Novel role of focused airway ultrasound in early airway assessment of suspected laryngeal trauma

The role of upper airway ultrasonography in tracheal necrosis diagnosis: a case report

BACKGROUND

Tracheal necrosis post endotracheal intubation is a rare life-threatening disease that can compromise airway patency. We demonstrated a novel usage of upper airway ultrasonography (USG) to diagnose tracheal necrosis.

CASE PRESENTATION

A middle-aged smoking male presented with productive cough, noisy breathing and exertional dyspnea for 2 weeks. He was intubated one month prior due to a traumatic brain injury. Upper airway USG findings showed irregular air-mucosal interface (AMI) and comet tail artefacts over the 1st and 2nd tracheal ring. A direct laryngoscopy in the operating room showed thick mucopus inferior to the vocal cords, with necrotic tracheal cartilages and debris obstructing the airway. He was successfully treated with parenteral antibiotics, wound debridement and tracheostomy.

CONCLUSION

Our case highlights the first documented USG findings of tracheal necrosis. Upper airway USG serves as a potential diagnostic modality in managing the condition.

Bedside Ultrasound: The Silent Guardian for Upper Airway Assessment and Management

Ultrasound evaluation of the upper airway has emerged as an essential instrument for clinicians, offering real-time assessment that can help to guide interventions and improve patient outcomes. This review aims to provide health care providers with a practical approach to performing ultrasound evaluation of the upper airway, covering basic physics relevant to upper airway ultrasound, the identification of key anatomical structures, and elucidating its various clinical applications, such as prediction of difficult airway, confirmation of endotracheal intubation, and guidance for surgical airway procedures and airway blocks. We also discuss evidence-based training programs, limitations, and future directions of ultrasound imaging of the upper airway.

The Role of Pocus in Acute Respiratory Failure: A Narrative Review on Airway and Breathing Assessment

Acute respiratory failure (ARF) is a challenging condition that clinicians, especially in emergency settings, have to face frequently. Especially in emergency settings, many underlying diseases can lead to ARF and life-threatening conditions have to be promptly assessed and correctly treated to avoid unfavorable outcomes. In recent years, point-of-care ultrasound (POCUS) gained growing consideration due to its bedside utilization, reliability and reproducibility even in emergency settings especially in unstable patients. Research on POCUS application to assess ARF has been largely reported mainly with observational studies showing heterogeneous results from many different applications. This narrative review describes the wide potentiality of POCUS to face airways and breathing life-threatening conditions such as upper airway management, pulmonary and pleural pathologies and diaphragm impairment. We conducted extensive research of the literature to report from major studies to case reports deemed useful in practical clinical utilization of POCUS in ARF. Due to the huge amount of the literature found, we focused on airways and breathing assessment trying to systematize the evidence according to clinical care of ARF in emergency settings. Further studies, possibly trials, should determine how POCUS is crucial in clinical practice in terms of standard of care improvements, patient safety and cost-benefit analysis.

Airway ultrasound to detect subglottic secretion above endotracheal tube cuff

BACKGROUND

Subglottic secretion had been proven as one of the causes of microaspiration and increased risk of ventilator-associated pneumonia (VAP). The role of ultrasound to detect subglottic secretion has not yet been established.

PURPOSE

The purpose of this study is to determine the sensitivity and specificity of upper airway ultrasound (US) in the detection of subglottic secretions as compared to computed tomography (CT) scanning.

MATERIAL AND METHODS

A prospective observational study was carried out in adult trauma patients requiring mechanical ventilation and cervical CT scan. All patients had an endotracheal tube cuff-pressure maintained between 20 and 30 cm H₂O. Airway US was performed at the bedside immediately before the patient was transferred to the CT scan suite. The sensitivity, specificity, and positive/negative predictive values (PPV, NPV) of the upper airway US detection of subglottic secretions were then calculated and compared with CT findings.

RESULTS

Fifty participants were consecutively included. Subglottic secretions were detected in 31 patients using upper airway US. The sensitivity and specificity of upper airway US in detecting subglottic secretion were 96.7% and 90%, respectively (PPV 93.5%, NPV 94.7%). 18 (58%) patients with subglottic secretions developed VAP during their ICU stay (p = 0.01). The area under the receiver operating curve (AUROC) was 0.977 (95% CI 0.936-1.00).

CONCLUSIONS

Upper airway US is a useful tool for detecting subglottic secretions with high sensitivity and specificity.

CLINICAL IMPLICATIONS

This study shows: 1. Upper airway US may aid in detecting subglottic secretions, which are linked to VAP. 2. Detecting subglottic secretions at the bedside aids in determining the best frequency of subglottic aspiration to clean the subglottic trachea. 3. Upper airway US may also aid in detecting the correct ETT position. Trial registration Clinicaltrials.gov.

CLINICALTRIALS

gov identifier NCT04739878 Date of registration 2nd May 2021 URL of trial registry record https://clinicaltrials.gov/ct2/show/NCT04739878 .

Systematic Review of Laryngeal Fractures and Trends in Operative Management

Study Design

Systematic review of the literature.

Objective

The goal of this study is to review the current literature on the trends in management of laryngeal fractures following trauma.

Methods

Independent searches of the PubMed and MEDLINE databases were performed. Articles from the period of 1963 to 2020 were collected. All studies which described laryngeal fractures using the Boolean method and relevant search term combinations, including "Laryngeal", "Fracture", "Operative", and "Management" were collected.

Results

A total of 588 relevant unique articles were identified for analysis. Of these, 24 articles were deemed appropriate for inclusion in the literature review. Due to variability in study design and outcome measures, formal synthesis of data in the form of a meta-analysis was not possible.

Conclusions

Laryngeal fractures are rare traumatic injuries that require early identification and evaluation with complex management options. This comprehensive review aims to highlight the breadth of the topic with regard to presentation and clinical management. Though there remains no clear best practice for laryngeal fracture management, we review trends in clinical practice throughout the literature.

[Traumatic Tracheobronchial Injuries - Recommendation of the Interdisciplinary Working Group of the DGT and DGU to Establish a Uniform Classification for Diagnostics and Therapy]

Traumatic tracheobronchial injuries are extremely rare. In comparison, iatrogenic injuries are somewhat more common. A literature search revealed that there is a large number of case reports and small case series for this clinical entity. There are hardly any reviews and they usually have a low level of evidence. One reason for this is the lack of a classification to allow comparison of the individual cases with each other. There is only one classification for iatrogenic injuries of the posterior tracheal wall, which the authors modified and expanded with regard to traumatic tracheobronchial injuries. This classification was extended by the authors to also include traumatic injuries. A three-digit classification is presented here. The grading of the injury covers the entire spectrum of injury patterns, from peribronchial emphysema to wall injuries of different depths to subtotal and complete rupture of the bronchus. In addition, the anatomical location and the cause of the injury were added to the classification. The levels of injury in the tracheobronchial tree are distinguished anatomically. The third digit distinguishes traumatic, iatrogenic and spontaneous injuries. On the basis of the three-digit classification resulting from these parameters, it is possible to group individual cases together and to develop recommendations for diagnostics and therapy.

[Management of blunt and penetrating laryngeal trauma]

Patients presenting with laryngotracheal trauma can be in a life-threatening situation. Early recognition of the severity of the injury and, if necessary, surgical intervention within the first 24-48 h increases the chance of achieving a good functional late result. Preservation or restoration of voice and swallowing function is the long-term therapeutic goal. Precise assessment of the extent of the injury can be achieved using a combination of computed tomography and flexible laryngotracheoscopy. Symptoms often do not reflect the extent of the injury, which can vary from endolaryngeal hemorrhage to complete laryngotracheal separation. Conservative treatment consists of observation with symptomatic therapy. On the other hand, surgery may include endolaryngeal repair and/or transcervical reconstruction; securing the airways is of utmost importance.

Airway Ultrasound in Critically Ill Patients: A Narrative Review

Airway assessment and management have a central role in critical care medicine. Airway ultrasound can help us evaluate the anatomy, facilitate interventions such as intubation in difficult airways and tracheostomy, prevent post-extubation complications, and diagnose dysphagia. In this review, we will summarize the current use of ultrasound in airway assessment and management in critically ill patients.

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

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.