Tracheal and bronchial stenoses and other obstructive conditions

Slide tracheoplasty for congenital tracheal stenosis: A systematic review

INTRODUCTION

Slide tracheoplasty has become the gold standard surgery for congenital tracheal stenosis (CTS). This condition is rare and the surgery can be challenging and is performed by experienced surgeons in tertiary centers. A few reports involving relatively small cohorts have been published. The aim of this review is to evaluate the post-operative mortality and morbidity of pediatric slide tracheoplasty for CTS.

METHODS

A systematic literature review was performed according to PRISMA guidelines. The Medline and EMBASE databases were screened using a search strategy defined in collaboration with a librarian. We included articles reporting the post-operative mortality rate of slide tracheoplasties for treatment of CTS in children, when at least 10 patients were included.

RESULTS

A total of 932 articles were reviewed, and 15 studies were eligible with a total of 845 patients. The overall post-operative mortality rate was 9.3 %, and most deaths were airway related. The open revision surgery rate after surgery was 2.8 % and the endoscopic revision rate was 27.6 %.

DISCUSSION

This study highlights key factors to consider before the surgery and helps anticipate post-operative follow-up considerations for children with CTS. Several factors were identified as predictors of mortality including young age, weight at the time of surgery and association with lung hypoplasia or aplasia.

CONCLUSION

Although slide tracheoplasty has gained popularity in recent years due to better outcomes, it remains a major surgery with mortality risk and the need for multidisciplinary management.

Micro-CT Imaging of Tracheal Development in Down Syndrome and Non-Down Syndrome Fetuses

OBJECTIVES

Down syndrome (DS) is associated with airway abnormalities including a narrowed trachea. It is uncertain whether this narrowed trachea in DS is a consequence of deviant fetal development or an acquired disorder following endotracheal intubation after birth. This study aimed to compare the tracheal morphology in DS and non-DS fetuses using microfocus computed tomography (micro-CT).

METHODS

Twenty fetal samples were obtained from the Dutch Fetal Biobank and divided into groups based on gestational age. Micro-CT images were processed to analyze tracheal length, volume, and cross-sectional area (CSA).

RESULTS

Mean tracheal length and tracheal volume were similar in DS and non-DS fetuses for all gestational age groups. Mean, minimum, and maximal tracheal CSA were statistically significantly increased in the single DS fetus in the group of 21-24 weeks of gestation, but not in other gestational age groups. In 90% of all studied fetuses, the minimum tracheal CSA was located in the middle third of the trachea.

CONCLUSION

Tracheal development in DS fetuses was similar to non-DS fetuses between 13 and 21 weeks of gestation. This suggests that the narrowed tracheal diameter in DS children may occur later in fetal development or results from postnatal intubation trauma. The narrowest part of the trachea is in majority of DS and non-DS fetuses the middle third.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2024.

Characteristics and Outcomes of Surgical Treatment for Bronchial Anomalies

OBJECTIVES

Bronchial anomalies are rare but challenging conditions to treat in children, encompassing a variety of structural abnormalities that could compromise airway patency. This includes complete rings, absent cartilage, traumatic avulsions, bronchoesophageal fistulas, and cartilaginous sleeves. The objective of this study is to describe the characteristics and outcomes of a series of pediatric cases of bronchial anomalies that were treated by slide tracheobronchoplasty.

METHODS

This is a single-institution retrospective case series of pediatric patients with bronchial anomalies who underwent surgical treatment between February 2004 and April 2020. Data extracted from electronic medical records included patient demographics, comorbidities, and surgical outcomes.

RESULTS

There were a total of 29 patients included in the study, of which 14 had complete bronchial rings, 8 had absent bronchial rings, 4 had traumatic bronchial avulsions, 2 had bronchoesophageal fistulas, and one had a cartilaginous sleeve. Median follow-up time was 13 months (with a range of 0.5-213 months). The overall mortality rate was 17.2% (5 patients), all of whom had complete bronchial rings. Patients with complete bronchial rings also had a higher rate of not only cardiac (85.7%) and pulmonary comorbidities (85.7%) but also secondary airway lesions (78.6%).

CONCLUSION

This is the largest series to date describing surgical treatment for bronchial anomalies. Complete bronchial rings were the most common anomaly treated, followed by absent rings and trauma. Surgical treatment can be successful but mortality rates are higher in patients with complete bronchial rings, possibly due to higher rates of pulmonary and cardiac comorbidities.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:3334-3340, 2023.

Double Aneuploidy of Down Syndrome (Trisomy 21) and Jacobs Syndrome (Trisomy XYY) with Complete Tracheal Rings Deformity: Case Report and Literature Review

Down syndrome (DS, trisomy 21) with an extra copy of chromosome 21 is one of the most common aneuploidies in humans. Jacobs syndrome or XYY syndrome (trisomy XYY) with an extra copy of sex chromosome Y is a rare sex chromosome trisomy in males. Double aneuploidy (DA) with an extra copy of chromosome 21 and sex chromosome Y is an extremely rare occurrence. Most trisomy 21 results from nondisjunction during maternal oocyte meiosis-I, whereas trisomy XYY is results from nondisjunction during paternal spermatocyte meiosis-I. We present a case of natural conception premature newborn of 30.4 weeks gestational age who had a DS facial phenotype with extensive syndactyly on both hands and feet. Other multisystem congenital anomalies were discovered, including mal-aligned perimembranous ventricular septal defect, bicuspid aortic valve, Dandy-Walker malformation's tetra-ventriculomegaly, and a rare complete tracheal rings deformity (CTRD) with trachea stenosis. Prenatal amniocentesis and postnatal chromosomal karyotyping analysis detected 48, XYY, + 21 nontranslocation trisomy 21, and free-lying Y chromosome without translocation. The existence of DA is rarely reported in literature reviews. In this review, we will discuss the characteristics of DS and Jacobs syndrome as well as the associated multiorgan malformation including the rare lethal CTRD.

Use of Virtual Reality and Three-Dimensional Printing in the Surgical Planning of Slide Tracheoplasty

Purpose: To describe our experience using virtual reality (VR) and three-dimensional (3D) printing as complements for the surgical planning process of slide tracheoplasty (ST) in patients with congenital tracheal stenosis (CTS). Description: VR and 3D printing are used for the surgical planning of ST as a therapeutic option in three female patients under five years of age with CTS. Evaluation: We assessed the planned surgical procedure, procedural time, postoperative complications, and outcomes, as well as the main surgeon's experience with the use of the applied technologies. Conclusions: The interaction within the VR environment allowed for collaboration of the surgical plan between surgical staff and enhancement of the radiologist-surgeon communication, while procedural simulation with 3D printing prototypes allowed for refining technical abilities for the surgical interventions. Based on our experience, the application of these technologies have added value to the surgical planning of ST and its outcomes in the treatment of CTS.

Missed bronchial web in a 4-year-old boy with foreign body aspiration: A case report

Congenital bronchial webs are extremely rare and usually remain undiagnosed due to nonspecific symptoms. Herein, we reported a 4-year-old case of the bronchial web who was initially undiagnosed upon bronchoscopy following foreign body aspiration and afterward misdiagnosed as childhood asthma through his consistent cough and exertional dyspnea for several months.

Mucosa-interfacing electronics

The surface mucosa that lines many of our organs houses myriad biometric signals and, therefore, has great potential as a sensor-tissue interface for high-fidelity and long-term biosensing. However, progress is still nascent for mucosa-interfacing electronics owing to challenges with establishing robust sensor-tissue interfaces; device localization, retention and removal; and power and data transfer. This is in sharp contrast to the rapidly advancing field of skin-interfacing electronics, which are replacing traditional hospital visits with minimally invasive, real-time, continuous and untethered biosensing. This Review aims to bridge the gap between skin-interfacing electronics and mucosa-interfacing electronics systems through a comparison of the properties and functions of the skin and internal mucosal surfaces. The major physiological signals accessible through mucosa-lined organs are surveyed and design considerations for the next generation of mucosa-interfacing electronics are outlined based on state-of-the-art developments in bio-integrated electronics. With this Review, we aim to inspire hardware solutions that can serve as a foundation for developing personalized biosensing from the mucosa, a relatively uncharted field with great scientific and clinical potential.

Cardiopulmonary bypass as a bridge for bronchial foreign body removal in a child with pulmonary artery sling: A case report

RATIONALE

Successful removal of an airway foreign body (FB) in some intractable cases can be very challenging, because of tracheal anomalies, unstable respiratory status of the patients, and the location of FB. The use of cardiopulmonary bypass (CPB) support for the treatment of a FB is extremely rare.

PATIENT CONCERNS

We present a case of a 39-month-old previously healthy girl who was admitted to our hospital for suspected FB aspiration (FBA). Initially, the attempt for removal of the FB by conventional bronchoscopy failed because of hypoxic intolerance.

DIAGNOSES

Bronchoscopy revealed tracheal anomalies and subsequent computed tomography angiography demonstrated the presence of a pulmonary artery sling (PAS), which confirmed the diagnosis of PAS accompanied with FBA.

INTERVENTIONS

With the assistance of CPB, multidisciplinary treatment involving the respiratory, cardiothoracic and anesthetic teams were involved and the bronchial FB was removed by flexible bronchoscopy successfully and then PAS was corrected by surgical intervention.

OUTCOMES

The patient remained asymptomatic, without shortness of breath or wheezing during the 15 months follow-up.

LESSONS

This case highlights that in a complicated case of FBA, bronchoscopy and computed tomography imaging are of great importance to achieve an accurate diagnosis, and a multidisciplinary treatment approach is essential for a satisfactory outcome. If the patient is unstable for bronchoscopy, CPB can be temporarily used in the stabilization of the patient to allow safe removal of the FB.

Mammalian tracheal development and reconstruction: insights from in vivo and in vitro studies

The trachea delivers inhaled air into the lungs for gas exchange. Anomalies in tracheal development can result in life-threatening malformations, such as tracheoesophageal fistula and tracheomalacia. Given the limitations of current therapeutic approaches, development of technologies for the reconstitution of a three-dimensional trachea from stem cells is urgently required. Recently, single-cell sequencing technologies and quantitative analyses from cell to tissue scale have been employed to decipher the cellular basis of tracheal morphogenesis. In this Review, recent advances in mammalian tracheal development and the generation of tracheal tissues from pluripotent stem cells are summarized.

Successful airway management with combined use of a McGRATHTM MAC videolaryngoscope and fiberoptic bronchoscope in a patient with congenital tracheal stenosis diagnosed in adulthood

Background

Most patients with congenital tracheal stenosis (CTS) develop respiratory symptoms early in life. CTS remaining undiagnosed until adulthood is rare.

Case presentation

A 51-year-old female was scheduled for cardiovascular surgery. She had undergone laparoscopic surgery 3 years earlier and was found to have a difficult airway. Postoperatively, she was diagnosed with CTS. For the current cardiovascular surgery, combined use of a McGRATH^TM MAC videolaryngoscope and fiberoptic bronchoscope allowed sufficient visualization of the glottis and trachea, resulting in successful intubation.

Conclusions

CTS patients have a high probability of difficult intubation. Our experience suggests the efficacy of combined use of a videolaryngoscope and fiberoptic bronchoscope for airway management in CTS patients.

Acquired tracheal stenosis: Cervical slide tracheoplasty

Acquired tracheal stenosis can result from iatrogenic injury or, less commonly, tracheal tumors. Symptoms can arise insidiously and typically include respiratory distress, sleep disordered breathing, or exercise intolerance. Diagnostic evaluation includes cross-sectional imaging and endoscopy. Various endoscopic and open procedures exist to address acquired tracheal stenosis and treatment should be tailored to the patient. Cervical slide tracheoplasty without cardiopulmonary bypass is a versatile technique that can address different types of tracheal stenosis. It allows for immediate reconstruction with vascularized tissue and continued opportunity for growth as the child ages, with high success rates with minimal morbidity.

Tracheal anomalies associated with Down syndrome: A systematic review

INTRODUCTION

Airway anomalies are accountable for a substantial part of morbidity and mortality in children with Down syndrome (DS). Although tracheal anomalies occur more often in DS children, a structured overview on the topic is lacking. We systematically reviewed the characteristics of tracheal anomalies in DS children.

METHODS

A MEDLINE and EMBASE search for DS and tracheal anomalies was performed. Tracheal anomalies included tracheal stenosis, complete tracheal ring deformity (CTRD), tracheal bronchus, tracheomalacia, tracheal web, tracheal agenesis or atresia, laryngotracheoesophageal cleft type 3 or 4, trachea sleeve, and absent tracheal rings.

RESULTS

Fifty-nine articles were included. The trachea of DS children is significantly smaller than non-DS children. Tracheomalacia and tracheal bronchus are seen significantly more often in DS children. Furthermore, tracheal stenosis, CTRD, and tracheal compression by vascular structures are seen regularly in children with DS. These findings are reflected by the significantly higher frequency of tracheostomy and tracheoplasty performed in DS children.

CONCLUSION

In children with DS, tracheal anomalies occur more frequently and tracheal surgery is performed more frequently than in non-DS children. When complaints indicative of tracheal airway obstruction like biphasic stridor, dyspnea, or wheezing are present in children with DS, diagnostic rigid laryngotracheobronchoscopy with special attention to the trachea is indicated. Furthermore, imaging studies (computed tomography, magnetic resonance imaging, and ultrasound) play an important role in the workup of DS children with airway symptoms. Management depends on the type, number, and extent of tracheal anomalies. Surgical treatment seems to be the mainstay in severe cases.

Development pattern of tracheal cartilage in human embryos

INTRODUCTION

Congenital tracheal anomalies are associated with high morbidity and mortality. The etiology of congenital tracheal anomalies is not well understood, but often attributed to malformed tracheal cartilage. The development of tracheal cartilage has not been described in detail. In this study, we aimed to investigate the development pattern and timing of normal tracheal cartilage to better understand the etiology of tracheal anomalies.

MATERIALS AND METHODS

The development of tracheal cartilage was examined by studying the trachea in histological sections of 14 healthy human embryos from the Carnegie collection. Two specimens for Carnegie Stages 17-23 (42-60 days of embryological development) were studied.

RESULTS

At Carnegie Stages 17-19 (42-51 days), a continuous mesenchymal condensation was observed ventral to the tracheal lumen. At Stages 20 and 21 (51-54 days), this pre-tracheal mesenchyme showed sites of increased condensation indicative of future tracheal rings. Furthermore, growth centers were identified both proximally and distally in the trachea. Characteristic horseshoe shaped tracheal rings were apparent at Carnegie Stages 22 and 23 (54-60 days).

CONCLUSIONS

In human embryos, tracheal rings arise from growth centers in the ventral mesenchyme at approximately 51-54 days of embryological development. The observation of proximal and distal growth centers suggests a centripetal growth gradient, potentially contributing to occurrence of complete tracheal ring deformity (CTRD). Although this study shows new insights on tracheal cartilage development, the exact origin of congenital tracheal defects has yet to be elucidated.

Tracheal A-Frame Deformities Following Airway Reconstruction

OBJECTIVES

Airway reconstruction for subglottic and tracheal stenosis is often successful in achieving tracheostomy decannulation and improving airway symptoms. However, one common reason for late failure is development of a tracheal A-frame deformity, which can necessitate additional surgery. Although knowledge of this deformity exists, the incidence and risk factors have not been reported. This study seeks to determine the incidence of A-frame following airway reconstruction and define factors that correlate with development of this deformity.

STUDY DESIGN

Retrospective case series.

METHODS

Patients under 21 years of age undergoing open airway reconstruction at our institution between January 2005-December 2006 were retrospectively reviewed. Demographic data, comorbidities, airway history/reconstruction type, and follow-up airway findings were examined using multivariable logistic regression. Kaplan-Meier curves were used to examine time to A-frame repair.

RESULTS

Two hundred patients underwent airway reconstruction and 69 (34.5%) developed an A-frame deformity. History of tracheostomy was the most significant contributor to A-frame development (P < .0001). Double- versus single-stage procedures were not associated with increased odds of A-frame development (P = .94), however, patients undergoing resection procedures as opposed to laryngotracheal reconstruction (LTR) with cartilage grafts had a significantly lower chance of developing this deformity (P = .004). Of the patients with an A-frame, 27 (39%) required further surgical intervention.

CONCLUSION

Approximately one-third of patients undergoing airway reconstruction developed a tracheal A-frame deformity, with a significantly higher rate among patients with a history of tracheostomy and those undergoing LTR. Patients should be followed long term to assess for the development of an A-frame.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E1363-E1368, 2021.

Management of A-Frame Tracheal Deformity in Children With Endoscopic Resection Tracheoplasty

OBJECTIVES

Tracheal A-frame deformity is a known consequence of tracheostomy that may lead to obstruction after decannulation. The goal of this study is to demonstrate the feasibility and success of endoscopic carbon dioxide (CO₂ ) laser-assisted tracheoplasty of tracheal A-frame deformity in children.

METHODS

Retrospective case series of symptomatic children with tracheal A-frame deformity with no other site of airway obstruction (2016-2018). All patients underwent CO₂ -laser assisted endoscopic resection tracheoplasty.

RESULTS

Eight patients (six male) were included with a median age of 15.4 (IQR 12.3-17.9) years. Patients had a median of two previous open airway surgeries (IQR 1-2.5) and all patients had a history of tracheostomy with successful decannulation. Tracheal A-frame deformity presented as dyspnea on exertion for all patients (n = 8, 100%). Obstructive sleep apnea was confirmed for all patients who underwent polysomnography (4/4, 100%). Median interval from decannulation to development of symptoms was 8.7 years (IQR 5.8-9.3). All patients sized with an age-appropriate endotracheal tube despite the deformity. Endoscopic A-frame tracheoplasty was successful for 7/8 (87.5%) patients and was performed with overnight observation for these patients (8/8, 100%). Unilateral A-frame tracheoplasty was performed successfully for five patients (62.5%), bilateral A-frame tracheoplasty was performed successfully for two patients (25.0%), and one patient (12.5%) did not have complete resolution of symptoms after bilateral A-frame tracheoplasty due to multi-level airway obstruction.

CONCLUSIONS

CO₂ laser-assisted tracheoplasty is an innovative endoscopic technique to relieve symptoms of airway obstruction for selected patients with tracheal A-frame deformity although avoiding the morbidity and hospital stay duration associated with tracheal resection.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E719-E723, 2021.

Congenital tracheal stenosis & associated cardiac anomalies: operative management & techniques

Congenital tracheal stenosis can lead to symptomatic airway obstruction in children and often mandates surgical correction. Over the past half-century, numerous tracheal reconstruction techniques have been developed, including tracheal resection with end-to-end anastomosis (for short-segment complete tracheal stenosis), patch tracheoplasty, slide tracheoplasty, and homograft and autograft augmentation repairs. However, operative management of congenital tracheal stenosis is often complicated by the presence of congenital heart disease, the most common of which is pulmonary artery sling. When present concomitantly, combined repair of both defects is feasible and is currently the preferred approach. Questions have been raised about the optimal timing and sequence of surgery, and some have advocated staged repair for patients with complex associated cardiac lesions. However, evidence from the past two decades suggests that concomitant repair can be performed with excellent results. The current standard of care involves the use of cardiopulmonary bypass to simultaneously repair the tracheal defect using slide tracheoplasty and all associated cardiac anomalies. Advances in operative techniques and extracorporeal circulation, progressive understanding of the pathological basis of combined congenital tracheal and cardiac disease, and a multidisciplinary approach to patient care have all contributed to the successful outcomes seen in the modern era. This article describes the combined surgical correction of tracheal stenosis and double-outlet right ventricle-tetralogy of Fallot type in an infant, provides a detailed step-by-step description for performing a slide tracheoplasty along with various other less favored tracheoplasty techniques, and reviews the current literature discussing such combined repairs.

Isolated congenital tracheal stenosis: A rare and deadly condition

INTRODUCTION

Congenital tracheal stenosis (CTS) is a serious and rare condition. In most cases, CTS is associated with cardiopulmonary abnormalities; however, isolated CTS is present in 10%-30% of patients. The severity of the disorder is dependent on the symptoms, which correlate with the CTS classification.

CASE PRESENTATION

We discuss our findings in an infant who presented with severe respiratory compromise where incidental intra-operative findings revealed CTS with no cardiopulmonary abnormalities. Because of a lack of resources in the emergency department, we created a tracheostoma and inserted an endotracheal tube.

CONCLUSION

The main aim in treating CTS is to secure the airway and provide sufficient oxygen.

Successful management of acquired left bronchial stenosis caused by massive atelectasis

Acquired bronchial stenosis is rare in children, usually caused by infection or traumatic granuloma due to chronic intubation. A case of severe acquired left bronchial stenosis successfully treated by conservative management for gastroesophageal reflux and atelectasis is reported. A male infant born at 24 weeks’ gestation, weighing 461 g, presented with massive atelectasis of the left lower lobe and severe left bronchial stenosis, based on chest computed tomography performed for the evaluation of respiratory failure at the age of 8 months. He responded well to the placement of a duodenal tube for gastroesophageal reflux and chest physiotherapy, reducing the symptoms of atelectasis and successfully managing the left bronchial stenosis. Acquired bronchial stenosis could be caused by bronchial shift due to atelectasis, and it can be cured by conservative management. In cases of acquired bronchial stenosis with massive atelectasis, it is important to consider atelectasis as a potential cause of the acquired bronchial stenosis.

Diagnostic Value of Multi-Slice Spiral Computed Tomography for Bronchial Dysplasia in Premature Infants

Background

The aim of this study was to investigate the diagnostic value of multi-slice spiral computed tomography (MSCT) for bronchial dysplasia in premature infants.

Material/Methods

A retrospective analysis of 248 premature infants who were highly suspected to have bronchial dysplasia and were admitted to our hospital from 2015 onwards was conducted. We observed bronchus morphologies, sizes, and tissue characteristics using fiberoptic bronchoscopy (FB) as the criterion standard for diagnosis. We calculated the sensitivity, specificity, and diagnostic compliance of MSCT in the diagnosis of bronchial dysplasia.

Results

Thoracic computed tomography mainly revealed capsular bubbles. The translucency of the 2 lungs was reduced, and extensive and local ground-glass changes were observed. Imaging findings mostly included strip or honeycomb-like shadows. Pleural thickening and pleural effusion were rare. MSCT was able to establish a diagnosis in 92 cases (37.10%) of bronchopulmonary cysts, 69 cases (27.82%) of congenital pulmonary emphysema, 31 cases (12.50%) of bronchial atresia, 1 case (0.40%) of congenital cystadenoma malformation, and 3 cases (1.21%) of giant tracheal bronchitis. Another 52 children (20.97%) were found to have conventional pulmonary inflammation. The sensitivity of MSCT in the diagnosis of bronchial dysplasia was 88.21%, the specificity was 75.00%, and the diagnostic compliance was 86.29%. There was a significant difference between the MSCT and FB findings in the diagnosis of bronchial hypoplasia (P<0.001).

Conclusions

MSCT has great utility in the diagnosis of bronchial dysplasia in premature infants and may become an excellent method for diagnosing bronchial dysplasia in the future.

Quantification of tissue-engineered trachea performance with computational fluid dynamics

OBJECTIVES/HYPOTHESIS

Current techniques for airway characterization include endoscopic or radiographic measurements that produce static, two-dimensional descriptions. As pathology can be multilevel, irregularly shaped, and dynamic, minimal luminal area (MLA) may not provide the most comprehensive description or diagnostic metric. Our aim was to examine the utilization of computational fluid dynamics (CFD) for the purpose of defining airway stenosis using an ovine model of tissue-engineered tracheal graft (TETG) implantation.

STUDY DESIGN

Animal research model.

METHODS

TETGs were implanted into sheep, and MLA was quantified with imaging and endoscopic measurements. Graft stenosis was managed with endoscopic dilation and stenting when indicated. Geometries of the TETG were reconstructed from three-dimensional fluoroscopic images. CFD simulations were used to calculate peak flow velocity (PFV) and peak wall shear stress (PWSS). These metrics were compared to values derived from a quantitative respiratory symptom score.

RESULTS

Elevated PFV and PWSS derived from CFD modeling correlated with increased respiratory symptoms. Immediate pre- and postimplantation CFD metrics were similar, and implanted sheep were asymptomatic. Respiratory symptoms improved with stenting, which maintained graft architecture similar to dilation procedures. With stenting, baseline PFV (0.33 m/s) and PWSS (0.006 Pa) were sustained for the remainder of the study. MLA measurements collected via bronchoscopy were also correlated with respiratory symptoms. PFV and PWSS found via CFD were correlated (R²  = 0.92 and 0.99, respectively) with respiratory symptoms compared to MLA (R²  = 0.61).

CONCLUSIONS

CFD is valid for informed interventions based on multilevel, complex airflow and airway characteristics. Furthermore, CFD may be used to evaluate TETG functionality.

LEVEL OF EVIDENCE

NA. Laryngoscope, E272-E279, 2018.

Difficult intubation due to unknown congenital tracheal stenosis in the adult: a case report and literature review

Congenital tracheal stenosis (CTS) is a rare disorder almost always diagnosed in infancy due to respiratory failure and other cardiopulmonary abnormalities. We experienced a 42-year-old female undiagnosed with CTS until difficult intubation upon surgery. Chest X-ray and computed tomography (CT) images revealed bronchial narrowing, which could already be seen prior to intubation, but was left unnoticed. Difficult airway management is a potentially lethal airway emergency. This life-threatening situation is preventable with the appropriate awareness. We report this clinically valuable case for the safety of future patient care. In English and Japanese literature, there are only 12 reported cases of CTS diagnosed in the adult. Ours and six previous cases were discovered with difficult intubation, a preventable life-threatening airway emergency. Pre-intubation images should be examined carefully for the possibility of CTS, as its frequency may be underestimated. Moreover, in treatment resistant recurrent asthmatic episodes, CTS should be kept in mind.

Management of the Critically Ill Adult With Congenital Heart Disease

Survival of adults with congenital heart disease (CHD) has improved significantly over the last 2 decades, leading to an increase in hospital and intensive care unit (ICU) admissions of these patients. Whereas most of the ICU admissions in the past were related to perioperative management, the incidence of medical emergencies from long-term sequelae of palliative or corrective surgical treatment of these patients is rising. Intensivists now are confronted with patients who not only have complex anatomy after congenital cardiac surgery, but also complex pathophysiology due to decades of living with abnormal cardiac anatomy and diseases of advanced age. Comorbidities affect all organ systems, including cognitive function, pulmonary and cardiovascular systems, liver, and kidneys. Critical care management requires an in-depth understanding of underlying anatomy and pathophysiology in order to apply contemporary concepts of adult ICU care to this population and optimize patient outcomes. In this review, the main CHD lesions and their common surgical management approaches are described, and the sequelae of CHD physiology are discussed. In addition, the effects of chronic comorbidities on the management of critically ill adults are explored, and the adjustments of current ICU management modalities and pharmacology to optimize care are discussed.