Tracheomalacia in an adult with respiratory failure and Morquio syndrome

Patients with Morquio syndrome can develop respiratory failure secondary to reduced chest wall compliance and airway collapse from irregularly shaped vocal cords and trachea. We report the case of a patient with Morquio syndrome whose clinical course was complicated by tracheomalacia. An obese 29-year-old female with Morquio syndrome presented with severe wheezing and tachycardia. One month prior to admission, she underwent elective spinal stabilization surgery, which resulted in fixed head flexion. The surgery was complicated by paraplegia and the need for mechanical ventilation via tracheostomy. Initial bronchoscopy revealed severe tracheomalacia, and the tracheostomy tube was changed to one with an adjustable flange. On 3 occasions over the next 20 days she had labored breathing with dramatically decreased V(T). Each time, bronchoscopy revealed almost complete occlusion of the distal end of the tracheostomy tube. Ventilation became much easier when the tracheostomy tube was advanced past the obstruction. After one month, she became febrile, severely hypoxemic, and her family decided to withdraw care. In patients with Morquio syndrome, close attention must be given to the patient's abnormal airways and malformed chest cage. Mechanical ventilation may be difficult because of upper-airway obstruction or low compliance imposed by the restrictive chest wall. Complete tracheal collapse can occur in these patients, especially with fixed head flexion.     

Tracheostomy in the intensive care unit: a safe alternative to the operating room

Severely injured patients frequently require endotracheal intubation, either by the nasotracheal (NT) or orotracheal (OT) route, for airway control and/or ventilatory support. If intubation is required for more than two to four weeks, an elective tracheostomy is usually indicated. Transferring these patients to the operating room is difficult, and it impairs their continued monitoring and care. Over a period of 48 months at our institution, 74 patients had tracheostomy done in the intensive care unit (ICU) by a surgical resident (PG2 level) assisted by a chief resident or attending faculty member. Local anesthesia was supplemented with intravenous sedatives, and operating room technique was used, with complete surgical instrument pack and adequate lighting. There were no deaths from the procedure. There were no complications specifically attributed to the performance of tracheostomy in the ICU, though one patient each suffered tracheitis, tracheostomy tube dislodgement, and tracheomalacia. Tracheostomy in the ICU avoids the risks of moving these patients with all their monitoring and infusion lines, and saves operating room time and charges. Trained surgical personnel using adequate instruments and lighting can safely perform a tracheostomy in the intensive care unit.     

Tracheal agenesis

Tracheal agenesis is a rare congenital anomaly. We report a case and review the cases previously reported. Clinical features that might indicate tracheal agenesis include antenatal polyhydramnios, severe respiratory distress, absence of an audible cry, failure to advance an endotracheal tube beyond the larynx, a palpable distal trachea, clinical improvement after esophageal intubation, and roentgenographic absence of a tracheal air column with an abnormal position of the carina. For immediate management of the affected infant, we recommend intubation of the esophagus with an endotracheal tube to provide an air passage, and determination of the level of the defect by careful use of contrast material and roentgenography. Infants having type I tracheal agenesis may benefit from immediate tracheostomy.     

Continuous control of endotracheal cuff pressure and tracheal wall damage: a randomized controlled animal study

Background  

Intubation is frequently performed in intensive care unit patients. Overinflation of the endotracheal tube cuff is a risk factor for tracheal ischemia and subsequent complications. Despite manual control of the cuff pressure, overinflation of the endotracheal cuff is common in intensive care unit patients. We hypothesized that efficient continuous control of the endotracheal cuff pressure using a pneumatic device would reduce tracheal ischemic lesions in piglets ventilated for 48 hours through a high-volume, low-pressure endotracheal tube.     

A novel airway device with tactile sensing capabilities for verifying correct endotracheal tube placement

We present a new device for verifying endotracheal tube (ETT) position that uses specialized sensors intended to distinguish anatomical features of the trachea and esophagus. This device has the potential to increase the safety of resuscitation, surgery, and mechanical ventilation and decrease the morbidity, mortality, and health care costs associated with esophageal intubation and unintended extubation by potentially improving the process and maintenance of endotracheal intubation. The device consists of a tactile sensor connected to the airway occlusion cuff of an ETT. It is intended to detect the presence or absence of tracheal rings immediately upon inflation of the airway occlusion cuff. The initial study detailed here verifies that a prototype device can detect contours similar to tracheal rings in a tracheal model.     

Obstructive fibrinous tracheal pseudomembrane: Sudden child death following laser removal of papillomata

Obstructive fibrinous tracheal pseudomembrane (OFTP) is a rare complication usually following endotracheal intubation, occurring when a collection of inflammatory exudate coalesces at the site of damaged epithelium within the trachea and along the tracheal mucosa, creating a luminal narrowing and subsequent airway obstruction.     

重症监护室气管切开并发症的护理研究进展

介绍了近年来重症监护室（ICU）中气管切开病人术后常见的并发症,包括误吸、导管堵塞、感染、伤口出血、脱管、气管软化和气管咽瘘,总结了ICU常见并发症的预防及护理,包括安置正确体位、加强气道湿化、加强吸痰护理、气道感染及出血的预防等,同时还应做好气管套管、更换导管、饮食、心理等方面的护理。     

Acute tracheal rupture related to endotracheal intubation: case report

Tracheal laceration is a rare complication of endotracheal intubation. We present a case of tracheal laceration after a simple prehospital tracheal intubation in a patient with severe tracheomalacia. The most likely cause of the tracheal injury was massive overinflation of the endotracheal tube cuff and the preexisting tracheal wall weakness. The case illustrates the classic radiologic signs of tracheal laceration, and we review the relevant literature.     

Selective bilateral bronchial intubation for large, acquired tracheoesophageal fistula

The anesthetic management of patients undergoing tracheoesophageal fistula repair often involves lung separation, usually selective bronchial intubation with a double-lumen endotracheal tube. However, in patients with airway fistulas arising below the tracheal lumen, selective lung ventilation and separation may require unusual methods of airway management. In the patient described in this report, the airway fistulas involved the distal 3 cm of the trachea, approximately half of the left main bronchus 1.5 cm beyond the carina, and the proximal 0.5 cm of the right main bronchus. To separate and ventilate the lungs during the repair of these large and complex airway fistulas, 2 individual Mallinckrodt microlaryngeal endotracheal tubes were used. While lung separation was achieved, contrary to previous reports, the Mallinckrodt's larger and more tapered cuff made positioning in the left main bronchus an ongoing issue that required the use of a conventional endotracheal tube and, eventually, intubation of the bronchus from the surgical field. Future cases involving complex airway fistulas should consider endotracheal tube limitations and other methods of providing ventilation such as high-frequency jet ventilation or cardiopulmonary bypass.     

Endotracheal tube cuff ignited by electrocautery during tracheostomy

A 64-year old female requiring prolonged ventilatory support was scheduled for an elective tracheostomy. Anesthesia consisted of surgical infiltration of 1% lidocaine and supplemental isoflurane. The patient was mechanically ventilated with an FIO2 of 1.0. An incision was made over the third and fourth tracheal rings. Opening the trachea with electrocautery resulted in a large leak around the endotracheal tube. The cuff was visualized through the tracheal incision and noted to be deflated. A small bleeder was coagulated on the tracheal ring. At this point, a flash fire occurred rising about one-inch high through the tracheal incision. The surgeon immediately covered the site with his hand. The anesthetist promptly disconnected the anesthesia circuit and removed the endotracheal tube. The surgeon inserted the tracheostomy tube and ventilation resumed. The fire lasted approximately 1-2 seconds. Dexamethasone 10 mg was administered intravenously. End-tidal CO2 and oxygen saturation levels were unchanged. The endotracheal tube was inspected. Approximately one-third to one-half of the cuff was charred. Proper management of an endotracheal tube fire includes stopping ventilation, disconnecting the oxygen source, removing the endotracheal tube, diagnosing injury, administering short-term steroids, administering antibiotics if indicated, providing ventilation and medical support as necessary and monitoring the patient for at least 24 hours. Extreme caution is necessary when using electrocautery in close proximity to an endotracheal tube. If electrocautery is used in close proximity to an endotracheal tube, an FIO2 of 0.3 or less with helium should be used.     

Intratracheal pulmonary ventilation keeps tracheal tubes clean without impairing mucociliary transport

Background : Intratracheal pulmonary ventilation (ITPV) is a form of tracheal gas insufflation through a reverse thrust catheter that facilitates expiration and enhances CO 2 removal. Tracheas of sheep mechanically ventilated for 3 days with gas delivered through the reverse-thrust catheter remained free of secretions, without suctioning. It was hypothesized that: 1) The expiratory flow from the lungs, combined with continuous cephalad flow from the reversethrust catheter keeps endotracheal tubes clean; and 2) tracheal mucus velocity is not impaired by ITPV. Methods : A model trachea connected to a test lung and to a ventilator, via an 8-mm endotracheal tube, was used. Inspiratory and expiratory peak flow velocities and the movement of mucus in the model trachea and in the endotracheal tube were measured during conventional mechanical ventilation and ITPV. Tracheal mucus velocity was measured radiographically, using tantalum discs as markers, in seven intubated sheep ventilated for one hour with volume-controlled ventilation, and with ITPV. One millilitre Evans Blue dye was introduced into the trachea, to visualize mucus transport into the endotracheal tube. Results : Peak expiratory flow velocity exceeded peak inspiratory flow velocity by 100% during ITPV. During volume-controlled ventilation, flow velocities were equal. During ITPV, there was slow, then rapid cephalad movement of mucus in the model trachea, 0.5 cm distal to the tip of the endotracheal tube, the velocity increasing once mucus entered the endotracheal tube. During volume-controlled ventilation, no movement of mucus was found. Baseline tracheal mucus velocity was equal during volume-controlled ventilation and ITPV. Secretions stained with Evans Blue dye entered the endotracheal tube and were rapidly expelled from within the endotracheal tubes during ITPV; only traces of mucus were found in two sheep during volume-controlled ventilation. Conclusion : The enhanced expiratory flow during ITPV expels secretions from the endotracheal tube through entraining of mucus at the tip of the endotracheal tube. Tracheal mucus velocity is not influenced by ITPV.     

Tracheal stenosis and obliteration above the tracheostoma after percutaneous dilational tracheostomy

Percutaneous dilational tracheotomy (PDT) as opposed to the conventional surgical tracheostomy is a procedure that allows airway control in critically ill patients without surgical exposure of the trachea. Based on the Seldinger technique, dilators are passed along a guiding wire through a small neck incision into the trachea under endoscopic surveillance. This separates the tracheal rings and results in a stoma. As opposed to the regular surgical tracheostoma, a PDT-stoma is not epithelialized. The procedure is cost effective and little time consuming. Considering the increasing number of performed PDTs in the last few years, we feel a need to be aware of possible long-term complications. Thus, in this report, we describe three cases of tracheal stenosis/obliteration after a PDT procedure. In all cases, tracheal narrowing occurred above the level of the stoma. This suggests a procedure-related mechanism, i.e., tracheal ring invagination and the consecutive development of granulation tissue, rather than a mechanism based on the duration of the cannula's placement, which would normally produce the stenosis below the stoma in the area of the cuff. Toward the end of the article, we provide evidence for this hypothesis and thus present a new subset of long-term complications after PDT.     

Intratracheal pulmonary ventilation keeps tracheal tubes clean without impairing mucociliary transport

BACKGROUND: Intratracheal pulmonary ventilation (ITPV) is a form of tracheal gas insufflation through a reverse thrust catheter that facilitates expiration and enhances CO2 removal. Tracheas of sheep mechanically ventilated for 3 days with gas delivered through the reverse-thrust catheter remained free of secretions, without suctioning. It was hypothesized that: 1) The expiratory flow from the lungs, combined with continuous cephalad flow from the reverse-thrust catheter keeps endotracheal tubes clean; and 2) tracheal mucus velocity is not impaired by ITPV. METHODS: A model trachea connected to a test lung and to a ventilator, via an 8-mm endotracheal tube, was used. Inspiratory and expiratory peak flow velocities and the movement of mucus in the model trachea and in the endotracheal tube were measured during conventional mechanical ventilation and ITPV. Tracheal mucus velocity was measured radiographically, using tantalum discs as markers, in seven intubated sheep ventilated for one hour with volume-controlled ventilation, and with ITPV. One millilitre Evans Blue dye was introduced into the trachea, to visualize mucus transport into the endotracheal tube. RESULTS: Peak expiratory flow velocity exceeded peak inspiratory flow velocity by 100% during ITPV. During volume-controlled ventilation, flow velocities were equal. During ITPV, there was slow, then rapid cephalad movement of mucus in the model trachea, 0.5 cm distal to the tip of the endotracheal tube, the velocity increasing once mucus entered the endotracheal tube. During volume-controlled ventilation, no movement of mucus was found. Baseline tracheal mucus velocity was equal during volume-controlled ventilation and ITPV. Secretions stained with Evans Blue dye entered the endotracheal tube and were rapidly expelled from within the endotracheal tubes during ITPV; only traces of mucus were found in two sheep during volume-controlled ventilation. CONCLUSION: The enhanced expiratory flow during ITPV expels secretions from the endotracheal tube through entraining of mucus at the tip of the endotracheal tube. Tracheal mucus velocity is not influenced by ITPV.     

Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation

ObjectiveThis study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR).MethodsWe performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air–mucosa (A–M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A–M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A–M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR.ResultsAmong the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4–100%), 85.7% (95% CI: 42.0–99.2%), 98.8% (95% CI: 92.5–99.0%) and 100% (95% CI: 54.7–100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1–43.0) and 0.0, respectively.ConclusionsReal-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands.     

高龄患者冠状动脉旁路移植术后气管切开的护理经验

目的 探讨高龄患者冠状动脉旁路移植术后气管切开期间的护理经验,提高护理质量。方法 我们对患者给予心理护理,观察气管切口及胸部切口,加强气道湿化和肺部体疗,改善吸痰操作,防止气管软化和狭窄,气管套管的清洁护理。结果 3例患者死于多器官功能衰竭。1例患者出现气道分泌物结痂堵塞,1例有气道内出血。结论 重视心理护理,改善气道,气管套管的护理操作,有效的营养支持有助于患者渡过术后危险期,减少并发症的发生。     

Bench-to-bedside review: Early tracheostomy in critically ill trauma patients

A significant proportion of trauma patients require tracheostomy during intensive care unit stay. The timing of this procedure remains a subject of debate. The decision for tracheostomy should take into consideration the risks and benefits of prolonged endotracheal intubation versus tracheostomy. Timing of tracheostomy is also influenced by the indications for the procedure, which include relief of upper airway obstruction, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation. This review summarizes the potential advantages of tracheostomy versus endotracheal intubation, the different indications for tracheostomy in trauma patients and studies examining early versus late tracheostomy. It also reviews the predictors of prolonged mechanical ventilation, which may guide the decision regarding the timing of tracheostomy.     

Bench-to-bedside review: Early tracheostomy in critically ill trauma patients

A significant proportion of trauma patients require tracheostomy during intensive care unit stay. The timing of this procedure remains a subject of debate. The decision for tracheostomy should take into consideration the risks and benefits of prolonged endotracheal intubation versus tracheostomy. Timing of tracheostomy is also influenced by the indications for the procedure, which include relief of upper airway obstruction, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation. This review summarizes the potential advantages of tracheostomy versus endotracheal intubation, the different indications for tracheostomy in trauma patients and studies examining early versus late tracheostomy. It also reviews the predictors of prolonged mechanical ventilation, which may guide the decision regarding the timing of tracheostomy.     

Emergency Endotracheal Intubation With a Rigid Stylet of an Infant With Severe Subglottic Stenosis

BackgroundSubglottic stenosis is a frequent complication of endotracheal intubation in children and can create a difficult airway situation for subsequent respiratory illnesses. Difficult airway algorithms are an essential aid when dealing with respiratory failure in clinical situations where ventilation or intubation is unsuccessful.Case ReportA 4-month-old infant with a history of previous endotracheal intubation required endotracheal intubation for stridor and respiratory failure due to croup. There was difficulty intubating the trachea due to severe subglottic stenosis that developed following the previous episode of endotracheal intubation. Successful intubation was facilitated by the use of a rigid endotracheal tube stylet to facilitate passage of an endotracheal tube through the stenotic segment.Why Should an Emergency Physician Be Aware of This?Difficult airway algorithms recommend the use of invasive airway access only as a last resort and noninvasive airway access should be explored prior to their use. The use of a readily available rigid stylet as an alternative method for tracheal intubation should be considered only after more conventional techniques and potential complications have been considered.     

Rapid progression of tracheal stenosis associated with tracheopathia osteo-chondroplastica

Tracheopathia osteochondroplastica (TPO) is a rare, but increasingly recognised condition in which there is accumulation of calcium phosphate with benign submucous proliferation of cartilage and bone beneath the tracheal mucosa, often with squamous metaplasia of the mucosal columnar epithelium. This condition is usually asymptomatic, but may be slowly progressive, causing haemoptysis, dry cough and dyspnoea. We report a case of TPO in which there was rapid progression of tracheal stenosis such that the size of endotracheal tube that the upper airway would accept changed from 8.00 mm to 3.0 mm during a six-week period. This extreme reduction in airway calibre had not been detected on spirometry nine days prior to his final admission. This is the first report of such rapid progression of tracheal stenosis associated with TPO.