Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy

Tracheostomy in patients requiring prolonged artificial ventilation in intensive care is increasingly being performed by a percutaneous dilatational technique, in preference to the standard surgical method. Since its introduction numerous series have reported favourably on its general safety in the short-term, but there have been few reports of longer term follow-up of patients. We present four cases of laryngotracheal stenosis, a previously unreported complication associated with the technique, and discuss the relevance of these to the future practice of percutaneous tracheostomy.     

Ear,nose and throat emergencies

Airway emergencies comprise a diverse group of conditions, which affect upper and lower airways, and have potential for rapid deterioration and lethal outcome unless managed promptly and efficiently. The latter depends on individual skills and effective interaction between anaesthetists, ENT surgeons and other members of the team.     

Anaesthesia for maxillofacial surgery

Maxillofacial surgeons are responsible for the operative management of pathologies such as head and neck cancer, facial trauma, infections, craniofacial deformities and temporomandibular joint dysfunction. Airway management for these patients can be particularly challenging for the anaesthetist. This article will focus on key aspects of airway assessment and the development of a comprehensive management strategy; including recognizing impending airway compromise, advanced airway management skills, appropriate rescue techniques and planning for tracheal extubation. We will describe the key aspects of clinical management for common maxillofacial surgical presentations, with reference to the most recent evidence base and clinical guidelines.     

High-flow via a tracheostomy tube and speaking valve during weaning from mechanical ventilation and tracheostomy

Background

Weaning from mechanical ventilation and tracheostomy after prolonged intensive care consume enormous resources with optimal management not currently well described. Restoration of respiratory flow via the upper airway is essential and early cuff-deflation using a one-way valve (OWV) is recommended. However, extended OWV use may cause dry airways and thickened secretions which challenge the weaning process. High-flow therapy via the tracheostomy tube (HFT-T) humidifies inspired air and may be connected via an in-line OWV (HFT-T-OWV) alleviating these problems. We aim to provide clinical and experimental data on the safety of HFT-T-OWV along with a practical guide to facilitate clinical use during weaning from mechanical ventilation and tracheostomy.

Methods

Data on adverse events of HFT-T-OWV were retrieved from a quality register for patients treated at an intensive care rehabilitation center between 2019 and 2022. Benchtop experiments were performed to measure maximum pressures and pressure support generated by HFT-T-OWV at 25–60 L/min flow using two different HFT-T adapters (interfaces). In simulated airway obstruction using a standard OWV (not in-line) maximum pressures were measured with oxygen delivered via the side port at 1–3 L/min.

Results

Of 128 tracheostomized patients who underwent weaning attempts, 124 were treated with HFT-T-OWV. The therapy was well tolerated, and no adverse events related to the practice were detected. The main reason for not using HFT-T-OWV was partial upper airway obstruction using a OWV. Benchtop experiments demonstrated HFT-T-OWV maximum pressures <4 cmH₂O and pressure support 0–0.6 cmH₂O. In contrast, 1–3 L/min supplemental oxygen via a standard OWV caused pressures between 84 and 148 cmH₂O during simulated airway obstruction.

Conclusions

Current study clinical data and benchtop experiments indicate that HFT-T-OWV was well tolerated and appeared safe. Pressure support was low, but humidification may enable extended use of a OWV without dry airway mucosa and thickened secretions. Results suggest the treatment could offer advantages to standard OWV use, with or without supplementary oxygen, as well as to HFT-T without a OWV, for weaning from mechanical ventilation and tracheostomy. However, for definitive treatment recommendations, randomized clinical trials are needed.     

纤维支气管镜在经皮扩张气管切开术中的应用

目的 评估纤维支气管镜(FOB)对学习曲线内麻醉科医师行经皮扩张气管切开术(PDT)的应用价值。方法 选择2020年9月至2022年1月行PDT的口腔癌患者60例,男47例,女13例,年龄18～80岁,BMI 15～28 kg/m²,ASAⅡ或Ⅲ级。随机分为两组：FOB引导下的PDT组(FP组)和无FOB引导的PDT组(NP组),每组30例。两组均在全麻经鼻气管插管后行PDT,FP组自穿刺至气切导管置入均在FOB引导下进行,NP组在盲视下进行。本研究中操作者均为PDT经验尚在学习曲线内的麻醉科医师,即PDT操作例数≤20例。记录入室时和置入气切导管即刻(置管即刻)HR、MAP,置管即刻P_ETCO₂,切口长度、PDT时间、首次置管成功率。记录术中出血、低氧血症、气管导管滑脱、气管后壁损伤、气管环断裂、皮下气肿、气胸等并发症发生率。结果 与NP组比较,FP组PDT时间明显缩短(P<0.05),首次置管成功率明显升高(P<0.05),气管后壁损伤发生率明显降低(P<0.05)。两组置管即刻HR、MAP、 P<...     

Unusual foreign body (broken tracheostomy tube) in left main bronchus

Foreign bodies in the tracheobroncial tree are commonly seen in children and less so in adults. All manners of materials have been described as accidentally entering the tracheobroncial tree. Although tracheostomy tube as a foreign body in tracheobroncial tree is not so common, it is still well known. They present as emergencies and require skillful management. Few cases of tracheotomy tube in the tracheobrochial tree. have been reported in the literature till date. We have some across such case of broken fuller’s tracheostomy tube (flange) in left main broncus and mwe are reporting this casedue to its rarity.     

改良经皮旋转扩张气管切开术与传统气管切开术效果比较

目的探讨改良经皮旋转扩张气管切开术在危重病中的应用价值。方法回顾性分析重症监护病房（ICU）中气管切开的危重病患者共126例,其中改良经皮扩张气管切开术组（PDT组）82例,常规外科气管切开术组（ST组）44例。比较两组手术操作时间、术中出血量、并发症发生率。结果改良PDT组的手术创伤和术后并发症较ST组明显减少。结论改良经皮旋转扩张气管切开术是一种快速、创伤小、并发症少的微创气管切开术。     

Tracheal stenting improves airway mechanics in infants with tracheobronchomalacia

The compliance and expiratory resistance of the tracheobronchial tree is increased in infants with tracheobronchomalacia because of a weakness in cartilaginous support of the airway. Life threatening episodes may occur in these patients due to airway collapse. The goals of this study were to compare the effects on respiratory system mechanics of stenting the airway with either continuous positive airway pressue (CPAP) or a long tracheostomy tube. Five infants were studied: two had bronchopulmonary dysplasia (BPD), 2 had associated congenital anomalies, and one had tracheomalacia and polydactyly; none had a tracheoesophageal fistula. All patients required tracheostomy and were treated with CPAP. Lung mechanics were evaluated by measuring transpulmonary pressure, obtained by subtracting airway opening pressure from pleural pressure measured with an esophageal balloon, and flow measured with a pneumotachometer placed in series with the tracheostomy. Dynamic compliance (C_dyn) and total respiratory system resistance (R_t) were calculated by two-factor, least-mean-squares analysis, solving for the equation of motion of the lung with the PeDS® system (MAS, Hatfield). In all subjects C_dyn increased and R, decreased with increasing CPAP. In 4 subjects the airway was stented with a specially designed, long tracheostomy tube which reached to just above the carina; the special tube improved dynamic mechanics sufficiently to permit the discontinuation of CPAP. Speech was improved by fenestrating the tube and the use of a one-way inspiratory valve, placed over the tracheostomy. Inspiration occurred via the tracheostomy and expiration was directed to the larynx. © 1995 Wiley-Liss, Inc.