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BMC Emergency Medicine Mar 2022Computed tomography (CT) is often performed to assess patients; however, little is known about how airway size measured by CT scan imaging might influence the occurrence... (Observational Study)
Observational Study
BACKGROUND
Computed tomography (CT) is often performed to assess patients; however, little is known about how airway size measured by CT scan imaging might influence the occurrence of post-extubation upper airway obstruction.
METHODS
This study aimed to evaluate the association between airway size measured by CT and the incidence of post-extubation upper airway obstruction symptoms for each sex. This single-center observational study was conducted at a tertiary emergency medical center/severe trauma center with a 12-bed intensive care unit. We enrolled consecutive adult patients (aged ≥ 20 years), who were intubated in the emergency room, between January 2016 and March 2019. Patients who underwent a CT scan of the glottic region within three hours before and after intubation were included in the analysis. For each sex, we first divided the patients into two groups: those who had post-extubation stridor, hoarseness, or both and those who had no such symptoms. Then, we compared the two groups using the Mann-Whitney U test and Fisher's exact test. Univariate and multivariate logistic regression analyses were also performed.
RESULTS
During the 39 months, 855 patients were enrolled in this study. A total of 217 patients underwent CT of the glottic region within three hours before and after intubation. Five patients had no records of symptoms after extubation. Thus, we analyzed data from 212 patients. This study included 144 males and 68 females. In female patients, the median [inter-quartile range] (average) of the transverse diameter of the glottis/endotracheal tube outer diameter (OD) ratio was smaller in patients with post-extubation upper airway obstruction symptoms than in patients without the symptoms (1.00 [1.00-1.00] (0.9572) vs. 1.00 [1.00-1.00] (1.00296), respectively; p = .013). Multivariate logistic regression analysis showed that the glottis/tube OD ratio < 1 was associated with the symptoms in females (odds ratio: 95% confidence interval, 5.68: 1.04-30.97). There was no relation between the airway sizes and the symptoms in male patients.
CONCLUSIONS
In female patients, no gap between the endotracheal tube and the vocal codes or the glottic transverse diameter being smaller than the endotracheal tube OD on CT scan was associated with post-extubation upper airway obstruction symptoms.
Topics: Adult; Airway Extubation; Airway Obstruction; Female; Humans; Incidence; Intubation, Intratracheal; Male; Tomography, X-Ray Computed; Young Adult
PubMed: 35361111
DOI: 10.1186/s12873-022-00615-7 -
BMJ Case Reports Aug 2021We describe the case of a 33-year-old female smoker who presented to the Accident and Emergency department with a 1-day history of rapidly evolving airway compromise....
We describe the case of a 33-year-old female smoker who presented to the Accident and Emergency department with a 1-day history of rapidly evolving airway compromise. She had no preceding illness or other objective signs/symptoms on presentation, had a history of Chronic Obstructive Pulmonary Disease (COPD) and a previous opioid addiction. Following failed endotracheal intubation, the airway was secured with an emergency surgical tracheostomy. Subsequent direct laryngoscopy revealed a severely diseased glottis and supraglottic area, from which biopsy samples revealed a multiple drug-resistant strain of requiring specialist microbiology input and antifungal treatment. We describe the presentation, investigation, management and outcome of this rare case, along with a literature review of the subject.
Topics: Adult; Airway Obstruction; Candidiasis; Female; Humans; Intubation, Intratracheal; Laryngoscopy; Larynx; Tracheostomy
PubMed: 34353829
DOI: 10.1136/bcr-2021-242910 -
Paediatric Anaesthesia Mar 2020In utero congenital malformations in the fetus can occasionally lead to an obstructed airway at birth accompanied by hypoxic injury or peripartum demise, without... (Review)
Review
In utero congenital malformations in the fetus can occasionally lead to an obstructed airway at birth accompanied by hypoxic injury or peripartum demise, without intervention. Ex utero intrapartum treatment (EXIT) may help reduce morbidity and mortality associated with challenging airways by providing extra time on uteroplacental circulation to secure the airway. Meticulous preparation and planning are crucial for this procedure. Many different types of congenital malformations can result in a difficult airway, but there is no correlation between specific malformations and a required type of airway intervention. Based on our experience and literature review, an airway process flow diagram has been created to help assist teams in decision-making for airway intervention in a neonate during the EXIT procedure. The management of the airway in this scenario involves additional unique considerations that accompany handling a partially delivered newborn in the uterine environment. Extensive preparation and team rehearsal are essential to the success of this procedure.
Topics: Airway Management; Airway Obstruction; Female; Humans; Infant, Newborn; Placental Circulation; Pregnancy
PubMed: 31898837
DOI: 10.1111/pan.13818 -
Pediatric Pulmonology Aug 2021
Topics: Airway Extubation; Airway Obstruction; Child; Dexamethasone; Humans; Intubation, Intratracheal; Steroids
PubMed: 34010510
DOI: 10.1002/ppul.25460 -
Revue Des Maladies Respiratoires Jan 2023Up to 30% of lung cancer patients suffer from central airway obstruction, resulting in major deterioration in prognosis and quality of life. Interventional bronchoscopy... (Review)
Review
Up to 30% of lung cancer patients suffer from central airway obstruction, resulting in major deterioration in prognosis and quality of life. Interventional bronchoscopy combines a number of invasive techniques used during rigid bronchoscopy. It is designed to rapidly improve symptoms, primarily dyspnea. Applied according to very precise indications, this technique requires careful patient selection and needs to be incorporated into the multimodal oncological management in combination with systemic treatments, radiation therapy and surgery.
Topics: Humans; Quality of Life; Airway Obstruction; Lung Neoplasms; Bronchoscopy; Prognosis; Stents
PubMed: 36577607
DOI: 10.1016/j.rmr.2022.11.084 -
Pediatric Critical Care Medicine : a... Oct 2021Post-extubation upper airway obstruction is the most common cause of extubation failure in children, but there are few data regarding long-term morbidity. We aim to...
OBJECTIVES
Post-extubation upper airway obstruction is the most common cause of extubation failure in children, but there are few data regarding long-term morbidity. We aim to describe the frequency of long-term airway sequelae in intubated children and determine the association with post-extubation upper airway obstruction.
DESIGN
Retrospective, post hoc analysis of previously identified prospective cohort of children in the pediatric/cardiothoracic ICU at Children's Hospital Los Angeles from July 2012 to April 2015. A single provider blinded to the upper airway obstruction classification reviewed the electronic medical records of all patients in the parent study, before and after the index extubation (extubation during parent study), to identify pre-index and post-index upper airway disease. Primary outcomes were prevalence of newly diagnosed airway anomalies following index extubation.
SETTING
Single center, tertiary, 391-bed children's hospital.
PATIENTS
From the parent study, 327 children younger than 18 years (intubated for at least 12 hr) were included if they received subsequent care (regardless of specialty) after the index extubation.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
New airway anomalies were identified in 40 of 327 children (12.2%). Patients labeled with subglottic upper airway obstruction at the index extubation were more likely to be diagnosed with new airway anomalies on subsequent follow-up, receive long-term Otolaryngology follow-up, or receive airway surgery (all p ≤ 0.006). In multivariable modeling, upper airway obstruction as the primary reason for initial intubation (odds ratio, 3.71; CI, 1.50-9.19), reintubation during the index ICU admission (odds ratio, 4.44; CI, 1.67-11.80), pre-index airway anomaly (odds ratio, 3.31; CI, 1.36-8.01), and post-extubation subglottic upper airway obstruction (odds ratio, 3.50; CI, 1.46-8.34) remained independently associated with the diagnosis of new airway anomalies.
CONCLUSIONS
Post-extubation subglottic upper airway obstruction is associated with a three-fold greater odds of long-term airway morbidity. These patients may represent an at-risk population that should be monitored closely after leaving the ICU.
Topics: Airway Extubation; Airway Obstruction; Child; Humans; Intubation, Intratracheal; Prospective Studies; Retrospective Studies
PubMed: 33833205
DOI: 10.1097/PCC.0000000000002724 -
Anesthesiology Jun 2021
Comparative Study Review
Topics: Airway Obstruction; Fiber Optic Technology; Head and Neck Neoplasms; Humans; Intubation, Intratracheal; Tracheostomy; Wakefulness
PubMed: 33684214
DOI: 10.1097/ALN.0000000000003744 -
Archives of Disease in Childhood.... Apr 2021Exertional dyspnoea among children and adolescents is a common presenting complaint to general practitioners. Exertional dyspnoea is most commonly attributed to... (Review)
Review
Exertional dyspnoea among children and adolescents is a common presenting complaint to general practitioners. Exertional dyspnoea is most commonly attributed to exercise-induced bronchoconstriction (EIB), but there are several other causes including hyperventilation syndrome, breathlessness associated with normal exercise limitation and exercise-induced laryngeal obstruction (EILO). The symptoms of EILO include stridor, throat tightness and difficulty on inspiration. If these are mistaken for EIB, children will receive asthma therapy. The underlying mechanism of EILO includes closure of the larynx during high-intensity exercise, which causes a reduction in airflow and breathlessness. This phenomenon is often associated with a background of psychological stress. Historically, a diagnosis of EILO has been considered 'rare' though this may be a reflection of under-recognition. Direct visual observation via laryngoscopy is the gold standard for diagnosis of EILO; however, this is rarely available even in specialised centres. Nevertheless, the diagnosis can usually be made by recognising the characteristic clinical pattern. Here we provide recommendations for appropriate investigations for the determination of EILO, together with suggested treatment.
Topics: Adolescent; Airway Obstruction; Asthma, Exercise-Induced; Child; Dyspnea; Humans; Laryngeal Diseases; Laryngoscopy
PubMed: 33077532
DOI: 10.1136/archdischild-2020-319454 -
Respiratory Medicine Oct 2021Increasing evidence shows that environmental factors in childhood play a role in development of irreversible airway obstruction. We evaluated early-life and...
BACKGROUND
Increasing evidence shows that environmental factors in childhood play a role in development of irreversible airway obstruction. We evaluated early-life and preschool-age risk factors for irreversible airway obstruction in adolescence after bronchiolitis in infancy.
METHODS
This study is a secondary analysis of data collected during prospective long-term follow-up of our post-bronchiolitis cohort. Risk factor data were collected during hospitalisation and on follow-up visits at 5-7 and 10-13 years of ages. Lung function was measured from 103 participants with impulse oscillometry at 5-7 years of age and from 89 participants with flow-volume spirometry at 10-13 years of age.
RESULTS
Asthma diagnosis at <12 months of age showed a significant association with irreversible airway obstruction at 10-13 years of age independently from current asthma. Irreversible airway obstruction was less frequent in children with variant than wild genotype of the Toll-like receptor 4(TLR4) rs4986790, but the significance was lost in logistic regression adjusted for current asthma and weight status. Higher post-bronchodilator respiratory system resistance at 5 Hz and lower baseline and post-bronchodilator reactance at 5 Hz by impulse oscillometry at 5-7 years of age were associated with irreversible airway obstruction at 10-13 years of age.
CONCLUSION
Asthma diagnosis during the first living year and worse lung function at preschool age increased the risk for irreversible airway obstruction at 10-13 years of age after bronchiolitis. TLR4 rs4986790 polymorphism may be protective for development of irreversible airway obstruction after bronchiolitis.
Topics: Adolescent; Age Factors; Airway Obstruction; Airway Resistance; Asthma; Bronchiolitis; Child; Child, Preschool; Female; Follow-Up Studies; Genotype; Humans; Male; Oscillometry; Polymorphism, Genetic; Prospective Studies; Risk Factors; Spirometry; Time Factors; Toll-Like Receptor 4
PubMed: 34332337
DOI: 10.1016/j.rmed.2021.106545 -
European Journal of Pediatrics Mar 2023The goal of this study was to explore the availability of diagnostic and treatment options for managing upper airway obstruction (UAO) in infants with Robin Sequence...
The goal of this study was to explore the availability of diagnostic and treatment options for managing upper airway obstruction (UAO) in infants with Robin Sequence (RS) in Europe. Countries were divided in lower- (LHECs, i.e., PPP per capita < $4000) and higher-health expenditure countries (HHECs, i.e., PPP per capita ≥ $4000). An online survey was sent to European healthcare professionals who treat RS. The survey was designed to determine the availability of diagnostic tools such as arterial blood gas analysis (ABG), pulse oximetry, CO2 analysis, polysomnography (PSG), and sleep questionnaires, as well as to identify the used treatment options in a specific center. Responses were received from professionals of 85 centers, originating from 31 different countries. It was equally challenging to provide care for infants with RS in both LHECs and HHECs (3.67/10 versus 2.65/10, p = 0.45). Furthermore, in the LHECs, there was less access to ABG (85% versus 98%, p = 0.03), CO2 analysis (45% versus 70%, p = 0.03), and PSG (54% versus 93%, p < 0.01). There were no significant differences in the accessibility concerning pulse oximetry, sleep questionnaires, home saturation monitoring, nasopharyngeal tubes, Tuebingen plates, and mandibular distraction. Conclusion: This study demonstrates a large difference in available care for infants with RS throughout Europe. LHECs have less access to diagnostic tools in RS when compared to HHECs. There is, however, no difference in the availability of treatment modalities between LHECs and HHECs. What is Known: • Patients with Robin sequence (RS) require complex and multidisciplinary care. They can present with moderate to severe upper airway obstruction (UAO). There exists a large variety in the use of diagnostics for both UAO treatment indications and evaluations. In most cases, conservative management of UAO in RS is sufficient. Patients with UAO that persist despite conservative management ultimately need surgical intervention. To determine which intervention is best suitable for the individual RS patient, the level of UAO needs to be determined through diagnostic testing. • There is a substantial variation among institutions across Europe for both diagnostics and treatment options in UAO. A standardized, internationally accepted protocol for the assessment and management of UAO in RS could guide healthcare professionals in the timing of assessment and indications to prevent escalation of UAO. Creating such a protocol might be a challenge, as there are large financial differences between countries in Europe (e.g., health expenditure per capita in purchasing power parity in international dollars ranges from $600 to over $8500). What is New: • There is a substantial variation in the availability of objective diagnostic tools between European countries. Arterial blood gas analysis, CO2 analysis and polysomnography are not equally accessible for lower-healthcare expenditure countries (LHECs) compared to higher-healthcare expenditure countries (HHECs). These differences are not only limited to availability; there is also a difference in quality of these diagnostic tools. Surprisingly, there is no difference in access to treatment tools between LHECs and HHECs. • There is national heterogeneity in access to tools for diagnosis and treatment of RS, which suggests centralization of health care, showing that specialized care is only available in tertiary centers. By centralization of care for RS infants, diagnostics and treatment can be optimized in the best possible way to create a uniform European protocol and ultimately equal care across Europe. Learning what is necessary for adequate monitoring could lead to better allocation of resources, which is especially important in a low-resource setting.
Topics: Infant; Humans; Airway Obstruction; Pierre Robin Syndrome; Carbon Dioxide; Europe; Mandible; Retrospective Studies
PubMed: 36633656
DOI: 10.1007/s00431-022-04781-5