Usage of airway ultrasound as an assessment and prediction tool of a difficult airway management.

Airway assessment is important in emergency airway management. A difficult airway can lead to life-threatening complications. A perfect airway assessment tool does not exist and unanticipated difficulty will remain unforeseen. Current bedside clinical predictors of the difficult airway are unreliable but airway ultrasound can be used as an adjunct to predict difficult laryngoscopy. We report a case of a 60-year-old man presenting to the emergency department with shortness of breath, hoarseness of voice and stridor. Airway ultrasound revealed a large laryngeal mass narrowing the upper airway, extending to bilateral vocal cords with heterogenous echogenicity. In view of impending complete upper airway obstruction, acute respiratory distress and airway ultrasound findings, urgent emergency tracheostomy was chosen as definitive airway over endotracheal intubation or surgical cricothyroidotomy. Point of care ultrasound (POCUS) was used to evaluate this patient with severe upper airway obstruction. A laryngeal mass was detected by ultrasound and this pointed towards the presence of a difficult airway. POCUS was a good non-invasive tool used for airway assessment in this uncooperative and unstable patient. Ultrasound predictors of the difficult airway include the inability to visualize the hyoid bone, short hyomental distance ratio, high pretracheal anterior neck thickness and large tongue size. Besides airway assessment, ultrasound can also help to predict endotracheal tube size, confirm intubation and guide emergency airway procedures such as cricothyroidotomy and tracheostomy. Point of care ultrasound of the upper airway can be used in airway assessment to identify distorted airway anatomy, pathological lesions and guide treatment decisions.

Airway ultrasound to detect subglottic secretion above endotracheal tube cuff.

BACKGROUND: Subglottic secretion had been proven as one of the causes of microaspiration and increased risk of ventilator-associated pneumonia (VAP). The role of ultrasound to detect subglottic secretion has not yet been established. PURPOSE: The purpose of this study is to determine the sensitivity and specificity of upper airway ultrasound (US) in the detection of subglottic secretions as compared to computed tomography (CT) scanning. MATERIAL AND METHODS: A prospective observational study was carried out in adult trauma patients requiring mechanical ventilation and cervical CT scan. All patients had an endotracheal tube cuff-pressure maintained between 20 and 30 cm H2O. Airway US was performed at the bedside immediately before the patient was transferred to the CT scan suite. The sensitivity, specificity, and positive/negative predictive values (PPV, NPV) of the upper airway US detection of subglottic secretions were then calculated and compared with CT findings. RESULTS: Fifty participants were consecutively included. Subglottic secretions were detected in 31 patients using upper airway US. The sensitivity and specificity of upper airway US in detecting subglottic secretion were 96.7% and 90%, respectively (PPV 93.5%, NPV 94.7%). 18 (58%) patients with subglottic secretions developed VAP during their ICU stay (p = 0.01). The area under the receiver operating curve (AUROC) was 0.977 (95% CI 0.936-1.00). CONCLUSIONS: Upper airway US is a useful tool for detecting subglottic secretions with high sensitivity and specificity. CLINICAL IMPLICATIONS: This study shows: 1. Upper airway US may aid in detecting subglottic secretions, which are linked to VAP. 2. Detecting subglottic secretions at the bedside aids in determining the best frequency of subglottic aspiration to clean the subglottic trachea. 3. Upper airway US may also aid in detecting the correct ETT position. Trial registration Clinicaltrials.gov. CLINICALTRIALS: gov identifier NCT04739878 Date of registration 2nd May 2021 URL of trial registry record https://clinicaltrials.gov/ct2/show/NCT04739878 .

Novel role of focused airway ultrasound in early airway assessment of suspected laryngeal trauma.

BACKGROUND: Upper airway injury secondary to blunt neck trauma can lead to upper airway obstruction and potentially cause a life-threatening condition. The most important aspect in the care of laryngeal trauma is to establish a secure airway. Focused airway ultrasound enables recognition of important upper airway structures, offers early opportunity to identify life-threatening upper airway injury, and allows assessment of the extent of injury. This information that can be obtained rapidly at the bedside has the potential to facilitate rapid intervention. CASE PRESENTATION: We report a case series that illustrate the diagnostic value of focused airway ultrasound in the diagnosis of laryngeal trauma in patients presenting with blunt neck injury. CONCLUSION: Early recognition, appropriate triaging, accurate airway evaluation, and prompt management of such injuries are essential. In this case series, we introduce the potential role of focused airway ultrasound in suspected laryngeal trauma, and the correlation of these exam findings with that of computed tomography (CT) scanning, based on the Schaefer classification of laryngeal injury.

Role of upper airway ultrasound in airway management.

Upper airway ultrasound is a valuable, non-invasive, simple, and portable point of care ultrasound (POCUS) for evaluation of airway management even in anatomy distorted by pathology or trauma. Ultrasound enables us to identify important sonoanatomy of the upper airway such as thyroid cartilage, epiglottis, cricoid cartilage, cricothyroid membrane, tracheal cartilages, and esophagus. Understanding this applied sonoanatomy facilitates clinician to use ultrasound in assessment of airway anatomy for difficult intubation, ETT and LMA placement and depth, assessment of airway size, ultrasound-guided invasive procedures such as percutaneous needle cricothyroidotomy and tracheostomy, prediction of postextubation stridor and left double-lumen bronchial tube size, and detecting upper airway pathologies. Widespread POCUS awareness, better technological advancements, portability, and availability of ultrasound in most critical areas facilitate upper airway ultrasound to become the potential first-line non-invasive airway assessment tool in the future.