The effects of suctioning techniques on the distal tracheal mucosa in intubated low birth weight infants

Microscopic pathology of the distal trachea at autopsy was retrospectively reviewed in 51 low birth weight infants (less than 1250 g). Twenty-six patients from 1977 who had nasal and/or orotracheal intubation and who underwent suctioning with uncontrolled deep suctioning technique were compared to 25 patients from 1980 who had orotracheal intubation with suctioning to the tube tip only. Clinical diagnoses, duration of intubation and number of intubations were correlated to degree of distal tracheal injury: absent (normal epithelium), mild (focal epithelial loss), moderate (diffuse epithelial loss/some inflammation), or severe (submucosal ulceration/squamous metaplasia). From 1977 to 1980 the mortality rate, mean gestational age and mean birth weight all decreased by 20% (P less than 0.05), 1.1 week (P less than 0.05) and 118 g (P less than 0.01) in both autopsied and non-autopsied infants. In 1977, 15 of 26 autopsies (58%) revealed mild (6), moderate (5) or severe (4) pathology. The mean duration of intubation was 71.3, 11.8, and 265 h. respectively. No history of intubation was obtained in two patients with mild injury. No significant tracheal pathology was seen in 11 patients (42%) in 1977. In 1980, fewer patients, 10 of 24 autopsies (42%), revealed mild (3), moderate (4) or severe (3) pathology. The mean duration of intubation was 19.3, 318.3 and 1391.3 h, respectively. One patient with no history of intubation had mild tracheal injury. No significant tracheal pathology was seen in 15 patients (58%) in 1980. The diagnoses of hyaline membrane disease, anemia, hyperbilirubinemia and coagulation disorder were seen more frequently in patients with moderate and severe tracheal pathology both in 1977 and 1980. Despite factors which should lead to greater tracheal injury--longer duration of intubation, lower birth weights and younger gestational age--less tracheal injury was seen in infants undergoing careful suctioning techniques. Clinical implications for the low birth weight neonate are discussed.     

Posterior tracheal wall disruption: a rare complication of pediatric tracheotomy and bronchoscopy

Disruption of the posterior tracheal wall is an uncommon complication of tracheotomy, bronchoscopy, or even endotracheal intubation. With disruption of the posterior tracheal wall, air tracking may present as surgical emphysema, pneumomediastinum, or pneumothoraces, and may be associated with respiratory distress. Six children with posterior tracheal wall disruptions are presented: three associated with tracheotomy, one bronchoscopy, and another during endotracheal intubation. Early recognition and appropriate management of tracheal disruption will minimize air tracking and the associated morbidity. Tracheal disruption may be avoided by utilizing appropriate surgical, endoscopic, and intubation techniques.     

Tracheal and laryngeal rupture in neonates: complication of delivery or of intubation?

Neonatal tracheal or laryngeal rupture is a rare but life-threatening condition that is attributable to traumatic endotracheal intubation or traumatic delivery. We present a review of the literature and 6 new cases of laryngeal or tracheal rupture following complicated delivery. High-risk groups were identified as 1) low-birth weight neonates, for intubation trauma, and 2) extremely high-birth weight neonates with shoulder dystocia, for trauma due to delivery. Two specific types of ruptures can be distinguished. The less-rare type involves a partial anterior rupture in the subglottic area, which can occur after traumatic intubation or traumatic delivery. The rarer type involves a distal circumferential tracheal rupture that gives rise to ventilatory problems, usually after a delay of several days. This type of rupture was only observed following traumatic delivery. Early diagnosis, optically guided orotracheal intubation, and timely treatment can reduce the risks of mortality and morbidity.     

气管插管导致气管狭窄的外科治疗

目的分析气管插管导致气管狭窄的临床特征,探讨其治疗方法。方法回顾性分析7例气管插管导致气管狭窄的临床资料,并介绍其治疗方法和疗效。结果实施狭窄气管袖状切除+端端吻合术的7例患者中6例均于术后5个月内拔管,随访3～24个月,未并发喉部狭窄及喉返神经损伤;1例患者因缺血缺氧性脑病死亡。结论气管插管是目前导致气管狭窄最常见的病因之一,正确的手术方法是治愈气管狭窄的重要手段。     

Airway complications in patients with closed-head injuries

The neurologic deficits in the closed-head injury population present special problems when managing the airway. Many of these closed-head injury patients require long-term intubation with endotracheal tube or tracheostomy to treat their central respiratory problems and control oral and pulmonary secretions. Four hundred sixty-seven closed-head injury patients were seen over a five-year period. Seventy-two of these patients required long-term endotracheal intubation, tracheostomy, or both. A prospective study by direct endoscopic examination prior to decannulation showed 23 of these 72 patients (32%) had important laryngeal or tracheal findings. The principal abnormalities observed were vocal cord paralysis, tracheal stenosis, subglottic stenosis, glottic stenosis, and tracheomalacia. This study suggests also that severely mentally impaired patients (cognitive function II and III) should retain their tracheostomy because of the high morbidity and mortality among these patients (31%) when they are decannulated. This mortality was directly related to poor pulmonary toilet, with pneumonia and sepsis being the major causes of death. This study did not show that the use of steroids or ventilators in the initial management adversely effected airway complications.     

Laryngeal mask versus endotracheal tube in a ferret model

Acquired subglottic stenosis in infants is a difficult iatrogenic problem with notable morbidity, primarily caused by prolonged endotracheal intubation. The laryngeal mask airway (LMA) is a recently developed, alternative airway device that does not contact the subglottis. To explore the possibility of preventing subglottic stenosis, we compared the endotracheal tube (ETT) and the LMA in terms of the incidence and severity of glottic and subglottic injury resulting from prolonged intubation in the adult ferret model of the infant airway. Ten adult ferrets were randomly intubated under inhalational anesthesia with either a 4.0 cuffless ETT or a size 1 LMA for a 24- to 48-hour period. Rigid laryngeal endoscopy was used to detect pharyngeal or glottic injury during the period of intubation and on a routine basis for 3 months after extubation. All 5 ferrets in the ETT group developed endoscopically evident glottic and subglottic injury; 2 of the 5 developed a symptomatic, mature subglottic stenosis. The 5 ferrets in the LMA group had endoscopically normal larynges. However, all ferrets in the LMA group developed significant tongue edema and cyanosis during the first 24 hours of intubation, and 3 of the 5 died of respiratory failure due to airway obstruction. In the 2 LMA survivors, evidence of oropharyngeal injury persisted until 6 weeks after extubation. We conclude that the LMA does not cause subglottic injury in this model. However, its prolonged use results in significant pharyngeal morbidity that raises serious doubt as to its potential routine use in infants requiring prolonged ventilatory support.     

Neonatal tracheal rupture complicating endotracheal intubation: a case report and indications for conservative management

Neonatal tracheal injury represents a rare complication of endotracheal intubation. Previous case reports have demonstrated high morbidity and mortality (75%) associated with the rapid occurrence of subcutaneous emphysema, respiratory failure and death in this patient population. This mandates the prompt recognition, evaluation and management of this injury in the neonate. Although there is no clear consensus, previous authors have described both surgical therapy and expectant management. We report a case of a newborn who sustained tracheal rupture following traumatic intubation who survived with expectant management. The pathophysiology, management and indications for conservative management of neonatal tracheal rupture are reviewed.     

Tracheal stenosis: conservative surgery as a primary mode of management

Tracheal and laryngeal stenosis has become increasingly common following prolonged intubation or tracheostomy for mechanical ventilation and is directly related to trauma. Tracheal resection up to 4 to 5 cm. with an end to end anastomosis is the generally accepted treatment. However, tracheal resection carries the danger of mortality and considerable morbidity. From 1974 to 1979 all patients in our series with tracheal stenosis, even with laryngeal involvement, regardless of etiology and age were intiially treated by conservative surgical management consisting of dilation, severance of the stenotic ring, intralesional injection of triamcinolone acetonide, and stenting with a silicone T tube for 90 days. Sixteen of 19 patients obtained good results and enjoy an adequate airway without a tracheostomy tube. The longest follow-up period was five years and the shortest, six months. Intralesional injection of triamcinolone acetonide is essential for successful treatment. No mortality or serious complications resulted from this treatment. Our experience indicates that patients with tracheal and laryngeal stenosis should undergo a primarily conservative surgical management. This technique appears worthy of trial prior to contemplating a more extensive procedure.     

Pediatric tracheal stenosis

Tracheal stenosis is a rare, potentially life-threatening condition described as innate narrowing of the tracheal lumen. The causes of tracheal stenosis vary widely. The most common forms result from prolonged intubation, although congenital causes usually involve complete tracheal rings or compression from cardiovascular malformations. The condition historically has harbored a poor prognosis, but significant advances in radiologic diagnosis, cardiac bypass, and endoscopic and surgical treatments have led to a range of options, better overall survival, and reduced morbidity. The complex, long-term manifestations of tracheal stenosis point to the need for individualized treatment as well as multidisciplinary care.     

Orotracheal intubation in the newborn

One hundred consecutive cases of orotracheal intubation in the premature and term newborn at the Hershey Medical Center were studied retrospectively. The reason for intubation was for respiratory failure most commonly associated with hyaline membrane disease. The duration of intubation ranged from six hours to 63 days. Seventy-nine percent required intubation for more than 24 hours and 28 percent required intubation for more than one week. No tracheotomies were performed. There were 56 survivors, 50 of which were seen in follow-up examination at three, six or 18-month intervals. There were no cases of clinically evident upper airway damage or obstruction in this group. Post mortem examinations were carried out on 35 infants with tracheal necrosis found in one case. The authors feel that orotracheal intubation is superior to nasotracheal intubation and tracheotomy in this age group. This method of management should be carried out where there is adequate trained personnel and professional staff and equipment capable of proper orotracheal tube placement and management.     

Early extubation following major tracheal surgery in select children

Major airway surgery in children has traditionally consisted of a period of endotracheal intubation after the procedure for a period of 1-2 weeks to ensure stability of the repair. Recent literature has supported a trend toward decreasing this time period to prevent the consequences of leaving a foreign body in the airway and the morbidity associated with the use of sedation and narcotics in children. We present a series of five select children from our institution that underwent major tracheal surgery and were successfully extubated early in their postoperative course; four on postoperative day number 1. This demonstrates the feasibility of this approach in select patients.     

Congenital tracheal anomalies

Congenital tracheal lesions are rare, but important, causes of morbidity in infants and children. Consequently, experience in their management is limited and dispersed. Given its small diameter, the juvenile trachea is obstructed easily by various natural causes, or following a surgical intervention. The diagnosis of a congenital, tracheal, obstructive anomaly is based on a high degree of suspicion in infants and children with respiratory distress accompanied by retraction. In this article, the authors discuss the various causes of these conditions, their diagnostic features, and the treatment possibilities.     

A quantitative comparison of the early histopathological changes from tracheotomy and endotracheal intubation on the distal trachea in fetal lambs

Twenty-four premature fetal lambs underwent tracheotomy (n = 11) or endotracheal intubation (n = 13) for 3-9 h for an unrelated experiment. All were maintained with 100% oxygen on a pressure cycled ventilator. No suctioning was performed. At sacrifice, sections of the distal trachea were studied for histopathological changes in epithelium, submucosa and mucous glands. All changes were confined to the epithelium and were reported as either partial or total epithelial erosion in regards to preservation of the basal cell layer. In tracheotomized and intubated animals, both partial and total erosion were seen as early as 3 and 3.5 h, respectively. In the intubated animals, 13.5% of the cumulative tracheal circumference showed total erosion; 19.8% showed partial erosion. In animals undergoing tracheotomy, 9.6% of the cumulative tracheal circumference had total erosion; 19.1% had partial erosion. Possible etiological factors include oxygen toxicity, lack of humidification, effects of mechanical ventilation and indirect trauma from surgery or intubation. The clinical significance for premature infants is discussed.     

Acquired tracheal diverticulum following repair of tracheo-oesophageal fistula: endoscopic management

Remnant tracheal diverticulum following the repair of a tracheo-oesophageal fistula (TOF) is an uncommon complication. The majority of lesions are discovered and repaired at the time of primary oesophageal repair. Respiratory complications are reported to be a major cause for morbidity after surgical repair of a TOF. They include anastomotic stricture, oesophageal dysmotility and tracheomalacia. These case reports highlight the need to be wary of tracheal diverticulum as a complication following the repair of a TOF, which may cause difficulty in intubation, airway compromise or an inability to provide effective ventilation. An effective endoscopic surgical technique has been described.     

Evaluation of neonatal subglottic stenosis: a 3-year prospective study

Subglottic stenosis is the most common cause of chronic airway obstruction. It results in prolonged tracheal cannulation of infants and children. Following the widespread adoption over the past 20 years of prolonged intubation for respiratory support in neonates, the incidence of acquired subglottic stenosis increased dramatically. On January 1, 1987, we began a 3-year prospective study to delineate potential etiologic factors involved in the development of subglottic stenosis in neonates. The present study analyzes data from 289 infants. Relationships between birth weight, gestational age, endotracheal tube size, duration of intubation and ventilation, number and difficulty of intubations, and the subsequent need for medical and surgical therapy are discussed. Whole organ larynges from autopsy specimens provide histological correlation.     

Bacterial tracheitis, diagnosis and treatment

During a 22-month period, 5 children, 6–13 months of age, presented with an acute obstructive upper airway infection which resembled both croup and epiglottitis. All 5 failed to respond to standard treatment for croup, including aerosolized racemic epinephrine. In all patients, direct laryngoscopy revealed minimal or no change in the epiglottis and aryepiglottic folds but severe subglottic swelling and copious purulent tracheal secretions. Gram stains of the purulent secretions revealed many polymorphonuclear leukocytes with gram-positive cocci (3 patients) and small gram-negative rods (2 patients). Cultures subsequently confirmed the presence of S. Aureus and H. Influenzae. Initial therapy for all patients included endotracheal intubation, antibiotic therapy for both S. Aureus and H. Influenzae and frequent tracheal suctioning. Hospitalization varied from one to 3 weeks. We reported findings in these patients because: (1) the initial diagnosis was unclear due to confusion caused by clinical features common to both croup and epiglottitis and (2) bacterial tracheitis requires a prompt accurate diagnosis and aggressive antibiotic and airway management in order to prevent unnecessary morbidity and mortality.     

两种麻醉方法用于气管切开及插管的效果比较

目的 观察瑞芬太尼复合咪达唑仑能否减轻喉肿瘤患者气管切开及插管时的心血管反应并同时降低知晓发生率。方法 择期喉肿瘤手术患者30例,年龄35～55岁,ASA为Ⅰ～Ⅱ级,喉阻塞为Ⅰ～Ⅱ度,随机分为氟芬合剂组（I组）、瑞芬太尼+咪达唑仑组（R组）,每组15例。所有患者在1%利多卡因局部浸润麻醉下行气管切开,气管切开之前,I组患者静脉注射氟芬合剂2mL,R组患者缓慢静脉注射咪达唑仑50μg·kg－1,继之瑞芬太尼0.05μg·kg－1·min－1持续输注。气管切开完成即将插管时,I组患者静脉注射氟芬合剂2mL,R组患者缓慢静脉注射瑞芬太尼1μg·kg－1（大于1min）,记录局部浸润麻醉前(T0)、插管前即刻(T1)、插管成功即刻(T2)、麻醉诱导后2min(T3)的HR、MAP、SpO2;记录麻醉诱导时得普利麻的用量;记录气管切开过程中患者有无躁动、呛咳等反应。术后随访患者对气管切开及插管过程的知晓情况。患者SpO2＜90％定义为呼吸抑制。结果 与T0比较,I组T1时的MAP及HR无明显变化,T2时MAP及HR明显升高（P＜0.05）,T3时MAP及HR明显降低（P＜0.05）;R组T1及T2时MAP及HR无明显变化,T3时MAP与T0比较有所下降,但无统计学意义,而HR明显降低（P＜0.05）。与I组比较,T2时R组MAP及HR明显降低（P＜0.05）,而T3时MAP明显升高（P＜0.05）。所有患者均无明显呼吸抑制。两组患者气管插管完成后麻醉诱导所需得普利麻量有显著差异（P＜0.01）;与I组比较,R组呛咳、躁动等插管反应及插管知晓发生率明显降低（P＜0.01）。结论 在局部麻醉的基础上,瑞芬太尼复合咪达唑仑能明显减轻气管切开及插管引起的心血管反应及知晓发生率。     

Administration of esmolol in microlaryngeal surgery for blunting the hemodynamic response during laryngoscopy and tracheal intubation in cigarette smokers

OBJECTIVES: Cigarette smokers constitute a group of patients with an increased hemodynamic response to tracheal intubation. We studied the dose-response and side effects of bolus administration of esmolol hydrochloride in cigarette smokers undergoing elective microlaryngeal surgery, when esmolol was used for reducing the intense hemodynamic response to laryngoscopy and tracheal intubation. METHODS: We randomly allocated 165 patients (American Society of Anesthesiologists physical status classes I to III) to receive placebo (Eplac) or esmolol 1 mg/kg (E1) or 2 mg/kg (E2). The esmolol was given 2 minutes before laryngoscopy and tracheal intubation. The same anesthetic technique was used in all patients. Cardiovascular parameters were recorded every minute for the first 5 minutes and thereafter every 3 minutes. Bronchospasm, other side effects, and rescue esmolol treatment were noted during anesthesia. RESULTS: In group Eplac, significant increases (p < .05) in arterial blood pressure and heart rate were observed in the first 3 minutes after tracheal intubation. In group E1, significant increases (p < .05) in diastolic blood pressure were observed in the first 2 minutes after intubation. In group E2, no significant fluctuations were recorded in cardiovascular parameters after intubation. During surgery, 17% of the patients in group Eplac showed an increase in blood pressure and tachycardia. CONCLUSIONS: We conclude that esmolol administration of 2 mg/kg during induction of anesthesia in smokers provides hemodynamic stability after laryngoscopy and tracheal intubation with no severe side effects.     

The prevention and management of tracheal and laryngeal steeosis in children (author's transl)]

During chronic intubation or tracheostomy in children, there is a risk of stenosis at three sites: the cricoid ring, the tracheostomy and the area of tube cuff inflation. The following measures are recommended to prevent this occurrence: endoscopic examination of the mucous membranes when changing the intubation tube or the tracheal cannula: nasotracheal intubation with the smallest possible diameter tubes when chronic intubation is required; use of the "open-type" tracheostomy utilizing mucosaskin retraction sutures but with out removal of tracheal cartilage. Careful inflation of the cuff and regular changing of the position of the cuff in ther cervican trachea also lower the risk of pressure-induced injury. Infection or co-existing metabolic disease increases mucosal sensitivity to pressure. Several stenosis of the laryngotracheal regions frequently requires staged laryngeal and tracheal plastic reconstruction. The curvature and stiffening of the ventral wall of the trachea can be achieved by the implantation of arched homograft cactilage taken from a tissue bank.     

Iatrogenic tracheal stenosis following endotracheal intubation: a study of 20 clinical cases

The authors report a case review series of 20 patients with tracheal stenosis after prolonged oral or nasotracheal intubation who underwent surgical treatment between 1995 and 1999. Seventeen were male (85%) and three (15%) were female. The age varied between 9 and 68 years (32.8 +/- 14.9 years). The stenotic area of the airway was limited to the trachea, and its length varied between 2 and 5 cm (3.3 +/- 1.2 cm.). All patients were treated surgically with an external approach for reconstruction after stenosis ablation. Follow up was at three and six months after surgery there were: 16 cases with (80%) good results, two (10%) with satisfactory results and two unsatisfactory (10%). We found a statistically significant correlation (Spearman correlation) of 5% level between the period of tracheal intubation and patient's age (R = 0.478, p = 0.033).