Airway Management of the Deformed Trachea Using T-Tube Stents in Patients with Mucopolysaccharidosis Type IVA

INTRODUCTION

Mucopolysaccharidosis (MPS) type IVA usually results in airway obstruction due to thoracic cage deformity and crowding of intrathoracic structures, causing tracheal compression by the tortuous innominate artery.

OBJECTIVES

To offer an alternative and effective method in dealing with the challenged deformity of the airway in patients with MPS type IVA.

METHODS

We present 3 patients with MPS type IVA who underwent airway stenting using Montgomery^® T-tube stents. Three-dimensional reconstructed computed tomography was essential to design the T-tube and evaluate the anatomical relationship between the innominate artery and the trachea. The Y-shaped Montgomery^® Pediatric Safe-T-Tube™ is more suitable for MPS type IVA. Regular follow-ups using fiberoptic bronchoscopy are necessary to evaluate the complications.

RESULTS

All 3 patients had good outcomes during the follow-ups until present, despite the complication of granulation formation, which was resolved by revising the limbs of the T-tube.

CONCLUSIONS

T-tube stents placed below the vocal cord may restore airway patency and preserve laryngeal function, including respiration, phonation, and swallowing, in patients with MPS type IVA.

Challenge for management without tracheostomy tube after laryngo-tracheal separation in children with neurological disorders

OBJECTIVES

The present study analyzed surgical outcomes of laryngotracheal separation (LTS) in children with neurological disorders. The purpose of this study was to investigate respiratory impairment and severe complications after LTS in children, and identify the possibility of permanent tracheostomy without a tracheostomy tube as the safest respiratory management method.

METHODS

Twenty-eight patients (male:female = 16:12) with neurological disorders (6 months to 32 years) who underwent LTS between January 2012 and April 2018 were reviewed. Tracheal diameter, Cobb angle, and sternocervical spine distance (SCD) were measured to assess the potential risk and possibility of removing tracheostomy tube management.

RESULTS

Tracheostomy tube could be removed shortly after LTS in 57% (16/28). However, nine of these patients developed respiratory problems that required tracheostomy tube placement 2 years after LTS. New requirements for a tracheostomy tube as a stent were strongly correlated with SCD (P < .05, odds ratio > 1) as well as tracheal deformity.

CONCLUSIONS

Respiratory management in neurologically impaired children after LTS without a tracheostomy tube is challenging because thoracic deformity during physical growth affects tracheal disfiguration. Thoracic deformities and progression of scoliosis should be considered in respiratory management approaches in children with neurological disorders, and long-term follow-up by computed tomography is necessary.

LEVEL OF EVIDENCE

IV.

Successful difficult airway management with emergent venovenous extracorporeal membrane oxygenation in a patient with severe tracheal deformity: a case report

Background

Difficult airway management is occasionally encountered in the emergency department, and recent studies suggest that extracorporeal membrane oxygenation can be useful in these cases.

Case Presentation

A 74-year-old man was transferred to our hospital due to worsening dyspnea. On arrival, it was found that he was in respiratory distress and was comatose. Arterial blood gas analysis showed severe hypercapnia and respiratory acidosis. Intubation could not be done because he had severe tracheal deformity due to cervical-thoracic kyphosis secondary to vertebral tuberculosis. Therefore, we carried out surgical tracheostomy under venovenous extracorporeal membrane oxygenation. The patient's oxygenation gradually improved, and extracorporeal membrane oxygenation was withdrawn on day 8. He was transferred to another hospital on day 46 and suffered no neurological deficits.

Conclusion

Severe tracheal deformity can result in a difficult airway. Extracorporeal membrane oxygenation is an effective life-saving approach in cases of difficult airway management due to severe tracheal deformity.