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Fulltext A case report of airway stenting in tracheal compression secondary to right subclavian artery pseudo-aneurysm

Muhammad Naimmuddin Abdul Azih, Aishah Ibrahim, How, Soon Hin, Kuan, Yeh Chunn

International Medical Journal Malaysia, 2018;17(1):141-144.
MyJurnal

We report a 55-year old lady with the presentation of stridor and type II respiratory failure requiring tracheal intubation. She had right Horner’s syndrome associated with pleural effusion. Her chest radiograph revealed right upper zone lobulated opacities and therefore right Pancoast tumor was the initial diagnosis. However, her CECT thorax revealed a huge right subclavian artery pseudoaneurysm with severe tracheal compression. This rare condition imposed a significant diagnostic as well as therapeutic challenge. Vascular surgery is the definitive treatment but it is associated with high risks. The exact role of rigid bronchoscopy for airway stenting is unknown due to limited evidence available. Indeed, this form of central airway obstruction may benefit from temporary tracheal stenting whilst the surgical repair of the lesion is planned. It may facilitate early weaning and allows less complicated airway control.

Matched MeSH terms: Intubation, Intratracheal
Challenges in electromyographic endotracheal tube (EMG ETT) placement via awake fibreoptic intubation during emergency thyroidectomy

Mohammad Iskandar FF, Nik Lah NAS, Ismail AJ, Yeap TB

BMJ Case Rep, 2021 May 13;14(5).
PMID: 33986014 DOI: 10.1136/bcr-2021-242286

Recurrent laryngeal nerve (RLN) injury is one of the main complications of total thyroidectomy. If the injury is bilateral, total airway obstruction, aphonia and hoarseness of voice could be precipitated. Hence, it is wise for the operating surgeon to be guided by neural monitoring during thyroidectomy. We present a valuable experience handling a middle-aged man with a huge papillary thyroid carcinoma . He needed an urgent thyroidectomy due to obstructive symptoms. We highlight our intraoperative dexterity in handling his surgery in the context of continuous monitoring of RLN using electromyography.

Matched MeSH terms: Intubation, Intratracheal
Fulltext Post-intubation airway related adverse effects: a aomparison between intra-cuff dexamethasone and intra-cuff alkalinized lignocaine

Kep, Kee W., Nadia, M.N., Melvin, K., Muhammad, M., Raha, R., Nurlia, Y.

Journal of Surgical Academia, 2013;3(2):26-31.
MyJurnal

Post-intubation airway related adverse effects such as coughing on the endotracheal tube (ETT), restlessness, hoarseness and sore throat are common and undesirable outcomes of anaesthesia using endotracheal intubation. This prospective randomized single blind study was carried out to compare the effectiveness of intra-cuff dexamethasone and alkalinized lignocaine in reducing the incidence of post-intubation airway related adverse effects. Eighty four patients aged 18 – 60 years, of ASA status I or II, were randomly allocated into three groups: air, dexamethasone and alkalinized lignocaine. Their ETT cuffs were inflated according to the group they were allocated to. The incidence of coughing on the ETT, restlessness, hoarseness and sore throat was assessed, postoperatively. The results showed a significant difference in the incidence of cough, restlessness, hoarseness and sore throat in the dexamethasone group compared to the air group. All the patients had minimal or no sore throat at all documented times. Both intra-cuff dexamethasone and alkalinized lignocaine significantly reduced the incidence of hoarseness. However, alkalinized lignocaine additionally lowered the incidence of restlessness, significantly.

Matched MeSH terms: Intubation, Intratracheal
Fulltext Comparison of cardiovascular responses between remifentanil and fentanyl on laryngoscopy and tracheal intubation in patients undergoing elective surgery

Lai, S.C., Choy, Y.C.

Journal of Surgical Academia, 2014;4(1):20-25.
MyJurnal

This was a prospective, randomized, double-blind study comparing the effect of remifentanil and fentanyl on cardiovascular responses from laryngoscopy and tracheal intubation. Forty-four ASA I or II patients aged between 18-65 yrs scheduled for elective surgery under general anaesthesia, were recruited and randomized into two groups. Each patient in Group R received remifentanil of 0.5 mcg/kg bolus over 30 seconds followed by an infusion of 0.25 mcg/kg/min and each patient in Group F received fentanyl of 2 mcg/kg bolus over 30 seconds followed by an infusion of normal saline. Anaesthesia was then induced with propofol, rocuronium and 2% sevoflurane with 100% oxygen. Cardiovascular changes were recorded every minute for 3 minutes after induction and 5 minutes after tracheal intubation. The heart rate remained stable throughout the induction and intubation period in both groups. None of the patients in the remifentanil group develop bradycardia. Systolic blood pressure (SBP) and mean arterial pressure (MAP) were significantly lower in the fentanyl group at the 3rd minute post-induction and 5th minute post- intubation (p < 0.05). Diastolic blood pressure (DBP) in the fentanyl group was significantly lower at the 2nd and 3rd minute post-induction and 4th and 5th minute post-intubation (p < 0.05). The blood pressure remained stable for the remifentanil group throughout the induction and intubation period. Six patients (27.2%) in the fentanyl group and one patient (4.5%) in the remifentanil group experienced hypertension. Three patients (13.7%) from each group experienced hypotensive episodes. In conclusion, remifentanil 0.5 mcg/kg bolus followed by 0.25 mcg/kg/min infusion resulted in SBP, MAP and DBP remained slightly lower than baseline throughout the whole period but still consider stable, as these changes were not statistically significant.

Matched MeSH terms: Intubation, Intratracheal
Comparison between the use of LMA™ and SLIPA™ in patients undergoing minor surgeries

Wan Rahiza, W.M., Nurlia, Y., Abd Rahman, I., Esa, K., Nadia, M.N., Raha, A. R.

Journal of Surgical Academia, 2012;2(1):8-13.
MyJurnal

Supraglottic airway devices have been used as safe alternatives to endotracheal intubation in appropriate types of surgery. This was a prospective, randomised, single blind study comparing the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and occurrence of adverse effects (e.g. blood stains on the device upon removal and sore throat). A total of 62 ASA I or II patients, aged between 18 to 70 years were recruited for this study. Patients were randomised into two groups; LMA™ and SLIPA™ group. Following induction of anaesthesia, an appropriate sized LMA™ or SLIPA™ was inserted after ensuring adequate depth of anaesthesia. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. The ease of insertion was graded and haemodynamic changes were recorded at 2 minute intervals up to 10 minutes after insertion of the airway devices. The presence of blood stains upon airway device removal at the end of surgery and incidence of sore throat was also recorded. No difficult insertion was experienced in either of these devices. Insertion was either easy [LMA™ 87.1% versus SLIPA™ 80.6% (p = 0.49)] or moderate [LMA™ 12.9% versus SLIPA™ 19.4% (p = 0.16)]. Throughout the study period, the haemodynamic changes that occurred in both groups were not statistically different. Traces of blood were noted on the surface of the device in 9.7% of patients in the SLIPA™ group versus 6.5% of patients in the LMA™ group. The incidence of sore throat was recorded in 12.9% versus 19.4% of patients in the SLIPA™ and the LMA™ groups respectively. These findings were not statistically significant. In conclusion, this study showed no significant differences between the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and adverse effects in patients undergoing minor surgical procedures.

Matched MeSH terms: Intubation, Intratracheal
Fulltext Awake fibre optic intubation with Dexmedetomidine for Ludwig Angina with severe Trismus

Mohd Zulfakar Mazlan, Nik Abdullah Nik Mohammad, Mohamad Hasyizan Hasan, Irfan Mohamad, Zeti Norfidiyati Salmuna, Roselinda Ab Rahman

Malaysian Journal of Medicine and Health Sciences, 2018;14(2):89-92.
MyJurnal

Ludwig angina is a submandibular space cellulitis secondary to oral cavity infection. It is strongly associated with difficult intubation due to limitation in the mouth opening. The presentation of Ludwig angina varies according to the severity of the infection. The extreme presentations include upper airway obstruction and respiratory failure. We present a female teenager with right submandibular abscess as the consequence of Ludwig angina, who was planned for incision and drainage. Successful awake fibre optic intubation was performed as a method of induction due to trismus, deferring the need for tracheostomy.

Matched MeSH terms: Intubation, Intratracheal
Fulltext The Use of Stents in Children with Nasolacrimal Duct Obstruction Requiring Surgical Intervention: A Systematic Review

Tai ELM, Kueh YC, Abdullah B

Int J Environ Res Public Health, 2020 02 07;17(3).
PMID: 32046207 DOI: 10.3390/ijerph17031067

Nasolacrimal duct obstruction (NLDO) is the most common cause of childhood epiphora. It is managed conservatively in the first year of life, after which surgical treatment is classically based on a stepwise paradigm of probing, intubation, and dacryocystorhinostomy. This systematic review aims to present the current role of intubation in the management of children with NLDO requiring surgical intervention. A search for English-language articles from the electronic databases PubMed, SCOPUS, and the COCHRANE library was conducted over a period of five months in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. The following keywords were used to aid retrieval: stents, children, lacrimal intubation, endoscopic dacryocystorhinostomy, external dacryocystorhinostomy, NLDO, dacryocystitis, congenital, acquired. The primary outcome was defined as the success of the intervention, determined by resolution of symptoms and patency of the lacrimal anatomy confirmed by the fluorescein dye disappearance test or syringing. Secondary outcomes included the presence of complications. A total of 144 articles were identified; of these, 35 fulfilled the study criteria. The majority of the included studies involved lacrimal intubation alone, followed by intubation as an adjunctive procedure to balloon dacryoplasty and dacryocystorhinostomy. The overall success rate of these procedures ranged from 41.1% to 100%. Post-operative complications were reported in 65.7% of the included studies. Lacrimal intubation was most commonly performed as a primary procedure in children with NLDO, with high success rates. The main complication was stent dislodgement. There is lack of evidence regarding the benefit of intubation over probing as primary treatment of congenital NLDO. In the absence of high-quality evidence, the decision of whether to perform lacrimal intubation in children with NLDO requiring surgical intervention depends on clinical judgement and other low-level evidence, such as observational non-randomised trials.

Matched MeSH terms: Intubation, Intratracheal
Fulltext Non-invasive ventilation in a pregnancy with severe pneumonia

Mazlan MZ, Ali S, Zainal Abidin H, Mokhtar AM, Ab Mukmin L, Ayub ZN, et al.

Respir Med Case Rep, 2017;21:161-163.
PMID: 28560149 DOI: 10.1016/j.rmcr.2017.05.002

INTRODUCTION: Non-invasive ventilation (NIV) is not proven to be effective in treating respiratory failure in severe pneumonia. However, some clinicians nevertheless attempt NIV to indirectly deliver adequate oxygenation and avoid unnecessary endotracheal intubation.
CASE PRESENTATION: In this article, we report the case of a 24-year-old woman at 32 weeks' gestation who presented with hypoxemic respiratory failure requiring mechanical ventilation. She was successfully managed by NIV.
DISCUSSION: However, NIV must be managed by providers who are trained in mechanical ventilation. This is of the utmost importance in avoiding any delay should the patient's condition worsen and require endotracheal intubation. Moreover, in pregnant women, the severity of illness may progress quickly due to the immunosuppression inherent in these patients.
CONCLUSION: Special attention should be given to the choices of invasive ventilation and NIV to manage community acquired pneumonia patients in third trimester.

Matched MeSH terms: Intubation, Intratracheal
Fentanyl dose for the insertion of Classic Laryngeal Mask Airways in non-paralysed patients induced with propofol 2.5 mg/kg

Tan AS, Wang CY

Anaesth Intensive Care, 2010 Jan;38(1):65-9.
PMID: 20191779

The aim of this randomised, controlled trial was to determine the optimum dose of fentanyl in combination with propofol 2.5 mg x kg(-1) when inserting the Classic Laryngeal Mask Airway. Seventy-five ASA I or II patients were randomly assigned to five groups of fentanyl dosage: 0 microg x kg(-1) (placebo), 0.5 microg x kg(-1), 1.0 microg x kg(-1), 1.5 microg x kg(-1) and 2.0 microg x kg(-1). Anaesthesia was induced by first injecting the study drug over 10 seconds. Three minutes after the study drug was injected, propofol (2.5 mg x kg(-1)) was injected over 10 seconds. The Classic Laryngeal Mask Airway was inserted four minutes and 30 seconds after injection of the study drug. Insertion conditions were evaluated using a four-category score. Thirty-nine males and 36 females aged 19 to 59 years were studied. The incidence of prolonged apnoea increased as fentanyl dose increased. We found that there was a high rate of successful first attempt at insertion with 1 microg x kg(-1) and 1.5 microg x kg(-1), 93% and 87% respectively, compared to 87% in the 2.0 microg x kg(-1) group. The 1.0 microg x kg(-1) group also achieved an 80% optimal insertion conditions score of 4, compared to 73% in the 1.5 microg x kg(-1) group and 80% in the 2 microg x kg(-1) group. Therefore we recommend 1.0 microg x kg(-1) as the optimal dose of fentanyl when used in addition to propofol 2.5 mg/kg for the insertion of the Classic Laryngeal Mask Airway.

Matched MeSH terms: Intubation, Intratracheal/methods*
Assessment of tracheal intubating conditions in children using remifentanil and propofol without muscle relaxant

Batra YK, Al Qattan AR, Ali SS, Qureshi MI, Kuriakose D, Migahed A

Paediatr Anaesth, 2004 Jun;14(6):452-6.
PMID: 15153205

Tracheal intubation in children can be achieved by deep inhalational anaesthesia or an intravenous anaesthetic and a muscle relaxant, suxamethonium being widely used despite several side-effects. Studies have shown that oral intubation can be facilitated safely and effectively in children after induction of anaesthesia with propofol and alfentanil without a muscle relaxant. Remifentanil is a new, ultra-short acting, selective mu-receptor agonist that is 20-30 times more potent than alfentanil. This clinical study was designed to assess whether combination of propofol and remifentanil could be used without a muscle relaxant to facilitate tracheal intubation in children.

Matched MeSH terms: Intubation, Intratracheal/methods*
Fulltext Comparison of the VBM laryngeal tube and laryngeal mask airway for ventilation during manual in-line neck stabilisation

Noor Zairul M, Khairul Faizi A

Singapore Med J, 2006 Oct;47(10):892-6.
PMID: 16990966

INTRODUCTION: The purpose of this study is to assess whether the newly-developed VBM (Medizintechnik GmbH, Sulz, Germany) laryngeal tube (LT) is able to provide adequate ventilation and oxygenation to patients with an unstable neck and require airway management. The haemodynamic responses to insertion between the two devices were also studied. We compared the LT to the laryngeal mask airway (LMA) as an alternative airway management tool in adult patients with unstable neck and who underwent intubation with manual in-line neck stabilisation.
METHODS: A randomised single-blinded prospective study was conducted involving a total of 40 American Society of Anesthesiology I and II pre-medicated patients who were divided into two groups, LT or LMA, for airway management during elective surgery. There were 20 patients for each group. After pre-oxygenation, anaesthesia was induced using intravenous (i.v.) fentanyl and i.v. propofol. The neuromuscular blockade was produced with either i.v. vecuronium or i.v. atracurium. The LT or LMA was inserted after neuromuscular blockade was confirmed using a peripheral nerve stimulator (train-of-four 1). A size 3, 4 or 5 LT or a size 3 or 4 LMA was inserted while the patient's head and neck were being stabilised by an assistant who held the sides of the neck and the mastoid processes (manual in-line stabilisation). If it was not possible to ventilate the lungs, or if end-tidal carbon dioxide and/or chest movement did not indicate a patent airway, the LT or LMA was removed. After three failed attempts, the study was terminated and the airway was secured in the most suitable manner determined by the anaesthetist. After successful placement of LT or LMA, anaesthesia was maintained with 66 percent nitrous oxide in oxygen and 2 minimum alveolar concentration sevoflurane. All patients received standard anaesthesia monitoring. The ease of insertion, the number of attempts needed to successfully secure the airway, episodes of desaturation (less than 95 percent) and end-tidal carbon dioxide at various time intervals were studied. The haemodynamic parameters such as systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate at different time intervals were also studied.
RESULTS: The study showed a statistically significant difference in time required for successful insertion between the groups; time required for LT was 24.8 +/- 7.7 seconds and LMA was 36.1 +/- 17.3 seconds (p-value equals 0.01). Both groups had no statistical differences (p-value is greater than 0.05) in number of attempts needed to achieve a patent airway, and the successful insertion rate was 100 percent for both groups. There were also no statistical differences in the haemodynamic response to insertion and the end-tidal carbon dioxide in this study.
CONCLUSION: We conclude that, under anaesthesia, the LT was a valuable and better alternative to LMA for ventilation and airway management when the patient's head and neck are stabilised by the manual in-line method.

Matched MeSH terms: Intubation, Intratracheal/instrumentation*
Iatrogenic tracheal flap mimicking tracheal stenosis with resultant stridor

Tan KL, Chong AW, Amin MA, Raman R

J Laryngol Otol, 2012 Jul;126(7):751-5.
PMID: 22578299 DOI: 10.1017/S0022215112000795

To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor.

Matched MeSH terms: Intubation, Intratracheal/adverse effects*
Anesthetic management of thoracoscopic resection of lung lesions in small children

Mohtar S, Hui TWC, Irwin MG

Paediatr Anaesth, 2018 11;28(11):1035-1042.
PMID: 30281181 DOI: 10.1111/pan.13502

BACKGROUND: Video-assisted thoracoscopic surgery has dramatically increased over the last decade because of both medical and cosmetic benefits. Anesthesia for video-assisted thoracoscopic surgery in small children is more challenging compared to adults due to the considerable problems posed by small airway dimensions and ventilation. The optimal technique for one-lung ventilation has yet to be established and the use of remifentanil infusion in this setting is not well described.
AIMS: This study investigated the use of extraluminal bronchial blocker placement for one-lung ventilation and the effect of infusion of remifentanil in infants and small children undergoing video-assisted thoracoscopic surgery.
METHODS: We retrospectively reviewed the technique of one-lung ventilation and the hemodynamic effects of remifentanil infusion in 31 small children during elective video-assisted thoracoscopic surgery for congenital lung lesions under anesthesia with sevoflurane or isoflurane, oxygen, and air. Patients' heart rate, blood pressure, and endtidal carbon dioxide at baseline (after induction of anesthesia), immediately after one-lung ventilation, during carbon dioxide insufflation, and at the end of one-lung ventilation were extracted from the database and analyzed. The use of vasopressors or dexmedetomidine was also recorded and analyzed.
RESULTS: Extraluminal placement of a bronchial blocker alongside the tracheal tube was successfully performed in 90.3% of cases (28 patients) without any serious complications or arterial oxygen desaturation. There was no significant rise in blood pressure or heart rate even with the rise of endtidal carbon dioxide concentration during video-assisted thoracoscopic surgery. In 58% of patients (18 patients), phenylephrine was administered to maintain the blood pressure within 20% of the baseline value. There was no significant change in the heart rate of all patients at each time point.
CONCLUSION: One-lung ventilation with an extraluminal parallel blocker was used effectively in this series of young children undergoing thoracoscopic excision of congenital pulmonary lesions. Remifentanil infusion attenuated surgical stress effectively in infants and small children undergoing video-assisted thoracoscopic surgery.

Matched MeSH terms: Intubation, Intratracheal/methods
Cardiac arrhythmia after succinylcholine administration in a patient with Guillain-Barré syndrome--a case report

Hor JY

Middle East J Anaesthesiol, 2010 Oct;20(6):881-3.
PMID: 21526679

We report a case of cardiac arrhythmia occurring in a Guillain-Barré syndrome (GBS) patient after succinylcholine administration during third endotracheal intubation, on day 13 of illness. The probable cause of arrhythmia is succinylcholine-induced hyperkalemia. Of interest, this case demonstrated in the same patient that arrhythmia only occurred during third intubation, when duration of illness is prolonged, and not during previous two intubation episodes, despite succinylcholine was also being used. In GBS, muscle denervation resulted in up-regulation of acetylcholine receptors at neuromuscular junctions, causing the muscle cell membrane to become supersensitive to succinylcholine, leading to severe hyperkalemia and arrhythmia when succinylcholine was administered.

Matched MeSH terms: Intubation, Intratracheal
The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children

Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani KG

Paediatr Anaesth, 2005 Dec;15(12):1094-7.
PMID: 16324030 DOI: 10.1111/j.1460-9592.2005.01633.x

BACKGROUND: Laryngospasm is a well-known problem typically occurring immediately following tracheal extubation. Propofol is known to inhibit airway reflexes. In this study, we sought to assess whether the empiric use of a subhypnotic dose of propofol prior to emergence will decrease the occurrence of laryngospasm following extubation in children.
METHODS: After approval from the Institutional Ethics Committee and informed parental consent, we enrolled 120 children ASA physical status I and II, aged 3-14 years who were scheduled to undergo elective tonsillectomy with or without adenoidectomy under standard general anesthesia. Before extubation, the patients were randomized and received in a blinded fashion either propofol 0.5 mg.kg(-1) or saline (control) intravenously. Tracheal extubation was performed 60 s after administration of study drug, when the child was breathing regularly and reacting to the tracheal tube.
RESULTS: Laryngospasm was seen in 20% (n = 12) of the 60 children in the control group and in only 6.6% (n = 4) of 60 children in the propofol group (P < 0.05).
CONCLUSIONS: During emergence from inhalational anesthesia, propofol in a subhypnotic dose (0.5 mg.kg(-1)) decreases the likelihood of laryngospasm upon tracheal extubation in children undergoing tonsillectomy with or without adenoidectomy.

Matched MeSH terms: Intubation, Intratracheal
Type IV laryngotracheo-oesophageal cleft--management of a difficult airway

Lim SK, Fadhilah T, Ibtisan I

Paediatr Anaesth, 1998;8(4):337-40.
PMID: 9672933

Congenital laryngotracheo-oesophageal cleft is a rare anomaly which presents a challenge to the anaesthetists because of the potential problems of establishing and maintaining an airway. We report the anaesthetic management of a one-month old baby with complete or type IV laryngotracheo-oesophageal presenting for the repair of the defect. The management of the precarious airway is presented and the various techniques of managing the airway are reviewed.

Matched MeSH terms: Intubation, Intratracheal
Bispectral index during modified rapid sequence induction using thiopentone or propofol and rocuronium

Sie MY, Goh PK, Chan L, Ong SY

Anaesth Intensive Care, 2004 Feb;32(1):28-30.
PMID: 15058117

This randomized controlled trial compared Bispectral Index (BIS) values in 40 patients after a modified rapid sequence induction using thiopentone 4 mg/kg or propofol 2 mg/kg with rocuronium 0.6 mg/kg as muscle relaxant. Endotracheal intubation was performed at 60 seconds from induction of anaesthesia and BIS values were recorded for three minutes after induction. At the 120, 150 and 180 second measurements there was a significantly greater proportion of subjects with BIS values < or = 60 ("anaesthetized") in the propofol group compared with the thiopentone group (P values < 0.02, < 0.01 and < 0.01 respectively). All intubations were completed within two minutes. No explicit recall of intubation was detected clinically with either induction agent. The BIS scores we have measured suggest that thiopentone 4 mg/kg is more likely to be associated with lighter planes of anaesthesia and consequent risk of awareness than propofol 2 mg/kg, if intubation is delayed or prolonged.

Matched MeSH terms: Intubation, Intratracheal
Reduction of the aspiration hazard in anaesthesia: use of methohexitone-suxamethonium mixtures

Khawaja AA

Med J Malaya, 1971 Jun;25(4):295-7.
PMID: 4261305
Matched MeSH terms: Intubation, Intratracheal
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: Intubation, Intratracheal
Fulltext Surgical outcomes of absent pulmonary valve syndrome: An institutional experience

Nair AK, Haranal M, Elkhatim IM, Dillon J, Hew CC, Sivalingam S

Ann Pediatr Cardiol, 2020 06 23;13(3):212-219.
PMID: 32863656 DOI: 10.4103/apc.APC_111_19

Background: Absent pulmonary valve syndrome (APVS) is a variant of tetralogy of Fallot characterized by aneurysmal pulmonary arteries, which compresses the tracheobronchial tree, leading to respiratory symptoms. We report the mid-term outcomes of surgical correction of patients with APVS.
Subject and Methods: A total of 27 patients underwent surgery between 2001 and 2015, and they were followed up for a mean period of 6.4 ± 4.1 years. Out of the 27 patients, 14 (51.9%) were infants. The median age at repair was 9.8 months. Preoperative intubation was required in six patients (22.2%), and 11 patients (40.7%) had symptoms of respiratory distress. The pulmonary valve was replaced with a valved conduit in 15 patients (55.6%), monocusp valve in 6 patients (22.2%), and a transannular patch in 6 patients (22.2%). Reduction pulmonary arterioplasty was done in all patients.
Results: The overall 10-year survival was 82.1%. There was 81.1% overall freedom from re-intervention at 10 years. No statistically significant difference was found in 10-year survival (P = 0.464) and reoperation rates (P = 0.129) between valved conduit, monocusp, or transannular patch techniques. Older children had statistically significantly longer survival (P = 0.039) and freedom from re-intervention (P = 0.016) compared to infants. Patients without respiratory complications had 100% 10-year survival and 93.3% freedom from reoperation at 10 years compared to 55.6% and 60.1%, respectively, for patients with respiratory complications.
Conclusion: There has been improvement in surgical results for APVS over the years. However, it still remains a challenge to manage infants and patients with persistent respiratory problems.

Matched MeSH terms: Intubation, Intratracheal

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