Management of airway obstruction

Airway management of adult epiglottitis: a systematic review and meta-analysis

Background

Adult epiglottitis is a life-threatening airway emergency where airway protection is the immediate priority. Despite its importance, the optimal approach to airway management remains unclear. We performed a systematic review of the airway management for adult epiglottitis, including meta-analysis of trends over time.

Methods

We systematically searched PubMed, Ovid MEDLINE®, and Embase® for adult epiglottitis studies that described the airway management between 1980 and 2020. The primary outcome was the prevalence of airway intervention. Secondary outcomes were prevalence of tracheal intubation, tracheostomy, and failed intubation. A random-effects model meta-analysis was performed with subgroups defined by decade of study publication. Cases that described the specific method of airway intervention and severity of epiglottitis were included in a separate technique summary.

Results

Fifty-six studies with 10 630 patients were included in the meta-analysis. The overall rate of airway intervention was 15.6% (95% confidence interval [CI] 12.9-18.8%) but the rate decreased from 20% to 10% between 1980 and 2020. The overall rate of tracheal intubation was 10.2% (95% CI 7.1-13.6%) and that of failed intubation was 4.2% (95% CI 1.4-8.0%). The airway technique summary included 128 cases, of which 75 (58.6%) were performed awake and 53 (41.4%) involved general anaesthesia. We identified 32 cases of primary technique failure.

Conclusion

The rate of airway intervention for adult epiglottitis has decreased over four decades to a current level of 10%. Tracheal intubation is a high-risk scenario with a 1 in 25 failure rate. Specific technique selection is most likely influenced by contextual factors including the severity of epiglottitis.

Association of airway obstruction with first-pass success and intubation-related adverse events in the emergency department: multicenter prospective observational studies

Background

Airway obstruction is a relatively rare but critical condition that requires urgent intervention in the emergency department (ED). The present study aimed to investigate the association of airway obstruction with first-pass success and intubation-related adverse events in the ED.

Methods

We analyzed data from two prospective multicenter observational studies of ED airway management. We included adults (aged ≥18 years) who underwent tracheal intubation for non-trauma indications from 2012 through 2021 (113-month period). Outcome measures were first-pass success and intubation-related adverse events. We constructed a multivariable logistic regression model adjusting for age, sex, modified LEMON score (without airway obstruction), intubation methods, intubation devices, bougie use, intubator's specialty, and ED visit year with accounting for patients clustering within the ED.

Results

Of 7,349 eligible patients, 272 (4%) underwent tracheal intubation for airway obstruction. Overall, 74% of patients had first-pass success and 16% had intubation-related adverse events. The airway obstruction group had a lower first-pass success rate (63% vs. 74%; unadjusted odds ratio [OR], 0.63; 95% CI, 0.49-0.80), compared to the non-airway obstruction group. This association remained significant in the multivariable analysis (adjusted OR 0.60, 95%CI 0.46-0.80). The airway obstruction group also had a significantly higher risk of adverse events (28% vs. 16%; unadjusted OR, 1.93; 95% CI, 1.48-2.56, adjusted OR, 1.70; 95% CI, 1.27-2.29). In the sensitivity analysis using multiple imputation, the results remained consistent with the main results: the airway obstruction group had a significantly lower first-pass success rate (adjusted OR, 0.60; 95% CI, 0.48-0.76).

Conclusion

Based on these multicenter prospective data, airway obstruction was associated with a significantly lower first-pass success rate and a higher intubation-related adverse event rate in the ED.

[Awake percutaneous tracheostomy in neurosurgical patients: clinical cases and literature review]

Transoral or combined transnasal-transoral approach is sometimes used for tumor resection in patients with skull base and vertebral neoplasms. In such cases, percutaneous tracheostomy before surgical intervention is advisable. Tracheostomy facilitates surgical access, eliminates intraoperative risk of endotracheal tube kinking and provides airway protection from aspiration in early postoperative period in case of bulbar disorders, hypopharynx and tongue edema. The authors present two patients with massive proliferation of pathological tissue in nasopharynx and oropharynx that excluded tracheal intubation before tracheostomy. These patients underwent awake percutaneous tracheostomy.

Awake nasotracheal intubation under bronchoscopic guidance and anesthetic management in a patient undergoing excision of an endotracheal mass: A case report

RATIONALE

The main challenge facing anesthesiologists during endotracheal mass resection is securing effective airway management during surgery. It is important to select an airway intubation and airway maintenance method according to the patient's condition and the characteristics of the mass.

PATIENT CONCERNS

A 74-year-old woman with aggravated dyspnea for 1 year was scheduled to undergo endotracheal mass excision under general anesthesia.

DIAGNOSIS

The mass was 4 × 3 × 3 cm ovoid-shaped, and located 4 cm above the carina, occupying 41% of the tracheal lumen in a preoperative chest computed tomography and bronchoscopy.

INTERVENTIONS

After preparing extracorporeal membrane oxygenation in case of the inability to ventilate and intubate, we attempted awake bronchoscopy-guided nasotracheal intubation using a reinforced endotracheal tube with an inner diameter of 5.5 mm and outer diameter of 7.8 mm after a translaryngeal block. The tube was passed around the mass without resistance and placed right above the carina. With the tube pulled back above the mass, another tube was introduced from the opened trachea below the mass to the right main bronchus. Following the resection of the tracheal portion containing the mass, the posterior wall of the remaining trachea was reconstructed. The tube placed in the right main bronchus was removed and the tube in the upper trachea was introduced right above the carina. The patient's head was kept flexed once the anastomosis of the trachea was completed, and the surgery ended uneventfully.

OUTCOMES

The mass was confirmed as schwannoma by histopathological finding. The patient was discharged from the hospital on the 6th postoperative day without complication.

LESSONS

Awake bronchoscopy-guided intubation is a safe airway management method in patients with an endotracheal mass. Close cooperation between anesthesiologist and surgeon, and preparation for airway management before surgery is essential. It is necessary to establish alternative plans that can be implemented in the case that intubation and ventilation are not possible.

Difficult airway management for the anaesthetist

This article reviews the key considerations when managing a patient with a difficult airway. The difficult airway may be anticipated from preassessment allowing time for investigations and preparation. Alternatively, the unanticipated difficult airway can present in an emergency situation, or unexpectedly during a routine anaesthetic. The main airway management techniques are discussed with a description of their advantages and limitations. Current guidelines are included that demonstrate how the techniques are incorporated into an overall strategy with a plan A-D when failure occurs. It is critical to progress through such an algorithm in a timely manner to prevent the onset of hypoxia.

Awake tracheostomy in a patient with acute upper airway obstruction: an emergency application of an elective percutaneous procedure

Since its introduction in 1985 with Ciaglia, percutaneous tracheostomy (PT) was contraindicated in emergency settings and obesity. However, several case series in the last 20 years have documented the use of PT in life-threatening airway emergencies. We present a case of severe acute airway obstruction in a 66-year-old woman successfully treated with a placement of an awake PT. The woman's glottic obstruction was caused by a recurrent laryngeal neoplasia and revealed by nasoendoscopy. This acute condition required a serious effort from the patient to oxygenate and therefore prevented orotracheal intubation as well as the use of any supraglottic device and/or sedation. Blood aspiration after a first attempt to make a quick access to the tracheal lumen with an emergency cricothyroidotomy, and difficulties in the exact identification of tumor infiltration, led us to perform an awake tracheostomy. Due to elevated risk of airway bleeding, we started with a surgical approach to better identify anatomical structures. After the correct inter-tracheal ring space identification, sudden worsening of clinical symptoms required that we complete the procedure quickly with the aid of a Ciaglia Blue Rhino™-Cook (CBR) tracheostomy kit. At the tracheostomy tube placement, the patient quickly resolved her dyspnea and physiological breathing was restored.