Significant Airway Obstruction Research Articles

The effect of deep and awake tracheal extubation on turnover times and postoperative respiratory complications post adenoid-tonsillectomy

To the Editor, Tonsillectomies and adenoidectomies (T&As) are increasingly performed in an outpatient setting in order to increase time efficiency with rapid turnover between cases. Though Patel et al. showed no difference in postoperative respiratory complications between deep and awake tracheal extubation after T&A, there remains considerable debate amongst pediatric anesthesiologists concerning which extubation technique is safer and more efficient. We undertook a retrospective review of T&As in our institution to examine whether one method of tracheal extubation (deep or awake) saved time in the operating room and reduced turnover time. We also examined differences between extubation techniques relating to postoperative respiratory complications following T&A. After approval by the Committee on Human Research on March 29, 2012, we reviewed the charts of all\18-yr-old patients who underwent tonsillectomy, adenoidectomy, or both over a one-year period at the University of California San Francisco Benioff Children’s Hospital Ambulatory Surgery Center. Inclusion criteria included otherwise healthy patients with a primary surgical diagnosis of sleepdisordered breathing, chronic nasal congestion, recurrent tonsillitis, recurrent otitis media, or hearing loss/speech delay. A single surgeon performed all procedures and pediatric anesthesiologists, usually with a resident, provided the anesthesia. Patients were excluded if they had a condition known to increase the incidence of postoperative respiratory complications, including active upper respiratory tract infection, moderate to severe asthma, age less than two years, American Society of Anesthesiologists’ physical status III or above, cerebral palsy, craniofacial anomalies, chronic cardiopulmonary disease, a history of seizures, a history of prematurity, hypotonia, and failure to thrive. ‘‘Deep’’ tracheal extubation was presumed when anesthesia records showed an age-appropriate end-tidal anesthetic concentration C 1.0 minimum alveolar concentration at extubation. Three time intervals were recorded: time from surgery end to exiting the operating room (out of operating room time), time from exiting the operating room to re-entering with the next patient (turnover time), and time from the end of surgery to transfer of anesthesia care to postanesthesia care unit (PACU) personnel (anesthesia end time). Significant respiratory complications requiring an anesthesia provider’s assessment and/or management were collected from the PACU record, including airway obstruction requiring jaw thrust and/or airway adjuncts, pulse oximetry reading \ 93% for more than two minutes (prolonged oxygen desaturation), bronchospasm, laryngospasm, bleeding episodes, and need for tracheal reintubation or admission to the intensive care unit. Sixty-two of the 110 patients who met the inclusion criteria underwent deep tracheal extubation and 48 patients underwent awake extubation. There were no statistically significant differences between groups for age, weight, sex, or opioid received. Most (77%) patients were diagnosed with sleep-disordered breathing, though not all had formal sleep studies preoperatively. There were no statistically significant differences between extubation groups for out of operating room time (P = 0.14), anesthesia end time (P = 0.17), or turnover time (P = 0.59) (Figure). Two postoperative respiratory complications were observed in the PACU: one episode of laryngospasm in the awake extubation group and one episode of significant airway obstruction in the deep extubation group. S. K. Menda, MD G. A. Gregory, MD J. R. Feiner, MD M. S. Zwass, MD M. B. Ferschl, MD (&) University of California San Francisco, San Francisco, CA, USA e-mail: ferschlm@anesthesia.ucsf.edu

Predictors and Clinical Outcomes from Failed Laryngeal Mask Airway Unique™

Although the estimated risk of life-threatening adverse respiratory events during supraglottic airway device use is rare, the reported rate of events leading to failure of the airway device is 0.2-8%. Little is known about the risk-adjusted prediction of Laryngeal Mask Airway failure requiring rescue tracheal intubation and its impact on patient outcomes. All adult patients in whom a laryngeal mask airway (LMA Unique™, uLMA™; LMA North America, Inc., San Diego, CA) was used in ambulatory and nonambulatory anesthesia settings were included. The primary outcome was uLMA™ failure, defined as an airway event requiring uLMA™ removal and tracheal intubation. The secondary outcomes were the incidence of difficult mask ventilation and unplanned hospital admissions. Of the 15,795 cases included in our study, 170 (1.1%) experienced the primary outcome of uLMA™ failure. More than 60% of patients with uLMA™ failure experienced significant hypoxia, hypercapnia, or airway obstruction, whereas 42% presented with inadequate ventilation related to leak. Four independent risk factors for failed uLMA™ were identified: surgical table rotation, male sex, poor dentition, and increased body mass index. A 3-fold increased incidence of difficult mask ventilation was observed in patients with uLMA™ failure. Among outpatients with uLMA™ failure, 13.7% had unplanned hospital admission, 5.6% of whom needed intensive care for persistent hypoxemia. The study supports the use of the uLMA™ as an effective supraglottic airway device with a relatively low failure rate. However, there are clinically relevant consequences of uLMA™ failure, as evidenced by the high rate of acute respiratory events and need for unplanned hospital admissions.

Bronchoscopic assessment of airway involvement in children presenting with clinically significant airway obstruction due to tuberculosis

Bronchoscopic assessment of airway involvement in children presenting with clinically significant airway obstruction due to tuberculosis

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

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

Ultrasonography assessment of vocal cords mobility in children after cardiac surgery

ObjectivesUpper airway obstruction after pediatric cardiac surgery is not uncommon. In the cardiac surgical population, an important etiology is vocal cord paresis or paralysis following extubation. In this study, we aimed to evaluate the feasibility and accuracy of ultrasonography (US) assessment of the vocal cords mobility and compare it to fiber-optic laryngoscope (FL). Material and methodsA prospective pilot study has been conducted in Pediatric Cardiac ICU (PCICU) at King Abdulaziz Cardiac Center (KACC) from the 1st of June 2009 till the end of July 2010. Patients who had cardiac surgery manifested with significant signs of upper airway obstruction were included. Each procedure was performed by different operators who were blinded to each other report. Results of invasive (FL) and non-invasive ultrasonography (US) investigations were compared. ResultsTen patients developed persistent significant upper airway obstruction after cardiac surgery were included in the study. Their mean±SEM of weight and age were 4.6±0.4kg and 126.4±51.4 days, respectively. All patients were referred to bedside US screening for vocal cord mobility. The results of US were compared subsequently with FL findings. Results were identical in nine (90%) patients and partially different in one (10%). Six patients showed abnormal glottal movement while the other four patients demonstrated normal vocal cords mobility by FL. Sensitivity of US was 100% and specificity of 80%. ConclusionUS assessment of vocal cord is simple, non-invasive and reliable tool to assess vocal cords mobility in the critical care settings. This screening tool requires skills that can be easily obtained.

Mandibular distraction in neonates: indications, technique, results

BackgroundThe Pierre Robin Sequence features were first described by Robin in 1923 and include micrognathia, glossoptosis and respiratory distress with an incidence estimated as 1:8,500 to 1:20,000 newborns. Upper airway obstruction and feeding difficulties are the main concerns related to the pathology. Mandibular distraction should be considered a treatment option (when other treatments result inadequate).Patiants and methodsTen patients between the ages of 1 month and 2 years with severe micrognathia and airway obstruction were treated with Mandibular Distraction Osteogenesis (MDO).All patients underwent fibroscopic examination of the upper airway and a radiographic imaging and/or computed tomography scans to detect malformations and to confirm that the obstruction was caused by posterior tongue displacement. All patients were evaluated by a multidisciplinary team. Indications for surgery included frequent apneic episodes with severe desaturation (70%). Gavage therapy was employed in all patients since oral feeding was not possible. The two tracheotomy patients were 5 months and 2 years old respectively, and the distraction procedure was performed to remove the tracheotomy tube. All patients were treated with bilateral mandibular distraction: two cases with an external multivector distraction device, six cases with an internal non-resorbable device and two cases with an internal resorbable device. In one case, the patient with Goldenhar's Syndrome, the procedure was repeated.ResultsThe resolution of symptoms was obtained in all patients, and, when present, tracheotomy was removed without complications. Of the two patients with pre-existing tracheotomies, in the younger patient (5 months old) the tracheotomy was removed 7 days postoperatively. In the Goldenhar's syndrome case (2 years old) a Montgomery device was necessary for 6 months due to the presence of tracheotomy-inducted tracheomalacia. Patients were discharged when the endpoint was obtained: symptoms and signs of airway obstruction were resolved, PAS and maxillomandibular relationship improved, and tracheotomy, when present, removed. During the follow-up, no injury to the inferior alveolar nerve was noted and scarring was significant in only the two cases treated with external devices.ConclusionMandibular Distraction Osteogenesis is a good solution in solving respiratory distress when other procedures are failed in paediatric patients with severe micrognatia.

“Discordant Airflow Obstruction: GOLD versus LLN”

I recently came across the paper of Lamprecht et al. “Subjects with discordant airways obstruction: lost between spirometric definitions of COPD” which deals with people who are defined as having COPD by the GOLD criteria [1] but not by using a lower limit of normal (LLN) method. The authors found this discordant group had fewer symptoms and less severe FEV1 impairment than those diagnosed with obstruction by both methods, and so the discordant group did not have clinically significant airway obstruction. However, they conclude that this discordant group had a clinical profile characterised by relevant comorbid disease, namely, more heart disease. The analysis they present does not allow for their conclusion that the GOLD criteria on lung function in some way specially identifies this risk, because the authors failed to account for other relevant covariates in their analysis. The discordant group is known to be biased towards men and older subjects by the way the fixed ratio of FEV1/FVC < 0.7 discriminates against them versus the LLN [2]. In their analysis the authors have accounted for the age differences between the groups but not for the observed sex differences; namely, men accounted for 81.5% of the discordant group but were only 48.7% of the concordant group. Since heart disease is more prevalent in men, the authors' results cannot be used to suggest that identifying their discordant group from lung function testing in some way specially identifies those at risk of heart disease. It just introduces a male bias.

Hairy Polyp of Nasopharynx

ABSTRACT Hairy polyps are rare benign congenital malformations occurring in the nasopharynx or oropharynx. They arise during early embryogenesis and are invariably benign. They usually present at or soon after birth with signs of airway obstruction or feeding difficulties. Hairy polyps rarely present in older patients and only few cases have been reported in adults. We report a case of hairy polyp of nasopharynx in a 22-year-old female.

Management of supraglottic dysgenesis presenting as laryngomalacia

Laryngomalacia is a common source of stridor and can lead to significant upper airway obstruction and feeding disturbances in infants. We describe a unique case of supraglottic dysgenesis presenting as laryngomalacia featuring a prominent “s-shaped” epiglottis with both posterior edges fused to the right aryepiglottic fold/arytenoid complex. Although this anomaly is not accounted for in any of the current laryngomalacia classification schemes, modified laser supraglottoplasty was a satisfactory approach leading to successful decannulation. Laryngeal embryology and possible timing of the pathogenesis of this rare occurrence are reviewed as well.

Acute Community Acquired Pneumonia in Emergency Room

Community acquired pneumonia is the leading killer of children under the age of 5 years. In ER, a diagnosis of pneumonia may be made and the severity graded on basis of WHO's classification for pneumonia in children up to 5 years of age. It relies on age-specific respiratory rate, presence of lower chest indrawing and signs of severe illness. A diagnosis of pneumonia is made if a febrile child has history of cough and difficult or rapid breathing and a respiratory rate above age specific threshold; however, signs of airway obstruction should be ruled out. Severe pneumonia is diagnosed if with the above features lower chest wall retraction is present; nonetheless, all infants below 2 months and children with moderate to severe malnutrition with pneumonia are categorized as having severe pneumonia. A chest radiograph is indicated only if the diagnosis is in doubt; complications are suspected and there is severe/very severe or recurrent pneumonia. Non-severe pneumonia is treated at home with oral amoxicillin for 3-5 days. If there is no improvement in 48 h it is changed to amoxicillin-clavulanate. Azithromycin is added for atypical pneumonia. Indications for hospitalization include age <2 months, treatment failure on oral antibiotics, severe/very severe or recurrent pneumonia, shock, hypoxemia, severe malnutrition, immunocompromised state. Severe pneumonia is treated with injectable ampicillin; Cloxacillin is added if clinical/radiographic features suggest Staphylococcal infection. On review after 48 h, if improved, the child may be sent home on oral amoxicillin for 5 more days; if not, it is treated as very severe pneumonia. Very severe pneumonia is treated with injectable Ampicillin plus gentamicin. If improved after 48 h, oral amoxicillin and gentamicin are continued for 10 days. If not, respiratory support is enhanced, antibiotics are changed to intravenous ceftriaxone and amikacin and further work up is planned. Children with chronic diseases and recurrent pneumonia require specific antibiotics depending on the underlying cause.

Lingual hematoma causing upper airway obstruction: an unusual manifestation of dengue fever

The spectrum of dengue infection varies from dengue fever to more severe forms such as dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). In DHF bleeding may be overt (external) or internal. At time bleeding can occur at unusual sites. We report one such case of DHF in which bleeding occurred within the tongue manifesting as an intra-lingual hematoma, causing significant upper airway obstruction.

Lung Dysfunction of Chronic Smokers with No Signs of COPD

Cigarette smoking causes airflow limitation with lung hyperinflation being the primary causes of COPD. Fifty chronic smokers (CSs) with no signs of GOLD-adjusted COPD with smoking habit at least ≥10 pack-years (p/yrs) were divided into CS-mild (n = 24) with smoking history from ≥10 to ≤20 p/yrs and CS-heavy groups (n = 26) with smoking history ≥21 p/yrs. Spirometry, plethysmography and diffusing capacity were measured and lung computed tomography (CT) was performed. Residual volume (RV) (L) and RV/TLC (total lung capacity) ratio were significantly increased in CS-heavy when compared to CS-mild (p = 0.001, p = 0.03). A significant reduction of forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio and airway specific conductance was shown in CS-heavy (p = 0.02, p = 0.03). Lung emphysema signs at CTs were revealed in 17 CSs and ten of them had declined diffusing capacity below 70% of predicted. The percentage of emphysematous lesions inversely and significantly correlated with measured diffusing capacity (p = 0.0009, r = −0.72). Study groups’ smoking intensity inversely correlated the declined airway specific conductance (p = 0.004, r = −0.39) and increase of the RV (L) (p = 0.0004, r = 0.46). Multiple regression analysis determined that smoking intensity regardless of the subjects’ age was significant factor for decline of airway specific conductance and increase of RV (L). Here we conclude that lung function deviation and lung structural changes are present in CSs before the clinical signs of airway obstruction reveal. Body plethysmography and diffusing capacity measurement with routine spirometry can provide valuable information for detection of changes reflecting to the early onset of COPD in CSs.

Oral and Nasal Steroids for Nasal Polyps

Oral and Nasal Steroids for Nasal Polyps

Analysis of the upper airway by the acoustic reflection method in children with mucopolysaccharidosis

Upper airway obstruction is common in children with mucopolysaccharidosis. The acoustic reflection method is a noninvasive technique that can analyze the caliber of the upper airways. The aim of the study was to evaluate the feasibility of the acoustic reflection method in children with mucopolysaccharidosis, and to compare the characteristics of the upper airways evaluated by the acoustic reflection method in patients with mucopolysaccharidosis to matched healthy counterparts. Open, single center, prospective, study. Accurate acoustic reflection measurements could be obtained in 7 of 10 patients (mean age: 10.4 ± 3.9 years; mucopolysaccharidosis type II (n = 3); type IV (n = 2), type VI (n = 1), and fucosidosis (n = 1)). The mean minimum cross-sectional area was lower in mucopolysaccharidosis patients (1.6 ± 0.3 cm(2) ) as compared to 14 healthy counterparts (1.8 ± 0.3 cm(2); P = 0.03). The mean resistance of the airways was significantly higher in the MPS group (7.9 ± 1.8 cmH(2) O l(-1) sec) as compared to the controls (5.5 ± 1.2 cmH(2) O l(-1) sec; P = 0.006). This study is the first to analyze the upper airways by the noninvasive acoustic reflection method in children with mucopolysaccharidosis. Due to a lack of cooperation, reliable measurements could only be obtained in 70% of a selected group of patients. Children with mucopolysaccharidosis have significant upper airway obstruction as assessed by the reduction of the minimal cross-sectional area of the upper airways and the increase in airway resistance.

Treatment of subglottic hemangiomas with propranolol: initial experience in 10 infants

Subglottic hemangiomas (SGH) are a rare tumour, often associated with significant airway obstruction in infants. Current treatment options, while effective, often expose the infant to potential complications. Emerging evidence suggests a role for the beta blocker propranolol in the initial management of SGH. We report our experience with propranolol 2 mg/kg/day in 10 consecutive cases of SGH with significant airway obstruction (age range 2–4 months). After a mean of 7.7 months of treatment, symptom resolution was observed in all cases and eight infants had regression and were stable. Two patients experienced regrowth after 9 months of therapy. To date, no infant has had a tracheostomy or surgical removal of the lesion. Early results with propranolol are promising; it is effective in controlling SGH, has a rapid onset of action, appears to obviate the need for tracheostomy and can allow tapering of the corticosteroid dose. Repeat laryngoscopy will be required to map the clinical course of these children and elucidate the long-term benefits of propranolol.

Clinical use of dexmedetomidine in monitored anesthesia care

Monitored anesthesia care (MAC) is useful for various clinical fields such as minimally invasive surgery, gastrointestinal endoscopy, and interventional or radiological procedures. It provides suitable intraoperative conditions as well as comfort for patients. The commonly used drugs are midazolam, propofol, and opioids such as fentanyl, alfentanil or remifentanil. Occasionally, the administration of sedatives or hypnotics in conjunction with analgesics can cause significant respiratory depression and/or transient upper airway obstruction. Dexmedetomidine is a highly selevtive α2-adrenoceptor agonist with eight times higher specificity for the receptor compared to clonidine. It provides excellent sedation and analgesia with minimal respiratory depression [1]. Recent multicenter trial indicated that it was an effective baseline sedative for patients undergoing a broad range of surgical procedures under MAC, providing greater patient satisfaction, less opioid requirements, and less respiratory depression compared with the placebo [2]. In patients undergoing diagnostic transesophageal echocardiography, the sedative effect of dexmedetomidine proved to be equivalent to that of the standard therapy using midazolam and fentanyl without increasing the incidences of respiratory depression or oxygen desaturation. It also seemed to be better in terms of hemodynamic results [3]. Dexmedetomidine with fentanyl could be used safely and effectively for sedation and analgesia during extracorporeal shockwave lithotripsy [4]. In the current issue of the Korean Journal of Anesthesiology [5], the authors demonstrated dexmedetomidine was a useful sedative drug for MAC in outpatients undergoing cataract surgery, and in aspects of patients' satisfaction and cardiovascular stability, it was superior to the combination of propofol and alfentanil. However, Muller et al. [6] have showed dexmedetomidine alone was not as effective as propofol with fentanyl for providing conscious sedation during ERCP. Furthermore, it was associated with greater hemodynamic instability and longer recovery time. Spontaneously breathing pediatrics patients undergoing cardiac catheterization with dexmedetomidine and ketamine experienced insufficient sedation and analgesia and prolonged recovery compared to propofol and ketamine [7]. Dexmedetomidine leads to dose-dependent decreases in blood pressure, heart rate, and plasma catecholamine concentrations [8,9]. Higher concentrations of this drug can also result in systemic and pulmonary hypertension [10]. Severe bradycardia progressing to pulseless electrical activity caused by dexmedetomidine was reported in a 74-year-old man who experienced a postoperative myocardial infarction [11]. These adverse effects on cardiovascular system might limit the use of high concentrations of dexmedetomidine, and clinicians must always be careful when using this drug, especially in patients with significant cardiac disease. Rapid administration of dexmedetomidine can lead to transient hypertension, bradycardia, or tachycardia, and therefore, administration of a loading dose for over 10 minutes is recommended [12]. The drug is sometimes used without a loading dose [11]. The report, published in the current issue of the Korean Journal of Anesthesiology [5], suggested continuous infusion of dexmedetomidine adjusted depending on the sedation scale without a loading dose neither disturbing cardiovascular stability nor delaying discharge. It is necessary to monitor blood pressure even after discontinuation of dexmedetomidine as its infusion for 2 minutes has induced a long-lasting decrease in mean arterial blood pressure in the healthy volunteers, with a maximum decrease of 14% for 0.25 µg/kg and 16% for 0.5 µg/kg at 60 minutes after the discontinuance of the drug [13]. Although dexmedetomidine is an attractive drug for MAC, further studies on appropriate dosage according to patients' age or race or the presence of other drugs and on the method of infusion suitable for each procedures are required for safe use. The use of dexmedetomidine in pediatric patients is not yet approved in Korea.

Management of Supraglottic Dysgenesis Presenting as Laryngomalacia

Abstract Laryngomalacia is a common source of stridor and can lead to significant upper airway obstruction and feeding disturbances in infants. We describe a unique case of supraglottic dysgenesis presenting as laryngomalacia featuring a prominent “s-shaped” epiglottis with both posterior edges fused to the right aryepiglottic fold/arytenoid complex. Although this anomaly is not accounted for in any of the current laryngomalacia classification schemes, modified laser supraglottoplasty was a satisfactory approach leading to successful decannulation. Laryngeal embryology and possible timing of the pathogenesis of this rare occurrence are reviewed as well.

Left Vocal Cord Paralysis After Extreme Preterm Birth, a New Clinical Scenario in Adults

The goal was to study the incidence and long-term consequences of left vocal cord paralysis (LVCP) after neonatal surgical treatment of patent ductus arteriosus (PDA) in a population-based cohort of adults who were born at gestational ages of ≤28 weeks or with birth weights of ≤1000 g in western Norway. Subjects with a history of neonatal PDA surgery were examined with transnasal flexible laryngoscopy, and those with LVCP were examined with continuous laryngoscopy during maximal treadmill exercise (continuous laryngoscopy exercise testing). All subjects underwent lung function testing, ergospirometry, and pulmonary high-resolution computed tomography. Symptoms were recorded with a questionnaire. Forty-four (86%) of 51 eligible preterm infants participated in the study, 13 (26%) had a history of PDA surgery and 7 (54%) had LVCP, with the laryngeal appearances varying slightly. As a group, subjects with LVCP had significant airway obstruction, no decreases in aerobic capacity, and no obvious evidence of longstanding aspiration on high-resolution computed tomography scans. The continuous laryngoscopy exercise tests revealed increasing respiratory symptoms in parallel with increasing anteromedial collapse of the left aryepiglottic folds as the exercise load increased. Hoarseness and voice-related symptoms were the most typical complaints. Symptoms were attributed erroneously to other diseases for at least 2 subjects. LVCP is not uncommon in young adults exposed to PDA surgery as preterm infants. The condition may be overlooked easily, and symptoms may be confused with those of other diseases. Laryngoscopy should be offered on the basis of liberal indications after PDA ligation.

Part 14: Pediatric Advanced Life Support

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Tracheal Squamous Cell Carcinoma Treated Endoscopically

Malignant primary tracheal tumors are extremely rare. The most common malignant primary tracheal tumors are squamous cell carcinoma and adenoid cystic carcinomas. In this brief report, we describe a patient who presented with a primary papillary squamous cell carcinoma in-situ at multiple areas in the trachea with a significant airway obstruction. Our case was successfully managed using a combination of electrocautery and argon photocoagulation for endotracheal ablation of the tumor and adjuvant external beam radiotherapy.