Airway Abnormalities in Patients With Congenital Heart Disease: Incidence and Associated Factors

Error traps in patients with congenital heart disease undergoing noncardiac surgery

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.

The Prevalence of Difficult Airway and Associated Risk Factors in Pediatric Patients: A Cross-sessional Observational Study

BACKGROUND

Difficult airway remains a great challenge in pediatric anesthesia practice. Previously published data show the prevalence of difficult airways in pediatric population varies in a wide range. However, there is a lack of studies in the Asian region.

METHODS

This cross-sectional single-center study was conducted in a tertiary pediatric hospital in China from October 2022 to October 2023. The patients who underwent elective surgery under general anesthesia with tracheal intubation were recruited consecutively. Data on patient characteristics, airway assessment, and airway management information were collected. Multivariable logistic regression analysis was performed to detect the independent variables of difficult airway in pediatric patients.

RESULTS

A total of 18,491 pediatric patients were included in this study. The overall incidence of difficult airways was 0.22%, 39% of whom were unanticipated. Very few previous airway management information was available in the patients presented with a known difficult airway. Patients with younger age, higher American Society of Anesthesiologists (ASA) physical status classification grade, and presented for craniofacial and thoracic surgery were associated with higher incidence of difficult airway. Further multivariable logistic regression analysis revealed that age ≤28 days (OR=50.48), age between 28days and 1 year (OR=6.053), craniofacial surgery (OR=1.81), and thoracic surgery (OR=0.2465) were independent risk factors of increased incidence of difficult airway.

CONCLUSIONS

Our study showed the prevalence of difficult airways in pediatric surgical patients. Patient characteristics, age, and type of surgery were identified as the independent factors associated with increased occurrence of difficult airways. Unanticipated difficult airway was not unusual in our study population, even for the patients with previous surgical history.

Tracheobronchial abnormalities on computed tomography angiography in children with congenital heart disease

OBJECTIVES

To evaluate the assortment of tracheobronchial abnormalities on computed tomography angiography (CTA) in children with congenital heart disease (CHD).

METHODS

In this study approved by the Institute ethics committee, CTA studies of 182 children (age range: 2 days-8 years) with CHD, performed from July 2021 to March 2023 were analyzed. Two pediatric radiologists independently assessed the tracheobronchial airways (from the trachea to lobar bronchi) for developmental and branching anomalies and airway compromise (narrowing). In cases which demonstrated airway compromise, the extent and the cause of airway narrowing were evaluated, and the etiology were divided into extrinsic and intrinsic causes. Interobserver agreement between the two radiologists was calculated using kappa statistics.

RESULTS

One hundred children demonstrated normal airway anatomy and no luminal narrowing. Airway narrowing was observed in 63 (34.6%) children (κ: 0.954), and developmental airway anomalies were seen in 32 (17.5%) children (κ: 0.935). Of the 63 children with airway narrowing, 47 (25.8%) children had extrinsic cause for narrowing, 11 (6%) children had intrinsic causes for narrowing, and 5 (2.7%) children had both intrinsic and extrinsic causes attributing to airway compromise. Significant airway narrowing (>50% reduction) was seen in 35 (19.2%) children (κ: 0.945).

CONCLUSION

Tracheobronchial airway abnormalities are frequently associated in children with CHD and need to be appraised preoperatively. Cross-sectional imaging with CTA provides excellent information on tracheobronchial airway anatomy and caliber as well as delineates the possible etiology of airway narrowing, thus accurately diagnosing airway anomalies.

The implications of airway anomalies on children with congenital heart disease and bronchiolitis

BACKGROUND

Bronchiolitis is a common airway infection in young children. Hemodynamically significant congenital heart disease (CHD) predicts a more complicated course. However, the role of airway anomalies remains unknown.

METHODS

We retrospectively reviewed the records of patients under 2 years old, diagnosed with CHD, and admitted between January 2011 and December 2013, before the palivizumab era. Records of bronchiolitis admissions were also extracted. Patients were grouped according to CHD condition and airway anomalies.

RESULTS

A total of 230 patients with CHD were enrolled. A total of 180 (78%) and 71 (31%) patients had hemodynamically significant CHD and airway anomalies, respectively. A total of 52 (22.6%) patients were admitted for bronchiolitis 78 times. Among them, 33 (63.5%) had hemodynamically significant CHD, and 28 (53.8%) had airway anomalies. In patients with bronchiolitis admissions, the mean ventilator use, intensive care unit stay, and hospital stay were 1.08, 4.08, and 15.19 days, respectively. When compared, the mean hospital stay for bronchiolitis patients with airway anomalies was significantly longer than that of those without airway anomalies (19.8 vs. 9.9 days, p = 0.008). When further divided the patients by the presence hemodynamic significance, patients with hemodynamically significant CHD and airway anomaly had longer hospital stay than those who had neither. (21.7 vs. 8.3 days, p = 0.004) Airway anomaly was a significant risk factor for longer hospital stay in linear regression model (p = 0.007).

CONCLUSIONS

Airway anomalies are common in children with CHD and are associated with longer hospital stays on bronchiolitis admission. An active survey for airway anomalies and adequate prophylaxis for bronchiolitis infection might be important in the care of children with CHD associated with airway anomalies.

Perioperative Considerations for Pediatric Patients With Congenital Heart Disease Presenting for Noncardiac Procedures: A Scientific Statement From the American Heart Association

Continuous advances in pediatric cardiology, surgery, and critical care have significantly improved survival rates for children and adults with congenital heart disease. Paradoxically, the resulting increase in longevity has expanded the prevalence of both repaired and unrepaired congenital heart disease and has escalated the need for diagnostic and interventional procedures. Because of this expansion in prevalence, anesthesiologists, pediatricians, and other health care professionals increasingly encounter patients with congenital heart disease or other pediatric cardiac diseases who are presenting for surgical treatment of unrelated, noncardiac disease. Patients with congenital heart disease are at high risk for mortality, complications, and reoperation after noncardiac procedures. Rigorous study of risk factors and outcomes has identified subsets of patients with minor, major, and severe congenital heart disease who may have higher-than-baseline risk when undergoing noncardiac procedures, and this has led to the development of risk prediction scores specific to this population. This scientific statement reviews contemporary data on risk from noncardiac procedures, focusing on pediatric patients with congenital heart disease and describing current knowledge on the subject. This scientific statement also addresses preoperative evaluation and testing, perioperative considerations, and postoperative care in this unique patient population and highlights relevant aspects of the pathophysiology of selected conditions that can influence perioperative care and patient management.

Airway anomalies in patients with 22q11.2 deletion syndrome: A scoping review

OBJECTIVE

People with 22q11.2 deletion syndrome (22q11DS) can present with a wide variety of findings. Various airway anomalies have been described intermittently within this syndrome, but this feature has not been extensively investigated. Increased provider awareness of these findings may help guide clinical decision-making and improve overall patient outcomes. The objectives of this review are to identify the types of airway anomalies in 22q11DS and the prevalence of airway anomalies within symptomatic individuals.

METHODS

PubMed/MEDLINE, Cochrane Library, and EMBASE databases were searched in February 2022 for all available articles. Search terms included those that described 22q11DS or one of its synonymous conditions AND those that described airway anatomy and anomalies. The term airway anomaly was defined as any structural aberration in the conductive airway from the oral or nasal vestibule region to the mainstem bronchus. Studies were screened by two authors. A review of references was conducted. Eligible manuscripts underwent full-text review for quality appraisal and data extraction.

RESULTS

From a total of 909 unique manuscripts, 58 studies were selected, describing 328 people. The prevalence of airway anomaly diagnosis within symptomatic individuals ranged from 14% to 74%. Twenty-two unique airway anomalies were described. Laryngeal web was the most frequently described anomaly, followed by airway malacia and subglottic stenosis. Laryngeal web was 40% sensitive for suggesting a diagnosis of 22q11DS. Among affected individuals, as many as 46% had multiple concomitant airway anomalies. Aside from respiratory symptoms, other features that prompted airway evaluation included difficult intubation or failed extubation.

CONCLUSION

The findings within this review support the notion that a wide variety of airway anomalies may be seen in people with 22q11DS and that these findings have been discovered frequently in those with airway symptoms. Providers should maintain a low threshold to perform an airway examination in those with 22q11DS, especially when airway symptoms are present.

Anaesthesia Challenges in a Neonate Having Supracardiac Total Anomalous Pulmonary Venous Return With Incidental Stridor for Non-operating Room Anaesthesia (NORA): Feed and Wrap Technique as a Rescue

This case represents anaesthetic challenges while managing a neonate having a congenital cardiac anomaly with incidental stridor for the non-operating room anaesthesia (NORA). Anaesthesia management of neonates is demanding even for experienced anaesthetists in terms of vascular access, airway management, relatively poor respiratory reservoir and transitional cardiac physiology. Neonate having cyanotic congenital heart disease with abnormal cardiac physiology demands further attention. In children with congenital heart disease, difficult intubation remains a possibility as they are more often associated with airway anomalies. NORA has its own set of anaesthesia challenges related to a lack of adequate anaesthesia equipment and monitoring devices, a limited and unfamiliar workspace, lack of trained support staff along with more medically complex patients. Recently there has been concern regarding the safety of anaesthetic agents in children < 3 years. So, techniques are being developed to promote immobilisation without using anaesthesia in short procedures. One such technique is the "feed and wrap" technique where feeding and swaddling induce natural sleep in infants. Here, we have used the "feed and wrap technique" in a 24-day-old neonate having supracardiac total anomalous pulmonary venous return with incidental stridor posted for contrast-enhanced computed tomography angiography.

Unexpected difficult airway due to severe upper tracheal distortion: A case report

BACKGROUND

Difficult airway is a significant cause of anesthesia-associated death and disability. Currently, physical examinations of thyromental distance, mouth opening, Mafampaii classification, etc. combined with X-ray, computed tomography (CT), and other imaging technologies are mainly used to evaluate difficult airways. However, in many special cases, i.e., emergency surgery, imaging examinations cannot be completed preoperatively. Such patients' airway can only be evaluated through general physical examination, which inevitably increases the likelihood of an unexpected difficult airway during anesthesia.

CASE SUMMARY

We report a rare case of difficult intubation because of severe upper trachea distortion after induction. Emergency holmium laser lithotripsy was performed under transurethral ureteroscopy because the patient had anuria for 4 d and a creatinine level of 890 μmol/L. Due to the urgency of the condition, chest radiography or chest CT was not examined before surgery and the anesthesiologist did not evaluate the airway adequately, resulting in an unexpected difficult airway.

CONCLUSION

The incidence of tracheal malformation and tracheal stenosis is extremely low, but the risk of hypoxia and even death due to difficult airways is extremely high for such patients. It is recommended to complete preoperative imaging examinations of the airway. For life-threatening emergency patients, a pre-anesthesia reassessment should be performed and surgeons should be prepared to prevent and manage the difficult airway.

The Phenotypical Profile and Outcomes of Neonates with Congenital Tracheoesophageal Fistula Associated with Congenital Cardiac Anomalies Presenting for Surgery

(1) Background: Neonates born with oesophageal atresia and/or tracheooesophageal fistula (OA/TOF) are usually born with a multitude of other congenital anomalies, which may affect their anaesthetic care and survival to hospital discharge. We reviewed the profile and outcome of neonates with OA/TOF and associated congenital cardiac anomalies presenting for surgery at an academic hospital in South Africa. (2) Methods: A retrospective, cross-sectional analysis of all medical records of neonates who had undergone surgical repair of OA/TOF was conducted at an academic hospital between January 2015 and December 2019. Descriptive statistics were used to report the data. Comparisons in perioperative events and outcomes between those with cardiac lesions and those without were done. (3) Results: Neonates presenting for OA/TOF repair with congenital cardiac defects had an incidence of 62 [95% CI 38.5–99.8] per 1000 days since birth. In total, 45.9% had associated cardiac anomalies, with PDA and ASD as the most prevalent lesions. There were statistically significant differences in intraoperative adverse events seen in neonates with congenital cardiac lesions as compared to those without. (4) Conclusion: Despite advances in neonatal critical care and anaesthetic and surgical techniques, OA/TOF associated with congenital cardiac anomalies is still associated with high mortality rates in developing countries.

Anesthetic Management in Adults with Congenital Heart Disease

PURPOSE OF REVIEW

Adults with congenital heart disease (ACHD) are a complex and growing population that presents numerous challenges for anesthetic management. This review summarizes special considerations for anesthetic management in ACHD.

RECENT FINDINGS

The adult patient with congenital heart disease may require anesthetic care for multiple surgeries and interventions throughout their lifetime. The cardiac and extracardiac manifestations of ACHD have important perioperative implications that affect anesthetic management. Recent American Heart Association/American College of Cardiology and European Society of Cardiology guidelines endorse a multidisciplinary, team-based approach to care. The cardiac anesthesiologist, endorsed as part of this multidisciplinary team, must have a thorough understanding of congenital heart disease pathophysiology and common extra-cardiac manifestations of ACHD. Safe anesthetic management in adult congenital heart disease should incorporate a multi-disciplinary approach to patient care. Anesthesiologists and centers with special expertise in ACHD care should be utilized or consulted whenever possible.

Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective study

BACKGROUND AND OBJECTIVE

Management of difficult tracheal intubation during induction of anesthesia in children with congenital heart disease is challenging. The aim of this study is to evaluate the incidence of difficult tracheal intubation in patients with congenital heart disease and compare the incidence of perioperative complications and outcomes in patients with and without difficult tracheal intubation.

DESIGN

Retrospective cohort study.

SETTING

Tertiary Children's Hospital.

PARTICIPANTS

6858 patient-encounters including cardiac diagnostic, interventional or surgical procedures from 2012 to 2018 were reviewed.

EXCLUSION CRITERIA

age > 18 years, endotracheal tube or tracheostomy in-situ.

METHODS/INTERVENTIONS

Patients' demographics, number and methods of intubation, peri-intubation hemodynamics, intensive care unit and postoperative hospital length of stay were recorded. Multivariable mixed-effects median, logistic, ordinal, and multinomial regression modeling were implemented to analyze outcomes in the matched sets.

RESULTS

Of the 6014 encounters examined in the study, the incidence of DTI was 0.96% and all 58 difficult tracheal intubations (DTI) were matched using 1:2 propensity score matching to 116 non-DTI encounters. Number of intubation attempts was significantly higher among patients with difficult tracheal intubation (ordinal logistic regression odds ratio = 2; 95% CI; 1.3, 2.7; P < 0.001). No significant differences in peri-intubation hemodynamic stability were noted. Patients with difficult tracheal intubation had longer postoperative hospital length of stay (median = 12.1 vs 7.9 days, coef. = 4; 95% CI: 1.3, 6.8; P = 0.004) than patients without.

CONCLUSION

Despite a higher number of intubation attempts, our study shows no major differences in the peri-intubation hemodynamics in patients with and without difficult tracheal intubation. This risk can be mitigated by a good understanding of cardiac physiology, management of hemodynamics, and early use of an indirect intubation technique to maximize first attempt success.

[Cochlear implant and surgical intervention for CHARGE syndrome with laryngeal airway lesions]

Objective:To evaluate the clinical efficacy of surgical intervention for laryngeal airway lesions with concurrent cochlear implantation in CHARGE syndrome concomitant laryngeal airway lesions, and provide clinical data for cochlear implantation in children with CHARGE syndrome concomitant laryngeal airway lesions. Methods:The medical records of five cases diagnosed with CHARGE syndrome were retrospectively reviewed, two of them treated with surgical intervention for laryngeal airway lesions and concurrent cochlear implantation. One child treated with balloon dilatation of laryngeal stenosis and Cochlear implant, and another case received with modified supraglottoplasty for laryngeal malacia and Cochlear implant. Results:Two cases of CHARGE syndrome concomitant laryngeal airway disease, who underwent Cochlear implant and concurrent surgical intervention, recovered well after treatment. The remining three cases treated with Cochlear implant, who previously received deformity-correction surgery. All of the five cases presented with CHD7 mutation. Conclusion:Cochlear implant concurrent with surgical intervention of laryngeal airway lesions for the treatment of CHARGE syndrome concomitant laryngeal airway disease was safe and efficient, which could be a treatment option for children in this situation.

Creation of an artificial intelligence model for intubation difficulty classification by deep learning (convolutional neural network) using face images: an observational study

Background

Tracheal intubation is the gold standard for securing the airway, and it is not uncommon to encounter intubation difficulties in intensive care units and emergency rooms. Currently, there is a need for an objective measure to assess intubation difficulties in emergency situations by physicians, residents, and paramedics who are unfamiliar with tracheal intubation. Artificial intelligence (AI) is currently used in medical imaging owing to advanced performance. We aimed to create an AI model to classify intubation difficulties from the patient’s facial image using a convolutional neural network (CNN), which links the facial image with the actual difficulty of intubation.

Methods

Patients scheduled for surgery at Yamagata University Hospital between April and August 2020 were enrolled. Patients who underwent surgery with altered facial appearance, surgery with altered range of motion in the neck, or intubation performed by a physician with less than 3 years of anesthesia experience were excluded. Sixteen different facial images were obtained from the patients since the day after surgery. All images were judged as “Easy”/“Difficult” by an anesthesiologist, and an AI classification model was created using deep learning by linking the patient’s facial image and the intubation difficulty. Receiver operating characteristic curves of actual intubation difficulty and AI model were developed, and sensitivity, specificity, and area under the curve (AUC) were calculated; median AUC was used as the result. Class activation heat maps were used to visualize how the AI model classifies intubation difficulties.

Results

The best AI model for classifying intubation difficulties from 16 different images was generated in the supine-side-closed mouth-base position. The accuracy was 80.5%; sensitivity, 81.8%; specificity, 83.3%; AUC, 0.864; and 95% confidence interval, [0.731-0.969], indicating that the class activation heat map was concentrated around the neck regardless of the background; the AI model recognized facial contours and identified intubation difficulties.

Conclusion

This is the first study to apply deep learning (CNN) to classify intubation difficulties using an AI model. We could create an AI model with an AUC of 0.864. Our AI model may be useful for tracheal intubation performed by inexperienced medical staff in emergency situations or under general anesthesia.