technique was done with 3/0 polypropylene suture on an SH needle. IS is used on the membranous portion of the anastomosis and multiple interrupted 3/0 polypropylene sutures are used for the cartilaginous portion. Demographic and clinical data, post op bronchial complications, and their interventions were compared and categorized. Survival was compared with Kaplan-Meier curves and log-rank tests. Cox regression analysis was run using all variables to assess impact on survival. P values <0.05 were considered significant. <h3>Results</h3> Of 444 patients in this single surgeon study, 259 received IS and 185 received CS. ECMO was utilized in 19 CS patients vs 18 IS patients IS (p = 0.371). There was no significant difference in post-transplant complication rates (p = 0.629). The most common complications were stenosis (CS14; IS-19), ischemia (CS 0; IS-7), and stenosis + malacia + dehiscence (CS 4; IS9). Treatment for bronchial complications was varied, including dilation and stent placement when indicated for the complications of both CS and IS. Kaplan-Meier curve showed no difference in survival outcomes between groups (p = 0.562). Cox regression analysis with all variables showed that the type of induction (Hz 1.48; p=0.01) and CPB (Hz 1.44; p=0.024) had a significant effect on survival. <h3>Conclusion</h3> Analysis of suturing techniques in a single surgeon at a single center showed comparable survival outcomes, bronchial complication rates, and follow up treatments between IS and CS techniques.

Quantitative Measurement of Throat and Larynx After Endotracheal Intubation for Palatoplasty.

IntroductionQuantitative morphometric measurements of living human upper airway remain challenging. This study aimed to introduce a special laser projection device that can facilitate computer-assisted, digitalized analysis and provide important information on airway mucosa change, before and after endotracheal intubation for palatoplasty.Materials and MethodsThe laryngeal images were captured before and after surgery. Image processing techniques were used to quantize the post-operative laryngeal variation, with its distinct color space and texture features. Meanwhile, the maximum length of the vocal fold, vocal width at the midpoint, maximum cross-sectional area of the glottic space, maximum cross-sectional area of the oropharyngeal inlet (CSAOI) and the depth of the retropalatal space were determined and calculated. These parameters were analyzed and compared before and after surgery.ResultsA total of 39 subjects were enrolled in this study. The color space and texture analysis all show trends toward higher measures in post-operative images than in pre-operative images, especially in the interarytenoid region. Furthermore, the glottic area showed a significant decrease of 31.2%, while the vocal width showed a significant increase after intubation. The post-operative retropalatal depth and CSAOI were significantly deeper and larger than the baseline, reaching their peak in the 4th week after the surgery, and then slightly reduced in the 12th week.ConclusionFor the first time we present a series of changes in upper airway after surgery, by using a laser module with quantitative measurement. Our equipment and processing can measure subtle mucosal changes that would allow a clinician to diagnose post-operative airway inflammation in a simpler and less invasive way. Here additional information collected by different imaging modalities would help to solve multiple current unmet needs in post-operative airway inflammation.

Patient-reported outcome measures following maxillomandibular advancement surgery in patients with obstructive sleep apnoea syndrome

Maxillomandibular advancement (MMA) is an effective treatment for obstructive sleep apnoea syndrome (OSAS) that is refractory to conventional treatment. However, it is a highly invasive procedure with several recognised side effects, and we know of few data on its effect on important patient-reported outcome measures (PROMS). Here we describe a case series of patients selected for MMA through our joint respiratory/maxillofacial surgery clinic, detailing the effect of MMA on objective physiological measurements and important PROMS. Patients with confirmed moderate/severe symptomatic OSAS who could not tolerate continuous positive airway pressure (CPAP) or mandibular advancement devices (MAD) were assessed in the clinic for consideration of MMA. Preoperative and postoperative airway measurements, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS) score, and quality of life (10-point Likert scale), were recorded. A customised questionnaire was administered postoperatively to assess selected psychosocial and functional domains (sleep quality, energy levels, appearance, ability to perform daily activities, and mood) and patient satisfaction using five-point Likert scales. Over an 18 month period, 39 patients were referred for consideration of MMA. Ten patients (7 men and 3 women, mean age 49.9, mean BMI 27.5) underwent surgery, which resulted in significant improvements in ESS, quality of life, AHI, and airway diameters. All patients reported improvements in all psychosocial/functional domains except appearance, in which five reported no change or worsened appearance. All subjects felt that MMA provided better symptom control than CPAP. The most commonly reported side effects were facial/lip numbness (9/10) and affected bite (6/10). MMA resulted in significant improvements in ESS, quality of life, and a range of PROMS, with a high level of patient satisfaction.

Comparison Between The Effects of Betamethasone Gel And Lidocaine Jelly To Reduce PostOperative Tracheal Tube Related Airway Symptoms

Objective: To determine the role of betamethasone gel and lidocaine jelly on reducing the post-operative airway complications related to tracheal tube.&#x0D; Study Design: Comparative prospective study.&#x0D; Place and Duration of Study: Department of Anesthesia, Liaquat National Hospital, from Jul 2019 to Jan 2020.&#x0D; Methodology: A total of 150 patients were randomly assigned into three different groups; group-B (0.05% betamethasone gel), group-L (tube lubricated with 2% lidocaine jelly) and group-C (intubated with un-lubricated tubes). Patients were assigned by using lottery method, which was carried out by a research assistant who was not involved in the study. There were 50 patients in each group.&#x0D; Results: Post-operative sore throat and post-extubation cough at 24-hours were statistically insignificant (p&gt;0.05) between groups while hoarseness of voice at 24-hours postoperatively was significant (p&lt;0.05) in all the groups. The overall difference for severity of postoperative sore throat, hoarseness of voice and post-extubation cough at24 hours in the groups B, L, and C were statistically significant (&lt;0.05).&#x0D; Conclusion: The application of betamethasone gel on endotracheal tube before intubation reduces the post-extubation cough, severity of post-operative sore throat, hoarseness of voice and post-extubation cough in comparison with the application of lidocaine jelly and un-lubricated ETT.

A comparative study of postoperative airway management between traditional nasal packing and modified nasal airway after nasal surgeries

BACKGROUND &amp; OBJECTIVE: One of the most common challenging complications after nasal surgeries is maintaining airways. The study aimed to use an alternative technique instead of nasal packing in the immediate postoperative period undergoing different nasal surgery under general anesthesia regarding airway management.&#x0D; METHODOLOGY: An interventional study was conducted at Aziz Fatimah Trust Hospital, Faisalabad, from March 20, 2018, to January 31, 2019. A total of 100 participants were enrolled in the study divided into two groups (A &amp; B), 50 each. Group A patients were treated postoperatively with a modified nasal airway devised with a Nelton catheter and Group B patients with traditional nasal packing. The participants were assessed on different parameters which were statistically compared and analyzed.&#x0D; RESULTS: Group Descriptive statistics revealed that the Mean±SD of the age of group A and group B patients was 24.28±9.72 and 26.68±11.09 respectively, which had no significant difference between them {p-value (0.008)}. The postoperative parameters such as patient's comfort and sleep, surgeon satisfaction, ease of suction through Nelton catheter, and oxygen saturation were evaluated as significant variables in the evaluation of the study. p-value ≤0.05 and ≤0.005 were considered as significant and highly significant respectively.&#x0D; CONCLUSION: This modified nasal airway has proven to be easily replicable and reliable, and a cost-effective measure elucidated as a potential and exclusive outcome of the present study.

Risk factors of bronchial dehiscence after primary lung transplantation.

Although the incidence of bronchial dehiscence following lung transplantation has decreased significantly due to improvements in perioperative managements and surgical techniques, it remains a devastating postoperative complication associated with high morbidity and mortality. We retrospectively reviewed 811 lung transplantation performed at our institution between January 2011 and December 2020. Bronchial dehiscence was confirmed with flexible bronchoscopy, computed tomography (CT) scan, or clinical findings grade using International Society for Heart and Lung Transplantation recommendations. Bronchial dehiscence was diagnosed in 38 patients (4.7%). The overall survival rates of the patients with bronchial dehiscence were significantly worse than those of the patients without bronchial dehiscence (p = .003). Multivariate analysis identified use of our basiliximab induction protocol (odds ratio = 3.03, p = .008) as an independent predictive factor of postoperative airway dehiscence in our multivariable model, along with total ventilator duration (odds ratio = 1.02, p = .002). Based on our analysis, patients that underwent our basiliximab induction protocol for lung transplantation experienced a higher rate of postoperative bronchial dehiscence when compared with patients who receive alemtuzumab induction. We believe this may be associated with a higher steroid exposure in this population. Additional studies are necessary to further characterize the relationship between different induction protocols and bronchial dehiscence following transplantation.

Comparison of harmonic shears, diode laser, and scissor cutting and suturing for caudal palatoplasty in dogs with brachycephalic obstructive airway syndrome

Traditionally, staphylectomy has been performed using scissors cutting and suturing. Alternative surgical techniques such as staphylectomy with monopolar electrocoagulation, CO2 or diode laser, bipolar vessel sealing device and harmonic shears have also been described. The purpose of this prospective study was to compare the difference in surgical time, intraoperative haemorrhage and histological damage between staphylectomy performed with harmonic shears (HSS), diode laser (DLS) and traditional scissor ‘cutting and suturing’ technique with Metzenbaum scissors (SIS). Group HSS included 17 dogs, whereas Group DLS and Group SIS included 10 dogs each. Double masked histological evaluation was performed on the excised specimens.The harmonic shears resulted in the shortest surgical times (HSS 46 s, DLS 300 s, SIS 360 s; P < 0.001). There was a difference in the intraoperative haemorrhage among the three techniques; intraoperative haemorrhage did not occur in HSS and DLS groups. HSS was associated with more frequent damage involving the connective tissue (P = 0.001), muscle (P = 0.038), salivary gland tissue (P < 0.001), but less oedema was observed (P < 0.001). HSS was the fastest of the techniques evaluated for caudal elongated soft palate resection, resulting in less tissue oedema, and no intra-operative haemorrhage. These characteristics might result in reduced postoperative swelling and airway obstruction compared to other techniques.

Protocol-driven early tracheal extubation in patients with flaccid neuromuscular scoliosis and pre-existing lung disease.

To review the results of a postoperative respiratory pathway for patients with muscular dystrophy (MD) and spinal muscular atrophy (SMA) undergoing spinal surgery. With IRB approval, a retrospective review was done on all patients with SMA and MD undergoing spinal surgery on a neuromuscular protocol. Baseline demographics, perioperative results, and long-term outcomes were collected. Per the protocol, patients remained intubated after surgery and were transported to the intensive care unit (ICU) for extubation. We present the results of protocol implementation and compare patients with MD to those with SMA. Twenty-four patients were treated using the protocol. Average age was 13.1years. Severe restrictive lung disease was present in 75% of patients. Nocturnal BiPAP was required in 68% of patients. Average number of instrumented levels was 17. All patients were immediately extubated upon entering the ICU. There were three respiratory complications and only was patient was re-intubated. Average ICU stay was 1.8days and average hospital length of stay was 6.7days. No differences in postoperative inspiratory or expiratory positive airway pressures were observed between the MD and SMA groups. Through a multidisciplinary neuromuscular protocol, excellent clinical outcomes were achieved in patients with neuromuscular scoliosis and restrictive lung disease, with complication rates and length of stay significantly lower than previously published data. IV.

Textbook surgical outcome in lung transplantation: Analysis of a US national registry.

Textbook surgical outcome (TO) is a novel composite quality measure in lung transplantation (LTx). Compared to 1-year survival metrics, TO may better differentiate center performance, and motivate improvements in care. To understand the feasibility of implementing this metric, we defined TO in LTx using US national data, and evaluated its ability to predict post-transplant outcomes and differentiate center performance. Adult patients who underwent isolated LTx between 2016 and 2019 were included. TO was defined as freedom from post-transplant length of stay>30 days, 90-day mortality, intubation or extracorporeal membrane oxygenation at 72h post-transplant, post-transplant ventilator support lasting ≥5 days, postoperative airway dehiscence, inpatient dialysis, pre-discharge acute rejection, and grade 3 primary graft dysfunction at 72h. Recipient and donor characteristics and post-transplant outcomes were compared between patients who achieved and failed TO. Of 8959 lung transplant recipients, 4664 (52.1%) achieved TO. Patient and graft survival were improved among patients who achieved TO (both log-rank P<.0001). Among 62 centers, adjusted rates of TO ranged from 27.0% to 72.4% reflecting a wide variability in center-level performance. TO defined using national data may represent a novel composite metric to guide quality improvement in LTx across US transplant centers. In this study we defined textbook outcome (TO) for lung transplantation (LTx) using US national data. We found that achievement of TO was associated with improved post-transplant survival, and wide variability in center-level LTx performance. These findings suggest that TO could be readily implemented to compare quality of care among US LTx centers.

Postoperative Continuous Positive Airway Pressure (CPAP) Therapy Experience in Patients Undergoing Minimal Invasive Multivessel Coronary Artery Bypass Grafting Via Left Anterior Mini-thoracotomy

Postoperative Continuous Positive Airway Pressure (CPAP) Therapy Experience in Patients Undergoing Minimal Invasive Multivessel Coronary Artery Bypass Grafting Via Left Anterior Mini-thoracotomy

Anterior Cervical Discectomy and Fusion Using Escherichia coli-Derived Recombinant Human Bone Morphogenetic Protein-2: A Pilot Study.

Recombinant human bone morphogenetic protein-2 (BMP-2) is an osteoinductive growth factor widely used in orthopedic surgery; it is also known to be associated with postoperative airway compromise or dysphagia when applied to anterior cervical discectomy and fusion (ACDF). However, there have been no reports on ACDF using Escherichia coli-derived BMP-2 (E.BMP-2) with hydroxyapatite (HA). This pilot study aimed to investigate the potential efficacy and safety of E.BMP-2 using HA as a carrier in ACDF prior to designing a larger-scale prospective study. Patients eligible for inclusion were those who underwent ACDF using 0.3 mg of E.BMP-2 with HA per segment for degenerative cervical disc disease between August 2019 and July 2020 and had at least 1 year of follow-up. Fusion rates were analyzed using computed tomography or flexion-extension radiographs. Visual analog scales for neck pain and arm pain and neck disability index were measured preoperatively and the final follow-up. In cases of cervical spondylotic myelopathy, modified Japanese Orthopaedic Association scores were also evaluated. Postoperative complications such as airway compromise, dysphagia, wound infection, neurologic deficit, hoarseness, heterotopic ossification, seroma, and malignancy were investigated. A total of 11 patients and 21 segments were analyzed. All clinical outcomes significantly improved at the final follow-up compared with the preoperative indices (p < 0.05). Only 1 case of dysphagia and no cases of airway compromise, wound infection, neurologic deficit, hoarseness, heterotopic ossification, seroma, or malignancy were observed during the follow-up period. Of the 21 segments, 15 segments showed solid fusion at 3 months after surgery, 4 segments at 6 months, and 1 segment at 12 months. Only 1 segment showed pseudoarthrosis, resulting in a fusion rate of 95.2%. The outcomes of ACDF could be enhanced using 0.3 mg of E.BMP-2 with HA per segment. Based on this study, larger-scale prospective studies can be conducted to evaluate the efficacy and safety of E.BMP-2 in ACDF.