Flexible CO2 Laser in Therapeutic Bronchoscopy: Initial Experiences in a Tertiary Center.

BACKGROUND: CO2 Laser (CO2L) technology deployable through flexible endoscopes now allows for their use throughout the airway, although published data are limited. METHODS: Retrospective analysis of CO2L bronchoscopic procedures, excluding glottic and subglottic interventions. Procedural success was defined as >50% visual reduction in airway obstruction in the area treated or resolution of the procedural indication. RESULTS: Seventy-two procedures were performed on 36 patients. Nonmalignant indications comprised 66%: stent-associated granulation tissue (28%), granulomatosis with polyangiitis lesions (23%), and lung transplant-related granulation tissue (16%) were the most common. Bronchoscopic access was flexible only in 81% and primarily rigid (combined with flexible) in 18%. The site of intervention was the trachea at 19%, the mainstem at 56%, and lobar/segmental airways at 45%. Procedural success was 89%. CO2L was used exclusively in 19%; in 81%, additional techniques were required, most commonly balloon dilation (59%), cryo-debulking (23%), and rigid dilation (16%). Malignant indications had a nonsignificant trend toward requiring adjuvant techniques ( P =0.05). Seventy-six percent of the patients required more than 1 procedure. CO2L exclusive cases had no statistically different needs for subsequent therapeutic bronchoscopies ( P =0.10) or time to reintervention (109 vs. 41 days, P =0.07), and reintervention-free survival was similar ( P =0.10) and difficult to predict. The complication rate attributable to CO2L was 2.7%. CONCLUSION: CO2L is a safe and useful tool when precise cutting and vaporization are desired. Its use in multi-modality approaches has high levels of success in adequately selected lesions, adding an ablative potential to dilation techniques. Vasculitis-associated scars/webs and granulation tissue (including stent-associated) appear to be ideal targets.

Nasopharyngeal diffuse large B-cells lymphoma causing acute airway obstruction amid COVID-19 crisis: an anaesthetist's nightmare.

Acute stridor is often an airway emergency. We present a valuable experience handling an elderly woman who was initially treated as COVID-19 positive during the pandemic in November 2020. She needed an urgent tracheostomy due to nasopharyngeal (NP) diffuse large B-cell lymphoma causing acute airway obstruction. Fortunately, 1 hour later, her NP swab real-time PCR test result returned as SARS-CoV-2 negative. This interesting article depicts the importance of adequate preparations when handling potentially infectious patients with anticipated difficult airway and the perioperative issues associated with it.

Awake fiberoptic intubation in patients with stenosis of the upper airways: Utility of the laryngeal nerve block.

Awake fiberoptic intubation (AFOI) is mandatory to manage difficult airways. Superior laryngeal nerve block (SLNB) could reduce risks and improve patient comfort. The aim of this study is to assess the procedural comfort of SLNB during AFOI in a population of patients undergoing upper airway oncological surgery. Forty patients were randomized into two groups and were treated with continuous infusion of remifentanil, topic anesthesia and intercricoid block. In the study group (=20), SLNB was performed with lidocaine (L-SLNB); in the control group (n=20) SLNB was performed using saline (S-SLNB). AFOI was more comfortable in the L-SLNB group compared to S-SLNB patients [FOICS ≤ 1 in 18 patients (90%) L-SLNB; 2 (10%) S-SLNB (P <0.001)]. Intubation was faster in L-SLNB (47.45 ±15.38 sec) than S-SLNB (80.15 ±37.91 sec) (p <0.001). The SLNB procedure during AFOI is a safe and comfortable procedure in a population of patients undergoing upper airways surgery. Time to intubation was shorter in L-SLNB than in S-SLNB.

Use of Helium/Oxygen Mixture in Noninvasive Ventilation During Urgent Tracheotomy for Upper Airway Compression: A Case Report.

Ventilation or oxygenation can be difficult or even impossible in cases of upper airway obstruction. In this case report, we used a helium/oxygen mixture administered via noninvasive positive-pressure ventilation to perform an urgent tracheotomy under local anesthesia on a patient presenting upper airway compression. It improved his comfort and his stridor, facilitating supine positioning. This case describes another potential indication of the helium/oxygen mixture in noninvasive ventilation.

Factors associated with changing indications for adenotonsillectomy: A population-based longitudinal study.

OBJECTIVE: Adenotonsillectomy (AT) is one of the most common surgical procedures performed in children and adults. We aim to assess the factors associated with changes in the incidence of and indications for AT using population-level data. STUDY DESIGN: This retrospective cohort study investigated patients who underwent AT between 1997 and 2010 by using data from the Taiwan National Health Insurance Research Database. We examined surgical rates and indications by the calendar year as well as age, sex, hospital level, and insured residence areas for the correlating factors. RESULTS: The average annual incidence rate of AT was 14.7 per 100,000 individuals during 1997-2010. Pediatric (<18 years) patients represented 48.2% of the total AT population. More than 99% of the patients underwent the AT procedures as an inpatient intervention. Longitudinal data demonstrated an increasing trend in the pediatric AT rates from 1997 (4.3/100,000) to 2010 (5.7/100,000) (p = 0.029). In the adult subgroup, a decreasing prevalence of infectious indications (p = 0.014) coincided with an increasing neoplastic indications (p = 0.001). In the pediatric subgroup, the prevalence of obstructive indications increased (p = 0.002). The logistic regression analyses indicated that the significant factors associated with the changing surgical indications for AT were the age in the adult subgroup and hospital level in the pediatric subgroup. CONCLUSIONS: This study revealed a low AT rate in Taiwan than that in other countries. Pediatric AT incidence increased during 1997-2010. Although a rising prevalence of obstructive and neoplastic indications was noted, infection remained the most common indications for AT. Age in the adult subgroup and hospital level in the pediatric subgroup were factors associated with the changing indications for AT.

Upper Airway Obstruction Requiring Emergent Tracheostomy Secondary to Laryngeal Sarcoidosis: A Case Report.

BACKGROUND Laryngeal sarcoidosis is a rare extrapulmonary manifestation of sarcoidosis, accounting for 0.33-2.1% of cases. A life-threatening complication of laryngeal sarcoidosis is upper airway obstruction. In this report we describe our experience in the acute and chronic care of a patient who required an emergent tracheostomy, with the aim to provide further insight into this difficult to manage disease. CASE REPORT A 37-year-old African American female with a 10-year history of stage 1 sarcoidosis presented with severe dyspnea. Laryngeal sarcoidosis was diagnosed three years previously, and she remained stable on low-dose prednisone until six months prior to admission, at which time she self-discontinued her prednisone for the homeopathic treatment Nopalea cactus juice. Her physical examination was concerning for impending respiratory failure as she presented with inspiratory stridor and hoarseness. Laryngoscopy showed a retroflexed epiglottis obstructing the glottis with edematous arytenoids and aryepiglottic folds. Otolaryngology performed an emergent tracheostomy to secure her airway and obtained epiglottic biopsies, which were consistent with sarcoidosis. She was eventually discharged home on prednisone 60 mg daily. Following months of corticosteroids, a laryngoscopy showed the epiglottis continuing to obstruct the glottis. The addition of methotrexate to a tapered dosage of prednisone 10 mg daily was unsuccessful, and she remains on prednisone 20 mg daily for disease control. CONCLUSIONS Laryngeal sarcoidosis, a rare extrapulmonary manifestation of sarcoidosis, uncommonly presents as the life-threatening complication of complete upper airway obstruction. As such, laryngeal sarcoidosis is associated with significant morbidity and mortality, requiring a high index of suspicion for timely diagnosis and treatment.

Anesthetic Management for Pediatric Awake Tracheostomy.

Awake tracheostomy is indicated for acute upper airway obstruction, when other methods of securing the airway, such as intubation and cricothyrotomy, have failed or are inappropriate. This option is rarely considered in pediatrics because of the concerns of patient cooperation and safety and has not been described in the literature. We describe the anesthetic management of an awake tracheostomy performed on a 7-year-old girl, with a large supraglottic mass obstructing the laryngeal introitus.

Silicone Y-Stent Placement on the Secondary Left Carina.

BACKGROUND: The silicone Y-stent has mainly been used for the treatment of lesions around the main carina, and only a few case reports have been published on the technique for the lesions around the secondary left carina (LC2). OBJECTIVES: We investigated the feasibility, efficacy and safety of a stenting technique using a silicone Y-stent for patients with airway stenosis around LC2. METHODS: Patients who underwent airway stent placement between December 2010 and September 2014 in a single center were retrospectively reviewed. Under general anesthesia, using rigid and flexible bronchoscopes, the airway lumen was re-established followed by Y-stent placement on LC2. RESULTS: We performed 274 airway stenting procedures for 253 patients during the study period. Twelve of them (7 with lung cancer, 3 with esophageal cancer/carcinosarcoma, 1 with thyroid cancer and 1 with renal cancer) underwent a Y-stent placement on LC2. Respiratory symptoms were relieved in all patients. Six of 7 patients with supplemental oxygen, including the mechanically ventilated patient before stent placement, could be discharged without supplemental oxygen. The chest radiograph after the procedure showed increased lung volume in all 7 patients with partial or complete atelectasis. Median survival after stenting was 197 days at the time of data collection. Retention of secretions occurred in 1 and hemoptysis in another patient. CONCLUSIONS: Silicone Y-stent placement on LC2 is technically feasible, effective and acceptably safe.

Emergent Awake tracheostomy--The five-year experience at an urban tertiary care center.

OBJECTIVES/HYPOTHESIS: There are few studies that discuss the issues surrounding emergent awake tracheostomy. We aim to review the indications, anesthesia used, complications, and outcomes of patients undergoing urgent awake tracheostomy. STUDY DESIGN: Chart review. METHODS: Medical charts of patients who underwent an emergent awake tracheostomy at our institution-affiliated tertiary care center over a 5-year period from 2009 to 2014 were reviewed. Data were collected from inpatient, outpatient, and operative records. RESULTS: Sixty-eight patients underwent emergent awake tracheostomy. Over half presented with hoarseness (n=37, 54.4%) and/or stridor (n=37, 54.4%). Acute upper airway obstruction secondary to malignancy was the most common indication and accounted for 58 cases (85.3%). Thirty-nine (70.1%) of the 55 patients with squamous cell carcinoma presented with advanced disease (stage III or IV). Other indications included glottic or subglottic stenosis (4.4%), failure to intubate (2.9%), and other (7.4%). Local anesthesia was used alone in 35.3% of cases and in combination with conscious sedation in 64.7% of cases. Mild bleeding occurred postoperatively in five patients (7.4%). There were no other postoperative complications. Nineteen patients were lost to follow-up. The mean follow-up of 49 patients was 7.2 weeks, ranging from 2 to 261 weeks. Long-term complications occurred in three patients and included tracheitis 7.4% and suprastomal granuloma 2.9%. Eleven patients (22%) were decannulated at a mean of 11.8 months following tracheostomy. CONCLUSIONS: Emergent awake tracheostomy should be considered in patients with impeding airway obstruction and is a safe and effective method to secure an airway in these patients. LEVEL OF EVIDENCE: 4.

Ablative therapies for central airway obstruction.

Central airway obstruction (CAO) is seen in malignant and nonmalignant airway disorders and can lead to significant morbidity and mortality. Endobronchial ablative therapies are used in conjunction with mechanical debridement to achieve hemostasis and restore airway patency. These therapies can be classified into modalities with immediate or delayed effect. Therapies with immediate effect include heat therapies (such as electrocautery, argon plasma coagulation, and laser) and cryorecanalization using a cryoprobe for tissue extraction. These modalities can be used in severe CAO for immediate relief of obstruction. Therapies with delayed effect include cryotherapy, brachytherapy, and photodynamic therapy. These modalities should not be used for acutely symptomatic CAO, and typically require follow-up bronchoscopy for removal of debris from the airway. Multimodality approach typically leads to better outcomes.

Subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia for patients with complex tracheobronchial stenosis: initial clinical experience.

PURPOSE: We aimed to report our preliminary results of subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia for patients with complex lower tracheal-carinal-main bronchial complex stenosis. MATERIALS AND METHODS: Seven consecutive patients with lower tracheal-carinal-main bronchial complex stenosis underwent Y-shaped stent insertion under local anesthesia. During the procedure, subcarinal ventilation was performed using a 4 F angiographic catheter, and stent insertion was performed under the protection of ventilation. Data on technical success, clinical outcome, and follow-up were collected and analyzed. RESULTS: Subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia was technically successful in all patients without any major procedure-related complications. Seven stents were inserted in seven patients. Respiratory function improved in all patients, with the Hugh-Jones classification of respiratory status improving from grade IV-V before stenting to grade I-II after stenting. During the follow-up, one patient experienced re-stenosis of the stent. Average survival time was 185.7 days (range, 96-285 days) after the stenting procedure. CONCLUSION: Subcarinal ventilation-assisted Y-shaped stent insertion under local anesthesia can be an effective, simple, and safe method for lower tracheal-carinal-main bronchial complex stenosis.

Optimizing emergent surgical cricothyrotomy for use in austere environments.

Emergent cricothyrotomy is an infrequently performed procedure used in the direst of circumstances on the most severely injured patients. Austere environments present further unique challenges to effective emergency medical practice. Recently, military trauma registry data were searched for the frequency of cricothyrotomy use and success rates during a 22-month period. These data revealed that cricothyrotomy performed in the most rigorous austere environment (ie, battlefield) had many successes, but also a large number of failed (33%) attempts by medics owing to many factors. Thus, the aim of this review article is to present what is known about cricothyrotomy and apply this knowledge to any austere environment for qualified providers. The National Library of Medicine's PubMed was used to conduct a thorough search using the terms "prehospital," "cricothyroidotomy," "cricothyrotomy," and "surgical airway." The findings were further narrowed by applicability to the austere environment. This review presents relevant airway anatomy, incidences, indications, contraindications, procedures, and equipment, including improvised devices, success rates, complications, and training methods. Recommendations are proffered for ways to optimize procedures, equipment, and training for successful application of this emergent skill set in the austere environment.

Comparing postoperative quality of life in children after microdebrider intracapsular tonsillotomy and tonsillectomy.

OBJECTIVE: To evaluate postoperative quality of life in patients undergoing microdebrider intracapsular tonsillotomy and adenoidectomy (PITA) in comparison with traditional adenotonsillectomy (AT) and to assess PITA's efficacy in solving upper-airway obstructive symptoms. METHODS: 29 children with adenotonsillar hyperplasia referred for AT were included. Patients were divided into two groups: Group 1 (underwent PITA) included 14 children (age 5.1±1.8 years) affected by night-time airway obstruction without a relevant history of recurrent tonsillitis; Group 2 (underwent AT) included 15 children (age 5.2±1.7 years) with a history of upper-airway obstruction during sleep and recurrent acute tonsillitis. Outcomes measures included the number of administered pain medications, time before returning to a full diet, Obstructive Sleep Apnea survey (OSA-18), parent's postoperative pain measure questionnaire (PPPM) and Wong-Baker Faces Pain Rating Scale (WBFPRS). RESULTS: Postoperative pain was significantly lower in the PITA group, as demonstrated by PPPM and WBFPRS scores and by a lower number of pain medications used. PITA group also resumed a regular diet earlier (P<0.001). OSA-18 scores proved that both PITA and AT were equally effective in curing upper-airway obstructive symptoms. CONCLUSION: PITA reduces post-tonsil ablation morbidity and can be a valid alternative to AT for treating upper-airway obstruction due to adenotonsillar hyperplasia.

Tracheotomy in the unprotected airway.

PURPOSE: Although rare, there are many circumstances in which a secure airway is needed urgently. A newly developed technique is presented for quick and efficient performance of this procedure. PATIENTS AND METHODS: All patients who had tracheotomies performed at a tertiary referral center from January 1, 2004, through December 31, 2008, were found by querying the admission database. Three hundred twenty-seven separate procedures performed in 325 patients were identified. Urgent tracheotomies were distinguished from elective and emergent tracheotomies by reading operative reports and excluding elective and emergent procedures. Elective procedures were defined as performed in patients with a secure airway (with an endotracheal tube or laryngeal mask airway). Urgent tracheotomies were defined as having an intact, unprotected airway. Emergent procedures were performed in a patient with complete airway obstruction. RESULTS: Twenty instances of urgent, awake tracheotomies were found in 19 patients, resulting in an incidence of 20 of 327 tracheotomies (6.1%) in 19 of 325 patients (5.8%). CONCLUSIONS: Tracheotomy is an alternative to cricothyroidotomy as a surgical airway in patients with deteriorating respiratory status who cannot be safely intubated by nonsurgical means.

Outcomes of airway stenting for advanced lung cancer with central airway obstruction.

Approximately 30% of lung cancer patients will develop central airway obstruction (CAO). Interventional therapeutic bronchoscopy including airway stenting (AS) providing immediate and effective palliation is therefore essential to improve quality of life (QoL). However, no report has demonstrated the survival benefit of AS. We retrospectively reviewed 65 patients with CAO due to lung cancer who underwent AS from June 1994 to May 2008. Seventy-nine stents were required. Silicon, metallic, or both stents were placed in 42 (60%), 19 (29%), or eight (11%) patients, respectively. Single stent was required in 53 (83%) patients, double in 10 (14%), and triple in two (3%). AS could provide acute relief of central airway and significant improvement was seen in 98% of patients. Fifty-nine patients with detailed observations were assessed further. Morbidity and mortality rates were 22% and 8%, respectively. AS resulted in 25.2% of one-year survival rate and 6.2 months of median survival time (MST). AS followed by adjuvant therapy provided a four-month increase in MST, although overall survival was not significantly changed. This study represents a single-institution experience. Although an aggressive strategy of AS is justified in order to improve symptoms and QoL, AS itself did not contribute to survival benefit.

Deep neck infections: clinical considerations in aggressive disease.

Deep neck infections are common and occur as a consequence of several etiologies. Antibiotic therapy, interventional radiology, and patient support modalities have become increasingly sophisticated, although surgery continues to be the mainstay of treatment for most patients. Today, neck infections are rarely life threatening when sound and timely management is applied.