Acute Upper Airway Obstruction

Management of a female patient with thyroid storm accompanied by acute airway obstruction: A case report

Thyroid storm (TS) is a life-threatening exacerbation of the hyperthyroid state. Acute airway obstruction is a life-threatening disease that requires emergency intervention. The present report describes a case of concomitant TS (Burch-Wartofsky Point Scale score, 70 points; thyroid-stimulating hormone, <0.01 µIU/ml; free triiodothyronine, 30.8 pmol/l; and free thyroxine, 106.7 pmol/l) and acute airway obstruction in a 63-year-old female patient. Although treating the TS was viewed as the primary medical concern, the airway obstruction induced by the large thyroid also needed to be solved urgently. In the present case, thyroidectomy was immediately performed, following which the TS was controlled by medical treatment (propylthiouracil, sodium iodide, hydrocortisone and esmolol). After the surgery, the airway obstruction and TS were alleviated, before the patient was eventually discharged from the hospital 14 days after surgery. At 1 month after discharge from the hospital, the patient had normal thyroid function with oral intake of levothyroxine tablet and did not complain of dyspnoea. The present case report aims to emphasize the need for the heightened awareness of patients with TS and trachea stenosis, and underscore the importance of solving the airway obstruction accompanying the TS.

Upper airway changes after orthognathic surgery in patients with skeletal class III high-angle malocclusion and mandibular deviation

OBJECTIVES

This study analyzed the differences in the upper airway of patients with skeletal Class III high-angle malocclusion with and without mandibular deviation, and further investigated whether there are differences in the changes in upper airway space after orthognathic surgery between the two groups.

MATERIALS AND METHODS

15 patients with skeletal Class III high-angle malocclusion and mandibular deviation, and 15 patients without mandibular deviation were selected to explore the impact of mandibular deviation on the upper airway. Additionally, 16 patients with mandibular deviation undergoing orthodontic-orthognathic combined treatment, and 13 patients without mandibular deviation, were selected to investigate the differences in the changes in upper airway space after orthognathic surgery between the two groups.

RESULTS

In patients with skeletal Class III high-angle malocclusion, the deviation group showed significantly smaller sagittal diameter/maximum transverse diameter, cross-sectional area, volumes of oropharynx and hypopharynx, and total volume compared to the normal group, with all differences being statistically significant. After orthognathic surgery, the postoperative sagittal diameter/maximum transverse diameter of the oropharyngeal airway increased in the deviation group, while it decreased in the normal group. The postoperative reductions in cross-sectional area, volumes, and total volume of the oropharynx and hypopharynx were more pronounced in the normal group.

CONCLUSION

In patients with skeletal Class III high-angle malocclusion, mandibular deviation results in narrowing of the lower portion of the upper airway. The orthognathic surgical correction of mandibular deviation compensates to some extent for the reduction in the cross-sectional area and volume of the upper airway caused by the surgery itself.

CLINICAL RELEVANCE

For patients with skeletal Class III high-angle malocclusion with mandibular deviation, a thorough assessment of the upper airway should precede the selection of orthognathic surgery procedures. For patients with normal preoperative upper airway morphology, consideration may prioritize correction of facial aesthetics and occlusion. For patients with pre-existing narrow upper airways, as mandibular setback exacerbates narrowing and the compensatory effect of mandibular deviation correction on the airway is limited, it is suggested that these patients prioritize bimaxillary surgery or reduce the amount of mandibular setback to better promote postoperative respiratory function health.

Extracorporeal membrane oxygenation as life-saving bridge for patients with airway obstruction caused by neck and chest tumors to salvage procedure: an in-depth review

Narrowed or stenotic airways are frequently encountered in emergency practice. Neck and chest tumors-caused airway obstruction usually follow a severe clinical course, necessitating urgent ventilation as a bridge to perform emergency operations. In certain cases, traditional ventilation methods may not safely address complicated airway conditions. In such instances, special cardiopulmonary support becomes necessary to manage both hemodynamics and ventilation for patients. Extracorporeal membrane oxygenation (ECMO) is considered a last resort treatment for respiratory failure. When dealing with emergency difficult airway situations, ECMO offers certain advantages over conventional ventilation. However, its effectiveness in managing airway obstruction due to solid tumors located in the neck or chest is not well-established due to limited clinical practice. Published articles about this topic are still limited and primarily rely on case series and reports. As a result, they offer insufficient data and illustrations to fully elucidate emergency issues. In the present article, the authors summarize the existing literature concerning ECMO utility in managing patients with airway obstruction due to solid tumor located in the neck or chest based on PubMed, Web of Science, and other medical databases, to conduct an in-depth review. The authors conducted an analysis of 27 studies, including a total of 54 patients with airway obstruction caused by tumors. All patients underwent surgical relief of airway obstruction with ECMO as ventilatory support. Postoperatively, 87% of the patients (47/54) survived. 7.4% of the patients (4/54) died due to postoperative disease progression, unrelated to ECMO complications. The prognosis of 5.6% of the patients (3/54) could not be obtained. Additionally, the authors present an interesting case series (n=5) based on a real-world research to demonstrate the different outcomes among airway-obstructed patients due to neck and chest masses. In this series, four patients supported by ECMO were successfully discharged postoperatively, while one patient on conventional ventilation died due to respiratory collapse before surgery. Meanwhile, the authors share novel illustrations and clinical figures to supplement the understanding of this condition. The findings presented in this article provide a basis for further studies and can be used to improve management of the patients.

Predictors of Emergency Interventions in Acute Airway Obstructive Diseases: A Retrospective Single-Center Observational Study

BACKGROUND

The factors related to emergency intervention for internal medicine conditions leading to airway obstruction are not clear.

OBJECTIVE

We aimed to identify factors associated with emergency interventions in acute airway obstructive diseases (AAODs).

METHODS

This is a retrospective observational single-center study. We defined AAODs as acute epiglottitis, peritonsillar abscess, tonsillitis, pharyngitis, oral floor abscess, neck abscess, angioedema, Lemierre's syndrome, hemoptysis, and airway foreign body. We compared the group required airway interventions (intubation, cricothyroidotomy, tracheostomy) with the group treated conservatively admitted to Yokosuka Kyosai Hospital, Japan (tertiary referral hospital) for AAOD between April 2012 and March 2022.

RESULTS

Two hundred fifty-five patients were admitted for AAOD, 104 patients were excluded, and 150 patients (39 intervention group, 111 conservative group) were analyzed. Univariate analysis revealed significant age differences (74(61-78) vs 67(31-76), p<0.01), Glasgow Coma Scale (15(14-15) vs 15(15-15), p<0.01), respiratory rate (24(20-30) vs 20(16-22), p<0.01), National Early Warning Score (NEWS) (6(3-9) vs 3(1-5), p<0.01), Sequential Organ Failure Assessment (SOFA) score (2(1-4) vs 0(0-2), p<0.01), stridor (26% vs 2%, p<0.01), dysphagia (41% vs 21%, p=0.02), drooling (18% vs 3%, p<0.01), frequent suctions (6% vs 0%, p<0.01), airway examination abnormalities (AEAs) (69% vs 32%, p<0.01) and diagnosis (p<0.01). Multivariate logistic regression analysis indicated AEA (OR=9.41, 95%CI 3.66-24.2), upper airway diseases (OR=5.74, 95%CI 2.12-15.6), and SOFA score (OR=2.88, 95%CI 1.06-7.83) were predictors for intervention. However, the sensitivity and specificity of AEA were 0.69 (95%CI 0.52-0.83) and 0.69 (95%CI 0.59-0.77), respectively.

CONCLUSIONS

AEAs were associated with a high risk of airway interventions in AAOD. Nevertheless, the sensitivity and specificity were insufficient.

Cough-induced laryngeal oedema requiring ventilator

This case report describes laryngeal oedema occurring in a 35-year-old woman with chronic bowel-associated dermatosis-arthritis syndrome, and stenosis of the left main bronchus. The oedema was attributed to persistent cough exacerbated by delayed treatment and intubation-related irritation. Evaluations ruled out inflammatory, autoimmune, and malignant causes. Literature lacks on specific descriptions of cough-induced laryngeal oedema, emphasizing the need for a multidisciplinary approach and early intervention in complex cases to prevent severe hospitalizations in patients with known serious conditions and symptom exacerbation.

Emergency Tracheostomy: Complications, Anesthetic Techniques, and Outcomes

Objectives: Acute upper airway obstruction is a critical medical condition that presents considerable challenges to anesthesiologists. This study aims to provide a formal report on the incidence and outcomes of perioperative complications, as well as the factors that influence unstable intraoperative hemodynamics. Methods: This retrospective study reviewed patients aged 18 years and older who underwent emergency tracheostomy between January 2013 and October 2021. Data on perioperative complications and outcomes within the first 24 hours and 7 days after surgery were subjected to analysis. Descriptive and multivariate analyses were used to examine the results. Results: A total of 253 patients were included in the study. The mean age was 61.5 ± 12.9 years. Malignancy was detected in 78.3% of the patients. General anesthesia was administered to 43.9% of the patients. The incidence of intraoperative complications was 51.8%, with hypotension and hypertension occurring in 30.4% and 22.5% of the cases, respectively. Desaturation and cardiac arrest were observed in 4.7% and 0.8% of the patients, respectively. The mortality rate at 7 days after surgery was 1.6%. Multivariate analysis revealed that monitored anesthesia care [adjusted odds ratio (OR) = 1.80; 95% confidence interval (CI): 1.08-3.00] and hypertensive patients (adjusted OR = 1.70, 95% CI: 1.01-2.86) were associated with unstable intraoperative hemodynamics. Conclusions: Cardiovascular instability represented the majority of the complications observed. Monitoring anesthesia care and hypertension were significant prognostic factors for unstable intraoperative hemodynamics. We recommend extensive communication between ear, nose, and throat surgeons and anesthesiologists to determine the appropriate choice of anesthesia.

Epiglottic retroversion as a cause of upper airway obstruction: A case report

RATIONALE

Epiglottic retroversion is the abnormal movement of the epiglottis to the rima glottis, resulting in blockage of inspiratory airflow. Acute upper airway obstruction caused by epiglottic retroversion can lead to sudden respiratory failure. Epiglottic retroversion has occasionally been reported in horses and dogs; however it is extremely rare in humans. Herein, we report a case of epiglottic retroversion causing recurrent upper airway obstruction in human.

PATIENT CONCERNS

We present the case of a 74-year-old man who was diagnosed with epiglottic retroversion without evidence of epiglottis. The patient presented with recurrent episodes of abnormal breathing sounds and dyspnea. Inspiratory stridor was evident whenever the patient experienced dyspnea.

DIAGNOSIS

Epiglottic retroversion was diagnosed as the cause of upper airway obstruction using fiber-optic bronchoscopy.

INTERVENTIONS

The patient underwent tracheostomy to prevent acute respiratory failure because the recurrent episodes of stridor and dyspnea did not improve.

OUTCOMES

The episodic dyspnea and oxygen desaturation did not relapse after tracheostomy and he could be discharged home.

LESSONS

This case highlights the importance of considering epiglottic retroversion as a cause of acute upper airway obstruction.

Application of prolonged submental perforator flap to repair the postoperative defect of upper airway malignancy

OBJECTIVES

To explore the feasibility of making a submental perforator flap distal to the connecting line between the mastoid and the sternoclavicular joint under the guidance of neck-enhanced CT and repairing the postoperative defect of upper airway malignancy.

MATERIALS AND METHODS

This study retrospectively analysed 19 cases of upper airway malignant tumours treated in our department from January 2021 to September 2022, including 17 males and 2 females, aged 43-70 years.

SITE OF LESIONS

15 cases were in the laryngopharynx, 2 cases in the nasal cavity and paranasal sinus and 2 cases on the soft palate. All the lesions were malignant and at stages T2-4N0-2M0.

SURGICAL METHOD

The extended submental perforator flap (size 22-15 × 6-7 cm) was prefabricated distal to the connecting line between the mastoid and the sternoclavicular joint. After tumour resection, the flap was used to repair the postoperative defect. Fifteen cases of laryngopharyngeal malignant tumours were repaired using the extended submental perforator flap with the vascular pedicle located on the opposite side of the tumour body. Two cases of nasal cavity and paranasal sinus tumours were repaired using the extended submental perforator flap combined with the temporalis muscle flap. The soft palate was completely removed in two patients with soft palate cancer and repaired using the folded extended submental perforator flap.

RESULTS

Before the surgery, the reflux vein was observed by neck-enhanced CT, including 12 cases returning to the internal jugular vein and 7 cases to the external jugular vein. All 19 cases in which flaps were used survived, and 1 case had a postoperative infection. All the patients had nasal feeding removed after surgery. The tracheal cannula was removed from the patients with laryngeal preservation, and the pronunciation was satisfactory. Among them, patients with soft palate cancer repair had mild nasal reflux symptoms with smooth breathing. During the follow-up period of 4-24 months, 18 patients had no tumour recurrence or metastasis, and 1 patient had cervical lymph node metastasis.

CONCLUSIONS

This study highlights the use of a submental perforator flap distal to the connecting line between the mastoid and the sternoclavicular joint to repair postoperative defects for upper airway malignancy as an innovative surgical approach that provides more tissue and good arteriovenous blood supply to adjacent sites. This method has high clinical value and provides an effective option for repairing postoperative defects of upper airway malignancy.

Insignificant Difference in Early Post-injury Gene Expression Between Patients with Burns Only and Those with Inhalation Injury: A Bioinformatics Analysis

Airway obstruction is fatal but common among burn patients in the early period after inhalation injury, during which most tracheotomies are performed within 48 h post-injury. Inflammation is common in laryngoscopy; however, the related gene expression has rarely been studied. In this study, we obtained the data of healthy control and patient samples collected within 8-48 hours post-injury from the Gene Expression Omnibus database and classified them into 10 inhalation-injury patients, 6 burn-only, and 10 healthy controls. Differential gene expression was identified between the patient groups; however, principal component analysis and cluster analysis indicated a similarity between groups. Furthermore, enrichment analysis, Kyoto Encyclopedia of Genes and Genomes, and gene set enrichment analyses showed no significant differences in immune regulation and cell adjustment between the patient groups; but differences were shown when comparing either patient group to the healthy control group, including prominent regulation in inflammatory cells, infection, and cell adjustment. Thus, the gene expression in inhalation injury and burn-only patients does not significantly differ in the early period after injury, especially in inflammation, indicating the absence of specific diagnostic markers or anti-inflammatory treatment in inhalation injury patients, with the potential to identify more subtle differences. Further research is warranted.

Airway Resistance and Respiratory Distress in Laryngeal Cancer: A Computational Fluid Dynamics Study

BACKGROUND

Obstructive upper airway pathologies are a great clinical challenge for the airway surgeon. Protection against acute obstruction is critical, but avoidance of unnecessary tracheostomy must also be considered. Decision-making regarding airway, although supported by some objective findings, is largely guided by subjective experience and training. This investigation aims to study the relationship between clinical respiratory distress and objective measures of airway resistance in laryngeal cancer as determined by computational fluid dynamic (CFD) and morphometric analysis.

METHODS

Retrospective CT and clinical data were obtained for series of 20 cases, defined as newly diagnosed laryngeal cancer patients who required admission or urgent airway surgery, and 20 controls. Cases and controls were matched based on T-staging. Image segmentation and morphometric analysis were first performed. Computational models based on the lattice Boltzmann method were then created and used to quantify the continuous mass flow, rigid wall, and constant static pressure inlet boundary conditions.

RESULTS

The analysis demonstrated a significant relationship between airway resistance and acute obstruction (OR 1.018, 95% CI 1.001-1.045). Morphometric analysis similarly demonstrated a significant relationship when relating measurements based on the minimum cross-section, but not on length of stenosis. Morphometric measurements also showed significance in predicting CFD results, and their relationship demonstrated that airway pressures increase exponentially below 2.5 mm. Tumor subsite did not show a significant difference, although the glottic subgroup tended to have higher resistances.

CONCLUSION

Airway resistance analysis from CFD computation correlated with presence of acute distress requiring emergent management. Morphometric analysis showed a similar correlation, demonstrating a radiologic airway assessment technique on which future risk estimation could be performed.

LEVEL OF EVIDENCE

4 (case-control study) Laryngoscope, 133:2734-2741, 2023.

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.

Accuracy of the nursing diagnosis of ineffective airway clearance in intensive care unit patients

OBJECTIVES

to analyze the accuracy of the clinical indicators of ineffective airway clearance in adult intensive care unit patients.

METHODS

diagnostic accuracy study, performed in the intensive care unit of a university hospital in northeastern Brazil. The sample consisted of 104 patients hospitalized between June and October 2019.

RESULTS

the prevalence of ineffective airway clearance was 36.54%. The indicators with high specificity included absence of cough (0.8326), orthopnea (0.6817), adventitious breath sounds (0.8175), and diminished breath sounds (0.8326). The clinical indicators with high sensitivity and specificity were alteration in respiratory rate (0.9999) and alteration in respiratory pattern (0.9999).

CONCLUSIONS

six clinical indicators provided an accurate identification of ineffective airway clearance. The clinical indicators alteration in respiratory rate and alteration in respiratory pattern were the most accurate for critical adult patients. The findings of this study contribute to accurate diagnostic inferences and to prevention of respiratory complications in these patients.

Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting

BACKGROUND

Airway foreign body can be a life-threatening issue in pediatric and adult patients, and the majority of these patients will first present to the emergency department.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of airway foreign bodies for the emergency clinician.

DISCUSSION

Foreign bodies in the upper and lower airways are potentially life threatening. This affects all age groups but is more common in pediatric patients. A history of a witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body. Patients with upper-airway foreign bodies are more likely to present in respiratory distress when compared with lower-airway foreign bodies, which often present with more subtle signs. Stridor, drooling, and wheezing suggest respiratory distress, but the presenting clinical picture is often unclear and may only include a cough. Immediate intervention is required in the patient with hemodynamic instability or respiratory distress. Airway management including laryngoscopy, fiberoptic bronchoscopy, and cricothyrotomy may be needed in these patients, with the emphasis on removing the obstructing foreign body and securing the airway. Specialist consultation can assist in retrieving the foreign body and managing the airway. If the patient is stable, imaging and specialist consultation for potential operating room intervention should be considered.

CONCLUSIONS

An understanding of the presentation, evaluation, and management of the patient with an airway foreign body is essential for emergency clinicians.

Acute Upper Airway Obstruction Due to Massive Cervical Subcutaneous Emphysema: A Case Report

With upper airway obstruction being an emergency, a high index of suspicion and proper and timely treatment planning are crucial to the patient's life. Spontaneous esophageal perforation, also known as Boerhaave syndrome, has been observed to cause subcutaneous emphysema; however, airway compromise secondary to subcutaneous emphysema is extremely rare when there is no associated broncho-tracheal injury. Here, we present a case of esophageal perforation complicated with cervical emphysema that led to acute airway obstruction requiring invasive ventilation.

A Closed-Loop Approach to Fight Coronavirus: Early Detection and Subsequent Treatment

The recent COVID-19 pandemic has caused tremendous damage to the social economy and people's health. Some major issues fighting COVID-19 include early and accurate diagnosis and the shortage of ventilator machines for critical patients. In this manuscript, we describe a novel solution to deal with COVID-19: portable biosensing and wearable photoacoustic imaging for early and accurate diagnosis of infection and magnetic neuromodulation or minimally invasive electrical stimulation to replace traditional ventilation. The solution is a closed-loop system in that the three modules are integrated together and form a loop to cover all-phase strategies for fighting COVID-19. The proposed technique can guarantee ubiquitous and onsite detection, and an electrical hypoglossal stimulator can be more effective in helping severe patients and reducing complications caused by ventilators.

Video-Assisted Intubating Stylet Technique for Difficult Intubation: A Case Series Report

Induction of anesthesia can be challenging for patients with difficult airways and head or neck tumors. Factors that could complicate airway management include poor dentition, limited mouth opening, restricted neck motility, narrowing of oral airway space, restricted laryngeal and pharyngeal space, and obstruction of glottic regions from the tumor. Current difficult airway management guidelines include awake tracheal intubation, anesthetized tracheal intubation, or combined awake and anesthetized intubation. Video laryngoscopy is often chosen over direct laryngoscopy in patients with difficult airways because of an improved laryngeal view, higher frequency of successful intubations, higher frequency of first-attempt intubation, and fewer intubation attempts. In this case series report, we describe the video-assisted intubating stylet technique in five patients with difficult airways. We believe that the intubating stylet is a feasible and safe airway technique for anesthetized tracheal intubation in patients with an anticipated difficult airway.

Dexmedetomidine for patients with croup

Agitation exacerbates symptoms in patients with croup, but the reports on the therapeutic effects of sedation in these patients without intubation are scarce. We describe a typical case of croup wherein light sedation with dexmedetomidine was effective in treating and discuss how agitation exacerbates and sedation improves symptoms from the viewpoint of fluid dynamics theory in addition to the conventional explanation. The mechanism of dynamic airway collapse during inspiration in these patients supports the effectiveness of sedation with dexmedetomidine.

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We describe a typical case of croup in which light sedation with dexmedetomidine was effective.

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How agitation exacerbates symptoms of croup can be explained by fluid dynamics theory in addition to the conventional explanation.

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The negative pressure produced by the patient's inspiration and the static pressure drop leads to dynamic airway collapse.

„A-Probleme“ des nichttraumatologischen Schockraummanagements

Im Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und interdisziplinär behandelt. Beim „primary survey“ dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter, Störungen werden hierbei sofort therapiert. „A-Probleme“ gehen mit einer drohenden Atemwegsverlegung und damit einer konsekutiven Hypoxie einher. Unterschiedlichste Pathologien können hier zugrunde liegen, meist ist aber zunächst eine symptomatische Therapie, also die Sicherung der Atemwege, die entscheidende Notfallmaßnahme. Ein strukturiertes Konzept zum Atemwegsmanagement unter Berücksichtigung lokaler Gegebenheiten sollte in jeder Notaufnahme etabliert sein und regelmäßig trainiert werden.

A 62-year-old man with stridor and dyspnoea

A 62-year-old man, without any past medical history, but a current 10-pack–year smoker, consulted a pulmonologist at the outpatient department for a gradually worsening dyspnoea over 1 year. Dyspnoea occurred first at exercise but, for 1 week, he felt short of breath, even at rest. He also reported a chronic cough with white sputum and frequent blood streaks. His voice was not affected and he had no swallowing difficulties. He lost 4 kg over the previous 3 months, along with a loss of appetite and tiredness. He did not have fever, night sweats, chest pain or choke.

Stridor is a sign of vital emergency that immediately orientates towards a laryngeal or tracheal obstruction. This case report focuses on the management of stridor, which comprises emergency securing of airways and parallel aetiological investigations.https://bit.ly/39CTjOg

Pseudomembranous laryngotracheobronchitis due to coinfection with human bocavirus 1 and Mycoplasma pneumoniae: a case report

Pseudomembranous laryngotracheobronchitis is rarely reported yet potentially life-threatening infectious cause of airway obstruction in children. The causative organisms of this condition are often considered to promote bacterial superinfection following viral infection. We report a case of pseudomembranous laryngotracheobronchitis in a patient caused by human bocavirus 1 and Mycoplasma pneumoniae (M. pneumoniae). A 2-year-old child was admitted to our hospital presenting with cough, hoarseness, and labored breathing. Computed tomography of the chest revealed atelectasis of the right middle lobe of the lung with bronchostenosis and occlusion. Laryngeal edema, pseudomembrane formation and ulceration of the trachea were found during bronchoscopy. Chronic inflammation of the mucosa and local cellulose exudation with acute and chronic inflammatory cell infiltration were confirmed by hematoxylin-eosin staining. Human bocavirus 1 and M. pneumoniae were detected in the bronchoalveolar lavage fluid by next-generation sequencing. The patient tested positive for IgM antibodies against M. pneumoniae. Bronchoscopy was performed three times to clear the secretions in the airway, and azithromycin, ceftriaxone, methylprednisolone, budesonide inhalation, and ambroxol were administered as treatment. The patient's condition improved and she was discharged 21 days after admission. Clinicians should be aware of the potential involvement of human bocavirus 1 and M. pneumoniae in pseudomembranous laryngotracheobronchitis for accurate diagnosis and timely antibiotic administration, and to lower mortality and morbidity rates.

Pediatric COVID-19 presenting as supraglottitis with vocal cord hypomobility

In the United States, an estimated 7.3% of confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19) are among persons aged less than 18 years. Data regarding clinical manifestations in this age group are still evolving. An upper airway predilection has been reported in children. We describe the case of a 15-year-old female with supraglottitis and unilateral hypomobility of vocal cord with concern for critical airway, associated with COVID-19. She was managed by a multidisciplinary team including critical care, infectious diseases, and otolaryngology. This report adds to the sparse but evolving body of literature on the clinical presentation of COVID-19 disease in children.

Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership

There is growing recognition of the need for a coordinated, systematic approach to caring for patients with a tracheostomy. Tracheostomy-related adverse events remain a pervasive global problem, accounting for half of all airway-related deaths and hypoxic brain damage in critical care units. The Global Tracheostomy Collaborative (GTC) was formed in 2012 to improve patient safety and quality of care, emphasising knowledge, skills, teamwork, and patient-centred approaches. Inspired by quality improvement leads in Australia, the UK, and the USA, the GTC implements and disseminates best practices across hospitals and healthcare trusts. Its database collects patient-level information on quality, safety, and organisational efficiencies. The GTC provides an organising structure for quality improvement efforts, promoting safety of paediatric and adult patients. Successful implementation requires instituting key drivers for change that include effective training for health professionals; multidisciplinary team collaboration; engagement and involvement of patients, their families, and carers; and data collection that allows tracking of outcomes. We report the history of the collaborative, its database infrastructure and analytics, and patient outcomes from more than 6500 patients globally. We characterise this patient population for the first time at such scale, reporting predictors of adverse events, mortality, and length of stay indexed to patient characteristics, co-morbidities, risk factors, and context. In one example, the database allowed identification of a previously unrecognised association between bleeding and mortality, reflecting ability to uncover latent risks and promote safety. The GTC provides the foundation for future risk-adjusted benchmarking and a learning community that drives ongoing quality improvement efforts worldwide.