MyMedR

Usage of airway ultrasound as an assessment and prediction tool of a difficult airway management

Adi O, Fong CP, Sum KM, Ahmad AH

Am J Emerg Med, 2021 04;42:263.e1-263.e4.

PMID: 32994082 DOI: 10.1016/j.ajem.2020.09.011

Airway assessment is important in emergency airway management. A difficult airway can lead to life-threatening complications. A perfect airway assessment tool does not exist and unanticipated difficulty will remain unforeseen. Current bedside clinical predictors of the difficult airway are unreliable but airway ultrasound can be used as an adjunct to predict difficult laryngoscopy. We report a case of a 60-year-old man presenting to the emergency department with shortness of breath, hoarseness of voice and stridor. Airway ultrasound revealed a large laryngeal mass narrowing the upper airway, extending to bilateral vocal cords with heterogenous echogenicity. In view of impending complete upper airway obstruction, acute respiratory distress and airway ultrasound findings, urgent emergency tracheostomy was chosen as definitive airway over endotracheal intubation or surgical cricothyroidotomy. Point of care ultrasound (POCUS) was used to evaluate this patient with severe upper airway obstruction. A laryngeal mass was detected by ultrasound and this pointed towards the presence of a difficult airway. POCUS was a good non-invasive tool used for airway assessment in this uncooperative and unstable patient. Ultrasound predictors of the difficult airway include the inability to visualize the hyoid bone, short hyomental distance ratio, high pretracheal anterior neck thickness and large tongue size. Besides airway assessment, ultrasound can also help to predict endotracheal tube size, confirm intubation and guide emergency airway procedures such as cricothyroidotomy and tracheostomy. Point of care ultrasound of the upper airway can be used in airway assessment to identify distorted airway anatomy, pathological lesions and guide treatment decisions.

Matched MeSH terms: Airway Obstruction/etiology

Fulltext Two cases of congenital vallecular cyst: a reminder of the potentially fatal cause of upper airway obstruction in infants

Abd Aziz A, Abdullah AF, Ahmad RA

Malays J Med Sci, 2010 Jul;17(3):68-73.

PMID: 22135553 MyJurnal

Vallecular cyst, a benign yet rare laryngeal lesion, may cause stridor and even life-threatening upper airway obstruction in infants. It can cause apnoea and poor feeding habits, thus reducing the chance of survival. Although laryngomalacia remains the most common cause of stridor in this age group, awareness and a high level of suspicion for this condition can help lead to early management and intervention. Direct laryngoscopy is accepted as the gold standard for diagnostic purposes, and marsupialisation of the cyst is the preferred treatment. We describe 2 cases of vallecular cysts in infants admitted to our hospital where timely diagnoses led to appropriate treatment.

Matched MeSH terms: Airway Obstruction

Tracheostomy in patients with cervical rib: a note of caution

Prepageran N, Raman R

Ear Nose Throat J, 2003 Aug;82(8):626-7.

PMID: 14503102

Cervical rib is a congenital phenomenon that usually occurs in association with upper-limb neurovascular symptoms. The presence of a cervical rib displaces the great vessels that cross the thoracic outlet superiorly and proceed into the neck. We report an unusual case of iatrogenic hemorrhage during a tracheostomy in a patient whose right subclavian artery had been displaced by a cervical rib. Our aim is to alert surgeons to the hidden risks of this phenomenon.

Matched MeSH terms: Airway Obstruction/complications; Airway Obstruction/surgery*

Fulltext Tracheobronchial stenting is safe and effective in relieving upper airway obstruction

Pang YK, Liam CK, Leow CH, Shyamala P, Zal AR

Med J Malaysia, 2006 Jun;61(2):147-50.

PMID: 16898303 MyJurnal

Many studies have shown that tracheobronchial stenting is effective in relieving respiratory distress secondary to major airway obstruction due to lung or oesophageal cancer. A retrospective review on the benefits and complications of self-expandable metallic stent (SEMS) insertion through flexible bronchoscopy for the palliative treatment of upper airway obstruction in University Malaya Medical Centre was performed. Ten patients underwent this procedure. Relief of dyspnoea was immediate following stent insertion in all patients. Stent migration occurred in one patient and three patients had restenosis of the central airway. We conclude that tracheobronchial stenting via flexible bronchoscopy is feasible and safe.

Matched MeSH terms: Airway Obstruction/surgery*

Fulltext Tracheal stent in the treatment of tracheal stenosis

Dipak S, Prepageran N, Rahmat O, Raman R

Med J Malaysia, 2005 Oct;60(4):498-501.

PMID: 16570716

The use of airway stents for the treatment of benign airway stenosis is increasingly advocated. However, the long-term safety and efficiency of these devices has not been established. We present a case of tracheal stenosis. which persisted despite open surgical and laser correction. The patient required tracheal stent insertion and is currently well with no respiratory difficulty. The use of metallic or silicon intraluminal stent remains appropriate in cases in which there is defined and relative short-term end point of treatment.

Matched MeSH terms: Airway Obstruction/therapy*

The use of modified VBM laryngeal tube compared to Laryngeal Mask Airway during spontaneous ventilation

Chiu CL, Murugasu J, Chan L

Anaesth Intensive Care, 2003 Apr;31(2):187-92.

PMID: 12712784

We have compared the use of the laryngeal mask airway with the new modified laryngeal tube in a prospective randomized controlled study. Sixty ASA 1 or 2 patients, aged 18 to 65 years, scheduled for elective surgery and breathing spontaneously under general anaesthesia, were studied. After preoxygenation, anaesthesia was induced with fentanyl and propofol. The patients were randomized to receive either a laryngeal mask airway or a laryngeal tube. Anaesthesia was maintained with nitrous oxide, oxygen and isoflurane. We recorded the speed and the ease of insertion, the number of attempts needed to successfully secure the airway and intraoperative complications, such as partial airway obstruction needing airway manipulation. The airway devices were removed with the patients fully awake at the end of surgery. Systolic arterial blood pressure, heart rate and end-tidal CO2 were recorded at various time intervals. Postoperative complications were recorded. We found that the incidence of partial airway obstruction needing intraoperative airway manipulation was higher with the laryngeal tube than with the laryngeal mask airway. We conclude that during spontaneous ventilation the modified laryngeal tube is not as reliable in providing a satisfactory airway and we consider it is not a suitable alternative to the laryngeal mask airway.

Matched MeSH terms: Airway Obstruction

Fulltext The dilemma of a lateral pharyngeal mass causing stridor in a neonate

Dipak RN, Kailesh P, Sherry MJ, Anindya C

Med J Malaysia, 2005 Oct;60(4):520-2.

PMID: 16570723

Neonatal stridor resulting from intrinsic or extrinsic aberration in the upper respiratory tract often poses not only a diagnostic problem, but also a difficult airway and a dilemma as to the necessity / timing of surgical intervention. A 45 day old female child with increasing stridor since birth was managed by emergency intubation and CT scan followed by excision biopsy of the cystic left sided parapharyngeal mass via a transcervical approach. On histopathology, the excised specimen was reported as cystic salivary choristoma.

Matched MeSH terms: Airway Obstruction/etiology; Airway Obstruction/surgery*

Fulltext The association of spirometric small airways obstruction with respiratory symptoms, cardiometabolic diseases, and quality of life: results from the Burden of Obstructive Lung Disease (BOLD) study

Knox-Brown B, Patel J, Potts J, Ahmed R, Aquart-Stewart A, Barbara C, et al.

Respir Res, 2023 May 23;24(1):137.

PMID: 37221593 DOI: 10.1186/s12931-023-02450-1

BACKGROUND: Spirometric small airways obstruction (SAO) is common in the general population. Whether spirometric SAO is associated with respiratory symptoms, cardiometabolic diseases, and quality of life (QoL) is unknown.

METHODS: Using data from the Burden of Obstructive Lung Disease study (N = 21,594), we defined spirometric SAO as the mean forced expiratory flow rate between 25 and 75% of the FVC (FEF25-75) less than the lower limit of normal (LLN) or the forced expiratory volume in 3 s to FVC ratio (FEV3/FVC) less than the LLN. We analysed data on respiratory symptoms, cardiometabolic diseases, and QoL collected using standardised questionnaires. We assessed the associations with spirometric SAO using multivariable regression models, and pooled site estimates using random effects meta-analysis. We conducted identical analyses for isolated spirometric SAO (i.e. with FEV1/FVC ≥ LLN).

RESULTS: Almost a fifth of the participants had spirometric SAO (19% for FEF25-75; 17% for FEV3/FVC). Using FEF25-75, spirometric SAO was associated with dyspnoea (OR = 2.16, 95% CI 1.77-2.70), chronic cough (OR = 2.56, 95% CI 2.08-3.15), chronic phlegm (OR = 2.29, 95% CI 1.77-4.05), wheeze (OR = 2.87, 95% CI 2.50-3.40) and cardiovascular disease (OR = 1.30, 95% CI 1.11-1.52), but not hypertension or diabetes. Spirometric SAO was associated with worse physical and mental QoL. These associations were similar for FEV3/FVC. Isolated spirometric SAO (10% for FEF25-75; 6% for FEV3/FVC), was also associated with respiratory symptoms and cardiovascular disease.

CONCLUSION: Spirometric SAO is associated with respiratory symptoms, cardiovascular disease, and QoL. Consideration should be given to the measurement of FEF25-75 and FEV3/FVC, in addition to traditional spirometry parameters.

Matched MeSH terms: Airway Obstruction*

Fulltext The Site of Airway Collapse in Sleep Apnea, Its Associations with Disease Severity and Obesity, and Implications for Mechanical Interventions

Sung CM, Tan SN, Shin MH, Lee J, Kim HC, Lim SC, et al.

Am J Respir Crit Care Med, 2021 07 01;204(1):103-106.

PMID: 33826879 DOI: 10.1164/rccm.202011-4266LE

Matched MeSH terms: Airway Obstruction/complications*; Airway Obstruction/therapy*

Superficial cervical plexus block combined with auriculotemporal nerve block for drainage of dental abscess in adults with difficult airways

Ling KU, Hasan MS, Ha KO, Wang CY

Anaesth Intensive Care, 2009 Jan;37(1):124-6.

PMID: 19157359

We report our use of a superficial cervical plexus block to manage three adults who presented for drainage of dental abscesses. All patients had difficult airways related to severe trismus (preoperative inter-incisor distance < or = 1.5 cm). The first two patients, whose abcesses involved both the submandibular and submasseteric spaces, were managed with combined superficial cervical plexus and auriculotemporal nerve block. In a third patient, a superficial cervical plexus block alone was sufficient because the abscess was confined to the submandibular region. The blocks were successful in all three cases with minimal requirement for supplemental analgesia. We recommend the consideration of superficial cervical plexus block, and if necessary an auriculotemporal nerve block, for the management of selected patients with difficult airways who present for drainage of dental abcesses.

Matched MeSH terms: Airway Obstruction/complications

Fulltext Stridor Secondary to Acquired Subglottic Cyst: Rarity Makes it Missed

See GB, Mesran I

Indian J Otolaryngol Head Neck Surg, 2019 Oct;71(Suppl 1):45-48.

PMID: 31741928 DOI: 10.1007/s12070-016-0992-2

Subglottic cysts (SGCs) are a rare cause of airway obstruction in children. Medical advances, higher survival rates for preterm infants, and improved diagnostic equipment have increased the number of reported cases of SGCs over the last three decades, the majority occurring in infants who had been extremely premature neonates and had suffered from respiratory distress, therefore having been intubated and managed in neonatal ICUs. Symptoms of laryngeal cysts depend on the size and the location of the cyst and include a change in the tone of voice, dysphonia, hoarseness, dysphagia, stridor, and dyspnea. This condition is often misdiagnosed as laryngomalacia, asthma, croup, or other diseases, due to the fact that it manifests as recurring respiratory infections, stridor, and wheezing. Death can occur in severe cases that are not treated. When present, it may account for severe inspiratory stridor that compromise the airway. The accepted gold standard treatment is direct laryngoscopy with marsupialization of the cyst to prevent recurrence. Two cases of subglottic cyst in our centre are described here. Although all cases presented differently, but in both of our cases, which have previous history of intubation with prematurity were initially diagnosed as laryngomalacia and croup.

Matched MeSH terms: Airway Obstruction

Spontaneous sublingual hematoma as a complication of severe hypertension: first report of a case

Prepageran N, Raman R, Ismail SM, Rahman ZA

Ear Nose Throat J, 2002 Aug;81(8):576-8.

PMID: 12199178

We describe what we believe is the first reported case of a sublingual hematoma secondary to severe hypertension. The patient, a 77-year-old woman, experienced a spontaneous hematoma of the floor of the mouth, tongue, and sublingual space that eventually caused an airway obstruction. We performed an emergency tracheostomy under local anesthesia and then evacuated the hematoma through an incision along the floor of the mouth. The patient recovered uneventfully.

Matched MeSH terms: Airway Obstruction/surgery

Fulltext Single rare central lesion with triple common aerodigestive symptoms

Mohamad I, Mohamad IS, Nik Hassan N

Malays Fam Physician, 2018;13(1):57-58.

PMID: 29796215 MyJurnal

An elderly gentleman with a known history of
well-controlled hypertension presented with
a three-week history of hoarseness associated
with mild breathlessness. There was no episode
of cyanosis, no noisy breathing, and no
reduction in effort tolerance. There was also no
history of chest pain or orthopnea. He denied
any feeling of food stuck in his throat or chest,
and he had no history of choking sensations
during meals. He, however, was unable to
count from 1 to 10 in one breath, and lung
auscultation revealed reduced air entry on both
sides. A chest radiograph was then obtained. (Copied from article).

Matched MeSH terms: Airway Obstruction

Sevoflurane induction in acute airway obstruction

Chiu CL, Delilkan AE

Hosp Med, 1998 Oct;59(10):828.

PMID: 9850310

Matched MeSH terms: Airway Obstruction/etiology; Airway Obstruction/surgery*

Fulltext Risk factors associated with severe viral croup in hospitalised Malaysian children

Chan PW

Singapore Med J, 2002 Mar;43(3):124-7.

PMID: 12005337

To determine the risk factors associated with severe viral croup in hospitalised Malaysian children.

Matched MeSH terms: Airway Obstruction/etiology*; Airway Obstruction/epidemiology; Airway Obstruction/virology

Right aortic arch with isolation of the left subclavian artery: a rare association with airway obstruction

Yubbu P, Latiff HA, Adam Abbaker AM

Cardiol Young, 2017 Apr;27(3):613-616.

PMID: 27817752 DOI: 10.1017/S1047951116001840

We present two interesting cases of isolated left subclavian artery from the pulmonary artery with symptoms of upper airway obstruction. The first patient had tetralogy of Fallot, pulmonary artery sling, bilateral superior caval veins, and left bronchial isomerism, suggesting heterotaxy syndrome. The second patient had a right aortic arch, isolated left subclavian artery, and bilateral arterial ducts. These two cases are interesting because of their rarity and uncommon presentation.

Matched MeSH terms: Airway Obstruction/diagnosis; Airway Obstruction/etiology*

Fulltext Revisiting asthma phenotype in children

Fahisham Taib

Malaysian Journal of Paediatrics and Child Health, 2011;17(1):0-0.

MyJurnal

Asthma is considered as heterogeneous multidimensional disorder due to variable phenotypic presentation. Phenotype is defined as a cluster of either clinical or pathologic features, which tends to be associated with the understanding the mechanisms of the disease. Asthma is typically characterized by airway inflammation, variable airway obstruction, bronchial hyper-reactivity, smooth muscle hypertrophy and apparent reversible airflow obstruction by bronchodilators. ‘Asthma syndrome’ is a term to describe complex pathophysiology of the condition which is not exclusive to allergen triggered episodes. Diagnosing childhood asthma is difficult, due to the similarity of symptoms and overlapping with other wheezing conditions. The precise mechanism for asthma exacerbation, for each individual phenotype is not fully understood. However, it is influenced by genetic interaction with variety of external environmental stimuli. The current understanding on asthma phenotypes were interpreted based on age of onset, associated triggers, clinical aspects, physiologic parameters and type of inflammation (Table 1). Due to the illdefined of the current phenotypic definition and disagreement among the respirologists, it is becoming a challenge to label specific phenotype with certainty. Accurate definition of each phenotype should therefore be helpful to provide better understanding of different mechanistic pathways and focusing on targeted therapy for individual phenotype. (Copied from article).

Matched MeSH terms: Airway Obstruction

Fulltext Respiratory diphtheria in three paediatric patients

Lee JK, Huda S, Francis A, Aisai, Jusoh M

Med J Malaysia, 1999 Sep;54(3):377-82.

PMID: 11045069

From August till November 1998, the Paediatric and Anaesthetic Units of Hospital Kuala Terengganu managed three patients from Kuala Terengganu District who were ventilated for respiratory diphtheria. Their ages were 5, 4 and 7 years old and their immunisation for diphtheria were not complete. All three patients presented with respiratory distress and were ventilated for upper airway obstruction. Their treatment included intravenous penicillin and diphtheria antitoxin. One patient died of cardiogenic shock with secondary pneumonia. Pharyngeal and tonsillar swabs of all three patients grew toxigenic Corynebacterium diphtheriae biotype mitis. There were 765 throat cultures taken from contacts. The confirmed positive cultures grew 2 toxigenic and 3 non-toxigenic Corynebacterium diphtheriae biotype mitis and surprisingly, 10 non-toxigenic biotype gravis. A prevalence study is needed to document the endemicity of diphtheria in Kuala Terengganu and to determine the carrier rate of both biotypes. Steps have been taken to increase the immunisation coverage in children. The giving of regular booster doses of diphtheria toxoid to the adult population should be considered.

Matched MeSH terms: Airway Obstruction/etiology*; Airway Obstruction/therapy

Resolution of asthmatic symptoms following successful endoscopic resection of tracheal mucoepidermoid carcinoma

Hanif Khan A, Faisal M, Mohd Ali R, Abdul Rahaman JA

BMJ Case Rep, 2019 Jan 17;12(1).

PMID: 30659001 DOI: 10.1136/bcr-2018-226202

Mucoepidermoid carcinoma (MEC) is a rare tumour of the trachea accounting for up to 0.2% of reported primary lung malignancy. We report a case of a 54-year-old man, ex-smoker, whose presentation mimicked adult onset asthma with cough and wheezing, which did not respond to conventional treatment. He had occasional haemoptysis and weight loss in which CT scan performed for malignancy screening showed a protruding mass in the distal trachea causing endobronchial obstruction. Bronchoscopic intervention was performed to relieve the obstruction that resulted in resolution of asthmatic symptoms. Histological diagnosis confirmed MEC. This case emphasised the importance of a high index of suspicion in an unusual presentation of a common disease and the pivotal role of bronchoscopic intervention in malignant central airway obstruction.

Matched MeSH terms: Airway Obstruction

Fulltext Relationship between symptoms and objective measures of airway obstruction in asthmatic patients

Liam CK, Goh CT, Isahak M, Lim KH, Wong CM

Asian Pac J Allergy Immunol, 2001 Jun;19(2):79-83.

PMID: 11699724

The objective of this study was to determine the relationship between asthma symptoms and the degree of airway obstruction as measured by the forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR) in a group of 64 asthmatic patients with clinically stable disease attending a university-based urban asthma clinic. Asthma symptoms did not correlate with the degree of airway obstruction as measured by prebronchodilator PEFR (total asthma symptom score vs PEFR: r = -0.214, p = 0.104, n = 59) and only correlated poorly with prebronchodilator FEV1 (total asthma symptom score vs FEV1: r = -0.256, p = 0.041, n = 64). These results lend support to the recommendation that airway obstruction should be measured objectively when assessing patients with chronic persistent asthma.
Study site: Asthma clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia

Matched MeSH terms: Airway Obstruction/complications*; Airway Obstruction/diagnosis*

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