Ultrasonography in the management of the airway

In this study, it is described how to use ultrasonography (US) for real-time imaging of the airway from the mouth, over pharynx, larynx, and trachea to the peripheral alveoli, and how to use this in airway management. US has several advantages for imaging of the airway - it is safe, quick, repeatable, portable, widely available, and it must be used dynamically for maximum benefit in airway management, in direct conjunction with the airway management, i.e. immediately before, during, and after airway interventions. US can be used for direct observation of whether the tube enters the trachea or the esophagus by placing the ultrasound probe transversely on the neck at the level of the suprasternal notch during intubation, thus confirming intubation without the need for ventilation or circulation. US can be applied before anesthesia induction and diagnose several conditions that affect airway management, but it remains to be determined in which kind of patients the predictive value of such an examination is high enough to recommend this as a routine approach to airway management planning. US can identify the croicothyroid membrane prior to management of a difficult airway, can confirm ventilation by observing lung sliding bilaterally and should be the first diagnostic approach when a pneumothorax is suspected intraoperatively or during initial trauma-evaluation. US can improve percutaneous dilatational tracheostomy by identifying the correct tracheal-ring interspace, avoiding blood vessels and determining the depth from the skin to the tracheal wall.     

Self-expandable metallic stent for unresectable malignant esophageal stricture

Intraesophageal stenting using a self-expandable metallic stent is currently the first choice for patients with unresectable malignant stricture of the esophagus to improve their quality of life because of its efficacy and less invasiveness. Two types of stent are commercially available in Japan. The Ultraflex stent (Boston Scientific Co. Ltd.) is more flexible and less expandable than the Cook-Z stent (Wilson-Cook Co. Ltd.). Care should be taken based on the position of the stricture. Stenting in the cervical esophagus may cause discomfort. Stenting for a lesion adjacent to the airway may cause airway obstruction. Therefore airway stenting or provision for emergency intratracheal intubation is necessary. A stent with an antireflux mechanism would be effective in preventing gastroesophageal reflux following stenting at the esophagogastric junction. The development and legal approval of a stent with antireflux mechanism are expected. Some reported that anticancer treatment after stenting was effective, and some radiologists cautioned against the risk of radiation after stenting. The safety and efficacy of anticancer treatment after stenting remain to be clarified.     

Tumors and pseudotumors of the hand: The role of imaging

The assessment of a swelling or mass of the wrist or the hand is commonly performed by radiologists. Because cysts on the wrist are, by far, the most frequent pathology. Diagnosis is usually based on standard radiography and ultrasound alone. Additional imaging techniques, and in particular MR imaging, are necessary to assess tumors, although malignant tumors of the hand are rare. Some benign cysts have pathognomonic characteristics visible on imaging. By understanding them, treatment planning may be improved.     

Lung separation in the patient with a difficult airway

During video-assisted thoracoscopy the lungs should be well collapsed to allow the surgeon an optimal view of the surgical field. The use of 'difficult tubes' such as the double lumen tube or Univent cannot be avoided despite the presence of a difficult airway. If it is only possible to place a single lumen tube, a tube exchanger can be used to switch to a double lumen tube or a Univent tube. Alternatively, a Fogarty embolectomy catheter can be passed down the single lumen tube as an independant bronchial blocker. The Bullard and the Wu laryngoscopes and the laryngeal airway mask can further assist in establishing an airway. Finally, depending on the extent and the length of the procedure, an airway, initially not classified as difficult, may become difficult and postoperative planning is a must.     

Airway management for neonates requiring ex utero intrapartum treatment (EXIT)

In utero congenital malformations in the fetus can occasionally lead to an obstructed airway at birth accompanied by hypoxic injury or peripartum demise, without intervention. Ex utero intrapartum treatment (EXIT) may help reduce morbidity and mortality associated with challenging airways by providing extra time on uteroplacental circulation to secure the airway. Meticulous preparation and planning are crucial for this procedure. Many different types of congenital malformations can result in a difficult airway, but there is no correlation between specific malformations and a required type of airway intervention. Based on our experience and literature review, an airway process flow diagram has been created to help assist teams in decision‐making for airway intervention in a neonate during the EXIT procedure. The management of the airway in this scenario involves additional unique considerations that accompany handling a partially delivered newborn in the uterine environment. Extensive preparation and team rehearsal are essential to the success of this procedure.     

Review of imaging techniques in the diagnosis and management of brain metastases

Brain metastasis is one of the most common diagnoses encountered by neurologists, neurosurgeons, radiologists, and oncologists. The aim of this article is to review imaging modalities used in the diagnosis and follow-up of brain metastases. Through the use of various imaging techniques more accurate preoperative diagnosis and more precise intraoperative planning can be made. Post-treatment evaluation can also be refined through the use of these imaging techniques.     

Responsive Contingency Planning: a novel system for anticipated difficulty in airway management in dental abscess

BACKGROUND: This study is of a novel system for management of anticipated difficult airway (Responsive Contingency Planning). It is based on the notion that almost all problems in airway management have already been experienced, so they can be anticipated and prepared for using 'worst case' planning. METHODS: Anaesthetic colleagues were introduced to the new system. Thirty-two patients with dental abscess were recruited for anaesthetic airway management based around the new scheme. Data collection involved a preoperative assessment of problems specific to dental abscess, fascia-spaces involved, details of the contingency planning process, laryngoscopy grade, and comments regarding the efficacy of the new system. RESULTS: No problems were encountered that had not been anticipated during planning and colleagues' comments about using the system were generally favourable. Examples are highlighted to suggest how the planning may have avoided certain complications (e.g. abscess rupture) and helped in dealing with others when they occurred. If trismus (2 cm) after induction of anaesthesia. In contrast, difficult laryngoscopy (grade 3 or 4) occurred in 6/15 cases of floor of mouth infection. CONCLUSIONS: The system fulfilled expectations for its use at this stage of development. It can be easily updated for refinements, alternative techniques, and tailoring to any difficult airway scenario. Computerization should make it easier to use and flag-up inconsistencies. Floor of mouth infections in the presence of trismus are easily underestimated and require careful assessment.     

Interventional radiology in breast cancer

Molecular profiling of metastatic disease may greatly influence the systemic therapy recommended by oncologists and chosen by patients, allowing treatment to be more targeted. Comprehensive care of patients with advanced breast cancer now includes percutaneous image-guided biopsy if this has the potential to influence systemic treatment [1]. Interventional radiologists can contribute significantly to the care of patients affected by breast cancer, in diagnostic and supportive procedures and importantly also in treatment. Interventional radiologists carry out image guided percutaneous biopsies not only of the primary tumour but also of metastases. They insert percutaneous ports and tunnelled central venous catheters. They ablate painful bone metastases, and can treat or prevent pathological fractures. Most importantly they can ablate liver metastases in patients with limited or oligometastatic disease. The inhomogeneity and variety of cell populations in metastatic tumours from breast cancer, which is an important consideration in systemic therapy, is not an important consideration in the treatment of metastatic tumours using percutaneous ablative techniques, which are the major focus of this article. The treatment of primary tumours in the breast is also being explored, but is considered in its infancy at this stage.     

Assessment and management of the predicted difficult airway in babies and children

It is essential that all anaesthetists have a strategy for managing the predicted difficult paediatric airway. The majority of children who have difficult airways are identifiable preoperatively. The situation where a child is unexpectedly difficult to bag-and-mask ventilate, intubate, or both is rare. Therefore anaesthetists usually have adequate time for thought and preparation with regard to ultimately securing the airway.Inadequate airway assessment can contribute to poor airway outcomes. This article outlines the anatomical and physiological differences present in the child and describes clinical assessment of the paediatric airway. Equipment available for managing the predicted difficult airway in a child is also reviewed. Video laryngoscopy, for example, has become more popular in recent years and may increasingly be incorporated into difficult airway algorithms of the future.Emphasis is placed on planning, preparation and practice: the three Ps of the difficult paediatric airway.     

Percutaneous treatment of cystic lymphangiomas

Management of cystic lymphangioma necessitate for optimal diagnosis and treatment the expertise of a trained multidisciplinary team including dermatologists, radiologists, plastic and vascular surgeons. An initial imaging work-up of these lesions by ultrasound Doppler examination and MR imaging are necessary before treatment planning. Depending of the size, the location, the risk for the adjacent organs, a therapeutic decision may be mandatory. Percutaneous sclerotherapy is a safe and efficient treatment. It is the treatment of choice that must be proposed in first intention.     

Airway trauma

Airway trauma should be considered according to location and mechanism of injury. Mechanisms of airway trauma can be broadly classified as blunt, penetrating and thermal/chemical. Airway strategy and planning is key to safe management. These patients may be challenging to manage and complicated by polytrauma. It is essential to remember that the patient's airway may deteriorate rapidly and contingency planning for this should be in place. A structured approach to the patient is essential and delayed diagnosis may worsen outcome.     

Airway trauma

Airway trauma should be considered according to location and mechanism of injury. Mechanism of airway trauma can be broadly classified as blunt, penetrating and thermal/chemical. Airway strategy and planning is key to safe management. These patients may be challenging to manage and complicated by polytrauma. It is essential to remember that the patient's airway may deteriorate rapidly and contingency planning for this should be in place. A structured approach to the patient is essential and delayed diagnosis may worsen outcome.     

Airway trauma

Trauma to the airway should be considered according to its anatomical location and the mechanism of injury, which can broadly be classified as blunt, penetrating and thermal/chemical. Patient management may be clinically challenging, and is often complicated by polytrauma. A comprehensive airway management strategy is key to safe patient care. Patients’ airway control may deteriorate rapidly, such that contingency planning must be in place. A structured approach to patient assessment is essential to avoid delayed diagnosis, which may worsen patient outcome.     

Bypass or angioplasty for severe limb ischaemia? A Delphi Consensus Study.

OBJECTIVES: To examine the level of agreement among vascular surgeons and interventional radiologists regarding their preference for the surgical or endovascular management of severe limb ischaemia. DESIGN: Delphi consensus study using 596 different hypothetical patient scenarios. PARTICIPANTS: Delphi consensus group for the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial. METHODS: Twenty consultant vascular surgeons and 17 interventional radiologists completed both rounds of the study. The scenarios detailed the anatomical extent of disease, whether the patients had rest pain only or had tissue loss, and whether or not a suitable vein for bypass was available. Panellists were asked to score their treatment preference for either surgery or angioplasty on an eight-point scale. Outliers (top 10% and bottom 10% responses) were removed. If the remaining 80% of responses fell within a 3-point range, this was defined as "agreement". If they did not, this was considered "disagreement". RESULTS: There was substantial disagreement in 484 (81%) of scenarios in round 1 and 401 (67%) in round 2. This disagreement was greater among surgeon than radiologists in both round 1 (83 vs 65%) and round 2 (69 vs 42%). Surgeons also demonstrated less convergence between rounds. CONCLUSIONS: There is substantial disagreement between and among surgeons and radiologists with regard to the appropriateness of surgery or angioplasty for severe limb ischaemia. This lack of consensus stems from the absence of an evidence base and means that the same patient may receive entirely different treatment depending on which hospital and consultant they attend. Not only may this unexplained variation be clinically unsatisfactory, it has major implications for the planning and use of health service resources.     

Bronchial artery embolization in hemoptysis

Bronchialarteryembolization(BAE)hasbecome anestablishedprocedureinthemanagementofmas siveandrecurrenthemoptysis;itsusewasfirstre portedin1973byRemyetal[1].Thistechniquewas introducedinChinabyChenYPin1986[2].Theeffi cacy,safety,andutilityofBAEincontrollingmas sivehemoptysishavebeenwelldocumentedinmany subsequentanduptodatereports.Areviewofclini calexperiencetoevaluatetechnique,embolicmateri als,outcomeandcomplicationsofBAEispresented here. 1Technique[1 8] Theprocedureinvolvestheinit…     

Management of the airway in intensive care

Airway management in the intensive care unit (ICU) is largely uneventful; there is a higher incidence of airway difficulties, however, than those encountered in the operating suite. Management of the airway in the ICU presents challenges unique to this environment that must be coped with by a multidisciplinary team that may be less experienced in airway management than clinicians in the operating theatre. The risks associated with this situation, I believe, may be ameliorated by planning and forethought. This article outlines some of the specific difficulties faced by clinicians in ICU and attempts to provide some guidance as to how these may be overcome, or at least abated. Drug choices are discussed, as are equipment choices. A suggestion for a difficult airway algorithm for use in the ICU is put forward. The timing of tracheostomy is discussed. Finally, the importance of the team and the human factors that are at play are touched upon.     

Management of the airway in intensive care

Airway management in the intensive care unit (ICU) is largely uneventful; there is a higher incidence of airway difficulties, however, than those encountered in the operating suite. Management of the airway in the ICU presents challenges unique to this environment that must be coped with by a multidisciplinary team that may be less experienced in airway management than clinicians in the operating theatre. The risks associated with this situation, we believe, may be ameliorated by planning and forethought. This article outlines some of the specific difficulties faced by clinicians in ICU and attempts to provide some guidance as to how these may be overcome, or at least abated. Drug and equipment choices are discussed. A suggestion for a difficult airway algorithm for use in the ICU is put forward. The timing of tracheostomy is discussed. Finally, the importance of the team and the human factors that are at play are touched upon.     

Cardiovascular causes of airway compression

Compression of the paediatric airway is a relatively common and often unrecognized complication of congenital cardiac and aortic arch anomalies. Airway obstruction may be the result of an anomalous relationship between the tracheobronchial tree and vascular structures (producing a vascular ring) or the result of extrinsic compression caused by dilated pulmonary arteries, left atrial enlargement, massive cardiomegaly, or intraluminal bronchial obstruction. A high index of suspicion of mechanical airway compression should be maintained in infants and children with recurrent respiratory difficulties, stridor, wheezing, dysphagia, or apnoea unexplained by other causes. Prompt diagnosis is required to avoid death and minimize airway damage. In addition to plain chest radiography and echocardiography, diagnostic investigations may consist of barium oesophagography, magnetic resonance imaging (MRI), computed tomography, cardiac catheterization and bronchoscopy. The most important recent advance is MRI, which can produce high quality three-dimensional reconstruction of all anatomic elements allowing for precise anatomic delineation and improved surgical planning. Anaesthetic technique will depend on the type of vascular ring and the presence of any congenital heart disease or intrinsic lesions of the tracheobronchial tree. Vascular rings may be repaired through a conventional posterolateral thoracotomy, or utilizing video-assisted thoracoscopic surgery (VATS) or robotic endoscopic surgery. Persistent airway obstruction following surgical repair may be due to residual compression, secondary airway wall instability (malacia), or intrinsic lesions of the airway. Simultaneous repair of cardiac defects and vascular tracheobronchial compression carries a higher risk of morbidity and mortality.     

Arterial thrombolysis in peripheral arterial occlusions--where are the limits of the realm and what are the responsibilities of a vascular surgeon?

Arterial thrombolysis is a well established treatment for acute myocardial ischaemia, with respectable results. It is gaining ground in peripheral vascular surgery as well, particularly in the treatment of acute ischaemia due to occlusion of a sclerotic artery or an arterial graft. However, in case of myocardial ischaemia diagnosis (coronary angiogram), treatment (thrombolysis, PTCA or revascularisation) and recognition for the need for acute surgical treatment are in the same hands in cardiology, in case of peripheral arterial occlusions diagnostics (and therapy in some extent) are provided by radiologists, while patients are usually referred to vascular surgeons. They can provide limited diagnostics (intraoperative angiogram) and can treat patients by non-surgical means (i.e. intraoperative thrombolysis). Although co-operation between radiology and vascular surgical services is crucial and can save limbs and lives, in everyday practice we frequently have to decide whether the ischaemic limb can be treated by thrombolysis only (carried out by radiologists) or the extent and stage of ischaemia are such that they require the faster surgical reconstruction, often completed with intraoperative angiogram and thrombolysis. Whose decision should it be? Should vascular surgeons force thrombolysis, should they do it themselves? What are the cost implications of the successful and unsuccessful thrombolysis?     

Airway trauma

Airway trauma can be considered according to the mechanism of injury, which may guide further management. Trauma may be mechanical, either blunt or penetrating, be due to burns or be iatrogenic as a result of instrumentation of the airway. Immediate airway intervention will be required for obvious airway compromise. Such patients may be difficult to manage, and may be complicated by polytrauma. It is important to appreciate the potential for rapid deterioration in patients with an injury to the aerodigestive tract. Delayed diagnosis can result in poor outcomes from airway and neck trauma, and a structured approach to resuscitation, investigations and ongoing care should be adopted. Iatrogenic airway trauma is not confined to patients in whom intubation is difficult or prolonged, although these are risk factors. Pharyngeal and oesophageal perforation are associated with greater risk of mortality than other iatrogenic airway injuries. Cricoarytenoid joint dysfunction, vocal cord palsy, granuloma, haematoma and tracheal stenosis can all occur as a result of airway instrumentation, and may not be apparent until some time later. Specialist referral of these patients is appropriate, and prompt treatment may improve outcomes. Careful sizing of endotracheal tubes and close monitoring of cuff pressures are important in minimizing airway trauma through intubation.