Urgent Surgical Airway Intervention: A 3 Year County Hospital Experience

A Study on Quality of Life in Post-tracheostomised Patients

Introduction

Tracheostomy is a complex procedure which includes special care and attention with respect to the stoma and wound. But apart from surgical pitfalls certain qualities of life are also affected which needs due consideration for positive prognostic outcomes.

Objective

To assess the quality of life in post tracheostomised patients.

Materials and Methods

This study was a hospital based observational study conducted for a period of one year and included 97 patients. All patients underwent tracheostomy in ENT department and Central ICU. Nineteen post tracheostomy quality of life parameters were evaluated in 1st, 4th and 12th week interval.

Results

83.51% were male belonging to 6th and 7th decade. Most of them were tracheostomised on emergency basis (90.72%) for malignant causes (82.47%) and 95.88% of them had it for temporary period of time. Aryepiglottic folds were the most common site of malignant lesion. In the 1st week post tracheostomy, all parameters were affected except taste, smell and aesthetic state whereas in the following weeks it was employment, anxiety and voice production which were the affected quality of life.

Conclusion

Most people had upper airway malignant growth and due to late presentation, they had to be put under emergency tracheostomy. Thus, leading to less time in pre-operative counselling that is a must in improving post-operative period quality of life. Awareness is required for timely screening of patients from 5th decade onwards so that adequate and timely treatment can be provided.

Outcomes of Patients Undergoing Emergency Tracheostomy During COVID 19 Pandemic: Our Experience from a Tertiary Care Centre in North-East India

Airway management in the form of tracheostomy may be done as an emergency or elective procedure depending on when the patient presents and it usually involves a multi-disciplinary team including the anesthesiologist and emergency physician. The purpose of this study is to present our experience with emergency tracheostomies carried out for patients presenting with tumors in the aerodigestive tract during this period of covid 19 pandemic and their outcomes. This is a cross sectional observational study. All the patients who underwent emergency tracheostomy at Dr. B. Borooah Cancer Institute, Guwahati, India, during the period 24th March, 2020 to 23rd September, 2020(6 months) are included in this study. A total of 115 patients underwent 117 emergency tracheostomies (two underwent redo tracheostomies). Median age of patients was 55 years. More than 85% of patients were male. The most common initial presenting complaint was dysphagia (40%) followed by dyspnea (25%). Most common site of tumor was pyriform sinus cancer (45.2%). Almost 45% of patients presented with stage IVA. Complications were seen in 10 patients (8.7%). These included stomal stenosis in 4(3.5%), primary hemorrhage in 3(2.6%), subcutaneous emphysema, infection and wound break down each in one patient (0.9% each). Among the eight residents who performed these procedures, five developed covid 19 symptoms subsequently, and were tested covid positive. Emergency tracheostomy is a safe procedure for patients; however it carries a higher risk of covid transmission despite using proper precautions.

Immediate Postoperative Complications in Adult Tracheostomy

Objective

Tracheostomy is one of the oldest operations for the management of airway obstruction. With time, indications expanded to prolonged mechanical ventilation, and currently, the majority of tracheostomies are done for this reason. There are several techniques used in a tracheostomy procedure, depending on surgeon preference. Immediate complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal wall perforation with esophageal injury are rare, although they do occur, and must be managed accordingly. This study aimed to assess differences in types and rates of immediate postoperative complications in patients undergoing tracheostomy when performed under general anesthesia and local anesthesia (awake tracheostomies) at a large academic institution. This is a continuing ongoing literature reporting tracheostomy adverse events.

Methods

A retrospective chart review was performed to identify patients who underwent tracheostomy placement between January 1, 2013 and December 31, 2019 at the Detroit Medical Center, USA. Postoperative complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal perforation were collected along with gender, age, and revision tracheostomy status. IBM SPSS Statistics (IBM Inc., Armonk, USA) was used for statistical analysis with the statical significance defined as a p<0.05.

Results

A total of 1,469 patient charts were reviewed. Of these, 1,342 met the inclusion and exclusion criteria, of which, males were 57.2% (n=768), and females were 42.8% (n=574). The age range was 18 years to 96 years (mean=58.03; SD= 15.97), and BMI range was 12-83 (mean=28.77; SD=7.885).

Multinomial logistic regression was performed to determine whether age, BMI, sex, and revision tracheostomies were represented across both general and awake tracheostomy groups proportionally to their numbers in the total sample. It showed non-significant value for age (χ2=0.776, p=0.378), BMI (χ2=0.004, p=0.947), but significant value for sex (χ2=4.645, p=0.031), revision tracheostomy (χ2=18.282, p<0.001), indicating that males and revision tracheostomies over-represented in awake tracheostomies.

Next, Pearson correlation analysis was performed to determine any significant linear relationship between age, sex, and tracheostomy complications. It showed a significant positive correlation between age and tracheal stomal infection [r(1,340)=0.062, p=0.022].

An independent sample t-test showed a statistically significant difference between the mean pneumothorax and pneumomediastinum of general (n=1,277, mean=0.01, SD=0.088) and awake tracheostomies (n=65, mean=0.08, SD=0.269, t=2.069, p=0.043).

Pneumothorax pneumomediastinum complications between the general tracheostomy and awake tracheostomy odds ratio (OR)-6.22, indicates the chance of pneumothorax /pneumomediastinum complication is 6.22 times more in awake tracheostomy than general tracheostomy. Based on the above statistical analysis, we rejected the null hypothesis.

Conclusions

Tracheostomy is the procedure of choice to relieve the upper airway obstruction and treat patients requiring prolonged mechanical ventilation. A slightly higher number of Immediate postoperative complications in awake tracheostomy were noticed in patients with more surgically challenging revision tracheostomies.

Predictors of Complications Occurrence Associated With Emergency Surgical Tracheotomy

OBJECTIVE

In emergency airway management, the occurrence of surgical tracheotomy complications is increased and may be fatal for the patient. However, the factors that play a role in complication occurrence and lead to lethal outcome are not known. The objective of this study was to determine predictors associated with the occurrence of complications and mortality after emergency surgical tracheostomy.

STUDY DESIGN

Retrospective study with a systematic review of the literature.

SETTING

Tertiary medical academic center.

SUBJECTS AND METHODS

We included 402 adult patients who underwent emergency surgical tracheostomy under local anesthesia due to upper airway obstruction. Demographic, clinical, complication occurrence, and mortality data were collected. For statistical analysis, univariable and multivariable logistic regression methods were used.

RESULTS

In multivariable analysis, significant positive predictors of complication occurrence were previously performed tracheotomy (odds ratio [OR] 3.67, 95% confidence interval [CI], 0.75-17.88), neck pathology (OR 2.05, 95% CI 1.1-1.77), and tracheotomy performed outside the operating room (OR 5.88, 95% CI, 1.58-20). General in-hospital mortality was 4%, but lethal outcome as a direct result of tracheotomy complications occurred in only 4 patients (1%) because of intraoperative and postoperative complications.

CONCLUSION

The existence of neck pathology and situations in which tracheotomy was performed outside the operating room in uncontrolled conditions were significant prognostic factors for complication occurrence. Tracheotomy-related mortality was greater in patients with intraoperative and early postoperative complications. Clinicians should be aware of the increased risk in specific cases, to prepare, prevent, or manage unwanted outcomes in further treatment and care.

Guidelines for Tracheostomy From the Korean Bronchoesophagological Society

The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.

Helmet CPAP as a Bridge From a Rapid Response Activation for Hypoxia Through Awake Tracheostomy in the Operating Room in a Patient With a Difficult Airway: A Case Report

Continuous positive airway pressure (CPAP) has been used in multiple clinical settings with increasing frequency. However, its use in improving blood oxygenation for difficult airways has never been a specific consideration. Here, we present a rapid response team (RRT) intervention in a patient with severe hypoxia requiring emergent surgical tracheostomy. To restore an adequate level of blood oxygen saturation, helmet CPAP was used during transportation and surgical tracheostomy. In selected cases involving difficult airways, helmet CPAP may have some advantages. Additional studies are warranted to assess the benefits of introducing this device to RRT equipment.

The Critical Response Team in Airway Emergencies

Successful outcomes of airway emergencies (AEs) in the hospital depend on rapid recognition and intervention before patients become unstable. We describe our medical center's experience with a coordinated rapid response to AEs, including an illustrative case. This approach emphasizes early recognition of impending AEs and instantaneous activation of a team of specialists and operating room personnel to rapidly respond to AEs anywhere in our medical center.The literature on critical response teams for AEs is reviewed.

Managing the airway catastrophe: longitudinal simulation-based curriculum to teach airway management

Background

A longitudinal curriculum was developed in conjunction with anesthesiologists, otolaryngologists, emergency physicians and experts in medical simulation and education.

Methods

Residents participated in four different simulation-based training modules using animal models, cadavers, task trainers, and crisis scenarios using high fidelity manikins. Scenarios were based on various clinical settings (i.e. emergency room, operating room) and were followed by video-assisted structured debriefings. Participants completed both a self-assessment questionnaire and an exit survey using five-point Likert scales.

Results

31 otolaryngology residents participated in the curriculum. Residents reported simulation training significantly improved technical skills such as tracheostomy, cricothyroidotomy and pediatric intubation (p < 0.05 for all). Non-technical skills, including communication, delegation and management were significantly improved on post-test surveys in simulated crisis scenarios (p < 0.05 for all). 90 (28/31) of participants found simulations to be very realistic. Junior residents placed increased value on didactic teaching and procedural skills, while senior residents on crisis scenarios. Survey results indicated that > 90% (28/31) of participants found the modules of the curriculum to be useful and would recommend them to others.

Conclusion

A longitudinal simulation-based medical curriculum can be an effective method to teach airway management and teamwork skills to otolaryngology residents.

Risk factors for acute unplanned tracheostomy during panendoscopy in HNSCC patients

Background

Despite of careful pre-operative risk evaluation some patients require an acute unplanned tracheostomy during panendoscopy.

Methods

Risk factors of patients requiring an unplanned tracheostomy during panendoscopy (n = 32) were compared to a control group with panendoscopy without tracheostomy (n = 180).

Results

2131 panendoscopies for Head and Neck squamous cell carcinoma were performed at our Department between 2000 and 2014. Unplanned tracheostomies were necessary in 1.6% of all panendoscopies. Patients with laryngeal cancer (p = 0.001) or abnormal activated partial thromboplastin time (aPTT) (p = 0.03) had a statistically significant higher risk of unplanned tracheostomy. Regression analysis showed that patients with advanced laryngeal cancer had an almost 6 times higher risk for tracheostomy than patients with early stage oropharyngeal cancer.

Conclusions

We identified abnormal aPTT and laryngeal carcinoma as significant predictors for unplanned tracheostomy during panendoscopy. The results of our study could improve preoperative risk evaluation in HNSCC patients.

Awake vs Sedated Tracheostomies: A Review and Comparison at a Single Institution

Objective

The literature surrounding awake tracheostomies is sparse, particularly comparing awake tracheostomy patients to that of the sedated tracheostomy population. This study sought to compare tracheostomy patient demographics, indications, and outcomes of the 2 populations.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Materials and Methods

All tracheostomies performed at our tertiary academic medical institution between January 2013 through November 2015 were reviewed. The data collected included demographics, comorbidity, anticoagulation, and outcomes.

Results

A total of 978 tracheostomies performed during this period met inclusion criteria, with 78 (8.0%) on awake patients. Most awake procedures were performed by otolaryngology (97.4%). Male sex predominated (73.1% awake vs 57.8% sedated). Forty-four patients (56.4%) were smokers in the awake group vs 326 of 900 (36.2%) in the sedated group. Malignancy was the primary indication for awake tracheostomy (68/78, 87.1%). One patient (1.3%) had significant postoperative bleeding compared to 26 of 900 (2.9%) of the sedated tracheostomy patients ( P = .406). Only 9 (11.4%) were ever decannulated. Thirty-one (39.2%) patients ultimately underwent total laryngectomy, 3 could not be decannulated secondary to anatomical causes (stenosis or vocal fold paralysis), and 19 were lost to follow-up after discharge. There were 12 of 78 (15.4%) overall deaths in the awake cohort, with 215 of 900 (23.9%) in the sedated cohort ( P = .088).

Conclusion

Despite all the differences between the 2 patient populations, the urgent awake tracheostomy appears to be safe and its complications do not appear significantly different from the sedated population.

Awake Tracheostomy: Indications, Complications and Outcome

BACKGROUND

Awake tracheostomy (AT) is aimed at securing the airway of patients with upper airway obstruction when other means are not feasible or have failed. Reports on AT in the literature are scarce. The goal of this study was to review our experience with the indications, complications and outcome of AT.

METHODS

A retrospective chart review was conducted on all ATs performed between 2010 and 2016 in two university-affiliated, tertiary medical centers. Data on demographics, indications, techniques, urgency and postoperative complications were retrieved from the medical charts.

RESULTS

The 37 of the 1023 recorded tracheostomies (3.62%) that were ATs comprised the study group (mean age of the patients 60.3 years, 32 [86.5%] males). The most common indication was head and neck (HN) malignancy (oncologic group, 70.3%), with the larynx (53.8%) being the most commonly involved site. Patients in the non-oncologic group (n = 11) were significantly younger (P = 0.048) and had a significantly higher prevalence of urgent surgery compared to the oncologic group (P = 0.0009). Major postoperative complications included tube dislodgement (n = 2) and pneumothorax (n = 1) that were managed successfully. One of the two patients with severe hypoxia and arrhythmia that necessitated cardiopulmonary resuscitation died.

CONCLUSION

Whether the etiology of the AT was related to HN oncological disease or not was the most important clinical factor in our cohort. The non-oncologic group was significantly younger, suffered from more urgent events and tended to have more complications (nonsignificant). ATs had a 97.3% rate of immediate survival, a 5.4% risk of major irreversible complications and a 2.7% risk of mortality.

Case Report of a Massive Retropharyngeal Goiter Resulting in Laryngeal Compression

This is a rare presentation of a morbidly obese male with a massive retropharyngeal goiter causing laryngeal compressive symptoms and unique airway management challenges. Flexible laryngoscopy revealed a retropharyngeal mass circumferentially compressing the oropharynx and supraglottis and preventing the visualization of the glottis. Awake tracheostomy was performed before total thyroidectomy. Airway compression from a goiter typically results from substernal extension, which usually does not cause difficulty with endotracheal intubation. Extensive retropharyngeal extension can cause supraglottic obstruction of the airway. In these cases, optimal management consists of a closely coordinated approach between anesthesia and surgery teams to establish a surgical airway.

CXC Chemokine Receptor Type 4 Antagonism Ameliorated Allograft Fibrosis in Rat Kidney Transplant Model

OBJECTIVES

In this study, we evaluated the effects of CXC chemokine receptor type 4 and stromal cell-derived factor 1 signaling in the progression of chronic allograft nephropathy in a rat model.

MATERIALS AND METHODS

Experimental rats were divided into 3 groups: Lewis-to-Lewis isograft transplant (group A), Fisher 344 rat-to-Lewis allograft transplant with immunosuppressant cyclosporine (group B), and Fisher 344 rat-to-Lewis allograft transplant treated with cyclosporine and the CXC chemokine receptor type 4 antagonist AMD3100 (1 mg/kg/d) (group C). On day 90 after the operation, renal graft function, proteinuria, and histologic Banff score were measured. The expression levels of transforming growth factor β1 and collagen IV were determined by quantitative real-time polymerase chain reaction.

RESULTS

Renal function and urinary protein were increased in allografts of groups B and C compared with isografts of group A. The Banff score was significantly decreased in the AMD3100-treated animals (group C), with renal fibrosis being reduced. In addition, overexpressed levels of transforming growth factor β1 and collagen IV in group B allografts were significantly reduced versus that shown with treatment with the CXC chemokine receptor type 4 antagonist in group C.

CONCLUSIONS

Together, these data strongly implicate that CXC chemokine receptor type 4 antagonism alleviated renal interstitial fibrosis in long-term surviving allografts by down-regulating expression of transforming growth factor β1.

Emergency Surgical Airways Following Activation of a Difficult Airway Management Team in Hospitalized Critically Ill Patients: A Case Series

INTRODUCTION

An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments.

METHODS

We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT).

RESULTS

Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event.

CONCLUSION

An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

Urgent tracheostomy: four-year experience in a tertiary hospital

BACKGROUND

Urgent airway management is one of the most important responsibilities of otolaryngologists, often requiring a multidisciplinary approach. Urgent surgical airway intervention is indicated when an acute airway obstruction occurs or there are intubation difficulties. In these situations, surgical tracheostomy becomes extremely important.

METHODS

We retrospectively studied the patients who underwent surgical tracheostomy from 2011 to 2014 by an otolaryngologist team at the operating theater of the emergency department of a tertiary hospital. Indications, complications and clinical evolution of the patients were reviewed.

RESULTS

The study included 56 patients (44 men and 12 women) with a median age of 55 years. The procedure was performed under local anesthesia in 21.4% of the patients. Two (3.6%) patients were subjected to conversion from cricothyrostomy to tracheostomy. Head and neck neoplasm was indicated in 44.6% of the patients, deep neck infection in 19.6%, and bilateral vocal fold paralysis in 10.7%. Stridor was the most frequent signal (51.8%). Of the 56 patients, 15 were transferred to another hospital. Among the other 41 patients, 21 were decannulated (average time: 4 months), and none of them were cancer patients. Complications occurred in 5 (12.2%) patients: hemorrhage in 3, surgical wound infection in 1, and cervico-thoracic subcutaneous emphysema in 1. No death was related to the procedure.

CONCLUSION

Urgent tracheostomy is a life-saving procedure for patients with acute airway obstruction or with difficult intubation. It is a safe and effective procedure, with a low complication rate, and should be performed before the patient's clinical status turns into a surgical emergency situation.

Urgent Awake Tracheotomy for Impending Airway Obstruction

BACKGROUND/OBJECTIVE: Awake tracheotomy is performed for patients with impending airway obstruction. Few studies to date have addressed the issues surrounding awake tracheotomy. We sought to review the indications, complications, and outcome of awake tracheotomy for urgent airway control.

MATERIALS AND METHODS: We conducted a retrospective review of patients who underwent awake tracheotomy over a 4-year period from 2001 to 2004 at an urban tertiary medical center. Data were obtained from inpatient records and operative charts.

RESULTS: We obtained data on 54 men and 19 women, with a mean age of 61 years. The majority of patients presented with hoarseness, dyspnea, and stridor. Twenty patients had obstruction from head and neck cancers. Nonmalignant causes included deep neck infections (n = 18), bilateral vocal cord paralysis (n = 17), trauma (n = 9), and laryngeal edema (n = 6). Other causes include laryngeal cyst, subglottic stenosis, and vocal cord granuloma. Six (8.2%) patients experienced complications, including postoperative hemorrhage, pneumothorax, and chest and wound infections. There were no long-term complications or deaths.

CONCLUSION: Awake tracheotomy is efficacious and safe and has a low complication rate.

SIGNIFICANCE: Awake tracheotomy should be performed for impending airway obstruction and in a timely manner before complete obstruction occurs.

Anaesthetic management of acute airway obstruction

The acutely obstructed airway is a medical emergency that can potentially result in serious morbidity and mortality. Apart from the latest advancements in anaesthetic techniques, equipment and drugs, publications relevant to our topic, including the United Kingdom's 4th National Audit Project on major airway complications in 2011 and the updated American Society of Anesthesiologists' difficult airway algorithm of 2013, have recently been published. The former contained many reports of adverse events associated with the management of acute airway obstruction. By analysing the data and concepts from these two publications, this review article provides an update on management techniques for the acutely obstructed airway. We discuss the principles and factors relevant to the decision-making process in formulating a logical management plan.

Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach

According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients.

The critical airway in adults: The facts

An algorithm on the indications and timing for a surgical airway in emergency as such cannot be drawn due to the multiplicity of variables and the inapplicability in the context of life-threatening critical emergency, where human brain elaborates decisions better in cluster rather than in binary fashion. In particular, in emergency or urgent scenarios, there is no clear or established consensus as to specifically who should receive a tracheostomy as a life-saving procedure; and more importantly, when. The two classical indications for emergency tracheostomy (laryngeal injury and failure to secure airway with endotracheal intubation or cricothyroidotomy) are too generic and encompass a broad spectrum of possibilities. In literature, specific indications for emergency tracheostomy are scattered and are biased, partially comprehensive, not clearly described or not homogeneously gathered. The review highlights the indications and timing for an emergency surgical airway and gives recommendations on which surgical airway method to use in critical airway.

Emergency percutaneous tracheostomy in two cancer patients with difficult airway: An alternative to cricothyroidotomy?

Inability to intubate and/or ventilate either due to distorted neck anatomy or restricted mouth opening is uncommon but potentially hazardous clinical scenario in head and neck cancer patients. Emergency cricothyroidotomy in such patients may provide a means of oxygenating the patient, but in practice has limitations and does not establish a definitive airway. We report 2 cases who had distorted face and neck anatomy in which percutaneous tracheostomy was done as an emergency life-saving procedure when other measures to obtain a definitive airway failed.

Emergency percutaneous tracheostomy in two cancer patients with difficult airway: An alternative to cricothyroidotomy?

Inability to intubate and/or ventilate either due to distorted neck anatomy or restricted mouth opening is uncommon but potentially hazardous clinical scenario in head and neck cancer patients. Emergency cricothyroidotomy in such patients may provide a means of oxygenating the patient, but in practice has limitations and does not establish a definitive airway. We report 2 cases who had distorted face and neck anatomy in which percutaneous tracheostomy was done as an emergency life-saving procedure when other measures to obtain a definitive airway failed.

Tracheotomy in the unprotected airway

PURPOSE

Although rare, there are many circumstances in which a secure airway is needed urgently. A newly developed technique is presented for quick and efficient performance of this procedure.

PATIENTS AND METHODS

All patients who had tracheotomies performed at a tertiary referral center from January 1, 2004, through December 31, 2008, were found by querying the admission database. Three hundred twenty-seven separate procedures performed in 325 patients were identified. Urgent tracheotomies were distinguished from elective and emergent tracheotomies by reading operative reports and excluding elective and emergent procedures. Elective procedures were defined as performed in patients with a secure airway (with an endotracheal tube or laryngeal mask airway). Urgent tracheotomies were defined as having an intact, unprotected airway. Emergent procedures were performed in a patient with complete airway obstruction.

RESULTS

Twenty instances of urgent, awake tracheotomies were found in 19 patients, resulting in an incidence of 20 of 327 tracheotomies (6.1%) in 19 of 325 patients (5.8%).

CONCLUSIONS

Tracheotomy is an alternative to cricothyroidotomy as a surgical airway in patients with deteriorating respiratory status who cannot be safely intubated by nonsurgical means.

Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children?

Cricothyrotomy or insertion of a transtracheal device is a life-saving maneuver that may be performed on an emergent or semi-elective basis as a means of bypassing an obstructed upper airway. A surgeon is trained to perform this life-saving procedure whereas most anesthesiologists are not facile with the scalpel. It is for this reason that many percutaneous devices have been developed for use by surgeons and nonsurgeons alike. Unfortunately, the majority of such devices are designed for use in adults and/or teenagers but are not appropriate for neonates and infants. The unique anatomy of the infant larynx, the small size of the cricothyroid membrane, and the technical difficulty of locating the correct anatomical structures make the use of most of these devices impractical if not outright dangerous in neonates and infants. This paper will review many (but not all) of the available devices, associated literature, pitfalls and dangers. It is emphasized that each clinician should become familiar with the advantages and disadvantages of these devices and obtain training with simulators or animal models. A strategy for management of the 'cannot ventilate, cannot oxygenate, cannot intubate' situation should be developed with age and size appropriate equipment.

Transglottic high frequency jet ventilation for management of laryngeal fracture associated with air bag deployment injury

Blunt laryngeal trauma is an uncommon injury associated with high prehospital mortality. Conventional airway management consists of awake tracheostomy. A case of laryngeal trauma associated with air bag deployment managed with tubeless suspension laryngoscopy with high frequency transglottic jet ventilation is presented. The advantages of this technique in the management of patients who are not good candidates for awake tracheostomy are discussed.

The difficult airway in adult critical care

INTRODUCTION

The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer.

AIMS

This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed.

RESULTS

All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation.

CONCLUSIONS

Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.