A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal.

Many guidelines consider supraglottic airway use to be an aerosol-generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real-time aerosol monitoring (0.3-10-µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0-3.1 [0-4.0]) particles.l-1 ) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3-11.0 [0-44]) particles.l-1 , p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0-4.2 [0-6.2]) particles.l-1 , n = 11), and removal (2.1 (0-17.5 [0-26.2]) particles.l-1 , n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66-169 [33-326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non-respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio-aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways.

Predictors of airway intervention in acute supraglottitis (AS), a recent 7- year experience.

AIMS: Acute supraglottitis (AS) can be a life threatening infection that may lead to sudden airway obstruction. Thankfully, paediatric instances have decreased with public health vaccination programmes. Owing to the nature of the location of pathology, this time sensitive emergency requires astute clinical acumen and awareness of early warning signs. This study aimed to i) determine if the incidence of AS has changed over time; ii) investigate geographical and seasonal variation of infection; iii) identify features of presentation which may predict airway intervention; iv) assess efficacy of treatment and make recommendations for management. MATERIALS AND METHOD: All adult patients admitted to a tertiary hospital with the diagnosis of acute supraglottitis between 2013 and 2021 were included. Diagnosis was confirmed with flexible nasendoscopy and consultant review. Demographics, management and outcomes were recorded. Statistical analysis was performed by calculating means and standard deviation for descriptive purposes. Fischer's exact test and two tailed t-test for categorical and continuous variables respectively. Results were deemed significant if P values of less than or equal to 0.05 were calculated. RESULTS: Forty-three adults were identified. Five patients (11.6%) required airway intervention. Stridor, respiratory distress and CRP of >100 mg/L were noted to be significant predictive factors for airway intervention. Intubated patients had a significantly longer hospital stay. Regions with a higher population density were noted to have a higher incidence but this did not prove to be significant. CONCLUSION: This is the largest study of AS in Ireland to date. There is a trend towards increasing incidence of acute supraglottitis in adults. Factors such as stridor, respiratory distress and elevated CRP should alert the clinician to the possible need for airway intervention. Acute supraglottitis is more common in higher density populated regions.

Low rates of airway intervention in adult supraglottitis: A case series and meta-analysis.

PURPOSE: Acute supraglottitis (SG) can potentially lead to rapid airway obstruction. The last few decades have witnessed a shift towards a more conservative approach in airway management of adult SG. This study aims to evaluate this watchful approach based on a large case series combined with a high-level meta-analysis of all reports in the English literature. METHODS: Retrospective case series and meta-analysis. The medical records of all adult patients diagnosed as having SG who were hospitalized in a large-volume tertiary referral center between January 2007 and December 2018 were reviewed. A meta-analysis was conducted on all English literature published between 1990 and 2018. RESULTS: A total of 233 patients (median age 49.1 years, 132 males), were admitted due to acute SG during the study period. No airway intervention was required in 228 patients (97.9%). Five patients (2.1%) required preventive intubation, and two of them (0.9%) were later surgically converted to a tracheotomy. Patients who required airway intervention had higher rates of diabetes (P = .001), cardiovascular diseases (P = .036) and other comorbidities (P = .022). There was no mortality. The meta-analysis revealed that the overall intubation rates random effects model was 8.8% [95% confidence interval (CI) 4.6%-14.0%] and that the tracheotomy random effects model was 2.2% (95% CI; 0.5%-4.8%). The overall mortality rate was 0.89%. CONCLUSIONS: This study provides evidence of low rates of surgical airway intervention in patients diagnosed with SG worldwide. A conservative approach in adult SG is safe and should be advocated. LEVEL OF EVIDENCE: 2.

When Specialty Care Is Unavailable to Rural Families.

We present the case of a 2-year-old boy with epidermolysis bullosa and supraglottic stenosis whose parents refuse an elective tracheostomy because of the significant care the tracheostomy would require. The patient's family lives in a rural area with few health care resources and his parents are already handling hours of daily skin care for his epidermolysis bullosa. In an attempt to convince the parents to pursue the intervention, the medical team recommends that the family move to an area with additional resources to assist in the child's care. The parents refuse to move, citing the many benefits their home environment provides for their son. The medical team calls an ethics consultation, questioning whether this decision constitutes medical neglect. This case raises important questions about medical decision-making in pediatrics. First, is a parent's refusal of a recommended medical intervention because it would require moving their family to a new environment a reasonable decision? Second, how broadly can parents define their child's best interest? Should only physical interests be included when making medical decisions? Is there a limit to what can be considered a relevant interest? Third, can parents only consider the interests of the individual child, or can they consider the interests of other members of the family? Finally, what is the threshold for overruling a parental decision? Is it whenever the parent's definition of a patient's best interest is different from the medical team's, or do other criteria have to be met?

Multipathogenic necrotising supraglottitis in an immunocompetent patient.

Supraglottitis is a potentially life-threatening condition. It is now uncommon due to the Haemophilus influenzae type B vaccination and is more recently caused by Streptococcus pneumoniae, S. pyogenes, H. influenzae non-type B, H. parainfluenzae, Staphylococcus aureus and Pasteurella multocida Very rarely, it can cause necrotising supraglottitis/epiglottitis, and this has been reported in immunocompromised individuals. We present a unique case of multipathogenic supraglottitis causing laryngeal fibrinoid necrosis in an immunocompetent patient. During his admission, the patient was critically unwell and required surgical intervention and tracheostomy. However, he made a full recovery with no persisting morbidity. We believe that this was owed to the aggressive antimicrobial therapy, timely surgical management of the disease process and the patient’s immunocompetency.

Infections and edema.

Infectious and inflammatory conditions of the head and neck may present with impaired airways. An understanding of the pathophysiology will allow for accurate diagnosis and prompt intervention. Preintervention discussion and planning by members of the airway team are crucial in developing a primary and backup plans for safely securing the airway.

Adult supraglottitis: changing trends.

There is no clinical dynamic staging system which scores according to severity all the anatomical regions in adult supraglottitis. The objective of the study was to describe the demographics, clinical presentation, interventions and outcomes of adult patients diagnosed with acute supraglottitis (AS), and to study the correlation of a new AS classification with the need for airway intervention, in comparison with the current classification. This was a retrospective, cohort study conducted at a secondary medical care center. Adults diagnosed with AS from the years 1990-2013 were identified. Data were extracted for demographic and clinical information and there was no intervention. The main outcome and measures were the need for airway intervention. 288 eligible patients were enrolled. AS incidence rate was 4.3/100,000 patients/year. The mean age was 50 ± 16 years. Sore throat (94 %) and dysphagia (88 %) were the most common presenting symptoms. Patients were hospitalized either in the Otolaryngology Department (n = 255, 89 %) or in the Intensive Care Unit (n = 33, 11 %). Of the latter, 19 (58 %) had an airway securing intervention procedure. Our suggested classification was more sensitive than the current one for predicting the need for intubation (p = 0.03). Signs and symptoms of AS in adults are different from those in children. Adult patients presenting with oropharyngeal complaints should be suspected for AS and treated appropriately.

Comorbidities and complications influence the diagnosis and management of geriatric supraglottitis.

INTRODUCTION: This study aimed to assess the differences in the clinical characteristics, management, and outcomes of supraglottitis between geriatric and nongeriatric adults over a 30-month period. METHODS: All adult patients admitted to the emergency department with suspected supraglottitis and who underwent laryngoscopy for confirmation were included. We collected the clinical characteristics, management, and outcomes of these patients and compared geriatric (≥60 years old) and nongeriatric (12-59 years old) groups in terms of these data. RESULTS: Eighty-one geriatric patients and 205 nongeriatric patients were reviewed during the study period. The accuracies of the clinical suspicions of supraglottitis were lower in the geriatric group (geriatric vs nongeriatric, 29.4% vs 47.3%, P = .008). The geriatric group constituted 19.8% of all supraglottitis patients. Comorbidities were discovered in 74.1% of the geriatric group and 25.4% of the nongeriatric group (P = .000). The complication rate in the geriatric patients was almost twice that of the nongeriatric patients (20.8% vs 10.8%). Additionally, the geriatric patients exhibited tendencies toward longer periods of intubation, hospitalization, and stay in the intensive care unit. CONCLUSIONS: The clinical characteristics and management were similar between the geriatric and nongeriatric supraglottitis patients. Nevertheless, the comorbidities altered the clinical presentations of the geriatric patients and resulted in lower diagnostic accuracy. Additionally, the elevated complication rates of the geriatric patient might have negatively affected their outcomes.

Chronic non-granulomatous supraglottitis: a rare and difficult disease.

OBJECTIVES: To examine chronic non-granulomatous supraglottitis, a rare disorder of uncertain aetiology with few reported cases in the literature. CASE REPORTS: We describe two cases of chronic non-granulomatous supraglottitis that led to persistent respiratory compromise. Patients underwent extensive investigation that failed to reveal a definitive diagnosis. CONCLUSION: In patients suffering from chronic inflammation of the supraglottic larynx without evidence of infection, neoplasm or granulomatous disease, many disorders must be ruled out in order to diagnose chronic non-granulomatous supraglottitis, which is a diagnosis of exclusion. We review the literature on this rare entity, discuss current management strategies, and suggest an algorithm for diagnostic investigation.

Acute supraglottitis in adults: what's the optimal airway intervention?

OBJECTIVES: To validate the Friedman stage and define the proper timing for airway intervention in adult cases of acute supraglottitis, we evaluated the clinical courses and management of adult patients. METHODS: 202 adult patients with acute supraglottitis were included in this study. The diagnosis of supraglottitis was established by flexible nasolaryngoscopic examination. Friedman stages were classified in each patient. In this study, the first three days of serial nasolaryngoscopic findings for each patient were evaluated. RESULTS: All patients were treated successfully with only conservative methods. There were no significant differences between patients with Friedman stages I or II/III. Among the patients that had serial nasolaryngoscopic findings, only one patient presented with progressive swelling of the epiglottis, and there were no cases of persistent swelling. CONCLUSION: The airway intervention threshold should be raised from Friedman stages II-III. And, airway intervention should not be needed if patients are tolerant of their respiratory discomfort.