Traumatic complications of airway management

Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy

PURPOSE

Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions.

METHODS AND MATERIALS

Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible.

RESULTS

Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively.

CONCLUSIONS

Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.

Life threatening abscess in the visceral space with penicillin and metronidazole resistant Prevotella Denticola following use of a laryngeal mask airway: case report

Background

Laryngeal mask airways (LMA) are commonly used for airway management. Complications with this device are rare. However, when they do occur, there is a high risk for respiratory problems, necessitating early diagnosis and treatment. We present the first case of a life-threatening abscess spreading in the visceral space caused by a penicillin and metronidazole resistant Prevotella Denticola after the use of an LMA.

Case presentation

A female patient was admitted to our day care centre for bunion surgery. A single use LMA size 3 (Solus®, intersurgical, Wokingham, Berkshire, United Kingdom) was successfully inserted. After surgery, the patient complained of a sore throat and amoxicillin was prescribed by the general practitioner. Three days after surgery the patient was admitted to the Intensive Care Unit (ICU) for obstructive breathing, due to an abscess in the visceral space. Retropharyngeal and certainly parapharyngeal abscesses in adults are already rare. This case however, is unique because it is the first case of abscess spreading into the visceral space after the use of an LMA. Amoxicillin/clavulanate and vancomycin were started. The abscess was incised 5 days later and microbiology showed 3 positive cultures of the anaerobe Prevotella denticola, resistant for penicillin and metronidazole, but sensitive for amoxicillin/clavulanate. The patient fully recovered.

Conclusion

LMA’s are easy to use and are established, safe tools to support ventilation of the airway. In this case, the authors hypothesise a small wound in the lateral pharyngeal wall probably created an opening into the visceral space causing infection with Prevotella denticola, supporting the idea that the pharyngeal mucosal space must be part of the visceral space. Additionally, early recognition and treatment of an LMA induced abscess is necessary to prevent evolution of complications leading to airway obstruction.

[Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients]

BACKGROUND

Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding.

MATERIAL AND METHODS

200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted.

RESULTS

Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG.

CONCLUSION

Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients.

Comparison between the Trachway video intubating stylet and Macintosh laryngoscope in four simulated difficult tracheal intubations: A manikin study

OBJECTIVES

It remains to be determined whether the TVI-4000 Trachway video intubating (TVI) stylet (Markstein Sichtec Medical Corp, Taichung, Taiwan), an airway device for novices, improves airway management practice by experienced anesthesiologists. The aim of this study was to evaluate the feasibility of using the TVI stylet in difficult tracheal intubation situations compared with that of using the Macintosh laryngoscope on an airway manikin.

MATERIALS AND METHODS

Ten anesthesiologists (with 3-21 years' experience), including three senior residents, participated. We compared tracheal intubation in four airway scenarios: normal airway, tongue edema, cervical spine immobilization, and tongue edema combined with cervical spine immobilization. The time of tracheal intubation (TTI), success rate, and perceived difficulty of intubation for each scenario were compared and analyzed.

RESULTS

The TTI was significantly shorter in both the tongue edema and combined scenarios with the TVI stylet compared with the Macintosh laryngoscope (21.60 ± 1.45 seconds vs. 24.07 ± 1.58 seconds and 23.73 ± 2.05 seconds vs. 26.6 ± 2.77 seconds, respectively). Success rates for both devices were 100%. Concomitantly, participants rated using the TVI stylet in these two scenarios as being less difficult.

CONCLUSION

The learning time for tracheal intubation using the TVI stylet in difficult airway scenarios was short. Use of the TVI stylet was easier and required a shorter TTI for tracheal intubation in the tongue edema and combined scenarios.

Vocal Cords-Carina Distance in Anaesthetised Caucasian Adults and its Clinical Implications for Tracheal Intubation

Previous work has assessed vocal cords-carina distance in Chinese patients and compared it to commonly used tracheal tubes. In addition, an attempt was made to identify surface anatomy measurements with short tracheas. We have examined the length of tracheas in Caucasian patients and compared it with currently used tracheal tubes. We have investigated a wider range of surface anatomy measurements in an attempt to correlate measurements with vocal cords-carina distance and identifying patients who may be at risk of endobronchial intubation. In this study, the vocal cords-carina distance was measured in 150 anaesthetised Caucasian patients with a fibreoptic bronchoscope. We also attempted to correlate height and various surface anatomy measurements on the patients’ chest, neck and limb regions to predict those patients at risk of endobronchial intubation. The mean vocal cords-carina distance was 12.7 cm (standard deviation 1.6 cm). The best predictors in our study of vocal cords-carina distance less than 11.3 cm were a height of ≤182 cm, an ulnar length of ≤31.2 cm or a thyroid to xiphisternum distance of ≤31.8 cm. This correlation is poor however, and prediction of vocal cords-carina distance remains difficult clinically. It was therefore concluded that surface anatomy measurements are a poor predictor of vocal cords-carina distance.

Complications associated with the use of the GlideScope videolaryngoscope

PURPOSE

Two cases are presented wherein the GlideScope videolaryngoscope (GVL) facilitated laryngeal exposure and successful endotracheal intubation, but resulted in pharyngeal injury.

CLINICAL FEATURES

GlideScope videolaryngoscopy was performed in two female patients, whose airways were anticipated to present difficulties for direct laryngoscopy. In the first case, following induction of anesthesia, moderate difficulty was encountered in directing the endotracheal tube (ETT) into the patient's larynx. In the second case, minimal difficulty with the GVL was experienced, and no problems were identified with airway instrumentation until the drapes covering the patient's face were removed. In both instances, the ETT had passed through the right palatopharyngeal arch, requiring suturing in the first patient, and electrocautery in the second patient.

CONCLUSION

There have been no previously published reports of injuries related to GlideScope laryngoscopy, but perforation of the palatopharyngeal arch occurring in two patients demonstrates a rare but potentially important complication of the GVL. Strategies to minimize this complication are considered.

The clinical implication of the vocal cords–carina distance in anaesthetized Chinese adults during orotracheal intubation

BACKGROUND

Previous studies have identified no strong correlation between patients' height and tracheal length in anaesthetized patients. We have attempted to compare vocal cords-carina distance (VCD) in Chinese patients with the dimensions of five commonly used tracheal tubes. In addition, we attempted to find a surface anatomy measurement that would identify patients with 'short tracheas'.

METHODS

We measured VCD in 130 anaesthetized Chinese patients with a fibreoptic bronchoscope. Also measurements were obtained of the distal ends of five commonly used tracheal tubes. We undertook various surface anatomy measurements on the patients' chest and neck region to predict those patients with short tracheas.

RESULTS

VCD averaged 12.6 (SD 1.4) cm. In seven patients (5%) this distance was particularly short (between 8.8 and 10.4 cm). Many of the commonly used tracheal tubes would be placed close to or beyond the carina when the black intubation guide mark(s) is (are) at the level of the vocal cords. The VCD of <or=11 cm (short trachea) could be predicted by patient height of <or=167.5 cm and a thyrosternal distance of <or=28.5 cm with limited reliability.

CONCLUSIONS

A significant number of patients with short VCD in our study group could be at risk of endobronchial intubation with many of the tracheal tubes. Patient height and thyrosternal distance can be useful in predicting short tracheas.

Apparent sialadenopathy of the sublingual glands after general anesthesia with placement of laryngeal mask airway

Sialadenopathy, inflammation of the salivary glands, is a rare anesthetic complication. This case conference describes a patient who developed sialadenopathy of the sublingual glands after placement of a laryngeal mask airway during a brief surgical procedure. The patient's history is detailed, the surgical and anesthetic procedures are described, and a discussion follows, which describes the different causes of this inflammatory process. In the comment, the physiology of the salivary gland is described in detail.

A new approach to securing a difficult airway

The ability to provide a patent airway for gas exchange is a mandatory skill for the anesthesiologist. Because of variations in the anatomy and physiology of patients, a technique used to intubate the trachea of one patient may not be successful for another. Thus, it is crucial that the anesthesiologist have multiple ways in which to approach an airway. We first describe a new technique for airway management that can be used electively or in an emergent situation to intubate the trachea of a patient during anesthesia. We then provide 2 detailed case reports in which the technique was found to be helpful. We have since used it in more than 60 patients, without any related complications.

Airway management after failure to intubate by direct laryngoscopy: outcomes in a large teaching hospital

PURPOSE

The purpose of this single-centre database review was to establish the incidence of failure to intubate by direct laryngoscopy, to measure morbidity and mortality associated with this event, and to examine the use and efficacy of alternative airway devices.

METHODS

Difficult intubation via direct laryngoscopy at Mayo Clinic Rochester is recorded in an electronic database using a functional classification: 0 = no difficulty; 1 = mild to moderate difficulty; and 2 = severe difficulty often requiring a change in intubation technique. Using this database, the total number of intubations was determined for a selected review period and the incidence of failure to intubate by direct laryngoscopy was established. Abstraction of chart data allowed for determination of associated morbidity and mortality, success of alternative airway devices, and case cancellation rate.

RESULTS

During the period from August 1, 2001 through December 31, 2002, 37,482 patients underwent general anesthesia with attempted direct laryngoscopy. One hundred sixty-one patients (0.43%) could not be intubated by direct laryngoscopy alone. Morbidity associated with difficult intubation included soft tissue/dental damage (n = 8), intraoperative cardiac arrest (n = 1), and possible aspiration (n = 1). Three patients required intensive care unit admission. There was no associated mortality. The most commonly used alternative airway device was the flexible fibreoptic scope. Five case cancellations resulted from failure to intubate with alternative devices.

CONCLUSION

The rate of unexpected failure to intubate by direct laryngoscopy is essentially unchanged from earlier studies. While morbidity was low, continued education and early use of alternative difficult airway devices may further limit complications associated with this event.

[Prehospital emergency airway management procedures. Success rates and complications]

BACKGROUND

Oxygenation and ventilation as well as prevention of aspiration are of vital importance for emergency patients. Prehospital airway management is not comparable to clinical anaesthesia. However, prehospital data of the occurrence of potential life-threatening complications and less severe adverse events of airway management procedures by emergency physicians are not yet available.

METHODS

All airway management procedures predominantly performed by emergency physicians over a period of 36 months were recorded prospectively.

RESULTS

Data of 598 consecutive patients were collected, in all patients prehospital airway management could be accomplished successfully. Of the patients 98.5% were successfully intubated endotracheally with a maximum of 3 attempts, 84.6% of patients were intubated at the first attempt, and in 9 patients other techniques such as the Combitube were required. In more than 80% of procedures, no complications or adverse events were recorded and potentially life-threatening complications occurred in 9% of patients only.

CONCLUSIONS

Prehospital airway management by emergency physicians experienced in anaesthesia is associated with low complication and high success rates.

A Case of Recurrent Subcutaneous Emphysema as a Complication of Endotracheal Intubation

We describe a case of subcutaneous cervicofacial emphysema in a 21-year-old man who had undergone endotracheal intubation while under general anesthesia 2 months earlier. The emphysema had arisen on the right side of the face and neck and extended to the right shoulder and the cubital fossa. The patient was hospitalized and treated with parenteral antibiotics and hyperbaric oxygen. On hospital day 10, he had improved sufficiently to warrant discharge on the next day. Two months later, the patient presented at a follow-up visit with a recurrence, and he was readmitted. By hospital day 28, his condition had improved and he was scheduled for discharge. However, he experienced another recurrence just before he was to leave the hospital. The circumstances of this second recurrence led us to suspect that the patient was able to produce these signs and symptoms on his own. He was referred for psychiatric evaluation, and findings were negative. He was then sent to the Ear, Nose, and Throat Service, where we confirmed that his subcutaneous emphysema could be brought on by Valsalva's maneuver. We performed suspension laryngoscopy and detected two orifices of fistular tracts next to the right vallecula and three at the root of the epiglottis. We repaired the injured mucosa and the orifices of the fistulae with absorbable sutures and cauterized the area. The swelling resolved completely within 4 days, and findings on a radiographic examination of the chest and neck 1 week later were normal. The patient was then lost to follow-up. The presence of air in the retropharyngeal and cervical subcutaneous spaces of the neck and shoulder without pneumomediastinum is an uncommon complication of endotracheal intubation. We discuss the clinical and radiographic findings associated with this complication, and we review diagnostic considerations and management.

Disruption of cleft palate repair following the use of the laryngeal mask airway

A 55-year-old man was admitted for routine examination of ears with insertion of grommets under general anaesthesia. At 2 years of age he had undergone successful repair of cleft lip and palate. A reinforced laryngeal mask airway was employed to maintain the airway. Postoperatively, it was evident he had suffered complete disruption of the soft palate repair, leading to velopharyngeal insufficiency with nasal regurgitation of fluids. We discuss the possible aetiology, having found no such reported injury pattern documented in the literature.