Tracheal granulation as a cause of unrecognized airway narrowing

Increased Intervals Between Paediatric Tracheostomy Tube Changes: Is it a Safe Technique?

To evaluate the safety of changing tracheostomy tubes every three months in paediatric patients and determine the occurrence of tube-related complications. Retrospective observational chart review was completed from 2018 to 2021 at a tertiary medical centre in Thailand. Tube associated complications were assessed with regards to interval length between tracheostomy tube changes. The rate of complication was compared with previous studies. Out of a total of 108 visits, the average interval between each tube change was 87 days. Of all encounters, 6.48% resulted in a tube-related complication. Of these seven visits, two had an admission for a respiratory infection within 30 days, three experienced accidental decannulation and two resulted in excess granulation tissue formation. A p-value of 0.8 was obtained from a chi-squared test. An interval of 90-days between paediatric tracheostomy tube changes does not increase the rate of tracheostomy tube related complications. This interval may be practical for those in resource limited settings.

Bench testing of tracheostomy tube-related insults using an instrumented manikin

PURPOSE

Choosing the right tracheal tube for the right patient is a daily preoccupation for intensivists and emergency physicians. Tracheal tubes can generate severe complications, which are chiefly due to the pressures applied by the tube to the trachea. We designed a bench study to assess the frequency of pressure levels likely to cause tracheal injury.

METHODS

We tested the pressure applied on the trachea by 17 tube models of a given size range. To this end, we added a pressure sensor to the posterior tracheal wall of a standardized manikin.

RESULTS

Only 2 of the 17 tubes generated pressures under the threshold likely to induce tracheal injury (30 mmHg/3.99 kPa). The force exerted on the posterior wall of the trachea varied widely across tube models.

CONCLUSION

Most models of tracheal tubes resulted in forces applied to the trachea that are usually considered capable of causing tracheal tissue injury.

LEVEL OF EVIDENCE

Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence: How common is the problem?: step 1; Is this diagnostic or monitoring test accurate? (Diagnosis) step 5; What will happen if we do not add a therapy? (Prognosis) n/a; Does this intervention help? (Treatment Benefits) step 5; What are the COMMON harms?(Treatment Harms) step 5; What are the RARE harms? (Treatment Harms) step 5; Is this (early detection) test worthwhile? (Screening) step 5.

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.

Death Due to Obstruction of Airways by a Hyperplastic Polyp: An Unusual Complication of Treated Desmoid Fibromatosis

Desmoid fibromatosis (DF) is a rare, locally aggressive but benign clonal fibroblastic lesion of deep soft tissue. It can occur at any age. Extra-abdominal lesions are more common in the pediatric population, with equal sex predilection. Desmoid fibromatosis of the head and neck, particularly the anterior neck, is more difficult to manage because of the proximity to vital structures and may eventually require definitive airway management with insertion of a tracheostomy tube. Indwelling tracheostomy tubes carry their own set of complications. This is the case of a 21-month-old boy who died suddenly due to tracheal obstruction by a hyperplastic polyp. He was diagnosed with DF of the neck before he was 1 month old and required an indwelling tracheostomy tube as a result. Chronic tracheostomy intubation can be complicated by granulation tissue polyp or, less commonly, fibroepithelial polyp formation that can become large enough to cause airway obstruction. To the authors' knowledge, this is the first case of hyperplastic polyp causing fatal airway obstruction.

Otoendoscope combined with ablation electrodes for treatment of benign tracheal stenosis caused by granulation tissue hyperplasia after tracheotomy

Benign tracheal stenosis mainly appears due to tracheotomy, tuberculosis, trauma, benign tumor, or ventilation. With the increase in the number of tracheotomies and the prolongation of the life span of patients after incision, the long-term complications after tracheotomy gradually increase, among which intratracheal granulation hyperplasia is a more serious complication. The present case describes a 59-year-old male with granulation tissue hyperplasia induced by tracheotomy. He underwent tracheal resection to remove the granulation tissue and he remained well after the follow-up. Even though the endoscopic intervention and tracheal resection are readily accessible, they usually quite challenging. Here we summarize the present details on this condition.

Dilation of tracheal stenosis below tracheostomy tube with Dolphin percutaneous tracheostomy kit : Tracheal stenosis treated with Dolphin PDT

We reported a new minimally invasive procedure to treat tracheal stenosis below tracheostomy tube using standard Ciaglia Blue Dolphin kit for percutaneous tracheostomy. Under endoscopic view, the Dolphin kit was inserted through the stoma into the stenosis; the balloon was inflated until a sufficient tracheal diameter was obtained; then, a longer tracheostomy tube was inserted through the stenosis and the distal tip placed near the carina. This procedure was succesfully applied in seven patients.

Diagnosis and conservative management of late tracheotomy complications in chronic ventilator-dependent patients

BACKGROUND

Complications associated with long-term tracheotomy are obstruction of the distal end of the tube by granulation tissue and tracheomalacia. These complications have traditionally been surgically treated.

METHODS

Prospective study in a chronic ventilator-dependent division, including 234 consecutive patients with tracheotomy and mechanical ventilation. Endoscopic evaluation was performed in patients in whom there was respiratory distress with difficulty in passing a suction catheter through the tube, and/or increased inspiratory resistance and increased peak inspiratory pressure.

RESULTS

Nineteen patients were diagnosed with granulation or tracheomalacia. Two patients were treated by surgical removal of the obstructing tissue. Nonsurgical patients were conservatively managed with symptoms' resolution by bypassing the pathology with a longer tube than the previous one or by an adjustable flange tube under endoscopic visualization, with a median symptom-free period of 433 days (range, 55-1230 days).

CONCLUSION

In nonsurgical candidates, insertion of a longer tube is a conservative and feasible long-term treatment.

Surgical management for complications of pediatric lung injury

The etiologies of pediatric lung injury requiring surgical intervention can be infectious, traumatic, congenital, or iatrogenic. Childhood pneumonia is a significant global health problem affecting 150 million children worldwide. Sequelae of pulmonary infections potentially requiring surgery include bronchiectasis, lung abscess, pneumatocele, and empyema. Trauma, congenital conditions such as cystic fibrosis and iatrogenic injuries can result in pneumothoraces, chylothoraces, or bronchopleural fistulae. Recurrence rates for spontaneous pneumothorax treated non-operatively in pediatric patients approach 50-60%. Chylothoraces in newborns may occur spontaneously or due to birth trauma, whereas in older children the etiology is almost always iatrogenic. This article examines the surgical management for the complications of lung injury in pediatric patients. In addition, we review the available pediatric evidence for early tracheostomy as well as treatment strategies for the negative ramifications of tracheostomy.

Optical imaging of subacute airway remodeling and adipose stem cell engraftment after airway injury

Acquired airway injury is frequently caused by endotracheal intubations, long-term tracheostomies, trauma, airway burns, and some systemic diseases. An effective and less invasive technique for both the early assessment and the early interventional treatment of acquired airway stenosis is therefore needed. Optical coherence tomography (OCT) has been proposed to have unique potential for early monitoring from the proliferative epithelium to the cartilage in acute airway injury. Additionally, stem cell therapy using adipose stem cells is being investigated as an option for early interventional treatment in airway and lung injury. Over the past decade, it has become possible to monitor the level of injury using OCT and to track the engraftment of stem cells using stem cell imaging in regenerative tissue. The purpose of this study was to assess the engraftment of exogenous adipose stem cells in injured tracheal epithelium with fluorescent microscopy and to detect and monitor the degree of airway injury in the same tracheal epithelium with OCT. OCT detected thickening of both the epithelium and basement membrane after tracheal scraping. The engraftment of adipose stem cells was successfully detected by fluorescent staining in the regenerative epithelium of injured tracheas. OCT has the potential to be a high-resolution imaging modality capable of detecting airway injury in combination with stem cell imaging in the same tracheal mucosa.