Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy.

During a period of 11 1/2 months, 41 of 217 adult burn patients admitted to the U.S. Army Institute of Surgical Research Burn Center required endotracheal intubation or tracheostomy for management of the airway and/or ventilatory assistance. Permanent upper airway sequelae were recorded and related to presence of inhalation injury, duration of tube placement, cuff pressure, and pulmonary compliance. An "inhalation injury scoring system" based upon history, physical examination, bronchoscopic findings, and abnormalities at 133xenon lung scan correlated well with postinjury alteration in compliance and subsequent sequelae. Significant inhalation injury was found in 35 patients. Seventeen of the study patients survived (Group I) and 24 patients expired (Group II). Group I patients were screened for permanent airway sequelae by fiberoptic bronchoscopy, xeroradiograms, and spirometry undertaken an average of 11 weeks after extubation or decannulation. Four patients developed tracheal stenosis and five patients had significant tracheal scar granuloma formation. Sequelae were generally more frequent and more severe after tracheostomy than after translaryngeal intubation, and duration of tube placement and presence of a tracheal stoma were the most important etiological factors in permanent damage. For initial respiratory support, we favor the use of translaryngeal (nasotracheal) tubes for periods up to 3 weeks. Fiberoptic bronchoscopic examination is the most reliable follow-up method for detecting anatomic damage in such patients. Spirometry can be used as a noninvasive screening test and xeroradiograms are helpful in assessing the degree of tracheal stenosis.     

Complications of tracheostomies in neurosurgical patients

The records of the neurosurgical patients with tracheostomies who were treated at the University of Mississippi Medical Center during the past 5 years were reviewed. Of the 84 such patients, 45% had posttracheostomy complications, including pneumonitis, pneumothorax, pneumomediastinum, infected stoma, subcutaneous emphysema, tracheal stenosis, aspiration, swallowing dysfunction, and tracheoarterial fistula. Reported complications related to prolonged nasotracheal intubation, the alternative to tracheostomy, are reviewed. These complications appear to be less frequent and less serious than those of tracheostomy, in the authors' experience as well as in the reports of others. It is concluded that in neurosurgical patients, tracheostomy is not a benign procedure. Unless a specific indication for tracheostomy exists, consideration should be given to the use of prolonged nasotracheal intubation for airway maintenance.     

Tracheal stenosis complicated with tracheoesophageal fistula.

OBJECTIVE: The aim of the present study was to evaluate the results of surgical treatment in patients with simultaneous occurrence of postintubation tracheal stenosis (TS) and tracheoesophageal fistula (TEF). METHODS: In the group of 51 patients with postcannulation tracheal stenosis who underwent segmental resection, TEF was identified simultaneously in five (10%) of them. The mean age of the TS-TEF patients was 43 years (range 35-60 years). The patients underwent a single-stage operation during which TEF was sealed and resection of the stenotic tracheal segment was performed. RESULTS: The cause of TEF and of TS was artificial pulmonary ventilation by tracheostomy tube (n=4) or by endotracheal tube (n=1) with a simultaneous insertion of nasogastric tube. In one of the patients with tracheostomy the fistula resulted from an injury to the pars membranacea tracheae and the esophageal wall during tracheostomy. All the patients were respiring spontaneously before the surgical treatment. The mean length of the fistula was 24.0 mm (range 15-30 mm), the fistulae were located at the junction of the upper and middle third of the trachea. The mean length of the resected tracheal segment was 29.6 mm (range 26-32 mm). Postoperative complications were not observed in the group of the TS-TEF patients, none of them died. CONCLUSIONS: The method of choice of the surgical treatment of TEF associated with TS is a single-stage procedure in the patient who respires spontaneously.     

Tracheoscopy assisted repair of tracheo-esophageal fistula (TARTEF): a 10-year experience

BACKGROUND: Fiberoptic tracheoscopy assisted repair of tracheoesophageal fistula (TARTEF) has been reported to be useful for the surgeon with regards to identification of the fistula and proper fistula ligation. The aim of this article is to report our 10-year experience using TARTEF with intermittent positive pressure ventilation (IPPV) during tracheoesophageal fistula (TEF) repair in newborns. METHODS: With ethical committee approval, we included all patients undergoing TARTEF from 1995-2005. Variables of interest were (1) respiratory deterioration caused by gastric inflation because of IPPV during surgery and endoscopy; (2) detection of additional airway anomalies; (3) success of intubation of the fistula; (4) other side effects or adverse events. Data are given in median and range. RESULTS: Forty-seven neonates with TARTEF were included. Mean gestational age was 37 weeks (31-42) and mean weight was 2.5 kg (1.1-3.8). The patients were intubated with tracheal tubes size 2.5-3.5 mm ID. Appropriately sized fiberoptic bronchoscopes with an outer diameter of 2.0, 2.4 and 2.8 mm were used; passed through the lumen of the tracheal tube (TT) thereby requiring the use of IPPV to ensure adequate ventilation. No respiratory deterioration was noted as a consequence of intraoperative fiberoptic manipulation within the trachea or because of gastric hyperinflation with IPPV. In all patients, the TEF was successfully penetrated with the fiberscope and this clearly helped the surgeon to rapidly identify and dissect the fistula. In two patients a tracheal bronchus was identified. In two patients accidental extubation occurred during endoscopic confirmation of successful fistula repair. CONCLUSIONS: While fiberoptic TARTEF through the tracheal tube with IPPV did expedite and facilitate surgery, it did not cause clinically relevant impairment of ventilation. Careful manipulation during fiberoptic assessment is required to avoid tube displacement.     

颌面整形外科经鼻气管插管静吸复合全身麻醉的应用及管理体会

目的：介绍经鼻气管插管静吸复合全身麻醉用于颌面整形外科中的经验,探讨颌面整形外科术中的管理体会,提高手术安全性,降低手术死亡率。方法：颌面整形外科手术538例,ASA分级Ⅰ～Ⅱ级,年龄19～58岁,均实施静吸复合全身麻醉,其中经鼻气管插管535例,另3例因经鼻插管困难或手术原因改行经口气管插管。结果：1例因困难气道,气管插管失败放弃手术,1例因困难气道实施经鼻气管插管困难改行经口逆行气管插管成功,术毕出现喉头水肿,环甲膜穿刺后通气障碍不能完全缓解行气管切开,3例在纤支镜辅助下气管插管成功。术后13例因出血血肿进行紧急气道处理。讨论：气管插管静吸复合全身麻醉是颌面整形外科最安全的麻醉方式,便于气道管理,经鼻插管较经口插管而言,不影响手术操作且固定性好,术毕可留作鼻咽通气道之用,颌面整形外科术操作复杂,术中术后均可能出现出血血肿、呼吸道梗阻,威胁患者生命,呼吸道管理尤为重要。     

Upper airway compromise after inhalation injury. Complex strictures of the larynx and trachea and their management.

OBJECTIVE: Strictures of the upper airway caused by burns have features distinct from other benign stenoses. The authors reviewed their experience with burn-related stenoses to define the principles of treatment. SUMMARY BACKGROUND DATA: The combined effects of inhaled gases and heat in burn victims produce an intense, often transmural, inflammation of the airway, further complicated by intubation. The incidence of laryngotracheal strictures in survivors of inhalation injury is high, but the reported experience with their treatment is limited and often unduly separated into injuries of larynx and trachea. METHODS: Presentation, treatment, and long-term follow-up are reviewed in 9 women and 9 men age 9 to 63 years, who were evaluated over a 22 year period for chronic airway compromise after inhalation injury. There were 18 tracheal stenoses, 14 subglottic strictures, and 2 main bronchial stenoses. Laryngotracheal strictures stenosis. T-tubes were placed in 15 patients, in low subglottic or tracheal stenosis below the vocal cords, in high subglottic stenosis through the vocal cords, and as a stent after resection of subglottic stenosis. RESULTS: There were two deaths during follow-up, one from respiratory failure and one from an unrelated cause. Two patients underwent evaluation only. Early in this series, one tracheal and one laryngotracheal resection resulted in prompt restenosis. Of the remaining 14 patients, 9 are without airway support from 2 to 20 years later. Four have permanent tracheal tubes. One patient required tracheostomy 8 years after successful subglottic reconstruction. CONCLUSIONS: Strictures of the upper airway related to inhalation injury are associated with prolonged inflammation and involve larynx and trachea in a majority of patients. These complex injuries respond to prolonged tracheal stenting (mean, 28 months) and resection or stenting of subglottic stenoses with recovery of a functional airway and voice in most patients. Early tracheal resection should be avoided.     

Anesthetic management for cleft palate plasty in a patient with Pierre-Robin syndrome

A girl (15 months-old) with Pierre-Robin Syndrome was scheduled for cleft palate plasty. She had a past history of difficulty feeding, mild airway obstruction during sleeping and mental retardation. After induction of anesthesia with an inhalational anesthetic technique, conventional tracheal intubation was impossible. We introduced a laryngeal mask airway (LMA) and successfully intubated through the LMA. After extubation of the tracheal tube, she developed upper airway obstruction with arterial desaturation. We ventilated her lungs in the lateral position with an inhalation of epinephrine and injection of methylprednisolone. Airway obstruction then improved gradually. In this case, LMA was a valuable device as a guide for the tracheal intubation. Because airway obstruction after extubation is a common complication in a patient with Pierre-Robin syndrome, we need to observe the patient closely.     

Using a nasopharyngeal airway during fiberoptic intubation in small children with a difficult airway

BACKGROUND: Induction of anesthesia and tracheal intubation in small children with a difficult airway is a challenging task. We report the experience with a procedure based on sevoflurane inhalation via a nasopharyngeal airway inserted early during induction before airway obstruction occurs. A pediatric fiberscope is used to perform a nasotracheal intubation via the opposite nostril. METHODS: All small children with suspected or known difficult airway needing tracheal intubation were scheduled for a fiberoptic intubation following the described protocol. RESULTS: In 3 years, we performed 27 successful fiberoptic guided tracheal intubations in 19 children, median age 8.2 months (1.0-39.1 months) and median weight 7.6 kg (3.0-15.0 kg). The optimal depth for placement of the nasopharyngeal airway was found to be 8.0 cm (7.0-8.5 cm) from the nostril in the first year of life and 8.5 cm (8.0-10 cm) in the second year. Oxygenation was sufficient during the entire procedure in all cases except one child who had short-lasting laryngeal spasm caused by instillation of lidocaine during light anesthesia. The duration of fiberoptic intubation was significantly shorter when performed by an experienced anesthesiologist (55 s vs. 120 s), but there was no significant correlation between the duration of fiberoscopy and oxygen saturation during fiberoscopy or endtidal CO(2) after intubation. CONCLUSION: The combination of nasopharyngeal airway and fiberoptic guided tracheal intubation seems to be a reliable and safe procedure for managing the difficult airway in small children.     

Tracheoesophageal fistula

Acquired TEF is a rare complication that can occur from a variety of causes. The most common etiology of nonmalignant TEF is as a complication of intubation with cuff-related tracheal injury. Most patients present with increased secretions, pneumonia, and evidence of aspiration of gastric contents while the patient is on mechanical ventilation. When diagnosed after extubation, the most frequent sign of TEF is coughing after swallowing. A high index of suspicion is required in patients at risk for developing a TEF. The diagnostic evaluation is by bronchoscopy and esophagoscopy. When the diagnosis has been made, the immediate goal should be to minimize tracheobronchial soilage by placing the cuff of a tracheostomy tube distal to the fistula. Reflux of gastric contents is diminished by placement of a gastrostomy tube, and adequate nutrition is facilitated by inserting a jejunostomy tube. Surgical correction is required because spontaneous closure is rare, but surgery should be postponed until the patient is weaned from mechanical ventilation because positive pressure ventilation after tracheal repair carries an increased risk of anastomotic dehiscence and restenosis. An anterior cervical collar incision can be used for most cases of post-intubation TEFs. The esophagus should be closed in two layers over a nasogastric tube and buttressed with a pedicled strap muscle flap. If the tracheal defect is small, primary repair can be employed. In most cases, however, the best results can be achieved with tracheal resection and reconstruction. The patient should be extubated at the completion of the case, if possible. With this strategy, as first described by Grillo and colleagues [27], single-stage repair can be performed safely and with a high success rate. Malignant TEFs cannot be cured because of the underlying incurable disease process. As with nonmalignant TEFs, the principal complications are tracheo-bronchial contamination and poor nutrition. Without prompt palliation, death occurs rapidly, with a mean survival time of between 1 and 6 weeks in patients who are treated with supportive care alone. The most common primary tumor causing malignant TEF is esophageal carcinoma. The other frequent cause is lung cancer. Patients present with signs and symptoms typical of TEF, including coughing after swallowing. Diagnosis is made by barium esophagography, and the location and size of the fistula is determined by bronchoscopy and esophagoscopy. Treatment must correct the two problems of airway contamination and poor nutrition. The most effective treatments are esophageal bypass and esophageal stenting. Bypass is demonstrated to resolve respiratory soilage and allow fairly normal swallowing, but it should be reserved for patients who can tolerate a major operation. Stenting can be offered to nearly all patients regardless of their physiologic condition. Stenting also limits aspiration and allows swallowing. Esophageal exclusion is rarely indicated in the current era of familiarity with stenting techniques. Direct fistula closure and fistula resection do not yield satisfactory results. Radiation therapy and chemotherapy combined might offer a survival benefit compared with supportive care alone. The complication of TEF secondary to malignancy is a devastating problem that carries a bleak prognosis, but when it is performed promptly after the diagnosis of a malignant TEF, esophageal bypass or stenting improves survival and quality of life for these unfortunate patients.     

Comparison of open, percutaneous, and translaryngeal tracheostomies.

INTRODUCTION: With 3 tracheostomy techniques currently available, controversy exists regarding which is safest and most economical. Percutaneous (PDT) and the new translaryngeal (TLT) tracheostomies are cited as more cost-effective than the traditional open surgical procedure because they are bedside techniques. Our objective was to compare the perioperative and postoperative complications of the 3 techniques.Study Design: This was a prospective trial involving 100 consecutive patients who underwent tracheostomy between April and December of 1997 at the London Health Sciences Centre and St Joseph's Health Centre in London, Canada. RESULTS: Fifty open tracheostomies were performed. Indications included prolonged ventilation (n = 42), airway protection (n = 5), pulmonary hygiene (n = 2), and sleep apnea (n = 1). A tension pneumothorax was the one significant intraoperative complication. Fifteen postoperative complications occurred, most notable of which was a 2-L hemorrhage at 24 hours. Thirty-seven TLTs were performed, 20 in patients with coagulopathy. Indications were prolonged intubation (n = 27), airway protection (n = 9), and pulmonary hygiene (n = 1). One intraoperative complication of accidental decannulation occurred. One postoperative complication, a pretracheal abscess, occurred in a decannulated transplant patient 2 weeks after the procedure. Thirteen PDTs were performed. Indications were prolonged intubation (n = 6), airway protection (n = 6), and tracheal toilet (n = 1). No significant complications occurred. CONCLUSIONS: TLT and PDT have fewer complications than the traditional open technique. TLT appears to have the greatest utility in the coagulopathic patient.     

Repair of postintubation tracheoesophageal fistula in polytrauma patients

OBJECTIVE: We present our modest experience in treating tracheoesophageal fistula (TEF) in polytrauma patients where tracheal resection turns to be risky due to the size of the fistula and to the general condition of the patient. MATERIALS AND METHODS: Four polytrauma patients, three male and one female were treated at our department due to postintubation TEF. Confirmation was obtained endoscopically and radiologically. Surgical treatment consisted of identification and dissection of the fistulous tract and closure of the tracheal defect by transposing strap muscles and suturing them to the defect. Finally, the oesophageal defect was closed and a flap of sternocleidomastoid muscle was interposed between oesophagus and trachea. RESULTS: There was no intraoperative mortality. Three of our patients had an excellent result. The one who unfortunately returned to mechanical ventilation due to respiratory insufficiency developed a recurrent fistula. CONCLUSIONS: (1) Repair of postintubation TEF should be delayed until the patient is fully stabilised and weaned from ventilation. (2) Indirect closure of the tracheal defect with strap muscle transposition and sternocleidomastoid muscle interposition between oesophagus and trachea can be lifesaving.     

Tracheal diverticula after tracheoesophageal fistula repair: case series and review of the literature

Background

Tracheoesophageal fistula (TEF) is the most common congenital tracheal abnormality, frequently associated with esophageal atresia. Respiratory symptoms are associated with all types of TEF, even after surgical repair of the fistula. Gastroesophageal reflux (GER) with aspiration of gastric contents, structural instability of the airways (tracheomalacia), abnormal respiratory epithelium, abnormal esophageal motility, recurrent TEF, and esophageal stenosis contribute to postsurgical complications.

Methods

We review 7 patients between 4 and 14 years of age with a history of TEF repair and persistent or worsening respiratory symptoms despite conventional airway clearance techniques and treatment of GER.

Results

Bronchoscopic evaluation in all 7 patients revealed tracheomalacia and a diverticulum on the posterior wall of the trachea at the fistula repair site.

Conclusion

We hypothesize that the diverticula impaired airway clearance and contributed to persistent respiratory symptoms. Possible mechanisms for the diverticulum contributing to poor airway clearance include facilitating the pooling of secretions and acting as a “barrier” to the lower airway clearance mechanism. The diagnosis of a diverticulum should be considered early in patients with persistent respiratory symptoms after management of GER and tracheomalacia. Early obliteration of tracheal diverticula might improve respiratory status in some patients.     

Tracheal intubation through the intubating laryngeal mask in patients with unstable necks

BACKGROUND: In patients with unstable necks, the neck should be stabilized during induction of anaesthesia, but this may make tracheal intubation difficult. Awake intubation may produce straining, which could be detrimental to the unstable neck. METHODS: We studied 20 patients with unstable necks to examine the efficacy of insertion of the intubating laryngeal mask under conscious sedation (to minimize the possibility of losing a patent airway and to facilitate fibrescope-aided intubation) followed by tracheal intubation through the laryngeal mask after induction of anaesthesia (to reduce stress response to intubation). After the patient had been sedated with midazolam (up to 5 mg) and fentanyl (up to 100 microg), the intubating laryngeal mask was inserted. General anaesthesia was then induced with sevoflurane and tracheal intubation attempted. RESULTS: In all patients, tracheal intubation through the laryngeal mask succeeded without airway obstruction. Neither insertion of the mask under conscious sedation nor tracheal intubation after induction of anaesthesia caused straining, and only two patients moved upper extremities at intubation. Insertion of the laryngeal mask did not significantly alter blood pressure or heart rate. Tracheal intubation significantly increased blood pressure and heart rate, but the increase was considered to be small. CONCLUSIONS: In the patient with an unstable neck with a low risk of pulmonary aspiration, insertion of the intubating laryngeal mask while the patient is sedated may minimize difficulty in obtaining a patent airway before tracheal intubation and may facilitate a fibrescope-aided tracheal intubation; subsequent induction of anaesthesia before tracheal intubation may minimize stress response to intubation.     

Effects of tracheostomies on infection and airway complications in pediatric burn patients

Considerable controversy exists as to whether tracheostomy is ever indicated in burn patients. New advents in the treatment of inhalation injury have improved survival, making the use of tracheostomy more usual. The purpose of this study was to analyze the outcome of tracheostomies, and the effect of time on complications. Patients requiring ventilatory support and tracheostomies were studied. Demographic data, hospital course, ventilatory parameters and complications were analyzed. Two hundred ninety patients required ventilation and 36 tracheostomy. Mean percentage of TBSA burned was 59%+/-4. Ninety percent of these patients presented with inhalation injury. Mortality in tracheostomy patients was 25 and 16% in all ventilated patients. Thirty-five percent of the patients developed late complications. Patients who had their airway converted to tracheostomy before day 10 postinjury had a significantly lower incidence of subglottic stenosis. and patients who required airway pressures over 50 cm H2O for more than 10 days had a significantly higher incidence of tracheomalacia. Pneumonia occurred at similar incidence in ventilated and tracheostomy patients. The mortality and late complications of pediatric burn patients with tracheostomy has decreased over the last decade. They do not present with higher incidence of pneumonia. Maintenance of airway pressures below 50 cm H2O and conversion of the artificial airway to tracheostomy before day 10 postinjury may be advisable in patients requiring long term ventilation to prevent late complications.     

Paediatric airway management

The first part of this article describes the anatomical and physiological features of the upper airway and the respiratory system in paediatric patients relevant to airway management. This is followed by a section on airway evaluation, which outlines elements of the patient's history and examination that should alert medical and nursing staff to potential airway problems. Subsequent sections deal with practical airway management, including the indications for tracheal intubation, and the use of cuffed tracheal tubes and laryngeal mask airways in children. The review concludes with a brief outline of the principles of managing the child with a potentially difficult airway.     

Tracheal intubation and sore throat: a mechanical explanation

Although tracheal intubation remains a valuable tool, it may result in pressure trauma and sore throat. The evidence for an association between these sequelae is not conclusive and sore throat may be caused at the time of intubation. This hypothesis was tested in a mechanical model and the results from tracheal intubation compared with those from insertion of a laryngeal mask airway, which is associated with a lower incidence of sore throat. Use of the model suggests that the tracheal tube and laryngeal mask airway impinge on the pharyngeal wall in different manners and involve different mechanisms for their conformation to the upper airway, but that in a static situation, the forces exerted on the pharyngeal wall are low with both devices. It also suggests that the incidence of sore throat should be lower for softer and smaller tracheal tubes and that the standard 'Magill' curve (radius of curvature 140 +/- 20 mm) is about optimum for the average airway.     

Safety and efficacy of rescue flexible bronchoscopic intubation using the Bentson floppy‐tip guidewire via a supraglottic airway in critically ill children

Difficulty in tracheal intubation in paediatric intensive care patients is associated with increased morbidity and mortality. Delays to intubation and interruption to oxygenation and ventilation are poorly tolerated. We developed a safe and atraumatic tracheal intubation technique. A floppy‐tipped guidewire and airway exchange catheter were placed to a pre‐determined length under bronchoscopic guidance while oxygenation and ventilation was maintained via a supraglottic airway device (SAD). We performed a retrospective review of this technique on patients who were either known to have or who had an unexpected difficultly in intubation. We describe the safety and experience of this in a broad range of critically ill children. Thirteen patients, median (IQR [range]) (9.0 (5.0–10.0 [4.0–12.0]) kg and 15.4 (12.1–23.2 [3.3–49.7]) months) underwent emergency tracheal intubation using this technique, after unsuccessful attempts at intubation using standard laryngoscopy blades. All intubations were successful at the first attempt using this technique and no airway trauma or significant clinical deteriorations were recorded.     

Redistribution of halothane and sevoflurane under simulated conditions of acute airway obstruction

Forty patients having surgery requiring muscle paralysis and tracheal intubation were randomly allocated to receive either halothane (n = 20) or sevoflurane (n = 20). Following intravenous anaesthesia and tracheal intubation, inhalation induction of anaesthesia was simulated. After attaining an end-tidal anaesthetic concentration of 2 MAC for the respective agent, the airway was obstructed for 3 min. The end-tidal anaesthetic concentration was measured for the first three breaths following the period of airway obstruction. The decrease in alveolar concentration of sevoflurane following 3 min of airway obstruction was found to be significantly greater than that of halothane. We conclude that even if the airway obstructs completely during inhalational induction of general anaesthesia, awakening would be faster with sevoflurane than with halothane.     

Respiratory care of the burn patient

The vast majority of respiratory disorders in thermally injured patients arise from associated inhalation injuries. The major forms of these injuries are carbon monoxide poisoning, injury to the upper airway, and pulmonary parenchymal damage. One hundred per cent oxygen, initiated at the scene of the accident, is the single most effective treatment of carbon monoxide toxicity, which must be assessed by carboxyhemoglobin determinations. Respiratory tract damage is identified by fiberoptic bronchoscopy and xenon ventilation-perfusion scintigrams. The compromised airway is protected by tracheal intubation, and respiratory failure is treated with assisted ventilation and supplemental oxygen. Pulmonary infection requires specific antibiotics based on isolated organisms and their sensitivities to antimicrobials. The upper respiratory tract of patients requiring long-term intubation should be assessed by fiberoptic bronchoscopy and other modalities to prevent fatal late airway occlusion.