A Case of Transient Ventilation Difficulty Caused by the Occlusion of a Nasotracheal Intubation Tube Due to the Weight of the Tongue in a Patient With Morbid Obesity.

In patients with obesity, airway obstruction is more likely to occur because of the effects of gravity on the supine position and compression of the airway caused by the weight of soft tissues. This significantly increases the risk of apnea and hypoxemia. Therefore, careful airway monitoring and securing are essential after anesthesia induction and during postoperative recovery. Herein, we report a case of nasotracheal intubation tube obstruction caused by the weight of the tongue in a patient with morbid obesity during general anesthesia. This rare complication highlights the importance of careful airway monitoring and management in patients with obesity undergoing general anesthesia.

A novel technique of airway silicon stent deployment under vision-Dr. Vidyasagar's technique.

The conventional methods of silicon stent insertion recommend usage of external loading devices, where the stent is folded into the loading device and pushed in to the tracheobronchial tree using an external pusher which is blind, and leads to placement of stent either distally or proximally needing repositioning or is done with fluoroscopy that involves radiation exposure. We demonstrate our experience in 16 cases of successful silicon stent placement using this technique, wherein an Ultrathin flexible bronchoscope or Hopkins Rigid telescope is pushed alongside the forceps that hold upper end of the folded silicon stent allowing stent placement under direct vision with control over the stent. The Proximal end of the stent can be pulled under vision before deployment for appropriate positioning while pulling the rigid barrel. The stent is always under the operator's control providing excellent control over placement, simplifies the procedure and is safe with no reported complications.

Approaching Saber-Sheath Trachea in a Patient with Bilateral Vocal Cord Abductor Palsy and Post Tracheostomy Tracheal Stenosis.

Human trachea has variable shapes and the most common are circular and oval-shaped. Other shapes are rare to find and usually related to some diseases. Such as the Saber-sheath shaped trachea, which was commonly attributed to patients with chronic obstructive pulmonary disease (COPD). This case is about a patient who was detected to have dual pathology, bilateral vocal cord abductor palsy, and post-tracheostomy complicated with tracheal stenosis for 40 years. Symptoms worsened in the last three years until he was admitted to the ward. However, upon managing this case with multilevel airway obstruction, we have found out that this patient who did not have COPD, has a Saber-sheath trachea shape. This finding may indicate that the shape is not limited to a certain disease only.

Live Fish in the Throat Causing Upper Airway Obstruction and Esophageal Perforation.

Having a large live fish stuck in the throat is rare and prompts the urgent need to secure a definitive airway. Such sizeable foreign body (FB) in the aerodigestive tract also poses a constant threat of hollow viscus perforation, and the removal process can be complex. This report describes a fishing mishap causing the impaction of a large live fish in the laryngopharynx and esophagus, leading to respiratory distress and upper esophageal perforation. The paper highlights the mechanism of injury, emergent airway management, anatomical consideration of the location of the FB, and technical challenges in FB removal. After endotracheal intubation, the depth and location of the live fish were confirmed with a plain radiograph. The removal of the live fish was eventually successful after dislodging its fins from the laryngopharynx and rotating its head out from the upper esophagus endoscopically. The upper esophageal perforation healed with non-operative management, and the patient was discharged well.

Management and treatment algorithm of airway complications after anterior cervical spine surgery: systematic review.

Background: Airway-related complications are rare after cervical spine surgery but can be devastating and compromise a successful outcome. The objective of this systematic review is to provide an overview of the management of airway complications after anterior cervical spine surgery (ACSS) and propose a treatment algorithm for approaching the patient with a compromised airway. Methods: A literature search was conducted in PubMed and adapted for use in other databases, including the Cochrane Register of Controlled Trials, Cochrane Library Health Technology Assessment Database, Embase, and the National Health Service (NHS) Economic Evaluation Database. Results: A total of 117 papers received a full text review. Thirty-seven studies were categorized as "management" and included. An additional four references were extracted from other references for a total of 41 studies. Conclusions: Most of the available evidence on airway compromise after ACSS is level III or IV. Similarly, most available evidence on the management of acute airway complications comes from case reports or anecdotal publications. There are currently no methods in place to stratify the risk of airway complications in patients undergoing these guidelines on the management of these complications when they occur. This review is focused on practice, including management of such complications with a proposed treatment algorithm.

Associations between vitamin A and K intake and lung function in the general US population: evidence from NHANES 2007-2012.

Introduction: While nutrition's critical role in enhancing respiratory health is acknowledged, the specific impacts of vitamins A and K on lung function remain largely unexplored. The study aimed to evaluate the relationships between vitamins A and K intake and lung function. Methods: The cross-sectional study focused on adults aged 20-79 with utilizing data from US National Health and Nutrition Examination Survey (NHANES) 2007-2012. Lung function was assessed by measuring forced expiratory volume (FEV1), forced vital capacity (FVC), and the ratio of these two values (FEV1/FVC). Regression model was performed to determine the associations between intake of vitamins A and K and outcomes. Results: Data of 10,034 participants (representing 142,965,892 adults in the US) were analyzed. After adjusting for relevant confounders, multivariable analysis revealed 1 µg/day increase of vitamin A intake was significantly associated with 0.03 ml increased FEV1 (p = 0.004) and 0.04 ml increased forced vital capacity (FVC) (p < 0.001). In addition, 1 µg/day increase in vitamin K intake was significantly associated with 0.11 ml increased FEV1 (p = 0.022). Neither vitamin A and K intake was associated with FEV1/FVC or presence of airway obstruction. Conclusions: In relatively healthy population of the US, greater vitamin A or K intake was independently associated with better lung function assessed by spirometry. Benefits of such vitamins for pulmonary health should be confirmed in future randomized controlled trials.

Postoperative respiratory difficulties following primary cleft palate repair in infants with Robin sequence versus isolated cleft palate: A retrospective study.

The study aimed to: (1) compare the occurrence of postoperative respiratory difficulties (PRD) following primary cleft palate repair (CPR) in infants with an isolated cleft palate (iCP) and infants with Robin sequence (RS), and (2) describe the possible benefit of preoperative analysis with palatal plate in infants with RS. All consecutive infants with an iCP and infants with RS who underwent CPR between January 2009 and June 2022 in the Wilhelmina Children's Hospital were retrospectively reviewed. A total of 127 infants were included of which 74 infants with an iCP and 53 infants with RS. The group of infants with RS consisted of 35 infants with non-isolated RS (niRS) and 18 infants with isolated RS (iRS). Significant more PRD were seen in infants with RS compared to infants with an iCP (14/53 versus 9/74; p = 0.04). Especially infants with niRS have a significant higher risk of developing PRD in comparison with infants with an iCP (OR = 4.16, 95% CI [1.17-15.99], p = 0.031). The preoperative palatal plate screening in infants with RS (n = 25) did not show abnormalities and had no effect on the perioperative policy. Within the limitations of this study it seems that infants with niRS are more prone to develop PRD following primary CPR when compared to infants with iRS or an iCP. No clear benefit was found in postponing surgery until 12 months or later in infants with RS to avoid PRD. The preoperative palatal plate screening did not demonstrate signs of UAO in infants with RS that developed PRD. These findings suggest that preoperative analysis with palatal plate has a low predictive value.

Clinical applications of forced oscillation technique (FOT) for diagnosis and management of obstructive lung diseases in children.

Obstructive lung diseases such as bronchial asthma, COPD, and cystic fibrosis are a burden on many patients across the globe. Spirometry is considered the gold standard for diagnosing airflow obstruction, but it can be difficult for pediatric patients to do and requires a lot of effort. As a result, healthcare providers need new, effortless methods to diagnose airway obstructions, particularly in young children and individuals unable to perform the spirometry maneuver. The forced oscillation technique is a modern method requiring only tidal breathing combined with the application of external, source of low-amplitude oscillations to evaluate the respiratory system's response. It might be essential for identifying early respiratory changes caused by smoking, childhood asthma, and may prove more sensitive than spirometry in identifying peripheral airway disturbances or evaluating the long-term success of therapy. This review describes the methodology and the indications for the forced oscillation technique and outlines its relevance in clinical practice.

The Ingestion Question: Public Knowledge of Safe Food Introduction in Children.

OBJECTIVES: National guidelines advise delaying initiation of solid foods until after 4-6 months of age and avoiding "high-risk" foods under the age of 4 years. However, foreign body aspiration of food remains a common preventable pediatric emergency. Our primary aim was to investigate public knowledge regarding the safe age of introduction of different foods to children and determine if demographic factors affect this knowledge. METHODS: An online survey was designed following a literature review and consultation with an expert panel. This was distributed via social media platforms. A review of our institutional data of bronchoscopy/foreign body retrievals was performed to identify trends. RESULTS: There were 1000 survey responses: 79.4% of respondents cared for children and 21.5% were medical professionals; 37.7% of respondents (n = 385) would offer high-risk foods to children <2 years of age and 56.9% (n = 582) to children <3 years. At our institution nuts (65.7%) were the most common food-related foreign body retrieved from a total of 265 over 21 years. Notably, 80% of respondents (n = 800) would offer whole nuts to children <4 years. Respondents with medical training were more likely to hold off on introducing nuts to children until a later age. CONCLUSION: Although the public has an overall appreciation of food safety, a significant proportion would feel comfortable offering high-risk foods to children under 2 and 3 years. There is a poor understanding of the danger of nuts and the appropriate age of introduction. Further research into effective public education strategies on safe food introduction in children are warranted. LEVELS OF EVIDENCE: V Laryngoscope, 2024.

Characteristics of lung resistance and elastance associated with tracheal stenosis and intrapulmonary airway narrowing in ex vivo sheep lungs.

BACKGROUND: Understanding the characteristics of pulmonary resistance and elastance in relation to the location of airway narrowing, e.g., tracheal stenosis vs. intrapulmonary airway obstruction, will help us understand lung function characteristics and mechanisms related to different airway diseases. METHODS: In this study, we used ex vivo sheep lungs as a model to measure lung resistance and elastance across a range of transpulmonary pressures (5-30 cmH2O) and ventilation frequencies (0.125-2 Hz). We established two tracheal stenosis models by inserting plastic tubes into the tracheas, representing mild (71.8% lumen area reduction) and severe (92.1%) obstructions. For intrapulmonary airway obstruction, we induced airway narrowing by challenging the lung with acetylcholine (ACh). RESULTS: We found a pattern change in the lung resistance and apparent lung elastance as functions of ventilation frequency that depended on the transpulmonary pressure (or lung volume). At a transpulmonary pressure of 10 cmH2O, lung resistance increased with ventilation frequency in severe tracheal stenosis, whereas in ACh-induced airway narrowing the opposite occurred. Furthermore, apparent lung elastance at 10 cmH2O decreased with increasing ventilation frequency in severe tracheal stenosis whereas in ACh-induced airway narrowing the opposite occurred. Flow-volume analysis revealed that the flow amplitude was much sensitive to ventilation frequency in tracheal stenosis than it was in ACh induced airway constriction. CONCLUSIONS: Results from this study suggest that lung resistance and apparent elastance measured at 10 cmH2O over the frequency range of 0.125-2 Hz can differentiate tracheal stenosis vs. intrapulmonary airway narrowing in ex vivo sheep lungs.

Indications and Evolution of the Butterfly Graft in Nasal Valve Repair.

Persistent nasal airway obstruction from inadequately addressed nasal valve compromise is common. Many techniques exist to perform nasal valve repair. Historically, spreader grafts are the most commonly used, despite a relative lack of evidence demonstrating its superiority over other methods. The butterfly graft is an alternative method of nasal valve repair and detailed surgical description from over 20 years of innovation follows in this section. There is growing evidence to suggest that the butterfly graft may be superior to spreader grafts with similar acceptability of the esthetic outcomes.

The role of respiratory function tests in infants with stridor: diagnosis at glance and follow-up.

BACKGROUND: Recently, the development of advanced, noninvasive methods has allowed the study of respiratory function even in uncooperative infants. To date, there is still little data on the application of this technique in infants with suspected airway obstruction. THE AIMS OF OUR STUDY WERE: - To evaluate the role of respiratory function testing (PFR) in the diagnosis and follow-up of infants with stridor - To evaluate the differences between patients with inspiratory stridor and expiratory stridor. - To evaluate the concordance between PFR and endoscopy. METHODS: We enrolled infants aged < 1 year with a diagnosis of inspiratory and/or expiratory chronic stridor and a group of healthy controls. For each patient we performed PFR at diagnosis (T0) and for cases at follow-up, at 3 months (T1), 6 months (T2), 12 months (T3). At T0, all patients were classified according to a clinical score, and at follow-up, stature-ponderal growth was assessed. When clinically indicated, patients underwent bronchoscopy. RESULTS: We enrolled 48 cases (42 diagnosed with inspiratory stridor and 6 expiratory stridor) and 26 healthy controls. At T0, patients with stridor had increased inspiratory time (p < 0.0001) and expiratory time (p < 0.001) than healthy controls and abnormal curve morphology depending on the type of stridor. At T0, patients with expiratory stridor had a reduced Peak expiratory flow (p < 0.023) and a longer expiratory time (p < 0.004) than patients with inspiratory stridor. We showed an excellent concordance between PFR and endoscopic examination (k = 0.885, p < 0.0001). At follow-up, we showed a progressive increase of the respiratory parameters in line with the growth. CONCLUSIONS: PFR could help improve the management of these patients through rapid and noninvasive diagnosis, careful monitoring, and early detection of those most at risk.

Cytomegalovirus tracheobronchitis mimicking lung cancer progression in a patient with lung adenocarcinoma: A case report.

Cytomegalovirus (CMV) commonly infects immunocompromised individuals, such as cancer patients. We present a case involving a 60-year-old male with Stage 3A lung adenocarcinoma and chronic obstructive pulmonary disease (COPD) diagnosed with CMV tracheobronchitis, initially suspected as cancer progression. Treatment with ganciclovir led to partial improvement in symptoms of shortness of breath and cough, as well as bronchoscopic findings. However, due to ganciclovir-induced neutropenia, the therapy was switched to foscarnet. Distinguishing between cancer progression and infectious tracheobronchitis through physical examination and chest CT scans remains challenging. In lung cancer patients presenting with airway and bronchial narrowing along with ulcerative mucosal lesions, CMV infection should be considered. A bronchoscopic biopsy is crucial for accurate diagnosis and determining the appropriate treatment in these patients.

Anaesthesia Management in a Case of Ludwig's Angina With Difficult Airway Managed by Emergency Tracheostomy.

Severe neck infections present significant challenges for anesthesiologists due to the complexities associated with managing difficult airways. Ludwig's angina, a rapidly progressing infection of the submandibular space, exemplifies these challenges due to the high risk of airway obstruction. This case report details an emergency procedure performed to drain Ludwig's angina, highlighting the difficulties encountered and the strategies employed. Awake fiberoptic intubation is demonstrated as an effective approach for maintaining the airway during such operations. The report underscores the critical nature of quick and effective management, emphasizing the importance of readiness for interventions such as tracheostomy in cases where oxygen saturation drops, thereby ensuring patient safety in precarious situations.

Objective Outcome Measures in Nasal Valve Repair and Nasal Obstruction.

The diagnosis of nasal valve compromise (NVC) is clinical. However, objective evaluation of the nasal airway can support the clinical diagnosis of NVC and quantify the derangement produced by NVC in nasal airflow and in nasal airway resistance. Computational fluid dynamics analysis can quantify disturbances of the normal nasal airway conditions and, furthermore, localize these disturbances to the nasal valve. Objective evaluation of the nasal airway is useful to assess the results of surgery addressing the nasal valve, being able to quantify the improvement in nasal airflow, nasal airway resistance and nasal airway dimensions achieved by surgery.

Congenital Nasal Pyriform Aperture Stenosis and the Significance of McGovern Nipple.

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare but potentially life-threatening cause of upper airway obstruction in infants. It was first described in 1988 and 1989 in the radiology and otolaryngology literature. Congenital airway obstruction affects up to 1 in 5,000 infants, and many of these obstructions result from choanal atresia. CNPAS is estimated to occur 1 in 25,000 live births. This case report describes a neonate with acute respiratory distress and obstructive breathing pattern relieved by opening her oral airway and maintained with the McGovern nipple decreasing ventilator days during hospitalization with viral bronchiolitis.

Combining transcatheter arterial embolization with endoscopic debulking for hypervascular airway tumor management: a retrospective single center study.

Background: Airway obstruction due to tumor invasion or concurrent respiratory distress and hemoptysis poses a significant challenge in clinical management, often requiring prompt and effective intervention to alleviate symptoms and improve patient outcomes. This study aimed to evaluate the efficacy and safety of selective transcatheter arterial embolization (TAE) as a preparatory measure to mitigate airway obstruction before bronchoscopic debulking as an approach to address this clinical challenge. Methods: The data of patients with airway obstruction due to tumor invasion or concurrent respiratory distress and hemoptysis treated at The First Affiliated Hospital of Zhengzhou University from January 2018 to August 2022 were analyzed. After computed tomography (CT) scans and bronchoscopic findings were assessed, selective TAE was performed as a preparatory measure to alleviate airway obstruction before bronchoscopic debulking, and the occurrence of hemorrhage-related complications, Karnofsky Performance Status (KPS) score, breathlessness index, and the extent of airway obstruction were evaluated. Results: All 22 patients underwent selective TAE before bronchoscopic tumor debulking. The overall efficacy rate was 100%, with a significant improvement in the KPS score from preoperative (60.45±14.63) to postoperative (74.55±9.63) levels (t=-6.891; P<0.001). Similarly, there was a considerable reduction in the shortness of breath score from preoperative (2.91±0.81) to postoperative (1.73±0.63) levels (t=6.973; P<0.001). Airway obstruction decreased substantially from preoperative (79.14%±14.56%) to postoperative (21.27%±7.19%) levels (t=26.857; P<0.001). Furthermore, the severity classification of airway obstruction decreased from preoperative (4±0.82) to postoperative (1.36±0.49) levels (t=18.794; P<0.001). Among the patients, only one experienced moderate bleeding necessitating prolonged mechanical balloon compression and intracavitary lesion removal, while the other patients had minor and negligible bleeding. Conclusions: TAE combined with endoscopic debulking can effectively control intraoperative bleeding and respiratory distress and achieve successful local resolution of endotracheal hypervascular tumors.

Fatal scenario following dental extraction in middle-aged man with history of acquired hemophilia: Employment of surgical tracheostomy and use of FFP and cryoprecipitate to gain patent airway.

Acquired hemophilia A can upshot in a life-threatening hemorrhage and airway obstruction. Airway bleeding is a weighty emergency in hemophilia care, necessitating the immediate start of effective hemostatic therapy (porcine factor VIII, the factor eight inhibitor bypassing activity and recombinant factor VIIa) and the decision to undertake proper airway control, such as tracheal intubation and tracheostomy. However, due to the dearth deficiency of effective hemostatic measures we relied upon the use of fresh frozen plasma and cryoprecipitate to gain control of the bleeding despite the precarious threat of infectious disease transmission associated with their use.

Tidal Breathing Analysis as a Prognostic Index for Airway Obstruction Trajectory and Asthma in Preterm Infants.

INTRODUCTION: An easy-to-implement and accurate lung function assessment tool for preterm infants is crucial to manage lifelong respiratory morbidities. We aimed to determine which pulmonary function parameters in preterm infants can predict the trajectory of airway obstruction and asthma development after 4 years of age. METHODS: We evaluated 52 preterm infants who had undergone both tidal breathing flow-volume loop (TBFVL) and multiple-breath washout (MBW) analyses in infancy and spirometry after the age of 4 years. We evaluated the association between pulmonary function parameters in infancy and childhood and the pulmonary function trajectory until 13 years of age and compared the changes in this trajectory according to pulmonary function parameters in infancy. RESULTS: Time to peak expiratory flow/expiratory time (TPEF/TE) in infancy was associated with FEV1, FEF25-75, and dysanapsis ratio in childhood and differed according to level of airway obstruction assessed by FEV1, FEV1/FVC, and FEF25-75, an asthma development. TPEF/TE was a significant predictive factor for airway obstruction and asthma after 4 years of age, after adjusting for sex, extreme prematurity, duration of supplementary oxygen and mechanical ventilation, and recurrent wheezing during infancy. In premature infants with lower TPEF/TE, subsequent pulmonary function parameters remained low until 13 years of age. CONCLUSION: In preterm infants, TPEF/TE could be useful to predict airway obstruction and asthma after 4 years of age and even a lower pulmonary function trajectory until 13 years of age. This information may help clinicians to provide lifelong care for pulmonary morbidity in children and adolescents born preterm.