Intubation trauma. Effects of short-term endotracheal intubation on the tracheal mucous membrane of the pig

Central airway issues in bronchopulmonary dysplasia

While there is a very large focus on the abnormalities of parenchymal lung development and extensive efforts to minimize alveolar damage with "gentle ventilation" and noninvasive respiratory support for neonates with bronchopulmonary dysplasia (BPD), there is relatively little consideration for the implications of central airway disease in this patient population. There are significant changes in the structure and conformation of the central airway during the last half of gestation, and premature birth disrupts this natural developmental process. The arrest of maturation results in a smaller airway that is more compliant, easier to deform, and more susceptible to damage. Consequently, neonates with BPD are prone to developing central airway pathology, particularly for patients who require intubation and positive pressure ventilation. Central airway disease can be divided into dynamic and fixed airway obstruction and results in increased respiratory morbidity in neonates with chronic lung disease of prematurity.

Airway management techniques in head and neck cancer surgeries: a retrospective analysis

BACKGROUND

The aim of this study was to conduct a retrospective analysis of modalities of airway management and its impact on patients undergoing head and neck cancer surgeries.

MATERIALS AND METHODS

A retrospective review of the medical record of 500 patients operated from January 2008 to December 2013 was conducted at our institute. Patients were reviewed for a mode of airway management, a total length of post-operative hospital stay (PLOS), and incidence of elderly patients in the total number of head and neck cancer surgeries posted for various diagnostic and definitive treatments.

RESULTS

Out of 500 patients, 462 patients (92.4%) underwent nasal intubation, of which 320 underwent fiberoptic (FO) intubation (64%), 7 underwent tracheotomies after completion of surgery (1.4%), and 3 underwent at the beginning of surgery (0.6%). The remaining 38 patients (7.6%) underwent oral intubation.

CONCLUSION

Nasotracheal intubation using fiberoptic bronchoscopy is the most preferred technique for the management of a difficult airway. Efficient airway management during the perioperative period significantly reduces the post-operative length of hospital stay and morbidity.

Prolonged Intubation Versus Tracheostomy in the Adult

The development of mechanical ventilators that can en sure adequate respiration for long periods of time has led to the problem of determining how to best integrate patients into the machine's airflow circuits. Tracheal tubes with inflatable cuffs efficiently connect the patient to the machine, but the tubes may be placed in one of two ways. Each option has relative advantages and disad vantages. Translaryngeal intubation (TLI) can be per formed safety and quickly and is the preferred first step in airway management. However, when TLI is needed for prolonged periods, it may damage the larynx. Tra cheostomy, on the otherhand, has potential operative and tracheal complications, but presents little risk to the larynx and may be better tolerated by the patient requir ing long-term intubation. This review provides a histor ical background of these two methods and analyzes their respective advantages and complications. Guide lines for the optimal use of TLI and tracheostomy, par ticularly in adult patients requiring long-term intuba tion, are developed by comparing the risks and benefits of these two methods.

Airway management of patients undergoing oral cancer surgery

OBJECTIVE

This retrospective study aims to describe the airway management and benefits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery.

METHODS AND RESULTS

The medical records of 260 patients undergoing surgery for oral cancer were reviewed for airway management during the perioperative period. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted and decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx or larynx by tumour, or radiation fibrosis. In 53 patients intubation was undertaken under spontaneous ventilation. In 20 cases the trachea was extubated in the immediate postoperative period. In 220 cases patients were extubated next morning in the intensive care unit. In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective tracheostomies were done in 17 cases. Three patients remained intubated for 24-48 h because of a high suspicion of airway obstruction following extubation due to a large pectoralis major flap. These three patients received a tracheostomy because of increased oropharyngeal and laryngeal oedema. In three cases emergency tracheostomies were performed due to upper airway obstruction after extubation and in one case prolonged elective ventilation was required due to severe chest infection.

CONCLUSION

Oral cancer patients have a potentially difficult airway but, if managed properly during perioperative period, morbidity and mortality can be reduced or avoided. Oral cancer patients can be managed safely without the routine use of a tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in oral cancer patients except in some selected patients.

Management of the airway in oral and oropharyngeal resections

A tracheostomy is the traditional method of maintaining an airway after major oral and oropharyngeal resections. Postoperative endotracheal intubation was used for 19 patients who underwent major oral and oropharyngeal resections over a 3-year period at the Royal Adelaide Hospital. This appears to be a safe alternative to tracheostomy if intensive care facilities are available.

Quantitative study of the early effects of tracheotomy and endotracheal intubation on the rabbit tracheobronchial tree

Histopathologic evaluation of the tracheobronchial tree was performed in 12 rabbits to study the effects of 1 hour of tracheotomy or endotracheal intubation. In five animals who underwent oral endotracheal intubation, epithelial erosions and submucosal inflammation in the proximal (bronchial) airway covered 34.9% and 71.3% of the luminal circumference, respectively. This was highly significant (p less than .001) against two control animals, in which 4.8% erosion and 3.9% inflammation were observed. Tracheotomy in three animals caused 22.8% bronchial epithelial erosion and 46.0% inflammation, which were not significantly greater than values of 15.0% and 20.6% observed following "sham" tracheotomy. The severity of the proximal (indirect) consequences of endotracheal intubation may have been attributable to the lack of humidification, but this does not explain the lesser damage caused by tracheotomy. It is postulated that increased inspiratory flow rate and pressures occurring in endotracheally intubated animals may be contributory factors.

The effects of suctioning techniques on the distal tracheal mucosa in intubated low birth weight infants

Microscopic pathology of the distal trachea at autopsy was retrospectively reviewed in 51 low birth weight infants (less than 1250 g). Twenty-six patients from 1977 who had nasal and/or orotracheal intubation and who underwent suctioning with uncontrolled deep suctioning technique were compared to 25 patients from 1980 who had orotracheal intubation with suctioning to the tube tip only. Clinical diagnoses, duration of intubation and number of intubations were correlated to degree of distal tracheal injury: absent (normal epithelium), mild (focal epithelial loss), moderate (diffuse epithelial loss/some inflammation), or severe (submucosal ulceration/squamous metaplasia). From 1977 to 1980 the mortality rate, mean gestational age and mean birth weight all decreased by 20% (P less than 0.05), 1.1 week (P less than 0.05) and 118 g (P less than 0.01) in both autopsied and non-autopsied infants. In 1977, 15 of 26 autopsies (58%) revealed mild (6), moderate (5) or severe (4) pathology. The mean duration of intubation was 71.3, 11.8, and 265 h. respectively. No history of intubation was obtained in two patients with mild injury. No significant tracheal pathology was seen in 11 patients (42%) in 1977. In 1980, fewer patients, 10 of 24 autopsies (42%), revealed mild (3), moderate (4) or severe (3) pathology. The mean duration of intubation was 19.3, 318.3 and 1391.3 h, respectively. One patient with no history of intubation had mild tracheal injury. No significant tracheal pathology was seen in 15 patients (58%) in 1980. The diagnoses of hyaline membrane disease, anemia, hyperbilirubinemia and coagulation disorder were seen more frequently in patients with moderate and severe tracheal pathology both in 1977 and 1980. Despite factors which should lead to greater tracheal injury--longer duration of intubation, lower birth weights and younger gestational age--less tracheal injury was seen in infants undergoing careful suctioning techniques. Clinical implications for the low birth weight neonate are discussed.

A quantitative comparison of the early histopathological changes from tracheotomy and endotracheal intubation on the distal trachea in fetal lambs

Twenty-four premature fetal lambs underwent tracheotomy (n = 11) or endotracheal intubation (n = 13) for 3-9 h for an unrelated experiment. All were maintained with 100% oxygen on a pressure cycled ventilator. No suctioning was performed. At sacrifice, sections of the distal trachea were studied for histopathological changes in epithelium, submucosa and mucous glands. All changes were confined to the epithelium and were reported as either partial or total epithelial erosion in regards to preservation of the basal cell layer. In tracheotomized and intubated animals, both partial and total erosion were seen as early as 3 and 3.5 h, respectively. In the intubated animals, 13.5% of the cumulative tracheal circumference showed total erosion; 19.8% showed partial erosion. In animals undergoing tracheotomy, 9.6% of the cumulative tracheal circumference had total erosion; 19.1% had partial erosion. Possible etiological factors include oxygen toxicity, lack of humidification, effects of mechanical ventilation and indirect trauma from surgery or intubation. The clinical significance for premature infants is discussed.