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At least 991 records · Page 55Linked to original sources
PubMed1987

Percutaneous transtracheal ventilation for laser endoscopic procedures in infants and small children with laryngeal obstruction: report of two cases.

The case reports of two children with obstructive lesions of the larynx are presented to illustrate the advantages of transtracheal ventilation for paediatric endoscopic laser surgery. The first patient was a four-month-old infant with inspiratory stridor due to a subglottic haemangioma obstructing 80 per cent of the lumen. The second patient was a five-year-old child with posterior synechiae of the larynx. The anaesthetic and ventilation techniques were the same for both cases. A transtracheal catheter was introduced percutaneously into the trachea under endoscopic control and connected to a high frequency jet ventilator. The advantages of this technique during laser surgery are: clear vision of the operative field, good gas exchange, elimination of airway trauma from intubation, reduction of the hazard of airway fires, and decreased risk of aspiration of blood and debris. In addition, this method of providing oxygen and/or mechanical ventilation may be extended into the postoperative period. In certain situations, this technique can be an attractive alternative to a tracheostomy with its potentially dangerous and incapacitating complications in infants and small children.

Airway Obstruction↗
PubMed1987

General anaesthetic management for laser resection of central airway lesions in 85 procedures.

The perioperative course of 41 patients undergoing 85 endoscopic laser resections of central airway lesions under general anaesthesia was reviewed. The CO2 laser was used in 60 procedures and the Nd:YAG in 25. Intravenous anaesthesia and Venturi ventilation were utilized for 65 resections; 20 procedures involved predominantly inhalation anaesthesia via the ventilating bronchoscope. Significant intraoperative complications included arterial desaturation (SaO2 less than 90 per cent) in 26 per cent of procedures, and refractory hypertension requiring vasodilator therapy in 19 per cent. Intravenous anaesthesia was associated with a longer duration of recovery room care and a higher incidence of postoperative respiratory complications (delayed extubation, recovery room re-intubation and ventilation, and post-extubation stridor). Inhalation anaesthesia appeared to simplify the intraoperative management and decrease the incidence, duration and severity of immediate postoperative respiratory complications.

Adult↗
PubMed1985

Intraoperative aspiration in a paediatric patient.

Aspiration around uncuffed endotracheal tubes in paediatric patients is an uncommon event. Uncuffed endotracheal tubes are commonly used in paediatrics even when the risk of gastric aspiration is significant. A case history is presented of an 81/2-year-old who aspirated during a laparotomy for bowel obstruction. The patient was intubated with an uncuffed #6.0 Portex endotracheal tube. A small leak was noted during positive pressure ventilation. The aspiration was significant such that the patient required 24 hours of positive end-expiratory pressure (PEEP) in an intensive care unit. Uncuffed endotracheal tubes are used because post-intubation stridor is minimized, the lungs are compliant and the funnel-shaped trachea is more likely to secure the airway from aspiration. An uncuffed tube however, does not completely seal the airway, particularly in the presence of an audible "leak." As a result of this case, we now consider the use of a cuffed endotracheal tube in children whenever a 5.5 internal diameter or larger is required. When the risk of pulmonary aspiration is present, the cuff is inflated to reduce the likelihood of contamination of the airway.

Airway Obstruction↗
PubMed1996

Respiratory depression after low-dose caudal morphine.

PURPOSE: To report a case of respiratory depression after a small dose of caudal morphine administered to a 15-mo-old child. CLINICAL FEATURES: A 15 mo, 9.8 kg boy underwent ureteral reimplantation with general endotracheal anaesthesia and 10 ml bupivacaine 0.25% (2.5 mg.kg-1). Ninety minutes after the bupivacaine, 0.4 mg (1 mg.ml-1, 0.4 ml, 0.04 mg.kg-1) preservative-free morphine was injected after negative aspiration. Slightly more than two hours after caudal morphine, the patient became lethargic and developed decreases in oxygen saturation (to 62%) without change in heart rate or respiratory rate. Intravenous naloxone 0.1 mg (0.01 mg.kg-1) markedly improved his level of consciousness. Racemic epinephrine was administered for treatment of coincident stridor. The patient required 11 hr continuous naloxone infusion (0.001-0.002 mg.kg-1.hr-1) in the intensive care unit. He was discharged on the second postopertive day without further complication. CONCLUSION: Respiratory depression can occur in children greater than one year of age, even when small doses of caudal morphine are used. Decreased arterial oxygen saturation and lethargy are important heralds. A normal respiratory rate despite substantial hypoxaemia argues that pulse oximetry (without supplemental oxygen where possible) has a clear advantage over impedance pneumography for electronic monitoring.

Analgesics, Opioid↗
PubMed1996

Bronchoscopic findings in post-obstructive pulmonary oedema.

PURPOSE: To present the first photographed bronchoscopic findings associated with negative pressure pulmonary oedema (NPPE). CLINICAL FEATURES: A previously healthy patient underwent anterior C3-C4 disc removal and arthrodesis. Following tracheal extubation he developed acute respiratory distress manifested as stridor, tachypnoea, restlessness, and desaturation. Once the trachea was reintubated, he displayed the classic findings of pulmonary oedema. Bronchoscopy was performed to confirm tracheal tube position and to rule out tracheal injury secondary to surgical manipulation. Diffuse punctate haemorrhages were noted throughout the visualised tracheobronchial tree. CONCLUSION: We believe that these haemorrhages represent disruption of the bronchial vasculature and may contribute to the clinical presentation of NPPE.

Acute Disease↗
PubMed1996

Excision of bronchogenic cysts in children using an ultrathin fibreoptic bronchoscope.

PURPOSE: We report the use of an ultrathin fibreoptic bronchoscope (Olympus N20: external diameter: 2.2 mm) as the means of airway endoscopic monitoring during anaesthesia for the excision of mediastinal bronchogenic cysts in two young children. CLINICAL FEATURES: The first, a four-month old boy, presented with stridor and wheezing due to a subcarinal bronchogenic cyst compressing the two main bronchi. The second, an eight-day-old girl whose trachea was intubated, presented with respiratory noise in relation to a bronchogenic cyst compressing the end of the trachea. In both cases, airway endoscopy was performed during anaesthesia with the ultra thin fibreoptic bronchoscope. Endoscopic monitoring allowed, first, a good evaluation of the degree of cyst compression on the airways. Second, the endotracheal tube could be positioned or repositioned with precision in order to avoid severe compression or spilling of liquid into the airways and to allow protection of the suture. Finally, video transmission helped the surgeon to visualize the surgical repair from the inside. CONCLUSION: When added to the classical monitoring using SpO2, PETCO2 and airway pressure, peroperative endoscopic control provides complementary information which can help to detect possible complications more rapidly. This technique could be extended to all airway surgery on very young children.

Bronchogenic Cyst↗
PubMed2004

Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway.

PURPOSE: To report a case of complete upper airway obstruction after topicalization with lidocaine in a completely conscious patient with partial upper airway obstruction. CLINICAL FEATURES: A 69-yr-old man with a history of neck cancer and radiation presented for resection of recurrent neck tumour. No preoperative sedation was given. He had inspiratory and expiratory stridor but had no history of aspiration or swallowing problem. Phonation was distorted but effective. The surgeon was reluctant to perform an awake tracheostomy under local anesthesia. In preparation for a fibrescope-assisted orotracheal intubation, the non-sedated patient was given topical upper airway lidocaine during which he developed total airway obstruction and hypoxemia. He was immediately intubated with a fibrescope. His vocal cords were not edematous although the supraglottic structures appeared to be. The vocal cords were abducted and their movement was limited and not paradoxical. Tumour resection was uneventful upon successful tracheal intubation and general anesthesia. Tracheostomy at the end of the case was difficult, as expected. The patient tolerated the procedures and regained consciousness with no neurologic sequelae. CONCLUSION: Dynamic airflow limitation associated with local anesthesia of the upper airway may lead to complete upper airway obstruction in a compromised airway. The main cause may be the loss of upper airway muscle tone, exacerbated by deep inspiration during panic.

Aged↗
PubMed2004

Laryngeal damage due to an unexpectedly large and inappropriately designed cuffed pediatric tracheal tube in a 13-month-old child.

PURPOSE: To present a case of laryngeal damage in an infant caused by a too large and inappropriately designed cuffed tracheal tube. CLINICAL FEATURES: A 13-month-old child undergoing cardiac surgery was intubated with an uncuffed endotracheal tube with an internal diameter (ID) of 4.0 mm. Because of an important air leak around the tracheal tube during mechanical ventilation, a cuffed endotracheal tube ID 4.0 mm was inserted. The air leak with the tube cuff not inflated was acceptable at 25 cm H2O airway pressure. After extubation on the third postoperative day, the patient showed increasing stridor and respiratory deterioration. Fibreoptic laryngoscopy of the spontaneously breathing patient showed a large intra-laryngeal web. After surgical removal of the web, the child rapidly recovered and was discharged from the hospital on the 12th postoperative day. Inspection of the 4.0 mm (ID) cuffed tracheal tube revealed a cuff positioned inappropriately high and an increase of 0.7 mm in outer tube diameter compared to the 4.0 mm (ID) uncuffed tracheal tube from the same manufacturer. The tube cuff is likely to be situated within the larynx when placed in accordance to insertion depth formulas or radiological criteria, as used for uncuffed tracheal tubes in children. CONCLUSION: The larger than expected tracheal tube with its intra-laryngeal cuff position in a 13-month-old child likely caused mucosal damage and an inflammatory reaction within the larynx resulting in granulation tissue formation and fibrous healing around the tracheal tube.

Anesthesia, General↗
PubMed2003

Acute upper airway angioedema secondary to acquired C1 esterase inhibitor deficiency: a case report.

PURPOSE: Adverse reactions to local anesthetics are widely reported. We report a case of acute upper airway angioedema presumed to be due to the local anesthetic articaine, which was subsequently diagnosed as acquired C1 esterase inhibitor deficiency. CLINICAL FEATURES: A 54-yr-old woman presented with a history of progressive facial and periorbital edema 24 hr after receiving articaine local anesthetic for a dental procedure. She was in mild respiratory distress but was not stridorous. After inhalational induction with sevoflurane in the operating room, direct laryngoscopy revealed marked edema of supraglottic structures including epiglottis, uvula and aryepiglottic folds and the larynx was not visualized. The patient's trachea was intubated under direct laryngoscopy. Seventy-two hours later, the endotracheal tube was removed and she made an uneventful recovery. Initially, the angioedema was thought to be caused by a hypersensitivity reaction to articaine. Later investigations showed normal C3 complement level, very low C4 complement and C1 esterase inhibitor levels confirming a diagnosis of C1 esterase inhibitor deficiency. Subsequently, the patient was started on androgen therapy. Her C1 esterase inhibitor level normalized and she remained symptom free nine months after initial presentation. CONCLUSION: We report a case of acute upper airway angioedema secondary to C1 esterase inhibitor deficiency requiring emergency airway management. Anesthesiologists should consider C1 esterase inhibitor deficiency in the differential diagnosis of patients with airway edema and be familiar with the acute and prophylactic treatment of patients with this diagnosis.

Acute Disease↗
PubMed2006

Upper airway compromise secondary to edema in Graves' disease.

PURPOSE: We report an unusual case of upper airway compromise in a patient with Graves' disease. We speculate that this complication may be due, in part, to poorly controlled hyperthyroidism. CLINICAL FEATURES: A 26-yr-old female suffering from Graves' disease underwent a total thyroidectomy. Awake fibreoptic intubation was attempted because of a large goiter and orthopnea. Upper airway edema impeded the passage of an armored 7.5 mm endotracheal tube. She was subsequently intubated awake with a regular 7.5 mm endotracheal tube under direct laryngoscopy over an Eschmann bougie. The patient was extubated in the operating room over a tube exchanger. Two hours later she developed stridor and upper airway obstruction. Using direct laryngoscopy, she was reintubated with difficulty because of upper airway edema. At this time, she manifested signs of thyrotoxicosis which were managed medically. On postoperative day three she underwent a tracheostomy after failing a trial of extubation. The upper airway was edematous with minimal vocal cord movement. On postoperative day nine the tracheostomy was downsized and the patient was sent home. The vocal cords were still edematous with minimal movement. Three weeks later, she demonstrated normal right vocal cord movement and weak left vocal cord movement, and the tracheostomy was decannulated. CONCLUSIONS: Uncontrolled hyperthyroid patients with large goiters secondary to Graves' disease may develop edema of the upper airway. A high degree of vigilance for airway obstruction is necessary, with a carefully planned approach at each stage of the patient's hospital course to treat this potentially life-threatening situation.

Adult↗
PubMed2006

Postoperative tracheal rupture in a patient with a difficult airway.

PURPOSE: Tracheal rupture is an uncommon and potentially life-threatening event. This report presents a case of postoperative tracheal rupture in a patient with a known difficult airway presenting to a rural hospital. CLINICAL FEATURES: A 29-yr-old man presented to a rural hospital with sudden onset neck pain and progressive dyspnea. Five days earlier the patient had undergone tracheal resection for tracheal stenosis related to prolonged intubation. The patient informed the emergency room staff that the attending anesthesiologist had made note of a "difficult airway". The community hospital had neither a portable storage unit for difficult airway management nor a bronchoscope available. In the presence of a general surgeon, an initial attempt at an awake intubation was unsuccessful. During this time the patient developed massive subcutaneous emphysema obliterating surgical landmarks and causing stridor. A modified rapid sequence intubation was performed. Intubation was successful using a Jackson-Wisconsin #3 straight blade and styletted endotracheal tube. The patient was transferred to a tertiary care centre where he underwent a primary repair of the trachea. CONCLUSION: Management of tracheal rupture in the patient with a difficult airway is a challenging problem, especially, in a rural hospital. This case highlights the need for skilled staff and resources to manage a difficult airway in the emergency room.

Adult↗
PubMed2006

Laryngeal edema associated with the ProSeal laryngeal mask airway in upper respiratory tract infection.

PURPOSE: We report an unusual case of vocal cord edema associated with the use of a ProSeal laryngeal mask airway (PLMA) in an adult patient with an undiagnosed upper respiratory tract infection (URTI). CLINICAL FEATURES: A 55-yr-old woman had fixation of a radial fracture under general anesthesia with muscle relaxation. She developed audible wheezing 30 min after PLMA insertion. Bronchoscopic examination revealed significant vocal cord edema. Adequate ventilation was possible at increased airway pressures, and the administration of dexamethasone 4 mg iv produced clinical resolution of the stridor and airway obstruction. The patient admitted to having mild symptoms of an URTI on postoperative questioning. CONCLUSION: Airway hyperreactivity secondary to the URTI is the most likely etiological factor; other possibilities include trauma from insertion and chemical irritation. Although pediatric studies suggest that the LMA-Classic carries less risk than endotracheal intubation in the presence of URTI, this case report demonstrates that caution is still warranted when using supraglottic airways. The PLMA permitted effective ventilation despite increased airway resistance; nevertheless its role in patients with URTI is unclear. It is possible that the bulkier cuff design of the PLMA, compared to that of the LMA-Classic, may have partly contributed to the development of edema in this setting.

Anti-Inflammatory Agents↗
PubMed1998

[Pulmonary artery sling with tracheal stenosis--primary repair in infancy].

Between 1984 and 1996 five infants underwent surgical repair of pulmonary artery sling associated with severe congenital tracheal stenosis. All infants had symptoms of severe respiratory distress and three of them required ventilator support preoperatively ages ranged from 2 to 11 months (mean age 6 months). Complete tracheal rings were present in all patients as an associated lesion and right upper lobe tracheal bronchus in 3 patients. The length of tracheal stenosis ranged from 18 to 45 mm (median 40 mm). Three had associated intracardiac anomalies (Scimitar syndrome (1), VSD (1), double-outlet right ventricle with VSD (1), double-outlet right ventricle with pulmonary hypertension (1)). Surgical intervention was carried out through a right thoracotomy (1) or median sternotomy (4). Cardiopulmonary bypass (CPB) was used in 3 patients and extracorporeal membrane oxgenator (ECMO). In 1. All infants had reimplantation of the left pulmonary artery into the main pulmonary artery left anterior to the trachea. Four patients underwent simultaneous tracheoplasty using costal cartilage grafts and one had complete resection of obstructed trachea between the right upper lobe tracheal bronchus and carina. The length of resected trachea was about 30% of the entire length of the trachea. Three infants underwent simultaneous intracardiac repair. There was no hospital death. All were weaned from ventilatory support and extubated on 1 to 16 months (mean 4, 5 months) postoperatively. AS an additional procedure, aortopexy, removal of granulation tissue or balloon dilatation of the trachea were carried out in one patient each following tracheoplasty using cartilage grafts. There was one late death at 1 year postoperatively. Three of 4 survivors are doing well with no stridor. We adonostridor. We adovocate 1) early aggressive primary repair of pulmonary artery sling with tracheal stenosis, 2) concomitant repair of tracheal lesion and intracardiac anomalies whenever possible, 3) application of CPB or ECMO to avoid cumbersome intubation technique, and 4) utmost effort to perform tracheal resection and end-to-end anastomosis.

Anastomosis, Surgical↗
PubMed2000

Early small cell lung cancer with extensive inflammation and scar formation.

A 56-year-old man, at one year before his first visit to our hospital, had presented cough, stridor and chest pain, and expectorated a mass, resulting in prompt disappearance of the symptoms. He was afflicted with recurrent symptoms, and the bronchoscopy showed a polypoid tumor occluding the right lower bronchus. The tumor was resected via bronchoscopy, which revealed histologically small cell carcinoma with significant inflammation and scar formation. The tumor was macroscopically the same as the one that had been expectorated by the patient at one year previously. A right lower lobectomy was conducted, but the specimen demonstrated no residual tumor. Tumor invasion into the bronchial wall was therefore limited within the submucosal layer for more than a year. Finally, the present tumor was diagnosed as an early small cell lung cancer with a characteristic of self involution. With no adjuvant treatment, the patient is well without tumor recurrence at 3 years to date after the surgery.

Bronchoscopy↗
PubMed2001

Extensive sterile abscess in an invasive fibrous thyroiditis (Riedel's thyroiditis) caused by an occlusive vasculitis.

Riedel's thyroiditis is a rare disease determined by an invasive fibrosclerotic transformation of the thyroid gland. It may be one manifestation of multifocal fibrosis with still unknown etiology. Because it mimics carcinoma, a biopsy must be performed to get the correct diagnosis. The condition is self-limiting when confined to the neck. Prognosis depends on the extent of extracervical fibrosclerosis. We present a patient with a huge cervical and mediastinal, unilateral thyroid mass expanding to the aortic curve, which led to tracheal deviation and compression with symptoms of stridor and dyspnea. These symptoms continued under a course of high-dose steroids; thus an operation was necessary to relieve the airway obstruction and limit inflammation. Intraoperative and pathological findings showed an inflammatory infiltration of the adjacent neck muscles and a sterile abscess caused by an occlusive vasculitis. Therefore, hemithyroidectomy had to be performed instead of a local limited resection.

Abscess↗
PubMed2002

[Anaesthetic management for endoscopy of the pediatric airway].

We have developed a modern strategy for the anaesthetic management of the pediatric airway using anaesthetic drugs such as sevoflurane, propofol, mivacurium and remifentanil, together with new techniques including the laryngeal mask. This strategy provides optimal conditions for the examiner and maximum safety for the pediatric patient. The endoscopic investigation of pediatric airways has become important for the diagnosis and treatment of many pediatric diseases, and is often performed with the support of a pediatric anaesthetist. Important indications include acute and chronic stridor, chronic obstructive airway disease, mucoviscidosis and foreign body aspiration. The best and safest techniques are outlined depending on the clinical situation, and the most frequent complications are discussed, e.g. hypoxaemia, respiratory arrest, laryngospasm, bronchial obstruction, pneumothorax and overdosing of local anaesthetic agents.

Anesthesia, Inhalation↗
PubMed1995

[Life-threatening postoperative angioedema following treatment with an angiotensin converting enzyme inhibitor].

Angio-oedema is a recognised complication of angiotensin converting enzyme (ACE) inhibitor therapy, occurring in 0.1% to 0.5% of patients taking captopril, enalapril, or lisinopril. This is the first report of severe angio-oedema complicating therapy with quinapril, a new, long-acting drug. CASE REPORT. A 74-year-old female had been taking quinapril (10 mg/day) and diuretics (fixed combination of triamterene and hydrochlorothiazide) for arterial hypertension for 18 months without any complication. After a fracture of the ankle, the patient received spinal anaesthesia uneventfully for an osteosynthesis. Ten days postoperatively, she noted swelling of the lips and the left half of the tongue. Following intravenous injection of antihistamines and prednisolone, these symptoms regressed. However, a relapse occurred on the 16th postoperative day with rapidly increasing oedema of the lips, face, ventral collar area, and entire tongue. Despite high-dose steroids, dyspnoea developed within 2 h. Direct laryngoscopy was impossible, and a flexible bronchoscope was used for nasotracheal intubation. At this point, the diagnosis of ACE inhibitor-induced angio-oedema was made and quinapril was withdrawn. The patient recovered, tracheal extubation was performed after 48 h, and the later course was uneventful. DISCUSSION. This is the second report of angio-oedema as a postoperative complication in a patient on long-term and previously unremarkable ACE inhibitor therapy. The first reported case occurred immediately after oral intubation and was perhaps precipitated by mechanical irritation. In this case, it is likely that postoperative deterioration of renal function due to dehydration and diuretic therapy was the precipitant, as has been reported in patients on lisinopril without surgery. Despite a significant increase in angio-oedema associated with the use of long-acting ACE-inhibitors, there appears to be a lack of familiarity among anaesthesiologist and other emergency physicians concerning this adverse effect. Withdrawal of the drug is the only effective treatment. High-dose steroids may be helpful, but if there is beginning dyspnoea or stridor, early endoscopically controlled intubation or emergency tracheostomy is essential to avoid hypoxaemia and death, as has occurred in the past.

Aged↗
PubMed2000

[Symptomatic struma intratrachealis, a differential diagnostic challenge].

The intratracheal goiter is a rare, benign disease accompanied by dyspnoea, stridor, and cough. The specific symptom within the non-specific symptoms is the rapid therapy-resistant progression that can be fatal if it is unrecognized and not treated. Observation of an intratracheal tumor leads to a series of further differential diagnostic considerations with the most important question--malignant or benign--which needs to be clarified. The type of tissue can be determined by means of a biopsy. Classification of the grade of the tissue is not possible in every case and always depends on the method used. This is especially true in the case of highly differentiated tumors as they appear on the thyroid. We introduce a 67-year-old female patient whose case history and results can be described as classic in comparison to the literature and who showed all the clinical and morphological characteristics of intratracheal goiter. We refer to the two most possible theories concerning the etiology. Extirpation of the tumor with or without a temporary tracheostomy is the suitable therapy for adults to achieve functionally indisputable results without recurrence. Knowledge about these rare intratracheal tumors can help avoid a generous resection with high risks or even foreseeable consequences.

Aged↗