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The Laryngoscope Jan 2016Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are... (Review)
Review
OBJECTIVES/HYPOTHESIS
Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are poorly understood. Our aim was to systematically review existing literature on the effects of anesthetic agents on the upper airway.
DATA SOURCES
PubMed, CINAHL, EBM reviews and Scopus (all indexed years).
REVIEW METHODS
Inclusion criteria included English language articles containing original human data. Two investigators independently reviewed all articles for outcomes related to upper airway morphology, dynamics, neuromuscular response, and respiratory control.
RESULTS
The initial search yielded 180 abstracts; 56 articles were ultimately included (total population = 8,540). The anesthetic agents studied were: topical lidocaine, propofol, dexmedetomidine, midazolam, pentobarbital, sevoflurane, desflurane, ketamine, and opioids. Outcome measures were diverse and included imaging studies, genioglossus electromyography, endoscopic airway assessment, polysomnography, upper airway closing pressure, and clinical evidence of obstruction. All agents caused some degrees of airway collapse. Dexmedetomidine did not have dose-dependent effects when evaluated using cine magnetic resonance imaging, unlike sevoflurane, isoflurane, and propofol, and caused less dynamic collapse than propofol.
CONCLUSIONS
Studies assessing the effect of anesthesia on the upper airway in patients with and without OSA are limited, and few compare effects between agents. Medications with minimal effect on respiratory control (e.g., dexmedetomidine) may work best for DISE.
Topics: Airway Resistance; Analgesics, Opioid; Anesthetics; Humans; Larynx; Pharynx; Sleep Apnea, Obstructive
PubMed: 26198715
DOI: 10.1002/lary.25399 -
Intensive Care Medicine Jul 2009To evaluate, in adults, the diagnostic accuracy of the cuff-leak test for the diagnosis of upper airway obstruction secondary to laryngeal edema and for reintubation... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To evaluate, in adults, the diagnostic accuracy of the cuff-leak test for the diagnosis of upper airway obstruction secondary to laryngeal edema and for reintubation secondary to upper airway obstruction.
METHODS
Systematic review without language restrictions based on electronic databases and manual review of the literature up to December 2008. When appropriate, a random-effects meta-analysis and meta-regression (Moses' method) were performed.
RESULTS
Upper airway obstruction was the outcome in nine studies with an overall incidence of 6.9%. There was significant heterogeneity among studies. The pooled sensitivity was 0.56 (95% confidence interval: 0.48-0.63), the specificity was 0.92 (95% CI: 0.90-0.93), the positive likelihood ratio was 5.90 (95% CI: 4.00-8.69), the negative likelihood ratio was 0.48 (95% CI: 0.33-0.72), and the diagnostic odds ratio was 18.78 (95% CI: 7.36-47.92). The area under the curve of the summary receiver-operator characteristic (SROC) was 0.92 (95% CI: 0.89-0.94). Only three studies have evaluated the accuracy of the cuff-leak test for reintubation secondary to upper airway obstruction. Overall incidence was 7%. The pooled sensitivity was 0.63 (95% CI: 0.38-0.84), the specificity was 0.86 (95% CI: 0.81-0.90), the positive likelihood ratio was 4.04 (95% CI: 2.21-7.40), the negative likelihood ratio was 0.46 (95% CI: 0.26-0.82), and the diagnostic odds ratio was 10.37 (95% CI: 3.70-29.13).
CONCLUSIONS
A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction.
Topics: Aged; Aged, 80 and over; Airway Obstruction; Equipment Failure Analysis; Female; Humans; Intensive Care Units; Laryngeal Edema; Male; Middle Aged; Respiration, Artificial; Retreatment
PubMed: 19399474
DOI: 10.1007/s00134-009-1501-9 -
JAMA Feb 2019Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available.
OBJECTIVE
To identify risk factors and physical findings that predict difficult intubation.
DATA SOURCES
The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies.
STUDY SELECTION
Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed.
DATA EXTRACTION AND SYNTHESIS
Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge.
RESULTS
Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]).
CONCLUSIONS AND RELEVANCE
Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.
Topics: Airway Obstruction; Humans; Intubation, Intratracheal; Jaw; Likelihood Functions; Mouth; Pharynx; Risk Factors; Sensitivity and Specificity
PubMed: 30721300
DOI: 10.1001/jama.2018.21413 -
Repair of the Lateral Nasal Wall in Nasal Airway Obstruction: A Systematic Review and Meta-analysis.JAMA Facial Plastic Surgery Jul 2018While functional rhinoplasty has been broadly studied, to our knowledge no systematic review and meta-analysis of lateral wall repair has been done previously. (Meta-Analysis)
Meta-Analysis
IMPORTANCE
While functional rhinoplasty has been broadly studied, to our knowledge no systematic review and meta-analysis of lateral wall repair has been done previously.
OBJECTIVE
To evaluate the effectiveness of repair of the lateral nasal wall in adult patients with nasal airway obstruction.
DATA SOURCES
Medline, Embase, Cinahl, Central, Scopus, and Web of Science databases and reference lists were searched for clinical and observational studies.
STUDY SELECTION
The selection criteria were defined according to the PICO (population, intervention, comparison, and outcome) framework. The relevant studies were selected by 2 independent reviewers based on the studies' abstracts and full texts.
DATA EXTRACTION AND SYNTHESIS
Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. The effect sizes were first calculated for each study and then pooled together using random effects synthesis. Heterogeneity was assessed using the I2 statistic, and publication bias was evaluated by the Egger test.
MAIN OUTCOMES AND MEASURES
The results were reported as pooled row mean differences in changes from preoperative to postoperative Nasal Obstruction Symptom Evaluation scores at different times of follow-up (≤3 months, >3 to 6 months, and >6 months).
RESULTS
Of 1522 initial records, 10 studies were considered relevant-all of them observational. The pooled study sample included 324 participants. When combining all the repeated measures together, the pooled effect size for functional rhinoplasty was -47.7 (95% CI, -53.4 to 42.1) points on the Nasal Obstruction Symptom Evaluation scale with high heterogeneity of 72%. The pooled effect size outcomes were similar in short- (-45.0 points [95% CI, -47.8 to -42.2 points]), mid- (-48.4 points [95% CI, -52.5 to -44.4 points]), and long-term (-49.0 points [95% CI, -62.1 to -35.8 points]) follow-ups.
CONCLUSIONS AND RELEVANCE
The pooled effect size of 10 observational studies supported the effectiveness of functional rhinoplasty for the treatment of nasal airway obstruction caused by lateral nasal wall insufficiency. To improve the level of evidence, randomized clinical trials are needed.
LEVEL OF EVIDENCE
NA.
Topics: Humans; Nasal Obstruction; Rhinoplasty
PubMed: 29543934
DOI: 10.1001/jamafacial.2018.0036 -
Pediatric Pulmonology Dec 2015Laryngomalacia is the most common cause of dyspnea and stridor in newborn infants. Laryngomalacia is a dynamic change of the upper airway based on abnormally pliable... (Review)
Review
OBJECTIVE
Laryngomalacia is the most common cause of dyspnea and stridor in newborn infants. Laryngomalacia is a dynamic change of the upper airway based on abnormally pliable supraglottic structures, which causes upper airway obstruction. In the past, different classification systems have been introduced. Until now no classification system is widely accepted and applied. Our goal is to provide a simple and complete classification system based on systematic literature search and our experiences.
STUDY DESIGN
Retrospective cohort study with literature review.
METHODS
All patients with laryngomalacia under the age of 5 at time of diagnosis were included. Photo and video documentation was used to confirm diagnosis and characteristics of dynamic airway change. Outcome was compared with available classification systems in literature.
RESULTS
Eighty-five patients were included. In contrast to other classification systems, only three typical different dynamic changes have been identified in our series. Two existing classification systems covered 100% of our findings, but there was an unnecessary overlap between different types in most of the systems. Based on our finding, we propose a new a classification system for laryngomalacia, which is purely based on dynamic airway changes.
CONCLUSION
The groningen laryngomalacia classification is a new, simplified classification system with three types, based on purely dynamic laryngeal changes, tested in a tertiary referral center: Type 1: inward collapse of arytenoids cartilages, Type 2: medial displacement of aryepiglottic folds, and Type 3: posterocaudal displacement of epiglottis against the posterior pharyngeal wall.
Topics: Arytenoid Cartilage; Child, Preschool; Cohort Studies; Endoscopy; Epiglottis; Female; Humans; Infant; Infant, Newborn; Laryngomalacia; Male; Pharynx; Retrospective Studies
PubMed: 25825153
DOI: 10.1002/ppul.23186 -
BMJ Clinical Evidence Jun 2009Sleep apnoea is the popular term for obstructive sleep apnoea-hypopnoea syndrome (OSAHS). OSAHS is abnormal breathing during sleep that causes recurrent arousals, sleep... (Review)
Review
INTRODUCTION
Sleep apnoea is the popular term for obstructive sleep apnoea-hypopnoea syndrome (OSAHS). OSAHS is abnormal breathing during sleep that causes recurrent arousals, sleep fragmentation, excessive daytime sleepiness, and nocturnal hypoxaemia. Apnoea may be "central", in which there is cessation of inspiratory effort, or "obstructive", in which inspiratory efforts continue but are ineffective because of upper airway obstruction. OSAHS affects up to 4% of men and 2% of women in the USA, with obesity being a major determinant.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatment for severe obstructive sleep apnoea-hypopnoea syndrome? What are the effects of treatment for non-severe obstructive sleep apnoea-hypopnoea syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 43 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: nasal continuous positive airway pressure (CPAP); measures aimed at improving compliance with CPAP; oral appliances; and weight loss.
Topics: Arousal; Emotions; Health Status; Humans; Patient Satisfaction; Psychological Distance; Single-Blind Method; Sleep Apnea Syndromes; United States Food and Drug Administration
PubMed: 21726484
DOI: No ID Found -
JAMA Facial Plastic Surgery 2014IMPORTANCE A gold standard objective measure of nasal airway obstruction (NAO) does not currently exist, so patient-reported measures are commonly used, particularly the... (Review)
Review
IMPORTANCE A gold standard objective measure of nasal airway obstruction (NAO) does not currently exist, so patient-reported measures are commonly used, particularly the Nasal Obstruction Symptom Evaluation (NOSE) scale and the visual analog scale (VAS). However, questions remain regarding how best to use these instruments. OBJECTIVES To systematically review studies on NOSE and VAS scores in patients with NAO and to compile and standardize the data to (1) define symptomatic and normative values for presurgical and postsurgical patients with NAO, asymptomatic individuals, and the general population; (2) determine if postsurgical scores are comparable with asymptomatic scores; and (3) determine if there is a clinically useful preoperative and postoperative score change. EVIDENCE REVIEW A systematic review of the literature was performed through PubMed for studies assessing NOSE and VAS scores in patients with chronic NAO. Strict inclusion criteria were applied to focus on anatomic obstruction only. For statistical analysis, the patients were classified as asymptomatic, presurgical and postsurgical with NAO, and the general population. FINDINGS The mean (SD) NOSE and VAS scores for a patient with NAO were 65 (22) and 6.9 (2.3), respectively. The mean postsurgical NOSE and VAS scores were 23 (20) and 2.1 (2.2), respectively. The mean asymptomatic individual NOSE and VAS scores were 15 (17) and 2.1 (1.6). The mean NOSE and VAS scores for the general population were 42 (27) and 4.6 (2.6), respectively. The mean presurgical to postsurgical change was more than 40 for NOSE scores and more than 4.0 for VAS scores. CONCLUSIONS AND RELEVANCE We have shown that normative and abnormal value ranges for NOSE and VAS can be established for clinical use. Given the consistency of both scales, we conclude that these measures can be used as a clinically meaningful measure of successful surgical outcomes.
Topics: Humans; Nasal Obstruction; Pain Measurement; Rhinoplasty; Self Report; Treatment Outcome
PubMed: 24604253
DOI: 10.1001/jamafacial.2013.2473 -
International Journal of Pediatric... Dec 2020Tracheal stenosis and tracheobronchomalacia are complicated, patient-specific diseases that can be treated with intraluminal stenting. Most commonly, silicone and metal... (Review)
Review
INTRODUCTION
Tracheal stenosis and tracheobronchomalacia are complicated, patient-specific diseases that can be treated with intraluminal stenting. Most commonly, silicone and metal stents are utilized, however, they pose significant early and late morbidity and are further complicated by growth of the airway in the pediatric population. Given recent improvements in materials science, there is a growing body of evidence suggesting a strong role for bioresorbable intraluminal stents in treating pediatric tracheobronchial obstruction.
METHODS
A PubMed.gov literature search was performed on December 3, 2019 and May 15, 2020, and a 2-researcher systematic review was performed following the PRISMA criteria. The following search query was utilized: (((((((bioresorbable) OR bioabsorbable) OR resorbable) OR absorbable) OR biodegradable AND airway) OR trachea) AND stent. A pooled statistical analysis was performed on all reported pediatric patients using SPSS software.
RESULTS
1369 publications were screened and 26 articles with original data were identified. Materials used included polydioxanone (PDO), poly-l-lactic acid (PLLA), polyglycolic acid/poly-l-lactide co-polymer with Proglactin 910 (Vicryl®-PDS®), polycaprolactone (PCL), magnesium alloys, and co-polymers in varying proportions. Twelve articles presented data on human subjects, 8 of which were case series and case reports on pediatric populations using polydioxanone (PDO) stents. Pooled statistical analysis demonstrated an average age of 19 months (range 0.25-144), 56.5% associated with a cardiovascular anomaly, and overall complication rate of 21.7%, with a stent fragment foreign body being the most common (8.7%), followed by significant granulation tissue (4.3%), stent migration (4.3%), and local stenosis (4.3%). Comparative analysis demonstrated short-term improvement (up to 1 month) has a statistically significant association with tracheobronchomalacia versus tracheal stenosis on chi-squared test (p = 0.001). The remaining analyses did not yield statistical significance.
CONCLUSION
The reported application of bioresorbable materials as intraluminal airway stents is positive. All comparative animal studies report biocompatibility and fewer morbidities compared to metal and silicone stents, however, in human studies there are concerns over the short interval of degradation and the potential for obstructive foreign bodies in poorly seated stents. Overall, there are clear, reproducible advantages to bioresorbable intraluminal stents in pediatric airway obstruction, as well as common pitfalls, that warrant further research.
Topics: Absorbable Implants; Airway Obstruction; Animals; Child; Child, Preschool; Humans; Infant; Infant, Newborn; Stents; Trachea; Tracheal Stenosis
PubMed: 33017664
DOI: 10.1016/j.ijporl.2020.110405 -
Seminars in Oncology Dec 2022Immune checkpoint inhibitors (ICI) are widely used for the treatment of various malignant neoplasms. Interstitial lung disease is a well-known immune-related adverse... (Review)
Review
Immune checkpoint inhibitors (ICI) are widely used for the treatment of various malignant neoplasms. Interstitial lung disease is a well-known immune-related adverse event, however, ICI-induced airway disease remains under-recognized. Herein, we report two similar cases of pembrolizumab-induced tracheobronchitis presenting as persistent chronic cough and dyspnea. Blood tests revealed elevated C-reactive protein levels without eosinophilia. Spirometry demonstrated mild airflow obstruction. Computed tomography revealed diffuse thickening of the tracheobronchial walls and bronchiectasis predominantly in the lower lobes. Bronchoscopy revealed edematous and erythematous tracheobronchial mucosa, and bronchial biopsy tissue exhibited marked inflammation with predominant infiltration of CD8+ lymphocytes. Subsequently, pembrolizumab-induced tracheobronchitis was diagnosed in both cases. Cessation of pembrolizumab and initiation of erythromycin, inhaled corticosteroids, and long-acting beta-agonists gradually improved the symptoms, airflow obstruction, and radiographic findings. These were completely resolved in one case. The other case initially showed a poor response to systemic corticosteroids combined with the aforementioned drugs, but improved gradually and almost completely. These cases exemplify ICI-induced airway disease that is, an under-recognized manifestation of immune-related adverse events. In addition, we have systematically searched the PubMed database for articles on ICI-induced airway disease, categorized the retrieved articles as eosinophilic and non-eosinophilic airway diseases, and reviewed the differences in treatment and prognoses between these two categories.
Topics: Humans; Immune Checkpoint Inhibitors; Lung; Neoplasms; Cough; Adrenal Cortex Hormones; Pulmonary Disease, Chronic Obstructive
PubMed: 36759235
DOI: 10.1053/j.seminoncol.2023.01.003 -
The Journal of Laryngology and Otology Jan 2015To systematically review outcomes of adults with obstructive sleep apnoea treated with nasopharyngeal airway stenting devices. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To systematically review outcomes of adults with obstructive sleep apnoea treated with nasopharyngeal airway stenting devices.
METHODS
Medline, Scopus, Web of Science and the Cochrane Library databases were searched, and data on device use and tolerability, sleepiness, oxygen saturation, apnoea index, apnoea-hypopnoea index, and sleep quality were collected.
RESULTS
Of 573 potential studies, 29 were retrieved for detailed evaluation and 16 met the study criteria. Polysomnography data for patients treated with nasal trumpets as an isolated therapy were pooled for meta-analysis. The mean apnoea index ± standard deviation, for 53 patients, decreased from 32.4 ± 15.9 to 9.0 ± 7.2 episodes per hour (p < 0.00001). The mean apnoea-hypopnoea index, for 193 patients, decreased from 44.1 ± 18.9 to 22.7 ± 19.3 episodes per hour (p < 0.00001). The mean lowest oxygen saturation, for 193 patients, increased from 66.5 ± 14.2 to 75.5 ± 13.9 per cent (p < 0.00001).
CONCLUSION
Some studies have demonstrated limited effectiveness and low tolerability of nasopharyngeal airway stenting devices, while other studies have shown a significant benefit in treating obstructive sleep apnoea, with a high level of patient acceptance. Nasal trumpets have been successful in decreasing airway obstruction in the short term.
Topics: Airway Management; Equipment Design; Humans; Nasopharynx; Polysomnography; Sleep Apnea, Obstructive; Stents; Treatment Outcome
PubMed: 25544266
DOI: 10.1017/S0022215114003119