Secondary Airway Research Articles

Video Versus Nonvideo in a Rabbit Training Model for Establishing an Emergency Front of Neck Airway in Children: A Prospective Trial.

Simulating a realistic "cannot intubate, cannot oxygenate" (CICO) situation to train an "emergency front of neck airway" is difficult. It further remains unclear if provision of regular technical refreshers improves performance in the setting of a real CICO situation. The purpose of this prospective study on an established surgical rabbit cadaver tracheostomy model was to evaluate the benefit of viewing training material shortly before performing "emergency front of neck airway." Previously trained participants were randomized into 2 groups. The control group (video) was allowed to watch an instructional video before performing a tracheotomy on the training model, while the study group (nonvideo) was not. Queried outcomes included success rate, performance time, and severe secondary airway injuries between the 2 groups. In 29 tracheotomies performed by 29 participants, the overall success rate was 86% (92% video; 81% nonvideo, P = 0.4). Performance time was not different between the 2 groups (video: 80 s [IQR25-75: 53-86], nonvideo 64 s [IQR25-75: 47-102]; P = 0.93). Only in the nonvideo group, the performance time and the time between the workshops correlated positively (P = 0.048). Severe secondary injuries were noted in 4 of 29 rabbit cadavers, 2 in each group. Watching a refresher video before performing an emergency surgical tracheostomy in an infant training model did not influence the success rate and the performance time in previously trained anesthetists. These results highlight the ease of learning, memorization, and recall of this emergency surgical tracheostomy technique and may demonstrate its applicability in a real infant CICO situation.

Ultrasound-Guided Dorsal Penile Nerve Block in Children: An Anatomical-Based Observational Study of a New Anesthesia Technique.

Dorsal penile nerve block stands out as one of the commonly employed regional anesthetic techniques in children. Despite the large body of experience, failure rates are still significant. We included 20 children (median (SD) age of 73 (31) months) scheduled for circumcision without general anesthesia and secondary airway manipulation in a consecutive case series. Under ultrasound guidance and utilizing an in-plane needle guidance technique, the dorsal penile nerve block was administered with slight sedation, and spontaneous respiration was maintained in all cases. To investigate the underlying anatomy for dorsal penile nerve blockade, we dissected three cadavers. The primary study endpoint was the success rate of surgical blockade, meaning that the surgical procedure could be performed without additional general anesthesia and invasive airway management. The secondary endpoint was the requirement of analgesics until discharge from the post-anesthesia care unit. The primary endpoint was successfully met in all patients according to our strict definition without additional general anesthesia or airway manipulation. In addition, no child received analgesics until discharge from the recovery room. The anatomical investigation clarified the specific anatomy as baseline knowledge for an ultrasound-guided dorsal penile nerve blockade and enabled successful performance in 20 consecutive children where penile surgery was possible in light sedation without additional airway manipulation.

Findings on drug-induced sleep endoscopy in infants with laryngomalacia

IntroductionObstructive sleep apnea (OSA) is highly prevalent in infants with laryngomalacia (LM). Previous studies have reported high rates of persistent OSA following supraglottoplasty (SGP). The objective of this study is to describe the findings on drug-induced sleep endoscopy (DISE) in infants with LM. MethodsA retrospective review was performed including infants (12.5 months of age or less) with LM who underwent DISE along with direct laryngoscopy and bronchoscopy (DLB). Data collected included clinical presentation, swallow study results, sleep study results, past medical and surgical history, and postoperative outcomes when follow-up data was available. The findings on DISE as well as DLB were reviewed and described. ResultsThirty-five infants were included in the study with a mean age of 0.42 years (range 0.04–1.04). Obstructive sleep-disordered breathing (oSDB) and/or OSA were identified in 26 patients (74.3%) in addition to 7 patients (20%) with noisy breathing during sleep. DISE demonstrated LM in 31 patients (89%). DISE identified 12 patients (34%) with partial or complete obstruction at the level of the tongue base. DLB identified 14 patients (40%) with a secondary airway abnormality including 7 patients (20%) with type 1 laryngeal cleft and 4 patients (11%) with grade 1 subglottic stenosis. Eighteen patients (51%) underwent SGP. ConclusionDISE at the time of airway endoscopy for infants with LM can be helpful in identifying additional sites of obstruction including the tongue base. Glossoptosis may explain and/or predict the previously reported persistence of OSA following SGP. Additionally, DISE can complement awake flexible laryngoscopy in the assessment of severity of LM.

The usefulness of ultrasonographic measurement of the laryngeal air column width difference before extubation as a predictor of secondary airway obstruction after extubation in children

Background: Postextubation airway obstruction, also called postextubation stridor, is one of the most frequent complications of orotracheal intubation and the main cause of extubation failure (EF). Several potential predictors of extubation outcomes have been investigated, although their predictive value and clinical usefulness are limited. Laryngeal ultrasound and measurements are new, noninvasive, easily reproducible methods for extubation success. The objective of the study was to determine the usefulness of measuring the laryngeal air column width difference (LACWD) as a predictor of EF. Subjects and Methods: This prospective observational study was conducted from December 2022 to March 2023. Patients older than 30 days and up to 16 years of age admitted to the pediatric intensive care unit (PICU) and intubated with an endotracheal tube with a balloon for >24 h and with their first attempt at extubation were evaluated. The LACWD was measured before extubation. The first measurement was made with the balloon inflated and the second with the balloon deflated, calculating the difference between the two measurements. Results: Forty-five patients were assessed. The median number of days in the PICU was 8 (interquartile range 2–6). We found that the greater the difference in the air column, the lower the risk of EF ([P = 0.418] odds ratio [OR] =0.101 95% confidence interval [CI] =0.000–26.000), and the greater the number of days (>3), the greater the risk of EF ([P = 0.819] OR = 0.996; 85% CI = 0.965–1.028). Conclusions: No statistically significant relationship was found in the LACWD in our patients. We believe that it is important to carry out an extended study, with age group stratification, to assess its use.

Swallowing Function After Epiglottopexy in Children.

Epiglottopexy has been an increasingly utilized intervention in children with epiglottic prolapse and airway obstruction. Given the role of the epiglottis in protecting the airway during swallowing and the potential effect of repositioning the epiglottis on the passage of the bolus, we aimed to compare swallowing outcomes before and after epiglottopexy in children. A retrospective cohort study. Tertiary care children's hospital. Data were extracted from charts of children who underwent epiglottopexy and had a subsequent instrumental swallowing evaluation between January 2018 and September 2022. A total of 93 patients underwent epiglottopexy. Of these, 38 patients met inclusion requirements. The mean age at surgery was 41 ± 47 months. Most patients (n = 37, 97.4%) had significant comorbidities such as secondary airway lesions (n = 33, 91.7%), a genetic or syndromic disorder (n = 25, 69.4%), and dysphagia (n = 29, 76.3%). All patients had a concurrent procedure at the time of epiglottopexy with supraglottoplasty (n = 24, 63.2%) and lingual tonsillectomy (n = 16, 42.1%) being the most common. No changes in initiation or patterns of swallowing were noted postoperatively. A total of 7 (18.4%) patients had worsening swallow function: 2 had new-onset dysphagia, and 5 had worsening pre-existing dysphagia. Liquid or food textures penetrated remained unchanged or improved in most cases. No risk factors for worsening dysphagia were identified in our cohort. Children with medical comorbidities undergoing epiglottopexy with additional airway interventions may experience new or worsening dysphagia. However, the procedure is generally safe without notable patterned changes in the swallowing mechanism.

Updates in neonatal resuscitation: routine use of laryngeal masks as an alternative to face masks.

Although positive-pressure ventilation (PPV) has traditionally been performed using a face mask in neonatal resuscitation, face mask ventilation for delivering PPV has a high failure rate due to mask leaks, airway obstruction, or gastric inflation. Furthermore, face mask ventilation is compromised during chest compressions. Endotracheal intubation in neonates requires a high skill level, with a first-attempt success rate of <50%. Laryngeal masks can transfer positive pressure more effectively even during chest compressions, resulting in a lower PPV failure rate compared to that of face masks in neonatal resuscitation. In addition, inserting a laryngeal mask is easier and more accessible than endotracheal intubation, and mortality rates do not differ between the 2 methods. Therefore, in neonatal resuscitation, laryngeal masks are recommended in infants with gestational age >34 weeks and/or with a birth weight >2 kg, in cases of unsuccessful face mask ventilation (as a primary airway device) or endotracheal intubation (as a secondary airway device, alternative airway). In other words, laryngeal masks are recommended when endotracheal intubation fails as well as when PPV cannot be achieved. Although laryngeal masks are commonly used in anesthetized pediatric patients, they are infrequently used in neonatal resuscitation due to limited experience, a preference for endotracheal tubes, or a lack of awareness among the healthcare providers. Thus, healthcare providers must be aware of the usefulness of laryngeal masks in depressed neonates requiring PPV or endotracheal intubation, which can promptly resuscitate these infants and improve their outcomes, resulting in decreased morbidity and mortality rates.

Surgical Outcome and Treatment Trends in 1289 Infants with Micrognathia: A Multicenter Cohort.

Studies of infants with micrognathia, especially Robin sequence, are limited by its rarity and both phenotypic and diagnostic variability. Most knowledge of this condition is sourced from small, single-institution samples. This is a cross-sectional study including infants with micrognathia admitted to 38 Children's Hospital Neonatal Consortium centers from 2010 through 2020. Predictor variables included demographic data, birth characteristics, cleft, and syndrome status. Outcome variables included length of stay, death, feeding or respiratory support, and secondary airway operations. A total of 1289 infants with micrognathia had surgery to correct upper airway obstruction. Mean age and weight at operation were 34.8 ± 1.8 weeks and 3515.4 ± 42 g, respectively. A syndromic diagnosis was made in 150 (11.6%) patients, with Stickler (5.4%) and Treacher Collins (2.2%) syndromes being the most common. Operations included mandibular distraction osteogenesis (MDO) in 66.3%, tracheostomy in 25.4%, and tongue-lip adhesion (TLA) in 8.3%. Patients receiving a tracheostomy had lower birthweight, head circumference, gestational age, and Apgar scores. Patients undergoing MDO were less likely to need a second airway operation compared with patients undergoing TLA (3.5% versus 17.8%; P < 0.001). The proportion of infants feeding exclusively orally at hospital discharge differed significantly, from most to least: MDO, TLA, and tracheostomy. Hospital length of stay was not statistically different for patients who had MDO or TLA, but was longer for those with primary tracheostomy. The mortality rate was low for all operations (0.5%). In this surgical patient cohort, MDO was associated with shorter hospital stay, improved oral feeding, and lower rates of secondary airway operations. Prospective multicenter studies are necessary to support these conclusions. Risk, III.

Characteristics and Outcomes of Surgical Treatment for Bronchial Anomalies.

Bronchial anomalies are rare but challenging conditions to treat in children, encompassing a variety of structural abnormalities that could compromise airway patency. This includes complete rings, absent cartilage, traumatic avulsions, bronchoesophageal fistulas, and cartilaginous sleeves. The objective of this study is to describe the characteristics and outcomes of a series of pediatric cases of bronchial anomalies that were treated by slide tracheobronchoplasty. This is a single-institution retrospective case series of pediatric patients with bronchial anomalies who underwent surgical treatment between February 2004 and April 2020. Data extracted from electronic medical records included patient demographics, comorbidities, and surgical outcomes. There were a total of 29 patients included in the study, of which 14 had complete bronchial rings, 8 had absent bronchial rings, 4 had traumatic bronchial avulsions, 2 had bronchoesophageal fistulas, and one had a cartilaginous sleeve. Median follow-up time was 13 months (with a range of 0.5-213 months). The overall mortality rate was 17.2% (5 patients), all of whom had complete bronchial rings. Patients with complete bronchial rings also had a higher rate of not only cardiac (85.7%) and pulmonary comorbidities (85.7%) but also secondary airway lesions (78.6%). This is the largest series to date describing surgical treatment for bronchial anomalies. Complete bronchial rings were the most common anomaly treated, followed by absent rings and trauma. Surgical treatment can be successful but mortality rates are higher in patients with complete bronchial rings, possibly due to higher rates of pulmonary and cardiac comorbidities. 4 Laryngoscope, 133:3334-3340, 2023.

Investigation on the effectiveness of ventilation dilution on mitigating COVID-19 patients’ secondary airway damage due to exposure to disinfectants

Chlorine-containing disinfectants are widely used in hospitals to prevent hospital-acquired severe acute respiratory syndrome coronavirus 2 infection. Meanwhile, ventilation is a simple but effective means to maintain clean air. It is essential to explore the exposure level and health effects of coronavirus disease 2019 patients’ inhalation exposure to by-products of chloride-containing disinfectants under frequent surface disinfection and understand the role of ventilation in mitigating subsequent airway damage.We determined ventilation dilution performance and indoor air quality of two intensive care unit wards of the largest temporary hospital constructed in China, Leishenshan Hospital. The chloride inhalation exposure levels, and health risks indicated by interleukin-6 and D-dimer test results of 32 patients were analysed.The mean ± standard deviation values of the outdoor air change rate in the two intensive care unit wards were 8.8 ± 1.5 h−1 (Intensive care unit 1) and 4.1 ± 1.4 h−1 (Intensive care unit 2). The median carbon dioxide and fine particulate matter concentrations were 480 ppm and 19 μg/m3 for intensive care unit 1, and 567 ppm and 21 μg/m3 for intensive care unit 2, all of which were around the average levels of those in permanent hospitals (579 ppm and 21 μg/m3). Of these patients, the median (lower quartile, upper quartile) chloride exposure time and calculated dose were 26.66 (2.89, 57.21) h and 0.357 (0.008, 1.317) mg, respectively.A statistically significant positive correlation was observed between interleukin-6 and D-dimer concentrations. To conclude, ventilation helped maintain ward air cleanliness and health risks were not observed.

Early Surgical Management of Infants with Robin Sequence in a Large Multi-center Sample

OBJECTIVE: Studies of infants with Robin sequence (RS), the triad of micrognathia, glossoptosis and upper airway obstruction, are limited by the rarity of the condition and heterogeneity of the sample that results from phenotypic and diagnostic variability. Most knowledge of this condition is sourced from small, single-institution samples and is inherently biased. The purpose of this study is to characterize early surgical management of infants with RS in a large multi-institution sample. METHODS: This is a cross-sectional study initiated as part of the Children’s Hospital Neonatal Consortium (CHNC) micrognathia working group and includes infants with micrognathia admitted to CHNC centers from 2010-2020. Data was abstracted from the Children’s Hospital Neonatal Database (CHND), which captures clinical information for infants admitted to neonatal intensive care units at each of the 34 CHNC centers. Predictor variables included demographic data, birth characteristics, cleft and syndrome status, and operative details. Outcome variables included length of stay, death, feeding and respiratory support at hospital discharge, and need for secondary airway operations. Trends in surgical management between centers and over time were also evaluated. A p-value<0.05 was considered statistically significant for all analyses. RESULTS: Of the 248,010 patients included in CHND during the study period, 3256 (1.3%) had a diagnosis of micrognathia and 1294 (39.7%) of these had an operation to correct upper airway obstruction during infancy. For those that had an operation, mean age and weight at operation were 34.9±33.6 days and 3515.4±712.8 grams, respectively. A syndromic diagnosis was made in 152 (1.2%) prior to hospital discharge, with Stickler (n=71, 46.7%) and Treacher Collins Syndromes (n=28, 18.4%) most common. Operations included: mandibular distraction osteogenesis (MDO), n=856 (66%); tracheostomy, n=331 (26%); and tongue-lip adhesion (TLA), n=107 (8%). Analysis revealed several notable associations: Compared to MDO and TLA, initial tracheostomy was performed more commonly for male (51.0% vs 58.0%, p=0.03) infants without a cleft palate (35.3% vs 63.1%, p<0.001), and/or with Treacher Collins syndrome (0.4% vs 7.3%, p<0.001). Length-of-stay was shorter for MDO compared to TLA (57.9 +/- 40 vs. 69.0 +/- 40 days, p=0.007), and shorter for TLA compared to tracheostomy (69.0 +/- 40.0 vs. 110.4 +/- 71.0 days, p<0.001). Exclusive oral feeding was achieved by NICU discharge more frequently after MDO than TLA (35.4% vs 15.0%, p<0.001) and least commonly after tracheostomy (3.6%). The rate of gastrostomy tube placement was highest after tracheostomy (76.4%) and was and lowest after MDO (TLA=54.7%, MDO=28.5%, p<0.001). Infants that had MDO were less likely to require a second airway operation than those with TLA (3.5% vs 17.8%, p<0.001). Mortality was low for all operations (0.5%). CONCLUSION: In this cohort, the largest dataset of infants with RS ever reported, MDO was associated with shorter hospital stay, improved oral feeding, and lower rates for gastrostomy tube placement and secondary airway operations compared to TLA and tracheostomy. Prospective multi-center studies are necessary to further support these conclusions.

Laryngeal electromyography, a useful tool in difficult cases of pediatric laryngeal mobility disorders

IntroductionPediatric laryngeal mobility disorders constitute a challenge in terms of diagnosis and treatment, especially in small children and those complex patients with prior history of prolonged intubation or surgery. Laryngeal electromyography (L-EMG) may help to distinguish vocal fold paralysis from fixation. Material and methodsTen children with laryngeal mobility disorders (including bilateral vocal fold immobility (BVFI) or unilateral vocal fold immobility (UVFI) with contralateral hypomobility) underwent suspension laryngoscopy and L-EMG between July 2019 and March 2021. The EMG data were acquired simultaneously in both thyroarytenoid muscles. Anesthesia was lightened until volitional activity appeared like cough, cry or spontaneous Valsalva maneuver. ResultsWe found secondary airway lesions in 2 patients and 3 vocal fold fixation. L-EMG recordings were pathologic in 4 patients (3 moderate and 1 severe nerve lesion). No recurrent laryngeal nerve injury was found in congenital BVFI cases. The data from both suspension laryngoscopy and L-EMG recordings influenced clinical decision-making. ConclusionsL-EMG adds value to suspension laryngoscopy in the management of pediatric patients with laryngeal mobility disorders. Selected cases such as patients with iatrogenic BVFI, UVFI with associated contralateral hypomobility or patients with combined pathologies may obtain the greatest benefit.

Outcomes following surgical repair of absent pulmonary valve syndrome: 30 years of experience from a Swedish tertiary referral centre.

Surgical approach with reduction pulmonary artery plasty and valved conduit in patients with respiratory compromise prior to repair is associated with excellent long-term survival at the cost of a higher reintervention rate. OBJECTIVESAbsent pulmonary valve syndrome is a rare congenital heart defect with pulmonary artery dilatation and secondary airway compression. Although preoperative respiratory support and early surgical repair with pulmonary arterioplasty are often required in patients with airway compromise, the need for extensive plasty in these patients and for plasty in general in those with no or mild respiratory issues remains debatable.METHODSWe performed a retrospective survey of patients with this diagnosis and repair from 1988 to 2018.RESULTSTwenty patients were identified. The median age and weight at repair were 0.8 (0.1–2.4) years and 7.0 (2.5–13.8) kg and included a valved conduit in 17 (85%) patients and a transannular patch in 3 patients. Five (29%) patients were ventilator-dependent prior to repair at the age of 0.3 (0.1–0.4) years. Pulmonary arterioplasty was performed in 7 patients (35%), including all 5 with ventilator dependency and 2 with respiratory symptoms due to recurrent infections. Two patients (10%) with preoperative ventilator dependency underwent extensive intrahilar arterioplasty. Preoperative ventilator dependency was associated with earlier repair and reinterventions (P < 0.05). There were 3 late deaths among cases with repair after 2000 (n = 14), none with preoperative ventilator dependency.CONCLUSIONSThe long-term outcomes of patients with this rare defect are good, comparable to those of other previous studies. Reduction pulmonary arterioplasty, which in this study was used only in patients with respiratory distress and ventilator dependency, is associated with excellent survival. Reinterventions are common in these patients.

Sleep Endoscopy and Cine Magnetic Resonance Imaging Evaluation of Children With Persistent Obstructive Sleep Apnea.

To compare findings of same-day cine magnetic resonance imaging (MRI) and drug-induced sleep endoscopy (DISE) and examine how each technique uniquely contributes to the evaluation of persistent obstructive sleep apnea following adenotonsillectomy. Retrospective cohort study. Quaternary care center. Chart review was performed for consecutive patients who underwent same-day cine MRI and DISE between 2015 and 2020. Descriptive statistics are reported, and Cohen kappa coefficients were calculated to evaluate the agreement between cine MRI and DISE for obstruction at the adenoids, lingual tonsils, and tongue base. There were 137 patients, the mean age was 10.4 years (95% CI, 3.2-16.7), and 62.8% were male. The most common sites of obstruction on DISE were the tongue base (86.9%), velum (78.7%), epiglottis (74.5%), inferior turbinate (68.6%), and lingual tonsil (61.3%). The most common sites of obstruction on cine MRI were the hypopharynx (56.3%), tongue base (44.8%), lingual tonsil (38.0%), and macroglossia (37.6%). There was moderate agreement for adenoid hypertrophy (κ = 0.53) and poor agreement for lingual tonsil hypertrophy (κ = 0.15) and tongue base obstruction (κ = 0.09). DISE identified more instances of multilevel obstruction when compared with cine MRI (94.9% vs 48.2%). DISE offered a better examination of nasal and supraglottic obstruction and is sensitive to partial vs complete collapse, while cine MRI offered better soft tissue resolution for lymphoid tissue hypertrophy and provided a global view of primary and secondary airway obstruction. Cine MRI and DISE are complementary modalities in the evaluation of children with persistent obstructive sleep apnea.

Laryngeal Masks in Neonatal Resuscitation-A Narrative Review of Updates 2022.

Positive pressure ventilation (PPV) is crucial to neonatal cardiopulmonary resuscitation because respiratory failure precedes cardiac failure in newborns affected by perinatal asphyxia. Prolonged ineffective PPV could lead to a need for advanced resuscitation such as intubation, chest compression, and epinephrine. Every 30 s delay in initiation of PPV increased the risk of death or morbidity by 16%. The most effective interface for providing PPV in the early phases of resuscitation is still unclear. Laryngeal masks (LMs) are supraglottic airway devices that provide less invasive and relatively stable airway access without the need for laryngoscopy which have been studied as an alternative to face masks and endotracheal tubes in the initial stages of neonatal resuscitation. A meta-analysis found that LM is a safe and more effective alternative to face mask ventilation in neonatal resuscitation. LM is recommended as an alternative secondary airway device for the resuscitation of infants > 34 weeks by the International Liaison Committee on Resuscitation. It is adopted by various national neonatal resuscitation guidelines across the globe. Recent good-quality randomized trials have enhanced our understanding of the utility of laryngeal masks in low-resource settings. Nevertheless, LM is underutilized due to its variable availability in delivery rooms, providers’ limited experience, insufficient training, preference for endotracheal tube, and lack of awareness.

Architecture of the bronchial tree in Cuvier's dwarf caiman (Paleosuchus palpebrosus).

We imaged the lungs of five Cuvier's dwarf caiman (Paleosuchus palpebrosus) via computed tomography (CT) and micro-computed tomography (μCT) and compared these data to the lungs of the American alligator (Alligator mississippiensis). These data demonstrate anatomical commonalities between the lungs of P. palpebrosus and A. mississippiensis, and a few notable differences. The structural similarities are (a) a proximally narrow, distally widened, hook-shaped primary bronchus; (b) a cervical ventral bronchus that branches of the primary bronchus and immediately makes a hairpin turn toward the apex of the lung; (c) a sequential series of dorsobronchi arising from the primary bronchus caudal to the cervical ventral bronchus; (d) intraspecifically highly variable medial sequence of secondary airways; (e) sac-like laterobronchi; and (f) grossly dead-ended caudal group bronchi in the caudal and ventral aspects of the lung. The primary differences between the two taxa are in the overall number of large bronchi (fewer in P. palpebrosus), and the number of branches that contribute to the cardiac regions. Imaging data of both a live and deceased specimen under varying states (postprandial, fasting, total lung capacity, open to atmosphere) indicate that the caudal margin and position of the lungs shift craniocaudally relative to the vertebral column. These imaging data suggest that the smooth thoracic ceiling may be correlated to visceral movement during ventilation, but this hypothesis warrants validation. These results provide the scaffolding for future comparisons between crocodilians, for generating preliminary reconstructions of the ancestral crocodilian bronchial tree, and establishing new hypotheses of bronchial homology across Archosauria.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow. NAEMSP recommends: Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles. EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies. EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children. Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting. Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation. If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention. Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Cuffed versus uncuffed tracheal tubes in a rabbit training model for establishing an emergency front-of-neck airway in infants: a prospective trial

BackgroundThere is a paucity of evidence regarding the optimal type of tracheal tube to be advanced over a Frova catheter when performing a ‘bougie’ emergency front-of-neck airway (eFONA) technique in infants during a ‘cannot intubate, cannot oxygenate’ situation. MethodsA prospective non-inferiority trial in a rabbit cadaver surgical tracheotomy model to assess the performance of the eFONA technique with an uncuffed 3.5 mm ID tracheal tube vs a cuffed 3.0 mm ID tracheal tube. Queried outcomes include success rate, performance time, and severe secondary airway injuries among tracheal tube types. ResultsIn 60 tracheostomies performed by 30 participants, the overall success rate was 98%. Performance time was independent from tracheal tube choice (uncuffed: 61 s [95% confidence interval (CI), 52–76], cuffed: 64 s [95% CI, 55–79]; P = 0.82). No tracheal tube type was preferred in terms of usability by participants. The cuffed tracheal tube required increased force to be advanced over the Frova catheter and was associated with a risk ratio of 2.5 (95% CI, 0.53–11.9; number needed to harm, 10) for severe secondary airway injuries when compared with the uncuffed tracheal tube. ConclusionIn performing eFONA in the rabbit cadaver model, an ID 3.5 uncuffed is non-inferior to an ID 3.0 cuffed tracheal tube regarding performance time and preference by the operator. Greater force application to advance the cuffed tube over the Frova catheter and more severe airway injuries may argue for the standardised performance of the eFONA technique with a uncuffed tracheal tube in infants.

Laryngomalacia: review of current evidence and considerations

Stridor is an alarming symptom for the pediatric population with a prevalence in newborns due to the anatomical features of the airways. Laryngomalacia (LM) is the main etiological cause with a frequency ranging between 45% and 75% according to different sources. The aetiology of laryngomalacia has not been defined—there are several theories that can be classified into two main groups—anatomical and neurological, neither of which is universally accepted. The criteria for diagnosis are not standardized—required is endoscopic registration of inspiratory supraglottic collapse in the presence of clinical symptoms. However, some of the endoscopic features of the condition have also been found in healthy patients. The standard approach to а mild and moderate form is an observation for 12-24 months. Spontaneous resolution of symptoms is usually observed during this period. The severe form affects 10-20% of the patients. It is characterized by a severe clinical picture that does not improve spontaneously. These patients require further examination to rule out a secondary airway lesion or require surgical correction of LM.

Uncommon thoracic manifestations from extrapulmonary tumors: Computed tomography evaluation - Pictorial review

Although metastasis can occur at a variety of sites, pulmonary involvement is common in patients with cancer. Depending on the source and type of tumor, pulmonary metastases present with a wide range of radiologic appearances. Hematogenous dissemination through the pulmonary arteries to the pulmonary capillary network is the most common form of spread in pulmonary metastases. However, they may also reach the lung via lymphatic dissemination, secondary airway involvement, vessel tumor embolism, and direct chest invasion. In the evaluation of patients with known extrathoracic tumors, CT is the state-of-the-art imaging modality for detecting and characterize pulmonary metastases as well as to predict resectability. Although CT limitations are well known, knowledge of growth rates of various tumors and understanding the pattern of spread may be helpful clues in suggesting and even establish the specific diagnosis. The purpose of this pictorial review is to discuss the imaging appearances of different patterns of intrathoracic tumoral dissemination.

Blocking Cell Extrusion Prevents Bronchoconstriction-Induced Airway Epithelial Damage and Inflammation

Asthma is a common disease characterized by airway constriction, excess mucus, and inflammation. We previously showed that cell crowding drives steady-state epithelial cell extrusion and cell death. Using ex vivo lung slices, we show that excessive crowding from methacholine-induced bronchoconstriction causes extensive cell extrusion leading to destruction of the airway epithelial barrier. In live mice, bronchoconstriction-induced extrusion caused airway epithelia damage and inflammation in secondary and tertiary airways. In primary airways, bronchoconstriction triggered mucus secretion by a mechanism reminiscent of extrusion. Reversing bronchoconstriction with albuterol failed to ameliorate these symptoms, whereas inhibiting the stretch-activated calcium channel, Piezo1, prevented extrusion, inflammation, and mucus secretion. Our findings propose a new etiology for asthma where the mechanical crowding from bronchoconstriction causes so much extrusion that it compromises the barrier, triggering subsequent inflammation. Furthermore, inhibiting extrusion, potentially with gadolinium, an inexpensive Piezo1 inhibitor, may prevent the asthma inflammatory cycle.