Veno-venous extracorporeal membrane oxygenation-assisted treatment of severe airway stenosis due to goiter: Two case reports.

RATIONALE: Extracorporeal membrane oxygenation (ECMO) is a critical care intervention that acts as a temporary substitute for the heart and lungs, facilitating adequate tissue perfusion and gas exchange. The 2 primary configurations, veno-arterial and veno-venous ECMO, are tailored to support either the heart and lungs or the lungs alone, respectively. PATIENT CONCERNS: The case report details patients with tumor-induced airway stenosis who encountered limitations with standard treatments, which were either insufficient or carried the risk of severe complications such as hypoxia and asphyxia. DIAGNOSES: Patients were diagnosed with severe airway stenosis caused by goiter, a condition that required innovative treatment approaches to prevent complications during the management process. INTERVENTIONS: Veno-venous ECMO was implemented as a bridging therapy to provide vital respiratory support during the tumor resection procedure. This intervention was crucial in reducing the risks associated with airway edema or tumor rupture. OUTCOMES: With the use of veno-venous ECMO, the patients successfully underwent tumor resection. They were subsequently weaned off the ECMO support, and after a course of treatment, they were discharged in good condition. LESSONS: The case demonstrates the efficacy of veno-venous ECMO as a bridging therapy for managing severe airway stenosis caused by goiter. Its use facilitated the successful resection of tumors and led to positive patient outcomes, highlighting its potential as a valuable treatment option in similar scenarios.

Cardiac arrest with severe airway stenosis due to retropharyngeal haematoma secondary to Stanford type B acute aortic dissection.

This was the case of a male patient in his 60s, who suddenly collapsed. When the ambulance team arrived, the initial waveform was pulseless electrical activity; accordingly, a supraglottic airway device was inserted, and the patient was immediately transported to a referring hospital. On arrival, the patient resumed spontaneous circulation, the patient was diagnosed with Stanford type B acute aortic dissection and was referred to the author's hospital, where diffuse swelling of the anterior cervical region was revealed. CT performed by the previous hospital revealed compression of the trachea. The cause of cardiac arrest was considered to be severe airway stenosis secondary to a retropharyngeal haematoma associated with Stanford type B acute aortic dissection. Stanford type B acute aortic dissection can be complicated by retropharyngeal haematomas, which can lead to airway obstruction and even cardiac arrest. This condition also requires careful airway examination.

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.

Giant laryngeal neuroendocrine neoplasm causing airway obstruction: A case report and literature review.

RATIONALE: Laryngeal neuroendocrine neoplasm (NEN) is a rare and heterogeneous disease that originates from neuroendocrine cells. It mainly occurs in middle-aged and elderly men. Due to the lack of specific clinical and imaging manifestations, diagnosis and treatment of the disease pose a challenge. Therefore, a consensus on the diagnosis and treatment of the disease is necessary. By discussing this case, we will be able to gain further insight into laryngeal NEN and will be able to provide some recommendations for the future management of this rare disease. PATIENT CONCERNS: A 67-year-old man was admitted to our department with a history of sore throat and dyspnea. After admission, the patient experienced acute airway obstruction and experienced an emergency bedside tracheotomy. DIAGNOSES: Flexible fiberoptic laryngoscopy and enhanced CT showed a cauliflower-like mass in the left supraglottic region and obstructed most of the laryngeal cavity. We biopsied the mass, and the pathology showed a poorly differentiated adenocarcinoma. INTERVENTIONS: A horizontal hemilaryngectomy and left neck dissection were performed. At 4 weeks after the operation, the patient underwent chemotherapy and radical radiotherapy. OUTCOMES: After a 1-year postoperative follow-up, the patient recovered well and showed no signs of recurrence. LESSONS: Laryngeal neuroendocrine neoplasm is very rare, early diagnosis remains difficult. Radical surgery combined with postoperative chemoradiotherapy is currently the most appropriate treatment.

EFFECT OF ENLARGED ADENOIDS AND TONSILS ON BLOOD OXYGEN SATURATION IN AL BAHA, SAUDI ARABIA.

INTRODUCTION: The adenoids and palatine tonsils, part of the lymphoid tissue, act as a first line of defense protecting the lower airways and gastrointestinal tract. Adenotonsillar hypertrophy in children may lead to airway obstruction. This study aims to demonstrate the association between adenotonsillar hypertrophy and decreased blood oxygen saturation. METHODS: A retrospective cohort study was conducted among children aged 7-12 years with adenotonsillar hypertrophy and obstructive symptoms, admitted to King Fahad Hospital and Prince Mishari Hospital, Saudi Arabia, for tonsillectomy between July 2023 and January 2024. Exclusion criteria included respiratory diseases, cardiac disease, nasal polyps, nasal septum deviation, chest wall abnormality, and lower airway diseases. The control group included 56 healthy children. An otolaryngologist determined the severity of airway obstruction using the tonsil size. Oxygen saturation was measured using pulse oximetry. The determinants of oxygen saturation were assessed using multiple linear regression, with significance set at p<0.05. RESULTS: The study included 357 participants, with an even age distribution between 7-9 years (49.6%) and 10-12 years (50.4%), and 52% males. Diagnoses included adenoid hypertrophy (30%), tonsil hypertrophy (35%), both conditions (19%), and the control group (16%). Tonsil sizes ranged from Grade 1 (48%) to Grade 4 (8.4%), with 17% normal. The median oxygen saturation was 96.0% for the adenotonsillar hypertrophy group and 99.0% for the control. Oxygen saturation levels differed significantly across groups (p<0.0001), with lower median saturation in hypertrophy groups than controls. Males had a lower oxygen than females (estimate: -0.338, 95% CI [--0.640, -0.036], p=0.028). Adenoid hypertrophy (estimate: -3.863, 95% CI [-5.241, -2.484], p<0.001), tonsil hypertrophy (estimate: -3.631, 95% CI [-5.053, -2.208], p<0.001) and having both conditions (estimate: -3.777, 95% CI [-5.3.7, -2.247], p<0.001) was associated with lower oxygen saturation. Grade 1 tonsil size was associated with an increase in oxygen saturation (estimate = 2.905, 95% CI [1.616, 4.194], p<0.001). In contrast, Grade 4 tonsil size was linked to lower oxygen saturation (estimate=-4.848, 95% CI [-6.367, -3.329], p<0.001). Grades 2 and 3 were not significantly associated with changes in oxygen saturation. CONCLUSION: Adenotonsillar hypertrophy is significantly associated with decreased blood oxygen saturation and related cardiopulmonary complications in children. Early adenotonsillectomy may be of benefit in preventing these complications and improving oxygen saturation levels.

Airway Stents for Excessive Central Airway Collapse: A Randomized Controlled Open-label Trial.

BACKGROUND: Short-term airway stent placement (stent evaluation) has been employed to evaluate whether patients with excessive central airway collapse (ECAC) will benefit from tracheobronchoplasty. Although retrospective studies have explored the impact of stent placement on ECAC, prospective randomized controlled trials are absent. METHODS: This was a randomized open-label trial comparing patients receiving airway stent placement and standard medical treatment (intervention group) versus standard medical treatment alone (control group) for ECAC. At baseline, patients' respiratory symptoms, self-reported measures, and functional capabilities were assessed. Follow-up evaluations occurred 7 to 14 days postintervention, with an option for the control group to crossover to stent placement. Follow-up evaluations were repeated in the crossover patients. RESULTS: The study enrolled 17 patients in the control group [medical management (MM)] and 14 patients in the intervention group. At follow-up, 15 patients in the MM crossed over to the stent group, resulting in a total of 29 patients in the combined stent group (CSG). Subjectively (shortness of breath and cough), 45% of the CSG exhibited improvement with the intervention compared with just 12% in the MM. The modified St. George Respiratory Questionnaire score in the CSG improved significantly from 61.2 at baseline to 52.5 after stent placement (-8.7, P = 0.04). With intervention, the 6-minute walk test in CSG improved significantly from 364 meters to 398 meters (34 m, P < 0.01). The MM did not show a significant change in the St. George Respiratory Questionnaire score or 6-minute walk test distance. CONCLUSION: Short-term airway stent placement in patients with ECAC significantly improves respiratory symptoms, quality of life, and exercise capacity.

Community experience and awareness regarding foreign body aspiration in Asir region, Kingdom of Saudi Arabia.

Foreign body aspiration (FBA) is a serious preventable pediatric health problem and one of the main causes of accidental death in children. Although unusual in adults, it is often overlooked as a cause of airway obstruction with serious consequences. This study assessed awareness and previous FBA experiences in the Asir community, Kingdom of Saudi Arabia. Using validated questionnaire, an annonymous online survey was conducted among 870 people aged 18 years and above. The questionnaire was used to collect data about the personal and sociodemographic characteristics of the respondents, as well as their experiences with FBA, and participants' knowledge and perceived seriousness of FBA. The level of knowledge was deemed good if the score ranged between 60% and 100%, and bad if the score fell below 60%The level of knowledge was deemed good if the score ranged between 60% and 100%, and bad if the score fell below 60%. The majority of the participants (79.7%) were females, 48.1% were aged 18 to 30 years, 72.9% had university degree, 30.6% were students, 26.9% worked in the educational sector, 43.6% reported monthly income of <5000 Saudi Riyals and 19.8% of them identified themselves as healthcarepractitioners. Although the community experience with FBA was considerably high (70.6%) among the study participants, their awareness levels about FBA were deficient. Only 24.7% of the respondents had good knowledge of FBA. Older age, being a health practitioner, and perceiving FBA as a serious incident were significantly associated with good knowledge (P < .001). The findings of this study indicate an urgent need to raise community awareness of FBA. To reduce FBA morbidity and mortality, health education efforts in community and healthcare settings are required to educate people about the seriousness and importance of early diagnosis and management of the condition.

Acute upper airway obstruction caused by mouth floor cellulitis in a patient of advanced age: a case report and literature review.

Mouth floor cellulitis is a type of diffuse cellulitis involving the submandibular, submental, and sublingual spaces. This condition may cause asphyxia due to elevation and posterior deviation of the tissues of the floor of the mouth. The severity of submandibular gland infection often escalates in the presence of underlying comorbidities. Advanced age, hyperglycemia, and an immunocompromised status often lead to the rapid development of infection, resulting in complications such as acute upper airway obstruction. These complications increase treatment difficulty and the risk of mortality. We herein report a case involving an older adult with diabetes who developed mouth floor cellulitis secondary to a submandibular gland infection. Despite the severity of the submandibular gland infection, a timely, effective, and multidisciplinary approach improved the patient's prognosis.

Neural network analysis of pharyngeal sounds can detect obstructive upper respiratory disease in brachycephalic dogs.

Brachycephalic obstructive airway syndrome (BOAS) is a highly prevalent respiratory disease affecting popular short-faced dog breeds such as Pugs and French bulldogs. BOAS causes significant morbidity, leading to poor exercise tolerance, sleep disorders and a shortened lifespan. Despite its severity, the disease is commonly missed by owners or disregarded by veterinary practitioners. A key clinical sign of BOAS is stertor, a low-frequency snoring sound. In recent years, a functional grading scheme has been introduced to semi-objectively grade BOAS based on the presence of stertor and other abnormal signs. However, correctly grading stertor requires significant experience and adding an objective component would aid accuracy and repeatability. This study proposes a recurrent neural network model to automatically detect and grade stertor in laryngeal electronic stethoscope recordings. The model is developed using a novel dataset of 665 labelled recordings taken from 341 dogs with diverse BOAS clinical signs. Evaluated via nested cross validation, the neural network predicts the presence of clinically significant BOAS with an area under the receiving operating characteristic of 0.85, an operating sensitivity of 71% and a specificity of 86%. The algorithm could enable widespread screening for BOAS to be conducted by both owners and veterinarians, improving treatment and breeding decisions.

Usefulness of net retrieval devices for central airway obstruction caused by blood clots during extracorporeal membrane oxygenation: Case series.

RATIONALE: Extracorporeal membrane oxygenation (ECMO) is the last trump card for severe respiratory failure. The main complications of ECMO are bleeding and thrombosis, both of which can be life-threatening. Large blood clots can cause central airway obstruction (CAO) during ECMO, and CAO should be removed as soon as possible because of asphyxiation. However, there is no comprehensive reports on its frequency and management. The purpose of this study is to share therapeutic experiences for rare and serious conditions and provide valuable insights. PATIENT CONCERNS: We report 3 patients placed on ECMO for severe respiratory failure. DIAGNOSIS: CAO due to large blood clots occurred during ECMO in all 3 patients. INTERVENTIONS: Large blood clots were removed using flexible bronchoscopy, grasping forceps, and net retrieval devices in all 3 patients. OUTCOMES: In all 3 patients, large blood clots were removed multiple times during ECMO. The patients' respiratory conditions improved and they were eventually weaned off the ECMO. LESSONS: CAO due to large blood clots during ECMO is rare. The frequency of CAO requiring bronchoscopic removal was estimated to be approximately 1,5%. When this occurs, clots should be removed as soon as possible. Net retrieval devices are useful tools for the collection of large blood clots.

Life-Threatening Tracheal Tube Obstruction by Vernix Caseosa in a Newborn: A Case Report.

Accurate diagnosis and optimal management of sudden intraoperative ventilatory failure is crucial in children. Herein, we report the case of a newborn who underwent pacemaker implantation immediately after birth via cesarean delivery. The vernix caseosa caused a partial tracheal obstruction and was dislodged during tracheal tube suctioning, leading to complete obstruction of the tracheal tube. Diagnosis of tracheal tube obstruction was challenging because the obstruction occurred immediately after airway suctioning, which is performed to rule out tracheal tube obstruction. Anesthesiologists must consider airway obstruction from high-viscosity vernix caseosa as a possibility immediately after airway suctioning in newborns.

Evaluation of brachycephalic obstructive airway syndrome breeding test results in Finland from 2017 to 2022.

BACKGROUND: Brachycephalic obstructive airway syndrome (BOAS), observed in many flat-faced dog breeds, is one of the most urgent welfare problems in pedigree dogs. Various breeding schemes against BOAS have been implemented in many countries during recent years, but their impact on breed health remains unknown. The BOAS breeding test, used by the Finnish Kennel Club (FKC), includes an exercise component with a recovery assessment, BOAS grading by a veterinarian that evaluates upper respiratory signs before and after exercise, and a nostril stenosis assessment. The aim of our study was to evaluate BOAS breeding test results and estimate the heritability of the BOAS grade using parent-offspring regression from FKC data collected during 2017-2022. RESULTS: The majority (80%) of dogs (n = 957) participating in FKC BOAS testing were English Bulldogs, French Bulldogs, and Pugs. In 2022, 89-100% of the litters from these three breeds registered with the FKC had at least one parent tested for BOAS. The proportion of dogs failing the exercise test was highest in English Bulldogs (11%), followed by French Bulldogs (4%) and Pugs (3%). In these three breeds, moderate to severe BOAS signs were reported in 28%, 22% and 30% of dogs, respectively. The proportion of moderate to severe nostril stenosis was highest (71%) in Pugs, followed by French Bulldogs (55%), and English Bulldogs (40%). Estimates of heritability for BOAS grade were separately calculated for these three breeds and for all dogs, and the estimates were moderate to high, ranging from 0.39 to 0.58. CONCLUSIONS: The exercise test alone did not sufficiently identify dogs with moderate to severe BOAS signs. To better consider the complex nature of BOAS and breed differences, exercise tolerance, the severity of upper respiratory signs (BOAS grade) and nostril stenosis should all be assessed together in breeding animals. The heritability estimates for veterinary-assessed BOAS grade indicated that BOAS grade could be used in selective breeding to obtain less-affected offspring.

Novel approach for tracheal resection in Morquio a syndrome with end-stage critical airway obstruction: a UK case series.

BACKGROUND: Mucopolysaccharidosis (MPS) type IVA is a rare lysosomal storage disorder caused by aberrations of the N-acetyl-galactosamine-6-sulfatase (GALNS) enzyme. MPS IVA is associated with a wide gamut of respiratory and airway disorders that manifest in a continuum of severity. In individuals exhibiting severe phenotypic expression, terminal stages of the disease frequently culminate in life-threatening, critical airway obstruction. These manifestations of end-stage disease are engendered by an insidious progression of multi-level airway pathologies, comprising of tracheomalacia, stenosis, tortuosity and 'buckling'. Historically, the management of end-stage airway disease has predominantly leaned towards palliative modalities. However, contemporary literature has posited that the potential benefits of tracheal resection with aortopexy, performed under cardiopulmonary bypass (CPB), may offer a promising therapeutic option. In this context, we report on outcomes from patients undergoing a novel approach to tracheal resection that is combined with manubrial resection, leading to improved airway calibre, obviating the requisition for CPB. RESULTS: In this study, seven patients with severe MPS IVA exhibited clinical symptoms and radiological evidence indicative of advanced airway obstruction. All patients had a tracheal resection with a partial upper manubriectomy via transcervical approach, which did not require CPB. The surgical cohort consisted of 5 females and 2 males, the median age was 16 years (range 11-19) and the median height was 105.6cm (range 96.4-113.4). Postoperatively, significant improvements were seen in forced expiratory volume in 1 second (FEV1), with a mean increase of 0.68 litres (95% CI: 0.45-0.91; SD: 0.20). Notably, other spirometry variables also showed meaningful improvements, providing evidence of positive treatment effects. Furthermore, there were no major long-term complications, and the procedure resulted in a significant enhancement in patient-reported domains using PedsQL (version 4.0). CONCLUSIONS: This study represents the largest case series to date, on tracheal resection in patients with severe MPS IVA. Our findings demonstrate the effectiveness of the transcervical approach with partial manubriectomy for improving respiratory function and quality of life for individuals with advanced airway obstruction. Tracheal resection presents a promising treatment modality for severe cases of MPS IVA. Successful outcomes rely on meticulous multidisciplinary assessment, judicious decision-making, and appropriate timing of tracheal surgery. Further research and long-term follow-up studies are warranted to validate the long-term efficacy and safety of this approach.

Long-awaited evidence on back blows versus abdominal thrusts.

This is a commentary on the study conducted by Dunne et al. from Alberta, Canada, which retrospectively analyzed data from patients with foreign body airway obstruction (FBAO) in the region. By linking the region's prehospital data with hospital data, the authors were able to report not only the FBAO relief of each intervention, but also patient survival outcomes and complications associated with the interventions. By analyzing the 709 patient encounters that received BLS interventions from bystanders, paramedics, or both, and adjusting for potential confounders, the study showed that abdominal thrusts and chest compressions were associated with decreased odds of FBAO relief compared to back blows as the first intervention. The commentary summarizes the study findings and discusses the importance of the study in the context of FBAO research, which has been choked for too many years.

Perioperative Management of Massive Anterior Encephalocele in a Newborn: A Case Report.

Anterior encephaloceles are rare neural tube defects posing anesthetic challenges. While anterior encephaloceles can cause airway obstruction at birth, this presentation is very rare and to our knowledge not reported in the literature. This case report describes a 34 weeks +0 days gestation, 2.6 kg, newborn with a massive nasoethmoidal anterior encephalocele creating significant external airway obstruction, necessitating emergent and thoughtful airway management and anesthetic care. Our most important perioperative considerations for this newborn included spontaneous ventilation using awake fiberoptic bronchoscopic intubation with lidocaine airway topicalization, secure endotracheal tube attachment, and avoiding noninvasive positive airway pressure postoperatively to avoid pneumocephalus.

Patient perceptions of the impact of inducible laryngeal obstruction on quality of life.

BACKGROUND: Inducible laryngeal obstruction (ILO) accounts for or contributes to dyspnea in a noteworthy proportion of treatment seeking populations including those misdiagnosed with asthma. Despite increasing awareness of the disorder, literature exploring patient experience is limited. The aim of this work is to report patient perspectives on ILO and the way in which it impacts quality of life. METHODS: This qualitative study utilized methods detailed in the literature on grounded theory and phenomenological research to analyze interviews collected from participants diagnosed with ILO. Interviews were conducted, audio recorded, and transcribed. Transcriptions underwent content-analysis using Burnard's 14 step method [15], which included review of content codes across multiple raters until consensus regarding analyses was reached. RESULTS: Twenty-six participants were included in the study. Most participants were female (92%). Ages ranged from 18-72 with a mean age of 45 for female participants and 37 for male participants. Without specific prompting to do so, all participants offered descriptions of the specific symptoms they experienced and the triggers for their symptoms. In the content analysis process, "descriptions of symptoms and triggers" was thus labeled a theme that was present in all interviews. Seven additional themes were shared consistently and judged to encapsulate the interview material. These themes were: 2) diagnosis and treatment, 3) emotional impact of ILO, 4) perception of health and prognosis, 5) ameliorating factors, 6) influence of ILO on lifestyle, 7) the physical impact of ILO, and 8), social consequences of ILO. In addition, 54 subthemes were identified. CONCLUSIONS: Patients appear to place particular emphasis on the emotional and psychosocial consequences of ILO as well as factors that ameliorate the condition. As such, future efforts to treat ILO and to collect outcomes measures should account for these aspects of the patient experience.