ABSTRACT Purpose To report a case series of recurrent dacryocystitis following long-term lacrimal duct intubation, and to clarify the side effects of long-term lacrimal duct intubation. Methods This study retrospectively evaluated 24 adults (27 eyes) who presented to our center between September 2019 and December 2024 with recurrent dacryocystitis following probing and subsequent stent intubation. Data collected included patient demographics, clinical presentation, duration of intubation, stent-related complications, computer tomography image, management strategies, and prognosis. Systematically reviewed randomized controlled trial articles on lacrimal duct intubation. Results Several stent-related complications were identified, including: punctal granuloma (11.1%, 3/27), stent fracture (11.1%, 3/27; all three fractured stents were plastic type, with fragments adherent to granulation tissue.), punctal laceration with recurrent extrusion (3.7%, 1/27; gold stent), soft tissue false passages (47.4%, 9/19), and bony false passages (7.4%, 2/27; cases with traumatic lacrimal obstruction). Among patients undergoing dacryocystorhinostomy, functional success was 81.48% (22/27) and anatomical success was 85.19% (23/27). Denominators vary across outcomes due to incomplete data availability for specific variables in the study cohort. Conclusions This study emphasizes the importance of standardized operative techniques and appropriate duration of intubation to prevent complications associated with lacrimal stenting.

Acquired Subglottic Stenosis in a 2-Month-Old Infant After Prolonged Intubation Associated with Pertussis Pneumonia: A Case Report

ABSTRACTBackgroundPatients with severe Bronchopulmonary dysplasia (BPD) are prone to upper airway complications due to their need for prolonged intubation, early tracheostomy placement, and chronic high‐pressure ventilation. This study examines structural changes over time in tracheostomy‐dependent BPD patients compared to those without BPD.MethodsA retrospective cohort study of children who underwent tracheostomy at an age less than 6 months at a tertiary‐care children's hospital between January 2012 and December 2022.ResultsA total of 82 patients underwent tracheostomy at an age of less than 6 months, of which 42 (51.2%) had BPD. Patients with BPD were older at the time of tracheostomy (4.44 vs. 3.36 months, p = 0.012) and had a younger gestational age (26.5 vs. 37.0 weeks, p < 0.001). Additionally, patients with BPD had higher rates of mechanical ventilation (42/42 vs. 24/40, p = 0.0018) and a greater number of days intubated prior to tracheostomy (92 vs. 21, p < 0.001). The median follow‐up period for all patients was 28.8 months [IQR = 36.8]. BPD infants were more likely to develop subglottic stenosis (30/42 vs. 16/40, p = 0.0082), glottic edema (32/42 vs. 19/40, p = 0.0074), require laryngotracheal reconstruction (16/42 vs. 5/40, p = 0.0095) and get decannulated (21/42 vs. 8/40, p = 0.0045) compared to infants without BPD.ConclusionsTracheostomy‐dependent infants with BPD had higher rates of glottic edema, subglottic stenosis, and laryngotracheal reconstruction but were more likely to be decannulated. These findings suggest that, despite increased airway pathology, tracheostomy is a safe and effective intervention in this population, with outcomes comparable to other pediatric cohorts.Level of Evidence4.

Clinical Case: A 62-year-old male with a history of HTN, HLD, and AUD, presented with an inferior STEMI. Angiography revealed a 95% mid RCA culprit lesion and severe multivessel disease: 50% distal LM, 99% ostial LAD, 80% mid LAD stenosis, and 100% proximal LCx occlusion with L-L, R-L collateral filling. An Impella CP was placed for narrow pulse pressure and LVEDP of 50 mmHg. The patient was referred for CABG, which was aborted due to access site bleeding, poor conduits and surgical targets. PCI of the RCA showed restoration of TIMI 3 flow. TTE revealed a LVEDVI of 127 ml/m2 with an EF of 16%, LBBB dyssynchrony, and severe MR. An Impella 5.5 was placed via the right axillary artery. He underwent complex IVUS guided, atherectomy facilitated PCI of the distal LM and ostial LAD. Revascularization of the LCx was unsuccessful. He required prolonged intubation due to dynamic MR causing recurrent flash pulmonary edema. He underwent percutaneous mitral valve repair with reduction in MR. A BiV–ICD was placed for recurrent VT and resynchronization therapy. He was liberated from the ventilator and discharged on GDMT. Discussion: Here we present a patient with a STEMI causing acute-on-chronic heart failure, as suggested from his baseline LBBB and dilated LV, complicated by monomorphic VT and severe MR. This poses the challenges of addressing each contributor to his cardiogenic shock versus upfront advanced heart replacement therapies such as OHT or LVAD. The patient’s AUD and smoking history precluded him from OHT and he was a poor candidate for LVAD given recurrent VT. Thus, we were left with an approach of weighing each targeted intervention’s expected benefits against the benefits of LVAD therapy. CABG in our patient was infeasible so the revascularization strategy was driven by hemodynamic stability. In hemodynamically unstable patients, revascularizing only the culprit lesion has demonstrated a reduction in all-cause mortality as compared to multivessel PCI. A percutaneous repair was deemed to be the only feasible option to reduce the patient’s secondary MR. Attention was paid to the trans-mitral gradient should an LVAD be needed downstream. The decision to pursue CRT-D was made given LBBB and prolonged QRS. This case underscores the complexity of managing multifactorial cardiogenic shock in which advanced heart replacement therapies are contraindicated. A multidisciplinary, stepwise approach can achieve favorable clinical outcomes.

Impact of lung resections on lung transplant grafts due to size discrepancy.

This study explores antibiotic resistance profiles in Pseudomonas aeruginosa infections among patients in a tertiary hospital in a developing nation. It aims to identify associated factors to enhance treatment strategies in the face of increasing resistance challenges. A retrospective observational study conducted at King Khalid Hospital, Saudi Arabia, from January 2019 to December 2020 analysed patients admitted with positive Pseudomonas aeruginosa cultures. It investigated Pseudomonas infection epidemiology, patient clinical characteristics, and antibiotic susceptibility patterns in 817 samples. A total of 817 patients were included, with a male predominance (63.8%). Common comorbidities included cardiovascular disease (53.7%), diabetes mellitus (36.3%), and cancer (14.8%). Invasive device use was frequent, with 41.1% having Foley catheters, 44.8% central lines, and 22.9% undergoing prolonged intubation. Most P. aeruginosa isolates (70.8%) were identified within three days of admission. Among 1,619 processed samples, sputum was the most common clinical specimen, while rectal swabs predominated among surveillance samples. Colistin (84.5%), amikacin (83.0%), and cefepime (73.2%) showed the highest susceptibility rates, while ceftazidime had the lowest (34.6%). MDR was observed in 73% of isolates and was significantly associated with tracheal intubation (p = 0.0003), central lines (p = 0.032), and hospital-onset infection (p < 0.001). Diabetes mellitus was linked to community-onset cases (p = 0.0457). Hospital-acquired cases were significantly associated with device use and dialysis. Phenotypically, phospholipase C was associated with non-MDR isolates, while biofilm formation correlated with MDR strains. Hemolysin and alkaline protease were not significantly linked to resistance. Genotypically, toxA and plcH were more prevalent in non-MDR isolates, while other virulence genes showed no significant differences. Biofilm production was significantly associated with the plcN gene. The study emphasises the critical prevalence of MDR Pseudomonas aeruginosa (73%), which is strongly linked to invasive medical devices and hospital-onset cases. High resistance to common antibiotics demands enhanced infection control, antimicrobial stewardship, and targeted strategies for high-risk patients to mitigate nosocomial infections and improve outcomes.

BackgroundDysphagia is as a common consequence of cerebral infarction affecting approximately 50% of stroke patients. It often results in aspiration pneumonia, malnutrition and dehydration. Dysphagia is also seen after mechanical manipulation of the larynx, for example after prolonged intubation and after the perioperative use of transesophageal echocardiography (TEE). TEE is a semi-invasive procedure assessing the function of the intra-atrial septum and heart valves, yielding more detailed results compared to transthoracic echocardiography (1). It has become a routine in the diagnostic work-up of stroke. The study Transoesophageal echocardiography: dysphagia risk in the acute phase after stroke (TEDRAS study) was the first to investigate the extent of dysphagia risk after TEE in acute stroke patients. The trial findings supported the hypothesis that dysphagia severity worsens following TEE. This follow-up trial is designed to address the limitations of the first TEDRAS study, focusing on patients with ischaemic stroke and transient ischemic attack (TIA).MethodsThe study is a prospective, single-blinded, controlled pilot trial, designed in accordance with the SPIRIT reporting guidelines. The study protocol outlines that both FEES and TEE will be performed on patients with acute ischaemic stroke or transient ischemic attack (TIA) who provide informed consent to participate. Specifically, the following parameters are to be analyzed in both groups: (1) The impact of the type and method of anaesthesia administration (intravenous vs. local anesthetic spray application) during TEE on swallowing function in both cohorts; (2) The effect of the duration of the TEE procedure on swallowing function in both cohorts; (3) The experience level of the TEE examiner; (4) The interrater reliability of the FEES assessment. The trial will be conducted at the University Medical Centre of the Justus-Liebig-University in Giessen (UKGM) through collaboration between the Departments of Neurology and Cardiology of the UKGM.DiscussionThis protocol presents a prospective pilot single-blinded controlled study designed to assess further risks of dysphagia following TEE. The trial aims to address several outcomes, specifically the impact of anaesthesia and the duration of TEE on swallowing, which will be correlated with the severity of dysphagia after TEE.Trial registrationClinTrial.gov Identifier NCT04302883.URL: https://clinicaltrials.gov/study/NCT06195501?term=TEDRAS&rank=1Registered June 2024.

IntroductionA tracheostomy is an important intervention for trauma patients referred to intensive care units (ICUs). Trauma patients often require prolonged intubation; timing of tracheostomy remains debated.The purpose of this study is to determine the impact of early tracheostomy on critical metrics such as mechanical ventilation duration, ICU length of stay (LOS) and ventilator acquired pneumonia (VAP) in trauma patients in ICU settings.MethodsWe conducted a retrospective cohort study of 383 trauma patients who underwent tracheostomy in a tertiary teaching hospital ICU (January 2018–December 2022). Inclusion: trauma patients with temporary tracheostomy; Exclusion: permanent tracheostomies. Early tracheostomy (ET) was defined as ≤7 days of mechanical ventilation, late (LT) as >7 days. The dataset includes demographic information, Acute physiology and chronic health evaluation II score, Simplified acute physiology score II, Glasgow coma scale score, Injury severity Score, type and cause of injuries, ICU outcomes, length of stay and rates of ventilator-associated pneumonia (VAP). Data were analyzed using Mann–Whitney U and Chi-square tests; significance at p < 0.05.. The study involved a comparison of the duration of mechanical ventilation, ICU LOS, VAP rates and extubation trials between patients who underwent ET and LT.ResultsOf the 804 patients who underwent tracheostomies from January 2018 to December 2022, 383 were trauma patients and were included in the study. There were no significant differences between the two groups in terms of age, sex, Acute physiology and chronic health evaluation II score, Simplified acute physiology score II and Injury severity score. The incidence of VAP was lower in the ET cohort (15.9%) than in the LT cohort (47.4%). The percentage of extubation trials was found to be higher in the LT cohort (43.1%) than in the ET cohort (9.3%), resulting in prolonged ICU LOS. Patients with an ET had a significantly shorter ICU LOS median of 15 days (IQR 13,17) and a mechanical ventilation median of 13 days (IQR 11,14) than LT patients who had an ICU LOS median of 33 days (IQR 30,36) and a mechanical ventilation median of 31 days (IQR 27,33) respectively.ConclusionImplementing an early tracheostomy protocol for trauma patients in the ICU is associated with a decreased incidence of VAP, shorter duration of mechanical ventilation and shorter ICU LOS while maintaining consistent ICU and hospital outcomes. The adoption of a standardized approach to perform early tracheostomy helps in improving resource utilization and patient outcomes in trauma patients.

Background/Objectives: C-reactive protein (CRP) is widely used as a marker of perioperative inflammation, but its predictive value for cardiac surgical outcomes remains uncertain. Obstructive sleep apnea (OSA), a prevalent and underrecognized comorbidity, may independently contribute to postoperative complications through non-inflammatory mechanisms. This study aimed to reevaluate the prognostic role of CRP and determine the clinical impact of OSA severity on postoperative recovery, focusing on new-onset atrial fibrillation (AF), prolonged intubation time, and postoperative CPAP/AIRVO use as indicators of respiratory burden. Methods: In this prospective cohort of 142 elective cardiac surgery patients, preoperative polysomnography and serial CRP measurements were obtained. Multivariable regression, mediation analysis, and propensity score matching (PSM) were performed to evaluate associations between OSA severity, CRP, and perioperative outcomes (AF, intubation time, CPAP/AIRVO use). Results: OSA severity independently predicted prolonged intubation (β = 1.74, p = 0.0019) and new-onset AF (β = 0.85, p = 0.004), even after excluding patients with preexisting arrhythmia. CRP showed poor discriminatory power as a standalone biomarker (AUC for IOT > 14 h = 0.445) and did not mediate OSA–outcome associations. However, CRP > 2.1 mg/dL doubled the odds of moderate-to-severe OSA (OR = 2.05, p = 0.041). A composite score integrating AHI, BMI, and postoperative CRP strongly correlated with postoperative respiratory support (p < 0.0001). Conclusions: OSA exerts a stronger and more consistent influence on perioperative outcomes than CRP, challenging reliance on CRP for risk stratification. Incorporating objective OSA screening and spirometry into preoperative assessment may enhance perioperative risk prediction and guide personalized management strategies.

Hereditary angioedema (HAE) causes recurrent angioedema attacks in the oropharynx, larynx, face, and other regions due to bradykinin overproduction as a result of C1 esterase inhibitor deficiency. Surgical interventions requiring general anaesthesia might trigger HAE attacks. Laryngeal angioedema is the most important cause of perioperative mortality. Tracheal dilatation was performed by rigid bronchoscopy in our patient with type 1 HAE, because of tracheal stenosis due to prolonged intubation, which occurred after the attack. The patient was administered 2x500 IU C1 esterase inhibitor approximately 24 hours before rigid bronchoscopy. No complication developed after the first procedure. Two months later, tracheal dilatation was repeated and 2x500 IU C1 esterase inhibitor was administered. While the patient was followed up in the intensive care unit, significant oedema developed in the facial area, especially the tongue and lips, approximately 10 hours after the procedure. Our patient also had stridor due to airway obstruction. The patient was treated with 1000 IU C1 esterase inhibitor and 3 units of fresh frozen plasma (FFP). After FFP, edema started to regress. The patient was discharged after symptoms improved. The patient should be monitored in the intensive care unit for a minimum of 48 hours to monitor for postoperative laryngeal oedema.

Background: Odontogenic abscesses may significantly affect maternal health during pregnancy. Aim: This study analyzes three cases of pregnant patients with odontogenic infections, comparing them to a control group of non-pregnant women, and reviews recent literature. Materials and Methods: Between January 2020 and April 2025, 3 pregnant and 70 non-pregnant women with odontogenic abscesses were treated. Clinical presentation, pathogens, therapy, and outcomes were compared. Results: Severe sequelae, such as rapid abscess spread and systemic inflammation, were more frequent in pregnant women, though not statistically significant (p = 0.068). Pregnant patients also tended toward prolonged intubation (p = 0.194) and targeted antibiotic use (p = 0.133). Antibiotic selection was based on gestational age, with beta-lactams preferred. Surgical interventions were more extensive, often involving multiple neck spaces. Hospitalization was longer (≥4 days in most cases) due to maternal–fetal monitoring. Conclusions: Odontogenic abscesses in pregnancy require individualized management and gestation-adjusted antibiotic therapy.

Background: Endotracheal intubation is necessary to establishing and maintaining a patent upper airway. However, this procedure is associated with complications that need to be detected early and managed appropriately. This study was undertaken to determine and understand the common complications seen in patients undergoing tracheostomy following prolonged endotracheal intubation. Objectives: To determine and analyze various complications in patients undergoing tracheostomy following prolonged endotracheal intubation. Methodology: 40 patients requiring artificial/assisted ventilation were observed during the period of the study for indications, duration of ventilation, complications of tracheostomy following prolonged endotracheal intubation, tube change, and decannulation. Results: The common complications observed were vocal edema, self extubation and Angle of mouth / lip ulceration. Many of the complications encountered after delayed tracheostomy can lead to morbidity and mortality, hence early tracheostomy and good endotracheal tube management can reduce complications and its late sequelae. Conclusion: Endotracheal intubation is a life-saving procedure but nevertheless, prolonging the same may be associated with its own set of complications and side effects.

Acute brain injury (ABI) is a severe, life-threatening condition with high mortality and morbidity rates. Surgical intervention is often necessary for patients with intracranial hematomas or refractory increased intracranial pressure, necessitating intubation and mechanical ventilation. These patients may experience both extubation failure and prolonged intubation during treatment. This study analyzed the risk factors associated with extubation failure and prolonged intubation in patients with ABIs who underwent surgery. In this retrospective cohort study, 641 adult patients with ABIs, including spontaneous intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and traumatic brain injury, who required mechanical ventilation for >48h and survived for >14days after surgery, were included. Clinical data, including demographics, clinical characteristics, Glasgow coma scale (GCS) scores, and laboratory test results, were analyzed at admission and before extubation. The mean age of recruited patients was 61.12±16.60years. In total, 496 (92.9%) patients were successfully extubated after meeting the criteria for weaning and passing the spontaneous breathing test, and 38 (7.1%) were reintubated. Prolonged intubation (>14days) was observed in 217 patients (33.9%). Multivariable regression analysis was conducted to identify independent predictors. GCS at the time of extubation was an independent predictor of reintubation, whereas age and initial GCS were identified as independent predictors of prolonged intubation. This study comprehensively characterizes indicators of both extubation failure and prolonged intubation in patients with ABI following surgery. Identifying these risk factors will enable timely intervention and precise prognostic assessment during the early management of patients with ABI.

Outcomes of introducing shared decision-making for tracheostomy on prolonged intubated critical patients.

Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator synchrony using diaphragmatic electrical activity. However, its long-term impact on neurodevelopment in extremely preterm infants remains unclear. This study examined the association between NAVA management and neurodevelopmental outcomes. We retrospectively compared infants born at ≤ 27 weeks' gestation who were admitted before (2016-2017, n = 38) and after (2019-2021, n = 44) NAVA implementation. The primary outcome was the developmental quotient (DQ) at 18 months, assessed using the Kyoto Scale of Psychological Development. Comparing the pre- and post-implementation groups: median gestational age, 25.5 versus 25.9 weeks (p = 0.67); postmenstrual age at extubation, 30.6 versus 32.1 weeks (p < 0.001); NAVA use, 0% versus 91%; and high-frequency oscillatory ventilation use, 74% versus 46% (p = 0.013). No significant differences were observed between the groups in corticosteroid use, bronchopulmonary dysplasia incidence, postmenstrual age at discharge, or home oxygen therapy. At 18 months, DQ scores were as follows in the pre- and post-implementation groups: Full Scale (83 vs. 89; p = 0.32), Gross Motor (81 vs. 86; p = 0.45), Cognitive/Adaptive (83 vs. 90; p = 0.56), and Language/Social (71 vs. 88; p = 0.109). Modified Checklist for Autism in Toddlers score was 3 in both groups (p = 0.86). Multivariable analysis revealed that NAVA use (adjusted odds ratio [aOR] 2.99, 95% confidence interval [CI]: 1.14-7.81) and gestational age (aOR 1.59, 95% CI: 1.08-2.33) were associated with Full Scale DQ ≥ 85; whereas sex and birth weight standard deviation were not. Despite the prolonged tracheal intubation period, NAVA management was associated with improved neurodevelopment outcomes at 18 months.

Introduction: New type of coronavirus SARS-CoV-2 (COVID-19) infection usually manifests as an upper respiratory tract infection. Some patients develop pneumonia, which can progress into serious respiratory insuffi ciency with the need of artifi cial pulmonary ventilation (APV). In case of a long-term APV, it is necessary to perform tracheotomy. Since COVID-19 infection causes thrombophilia and patients are treated with anticoagulants, these patients might be in greater risk of postoperative complications, mainly bleeding, after tracheotomy. Aims: To assess the frequency of severe postoperative bleeding after tracheotomy in COVID-19 positive patients with prolonged orotracheal intubation and to identify risk factors of severe bleeding in patients after tracheotomy. Materials and methodology: A retrospective analysis of patients with tracheostomy due to prolonged APV was performed between 2020– 2022. The data were obtained from the hospital information system and were statistically analyzed. Results: Out of a total of 146 patients, bleeding requiring surgical revision in the intensive care unit or in the operating room occurred in 30 (20.5%) patients. Among these patients, a COVID-19 PCR test was positive in 20/ 30 (66.7%) and negative in 10/ 30 (33.3%) patients. From all of the analyzed factors, the only factor with statistical signifi cance was a therapeutical dose of anticoagulants (P = 0.012). Ocurrence of bleeding was not infl uenced by the type of surgery, transsection of the thyroid gland isthmus, setting of the surgery, or qualifi cation of the surgeon. Conclusion: Results of this retrospective study did not show a higher risk of bleeding after tracheotomy in COVID-19 positive patients compared to COVID-19 negative patients. However, the multiple logistic regression model suggested that COVID-19 infection could increase the risk. Therapeutical anticoagulant treatment is a clear risk factor of severe postoperative bleeding after tracheotomy. Key words tracheotomy – COVID-19 pneumonia – hemorrhagic complications – complications of tracheotomy

Rebuilding the airway: Integrated surgical management of severe subglottic stenosis.

Background Tracheostomy is widely used in critically ill patients, yet limited clinical data exist from Danish ENT departments. Aims/objectives To describe clinical outcomes and perioperative care in patients undergoing tracheostomy at a secondary ENT department in Denmark. Material and methods This retrospective cohort study included all adult patients who underwent tracheostomy at Gødstrup Hospital between 2019 and 2024. Data were extracted from electronic records. Postoperative pneumonia was the primary outcome; secondary outcomes included perioperative care assessment and in-hospital mortality. Results Seventy-seven patients were included, of whom 71 were evaluable for pneumonia outcome. Postoperative pneumonia occurred in 63% of patients. Neurological comorbidity was more frequent among patients with pneumonia (31% versus 8%, p = 0.037). Prophylactic antibiotics alone did not reduce pneumonia rates (61% versus 67%, p = 0.81). Postoperative dysphagia screening, pulmonary physiotherapy, and dietetic referral were more common in patients with pneumonia. In-hospital mortality was 14%, primarily in patients with prolonged intubation due to non-ENT causes. No deaths were directly related to the procedure. Conclusions and significance Postoperative pneumonia rates were high and associated with neurological comorbidity. Prophylactic antibiotics alone did not reduce pneumonia rates. These findings highlight the need for structured perioperative care in patients undergoing tracheostomy.

Viral lower respiratory tract infections (LRTIs) are a leading cause of mortality among children. Bacterial coinfections in viral LRTI are associated with severe clinical outcomes. Identifying lower airway bacterial involvement in viral LRTI is challenging. Our objective was to define the concordance of bacterial detection between paired upper nasopharyngeal (NP) swabs and lower endotracheal airway samples (ETAs) in children with severe viral LRTI. Convenience sample of children <5 years intubated with LRTI. Children were enrolled within 48 hours of ICU admission, and NP/ETAs were obtained for the detection of Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus. Concordance was assessed via intraclass correlation coefficient (ICC), according to the respiratory virus and age. Clinical outcomes were also assessed. From 2017 to 2021, we enrolled 76 children [median age: 2.1 (1.2-4.3) months]. The most common respiratory virus was respiratory syncytial virus (RSV) (73.7%). Overall concordance for bacterial detection was high for M. catarrhalis, H. influenzae, and S. pneumoniae (ICC ≥0.75) but low for S. aureus (ICC 0.36). Detection rates varied by viral pathogen, with M. catarrhalis and S. pneumoniae showing the highest agreement in children with RSV. Agreement was higher in infants <6 months. Prolonged intubation was observed in children with RSV and NP codetection of S. pneumoniae or H. influenzae. Concordance was high for M. catarrhalis, H. influenzae, and S. pneumoniae, but not for S. aureus, and was influenced by the viral etiology and age. These findings suggest the applicability of NP swabs as surrogates for lower airway cultures for specific bacterial-virus combinations in children with severe LRTI.

Assessment of adherence to the neonatal resuscitation program using video recording: a prospective observational study