A prospective study to evaluate and compare laryngeal mask airway ProSeal and i-gel airway in the prone position.

PubMed

Taxak, Susheela; Gopinath, Ajith; Saini, Savita; Bansal, Teena; Ahlawat, Mangal Singh; Bala, Manju

2015-01-01

Prone position is commonly used to provide surgical access to a variety of surgeries. In view of the advantages of induction of anesthesia in the prone position, we conducted a randomized study to evaluate and compare ProSeal laryngeal mask airway (LMA) and i-gel in the prone position. Totally, 40 patients of either sex as per American Society of Anesthesiologists physical status I or II, between 16 and 60 years of age, scheduled to undergo surgery in prone position were included in the study. After the patients positioned themselves prone on the operating table, anesthesia was induced by the standard technique. LMA ProSeal was used as an airway conduit in group 1 while i-gel was used in group 2. At the end of surgery, the airway device was removed in the same position. Insertion of airway device was successful in first attempt in 16, and 17 cases in ProSeal laryngeal mask airway (PLMA) and i-gel groups, respectively. A second attempt was required to secure the airway in 4 and 3 patients in PLMA and i-gel groups, respectively. The mean insertion time was 21.8 ± 2.70 s for group 1 and 13.1 ± 2.24 s for group 2, the difference being statistically significant (P < 0.05). The mean seal pressure in group 1 was 36 ± 6.22 cm H2 O and in group 2 was 25.4 ± 3.21 cm H2 O. The difference was statistically significant (P < 0.05). 13 patients in group 1 had fiberoptic bronchoscopy (FOB) grade 1 while it was 6 for group 2. The remaining patients in both groups had FOB grade 2. Insertion of supraglottic airways and conduct of anesthesia with them is feasible in the prone position. The PLMA has a better seal while insertion is easier with i-gel.

Eschmann introducer through laryngeal mask airway: a cadaveric trial of an alternate means of rescue intubation.

PubMed

Miller, Joel A; Levsky, Marc E; Givens, Melissa L; Miller, Michael A

2010-02-01

Laryngeal mask airways (LMAs) are often used as airway rescue devices where laryngoscopy is difficult. The LMA does not protect the airway and is preferably replaced with a cuffed endotracheal tube. There are reports of cases where an Eschmann tracheal tube introducer (ETTI) was successfully used to bridge between a standard LMA and an endotracheal tube. This project was designed to determine whether an Eschmann stylet can reliably be passed through an LMA into the trachea as a means of rescue intubation. Nineteen emergency medicine residents and attending physicians, who were participants in a cadaveric airway course, placed and inflated a size 4 LMA (The Laryngeal Mask Company Ltd., San Diego, CA) on each of six unembalmed human cadavers in the usual fashion. They then attempted to pass a lubricated, 15 Fr, reusable, coude-tipped ETTI (Portex, Smiths Medical, Keene, NH)) through the airspace/handle of the inflated LMA. The LMA was then deflated and removed while the ETTI was held in place. Investigators then determined the location of the ETTI by laryngoscopy. Of 114 attempts at the rescue procedure, 59 resulted in placement of the bougie into the trachea, yielding an overall success rate of 52% (95% CI 48%-56%). There were no significant differences in performance based on level of training of residents or years of experience of attending physicians. While not a primary difficult airway option, the use of a ETTI as a bridge device between LMA and endotracheal tube was successful about 50% of the time.

A randomized non-crossover study comparing the ProSeal and Classic laryngeal mask airway in anaesthetized children.

PubMed

Lopez-Gil, M; Brimacombe, J; Garcia, G

2005-12-01

We tested the hypothesis that ease of insertion, oropharyngeal leak pressure, fibreoptic position, gastric insufflation, and the frequency of mucosal trauma differ between the ProSeal laryngeal mask airway (PLMA) and the classic laryngeal mask airway (cLMA) in anaesthetized children. For the PLMA, we also assessed the ease of gastric tube placement via the PLMA drain tube and measure residual gastric volume. 240 consecutive ASA I-III children aged 1-16 yr were randomized for airway management with the ProSeal or cLMA. The time taken to provide an effective airway, the number of insertion attempts, fibreoptic position of the airway tube and frequency of mucosal trauma were similar, but oropharyngeal leak pressure was higher (33 vs 26 cm H(2)O, P<0.0001) and gastric insufflation less common (0 vs 6%, P<0.01) for the PLMA. Gastric tube insertion was successful at the first attempt in 106 of 120, and at the second attempt in 14 of 120. The mean (sd; range) value for residual gastric volume was 2.2 (5.9; 0-30) ml. There were no differences in performance among sizes for the PLMA and the cLMA. We conclude that ease of insertion, fibreoptic position, and frequency of mucosal trauma are similar for the PLMA and cLMA in children, but oropharyngeal leak pressure is higher and gastric insufflation less common for the PLMA. Gastric tube insertion has a high success rate, provided the PLMA is correctly positioned.

Use of a laryngeal mask airway in a brachycephalic dog with masticatory myositis and trismus

PubMed Central

Reed, Frances; Iff, Isabelle

2012-01-01

An 8-month old, male, neutered bulldog was presented for investigation of a 2-day history of trismus. Endotracheal intubation was impossible as the dog was only able to open his mouth approximately 2 cm. A laryngeal mask airway was blindly inserted after induction of general anesthesia to maintain the patient on inhalational anesthesia and improve respiration for computed tomography and muscle biopsy. The dog recovered from anesthesia uneventfully. PMID:22942446

[Difficult Ventilation Requiring Emergency Endotracheal Intubation during Awake Craniotomy Managed by Laryngeal Mask Airway].

PubMed

Matsuda, Asako; Mizota, Toshiyuki; Tanaka, Tomoharu; Segawa, Hajime; Fukuda, Kazuhiko

2016-04-01

We report a case of difficult ventilation requiring emergency endotracheal intubation during awake craniotomy managed by laryngeal mask airway (LMA). A 45-year-old woman was scheduled to receive awake craniotomy for brain tumor in the frontal lobe. After anesthetic induction, airway was secured using ProSeal LMA and patient was mechanically ventilated in pressure-control mode. Patient's head was fixed with head-pins at anteflex position, and the operation started. About one hour after the start of the operation, tidal volume suddenly decreased. We immediately started manual ventilation, but the airway resistance was extremely high and we could not adequately ventilate the patient. We administered muscle relaxant for suspected laryngospasm, but ventilatory status did not improve; so we decided to conduct emergency endotracheal intubation. We tried to intubate using Airwayscope or LMA-Fastrach, but they were not effective in our case. Finally trachea was intubated using transnasal fiberoptic bronchoscopy. We discuss airway management during awake craniotomy, focusing on emergency endotracheal intubation during surgery.

Anesthetic Management by Laryngeal Mask Airway in a Patient With a History of Difficult Intubation Resulting in Dental Injuries

PubMed Central

Asahi, Yoshinao; Fujii, Ryosuke; Usui, Naoko; Kagamiuchi, Hajime; Omichi, Shiro; Kotani, Junichiro

2015-01-01

Disabled patients may face respiratory problems during general anesthesia because of head and neck anomalies. We describe a case of dental treatment under general anesthesia using a laryngeal mask airway in a disabled patient who faced difficulty in endotracheal intubation on several occasions, 5 of which resulted in dental injuries. PMID:25849470

The relationship of placement accuracy and insertion times for the laryngeal mask airway to the training of inexperienced dental students.

PubMed

Morse, Zac; Sano, Kimito; Kageyama, Ikuo; Kanri, Tomio

2002-01-01

Any health care professional can be faced with a medical emergency in which the patient needs ventilatory support. Bag-valve-mask ventilation with the assistance of an oropharyngeal airway that uses 100% oxygen is currently the preferred method for artificial ventilation. This procedure is generally performed ineffectively by most dentists inexperienced in airway management. We examined whether a short and simple period of training by dental students inexperienced in airway management would increase the speed and accuracy of the placement of the laryngeal mask airway (LMA), which may be a superior airway device to the bag-valve-mask and oropharyngeal airway. Thirty-five dental students inexperienced in airway management were divided into 3 groups. The first group received only a demonstration on how to use the LMA. The second and third groups received the demonstration plus practiced inserting the LMA 5 and 10 times, respectively. A dental anesthesiologist graded the placement of the LMA with a tracheobroncho-fiberscope (fiberoptic bronchoscope). Those who practiced inserting the LMA 5 times faired better than those who received no training; however, those who practiced 10 times did not do any better than the second group. The LMA can be inserted rapidly and effectively by dentists inexperienced in airway management after a short period of simple training that may be critical when personnel experienced in intubation are not readily available.

Placement of Intubating Laryngeal Mask Airway Is Easier than Placement of Laryngeal Tube during Manual In-Line Stabilisation of The Neck

PubMed Central

Komatsu, R.; Nagata, O.; Kamata, K.; Yamagata, K.; Sessler, D.I.; Ozaki, M.

2005-01-01

Summary We compared the usefulness of the laryngeal tube (LT) with the intubating laryngeal mask airway (ILMA) in 51 patients whose necks were stabilised by manual in-line traction. After induction of anaesthesia and neuromuscular block, the LT and ILMA were inserted consecutively in a randomised, crossover design. During pressure-controlled ventilation (20 cmH2O inspiratory pressure), we measured insertion attempts, time to establish positive-pressure ventilation, tidal volume, gastric insufflation, and minimum airway pressure at which gas leaked around the cuff. Data were compared using Wilcoxon signed-rank tests; P<0.05 was considered significant. Insertion was more difficult with the LT (successful at first attempt in 16 patients) than with the ILMA (successful at first attempt in 42 patients, P<0.0001). Time required for insertion was longer for the LT (28 [23–35] sec, median [interquartile range]) than the ILMA (20 [15–25] sec, P=0.0009). Tidal volume was less for the LT (440 [290–670] ml) than the ILMA. (630 [440–750] ml, P=0.013). Minimum airway pressure at which gas leak occurred and incidence of gastric insufflation were similar with two devices. In patients whose necks were stabilised with manual in-line traction, insertion of the ILMA was easier and quicker than insertion of the LT and tidal volume was greater with the ILMA than the LT. PMID:15644005

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art].

PubMed

Keil, J; Jung, P; Schiele, A; Urban, B; Parsch, A; Matsche, B; Eich, C; Becke, K; Landsleitner, B; Russo, S G; Bernhard, M; Nicolai, T; Hoffmann, F

2016-01-01

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine. Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence. The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage. Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

The New Perilaryngeal Airway (CobraPLA™)1 Is as Efficient as the Laryngeal Mask Airway (LMA™)2, But Provides Better Airway Sealing Pressures

PubMed Central

Akça, Ozan; Wadhwa, Anupama; Sengupta, Papiya; Durrani, Jaleel; Hanni, Keith; Wenke, Mary; Yücel, Yüksel; Lenhardt, Rainer; Doufas, Anthony G.; Sessler, Daniel I.

2006-01-01

The Laryngeal Mask Airway (LMA) is a frequently-used efficient airway device, yet it sometimes seals poorly, thus reducing the efficacy of positive-pressure ventilation. The Perilaryngeal Airway (CobraPLA) is a novel airway device with a larger pharyngeal cuff (when inflated). We tested the hypothesis that the CobraPLA was superior to LMA with regard to insertion time and airway sealing pressure and comparable to LMA in airway adequacy and recovery characteristics. After midazolam and fentanyl, 81 ASA I-II outpatients having elective surgery were randomized to receive an LMA or CobraPLA. Anesthesia was induced with propofol (2.5 mg/kg, IV), and the airway inserted. We measured 1) insertion time; 2) adequacy of the airway (no leak at 15-cm-H2O peak pressure or tidal volume of 5 ml/kg); 3) airway sealing pressure; 4) number of repositioning attempts; and 5) sealing quality (no leak at tidal volume of 8 ml/kg). At the end of surgery, gastric insufflation, postoperative sore throat, dysphonia, and dysphagia were evaluated. Data were compared with unpaired t-tests, chi-square tests, or Fisher’s Exact tests; P<0.05 was significant. Patient characteristics, insertion times, airway adequacy, number of repositioning attempts, and recovery were similar in each group. Airway sealing pressure was significantly greater with CobraPLA (23±6 cm H2O) than LMA (18±5 cm H2O, P<0.001). The CobraPLA has insertion characteristics similar to LMA, but better airway sealing capabilities. PMID:15281543

The Soft Seal disposable laryngeal mask airway in adults: comparison of two insertion techniques without intra-oral manipulation.

PubMed

Kuvaki, B; Küçükgüçlü, S; Iyilikçi, L; Tuncali, B E; Cinar, O

2008-10-01

We investigated whether insertion of the disposable Soft Seal laryngeal mask airway (SSLM) was successful without intra-oral digital manipulation. One hundred patients undergoing anaesthesia using the SSLM were randomly assigned into two groups. Insertion was performed by either a direct or a rotational technique, both without intra-oral digital manipulation. The primary outcome measure was successful insertion at first attempt. Other outcomes included insertion time, fibreoptic assessment of the airway view and airway morbidity. The first attempt success rate was higher (98%) with the direct technique than with the rotational technique (75%; p = 0.002) but insertion time was faster with the latter method (mean [range] 15 [8-50] s) than with the direct method (20 [8-56] s; p = 0.035). Fibreoptic assessment and airway morbidity were similar in both groups. We conclude that the SSLM can be successfully inserted without intra-oral digital manipulation.

Comparison of 2 cuff inflation methods of laryngeal mask airway Classic for safe use without cuff manometer in adults.

PubMed

Kim, Min-Soo; Lee, Jeong-Rim; Shin, Yang-Sik; Chung, Ji-Won; Lee, Kyu-Ho; Ahn, Ki Ryang

2014-03-01

This single-center, prospective, randomized, double-blind, 2-arm, parallel group comparison trial was performed to establish whether the adult-sized laryngeal mask airway (LMA) Classic (The Laryngeal Mask Company Ltd, Henley-on-Thames, UK) could be used safely without any consideration of cuff hyperinflation when a cuff of the LMA Classic was inflated using half the maximum inflation volume or the resting volume before insertion of device. Eighty patients aged 20 to 70 years scheduled for general anesthesia using the LMA Classic were included. Before insertion, the cuff was partially filled with half the maximum inflation volume in the half volume group or the resting volume created by opening the pilot balloon valve to equalize with atmospheric pressure in the resting volume group. Several parameters regarding insertion, intracuff pressure, airway leak pressure, and leakage volume/fraction were collected after LMA insertion. The LMA Classic with a partially inflated cuff was successfully inserted in all enrolled patients. Both groups had the same success rate of 95% at the first insertion attempt. The half volume group had a lower mean intracuff pressure compared with the resting volume group (54.5 ± 16.1 cm H2O vs 61.8 ± 16.1 cm H2O; P = .047). There was no difference in airway leak pressure or leakage volume/fraction between the 2 groups under mechanical ventilation. The partially inflated cuff method using half the maximum recommended inflation volume or the resting volume is feasible with the adult-sized LMA Classic, resulting in a high success rate of insertion and adequate range of intracuff pressures. Copyright © 2014 Elsevier Inc. All rights reserved.

[A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation].

PubMed

Metterlein, Thomas; Dintenfelder, Anna; Plank, Christoph; Graf, Bernhard; Roth, Gabriel

Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anaesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p<0.05). Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical

A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation.

PubMed

Metterlein, Thomas; Dintenfelder, Anna; Plank, Christoph; Graf, Bernhard; Roth, Gabriel

Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p<0.05). Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical

A cohort evaluation of the pediatric ProSeal laryngeal mask airway in 100 children.

PubMed

Kelly, Fiona; Sale, Steven; Bayley, Guy; Cook, Tim; Stoddart, Peter; White, Michelle

2008-10-01

The ProSeal laryngeal mask airway (PLMA) has been available in pediatric sizes in the UK since 2007. Although several non-UK studies have evaluated PLMAs in children, there are little published data regarding their use in this country. Having decided to introduce the pediatric PLMA into our practice, we chose to prospectively audit the first 100 uses as part of our clinical governance. We studied children undergoing elective surgery who were considered suitable for a supraglottic airway. We recorded patient, surgical and insertion details, device performance data and complications. Patient management was not altered by inclusion in this audit. Twenty size 1.5, 55 size 2.0, 15 size 2.5 and 10 size 3.0 PLMAs were inserted in 100 consecutive children [median age 2 years (range 2 months to 10 years) and median weight 15 kg (range 4.9-60 kg)]. The overall first attempt success rate was 93% (size 1.5, 100%; size 2.0, 100%; size 2.5, 87%; size 3.0, 90%) and overall successful insertion rate was 99%. Median leak pressure was 25 cmH(2)O. Outright failure was seen in one patient; complications were seen in another six patients (partial airway obstruction in five patients and mild laryngospasm in one patient), all of whom were transient and none of whom required intubation. No episodes of regurgitation were recorded. Even without prior experience and using nonconventional insertion, pediatric PLMAs (including size 1.5) can be easily inserted and provide an effective airway.

[Laryngeal mask].

PubMed

Villaverde Rozados, María José; Mos Reguera, M Esther; González Argibay, M Concepción; Sixto Gato, Sandra; Radío, Beatriz Alfonso; Fernández Díaz, María José

2003-11-01

A laryngeal mask is a very useful instrument to use both in easy as well as difficult handling situations related to the air tract. This mask is placed in the pharynx and it permits a patient to breathe in different modes, either spontaneously or mechanically. Different models are available; some even facilitate the tracheal intubation through the mask. The authors highlight that this type of mask does not protect nor isolate the air tract. As advantages, the authors point out its easy installation; thus, it is an alternative when an air tract presents difficulties; therefore, it is necessary that all personnel who have to deal with the air tract be aware of this mask and know how to handle it.

Comparison of Laryngeal Mask Airway Supreme and Laryngeal Mask Airway Proseal with respect to oropharyngeal leak pressure during laparoscopic cholecystectomy: a randomised controlled trial.

PubMed

Beleña, José M; Núñez, Mónica; Anta, Diego; Carnero, Maria; Gracia, José L; Ayala, José L; Alvarez, Raquel; Yuste, Javier

2013-03-01

A comparison of the efficacy and safety of the Laryngeal Mask Airway (LMA) Supreme (LMAS) versus the LMA Proseal (LMAP) in elective laparoscopic cholecystectomy. To compare the LMAS with LMAP in terms of ventilatory efficacy, airway leak pressure (airway protection), ease-of-use and complications. Prospective, single-blind, randomised, controlled study. The Hospital del Sureste and Hospital Ramon y Cajal, Madrid, between May 2009 and March 2011. The Hospital del Sureste is a secondary hospital and Hospital Ramon y Cajal is a tertiary hospital. Patients undergoing elective laparoscopic cholecystectomy were studied following informed consent. Inclusion criteria were American Society of Anesthesiologists physical status I to III and age 18 or more. Exclusion criteria were BMI more than 40 kg m, symptomatic hiatus hernia or severe gastro-oesophageal reflux. Anaesthesiologists experienced in the use of LMAP and LMAS participated in the trial. One hundred twenty-two patients were randomly allocated to LMAS or LMAP. Our primary outcome measure was the oropharyngeal leak pressure (OLP). Secondary outcomes were the time and number of attempts for insertion, ease of insertion of the drain tube, adequacy of ventilation and the incidence of complication. Patients were interviewed postoperatively to evaluate the presence of sore throat, dysphagia or dysphonia. Two patients were excluded when surgery changed from laparoscopic to open. A total of 120 patients were finally included in the analysis. The mean OLP in the LMAP group was significantly higher than that in the LMAS group (30.7 ± 6.2 versus 26.8 ± 4.1 cmH2O;P < 0.01). This was consistent with a higher maximum tidal volume achieved with the LMAP compared to the LMAS (511 ± 68 versus 475 ± 55 ml; P = 0.04). The success rate of the first attempt insertion was higher for the LMAS group than the LMAP group (96.7 and 71.2%, respectively; P < 0.01). The time taken for insertion, ease of

A randomised controlled trial comparing ProSeal laryngeal mask airway, i-gel and Laryngeal Tube Suction-D under general anaesthesia for elective surgical patients requiring controlled ventilation.

PubMed

Das, Bikramjit; Varshney, Rahul; Mitra, Subhro

2017-12-01

The ProSeal™ laryngeal mask airway (PLMA), i-gel™ and Laryngeal Tube Suction-D (LTS-D™) have previously been evaluated alone or in pair-wise comparisons but differing study designs make it difficult to compare the results. The aim of this study was to compare the clinical performance of these three devices in terms of efficacy and safety in patients receiving mechanical ventilation during elective surgical procedures. This prospective, randomised, double-blind study was conducted on 150 American Society of Anesthesiologists physical status I-II patients, randomly allocated into 3 groups, undergoing elective surgical procedures under general anaesthesia. PLMA, i-gel™ or LTS-D™ appropriate for weight or/and height was inserted. Primary outcome measured was airway sealing pressure. Insertion time, ease of insertion, number of attempts, overall success rate and the incidence of airway trauma and complications were also recorded. Intergroup differences were compared using one-way analysis of variance with post hoc correction for continuous data and Chi-square test for categorical variables. Overall success rate was comparable between the three devices (i-gel™ 100%, LTS-D™ 94%, PLMA 96%). Airway sealing pressure was lower with i-gel™ (23.38 ± 2.06 cm H 2 O) compared to LTS-D™ (26.06 ± 2.11 cm H 2 O) and PLMA (28.5 ± 2.8 cm H 2 O; P < 0.0005). The mean insertion time was significantly more in PLMA (38.77 ± 3.2 s) compared to i-gel™ (27.9 ± 2.53 s) and LTS-D™ (21.66 ± 2.31 s; P < 0.0005). Airway sealing pressure and insertion time were significantly higher in PLMA compared to i-gel™ and LTS-D™.

Efficacy of the laryngeal tube by inexperienced personnel.

PubMed

Asai, Takashi; Hidaka, Ikuriho; Kawachi, Shoji

2002-11-01

We compared the laryngeal tube and the laryngeal mask in the ease of insertion, ventilation volume and the incidence of gastric insufflation by inexperienced personnel. In a randomized, cross-over design, each of 28 students of a Fire Defense Academy attempted to insert the laryngeal tube and laryngeal mask in turn using an airway management trainer manikin. A self-inflating bag (2000 ml) was attached and ventilation volume was measured. The number of attempts at the insertion and the presence or absence of gastric insufflation were also recorded. After completion of the study, each student was asked whether insertion of one device was easier than the other. All 28 students could insert the laryngeal tube at the first attempt. As for the laryngeal mask, 27 could insert it at the first attempt, whereas the remaining one student could insert it after two attempts. The tidal volume was significantly greater for the laryngeal tube (median 842 ml) than the laryngeal mask (median 716 ml) (95%CI for median difference: 10-116 ml; P < 0.02). The incidence of gastric insufflation was significantly lower for the laryngeal tube (2 times) than for the laryngeal mask (10 times) (P < 0.05). Twenty six of 28 students stated that insertion of the laryngeal tube was easier than insertion of the laryngeal mask, whereas the remaining two stated that there was no difference in the ease of insertion between two devices. Therefore, the laryngeal tube has a potential role in providing a clear airway during cardiopulmonary resuscitation. Copyright 2002 Elsevier Science Ireland Ltd.

[Difficult reintubation during a Fantoni's tracheostomy resolved using a laryngeal mask].

PubMed

Ould-Ahmed, M; Mas, B; Paris, A; Caroff, P; Segalen, F

2001-04-01

We report the failure of a reintubation under direct laryngoscopy, during a percutaneous tracheostomy by Fantoni method. After the accidental per-procedural extubation and in front of an unpredicted difficult conventional endotracheal intubation, a laryngeal mask was used as an airway intubator conduit for the blind passage of the set's ventilation tube. This ventilation tube is a 40 cm long, 4 mm internal diameter special catheter with low pressure cuff, included into the TLT kit. The end of the procedure was uneventful.

Rescue ventilation: resolving a "cannot mask ventilate, cannot intubate" situation during exchange of a Combitube for a definitive airway.

PubMed

Rich, James M; Mason, Andrew M; Tillmann, H A; Foreman, Michael

2009-10-01

Our anesthesia care team was called to care for a patient who was admitted to the emergency department with the esophageal-tracheal double-lumen airway device (Combitube, Tyco Healthcare, Nellcor, Pleasanton, California) in place, which needed to be exchanged for a definitive airway because the patient required an extended period of mechanical ventilation. Several techniques were attempted to exchange the esophageal-tracheal Combitube (ETC) without success. First, we attempted direct laryngoscopy with the ETC in place after deflation of the No. 1 proximal cuff and sweeping the ETC to the left. We were prepared to use bougie-assisted intubation but could not identify any airway anatomy. After removal of the ETC, we unsuccessfully attempted ventilation/intubation with a laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, California). Our third attempt was insertion of another laryngeal mask airway (LMA Unique, LMA North America) with marginal ventilation, but we again experienced unsuccessful intubation using a fiberscope. The ETC was reinserted after each intubation attempt because mask ventilation was impossible. Before proceeding with cricothyrotomy, we repeated direct laryngoscopy but without the ETC in place. We identified the tip of the epiglottis, which allowed for bougie-assisted intubation. This obviated the need for emergency cricothyrotomy.

Emergence times and airway reactions in general laryngeal mask airway anesthesia: study protocol for a randomized controlled trial.

PubMed

Stevanovic, Ana; Rossaint, Rolf; Keszei, András P; Fritz, Harald; Fröba, Gebhard; Pühringer, Friedrich; Coburn, Mark

2015-07-26

The use of a laryngeal mask airway (LMA) in appropriate patients supports fast-track anesthesia with a lower incidence of postoperative airway-connected adverse events. Data on the most favorable anesthetic in this context, with the lowest rate of upper airway complications and fast emergence times, are controversial and limited. Desflurane seems to match these criteria best, but large randomized controlled trials (RCTs) with a standardized study protocol are lacking. Therefore, we aim to compare desflurane with other commonly used anesthetics, sevoflurane and propofol, in a sufficiently powered RCT. We hypothesize that desflurane is noninferior regarding the frequency of upper airway events and superior regarding the emergence times to sevoflurane and propofol. A total of 351 patients undergoing surgery with an LMA will be included in this prospective, randomized, double-blind controlled, multicenter clinical trial. The patients will be randomly assigned to the three treatment arms: desflurane (n = 117), sevoflurane (n = 117), and propofol (n = 117). The emergence time (time to state the date of birth) will be the primary endpoint of this study. The secondary endpoints include further emergence times, such as time to open eyes, to remove LMA, to respond to command and to state name. Additionally, we will determine the frequency of cough and laryngospasm, measured intraoperatively and at emergence. We will assess the postoperative recovery on the first postoperative day via the Postoperative Quality Recovery Scale. Despite increasing importance of cost-effective and safe anesthesia application, we lack proof for the most advantageous anesthetic agent, when an LMA is used. There are only a few RCTs comparing desflurane to other commonly used anesthetics (sevoflurane, propofol and isoflurane) in patients with LMA. These RCTs were conducted with small sample sizes, huge interstudy variability, and some also showed strong biases. The present multicenter RCT will

Optimal degree of mouth opening for laryngeal mask airway function during oral surgery.

PubMed

Sanuki, Takuro; Sugioka, Shingo; Hirokane, Motoko; Son, Hiroki; Uda, Rumiko; Akatsuka, Masafumi; Kotani, Junichiro

2011-04-01

This study was performed to determine the optimal degree of mouth opening in anesthetized patients requiring laryngeal mask airway (LMA) during oral surgery. A single, experienced LMA user inserted the LMA in 15 patients who were scheduled for elective oral surgery. Oropharyngeal leak pressure, intracuff pressure, and fiberoptic assessment of the LMA position were sequentially documented in 5 mouth conditions-opening of 1.4 (neutral position), 2, 3, 4, and 5 cm-and any resulting ventilatory difficulties were recorded. Oropharyngeal leak pressure with the mouth open 4 cm (21.8 ± 3.2 cm H(2)O, P = .025) and 5 cm (27.3 ± 7.2 cm H(2)O, P < .001) was significantly higher than in the neutral position (18.1 ± 1.5 cm H(2)O), as was intracuff pressure (neutral position, 60.0 ± 0 cm H(2)O; 4 cm, 72.6 ± 5.1 cm H(2)O [P < .001]; and 5 cm, 86.9 ± 14.4 cm H(2)O [P < .001]). LMA position, observed by fiberoptic bronchoscopy, was unchanged by mouth opening, being similar in the 5 mouth conditions (P = .999). In addition, ventilation difficulties (abnormal capnograph curves or inadequate tidal volume) occurred in 2 of 15 patients (13%) and 7 of 15 patients (53%) (P < .001) with the mouth opening of 4 and 5 cm, respectively. This study showed that a mouth opening over 4 cm led to substantial increases in oropharyngeal leak pressure and intracuff pressure of the LMA, warranting caution, because gastric insufflation, sore throat, and ventilation difficulties may occur. A mouth opening of 3 cm achieves acceptable airway conditions for anesthetized patients requiring LMA. Copyright © 2011 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea.

PubMed

Brain, A I; Verghese, C; Addy, E V; Kapila, A; Brimacombe, J

1997-12-01

We have assessed the efficacy of a new laryngeal mask prototype, the intubating laryngeal mask airway (ILMA), as a ventilatory device and blind intubation guide. The ILMA consists of an anatomically curved, short, wide bore, stainless steel tube sheathed in silicone which is bonded to a laryngeal mask and a guiding handle. It has a single moveable aperture bar, a guiding ramp and can accommodate an 8 mm tracheal tube (TT). After induction of anaesthesia with propofol 2.5 mg kg-1 and fentanyl 2.5 micrograms kg-1, the device was inserted successfully at the first attempt in all 150 (100%) patients and adequate ventilation achieved in all, with minor adjustments required in four patients. Placement did not require movement of the head and neck or insertion of the fingers in the patient's mouth. Blind tracheal intubation using a straight silicone cuffed TT was attempted after administration of atracurium 0.5 mg kg-1. If resistance was felt during intubation, a sequence of adjusting manoeuvres was used based on the depth at which resistance occurred. Tracheal intubation was possible in 149 of 150 (99.3%) patients. In 75 (50%) patients no resistance was encountered and the trachea was intubated at the first attempt, 28 (19%) patients required one adjusting manoeuvre and 46 (31%) patients required 2-4 adjusting manoeuvres before intubation was successful. There were 13 patients with potential or known airway problems. The lungs of all of these patients were ventilated easily and the trachea intubated using the ILMA. In 10 of 13 (77%) of these patients, no resistance was encountered and the trachea was intubated at the first attempt; three of 13 (23%) patients required one adjusting manoeuvre. Tracheal intubation required significantly fewer adjusting manoeuvres in patients with a predicted or known difficult airway (P < 0.05). We conclude that the ILMA appeared on initial assessment to be an effective ventilatory device and intubation guide for routine and difficult

Comparative life cycle assessment of disposable and reusable laryngeal mask airways.

PubMed

Eckelman, Matthew; Mosher, Margo; Gonzalez, Andres; Sherman, Jodi

2012-05-01

Growing awareness of the negative impacts from the practice of health care on the environment and public health calls for the routine inclusion of life cycle criteria into the decision-making process of device selection. Here we present a life cycle assessment of 2 laryngeal mask airways (LMAs), a one-time-use disposable Unique™ LMA and a 40-time-use reusable Classic™ LMA. In life cycle assessment, the basis of comparison is called the "functional unit." For this report, the functional unit of the disposable and reusable LMAs was taken to be maintenance of airway patency by 40 disposable LMAs or 40 uses of 1 reusable LMA. This was a cradle-to-grave study that included inputs and outputs for the manufacture, transport, use, and waste phases of the LMAs. The environmental impacts of the 2 LMAs were estimated using SimaPro life cycle assessment software and the Building for Environmental and Economic Sustainability impact assessment method. Sensitivity and simple life cycle cost analyses were conducted to aid in interpretation of the results. The reusable LMA was found to have a more favorable environmental profile than the disposable LMA as used at Yale New Haven Hospital. The most important sources of impacts for the disposable LMA were the production of polymers, packaging, and waste management, whereas for the reusable LMA, washing and sterilization dominated for most impact categories. The differences in environmental impacts between these devices strongly favor reusable devices. These benefits must be weighed against concerns regarding transmission of infection. Health care facilities can decrease their environmental impacts by using reusable LMAs, to a lesser extent by selecting disposable LMA models that are not made of certain plastics, and by ordering in bulk from local distributors. Certain practices would further reduce the environmental impacts of reusable LMAs, such as increasing the number of devices autoclaved in a single cycle to 10 (-25% GHG

Conventional tracheal tubes for intubation through the intubating laryngeal mask airway.

PubMed

Kundra, Pankaj; Sujata, N; Ravishankar, M

2005-01-01

The laryngeal mask airway (LMA)-Fastrach silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n=50), prewarmed PVCT (n=50), and LAT (n=50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P <0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P <0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P <0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.

Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation.

PubMed

Qureshi, Mosarrat J; Kumar, Manoj

2018-03-15

Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation. Among newborns requiring positive pressure ventilation for cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation? We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review. Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates. We included seven trials that involved a total of 794 infants. Five

A randomized prospective controlled trial comparing the laryngeal tube suction disposable and the supreme laryngeal mask airway: the influence of head and neck position on oropharyngeal seal pressure.

PubMed

Somri, Mostafa; Vaida, Sonia; Garcia Fornari, Gustavo; Mendoza, Gabriela Renee; Charco-Mora, Pedro; Hawash, Naser; Matter, Ibrahim; Swaid, Forat; Gaitini, Luis

2016-10-06

The Laryngeal Tube Suction Disposable (LTS-D) and the Supreme Laryngeal Mask Airway (SLMA) are second generation supraglottic airway devices (SADs) with an added channel to allow gastric drainage. We studied the efficacy of these devices when using pressure controlled mechanical ventilation during general anesthesia for short and medium duration surgical procedures and compared the oropharyngeal seal pressure in different head and-neck positions. Eighty patients in each group had either LTS-D or SLMA for airway management. The patients were recruited in two different institutions. Primary outcome variables were the oropharyngeal seal pressures in neutral, flexion, extension, right and left head-neck position. Secondary outcome variables were time to achieve an effective airway, ease of insertion, number of attempts, maneuvers necessary during insertion, ventilatory parameters, success of gastric tube insertion and incidence of complications. The oropharyngeal seal pressure achieved with the LTS-D was higher than the SLMA in, (extension (p=0.0150) and right position (p=0.0268 at 60 cm H 2 O intracuff pressures and nearly significant in neutral position (p = 0.0571). The oropharyngeal seal pressure was significantly higher with the LTS-D during neck extension as compared to SLMA (p= 0.015). Similar oropharyngeal seal pressures were detected in all other positions with each device. The secondary outcomes were comparable between both groups. Patients ventilated with LTS-D had higher incidence of sore throat (p = 0.527). No major complications occurred. Better oropharyngeal seal pressure was achieved with the LTS-D in head-neck right and extension positions , although it did not appear to have significance in alteration of management using pressure control mechanical ventilation in neutral position. The fiberoptic view was better with the SLMA. The post-operative sore throat incidence was higher in the LTS-D. ClinicalTrials.gov ID: NCT02856672

Comparison of the Ambu AuraFlex with the laryngeal mask airway Flexible: a manikin study.

PubMed

Sanuki, Takuro; Nakatani, Gosuke; Sugioka, Shingo; Daigo, Erina; Kotani, Junichiro

2011-07-01

The present study compared the Ambu AuraFlex and the laryngeal mask airway (LMA) Flexible with regard to time required for and success rates of insertion on a manikin by dental students who had never used an LMA. In addition, participants' views on ease of insertion of each device were surveyed. Subjects consisted of 30 dental students who inserted each airway device in a manikin. The time required for and success rates of insertion were measured. Subjects were then asked to rate the ease of insertion of each device using the 100-mm visual analog scale (from 0 mm = extremely easy to 100 mm = extremely difficult). Insertion time was shorter with the Ambu AuraFlex (26.6 ± 7.1 seconds) than with the LMA Flexible (30.3 ± 6.8 seconds; P = .045). The rate of successful insertion using the Ambu AuraFlex (28 of 30 attempts, 93.3%) was greater than that with the LMA Flexible (23 of 30 attempts, 76.7%), although the difference was not statistically significant (P = .145). Ambu AuraFlex insertion was considered less difficult (median, 41 mm; 10th to 90th percentiles, 18 to 78 mm) than LMA Flexible insertion (60 mm; 42 to 82 mm; P = .004), as rated using the 100-mm visual analog scale. The Ambu AuraFlex appears to be useful for inexperienced users because it enables quicker and easier insertion than the LMA Flexible. Copyright © 2011 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

A 12-month audit of laryngeal mask airway (LMA) use in a South Australian ambulance service.

PubMed

Hein, Cindy; Owen, Harry; Plummer, John

2008-11-01

The aim of the study was to provide an accurate account of current practice of laryngeal mask airway (LMA) use within SA Ambulance Service (SAAS) and identify issues that could lead to constructive training for paramedics and improve clinical care and patient safety. A clinical audit of LMA use within SAAS was registered with the Director of Clinical Governance at Flinders Medical Centre in South Australia. Data were collected prospectively in a state wide all inclusive study over 12 months (February 2006 to January 2007). The primary outcome variable we determined was successful insertion after one or two attempts. Secondary outcome measures were overall success rate and reasons for failure. Insertion of an LMA was attempted by 179 paramedical staff in 164 patients. Success after one or two attempts was obtained in 65% of patients (107/164). Overall success rate (any number of attempts) was 74% (121/164), of those 45% were on the first attempt, 20% on the second attempt and the remainder (9%) required three or more attempts to achieve successful insertion. Reported failures were ascribed to patient anatomy (13), technique (9), airway soiling (7), device (6), trismus (1), high Glasgow Coma Score (1), trauma (1) or unknown (5). This clinical audit provides a comprehensive account of LMA use within SA Ambulance Service. Although the current practice was found to be acceptable, these results are below those of comparable groups and should be improved upon.

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol.

PubMed

Benger, Jonathan Richard; Voss, Sarah; Coates, David; Greenwood, Rosemary; Nolan, Jerry; Rawstorne, Steven; Rhys, Megan; Thomas, Matthew

2013-01-01

Effective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the UK. The Joint Royal Colleges Ambulance Liaison Committee recently concluded that newer supraglottic airway devices (SADs) are safe and effective devices for hospital procedures and that their use in OHCA should be investigated. This study will address an identified gap in current knowledge by assessing whether it is feasible to use a cluster randomised design to compare SADs with current practice, and also to each other, during OHCA. The primary objective of this study is to assess the feasibility of a cluster randomised trial to compare the ventilation success of two newer SADs: the i-gel and the laryngeal mask airway supreme to usual practice during the initial airway management of OHCA. The secondary objectives are to collect data on ventilation success, further airway interventions required, loss of a previously established airway during transport, airway management on arrival at hospital (or termination of the resuscitation attempt), initial resuscitation success, survival to intensive care admission, survival to hospital discharge and patient outcome at 3 months. Ambulance paramedics will be randomly allocated to one of the three methods of airway management. Adults in medical OHCA attended by a trial paramedic will be eligible for the study. Approval for the study has been obtained from a National Health Service Research Ethics Committee with authority to review proposals for trials of a medical device in incapacitated adults. The results will be made publicly available on an open access website, and we will publish the findings in appropriate journals and present them at national and international conferences relevant to the subject field. ISRCTN: 18528625.

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol

PubMed Central

Benger, Jonathan Richard; Voss, Sarah; Coates, David; Greenwood, Rosemary; Nolan, Jerry; Rawstorne, Steven; Rhys, Megan; Thomas, Matthew

2013-01-01

Introduction Effective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the UK. The Joint Royal Colleges Ambulance Liaison Committee recently concluded that newer supraglottic airway devices (SADs) are safe and effective devices for hospital procedures and that their use in OHCA should be investigated. This study will address an identified gap in current knowledge by assessing whether it is feasible to use a cluster randomised design to compare SADs with current practice, and also to each other, during OHCA. Methods and analysis The primary objective of this study is to assess the feasibility of a cluster randomised trial to compare the ventilation success of two newer SADs: the i-gel and the laryngeal mask airway supreme to usual practice during the initial airway management of OHCA. The secondary objectives are to collect data on ventilation success, further airway interventions required, loss of a previously established airway during transport, airway management on arrival at hospital (or termination of the resuscitation attempt), initial resuscitation success, survival to intensive care admission, survival to hospital discharge and patient outcome at 3 months. Ambulance paramedics will be randomly allocated to one of the three methods of airway management. Adults in medical OHCA attended by a trial paramedic will be eligible for the study. Ethics and dissemination Approval for the study has been obtained from a National Health Service Research Ethics Committee with authority to review proposals for trials of a medical device in incapacitated adults. The results will be made publicly available on an open access website, and we will publish the findings in appropriate journals and present them at national and international conferences relevant to the subject field. Trial

Layperson mouth-to-mask ventilation using a modified I-gel laryngeal mask after brief onsite instruction: a manikin-based feasibility trial.

PubMed

Schälte, Gereon; Bomhard, Lilli-Theresa; Rossaint, Rolf; Coburn, Mark; Stoppe, Christian; Zoremba, Norbert; Rieg, Annette

2016-05-12

The intention of this manikin-based trial was to evaluate whether laypersons are able to operate an I-gel laryngeal mask (I-gel) modified for mouth-to-mask ventilation after receiving brief on-site instruction. Entrance hall of a university hospital and the city campus of a public technical university, using a protected manikin scenario. Laypersons were handed a labelled, mouthpiece-integrated I-gel laryngeal mask and a corresponding instruction chart and were asked to follow the printed instructions. The overall process was analysed and evaluated according to quality and duration. Data from 100 participants were analysed. Overall, 79% of participants were able to effectively ventilate the manikin, 90% placed the laryngeal mask with the correct turn and direction, 19% did not position the mask deep enough and 85% believed that their inhibition threshold for performing resuscitation was lowered. A significant reduction in reluctance before and after the trial was found (p<0.0001). A total of 35% of participants had concerns about applying first aid in an emergency. Former basic life support (BLS) training significantly reduced the time of insertion (19.6 s, 95% CI 17.8 to 21.5, p=0.0004) and increased overall success (p=0.0096). Laypersons were able to manage mouth-to-mask ventilation in the manikin with a reasonable success rate after receiving brief chart-based on-site instructions using a labelled I-gel mask. Positioning the mask deep enough and identifying whether the manikin was successfully ventilated were the main problems observed. A significant reduction in reluctance towards initialising BLS by using a modified supraglottic airway device (SAD) may lead to better acceptance of bystander resuscitation in laypersons, supporting the introduction of SADs into BLS courses and the stocking of SADs in units with public automatic external defibrillators. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a

The Intubating Laryngeal Mask Airway Allows Tracheal Intubation When the Cervical Spine Is Immobilized by a Rigid Collar

PubMed Central

Komatsu, Ryu; Nagata, Osamu; Kamata, Kotoe; Yamagata, Katsuyuki; Sessler, Daniel I.; Ozaki, Makoto

2005-01-01

Summary An intubating laryngeal mask airway (ILMA) facilitates tracheal intubation with the neck in neutral position, which is similar to the neck position maintained by a rigid cervical collar. However, a cervical collar virtually obliterates neck movement, even the small movements that normally facilitate airway insertion. We therefore tested the hypothesis that the ILMA facilitates tracheal intubation even in patients wearing a rigid cervical collar. In 50 cervical spine surgery patients with a rigid Philadelphia collar in place and 50 general surgery patients under general anaesthesia, we performed blind tracheal intubation via an ILMA. The time required for intubation, intubation success rate, and numbers and type of adjusting manoeuvres employed were recorded. Inter-incisor distance was significantly smaller (4.1 [0.8] cm vs. 4.6 [0.7] cm, mean [SD], P<0.01) and Mallampati scores were significantly greater (P<0.001) in the collared patients. ILMA insertion took longer (30 [25] vs. 22 [6] seconds), more patients required 2 insertion attempts (15 vs. 3; P<0.005), and ventilation adequacy with ILMA was worse (P<0.05) in collared patients. However, there were no significant differences between the collared and control patients in terms of total time required for intubation (60 [41] vs. 50 [30] seconds), number of intubation attempts, overall intubation success rate (96 vs. 98%), or the incidence of intubation complications. Blind intubation through an ILMA is thus a reasonable strategy for controlling the airway in patients who are immobilized with a rigid cervical collar, especially when urgency precludes a fiberoptic approach. PMID:15321932

A novel combination of the Arndt endobronchial blocker and the laryngeal mask airway ProSeal™ provides one-lung ventilation for thoracic surgery

PubMed Central

LI, QIONG; LI, PEIYING; XU, JIANGHUI; GU, HUAHUA; MA, QINYUN; PANG, LIEWEN; LIANG, WEIMIN

2014-01-01

In this study, the feasibility and performance of the combination of the Arndt endobronchial blocker and the laryngeal mask airway (LMA) ProSeal™ in airway establishment, ventilation, oxygenation and lung isolation was evaluated. Fifty-five patients undergoing general anesthesia for elective thoracic surgeries were randomly allocated to group Arndt (n=26) or group double-lumen tube (DLT; n=29). Data concerning post-operative airway morbidity, ease of insertion, hemodynamics, lung collapse, ventilators, oxygenation and ventilation were collected for analysis. Compared with group DLT, group Arndt showed a significantly attenuated hemodynamic response to intubation (blood pressure, 149±31 vs. 115±16 mmHg; heart rate, 86±15 vs. 68±15 bpm), less severe injuries to the bronchus (injury score, 1.4±0.2 vs. 0.4±0.1) and vocal cords (injury score, 1.3±0.2 vs. 0.6±0.1), and lower incidences of post-operative sore throat and hoarseness. Furthermore, the novel combination of the Arndt and the LMA ProSeal showed similar ease of airway establishment, comparable ventilation and oxygenation performance, and an analogous lung isolation effect to DLT. The novel combined use of the Arndt endobronchial blocker and the LMA ProSeal can serve as a promising alternative for thoracic procedures requiring one-lung ventilation. The less traumatic properties and equally ideal lung isolation are likely to promote its use in rapidly spreading minimally invasive thoracic surgeries. PMID:25289071

[Use of the air-Q laryngeal airway and tube exchanger in a case of difficult tracheal extubation after maxillectomy].

PubMed

Komasawa, Nobuyasu; Ueki, Ryusuke; Iwasaki, Yohei; Tatara, Tsuneo; Tashiro, Chikara; Kaminoh, Yoshiroh

2012-10-01

A 79-year-old man was diagnosed with maxillary cancer and underwent total maxillectomy under general anesthesia. The oropharyngeal airway was needed for efficient mask ventilation during anesthesia induction. The maxilla was totally resected and reconstructed with skin from a femoral flap. Tracheal extubation was considered to be difficult given that mask ventilation was contraindicated due to reconstruction of the maxilla. After inserting a tube exchanger (TE) into the trachea, the tracheal tube was exchanged with an air-Q laryngeal airway through the TE. After confirming effective ventilation with the air-Q mask, the patient was awakened from anesthesia. We confirmed sufficient spontaneous breathing and no active bleeding in the pharynx. After re-inserting the TE thorough air-Q, the air-Q was removed, followed by removal of the TE. These findings suggest that the air-Q and TE were effective in a case of difficult extubation after maxillectomy.

Basic life support trained nurses ventilate more efficiently with laryngeal mask supreme than with facemask or laryngeal tube suction-disposable--a prospective, randomized clinical trial.

PubMed

Gruber, Elisabeth; Oberhammer, Rosmarie; Balkenhol, Karla; Strapazzon, Giacomo; Procter, Emily; Brugger, Hermann; Falk, Markus; Paal, Peter

2014-04-01

In some emergency situations resuscitation and ventilation may have to be performed by basic life support trained personnel, especially in rural areas where arrival of advanced life support teams can be delayed. The use of advanced airway devices such as endotracheal intubation has been deemphasized for basically-trained personnel, but it is unclear whether supraglottic airway devices are advisable over traditional mask-ventilation. In this prospective, randomized clinical single-centre trial we compared airway management and ventilation performed by nurses using facemask, laryngeal mask Supreme (LMA-S) and laryngeal tube suction-disposable (LTS-D). Basic life support trained nurses (n=20) received one-hour practical training with each device. ASA 1-2 patients scheduled for elective surgery were included (n=150). After induction of anaesthesia and neuromuscular block nurses had two 90-second attempts to manage the airway and ventilate the patient with volume-controlled ventilation. Ventilation failed in 34% of patients with facemask, 2% with LMA-S and 22% with LTS-D (P<0.001). In patients who could be ventilated successfully mean tidal volume was 240±210 ml with facemask, 470±120 ml with LMA-S and 470±140 ml with LTS-D (P<0.001). Leak pressure was lower with LMA-S (23.3±10.8 cm H2O, 95% CI 20.2-26.4) than with LTS-D (28.9±13.9 cm·H2O, 95% CI 24.4-33.4; P=0.047). After one hour of introductory training, nurses were able to use LMA-S more effectively than facemask and LTS-D. High ventilation failure rates with facemask and LTS-D may indicate that additional training is required to perform airway management adequately with these devices. High-level trials are needed to confirm these results in cardiac arrest patients. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Agents for facilitation of laryngeal mask airway insertion: a comparative study between thiopentone sodium and propofol.

PubMed

Sengupta, Janmejoy; Sengupta, Mohua; Nag, Tulsi

2014-01-01

Development of endotracheal intubation to avoid deleterious effect on hemodynamic responses occurring during laryngoscopy and intubation compelled researchers to venture into alternative measures of airway management with subtle hemodynamic responses. This study was carried out to compare the conditions for laryngeal mask airways LMA insertion with widely used intravenous induction agents, thiopentone sodium and propofol, and also to compare the undesired responses occurring during LMA insertion with them. The study was prospective, randomized, and double blind. All patients selected were randomly allocated into two groups: Group 1 (propofol) and group II (thiopentone). Preinduction heart rate and blood pressure were recorded. Sixty healthy adult patients of either sex belonging to age group of 20-60 years and ASA grade I or II, to undergo surgery less than 1 h, were selected for the study-Patients were randomly allocated in two groups, 30 in each group. Premedication with midazolam 0.04 mg/kg and fentanyl 2 mg/kg done in both groups. Thereafter, group 1 was induced with 2 mg/kg of propofol and group 2 with 5 mg/kg of thiopentone sodium. The study revealed that, ease of insertion of LMA, was statistically significantly greater in group 1 when compared with group 2 (P 0.05). The time required for successful insertion of LMA was lesser in group 1 patients (53.8 ± 7.77 s) than in group 2 patients (84.7 ± 16.54 s) (P 0.001). Severity of undesired responses were more in group 2, as incremental boluses of respective induction agents were required in 20% patients in thiopentone group compared to only 6% patients in propofol group and 13% of patients in thiopentone group required rescue succinylcholine.

Air-Q intubating laryngeal airway: A study of the second generation supraglottic airway device.

PubMed

Attarde, Viren Bhaskar; Kotekar, Nalini; Shetty, Sarika M

2016-05-01

Air-Q intubating laryngeal mask airway (ILA) is used as a supraglottic airway device and as a conduit for endotracheal intubation. This study aims to assess the efficacy of the Air-Q ILA regarding ease of insertion, adequacy of ventilation, rate of successful intubation, haemodynamic response and airway morbidity. Sixty patients presenting for elective surgery at our Medical College Hospital were selected. Following adequate premedication, baseline vital parameters, pulse rate and blood pressure were recorded. Air-Q size 3.5 for patients 50-70 kg and size 4.5 for 70-100 kg was selected. After achieving adequate intubating conditions, Air-Q ILA was introduced. Confirming adequate ventilation, appropriate sized endotracheal tube was advanced through the Air-Q blindly to intubate the trachea. Placement of the endotracheal tube in trachea was confirmed. Air-Q ILA was successfully inserted in 88.3% of patients in first attempt and 11.7% patients in second attempt. Ventilation was adequate in 100% of patients. Intubation was successful in 76.7% of patients with Air-Q ILA. 23.3% of patients were intubated by direct laryngoscopy following failure with two attempts using Air-Q ILA. Post-intubation the change in heart rate was statistically significant (P < 0.0001). 10% of patients were noted to have a sore throat and 5% of patients had mild airway trauma. Air-Q ILA is a reliable device as a supraglottic airway ensuring adequate ventilation as well as a conduit for endotracheal intubation. It benefits the patient by avoiding the stress of direct laryngoscopy and is also superior alternative device for use in a difficult airway.

Techniques for the insertion of the ProSeal laryngeal mask airway: comparison of the Foley airway stylet tool with the introducer tool in a prospective, randomized study.

PubMed

Chen, Mao-Kai; Hsu, Hung-Te; Lu, I-Cheng; Shih, Chih-Kai; Shen, Ya-Chun; Tseng, Kuang-Yi; Cheng, Kuang-I

2014-01-01

Many tools have been developed to facilitate the insertion of the ProSeal laryngeal mask airway (LMA) insertion, which can be impeded by folding of its soft cuff. The aim of this study was to compare the efficiency of ProSeal LMA insertion guided by a soft, direct optical Foley Airway Stylet Tool (FAST) with the standard introducer tool (IT). One hundred sixty patients undergoing general anesthesia using the ProSeal LMA as an airway management device were randomly allocated to either FAST-guided or IT-assisted groups. Following ProSeal LMA insertion, the glottic and esophageal openings were identified using a fiberoptic bronchoscope introduced through the airway and the drain tube. The primary outcomes were time taken to insert the ProSeal LMA and the success rate at the first attempt. Secondary end points included ease of insertion, hemodynamic response to insertion, and postoperative adverse events recorded in the recovery room and on the first postoperative morning. One hundred forty patients were included in the final analysis: 66 in the FAST-guided group and 74 in the IT-assisted group. The success rate of FAST device-guided ProSeal LMA insertion (95.7%) was broadly comparable with IT-assisted insertion (98.7%). However, the time taken to insert the ProSeal LMA was significantly longer when the FAST technique was used (p <0.001). The incidence of correct alignment of the airway tube and the drain tube did not differ significantly between the groups. There were no significant differences in ease of insertion or hemodynamic responses to insertion, except that the incidence of postoperative sore throat was significantly higher in the FAST group on the first postoperative day (22.2% compared with 6.8% in the IT group; p = 0.035). Both FAST-guided and IT-assisted techniques achieved correct ProSeal LMA positioning, but the IT technique was significantly quicker and less likely to cause a sore throat. ClinicalTrials.gov Identifier: NCT02048657.

Endotracheal tube and laryngeal mask airway cuff volume changes with altitude: a rule of thumb for aeromedical transport.

PubMed

Mann, Catherine; Parkinson, Neil; Bleetman, Anthony

2007-03-01

Helicopters and light (unpressurised) aircraft are used increasingly for the transport of ventilated patients. Most of these patients are ventilated through endotracheal tubes (ETTs), others through laryngeal mask airways (LMAs). The cuffs of both ETTs and LMAs inflate with increases in altitude as barometric pressure decreases (30 mbar/1000 feet). Tracheal mucosa perfusion becomes compromised at a pressure of approximately 30 cm H2O; critical perfusion pressure is 50 cm H2O. The change in dimensions of the inflated cuffs of a size 8 ETT and a size 5 LMA were measured with digital callipers at 1000 feet intervals in the unpressurised cabin of an Agusta 109 helicopter used by the Warwickshire and Northamptonshire Air Ambulance. A linear expansion in cuff dimensions as a function of altitude increase was identified. For ETTs, a formula for removal of air from the cuff with increasing altitude was calculated and is recommended for use in aeromedical transfers. This is 1/17x1.1 = 0.06 ml/1000 foot ascent/ml initial cuff inflation. The data for LMA cuff expansion failed to show significant correlation with altitude change. Further work is required to determine a similar rule of thumb for LMA cuff deflation.

Predicted EC50 and EC95 of Remifentanil for Smooth Removal of a Laryngeal Mask Airway Under Propofol Anesthesia

PubMed Central

Yoo, Ji Young; Kwak, Hyun Jeong; Lee, Kyung Cheon; Kim, Go Wun

2015-01-01

Purpose The purpose of this study was to determine the effect-site concentration (Ce) of remifentanil in 50% of patients (EC50) and 95% of patients (EC95) for smooth laryngeal mask airway (LMA) removal in adults under propofol and remifentanil anesthesia. Materials and Methods Twenty-five patients of ASA physical status I-II and ages 18-60 years who were to undergo minor gynecological or orthopedic surgery were assessed in this study. Anesthesia was induced and maintained with propofol and remifentanil target-controlled infusion (TCI). Remifentanil was maintained at a predetermined Ce during the emergence period. The modified Dixon's up-and-down method was used to determine the remifentanil concentration, starting from 1.0 ng/mL (step size of 0.2 ng/mL). Successful removal of the LMA was regarded as absence of coughing/gagging, clenched teeth, gross purposeful movements, breath holding, laryngospasm, or desaturation to SpO2<90%. Results The mean±SD Ce of remifentanil for smooth LMA removal after propofol anesthesia was 0.83±0.16 ng/mL. Using isotonic regression with a bootstrapping approach, the estimated EC50 and EC95 of remifentanil Ce were 0.91 ng/mL [95% confidence interval (CI), 0.77-1.07 ng/mL] and 1.35 ng/mL (95% CI, 1.16-1.38 ng/mL), respectively. Conclusion Our results showed that remifentanil TCI at an established Ce is a reliable technique for achieving safe and smooth emergence without coughing, laryngospasm, or other airway reflexes. PMID:26069139

A training program for novice paramedics provides initial laryngeal mask airway insertion skill and improves skill retention at 6 months.

PubMed

Hein, Cindy; Owen, Harry; Plummer, John

2010-02-01

Major resuscitation councils endorse the use of the laryngeal mask airway (LMA) by paramedics for lifesaving airway interventions. Learning and maintaining adequate skill level is important for patient safety. The aim of this project was to develop a training program that provides student paramedics with initial knowledge and experience in LMA insertion skills but equally important to provide ongoing skill retention. After ethics approval and informed consent, 55 first year Paramedic degree students watched a manufacturer's LMA instruction video and practiced insertion in three different part task trainers. Six months later, subjects were randomized to an intervention (reviewing the video and 10 minutes unsupervised practice) or control group before participating in a high-fidelity simulated clinical scenario. For equity of training, the control group received the intervention after the scenario. Main outcomes measured were time to insertion; success rate; and LMA skill retention (sum of LMA orientation; cuff inflation; bite block; securing; patient positioning; and overall subject performance). Fifty subjects completed the study. Those in the intervention group displayed significantly shorter insertion times (P = 0.029), fewer attempts to achieve success (P = 0.033), and had significantly higher LMA skill performance levels (P = 0.019) at 6 months. We devised a short intervention based on our training program using a video and practice in part task trainers. In an assessment using high-fidelity simulation, we demonstrated significant improvements in maintenance of LMA insertion skills in student paramedics at 6 months. Our model of just-in-time assessment and reinforcement of training prevents skill decay and has implications for healthcare skills training in general.

Comparison of postoperative complication between Laryngeal Mask Airway and endotracheal tube during low-flow anesthesia with controlled ventilation

PubMed Central

Peirovifar, Ali; Eydi, Mahmood; Mirinejhad, Mir Mousa; Mahmoodpoor, Ata; Mohammadi, Afsaneh; EJ Golzari, Samad

2013-01-01

Objective: To compare the postoperative complications between Laryngeal Mask Airway (LMA) and endotracheal tube (ETT) during low-flow anesthesia with controlled ventilation. Methodology: Eighty adult Patients with ASA class I or II were randomly allocated into two forty-patient groups (ETT or LMA). Cuff pressure was monitored during anesthesia. After high uptake period, fresh gas flow (FGF) was decreased to 1 lit/min and isoflurane set to 1%. Monitoring during anesthesia included non-invasive blood pressure, ECG, ETCO2 and pulse oximetry. System leakage (>100 ml/min), rebreathing and any attempt to increase FGF to overcome the leak were monitored during anesthesia. Later, patients were extubated and transferred to Post Anesthesia Care Unit (PACU). In PACU, the incidence of sore throat, cough, difficulty in swallowing and shivering was monitored for all patients. Results: Leakage was observed in two and three cases in ETT and LMA groups respectively (P>0.05). Postoperative cough, sore throat and difficulty in swallowing were significantly less in LMA than ETT group. No significant difference was observed regarding ETCo2 values between 2 groups. Conclusion: If careful measures regarding insertion techniques, correct LMA position and routine monitoring of LMA cuff pressure are taken, LMA can be used as a safe alternative with lower incidence of post operation complication compared with ETT during low-flow controlled anesthesia with modern anesthetic machines. PMID:24353586

Disposable laryngeal mask airway (Soft Seal) for endotracheal intubation: FOB guidance technique and blind technique.

PubMed

Boonmak, S; Boonmak, P; Bunsaengjaroen, P; Srichaipanha, S

2006-05-01

To evaluate disposable LMA for endotracheal intubation using the FOB guidance and blind techniques. The authors included ASA class I-II patients between 15 and 60 years of age, with mouth opening more than 3 cm, scheduled for elective surgery. The authors excluded patients with any history of gastro-esophageal reflux, full stomach or a body weight < 30 kg. All of the patients received standard general anesthesia. After inducing anesthesia, a disposable LMA No. 3 or No. 4 (Soft Seal, Smiths Medical, Portex Inc, USA) was inserted while the patient was in the sniff position. The authors recorded the insertion time, the ease of insertion, the anatomic placement and position. The authors then inserted a flexible endotracheal tube (No. 6.5 for LMA No. 4 and No. 6 for LMA No. 3) and recorded the success rate and the ease of insertion. After three failures, the authors used FOB guidance. Sixty patients were enrolled (32 males). The mean +/- SD age and BMI was 43.2 +/- 13.4 years and 22.6 +/- 3.9, respectively. Most of the patients had a Mallampati of grade I. The mean +/- SD insertion time was 24.6 +/- 16.1 sec. After the FOB evaluation, only 27 patients had an anatomic placement in full view of the glottis. Eighteen patients had vocal cords in the middle part of the opening. The success rate of blind endotracheal intubation was 5 percent (95%CI 1.0-13.9) (3/60); while the success rate with FOB guidance was 85 percent (95%CI 73.4-92.9). A disposable laryngeal mask airway (Soft Seal) for blind endotracheal intubation had a low success rate, but it could be used more successfully with FOB guidance.

Relationship Between Respiratory Dynamics and Body Mass Index in Patients Undergoing General Anesthesia with Laryngeal Mask Airway (LMA) and Comparison Between Lithotomy and Supine Positions

PubMed Central

Zhao, Xiao; Huang, Shiwei; Wang, Zhaomin; Chen, Lianhua; Li, Shitong

2016-01-01

Background This study aimed to compare respiratory dynamics in patients undergoing general anesthesia with a laryngeal mask airway (LMA) in lithotomy and supine positions and to validate the impact of operational position on effectiveness of LMA ventilation. Material/Methods A total of 90 patients (age range, 18–65 years) who underwent general anesthesia were selected and divided into supine position (SP group) and lithotomy position groups (LP group). Vital signs and respiratory dynamic parameters of the 2 groups were measured at different time points and after implantation of an LMA. The arterial blood gas was monitored at 15 min after induction. The intraoperative changes of hemodynamic indexes and postoperative adverse reactions of LMA were recorded. The possible correlation between body mass index (BMI) and respiratory dynamic indexes was analyzed. Results With prolonged duration of the operation, the inspiratory plateau pressure (Pplat), inspiratory resistance (RI), and work of breathing (WOB) gradually increased, while chest-lung compliance (Compl) and partial pressure of carbon dioxide in end-expiratory gas (PetCO2) gradually decreased (all P value <0.05). The mean airway pressure (Pmean), Pplat, and expiratory resistance (Re) in the LP group were significantly higher than in the SP group (P<0.05), while the peak inspiratory flow (FImax), peak expiratory flow (FEmax), WOB, and Compl in the LP group were significantly lower than in the SP group (P<0.05). BMI was positively correlated with peak airway pressure (PIP/Ppeak), Pplat, and airway resistance (Raw) and was negatively correlated with Compl; the differences among patients in lithotomy position were more remarkable (P<0.05). Conclusions The inspiratory plateau pressure and airway resistance increased with prolonged duration of the operation, accompanied by decreased chest-lung compliance. Peak airway pressure and airway resistance were positively correlated with BMI, and chest-lung compliance was

Electroconvulsive therapy can benefit from controlled hyperventilation using a laryngeal mask.

PubMed

Haeck, Martina; Gillmann, Benjamin; Janouschek, Hildegard; Grözinger, Michael

2011-11-01

Hypocapnia through hyperventilation is a well-known procedure in electroconvulsive therapy (ECT) to enhance seizure activity. However, it has mostly been applied in an uncontrolled manner. Originally intended for a better management of the supraglottic airway, laryngeal masks are more suited to monitor levels of CO(2) during hyperventilation than face masks and thereby provide for the possibility of controlled hyperventilation (CHV). The impact of CHV was retrospectively studied in 114 consecutive patients; 65 of them had received ECT with CHV and 49 had received ECT with uncontrolled hyperventilation (UHV) directly prior to the time period when the laryneal mask was introduced to the ECT treatment procedure. The CO(2) level in the CHV group was aimed at 30 mmHg or below. CHV considerably enhanced the seizure activity leading to changes in clinically determined parameters of the treatment course: the necessity for increasing the electric charge, for re-stimulations (trend) and for bilateral stimulations was lower in the CHV group as compared to the UHV group. The improvement in the Global Assessment of Functioning Scores was not different in both groups. CHV was associated with a higher amount of prolonged seizures, with a reduced number of delirious symptoms after treatments and an attenuating effect on heart rate. Concluding, CHV can help to maintain the applied electric charge low without worsening the clinical outcome. Therefore, it is a helpful technical improvement. However, it should be used carefully with regard to prolonged seizures.

Effects of fentanyl administration before induction of anesthesia and placement of the Laryngeal Mask Airway: a randomized, placebo-controlled trial.

PubMed

Joshi, Girish P; Kamali, Amin; Meng, Jin; Rosero, Eric; Gasanova, Irina

2014-03-01

To assess the effects of fentanyl administered before induction of anesthesia on movement and airway responses during desflurane anesthesia via the Laryngeal Mask Airway (LMA). Randomized, double-blinded, controlled trial. Tertiary-care academic center. 100 adult, ASA physical status 1, 2, and 3 patients undergoing ambulatory surgery. Patients were administered fentanyl 1 μg/kg (n=51) or saline (n=49) 3 to 5 minutes before induction with propofol 2-2.5 mg/kg intravenously (IV), followed by LMA placement. Anesthesia was maintained with desflurane titrated to a bispectral index (BIS) of 50-60 and 50% nitrous oxide in oxygen, and fentanyl 25 μg boluses were titrated to respiratory rate. Apnea occurrence and duration of manual ventilation, as well as frequency and severity of movement, coughing, breath holding, and laryngospasm were recorded. Two patients in each group were excluded from analysis. The fentanyl pretreatment group had a higher frequency of apnea (94% vs 64%; P=0.0003) and longer duration of manual ventilation (3 [interquartile range (IQR), 1.5-5] min vs 1 [0-1.5] min; P<0.0001) at induction. In contrast, the fentanyl pretreatment group had a lower frequency of movements (16% vs 51%;P=0.0001). The rates of intraoperative breath holding (6.1% vs 8.5%) and laryngospasm (2% vs 4.3%) in the two groups were similar. All subjects experiencing laryngospasm were smokers. Adjusting for smoking status did not affect the differences noted in apnea, duration of manual ventilation, or movement between groups; however, coughing occurrence was statistically higher in the placebo group (P=0.043). Preinduction fentanyl increased the frequency of apnea at induction and duration of manual ventilation, but reduced the frequency of movements. In addition, it reduced intraoperative coughing in smokers. Copyright © 2014 Elsevier Inc. All rights reserved.

The intuitive use of laryngeal airway tools by first year medical students.

PubMed

Bickenbach, Johannes; Schälte, Gereon; Beckers, Stefan; Fries, Michael; Derwall, Matthias; Rossaint, Rolf

2009-09-22

Providing a secured airway is of paramount importance in cardiopulmonary resuscitation. Although intubating the trachea is yet seen as gold standard, this technique is still reserved to experienced healthcare professionals. Compared to bag-valve facemask ventilation, however, the insertion of a laryngeal mask airway offers the opportunity to ventilate the patient effectively and can also be placed easily by lay responders. Obviously, it might be inserted without detailed background knowledge.The purpose of the study was to investigate the intuitive use of airway devices by first-year medical students as well as the effect of a simple, but well-directed training programme. Retention of skills was re-evaluated six months thereafter. The insertion of a LMA-Classic and a LMA-Fastrach performed by inexperienced medical students was compared in an airway model. The improvement on their performance after a training programme of overall two hours was examined afterwards. Prior to any instruction, mean time to correct placement was 55.5 +/- 29.6 s for the LMA-Classic and 38.1 +/- 24.9 s for the LMA-Fastrach. Following training, time to correct placement decreased significantly with 22.9 +/- 13.5 s for the LMA-Classic and 22.9 +/- 19.0 s for the LMA-Fastrach, respectively (p < 0.05). After six months, the results are comparable prior (55.6 +/- 29.9 vs 43.1 +/- 34.7 s) and after a further training period (23.5 +/- 13.2 vs 26.6 +/- 21.6, p < 0.05). Untrained laypersons are able to use different airway devices in a manikin and may therefore provide a secured airway even without having any detailed background knowledge about the tool. Minimal theoretical instruction and practical skill training can improve their performance significantly. However, refreshment of knowledge seems justified after six months.

Laryngeal debridement: an alternative treatment for a laryngopyocele presenting with severe airway obstruction.

PubMed

Fraser, L; Pittore, B; Frampton, S; Brennan, P; Puxeddu, R

2011-04-01

The laryngocele is an abnormal saccular dilatation of the ventricle of Morgagni, which maintains its communication with the laryngeal vestibule. Three types of laryngoceles have been described: internal, external, and combined or mixed in relation to the position of the sac with respect to the thyrohyoid membrane. If the laryngocele becomes obstructed and infected it leads to the so-called laryngopyocele which, although a rare disease (8% of laryngoceles), can become an emergency causing severe airway obstruction needing urgent management, even tracheostomy. An alternative method is presented of emergency management of an internal laryngopyocele causing severe airway obstruction using a laryngeal microdebrider and avoiding tracheostomy.

Comparison of the Supreme™ and ProSeal™ laryngeal mask airways in infants: a prospective randomised clinical study.

PubMed

Oba, Sibel; Turk, Hacer Sebnem; Isil, Canan Tulay; Erdogan, Huseyin; Sayin, Pinar; Dokucu, Ali Ihsan

2017-09-05

The Supreme™ and ProSeal™ laryngeal mask airways (LMAs) are widely used in paediatric anaesthesia; however, LMA use in infants is limited because many anaesthesiologists prefer to use tracheal intubation in infants. In this study, we compared the Supreme and ProSeal LMAs in infants by measuring their performance characteristics, including insertion features, ventilation parameters, induced changes in haemodynamics and rates of postoperative complications. Infants of ASA physical status I scheduled for elective, minor, lower abdominal surgery were divided into two groups: the Supreme LMA group and the ProSeal LMA group. Times and ease of LMA insertion were noted. The percentages of tidal volume leakage as well as peak, mean and leakage pressures for all infants were measured. Heart rate (HR), oxygen saturation (SpO2) and end tidal carbon dioxide (EtCO2) values were recorded before and after LMA insertion and before and after extubation. After extubation, complications and adverse effects were noted. Demographic and surgical data were similar between the two groups. LMA insertion times were shorter for the ProSeal group than for the Supreme group (P < 0.002). The mean HR value for the ProSeal group was lower than for the Supreme group (P < 0.011). Both the peak pressure and the leakage percentage for the ProSeal group were statistically lower than for the Supreme group. The leakage pressure for the ProSeal group was statistically higher than for the Supreme group (P < 0.001). The ProSeal LMA is superior to the Supreme LMA for use in infants due to the ease of insertion, high oropharyngeal leakage pressure and fewer induced changes in haemodynamics. ClinicalTrial.gov, NCT03251105 , retrospectively registered on 15 Aug 2017.

Early versus late removal of the laryngeal mask airway (LMA) for general anaesthesia.

PubMed

Mathew, Preethy J; Mathew, Joseph L

2015-08-10

The laryngeal mask airway (LMA) is a safe and effective modality to maintain the airway for general anaesthesia during surgical procedures. The LMA is removed at the end of surgery and anaesthesia, when the patient maintains an adequate respiratory rate and depth. This removal of the LMA can be done either when the patient is deep under anaesthesia (early removal) or only after the patient has regained consciousness (late removal). It is not clear which of these techniques is superior. The objective of this review was to compare the safety of LMA removal in the deep plane of anaesthesia (early removal) versus removal in the awake state (late removal) for participants undergoing general anaesthesia. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (1966 to August 2014); EMBASE (1980 to August 2014); LILACS (1982 to August 2014); CINAHL (WebSPIRS; 1984 to August 2014); and ISI Web of Science (1984 to August 2014). We searched for ongoing trials through various trial registration websites. In addition, we searched conference proceedings and reference lists of relevant articles. We included randomized controlled trials (RCTs) on adults and children undergoing elective general anaesthesia using the LMA, that compared early removal of the LMA (defined as removal of the LMA in the deep plane of anaesthesia) versus late removal of the LMA (defined as removal of the LMA after the patient is awake). Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We used a random-effects model to generate forest plots from the data. We identified a total of 9188 citations and included 15 RCTs conducted on 2242 participants in this review. All trials used the LMA Classic in American Society of Anesthesiologists (ASA) physical status I or II for patients undergoing elective general anaesthesia. Children were enrolled in 11 trials and adults in five trials. None of the

Comparison of the upper airway dynamics of oronasal and nasal masks with positive airway pressure treatment using cine magnetic resonance imaging.

PubMed

Ebben, Matthew R; Milrad, Sara; Dyke, Jonathan P; Phillips, C Douglas; Krieger, Ana C

2016-03-01

It is known that oronasal masks are not as effective at opening the upper airway compared to nasal only continuous positive airway pressure (CPAP) masks in patients with sleep-disordered breathing. However, the physiological mechanism for this difference in efficacy is not known; although, it has been hypothesized to involve the retroglossal and/or retropalatal region of the upper airway. The objective of this study was to investigate differences in retroglossal and retropalatal anterior-posterior space with the use of oronasal vs. nasal CPAP masks using real-time cine magnetic resonance imaging (cMRI). Ten subjects (eight men, two women) with obstructive sleep apnea (OSA) were given cMRI with both nasal and oronasal CPAP masks. Each subject was imaged with each interface at pressures of 5, 10, and 15 cm of H2O, while in the supine position along the sagittal plane. The oronasal mask produced significantly less airway opening in the retropalatal region of the upper airway compared to the nasal mask interface. During exhalation, mask style had a significant effect on anterior-posterior distance p = 0.016. No differences were found in the retroglossal region between mask styles. Our study confirmed previous findings showing differences in treatment efficacy between oronasal and nasal mask styles. We have shown anatomic evidence that the nasal mask is more effective in opening the upper airway compared to the oronasal mask in the retropalatal region.

Comparison of the Upper Airway Dynamics of Oronasal and Nasal Masks with Positive Airway Pressure Treatment using cine Magnetic Resonance Imaging

PubMed Central

Ebben, Matthew R.; Milrad, Sara; Dyke, Jonathan P.; Phillips, C. Douglas; Krieger, Ana C.

2016-01-01

Purpose It is known that oronasal masks are not as effective at opening the upper airway compared to nasal only continuous positive airway pressure (CPAP) masks in patients with sleep disordered breathing. However, the physiological mechanism for this difference in efficacy is not known; although, it has been hypothesized to involve the retroglossal and/or retropalatal region of the upper airway. The objective of this study was to investigate differences in retroglossal and retropalatal anterior-posterior space with the use of oronasal vs. nasal CPAP masks using real-time cine Magnetic Resonance Imaging (cMRI). Methods 10-Subjects (8-men, 2-women) with obstructive sleep apnea (OSA) were given cMRI with both nasal and oronasal CPAP masks. Each subject was imaged with each interface at pressures of 5, 10 and 15 cm of H2O, while in the supine position along the sagittal plane. Results The oronasal mask produced significantly less airway opening in the retropalatal region of the upper airway compared to the nasal mask interface. During exhalation, mask style had a significant effect on anterior-posterior distance p=0.016. No differences were found in the retroglossal region between mask styles. Conclusions Our study confirmed previous findings showing differences in treatment efficacy between oronasal and nasal mask styles. We have shown anatomic evidence that the nasal mask is more effective in opening the upper airway compared to the oronasal mask in the retropalatal region. PMID:25924934

Simple solution for difficult face mask ventilation in children with orofacial clefts.

PubMed

Veerabathula, Prardhana; Patil, Manajeet; Upputuri, Omkar; Durga, Padmaja

2014-10-01

Significant air leak from the facial cleft predisposes to difficult mask ventilation. The reported techniques of use of sterile gauze, larger face mask and laryngeal mask airway after intravenous induction have limited application in uncooperative children. We describe the use of dental impression material molded to the facial contour to cover the facial defect and aid ventilation with an appropriate size face mask in a child with a bilateral Tessier 3 anomaly. © 2014 John Wiley & Sons Ltd.

An ultrasound evaluation of laryngeal mask airway position in pediatric patients: an observational study.

PubMed

Kim, Jeongmin; Kim, Ji Young; Kim, Won Oak; Kil, Hae Keum

2015-02-01

In children, the laryngeal mask airway (LMA) is frequently displaced within the hypopharynx, resulting in repositioning of the device. When the tip of the LMA is placed in the esophageal inlet, the arytenoids are moved ventrally. When the LMA is rotated or deviated, the ventral movement of the arytenoids may result in asymmetric elevation of an arytenoid cartilage, which can be detected with ultrasound (US). In this study, we sought to estimate the incidence of LMA malposition detected with US in pediatric patients. The primary end point was to compare the incidence of LMA malposition between US and fiber optic bronchoscopy (FOB). The secondary end points were to find the interrelationship between US-detected and FOB-detected malposition of the LMA and to locate the diagnostic performance of US in detecting LMA malposition. In this observational study, 100 consecutive children were included. After anesthetic induction, US evaluation was performed before and after LMA insertion to obtain the glottic image on the anterior neck. FOB was performed to assess LMA position (FOB LMA grade and LMA rotation grade). With a post-LMA US image, the symmetry of the arytenoid cartilages was evaluated. Asymmetrical elevation of an arytenoid cartilage in reference to the glottic midline and the opposite arytenoid cartilage was graded as 0 to 3 (US arytenoid grade). The interrelationships between US arytenoid grade and FOB LMA grade or LMA rotation grade were assessed. The incidence of asymmetrical elevation of an arytenoid was 50% (95% confidence interval [CI], 40%-60%). On FOB, the incidence of LMA malposition was 78% (95% CI, 69%-86%), and that of LMA rotation was 43% (95% CI, 33%-53%). The incidence of LMA malposition was higher with FOB (P < 0.0001), but the incidence of rotation was similar (P = 0.395). US arytenoid grade did not correlate with FOB LMA grade (P = 0.611) but showed a significant correlation with LMA rotation grade (P < 0.0001; 95% CI, 60%-83%). To detect a

Awake Craniotomy: A New Airway Approach.

PubMed

Sivasankar, Chitra; Schlichter, Rolf A; Baranov, Dimitry; Kofke, W Andrew

2016-02-01

Awake craniotomies have been performed regularly at the University of Pennsylvania since 2004. Varying approaches to airway management are described for this procedure, including intubation with an endotracheal tube and use of a laryngeal mask airway, simple facemask, or nasal cannula. In this case series, we describe the successful use (i.e., no need for endotracheal intubation related to inadequate gas exchange) of bilateral nasopharyngeal airways in 90 patients undergoing awake craniotomies. The use of nasopharyngeal airways can ease the transition between the asleep and awake phases of the craniotomy without the need to stimulate the airway. Our purpose was to describe our experience and report adverse events related to this technique.

Choosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series

PubMed Central

Ng, Justin R.; Aiyappan, Vinod; Mercer, Jeremy; Catcheside, Peter G.; Chai-Coetzer, Ching Li; McEvoy, R. Doug; Antic, Nick

2016-01-01

Study Objectives: The choice of mask interface used with continuous positive airway pressure (CPAP) therapy can affect the control of upper airway obstruction (UAO) in obstructive sleep apnea (OSA). We describe a case series of four patients with paradoxical worsening of UAO with an oronasal mask and the effect of changing to a nasal mask. Methods: We retrospectively reviewed the case histories of 4 patients and recorded patient demographics, in-laboratory and ambulatory CPAP titration data, CPAP therapy data, type of mask interface used and potential confounding factors. Results: The 4 cases (mean ± SD: age = 59 ± 16 y; BMI = 30.5 ± 4.5 kg/m2) had a high residual apnoea-hypopnea index (AHI) (43 ± 14.2 events/h) and high CPAP pressure requirements (14.9 ± 6.6 cmH2O) with an oronasal mask. Changing to a nasal mask allowed adequate control of UAO with a significant reduction in the average residual AHI (3.1 ± 1.5 events/h). In two of the four cases, it was demonstrated that control of UAO was obtained at a much lower CPAP pressure compared to the oronasal mask (Case one = 17.5 cmH2O vs 12cmH2O; Case two = 17.9 cmH2O vs 7.8 cmH2O). Other potential confounding factors were unchanged. There are various physiological observations that may explain these findings but it is uncertain which individuals are susceptible to these mechanisms. Conclusions: If patients have OSA incompletely controlled by CPAP with evidence of residual UAO and/or are requiring surprisingly high CPAP pressure to control OSA with an oronasal mask, the choice of mask should be reviewed and consideration be given to a trial of a nasal mask. Commentary: A commentary on this article appears in this issue on page 1209. Citation: Ng JR, Aiyappan V, Mercer J, Catcheside PG, Chai-Coetzer CL, McEvoy RD, Antic N. Choosing an oronasal mask to deliver continuous positive airway pressure may cause more upper airway obstruction or lead to higher continuous positive airway pressure requirements than a nasal

[Prehospital airway management of laryngeal tubes. Should the laryngeal tube S with gastric drain tube be preferred in emergency medicine?].

PubMed

Dengler, V; Wilde, P; Byhahn, C; Mack, M G; Schalk, R

2011-02-01

Laryngeal tubes (LT) are increasingly being used for emergency airway management. This article reports on two patients in whom out-of-hospital intubation with a single-lumen LT was associated with massive pulmonary aspiration in one patient and gastric overinflation in the other. In both cases peak inspiratory pressures exceeded the LT leak pressure of approximately 35 mbar. This resulted in gastric inflation and decreased pulmonary compliance and increased inspiratory pressure further, thereby creating a vicious circle. It is therefore recommended that laryngeal tube suction (LTS) should be used in all cases of emergency airway management and a gastric drain tube be inserted through the dedicated second lumen. Apart from gastric overinflation, incorrect LT/LTS placement must be detected and immediately corrected, e.g. in cases of difficult or impossible gastric tube placement, permanent drainage of air from the gastric tube, decreasing minute ventilation or an ascending capnography curve.

Assessment of the speed and ease of insertion of three supraglottic airway devices by paramedics: a manikin study.

PubMed

Castle, Nick; Owen, Robert; Hann, Mark; Naidoo, Raveen; Reeves, David

2010-11-01

Control of the airway is a priority during cardiopulmonary resuscitation and/or following a failed intubation attempt. Supraglottic airway devices provide more effective airway management than bag-valve-mask-ventilation (BVMV) and can be effectively used by non-anaesthetists. 36 paramedic students were timed to ascertain how long it took them to place an Igel, laryngeal mask airway (LMA) or laryngeal tube airway (LTA) into a manikin. Following insertion, students were interviewed to see which device they preferred and why. The Igel was consistently the fastest airway device, taking a mean of 12.3 s (95% CI 11.5 to 13.1) to insert, the LTA took a mean time of 22.4 s (95% CI 20.3 to 24.5) and the LMA 33.8 s (95% CI 30.9 to 36.7). 63% of students would choose the Igel as their preferred intermediate airway device, stating ease of use and speed of insertion as the primary reasons. The ease and speed at which a supraglottic airway can be inserted means that it is a viable alternative to the use of the BVMV.

Extraglottic airway devices: technology update.

PubMed

Sharma, Bimla; Sahai, Chand; Sood, Jayashree

2017-01-01

Extraglottic airway devices (EADs) have revolutionized the field of airway management. The invention of the laryngeal mask airway was a game changer, and since then, there have been several innovations to improve the EADs in design, functionality, safety and construction material. These have ranged from changes in the shape of the mask, number of cuffs and material used, like rubber, polyvinylchloride and latex. Phthalates, which were added to the construction material in order to increase device flexibility, were later omitted when this chemical was found to have serious adverse reproductive outcomes. The various designs brought out by numerous companies manufacturing EADs resulted in the addition of several devices to the airway market. These airway devices were put to use, many of them with inadequate or no evidence base regarding their efficacy and safety. To reduce the possibility of compromising the safety of the patient, the Difficult Airway Society (DAS) formed the Airway Device Evaluation Project Team (ADEPT) to strengthen the evidence base for airway equipment and vet the new extraglottic devices. A preuse careful analysis of the design and structure may help in better understanding of the functionality of a particular device. In the meantime, the search for the ideal EAD continues.

Arytenoid lateralization for management of combined laryngeal paralysis and laryngeal collapse in small dogs.

PubMed

Nelissen, Pieter; White, Richard A S

2012-02-01

To identify combined laryngeal paralysis and collapse in small dogs and describe postoperative outcome after arytenoid lateralization. Case series. Small nonbrachycephalic breed dogs with laryngeal paralysis and collapse (n = 6). Medical records of small breed dogs with airway problems and undergoing laryngeal surgery (January-December 2008) were reviewed. Dogs with combined laryngeal paralysis and laryngeal collapse (LPLC) had arytenoid lateralization. The immediate, 4 week and 6 month postoperative outcomes were described. Direct visual laryngeal exam under a light plane of anesthesia revealed bilateral failure of arytenoid and vocal fold movement and concurrent bilateral medial folding with contact of the cuneiform processes in all dogs. None of the dogs had intra- or immediate postoperative complications after arytenoid lateralization. Two dogs required a 2nd contralateral procedure. Follow-up after 6 months revealed marked improvement in clinical signs related to upper airway obstruction, but all dogs continued to have mild respiratory noise. Concurrent laryngeal paralysis and collapse should be considered as part of the differential diagnosis for small, nonbrachycephalic dogs with upper airway disease. Arytenoid lateralization resulted in improvement of clinical signs related to obstructive airway disease. © Copyright 2011 by The American College of Veterinary Surgeons.

Carbachol injection into the pontine reticular formation depresses laryngeal muscle activities and airway reflexes in decerebrate cats.

PubMed

Adachi, Masaaki; Nonaka, Satoshi; Katada, Akihiro; Arakawa, Takuya; Ota, Ryo; Harada, Hirofumi; Takakusaki, Kaoru; Harabuchi, Yasuaki

2010-05-01

To understand the role of cholinoceptive, medial pontine reticular formation (mPRF) neurons in the control of upper airway, pharyngolaryngeal reflexes, we measured activities of intrinsic laryngeal muscles (posterior cricoarytenoid, PCA; thyroarytenoid, TA), diaphragm (DIA), genioglossus (GG) and a neck muscle (trapezius) in unanesthetized, decerebrated, spontaneously breathing cats with and without mPRF carbachol injections. The ethimoidal nerve was electrically stimulated to evoke sneezing, and the superior laryngeal nerve to evoke the laryngeal reflex, swallowing, and coughing. Carbachol reduced the amplitudes of the spontaneous electromyographic activities in the neck, TA, PCA, GG, and DIA to 7%, 30%, 54%, 45% and 71% of control, respectively, reduced the respiratory rate to 53% without changes in expiratory CO(2) concentration; the magnitude of the laryngeal reflex in the TA muscle to 56%; increased its latency by 13%; and reduced the probability of stimulus-induced sneezing, swallowing, and coughing to less than 40%. These changes lasted more than 1h. These data demonstrate that important upper airway reflexes are suppressed by increasing cholinergic neurotransmission in the mPRF. Because acetylcholine release in the mPRF changes in accordance with sleep-wake cycles, the present findings are relevant to the control of upper airway reflexes during various vigilance states. 2010 Elsevier Ireland Ltd and the Japan Neuroscience Society. All rights reserved.

Evaluation of a New Pediatric Positive Airway Pressure Mask

PubMed Central

Kushida, Clete A.; Halbower, Ann C.; Kryger, Meir H.; Pelayo, Rafael; Assalone, Valerie; Cardell, Chia-Yu; Huston, Stephanie; Willes, Leslee; Wimms, Alison J.; Mendoza, June

2014-01-01

Study Objectives: The choice and variety of pediatric masks for continuous positive airway pressure (CPAP) is limited in the US. Therefore, clinicians often prescribe modified adult masks. Until recently a mask for children aged < 7 years was not available. This study evaluated apnea-hypopnea index (AHI) equivalence and acceptability of a new pediatric CPAP mask for children aged 2-7 years (Pixi; ResMed Ltd, Sydney, Australia). Methods: Patients aged 2-7 years were enrolled and underwent in-lab baseline polysomnography (PSG) using their previous mask, then used their previous mask and the VPAP III ST-A flow generator for ≥ 10 nights at home. Thereafter, patients switched to the Pixi mask for ≥ 2 nights before returning for a PSG during PAP therapy via the Pixi mask. Patients then used the Pixi mask at home for ≥ 21 nights. Patients and their parents/guardians returned to the clinic for follow-up and provided feedback on the Pixi mask versus their previous mask. Results: AHI with the Pixi mask was 1.1 ± 1.5/h vs 2.6 ± 5.4/h with the previous mask (p = 0.3538). Parents rated the Pixi mask positively for: restfulness of the child's sleep, trouble in getting the child to sleep, and trouble in having the child stay asleep. The Pixi mask was also rated highly for leaving fewer or no marks on the upper lip and under the child's ears, and being easy to remove. Conclusions: The Pixi mask is suitable for children aged 2-7 years and provides an alternative to other masks available for PAP therapy in this age group. Citation: Kushida CA, Halbower AC, Kryger MH, Pelayo R, Assalone V, Cardell CY, Huston S, Willes L, Wimms AJ, Mendoza J. Evaluation of a new pediatric positive airway pressure mask. J Clin Sleep Med 2014;10(9):979-984. PMID:25142768

Morphological findings in the tracheal epithelium of dogs exposed to the inhalation of poorly conditioned gases under use of an endotracheal tube or laryngeal mask airway.

PubMed

Dias, Norimar Hernandes; Braz, José Reinaldo Cerqueira; Defaveri, Júlio; Carvalho, Lídia Raquel; Martins, Regina Helena Garcia

2011-10-01

To study morphological findings in the tracheal epithelium of dogs exposed to the inhalation of poorly conditioned gases under use of an endotracheal tube (ET) or laryngeal mask airway (LMA). Twelve dogs randomly were allocated to two groups: ET group (n-6) and LMA group (n-6), anaesthetized and mechanically ventilated, without CO(2) reabsorption. Haemodynamic and ventilatory parameters, tympanic temperature, temperature, relative and absolute humidity of the ambient and inhaled gases were analyzed during three hours. The animals were submitted to euthanasia and biopsies were carried out along the tracheal segment to morphological study. Three healthy dogs were used to morphological control. Inhaled gas temperature was maintained between 24ºC and 26ºC, relative humidity between 10% and 12%, and absolute humidity between 2 - 3 mg H(2)O.L(-1) with no significant differences between groups. In both groups, histological analysis showed epithelial inflammation and congestion in the corion and scanning electron microscopy showed ciliary grouping and disorganization. Transmission electron microscopy showed higher alterations in ET group than LMA group as widening of cell junctions, ciliary disorientation, cytoplasmic vacuolization, nuclear abnormalities, picnosis and chromatin condensation. LMA determined less pronounced changes in the tracheal epithelium in dogs exposed to the inhalation of poorly conditioned gases.

Comparison of Different Cuff Pressure Use with the Supreme Laryngeal Mask Airway on Haemodynamic Response, Seal Pressure and Postoperative Adverse Events: A Prospective Randomized Study.

PubMed

Ali, Achmet; Altun, Demet; Sivrikoz, Nukhet; Yornuk, Mesut; Turgut, Namigar; Akıncı, İbrahim Özkan

2018-04-01

The Supreme™ laryngeal mask airway (SLMA) is a supra glottic airway (SGA) device that is used as an alternative to endotracheal tubes. In the present study, we aimed to compare the use of the SLMA with normal cuff pressure and low cuff pressure, primarily for haemodynamic response. In the present study, 120 patients diagnosed with hypertension and scheduled for varicose vein or inguinal hernia operation were enrolled and 99 patients finished. Using randomization, patients were divided into two groups according to cuff pressure as a low-pressure group (Group L, 45 cm H 2 O) and a normal-pressure group (Group N, 60 cm H 2 O). Demographics, Mallampati score and the type and duration of surgery, heart rate (HR), mean arterial pressure (MAP), percentage of tidal volume leakage, Ppeak, Pmean, etCO 2 , seal pressure, fibreoptic scores and postoperative adverse effects of all patients were recorded. MAP and HR values immediately and 2 minutes after SLMA insertion were significantly lower in Group L (p<0.001). In Group L and Group N, the seal pressures were 24.1±3.1 cm H 2 O and 26.2±3.9 cm H 2 O, respectively (p=0.003). Also, blood staining and sore throat occurred less frequently in Group L (p<0.05). The fibreoptic average score, insertion features and ventilation parameters were similar between the groups (p>0.05). SLMA use with a cuff pressure of 45 cm H 2 O significantly decreases haemodynamic response and post-operative side effects compared with a normal cuff pressure. Therefore, except for some specific surgeries that require higher seal pressures, we recommend the use of the SLMA with cuff pressures as low as 45 cm H 2 O.

[Postextubation laryngeal edema seven years after undergoing neck dissection].

PubMed

Daijo, Hiroki; Habara, Toshie; Katagawa, Tomoko; Yoshikawa, Yukiko; Shinomura, Tetsutaro

2008-05-01

We report a case of upper airway obstruction after extubation in a 69-year-old female patient who underwent transurethral ureterolithotripsy (TUL). She had underwent bilateral modified radical neck dissection 7 years previously. TUL went smoothly in Trenderenburg position, and the extubation was performed after antagonism of neuromuscular block. The patient was closely observed in the operating theater, but about 10 minutes after extubation, she was noted to have dyspnea and tracheal tug. Dexamathasone 2 mg IV was given but was unsuccessful. Although we could support the airway with bag-mask ventilation, continuous stridor required re-intubation. Direct laryngoscopy revealed severe obstruction caused by laryngeal edema. An otolaryngologist was consulted and he performed tracheostomy. We transferred the patient to the intensive care unit for observation. Flexible fiberoptic scope examination performed on postoperative day (POD) 1 showed the decrease of the laryngeal edema. Tacheal tube was removed on POD 7 and she was discharged from the hospital POD 10 without further complications. Patients after a neck dissection may be at elevated risk for postoperative laryngeal edema caused by lymphatic destruction or venous congestion of the neck.

Comparison of trapezius squeeze test and jaw thrust as clinical indicators for laryngeal mask airway insertion in spontaneously breathing children

PubMed Central

Dinesh Kumar, K. K.; Bhardwaj, Neerja; Yaddanapudi, Sandhya

2017-01-01

Background and Aims: It is not known whether trapezius squeeze test (TPZ) is a better clinical test than jaw thrust (JT) to assess laryngeal mask airway (LMA) insertion conditions in children under sevoflurane anesthesia. Material and Methods: After the Institutional Ethics Committee approval and written informed parental consent, 124 American Society of Anesthesiologists I and II children of 2–8 years of age undergoing minor surgical procedures were randomized into TPZ and JT groups. The children were induced with 8% sevoflurane in oxygen at a fresh gas flow of 4 L/min. TPZ or JT was performed after 1 min of start of sevoflurane and then every 20 s till the test was negative, when end-tidal (ET) sevoflurane concentration was noted. Classic LMA of requisite size was inserted by a blinded anesthetist and conditions at the insertion of LMA, insertion time, and the number of attempts of LMA insertion were recorded. Results: The mean LMA insertion time was significantly longer (P < 0.001) for TPZ (145 ± 28.7 sec) compared to JT group (111.8 ± 31.0 sec). ET sevoflurane concentration at the time of LMA insertion was comparable in the two groups. LMA insertion conditions were similar in the two groups. There was no difference between the two groups regarding total number of attempts of LMA insertion. Heart rate (HR) decreased in both groups after LMA insertion (P < 0.001) but TPZ group had significantly lower HR compared with the JT group up to 5 min after LMA insertion (P = 0.03). Conclusion: Both JT and TPZ are equivalent clinical indicators in predicting the optimal conditions of LMA insertion in spontaneously breathing children; however, it takes a longer time to achieve a negative TPZ squeeze test. PMID:28413275

Sensory regulation of swallowing and airway protection: a role for the internal superior laryngeal nerve in humans

PubMed Central

Jafari, Samah; Prince, Rebecca A; Kim, Daniel Y; Paydarfar, David

2003-01-01

During swallowing, the airway is protected from aspiration of ingested material by brief closure of the larynx and cessation of breathing. Mechanoreceptors innervated by the internal branch of the superior laryngeal nerve (ISLN) are activated by swallowing, and connect to central neurones that generate swallowing, laryngeal closure and respiratory rhythm. This study was designed to evaluate the hypothesis that the ISLN afferent signal is necessary for normal deglutition and airway protection in humans. In 21 healthy adults, we recorded submental electromyograms, videofluoroscopic images of the upper airway, oronasal airflow and respiratory inductance plethysmography. In six subjects we also recorded pressures in the hypopharynx and upper oesophagus. We analysed swallows that followed a brief infusion (4–5 ml) of liquid barium onto the tongue, or a sip (1–18 ml) from a cup. In 16 subjects, the ISLN was anaesthetised by transcutaneous injection of bupivacaine into the paraglottic compartment. Saline injections using the identical procedure were performed in six subjects. Endoscopy was used to evaluate upper airway anatomy, to confirm ISLN anaesthesia, and to visualise vocal cord movement and laryngeal closure. Comparisons of swallowing and breathing were made within subjects (anaesthetic or saline injection vs. control, i.e. no injection) and between subjects (anaesthetic injection vs. saline injection). In the non-anaesthetised condition (saline injection, 174 swallows in six subjects; no injection, 522 swallows in 20 subjects), laryngeal penetration during swallowing was rare (1.4 %) and tracheal aspiration was never observed. During ISLN anaesthesia (16 subjects, 396 swallows), all subjects experienced effortful swallowing and an illusory globus sensation in the throat, and 15 subjects exhibited penetration of fluid into the larynx during swallowing. The incidence of laryngeal penetration in the anaesthetised condition was 43 % (P < 0.01, compared with either

Effects of Masking Noise on Laryngeal Resistance for Breathy, Normal, and Pressed Voice

ERIC Educational Resources Information Center

Grillo, Elizabeth U.; Abbott, Katherine Verdolini; Lee, Timothy D.

2010-01-01

Purpose: The purpose of the present study was to explore the effects of masking noise on laryngeal resistance for breathy, normal, and pressed voice in vocally trained women. Method: Eighteen vocally trained women produced breathy, normal, and pressed voice across 7 fundamental frequencies during a repeated CV utterance of /pi/ under normal and…

The Effects of Hyper- and Hypocapnia on Phonatory Laryngeal Airway Resistance in Women

ERIC Educational Resources Information Center

Gillespie, Amanda I.; Slivka, William; Atwood, Charles W., Jr.; Abbott, Katherine Verdolini

2015-01-01

Purpose: The larynx has a dual role in the regulation of gas flow into and out of the lungs while also establishing resistance required for vocal fold vibration. This study assessed reciprocal relations between phonatory functions--specifically, phonatory laryngeal airway resistance (R[subscript law])--and respiratory homeostasis during states of…

Laryngeal airway reconstruction indicates that rodent ultrasonic vocalizations are produced by an edge-tone mechanism

PubMed Central

Borgard, Heather L.

2017-01-01

Some rodents produce ultrasonic vocalizations (USVs) for social communication using an aerodynamic whistle, a unique vocal production mechanism not found in other animals. The functional anatomy and evolution of this sound production mechanism remains unclear. Using laryngeal airway reconstruction, we identified anatomical specializations critical for USV production. A robust laryngeal cartilaginous framework supports a narrow supraglottal airway. An intralaryngeal airsac-like cavity termed the ventral pouch was present in three muroid rodents (suborder Myomorpha), but was absent in a heteromyid rodent (suborder Castorimorpha) that produces a limited vocal repertoire and no documented USVs. Small lesions to the ventral pouch in laboratory rats caused dramatic changes in USV production, supporting the hypothesis that an interaction between a glottal exit jet and the alar edge generates ultrasonic signals in rodents. The resulting undulating airflow around the alar edge interacts with the resonance of the ventral pouch, which may function as a Helmholtz resonator. The proposed edge-tone mechanism requires control of intrinsic laryngeal muscles and sets the foundation for acoustic variation and diversification among rodents. Our work highlights the importance of anatomical innovations in the evolution of animal sound production mechanisms. PMID:29291091

Reconstructive procedures for impaired upper airway function: laryngeal respiration

PubMed Central

Müller, Andreas

2005-01-01

The larynx is the "bottleneck" of the human airway. For this reason, the effects of stenosing laryngeal pathologies on the vital factor respiratory gas exchange are particularly critical. Internal stabilization is a prerequisite for recovery of the laryngeal respiratory function in severe forms of inspiratory collapse (laryngomalacia). Effective laser surgery techniques have been developed to this end in recent years. Glottis-dilating surgery in cases of bilateral vocal cord motion impairment is now moving in the direction of endoscopic laser cordotomy or cordectomy, whereas arytenoidectomy and open surgical procedures are now used only rarely due to higher secondary morbidity rates. In individual cases, in particular if functional recovery is expected, temporary laterofixation of a vocal cord using an endoscopic suturing technique can be a helpful approach. Extensive laryngeal defects can be covered by means of composite grafts with mucosal lining, a supporting skeleton and their own vascularization. Autologous transplantation of the larynx, with its complex surgical and immunological problems, has become a manageable procedure. The problems of post-transplantation reinnervation and risk assessment of immunosuppression-induced recurrence of the tumor are still under consideration. Reanimation of the bilaterally paralyzed larynx by means of neurorrhaphy (neurosuture), neural grafting and, more recently, functional electrostimulation (pacemaker) represents a challenge for the coming years. In most cases of paralysis of the recurrent laryngeal nerve, a part of the muscles is maintained by synkinetic reinnervation when therapy is carried out, which however also prevents effective vocal cord movement due to simultaneous activity of agonists and antagonists. Modulation of reinnervation by means of electrostimulation and modern genetic therapy approaches justify hopes of better outcomes in the future. PMID:22073057

The development of the Laryngeal Mask--a brief history of the invention, early clinical studies and experimental work from which the Laryngeal Mask evolved.

PubMed

Brain, A I

1991-01-01

The history of the invention and development of the Laryngeal Mask in the East End of London during the years 1981-88 is briefly described. The concept evolved from home-made prototypes built from the Goldman Dental Mask through a complex series of one-off latex models culminating in a primitive factory-made silicone cuff in 1986. This work defined the design parameters necessary to reconcile the needs for safety, reliability and ease of insertion while at the same time exploring the limits to possible use. In early 1988 the final version was tested by the inventor who had by this time used the device in more than 7500 patients undergoing routine surgery. From this experience a number of important lessons were learned relating to safe and effective use, which are summarized in the inventor's Instruction Manual. The importance of referring to this volume before use is stressed.

Catheter and Laryngeal Mask Endotracheal Surfactant Therapy: the CALMEST approach as a novel MIST technique.

PubMed

Vannozzi, Ilaria; Ciantelli, Massimiliano; Moscuzza, Francesca; Scaramuzzo, Rosa T; Panizza, Davide; Sigali, Emilio; Boldrini, Antonio; Cuttano, Armando

2017-10-01

Neonatal respiratory distress syndrome (RDS) is a major cause of mortality and morbidity among preterm infants. Although the INSURE (INtubation, SURfactant administration, Estubation) technique for surfactant replacement therapy is so far the gold standard method, over the last years new approaches have been studied, i.e. less invasive surfactant administration (LISA) or minimally invasive surfactant therapy (MIST). Here we propose an originally modified MIST, called CALMEST (Catheter And Laryngeal Mask Endotracheal Surfactant Therapy), using a particular laryngeal mask as a guide for a thin catheter to deliver surfactant directly in the trachea. We performed a preliminary study on a mannequin and a subsequent in vivo pilot trial. This novel procedure is quick, effective and well tolerated and might represent an improvement in reducing neonatal stress. Ultimately, CALMEST offers an alternative approach that could be extremely useful for medical staff with low expertise in laryngoscopy and intubation.

Cricothyroid Muscle Botulinum Toxin Injection to Improve Airway for Bilateral Recurrent Laryngeal Nerve Paralysis, A Case Series.

PubMed

Benninger, Michael S; Hanick, Andrea; Hicks, Douglas M

2016-01-01

Bilateral vocal fold paralysis most commonly results from iatrogenic trauma to the recurrent laryngeal nerve during surgical procedures in the anterior neck. Patients may require tracheostomy because of acute or gradual onset of dyspnea and airway compromise. The intralaryngeal injection of Botox has been considered as a possible therapy for these airway symptoms of bilateral vocal fold paralysis. Chronic unopposed activity of intact cricothyroid muscles could potentially result in gradual medialization of the vocal folds in patients with bilateral recurrent laryngeal nerve paralysis. This case series describes three patients who successfully underwent injections of botulinum toxin into the bilateral cricothyroid muscles to offer sustained relief of dyspnea resulting from bilateral vocal fold paralysis. Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Results of upper airway radiography and ultrasonography predict dynamic laryngeal collapse in affected horses.

PubMed

Fjordbakk, C T; Chalmers, H J; Holcombe, S J; Strand, E

2013-11-01

The pathogenesis of dynamic bilateral laryngeal collapse (DLC) associated with poll flexion is unknown. Diagnosis is dependent upon exercise endoscopy while replicating the flexed head position harness racehorses experience during racing. To describe the effects of poll flexion on rostrocaudal laryngeal positioning and laryngeal lumen width in resting horses diagnosed with DLC compared to controls, and to establish diagnostic criteria for DLC by use of diagnostic imaging. Case-control study. Fifty harness racehorses were prospectively included in the study: 25 cases diagnosed with DLC by treadmill endoscopy and 25 controls in which treadmill endoscopy revealed no abnormal findings. Laryngeal radiography and ultrasonography were obtained in neutral and flexed head positions. Laryngeal positioning and laryngohyoid conformation were compared between the groups and head positions. Poll flexion induced a greater rostral advancement of the larynx in relation to the hyoid apparatus in resting harness racehorses affected with DLC compared to controls (P = 0.007). At the level of the vocal folds, poll flexion resulted in a smaller laryngeal lumen width in horses affected with DLC compared to controls (P = 0.04). Horses were significantly more likely to be affected with DLC when the thyrohyoid bone to thyroid cartilage distance was ≥12 mm in poll flexion (odds ratio 21.3, 95% confidence interval 3.65-124.8, P = 0.004) and when laryngeal lumen width at the level of the vocal folds was less in poll flexion than in the neutral head position (odds ratio 8.4; 95% confidence interval 1.6-44.1, P = 0.012). In DLC horses, poll flexion advanced the larynx more rostrally and resulted in a decreased airway lumen width compared to control horses. Laryngeal ultrasound and radiography may facilitate the diagnosis of DLC at rest. © 2013 EVJ Ltd.

Success rates of pre-hospital difficult airway management: a quality control study evaluating an in-hospital training program.

PubMed

Trimmel, Helmut; Beywinkler, Christoph; Hornung, Sonja; Kreutziger, Janett; Voelckel, Wolfgang G

2018-03-16

Competence in emergency airway management is key in order to improve patient safety and outcome. The scope of compulsory training for emergency physicians or paramedics is quite limited, especially in Austria. The purpose of this study was to review the difficult airway management performance of an emergency medical service (EMS) in a region that has implemented a more thorough training program than current regulations require, comprising 3 months of initial training and supervised emergency practice and 3 days/month of on-going in-hospital training as previously reported. This is a subgroup analysis of pre-hospital airway interventions performed by non-anesthesiologist EMS physicians between 2006 and 2016. The dataset is part of a retrospective quality control study performed in the ground EMS system of Wiener Neustadt, Austria. Difficult airway missions recorded in the electronic database were matched with the hospital information system and analyzed. Nine hundred thirty-three of 23060 ground EMS patients (4%) required an airway intervention. In 48 cases, transient bag-mask-valve ventilation was sufficient, and 5 patients needed repositioning of a pre-existing tracheostomy cannula. Eight hundred thirty-six of 877 patients (95.3%) were successfully intubated within two attempts; in 3 patients, a supraglottic airway device was employed first line. Management of 41 patients with failed tracheal intubation comprised laryngeal tubes (n = 21), intubating laryngeal mask (n = 11), ongoing bag-mask-valve ventilation (n = 8), and crico-thyrotomy (n = 1). There was no cannot intubate/cannot ventilate situation. Blood gas analysis at admission revealed hypoxemia in 2 and/or hypercapnia in 11 cases. During the 11-year study period, difficult airways were encountered in 5% but sufficiently managed in all patients. Thus, the training regime presented might be a feasible and beneficial model for training of non-anesthesiologist emergency physicians as well as

[Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome].

PubMed

Fuentes, Ricardo; De la Cuadra, Juan Carlos; Lacassie, Hector; González, Alejandro

Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al. An one month-old infant with Treacher Collins Syndrome was scheduled for mandibular surgery under general endotracheal anesthesia. Direct laryngoscopy for oral intubation failed to reveal the glottis. Fiberoptic intubation using nasal approach and using oral approach through a 1.5 size laryngeal mask airway were performed; however, both approach failed because the fiberscope loaded with a one 3.5mm ID uncuffed tube was stuck inside the nasal cavity or inside the laryngeal mask airway respectively. Therefore, the laryngeal mask airway was keep in place and the fiberoptic intubation technique described by Ellis et al. was planned: the tracheal tube with the 15mm adapter removed was loaded proximally over the fiberscope; the fiberscope was advanced under video-screen visualization into the trachea; the laryngeal mask airway was removed, leaving the fiberscope in place; the tracheal tube was passed completely through the laryngeal mask airway and advanced down over the fiberscope into the trachea; the fiberscope was removed and the 15mm adapter was reattached to the tracheal tube. The fiberoptic intubation method through a laryngeal mask airway described by Ellis et al. can be successfully used in small infants with Treacher Collins Syndrome. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Evaluation of a new pediatric positive airway pressure mask.

PubMed

Kushida, Clete A; Halbower, Ann C; Kryger, Meir H; Pelayo, Rafael; Assalone, Valerie; Cardell, Chia-Yu; Huston, Stephanie; Willes, Leslee; Wimms, Alison J; Mendoza, June

2014-09-15

The choice and variety of pediatric masks for continuous positive airway pressure (CPAP) is limited in the US. Therefore, clinicians often prescribe modified adult masks. Until recently a mask for children aged < 7 years was not available. This study evaluated apnea-hypopnea index (AHI) equivalence and acceptability of a new pediatric CPAP mask for children aged 2-7 years (Pixi; ResMed Ltd, Sydney, Australia). Patients aged 2-7 years were enrolled and underwent in-lab baseline polysomnography (PSG) using their previous mask, then used their previous mask and the VPAP III ST-A flow generator for ≥ 10 nights at home. Thereafter, patients switched to the Pixi mask for ≥ 2 nights before returning for a PSG during PAP therapy via the Pixi mask. Patients then used the Pixi mask at home for ≥ 21 nights. Patients and their parents/guardians returned to the clinic for follow-up and provided feedback on the Pixi mask versus their previous mask. AHI with the Pixi mask was 1.1 ± 1.5/h vs 2.6 ± 5.4/h with the previous mask (p = 0.3538). Parents rated the Pixi mask positively for: restfulness of the child's sleep, trouble in getting the child to sleep, and trouble in having the child stay asleep. The Pixi mask was also rated highly for leaving fewer or no marks on the upper lip and under the child's ears, and being easy to remove. The Pixi mask is suitable for children aged 2-7 years and provides an alternative to other masks available for PAP therapy in this age group. © 2014 American Academy of Sleep Medicine.

Choosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series.

PubMed

Ng, Justin R; Aiyappan, Vinod; Mercer, Jeremy; Catcheside, Peter G; Chai-Coetzer, Ching Li; McEvoy, R Doug; Antic, Nick

2016-09-15

The choice of mask interface used with continuous positive airway pressure (CPAP) therapy can affect the control of upper airway obstruction (UAO) in obstructive sleep apnea (OSA). We describe a case series of four patients with paradoxical worsening of UAO with an oronasal mask and the effect of changing to a nasal mask. We retrospectively reviewed the case histories of 4 patients and recorded patient demographics, in-laboratory and ambulatory CPAP titration data, CPAP therapy data, type of mask interface used and potential confounding factors. The 4 cases (mean ± SD: age = 59 ± 16 y; BMI = 30.5 ± 4.5 kg/m(2)) had a high residual apnoea-hypopnea index (AHI) (43 ± 14.2 events/h) and high CPAP pressure requirements (14.9 ± 6.6 cmH2O) with an oronasal mask. Changing to a nasal mask allowed adequate control of UAO with a significant reduction in the average residual AHI (3.1 ± 1.5 events/h). In two of the four cases, it was demonstrated that control of UAO was obtained at a much lower CPAP pressure compared to the oronasal mask (Case one = 17.5 cmH2O vs 12cmH2O; Case two = 17.9 cmH2O vs 7.8 cmH2O). Other potential confounding factors were unchanged. There are various physiological observations that may explain these findings but it is uncertain which individuals are susceptible to these mechanisms. If patients have OSA incompletely controlled by CPAP with evidence of residual UAO and/or are requiring surprisingly high CPAP pressure to control OSA with an oronasal mask, the choice of mask should be reviewed and consideration be given to a trial of a nasal mask. A commentary on this article appears in this issue on page 1209. © 2016 American Academy of Sleep Medicine.

Laryngeal structure and function in dogs with cough.

PubMed

Johnson, Lynelle R

2016-07-15

OBJECTIVE To investigate the prevalence and type of laryngeal abnormalities in dogs examined because of cough that did not have signs of upper airway disease and to compare the prevalence of those abnormalities among dogs with various respiratory tract diseases. DESIGN Prospective study. ANIMALS 138 dogs with cough that did not have signs of upper airway disease. PROCEDURES The study was conducted between July 2001 and October 2014 and included dogs examined for cough that had laryngoscopic and bronchoscopic examinations performed by 1 examiner. Laryngeal hyperemia and swelling were recorded, and laryngeal function was assessed before and after doxapram stimulation when indicated. Results were compared among dogs on the basis of cough duration (acute [< 2 weeks], subacute [2 weeks to 2 months], and chronic [> 2 months]) and disease diagnosed (inflammatory airway disease, airway collapse, lower respiratory tract infection, and eosinophilic bronchopneumopathy). RESULTS Laryngeal hyperemia was detected in 73 of 134 (54%) dogs with cough of subacute or chronic duration, and its prevalence did not vary significantly among dogs with various diseases. Thirteen dogs had laryngeal paresis, and 13 dogs had laryngeal paralysis; dysphonia (n = 2) and stridor (1) were uncommon findings in those dogs. The prevalence of laryngeal dysfunction (paresis or paralysis) did not differ significantly among diseases. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that 26 of 138 (19%) dogs examined because of cough alone had laryngeal dysfunction, which suggested that a complete laryngoscopic examination should be included in the diagnostic evaluation of dogs with cough.

Surgical management of laryngeal collapse associated with brachycephalic airway obstruction syndrome in dogs.

PubMed

White, R N

2012-01-01

To describe the use of cricoarytenoid lateralisation combined with thyroarytenoid caudo- lateralisation (arytenoid laryngoplasty) for the management of stage II and III laryngeal collapse in dogs. A retrospective study of a consecutive series of 12 dogs suffering from life-threatening stage II or III laryngeal collapse associated with brachycephalic airway obstruction syndrome. Pre-operatively, either stage II collapse (2/12) or stage III collapse (10/12) was confirmed on visual examination. In all cases, a left-sided arytenoid laryngoplasty was performed. Two dogs were euthanased postoperatively as a result of persistent life-threatening respiratory compromise. The procedure resulted in subjective enlargement of the rima glottidis and an associated improvement in respiratory function in the remaining 10 dogs. Follow-up, long-term outcome (median, 3·5 years) in these dogs indicated that all owners considered that the surgery had resulted in marked improvements in their dog's respiratory function, tolerance to exercise, and quality of life. Combined cricoarytenoid and thyroarytenoid caudo-lateralisation may be a useful procedure for treatment of stage II and III laryngeal collapse in the dog. © 2011 British Small Animal Veterinary Association.

Paramedic King Laryngeal Tube airway insertion versus endotracheal intubation in simulated pediatric respiratory arrest.

PubMed

Mitchell, Michael S; Lee White, Marjorie; King, William D; Wang, Henry E

2012-01-01

Pediatric endotracheal intubation (ETI) is difficult and can have serious adverse events when performed by paramedics in the prehospital setting. Paramedics may use the King Laryngeal Tube airway (KLT) in difficult adult airways, but only limited data describe their application in pediatric patients. To compare paramedic airway insertion speed and complications between KLT and ETI in a simulated model of pediatric respiratory arrest. This prospective, randomized trial included paramedics and senior paramedic students with limited prior KLT experience. We provided brief training on pediatric KLT insertion. Using a random allocation protocol, participants performed both ETI and KLT on a pediatric mannequin (6-month old size) in simulated respiratory arrest. The primary outcomes were 1) elapsed time to successful airway placement (seconds), and 2) proper airway positioning. We compared airway insertion performance between KLT and ETI using the Wilcoxon signed-ranks test. Subjects also indicated their preferred airway device. The 25 subjects included 19 paramedics and 6 senior paramedic students. Two subjects had prior adult KLT experience. Airway insertion time was not statistically different between the KLT (median 27 secs) and ETI (median 31 secs) (p = 0.08). Esophageal intubation occurred in 2 of 25 (8%) ETI. Airway leak occurred in 3 of 25 (12%) KLT, but ventilation remained satisfactory. Eighty-four percent of the subjects preferred the KLT over ETI. Paramedics and paramedic students demonstrated similar airway insertion performance between KLT and ETI in simulated, pediatric respiratory arrest. Most subjects preferred KLT. KLT may provide a viable alternative to ETI in prehospital pediatric airway management.

Definitive airway management of patients presenting with a pre-hospital inserted King LT(S)-D laryngeal tube airway: a historical cohort study.

PubMed

Subramanian, Arun; Garcia-Marcinkiewicz, Annery G; Brown, Daniel R; Brown, Michael J; Diedrich, Daniel A

2016-03-01

The King LT(S)-D laryngeal tube (King LT) has gained popularity as a bridge airway for pre-hospital airway management. In this study, we retrospectively reviewed the use of the King LT and its associated airway outcomes at a single Level 1 trauma centre. The data on all adult patients presenting to the Mayo Clinic in Rochester, Minnesota with a King LT in situ from July 1, 2007 to October 10, 2012 were retrospectively evaluated. Data collected and descriptively analyzed included patient demographics, comorbidities, etiology of respiratory failure, airway complications, subsequent definitive airway management technique, duration of mechanical ventilation, and status at discharge. Forty-eight adult patients met inclusion criteria. The most common etiology for respiratory failure requiring an artificial airway was cardiac arrest [28 (58%) patients] or trauma [9 (19%) patients]. Four of the nine trauma patients had facial trauma. Surgical tracheostomy was the definitive airway management technique in 14 (29%) patients. An airway exchange catheter, direct laryngoscopy, and video laryngoscopy were used in 11 (23%), ten (21%), and ten (21%) cases, respectively. Seven (78%) of the trauma patients underwent surgical tracheostomy compared with seven (18%) of the medical patients. Adverse events associated with King LT use occurred in 13 (27%) patients, with upper airway edema (i.e., tongue engorgement and glottic edema) being most common (19%). In this study of patients presenting to a hospital with a King LT, the majority of airway exchanges required an advanced airway management technique beyond direct laryngoscopy. Upper airway edema was the most common adverse observation associated with King LT use.

The Supraglottic Effect of a Reduction in Expiratory Mask Pressure During Continuous Positive Airway Pressure

PubMed Central

Masdeu, Maria J.; Patel, Amit V.; Seelall, Vijay; Rapoport, David M.; Ayappa, Indu

2012-01-01

Study Objectives: Patients with obstructive sleep apnea may have difficulty exhaling against positive pressure, hence limiting their acceptance of continuous positive airway pressure (CPAP). C-Flex is designed to improve comfort by reducing pressure in the mask during expiration proportionally to expiratory airflow (3 settings correspond to increasing pressure changes). When patients use CPAP, nasal resistance determines how much higher supraglottic pressure is than mask pressure. We hypothesized that increased nasal resistance results in increased expiratory supraglottic pressure swings that could be mitigated by the effects of C-Flex on mask pressure. Design: Cohort study. Setting: Sleep center. Participants: Seventeen patients with obstructive sleep apnea/hypopnea syndrome and a mechanical model of the upper airway. Interventions: In patients on fixed CPAP, CPAP with different C-Flex levels was applied multiple times during the night. In the model, 2 different respiratory patterns and resistances were tested. Measurements and Results: Airflow, expiratory mask, and supraglottic pressures were measured on CPAP and on C-Flex. Swings in pressure during expiration were determined. On CPAP, higher nasal resistance produced greater expiratory pressure swings in the supraglottis in the patients and in the model, as expected. C-Flex 3 produced expiratory drops in mask pressure (range −0.03 to −2.49 cm H2O) but mitigated the expira-tory pressure rise in the supraglottis only during a sinusoidal respiratory pattern in the model. Conclusions: Expiratory changes in mask pressure induced by C-Flex did not uniformly transmit to the supraglottis in either patients with obstructive sleep apnea on CPAP or in a mechanical model of the upper airway with fixed resistance. Data suggest that the observed lack of expiratory drop in supraglottic pressure swings is related to dynamics of the C-Flex algorithm. Citation: Masdeu MJ; Patel AV; Seelall V; Rapoport DM; Ayappa I. The

LMA Supreme for neonatal resuscitation: study protocol for a randomized controlled trial

PubMed Central

2014-01-01

Background The most important action in the resuscitation of a newborn in the delivery room is to establish effective assisted ventilation. The face mask and endotracheal tube are the devices used to achieve this goal. Laryngeal mask airways that fit over the laryngeal inlet have been shown to be effective for ventilating newborns at birth and should be considered as an alternative to facemask ventilation or endotracheal intubation among newborns weighing >2,000 g or delivered ≥34 weeks’ gestation. A recent systematic review and meta-analysis of supraglottic airways in neonatal resuscitation reported the results of four randomized controlled trials (RCTs) stating that fewer infants in the group using laryngeal mask airways required endotracheal intubation (1.5%) compared to the group using face masks (12.0%). However, there were methodological concerns over all the RCTs including the fact that the majority of the operators in the trials were anesthesiologists. Our hypothesis is based on the assumption that ventilating newborns needing positive pressure ventilation with a laryngeal mask airway will be more effective than ventilating with a face mask in a setting where neonatal resuscitation is performed by midwives, nurses, and pediatricians. The primary aim of this study will be to assess the effectiveness of the laryngeal mask airway over the face mask in preventing the need for endotracheal intubation. Methods/design This will be an open, prospective, randomized, single center, clinical trial. In this study, 142 newborns weighing >1,500 g or delivered ≥34 weeks gestation needing positive pressure ventilation at birth will be randomized to be ventilated with a laryngeal mask airway (LMA SupremeTM, LMA Company, UK - intervention group) or with a face mask (control group). Primary outcome: Proportion of newborns needing endotracheal intubation. Secondary outcomes: Apgar score at 5 minutes, time to first breath, onset of the first cry, duration of

Inducible Laryngeal Obstruction: Excessive Dynamic Airway Collapse vs. Inducible Laryngeal Obstruction

DTIC Science & Technology

2017-10-20

testing unremarkable (’lilble 1) • Repeat exerciBe laryogoacopy found laryngeal edema and no 1LO Noted to have expindory wheezing belt belrd over...DLo/VA 4.l! 187" ) Vocal cord edema or paralysis Paradoxical vocal cord motion Laryngeal stenosls Laryngocele Tonsillar hypertrophy Post nasal

Laryngeal aerodynamics associated with oral contraceptive use: preliminary findings.

PubMed

Gorham-Rowan, Mary; Fowler, Linda

2009-01-01

The purpose of this study was to examine possible differences in laryngeal aerodynamic measures during connected speech associated with oral contraceptive (OC) use. Eight women taking an OC, and eight others not taking an OC, participated in the study. Three trials of syllable /p/repetitions were obtained using a circumferentially vented face mask and small translabial tube. All participants were recorded on or near days 7 and 14 of their menstrual cycle. Subglottal pressure (P(SG)) and average airflow rates were obtained to determine laryngeal airway resistance. Glottal airflow measures of peak flow, minimum flow, alternating flow, as well as relative sound level (RSL) were obtained. P(SG) was obtained from the pressure peak associated with/p/. All airflow parameters and RSL were obtained from the vowel portion. No significant differences were found related to day of recording or OC use, indicating that OC use does not significantly affect laryngeal airflow regulation. The reader will better understand the effects of hormones and oral contraceptives on the female voice, as well as the specific changes in vocal function that may occur in conjunction with the use of oral contraceptives.

Laryngeal and tracheal afferent nerve stimulation evokes swallowing in anaesthetized guinea pigs

PubMed Central

Tsujimura, Takanori; Udemgba, Chioma; Inoue, Makoto; Canning, Brendan J

2013-01-01

We describe swallowing reflexes evoked by laryngeal and tracheal vagal afferent nerve stimulation in anaesthetized guinea pigs. The swallowing reflexes evoked by laryngeal citric acid challenges were abolished by recurrent laryngeal nerve (RLN) transection and mimicked by electrical stimulation of the central cut ends of an RLN. By contrast, the number of swallows evoked by upper airway/pharyngeal distensions was not significantly reduced by RLN transection but they were virtually abolished by superior laryngeal nerve transection. Laryngeal citric acid-evoked swallowing was mimicked by laryngeal capsaicin challenges, implicating transient receptor potential vanilloid 1 (TRPV1)-expressing laryngeal afferent nerves arising from the jugular ganglia. The swallowing evoked by citric acid and capsaicin and evoked by electrical stimulation of either the tracheal or the laryngeal mucosa occurred at stimulation intensities that were typically subthreshold for evoking cough in these animals. Swallowing evoked by airway afferent nerve stimulation also desensitized at a much slower rate than cough. We speculate that swallowing is an essential component of airway protection from aspiration associated with laryngeal and tracheal afferent nerve activation. PMID:23858010

A randomized comparison of the i-gel with the self-pressurized air-Q intubating laryngeal airway in children.

PubMed

Kim, Min-Soo; Lee, Jae Hoon; Han, Sang Won; Im, Young Jae; Kang, Hyo Jong; Lee, Jeong-Rim

2015-04-01

Supraglottic airway devices with noninflatable cuff have advantages in omitting the cuff pressure monitoring and reducing potential pharyngolaryngeal complications. Typical devices without cuff inflation available in children are the i-gel and the self-pressurized air-Q intubating laryngeal airway (air-Q SP). To date, there is no comparative study between these devices in pediatric patients. The purpose of this randomized study was to compare the i-gel(™) and the self-pressurized air-Q(™) intubating laryngeal airway (air-Q SP) in children undergoing general anesthesia. Eighty children, 1-108 months of age, 7-30 kg of weight, and scheduled for elective surgery in which supraglottic airway devices would be suitable for airway management, were randomly assigned to either the i-gel or the air-Q SP. Oropharyngeal leak pressure and fiberoptic view were assessed three times as follows: after insertion and fixation of the device, 10 min after initial assessment, and after completion of surgery. We also assessed insertion parameters and complications. Insertion of the i-gel was regarded as significantly easier compared to the air-Q SP (P = 0.04). Compared to the air-Q SP group, the i-gel group had significantly higher oropharyngeal leak pressures at all measurement points and significantly lower frequencies of gastric insufflation at 10 min after initial assessment and completion of surgery. The air-Q SP group had better fiberoptic views than the i-gel group at all measurement points. Our results showed that the i-gel had easier insertion and better sealing function, and the air-Q SP provided improved fiberoptic views in children requiring general anesthesia. © 2015 John Wiley & Sons Ltd.

Design and Implementation of the Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART)

PubMed Central

Wang, Henry E.; Prince, David; Stephens, Shannon W.; Herren, Heather; Daya, Mohamud; Richmond, Neal; Carlson, Jestin; Warden, Craig; Colella, M. Riccardo; Brienza, Ashley; Aufderheide, Tom P.; Idris, Ahamed; Schmicker, Robert; May, Susanne; Nichol, Graham

2016-01-01

Airway management is an important component of resuscitation from out-of-hospital cardiac arrest (OHCA). The optimal approach to advanced airway management is unknown. The Pragmatic Airway Resuscitation Trial (PART) will compare the effectiveness of endotracheal intubation (ETI) and Laryngeal Tube (LT) insertion upon 72-hour survival in adult OHCA. Encompassing United States Emergency Medical Services agencies affiliated with the Resuscitation Outcomes Consortium (ROC), PART will use a cluster-crossover randomized design. Participating subjects will include adult, non-traumatic OHCA requiring bag-valve-mask ventilation. Trial interventions will include 1) initial airway management with ETI and 2) initial airway management with LT. The primary and secondary trial outcomes are 72-hour survival and return of spontaneous circulation. Additional clinical outcomes will include airway management process and adverse events. The trial will enroll a total of 3,000 subjects. Results of PART may guide the selection of advanced airway management strategies in OHCA. PMID:26851059

Air-Q laryngeal airway for rescue and tracheal intubation.

PubMed

Ads, Ayman; Auerbach, Frederic; Ryan, Kelly; El-Ganzouri, Abdel R

2016-08-01

We report the successful use of the Air-Q laryngeal airway (Air-Q LA) as a ventilatory device and a conduit for tracheal intubation to rescue the airway in a patient with difficult airway and tracheal stenosis. This is the first case report of the device to secure the airway after two episodes of hypoxemia in the operating room and intensive care unit. Consent for submission of this case report was obtained from our institution's human studies institutional review board given that the patient died a few months after his discharge from the hospital before his personal consent could be obtained and before preparation of this report. All personal identifiers that could lead to his identification have been removed from this report. A 59-year-old man was scheduled for a flexible and rigid bronchoscopy with possible laser excision of tracheal stenosis. He had a history of hypertension, atrial fibrillation, and diabetes. Assessment of airway revealed a thyromental distance of 6.5 cm, Mallampati class II, and body weight of 110 kg. He had hoarseness and audible inspiratory/expiratory stridor with Spo2 90% breathing room air. After induction and muscle relaxation, tracheal intubation and flexible bronchoscopy were achieved without incident. The patient was then extubated and a rigid bronchoscopy was attempted but failed with Spo2 dropping to 92%; rocuronium 60 mg was given, and reintubation was accomplished with a 7.5-mm endotracheal tube. A second rigid bronchoscopy attempt failed, with Spo2 dropping to 63%. Subsequent direct laryngoscopy revealed a bloody hypopharynx. A size 4.5 Air-Q LA was placed successfully and confirmed with capnography, and Spo2 returned to 100%. The airway was suctioned through the Air-Q LA device, and the airway was secured using a fiberoptic bronchoscope to place an endotracheal tube of 7.5-mm internal diameter. The case was canceled because of edema of the upper airway from multiple attempts with rigid bronchoscopy. The patient was transported

Nasal versus oronasal continuous positive airway pressure masks for obstructive sleep apnea: a pilot investigation of pressure requirement, residual disease, and leak.

PubMed

Bakker, Jessie P; Neill, Alister M; Campbell, Angela J

2012-09-01

This single-blinded, randomized, controlled pilot study aimed to investigate whether there is a difference between nasal and oronasal masks in therapeutic continuous positive airway pressure (CPAP) requirement, residual disease, or leak when treating obstructive sleep apnea (OSA) and if differences were related to measures of upper airway size. Patients with severe OSA currently using CPAP at ≥4 h/night with a nasal mask were examined (including Mallampati scale, incisal relationship, and mandibular protrusion) and then randomized to receive auto-positive airway pressure (PAP) or fixed CPAP at a manually titrated pressure for 1 week each at home, with immediate crossover. Within each week, a nasal mask and two oronasal masks were to be used for two or three nights each in random order. Data were downloaded from the device. Twelve patients completed the trial (mean ± SD AHI 59.8 ± 28.6 events/h; CPAP 11.1 ± 3.2 cmH(2)O; BMI 37.7 ± 5.0 kg/m(2)). During auto-PAP, the median 95th percentile pressure delivered with all masks was within 0.5 cmH(2)O (p > 0.05). During CPAP, median residual AHI was 0.61 (IQR = 1.18) for the nasal mask, 1.70 (IQR = 4.04) for oronasal mask 1, and 2.48 (IQR = 3.74) for oronasal mask 2 (p = 0.03). The 95th percentile leak was lowest with the nasal mask during both CPAP and auto-PAP (both p < 0.01). Differences in pressure or residual disease were not related to measures of upper airway shape or body habitus. In obese OSA patients changing from a nasal to oronasal mask increased leak and residual AHI but did not affect the therapeutic pressure requirement. The findings of the current study highlight mask leak as the major difficulty in the use of oronasal masks.

A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates.

PubMed

Hubble, Michael W; Wilfong, Denise A; Brown, Lawrence H; Hertelendy, Attila; Benner, Randall W

2010-01-01

Airway management is a key component of prehospital care for seriously ill and injured patients. Oral endotracheal intubation (OETI) is the definitive airway of choice in most emergency medical services (EMS) systems. However, OETI may not be an approved skill for some clinicians or may prove problematic in certain patients because of anatomic abnormalities, trauma, or inadequate relaxation. In these situations alternative airways are frequently employed. However, the reported success rates for these devices vary widely, and established benchmarks are lacking. We sought to determine pooled estimates of the success rates of alternative airway devices (AADs) and needle cricothyrotomy (NCRIC) and surgical cricothyrotomy (SCRIC) placement through a meta-analysis of the literature. We performed a systematic literature search for all English-language articles reporting success rates for AADs, SCRIC, and NCRIC. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique were calculated using a random-effects meta-analysis model. Of 2,005 prehospital airway titles identified, 35 unique studies were retained for analysis of AAD success rates, encompassing a total of 10,172 prehospital patients. The success rates for SCRIC and NCRIC were analyzed across an additional 21 studies totaling 512 patients. The pooled estimates (and 95% confidence intervals [CIs]) for intervention success across all clinicians and patients were as follows: esophageal obturator airway-esophageal gastric tube airway (EOA-EGTA) 92.6% (90.1%-94.5%); pharyngeotracheal lumen airway (PTLA) 82.1% (74.0%-88.0%); esophageal-tracheal Combitube (ETC) 85.4% (77.3%-91.0%); laryngeal mask airway (LMA) 87.4% (79.0%-92.8%); King Laryngeal Tube airway (King LT) 96.5% (71.2%-99.7%); NCRIC 65.8% (42.3%-83.59%); and SCRIC 90.5% (84

Continuous positive airway pressure and ventilation are more effective with a nasal mask than a full face mask in unconscious subjects: a randomized controlled trial.

PubMed

Oto, Jun; Li, Qian; Kimball, William R; Wang, Jingping; Sabouri, Abdolnabi S; Harrell, Priscilla G; Kacmarek, Robert M; Jiang, Yandong

2013-12-23

Upper airway obstruction (UAO) is a major problem in unconscious subjects, making full face mask ventilation difficult. The mechanism of UAO in unconscious subjects shares many similarities with that of obstructive sleep apnea (OSA), especially the hypotonic upper airway seen during rapid eye movement sleep. Continuous positive airway pressure (CPAP) via nasal mask is more effective at maintaining airway patency than a full face mask in patients with OSA. We hypothesized that CPAP via nasal mask and ventilation (nCPAP) would be more effective than full face mask CPAP and ventilation (FmCPAP) for unconscious subjects, and we tested our hypothesis during induction of general anesthesia for elective surgery. In total, 73 adult subjects requiring general anesthesia were randomly assigned to one of four groups: nCPAP P0, nCPAP P5, FmCPAP P0, and FmCPAP P5, where P0 and P5 represent positive end-expiratory pressure (PEEP) 0 and 5 cm H2O applied prior to induction. After apnea, ventilation was initiated with pressure control ventilation at a peak inspiratory pressure over PEEP (PIP/PEEP) of 20/0, then 20/5, and finally 20/10 cm H2O, each applied for 1 min. At each pressure setting, expired tidal volume (Vte) was calculated by using a plethysmograph device. The rate of effective tidal volume (Vte > estimated anatomical dead space) was higher (87.9% vs. 21.9%; P<0.01) and the median Vte was larger (6.9 vs. 0 mL/kg; P<0.01) with nCPAP than with FmCPAP. Application of CPAP prior to induction of general anesthesia did not affect Vte in either approach (nCPAP pre- vs. post-; 7.9 vs. 5.8 mL/kg, P = 0.07) (FmCPAP pre- vs. post-; 0 vs. 0 mL/kg, P = 0.11). nCPAP produced more effective tidal volume than FmCPAP in unconscious subjects. ClinicalTrials.gov identifier: NCT01524614.

Increased dead space in face mask continuous positive airway pressure in neonates.

PubMed

Hishikawa, Kenji; Fujinaga, Hideshi; Ito, Yushi

2017-01-01

Continuous positive airway pressure (CPAP) by face mask is commonly performed in newborn resuscitation. We evaluated the effect of face mask CPAP on system dead space. Face mask CPAP increases dead space. A CPAP model study. We estimated the volume of the inner space of the mask. We devised a face mask CPAP model, in which the outlet of the mask was covered with plastic; and three modified face mask CPAP models, in which holes were drilled near to the cushion of the covered face mask to alter the air exit. We passed a continuous flow of 21% oxygen through each model and we controlled the inner pressure to 5 cmH 2 O by adjusting the flow-relief valve. To evaluate the ventilation in the inner space of each model, we measured the oxygen concentration rise time, that is, the time needed for the oxygen concentration of each model to reach 35% after the oxygen concentration of the continuous flow was raised from 21% to 40%. The volume of inner space of the face mask was 38.3 ml. Oxygen concentration rise time in the face mask CPAP model was significantly longer at various continuous flow rates and points of the inner space of the face mask compared with that of the modified face mask CPAP model. Our study indicates that face mask CPAP leads to an increase in dead space and a decrease in ventilation efficiency under certain circumstances. Pediatr Pulmonol. 2017;52:107-111. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Phonological outcome of laryngeal framework surgery by different anesthesia protocols: a single-surgeon experience.

PubMed

Kanazawa, Takeharu; Watanabe, Yusuke; Komazawa, Daigo; Indo, Kanako; Misawa, Kiyoshi; Nagatomo, Takafumi; Shimada, Mari; Iino, Yukiko; Ichimura, Keiichi

2014-02-01

Similar to combined arytenoid adduction and medialization laryngoplasty (i.e. combined surgery) under local anesthesia, general anesthesia by intubation or by the laryngeal mask airway (LMA) method significantly improves phonological outcome. Thus, laryngeal framework surgery under general anesthesia is a promising surgical approach for selected patients with unilateral vocal cord paralysis (UVCP). The advantages of laryngeal framework surgery under local anesthesia have been described, but no studies exist concerning the difference in phonological outcome of laryngeal framework surgery performed under general anesthesia. To add new information, we retrospectively investigated the phonological outcome of the combined surgery performed under three different anesthesia protocols. Thirty-nine consecutive patients with severe UVCP underwent the combined surgery under three anesthesia protocols performed by a single surgeon: (1) under general anesthesia by intubation, (2) under general anesthesia using LMA, and (3) under local anesthesia. Under all anesthesia protocols, the vocal cords of most patients could be positioned such that the best vocal outcome could be expected. Statistical analyses demonstrated improved maximum phonation time and mean airflow rate, and grade, roughness, breathiness, asthenia, and strain (GRBAS) scale in all patients, regardless of their anesthesia protocol. Furthermore, of the three protocols, local anesthesia had the shortest operation time.

Airway complications in the head injured.

PubMed

Woo, P; Kelly, G; Kirshner, P

1989-07-01

Fifty head-injured patients who had tracheostomy were followed during rehabilitation by video fiberoptic laryngoscopy examination. Complications of aspiration (23/50), airway stenosis (13/50), and phonation dysfunction (16/24) were followed. Spontaneous resolution of aspiration may require a prolonged course. A majority of patients (37/50) had improvement and could be decannulated. Prognostic factors correlated to eventual decannulation included age, level on the Glasgow Coma Outcome Scale, and type of head injury. Those with poor neurologic improvement and glottic incompetence (13/50) are poor candidates for decannulation. Significant airway stenosis can involve both laryngeal and tracheal sites. Neurologic dysfunction may complicate the decannulation process after airway anatomy has been restored by surgery. Dysphonia resulting from intubation, peripheral laryngeal and nerve injury, or central laryngeal movement dysfunction are common. Preventive maintenance with ongoing evaluation can avoid airway crises such as aspiration pneumonia, hemoptysis, and innominate artery.

Pre-pharyngeal Swallow Effects of Recurrent Laryngeal Nerve Lesion on Bolus Shape and Airway Protection in an Infant Pig Model.

PubMed

Gould, Francois D H; Yglesias, B; Ohlemacher, J; German, R Z

2017-06-01

Recurrent laryngeal nerve (RLN) damage in infants leads to increased dysphagia and aspiration pneumonia. Recent work has shown that intraoral transport and swallow kinematics change following RLN lesion, suggesting potential changes in bolus formation prior to the swallow. In this study, we used geometric morphometrics to understand the effect of bolus shape on penetration and aspiration in infants with and without RLN lesion. We hypothesized (1) that geometric bolus properties are related to airway protection outcomes and (2) that in infants with RLN lesion, the relationship between geometric bolus properties and dysphagia is changed. In five infant pigs, dysphagia in 188 swallows was assessed using the Infant Mammalian Penetration-Aspiration Scale (IMPAS). Using images from high-speed VFSS, bolus shape, bolus area, and tongue outline were quantified digitally. Bolus shape was analyzed using elliptical Fourier analysis, and tongue outline using polynomial curve fitting. Despite large inter-individual differences, significant within individual effects of bolus shape and bolus area on airway protection exist. The relationship between penetration-aspiration score and both bolus area and shape changed post lesion. Tongue shape differed between pre- and post-lesion swallows, and between swallows with different IMPAS scores. Bolus shape and area affect airway protection outcomes. RLN lesion changes that relationship, indicating that proper bolus formation and control by the tongue require intact laryngeal sensation. The impact of RLN lesion on dysphagia is pervasive.

Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of a preclinical cardiopulmonary resuscitation.

PubMed

Jaeger, K; Ruschulte, H; Osthaus, A; Scheinichen, D; Heine, J

2000-01-01

Management of the difficult airway requires an appropriate approach based on personal clinical experiences. For every physician involved in rescue and emergency medicine, it is important to know the difficult airway algorithm and be familiar with alternative techniques of managing the difficult airway. We report a case of tracheal injury caused by multiple attempts at intubating the trachea. Based on current knowledge, apart from surgical equipment for cricothyroidotomy the laryngeal mask airway (LMA) and the Combitube (ETC) should be available on any ambulance vehicle staffed by an emergency physician. In future, blind intubation through the intubating laryngeal mask airway (ILMA) could offer a new opportunity.

[Comparison of jaw thrust and trapezius squeezing test as indicators for laryngeal mask airway insertion in infants and young children].

PubMed

Liu, J Z; Zhao, J; Zhang, Y J

2016-02-01

To compare the effectiveness of the jaw thrust and the trapezius squeezing test(TST) for laryngeal mask airway (LMA) insertion in infants and children under sevoflurane anesthesia. A total of 100 children aged from 6 month to 3 years, American Society of Anesthesiologists(ASA) Ⅰ-Ⅱ and undergoing minor operation were enrolled from January to June 2015 in Tianjin Children's Hospital. The patients were randomly divided into jaw thrusting group (Group J, n=50)and trapezius squeezing group(Group T, n=50). Anesthesia was induced with sevoflurane. When children's eyelash reflex lose, jaw thrust/trapezius squeeze was applied every 15 seconds.It's considered that the depth of anesthesia was not enough, and test reaction was positive if any movements of body, limbs or toes were found at the point of test. Sevoflurane should be keep on inhalation until negative test reaction was appeared. Then LMA was inserted immediately.The time required for the negative test, end-tidal sevoflurane concentrations (ETsev), the index of Narcotrend anesthesia monitor(NT), the occurrence of gross purposeful movements, coughing, gagging, breath-holding, laryngospasm or an SpO2 < 90% during LMA insertion in two groups of patients were observed and recorded. The condition of LMA insertion and the rate of successful insertion were evaluated. The blood pressure(BP), heart rate(HR) and SpO2 were also recorded before and after LMA insertion. In group J and group T, the time required for the negative test was (2.31±1.03) vs (2.85±0.97)min(t=-2.462, P<0.05), ETsev was(3.25±1.02)% vs (3.81±0.87) %(t=-2.361, P<0.05), the depth of anesthesia NT index was(50.41±5.38) vs (41.32±4.92)(t=3.021, all P<0.05). All of above results were significantly different. The successful rate of the first attempt LMA insertion was 78% vs 100%(χ(2)=12.36 , P<0.01), respectively. The differences had statistical significance. The conditions of LMA insertion in group T were superior to those in group J. The incidences

Pre-pharyngeal swallow effects of recurrent laryngeal nerve lesion on bolus shape and airway protection in an infant pig model

PubMed Central

Gould, Francois D. H.; Yglesias, B.; Ohlemacher, J.; German, R. Z.

2016-01-01

Recurrent laryngeal nerve (RLN) damage in infants leads to increased dysphagia and aspiration pneumonia. Recent work has shown that intra oral transport and swallow kinematics change following RLN lesion, suggesting potential changes in bolus formation prior to the swallow. In this study we used geometric morphometrics to understand the effect of bolus shape on penetration and aspiration in infants with and without RLN lesion. We hypothesized 1) that geometric bolus properties are related to airway protection outcomes and 2) that in infants with RLN lesion, the relationship between geometric bolus properties and dysphagia is changed. In five infant pigs, dysphagia in 188 swallows was assessed using the Infant Mammalian Penetration Aspiration Score (IMPAS). Using images from high-speed VFSS, bolus shape, bolus area, and tongue outline were quantified digitally. Bolus shape was analyzed using elliptical Fourier analysis, and tongue outline using polynomial curve fitting. Despite large inter-individual differences, significant within individual effects of bolus shape and bolus area on airway protection exist. The relationship between penetration-aspiration score and both bolus area and shape changed post lesion. Tongue shape differed between pre and post lesion swallows, and between swallows with different IMPAS scores. Bolus shape and area affect airway protection outcomes. RLN lesion changes that relationship, indicating that proper bolus formation and control by the tongue requires intact laryngeal sensation. The impact of RLN lesion on dysphagia is pervasive. PMID:27873091

Ultrasound comparison of external and internal neck anatomy with the LMA Unique.

PubMed

Lee, Steven M; Wojtczak, Jacek A; Cattano, Davide

2017-12-01

Internal neck anatomy landmarks and their relation after placement of an extraglottic airway devices have not been studied extensively by the use of ultrasound. Based on our group experience with external landmarks as well as internal landmarks evaluation with other techniques, we aimed use ultrasound to analyze the internal neck anatomy landmarks and the related changes due to the placement of the Laryngeal Mask Airway Unique. Observational pilot investigation. Non-obese adult patients with no evidence of airway anomalies, were recruited. External neck landmarks were measured based on a validated and standardized method by tape. Eight internal anatomical landmarks, reciprocal by the investigational hypothesis to the external landmarks, were also measured by ultrasound guidance. The internal landmarks were re-measured after optimal placement and inflation of the extraglottic airway devices cuff Laryngeal Mask Airway Unique. Six subjects were recruited. Ultrasound measurements of hyoid-mental distance, thyroid-cricoid distance, thyroid height, and thyroid width were found to be significantly ( p < 0.05) overestimated using a tape measure. Sagittal neck landmark distances such as thyroid height, sternal-mental distance, and thyroid-cricoid distance significantly decreased after placement of the Laryngeal Mask Airway Unique. The laryngeal mask airway Unique resulted in significant changes in internal neck anatomy. The induced changes and respective specific internal neck anatomy landmarks could help to design devices that would modify their shape accordingly to areas of greatest displacement. Also, while external neck landmark measurements overestimate their respective internal neck landmarks, as we previously reported, the concordance of each measurement and their respective conversion factor could continue to be of help in sizing extraglottic airway devices. Due to the pilot nature of the study, more investigations are warranted.

Multi-stage surgery for airway patency after metallic stent removal in benign laryngotracheal airway disease in two adolescents.

PubMed

Coordes, Annekatrin; Todt, Ingo; Ernst, Arne; Seidl, Rainer O

2013-05-01

Laryngotracheal stents may damage the highly complex laryngeal structures, impair voice and swallowing functions and cause tissue ingrowths, thereby necessitating airway patency interventions. In benign airway disease, the number of adolescents with laryngotracheal stents is therefore limited. We present two cases of laryngeal metallic stent placement following benign airway disease. Two adolescents presented with severe dyspnea and self-expandable metallic stent placement after benign laryngotracheal stenoses. Granulation tissue ingrowths required additional surgical interventions every 6-8 weeks to recanalize the stent lumen. We performed multi-stage surgery including removal of the embedded stent, segmental resection of the stenotic area, end-to-end-anastomosis and laryngotracheal reconstruction respectively, to achieve patent airway without tracheal cannulation. Montgomery T-tubes were temporarily inserted to bridge the complex reconstructions. In both adolescents, we achieved successful removal of the embedded stent and patent airway. Bilateral vocal fold paralysis required additional surgery to improve the final airway patency and vocal rehabilitation. Stent removal, segmental resection and laryngotracheal reconstruction provide the achievement of patent airway and allow decannulation. Temporary Montgomery T-tubes bridge complex laryngotracheal reconstructions. In benign laryngeal airway disease, stent placement should be avoided, especially in adolescents. Transfer to a specialist center should be considered prior to metallic stent implantation. In general, self-expanding tracheobronchial stents can be placed in selected patients where surgical interventions are limited. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Oronasal mask may compromise the efficacy of continuous positive airway pressure on OSA treatment: is there evidence for avoiding the oronasal route?

PubMed

Andrade, Rafaela Garcia Santos; Madeiro, Fernanda; Genta, Pedro Rodrigues; Lorenzi-Filho, Geraldo

2016-11-01

Continuous positive airway pressure (CPAP) delivered by nasal mask is the gold standard treatment for obstructive sleep apnea (OSA). However, oral and oronasal masks are also available. We considered experimental evidence and reviewed clinical trials that evaluated the impact of oral and oronasal mask on OSA treatment. One recent study in 18 OSA patients that slept with a customized oronasal mask with two sealed compartments showed that the change of CPAP flow from nasal to oronasal and oral caused upper airway obstruction because of posterior displacement of the tongue demonstrated by nasoendoscopy. Oral masks use a mouthpiece that may stabilize the jaw and the tongue and have shown to be effective. However, oral masks are not widely used in clinical practice. Four out of five observational studies and all five reviewed randomized studies showed a worse performance of oronasal when compared with nasal masks. Oronasal masks were associated with higher residual apnea-hypopnea index, lower adherence, more leaks, and less satisfaction than nasal mask in the majority of the studies. Nasal CPAP must be the first choice to treat OSA. Patients on oronasal mask should be carefully followed. VIDEO ABSTRACT.

Plastic laryngeal foreign bodies in children: a diagnostic challenge.

PubMed

Bloom, David C; Christenson, Tom E; Manning, Scott C; Eksteen, Eduard C; Perkins, Jonathan A; Inglis, Andrew F; Stool, Sylvan E

2005-05-01

To review Children's Hospital and Regional Medical Center experience with pediatric airway foreign bodies, and examine the incidence and treatment of laryngeal foreign bodies. To determine if plastic laryngeal foreign bodies present differently than other laryngeal foreign bodies. A retrospective review of all cases of children (1874 patients) undergoing direct laryngoscopy and/or bronchoscopy from 1st January 1997 to 9th September 2003 at a tertiary care children's hospital. Patients with endoscopically documented laryngeal foreign bodies were identified and the medical record reviewed in more detail. Patient age, gender, foreign body location, foreign body type, duration of foreign body presence, radiographic findings, endoscopic findings and treatment complications were recorded. One hundred and five aspirated foreign bodies were identified. The nine laryngeal foreign bodies included five clear plastic radiolucent items, two radiolucent food items, and two sharp radioopaque pins. Time to diagnosis and treatment was on average 11.6 days with 17.6 days for thin/plastic foreign bodies and 1.6 days for metal/food foreign bodies. Laryngeal foreign bodies represent a small portion of all pediatric airway foreign bodies. Difficulty in identifying laryngeal foreign bodies, especially thin, plastic radiolucent foreign bodies can delay treatment. Thin plastic foreign bodies can present without radiographic findings, can be difficult to image during endoscopy and can be particularly difficult to diagnose. A history of choking and vocal changes is associated with laryngeal foreign bodies. Laryngeal foreign bodies should be in the differential diagnosis of all children presenting with atypical upper respiratory complaints especially if a history suggestive of witnessed aspiration and dysphonia can be obtained.

Identification of the tracheal and laryngeal afferent neurones mediating cough in anaesthetized guinea-pigs

PubMed Central

Canning, Brendan J; Mazzone, Stuart B; Meeker, Sonya N; Mori, Nanako; Reynolds, Sandra M; Undem, Bradley J

2004-01-01

We have identified the tracheal and laryngeal afferent nerves regulating cough in anaesthetized guinea-pigs. Cough was evoked by electrical or mechanical stimulation of the tracheal or laryngeal mucosa, or by citric acid applied topically to the trachea or larynx. By contrast, neither capsaicin nor bradykinin challenges to the trachea or larynx evoked cough. Bradykinin and histamine administered intravenously also failed to evoke cough. Electrophysiological studies revealed that the majority of capsaicin-sensitive afferent neurones (both Aδ- and C-fibres) innervating the rostral trachea and larynx have their cell bodies in the jugular ganglia and project to the airways via the superior laryngeal nerves. Capsaicin-insensitive afferent neurones with cell bodies in the nodose ganglia projected to the rostral trachea and larynx via the recurrent laryngeal nerves. Severing the recurrent nerves abolished coughing evoked from the trachea and larynx whereas severing the superior laryngeal nerves was without effect on coughing. The data indicate that the tracheal and laryngeal afferent neurones regulating cough are polymodal Aδ-fibres that arise from the nodose ganglia. These afferent neurones are activated by punctate mechanical stimulation and acid but are unresponsive to capsaicin, bradykinin, smooth muscle contraction, longitudinal or transverse stretching of the airways, or distension. Comparing these physiological properties with those of intrapulmonary mechanoreceptors indicates that the afferent neurones mediating cough are quite distinct from the well-defined rapidly and slowly adapting stretch receptors innervating the airways and lungs. We propose that these airway afferent neurones represent a distinct subtype and that their primary function is regulation of the cough reflex. PMID:15004208

Effect of ventriculectomy versus ventriculocordectomy on upper airway noise in draught horses with recurrent laryngeal neuropathy.

PubMed

Cramp, P; Derksen, F J; Stick, J A; Nickels, F A; Brown, K E; Robinson, P; Robinson, N E

2009-11-01

Little is known about the efficacy of bilateral ventriculectomy (VE) or bilateral ventriculocordectomy (VCE) in draught horses. To compare the effect of VE and VCE on upper airway noise in draught horses with recurrent laryngeal neuropathy (RLN) by use of quantitative sound analysis techniques. In competitive draught horses with grade 4 RLN, VE and VCE reduce upper airway noise during exercise, but VCE is more effective. Thirty competitive hitch or pulling draught horses with grade 4 RLN were evaluated for upper airway sound during exercise. Respiratory rate (RR), inspiratory (Ti) and expiratory time (Te), the ratio between Ti and Te (Ti/Te), inspiratory (Sli) and expiratory sound levels (Sle), the ratio between Sli and Sle (Sli/Sle), and peak sound intensity of the second formant (F2) were calculated. Eleven horses were treated with VE and 19 with VCE. After 90 days of voice and physical rest and 30 days of work, the horses returned for post operative upper airway sound evaluation and resting videoendoscopy. VE significantly reduced Ti/Te, Sli, Sli/Sle and the sound intensity of F2. Respiratory rate, Ti, Te and Sle were unaffected by VE. VCE significantly reduced Ti/Te, Ti, Te, Sli, Sli/Sle and the sound intensity of F2, while RR and Sle were unaffected. The reduction in sound intensity of F2 following VCE was significantly greater than following VE. After VE and VCE, 7/11 (64%) and 15/18 (83%) owners, respectively, concluded that the surgery improved upper airway sound in their horses sufficiently for successful competition. VE and VCE significantly reduce upper airway noise and indices of airway obstruction in draught horses with RLN, but VCE is more effective than VE. The procedures have few post operative complications. VCE is recommended as the preferred treatment for RLN in draught horses. Further studies are required to evaluate the longevity of the procedure's results.

Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates-a randomised trial.

PubMed

Chandrasekaran, Aparna; Thukral, Anu; Jeeva Sankar, M; Agarwal, Ramesh; Paul, Vinod K; Deorari, Ashok K

2017-03-01

The objective of this study was to compare the efficacy and safety of continuous positive airway pressure (CPAP) delivered using nasal masks with binasal prongs. We randomly allocated 72 neonates between 26 and 32 weeks gestation to receive bubble CPAP by either nasal mask (n = 37) or short binasal prongs (n = 35). Primary outcome was mean FiO 2 requirement at 6, 12 and 24 h of CPAP initiation and the area under curve (AUC) of FiO 2 against time during the first 24 h (FiO 2 AUC 0-24 ). Secondary outcomes were the incidence of CPAP failure and nasal trauma. FiO 2 requirement at 6, 12 and 24 h (mean (SD); 25 (5.8) vs. 27.9 (8); 23.8 (4.5) vs. 25.4 (6.8) and 22.6 (6.8) vs. 22.7 (3.3)) as well as FiO 2 AUC 0-24 (584.0 (117.8) vs. 610.6 (123.6)) were similar between the groups. There was no difference in the incidence of CPAP failure (14 vs. 20%; relative risk 0.67; 95% confidence interval 0.24-1.93). Incidence of severe nasal trauma was lower with the use of nasal masks (0 vs. 31%; p < .001). Nasal masks appear to be as efficacious as binasal prongs in providing CPAP. Masks are associated with lower risk of severe nasal trauma. CTRI2012/08/002868 What is Known? • Binasal prongs are better than single nasal and nasopharyngeal prongs for delivering continuous positive airway pressure (CPAP) in preventing need for re-intubation. • It is unclear if they are superior to newer generation nasal masks in preterm neonates requiring CPAP. What is New? • Oxygen requirement during the first 24 h of CPAP delivery is comparable with use of nasal masks and binasal prongs. • Use of nasal masks is, however, associated with significantly lower risk of severe grades of nasal injury.

Laryngeal Trauma Following an Inhalation Injury: A Review and Case Report.

PubMed

Hogg, Gemma; Goswamy, Jay; Khwaja, Sadie; Khwaja, Nadeem

2017-05-01

The primary concern when managing a patient with inhalation injury is security of the airway. Airflow may be impeded by both edema of the upper airway and reduction of oxygen delivery to the lower respiratory tract. Although there has been much discussion regarding management of the latter, the focus of this article is the management of the former. This review aimed to determine the optimum management in burn victims with upper airway inhalation injury as an attempt to prevent laryngeal trauma leading to long-term voice disorders and upper airway dyspnea. We describe the case of a 57-year-old woman with significant inhalation injury and discuss the natural progression of her injuries and the laryngeal controversies surrounding her care. We conclude with advice on the optimal management of this condition based on our experience, combined with current best evidence. Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.

Comparison of effects of ProSeal LMA™ laryngeal mask airway cuff inflation with air, oxygen, air:oxygen mixture and oxygen:nitrous oxide mixture in adults: A randomised, double-blind study.

PubMed

Sharma, Mona; Sinha, Renu; Trikha, Anjan; Ramachandran, Rashmi; Chandralekha, C

2016-08-01

Laryngeal mask airway (LMA) cuff pressure increases when the air is used for the cuff inflation during oxygen: nitrous oxide (O2:N2O) anaesthesia, which may lead to various problems. We compared the effects of different gases for ProSeal LMA™ (PLMA) cuff inflation in adult patients for various parameters. A total of 120 patients were randomly allocated to four groups, according to composition of gases used to inflate the PLMA cuff to achieve 40 cmH2 O cuff pressure, air (Group A), 50% O2 :air (Group OA), 50% O2:N2O (Group ON) and 100% O2 (Group O). Cuff pressure, cuff volume and ventilator parameters were monitored intraoperatively. Pharyngolaryngeal parameters were assessed at 1, 2 and 24 h postoperatively. Statistical analysis was performed using ANOVA, Fisher's exact test and step-wise logistic regression. Cuff pressure significantly increased at 10, 15 and 30 min in Group A, OA and O from initial pressure. Cuff pressure decreased at 5 min in Group ON (36.6 ± 3.5 cmH2 O) (P = 0.42). PLMA cuff volume increased in Group A, OA, O, but decreased in Group ON (6.16 ± 2.8 ml [P < 0.001], 4.7 ± 3.8 ml [P < 0.001], 1.4 ± 3.19 ml [P = 0.023] and - 1.7 ± 4.9 ml [P = 0.064], respectively), from basal levels. Ventilatory parameters were comparable in all four groups. There was no significant association between sore throat and cuff pressure, with odds ratio 1.002. Cuff inflation with 50% O2:N2O mixture provided more stable cuff pressure in comparison to air, O2 :air, 100% O2 during O2:N2O anaesthesia. Ventilatory parameters did not change with variation in PLMA cuff pressure. Post-operative sore throat had no correlation with cuff pressure.

Does a 4 diagram manual enable laypersons to operate the Laryngeal Mask Supreme®? A pilot study in the manikin.

PubMed

Schälte, Gereon; Stoppe, Christian; Rossaint, Rolf; Gilles, Laura; Heuser, Maike; Rex, Steffen; Coburn, Mark; Zoremba, Norbert; Rieg, Annette

2012-03-27

Bystander resuscitation plays an important role in lifesaving cardiopulmonary resuscitation (CPR). A significant reduction in the "no-flow-time", quantitatively better chest compressions and an improved quality of ventilation can be demonstrated during CPR using supraglottic airway devices (SADs). Previous studies have demonstrated the ability of inexperienced persons to operate SADs after brief instruction. The aim of this pilot study was to determine whether an instruction manual consisting of four diagrams enables laypersons to operate a Laryngeal Mask Supreme® (LMAS) in the manikin. An instruction manual of four illustrations with speech bubbles displaying the correct use of the LMAS was designed. Laypersons were handed a bag containing a LMAS, a bag mask valve device (BMV), a syringe prefilled with air and the instruction sheet, and were asked to perform and ventilate the manikin as displayed. Time to ventilation was recorded and degree of success evaluated. A total of 150 laypersons took part. Overall 145 participants (96.7%) inserted the LMAS in the manikin in the right direction. The device was inserted inverted or twisted in 13 (8.7%) attempts. Eight (5.3%) individuals recognized this and corrected the position. Within the first 2 minutes 119 (79.3%) applicants were able to insert the LMAS and provide tidal volumes greater than 150 ml (estimated dead space). Time to insertion and first ventilation was 83.2 ± 29 s. No significant difference related to previous BLS training (P = 0.85), technical education (P = 0.07) or gender could be demonstrated (P = 0.25). In manikin laypersons could insert LMAS in the correct direction after onsite instruction by a simple manual with a high success rate. This indicates some basic procedural understanding and intellectual transfer in principle. Operating errors (n = 91) were frequently not recognized and corrected (n = 77). Improvements in labeling and the quality of instructional photographs may reduce individual error

Type of mask may impact on continuous positive airway pressure adherence in apneic patients.

PubMed

Borel, Jean Christian; Tamisier, Renaud; Dias-Domingos, Sonia; Sapene, Marc; Martin, Francis; Stach, Bruno; Grillet, Yves; Muir, Jean François; Levy, Patrick; Series, Frederic; Pepin, Jean-Louis

2013-01-01

In obstructive sleep apnea patients (OSA), continuous positive airway pressure (CPAP) adherence is crucial to improve symptoms and cardiometabolic outcomes. The choice of mask may influence CPAP adherence but this issue has never been addressed properly. To evaluate the impact of nasal pillows, nasal and oronasal masks on CPAP adherence in a cohort of OSA. Newly CPAP treated OSA participating in "Observatoire Sommeil de la Fédération de Pneumologie", a French national prospective cohort, were included between March 2009 and December 2011. Anthropometric data, medical history, OSA severity, sleepiness, depressive status, treatment modalities (auto-CPAP versus fixed pressure, pressure level, interface type, use of humidifiers) and CPAP-related side effects were included in multivariate analysis to determine independent variables associated with CPAP adherence. 2311 OSA (age = 57(12) years, apnea+hypopnea index = 41(21)/h, 29% female) were included. Nasal masks, oronasal masks and nasal pillows were used by 62.4, 26.2 and 11.4% of the patients, respectively. In univariate analysis, oronasal masks and nasal pillows were associated with higher risk of CPAP non-adherence. CPAP non-adherence was also associated with younger age, female gender, mild OSA, gastroesophageal reflux, depression status, low effective pressure and CPAP-related side effects. In multivariate analysis, CPAP non-adherence was associated with the use of oronasal masks (OR = 2.0; 95%CI = 1.6; 2.5), depression, low effective pressure, and side effects. As oronasal masks negatively impact on CPAP adherence, a nasal mask should be preferred as the first option. Patients on oronasal masks should be carefully followed.

Type of Mask May Impact on Continuous Positive Airway Pressure Adherence in Apneic Patients

PubMed Central

Borel, Jean Christian; Tamisier, Renaud; Dias-Domingos, Sonia; Sapene, Marc; Martin, Francis; Stach, Bruno; Grillet, Yves; Muir, Jean François; Levy, Patrick; Series, Frederic; Pepin, Jean-Louis

2013-01-01

Rationale In obstructive sleep apnea patients (OSA), continuous positive airway pressure (CPAP) adherence is crucial to improve symptoms and cardiometabolic outcomes. The choice of mask may influence CPAP adherence but this issue has never been addressed properly. Objective To evaluate the impact of nasal pillows, nasal and oronasal masks on CPAP adherence in a cohort of OSA. Methods Newly CPAP treated OSA participating in “Observatoire Sommeil de la Fédération de Pneumologie”, a French national prospective cohort, were included between March 2009 and December 2011. Anthropometric data, medical history, OSA severity, sleepiness, depressive status, treatment modalities (auto-CPAP versus fixed pressure, pressure level, interface type, use of humidifiers) and CPAP-related side effects were included in multivariate analysis to determine independent variables associated with CPAP adherence. Results 2311 OSA (age = 57(12) years, apnea+hypopnea index = 41(21)/h, 29% female) were included. Nasal masks, oronasal masks and nasal pillows were used by 62.4, 26.2 and 11.4% of the patients, respectively. In univariate analysis, oronasal masks and nasal pillows were associated with higher risk of CPAP non-adherence. CPAP non-adherence was also associated with younger age, female gender, mild OSA, gastroesophageal reflux, depression status, low effective pressure and CPAP-related side effects. In multivariate analysis, CPAP non-adherence was associated with the use of oronasal masks (OR = 2.0; 95%CI = 1.6; 2.5), depression, low effective pressure, and side effects. Conclusion As oronasal masks negatively impact on CPAP adherence, a nasal mask should be preferred as the first option. Patients on oronasal masks should be carefully followed. PMID:23691209

Estimating subglottal pressure via airflow interruption with auditory masking.

PubMed

Hoffman, Matthew R; Jiang, Jack J

2009-11-01

Current noninvasive measurement of subglottal pressure using airflow interruption often produces inconsistent results due to the elicitation of audio-laryngeal reflexes. Auditory feedback could be considered as a means of ensuring measurement accuracy and precision. The purpose of this study was to determine if auditory masking could be used with the airflow interruption system to improve intrasubject consistency. A prerecorded sample of subject phonation was played on a loop over headphones during the trials with auditory masking. This provided subjects with a target pitch and blocked out distracting ambient noise created by the airflow interrupter. Subglottal pressure was noninvasively measured using the airflow interruption system. Thirty subjects, divided into two equal groups, performed 10 trials without auditory masking and 10 trials with auditory masking. Group one performed the normal trials first, followed by the trials with auditory masking. Group two performed the auditory masking trials first, followed by the normal trials. Intrasubject consistency was improved by adding auditory masking, resulting in a decrease in average intrasubject standard deviation from 0.93+/-0.51 to 0.47+/-0.22 cm H(2)O (P < 0.001). Auditory masking can be used effectively to combat audio-laryngeal reflexes and aid subjects in maintaining constant glottal configuration and frequency, thereby increasing intrasubject consistency when measuring subglottal pressure. By considering auditory feedback, a more reliable method of measurement was developed. This method could be used by clinicians, as reliable, immediately available values of subglottal pressure are useful in evaluating laryngeal health and monitoring treatment progress.

Transendoscopic, laser-assisted ventriculocordectomy for treatment of left laryngeal hemiplegia in horses: 22 cases (1999-2005).

PubMed

Henderson, Cortney E; Sullins, Kenneth E; Brown, Jennifer A

2007-12-15

To determine long-term effects of transendoscopic, laser-assisted ventriculocordectomy (LAVC) on airway noise and performance in horses with naturally occurring left laryngeal hemiplegia. Retrospective case series. 22 horses with left laryngeal hemiplegia treated by means of LAVC. Medical records were reviewed and initial complaint, intended use of the horse, duration of abnormal airway noise, preoperative performance level, endoscopic findings, surgical procedure, postoperative treatment, and complications were recorded. Follow-up telephone interviews with owners and trainers were conducted to determine time for return to intended use, level of postoperative performance, and percentage reduction in airway noise. All horses were examined because of excessive airway noise; 10 (45%) had concurrent exercise intolerance. Left ventriculocordectomy was performed in all 22 horses; bilateral ventriculocordectomy (right ventriculocordectomy was done 1 year later) was performed in 1 horse (5%). Complications occurred in 3 (14%) horses. Twenty (91%) horses returned to their intended use. Excessive airway noise was eliminated after surgery in 18 (82%) horses; exercise intolerance improved postoperatively in 8 of 10 horses. Three racing Thoroughbreds returned to racing; 1 additional racehorse returned to racing but required a laryngoplasty 1 year later to continue racing. Results suggested that LAVC was an effective procedure for elimination of excessive airway noise and improvement of performance in horses with left laryngeal hemiplegia.

Laryngeal complications after type 1 thyroplasty.

PubMed

Cotter, C S; Avidano, M A; Crary, M A; Cassisi, N J; Gorham, M M

1995-12-01

Type I thyroplasty has become a primary surgical choice for voice restoration in patients with glottal incompetence. This study examines factors associated with laryngeal complications after type I thyroplasty. Ten laryngoscopic variables were analyzed from preoperative, intraoperative, and postoperative videolaryngoscopies of 51 patients undergoing 58 medialization procedures. Ten patient and operative variables were examined by medical record review. Major complications were defined as wound hemorrhage, airway obstruction, or prosthesis extrusion. Minor complications were defined as vocal fold hematoma without airway obstruction or prosthesis movement. The major complication rate was 8.6%, and the minor complication rate was 29%. No delayed hemorrhage or airway obstruction occurred. Prosthesis extrusion occurred in five (8.6%) patients 1 week to 5 months after surgery. Extrusion was associated with suboptimal prosthesis placement in 80% of cases. Two patients retained excellent glottal closure despite extrusion. Vocal fold hematoma was identified in 14 (24%) cases and resolved within 1 week. Prosthesis movement occurred in three (5%) patients 1 week to 6 months after surgery and resulted in poor glottal closure. All patients with prosthesis extrusion or movement were female. Type I thyroplasty remains a safe outpatient procedure with few major complications. Prosthesis extrusion was associated with suboptimal prosthesis placement and may or may not result in poor glottal closure. Minor vocal fold hematomas were relatively frequent, resolved rapidly, and were not associated with airway obstruction. Female patients may be more prone to complications because of their small laryngeal size.

The impact of airway management on quality of cardiopulmonary resuscitation: an observational study in patients during cardiac arrest.

PubMed

Yeung, Joyce; Chilwan, Mehboob; Field, Richard; Davies, Robin; Gao, Fang; Perkins, Gavin D

2014-07-01

Minimising interruptions in chest compressions is associated with improved survival from cardiac arrest. Current in-hospital guidelines recommend continuous chest compressions after the airway is secured on the premise that this will reduce no flow time. The aim of this study was to determine the effect of advanced airway use on the no flow ratio and other measures of CPR quality. Consecutive adult patients who sustained an in-hospital cardiac arrest were enrolled in this prospective observational study. The quality of CPR was measured using the Q-CPR device (Phillips, UK) before and after an advanced airway device (endotracheal tube [ET] or laryngeal mask airway [LMA]) was inserted. Patients receiving only bag-mask ventilation were used as the control cohort. The primary outcome was no flow ratio (NFR). Secondary outcomes were chest compression rate, depth, compressions too shallow, compressions with leaning, ventilation rate, inflation time, change in impedance and time required to successfully insert airway device. One hundred patients were enrolled in the study (2008-2011). Endotracheal tube and LMA placement took similar durations (median 15.8 s (IQR 6.8-19.4) vs. LMA median 8.0s (IQR 5.5-15.9), p=0.1). The use of an advanced airway was associated with improved no flow ratios (endotracheal tube placement (n=50) improved NFR from baseline median 0.24 IQR 0.17-0.40) to 0.15 to (IQR 0.09-0.28), p=0.012; LMA (n=25) from median 0.28 (IQR 0.23-0.40) to 0.13 (IQR 0.11- 0.19), p=0.0001). There was no change in NFR in patients managed solely with bag valve mask (BVM) (n=25) (median 0.29 (IQR 0.18-0.59) vs. median 0.26 (IQR 0.12-0.37), p=0.888). There was no significant difference in time taken to successfully insert the airway device between the two groups. The use of an advanced airway (ETT or LMA) during in-hospital cardiac arrest was associated with improved no flow ratio. Further studies are required to determine the effect of airway devices on overall patient

Comminuted Laryngeal Fracture Following Blunt Trauma: A Need for Strict Legislation on Roads!

PubMed

Jain, Shraddha; Singh, Pragya; Gupta, Minal; Kamble, Bhavna; Phatak, Suresh S

2017-01-01

Laryngeal fracture is a rare condition with potential life-long implications related to airway patency, voice quality, and swallowing. Rarity of the condition leads to lack of consensus on the most suitable way to manage this injury. The mode of injury can be prevented by strict legislation on the roads. We report a case of a 28-year-old Indian male who sustained a comminuted displaced fracture of the thyroid cartilage with disruption of anterior commissure due to blunt trauma caused by the metallic side rod of a ladder projecting from the rear of a vehicle in front of the bike on which he was riding. He presented with breathing difficulty, change in voice, surgical emphysema, and pneumomediastinum, but without any skin changes over the neck. His airway could be restored due to early tracheostomy and open reduction with internal fixation with sutures along with laryngeal stenting. He has no significant swallowing or breathing problem and reasonably good voice 6 months after surgery. This case highlights the need for strict legislation on roads in India and the importance of high level of suspicion for laryngeal fracture in acute trauma patient. Early identification and timely internal fixation not only restore the airway but also improve long-term voice and airway outcomes.

Continuous positive airway pressure with helmet versus mask in infants with bronchiolitis: an RCT.

PubMed

Chidini, Giovanna; Piastra, Marco; Marchesi, Tiziana; De Luca, Daniele; Napolitano, Luisa; Salvo, Ida; Wolfler, Andrea; Pelosi, Paolo; Damasco, Mirco; Conti, Giorgio; Calderini, Edoardo

2015-04-01

Noninvasive continuous positive airway pressure (CPAP) is usually applied with a nasal or facial mask to treat mild acute respiratory failure (ARF) in infants. A pediatric helmet has now been introduced in clinical practice to deliver CPAP. This study compared treatment failure rates during CPAP delivered by helmet or facial mask in infants with respiratory syncytial virus-induced ARF. In this multicenter randomized controlled trial, 30 infants with respiratory syncytial virus-induced ARF were randomized to receive CPAP by helmet (n = 17) or facial mask (n = 13). The primary endpoint was treatment failure rate (defined as due to intolerance or need for intubation). Secondary outcomes were CPAP application time, number of patients requiring sedation, and complications with each interface. Compared with the facial mask, CPAP by helmet had a lower treatment failure rate due to intolerance (3/17 [17%] vs 7/13 [54%], P = .009), and fewer infants required sedation (6/17 [35%] vs 13/13 [100%], P = .023); the intubation rates were similar. In successfully treated patients, CPAP resulted in better gas exchange and breathing pattern with both interfaces. No major complications due to the interfaces occurred, but CPAP by mask had higher rates of cutaneous sores and leaks. These findings confirm that CPAP delivered by helmet is better tolerated than CPAP delivered by facial mask and requires less sedation. In addition, it is safe to use and free from adverse events, even in a prolonged clinical setting. Copyright © 2015 by the American Academy of Pediatrics.

Comparison of the Force Required for Dislodgement Between Secured and Unsecured Airways.

PubMed

Davenport, Curtis; Martin-Gill, Christian; Wang, Henry E; Mayrose, James; Carlson, Jestin N

2018-05-01

Airway device placement and maintenance are of utmost importance when managing critically ill patients. The best method to secure airway devices is currently unknown. We sought to determine the force required to dislodge 4 types of airways with and without airway securing devices. We performed a prospective study using 4 commonly used airway devices (endotracheal tube [ETT], laryngeal mask airway [LMA], King laryngeal tube [King], and iGel) performed on 5 different mannequin models. All devices were removed twice per mannequin in random order, once unsecured and once secured as per manufacturers' recommendations; Thomas Tube Holder (Laerdal, Stavanger, Norway) for ETT, LMA, and King; custom tube holder for iGel. A digital force measuring device was attached to the exposed end of the airway device and gradually pulled vertically and perpendicular to the mannequin until the tube had been dislodged, defined as at least 4 cm of movement. Dislodgement force was reported as the maximum force recorded during dislodgement. We compared the relative difference in the secured and unsecured force for each device and between devices using a random-effects regression model accounting for variability in the manikins. The median dislodgment forces (interquartile range [IQR]) in pounds for each secured device were: ETT 13.3 (11.6, 14.1), LMA 16.6 (13.9, 18.3), King 21.7 (16.9, 25.1), and iGel 8 (6.8, 8.3). The median dislodgement forces for each unsecured device were: ETT 4.5 (4.3, 5), LMA 8.4 (6.8, 10.7), King 10.6 (8.2, 11.5), and iGel 3.9 (3.2, 4.2). The relative difference in dislodgement forces (95% confidence intervals) were higher for each device when secured: ETT 8.6 (6.2 to 11), LMA 8.8 (4.6 to 13), King 12.1 (7.2 to 16.6), iGel 4 (1.1 to 6.9). When compared to secured ETT, the King required greater dislodgement force (relative difference 8.6 [4.5-12.7]). The secured iGel required less force than the secured ETT (relative difference -4.8 [-8.9 to -0.8]). Compared with a

Atraumatic laser treatment for laryngeal papillomatosis

NASA Astrophysics Data System (ADS)

McMillan, Kathleen; Pankratov, Michail M.; Wang, Zhi; Bottrill, Ian; Rebeiz, Elie E.; Shapshay, Stanley M.

1994-09-01

Ten to fifteen thousand new cases of recurrent respiratory papillomatosis (RRP) are diagnosed each year in the United States. RRP is caused by the human papillomavirus (HPV) and is characterized by recurrent, non-malignant, proliferative lesions of the larynx. Patients with RRP undergo numerous microsurgical procedures to remove laryngeal papilloma threatening airway patency and interfering with phonation. The standard surgical technique involves CO2 laser vaporization of laryngeal epithelium affected by the lesions, and requires general anesthesia. The pulsed dye laser operating at 585 nm has previously been demonstrated to be effective in clearing HPV lesions of the skin (verrucae). For treatment of RRP, the fiber- compatible pulsed dye laser radiation may be delivered under local anesthesia using a flexible intranasal laryngoscope. Potential advantages of the pulsed dye laser treatment over CO2 laser surgery include (1) reduced morbidity, especially a lower risk of laryngeal scarring; (2) lower cost; (3) reduced technical difficulty; and (4) reduced risk of viral dissemination or transmission. In vivo studies are underway to determine the effect of pulsed dye laser radiation on normal canine laryngeal tissue.

Noninvasive CPAP with face mask: comparison among new air-entrainment masks and the Boussignac valve.

PubMed

Mistraletti, Giovanni; Giacomini, Matteo; Sabbatini, Giovanni; Pinciroli, Riccardo; Mantovani, Elena S; Umbrello, Michele; Palmisano, Debora; Formenti, Paolo; Destrebecq, Anne L L; Iapichino, Gaetano

2013-02-01

The performances of 2 noninvasive CPAP systems (high flow and low flow air-entrainment masks) were compared to the Boussignac valve in 3 different scenarios. Scenario 1: pneumatic lung simulator with a tachypnea pattern (tidal volume 800 mL at 40 breaths/min). Scenario 2: Ten healthy subjects studied during tidal breaths and tachypnea. Scenario 3: Twenty ICU subjects enrolled for a noninvasive CPAP session. Differences between set and effective CPAP level and F(IO(2)), as well as the lowest airway pressure and the pressure swing around the imposed CPAP level, were analyzed. The lowest airway pressure and swing were correlated to the pressure-time product (area of the airway pressure curve below the CPAP level) measured with the simulator. P(aO(2)) was a subject's further performance index. Lung simulator: Boussignac F(IO(2)) was 0.54, even if supplied with pure oxygen. The air-entrainment masks had higher swing than the Boussignac (P = .007). Pressure-time product correlated better with pressure swing (Spearman correlation coefficient [ρ] = 0.97) than with lowest airway pressure (ρ = 0.92). In healthy subjects, the high-flow air-entrainment mask showed lower difference between set and effective F(IO(2)) (P < .001), and lowest airway pressure (P < .001), compared to the Boussignac valve. In all measurements the Boussignac valve showed higher than imposed CPAP level (P < .001). In ICU subjects the high-flow mask had lower swing than the Boussignac valve (P = .03) with similar P(aO(2)) increase. High-flow air-entrainment mask showed the best performance in human subjects. During high flow demand, the Boussignac valve delivered lower than expected F(IO(2)) and showed higher dynamic hyper-pressurization than the air-entrainment masks. © 2013 Daedalus Enterprises.

Use of videoendoscopy during exercise for determination of appropriate surgical treatment of laryngeal hemiplegia in a colt.

PubMed

Stick, J A; Derksen, F J

1989-09-01

Videoendoscopy of the larynx during treadmill exercise was used to determine the surgical treatment of upper airway obstruction in a Standardbred colt. Surgical correction of right-sided laryngeal hemiplegia, first by laryngoplasty, then subtotal arytenoidectomy, was ineffective. Videoendoscopy indicated, and upper airway flow mechanics confirmed, that the laryngeal opening was adequate at rest, but obstruction occurred during exercise. On the basis of the appearance of the larynx during high airflow rates on slow-motion playback of the videorecording, total arytenoidectomy was performed, which permitted the horse to race successfully. Videoendoscopy of the upper airway during exercise accurately predicted airflow impedance and permitted salvage of this racehorse, indicating that this is a practical, useful technique that will improve evaluation of upper airway obstructions in the horse.

Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure.

PubMed

Driver, Brian E; Plummer, David; Heegaard, William; Reardon, Robert F

2016-12-01

The King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. We report a case of tracheal malplacement of the King airway with a severe kink in the distal tube. A 51-year-old unhelmeted motorcyclist collided with a freeway median and was obtunded when paramedics arrived. After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department. Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. After reviewing the radiograph, ventilations were reassessed and remained adequate. Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. Ventilation was not impaired in this patient, but tracheal malplacement may be an important cause of prehospital device failure. If a first placement attempt of a King airway device fails, it is reasonable to reattempt King airway placement with a new, unkinked device before abandoning King airway placement. Copyright © 2016 Elsevier Inc. All rights reserved.

Laryngeal Involvement of Rhabdomyosarcoma in an Adult

PubMed Central

Abali, Hüseyin; Aksoy, Sercan; Sungur, Arzu; Yalçin, Suayib

2003-01-01

Background Although initial presentation of sarcomas in the head and neck region is relatively common, involvements of the larynx by rhabdomyosarcoma either primary or metastatic have been reported rarely. Case report A case of rhabdomyosarcoma in the right thigh, which involved laryngeal structures three years after the diagnosis, is presented. Conclusions The laryngeal involvement by primary and metastatic rhabdosarcomas is very rare, however when it occurs it can result in life treating upper airway obstruction. After emergency intervention, radiotherapy and / or chemotherapy must be undertaken for long-term benefit and surgery may be helpful only in selected cases. PMID:14556654

Long-term outcome of permanent tracheostomy in 15 dogs with severe laryngeal collapse secondary to brachycephalic airway obstructive syndrome.

PubMed

Gobbetti, Matteo; Romussi, Stefano; Buracco, Paolo; Bronzo, Valerio; Gatti, Samuele; Cantatore, Matteo

2018-06-12

To report the long-term outcome of permanent tracheostomy for the management of severe laryngeal collapse secondary to brachycephalic airway obstructive syndrome. Retrospective case series. Fifteen brachycephalic dogs with severe laryngeal collapse treated with permanent tracheostomy. Follow-up data were obtained from medical records or via telephone conversation with the owners. The Kaplan-Meier estimator was used to calculate median survival time. Death was classified as related or unrelated to tracheostomy surgery. Complications were classified as major when they were life-threatening or required revision surgery. Owners were asked to classify the postoperative quality of life as improved, unchanged, or worse and the management of the stoma as simple or demanding. The median survival time was 100 days. Major complications were diagnosed in 12 of 15 (80%) dogs, resulting in death in 8 (median survival time 15 days) and revision surgery in 4 dogs. Seven of 15 (47%) dogs died of unrelated causes or were alive at the end of the study (median survival time 1982 days). The postoperative quality of life of 9 dogs was judged as markedly improved. Stoma management was defined as simple in 8 dogs and demanding in 4. Permanent tracheostomy was associated with a high risk of complications and postoperative death in brachycephalic dogs. However, long-term survival (exceeding 5 years) with a good quality of life was documented in 5 of 15 dogs. Permanent tracheostomy is a suitable salvage option in brachycephalic dogs with severe laryngeal collapse that did not improve following more conservative surgeries. © 2018 The American College of Veterinary Surgeons.

Tactical Combat Casualty Care 2007: Evolving Concepts and Battlefield Experience

DTIC Science & Technology

2007-11-01

airway obstruction: chin lift or jaw thrust, nasopharyngeal airway, place casualty in recovery position Surgical cricothyroidotomy (with lidocaine ...laryngeal mask airway /ILMA or Combitube or endotracheal intubation or surgical cricothyroidotomy (with lidocaine if conscious) Spinal immobilization is...surgical cricothyroidotomy (with lidocaine If conscious) 3. Breathing Consider tension pneumothorax and decompress with needle thoracostomy if

Laryngeal paralysis in dogs: an update on recent knowledge.

PubMed

Kitshoff, Adriaan M; Van Goethem, Bart; Stegen, Ludo; Vandekerckhov, Peter; de Rooster, Hilde

2013-04-05

Laryngeal paralysis is the effect of an inability to abduct the arytenoid cartilages during inspiration, resulting in respiratory signs consistent with partial airway obstruction. The aetiology of the disease can be congenital (hereditary laryngeal paralysis or congenital polyneuropathy), or acquired (trauma, neoplasia, polyneuropathy, endocrinopathy). The most common form of acquired laryngeal paralysis (LP) is typically seen in old, large breed dogs and is a clinical manifestation of a generalised peripheral polyneuropathy recently referred to as geriatric onset laryngeal paralysis polyneuropathy. Diagnosing LP based on clinical signs, breed and history has a very high sensitivity (90%) and can be confirmed bylaryngeal inspection. Prognosis after surgical correction depends on the aetiology: traumatic cases have a good prognosis, whereas tumour-induced or polyneuropathy-induced LP has a guarded prognosis. Acquired idiopathic LP is a slow progressive disease, with dogs reaching median survival times of 3-5 years after surgical correction.

Inhalation of volatile anesthetics via a laryngeal mask is associated with lower incidence of intraoperative awareness in non-critically ill patients

PubMed Central

Wang, Jen-Huang; Hsieh, Shiu-Ying; Huang, Shian-Che

2017-01-01

Background Increased incidence of intraoperative awareness was reported in critically ill patients during major operations, particularly under total intravenous (TIVA) or endotracheal general anesthesia (ETGA). However, the incidence and effect of anesthesia techniques on awareness in generally healthy, non-critically ill patients during operations have yet to receive significant attention. Methods and results This retrospective matched case-control study was conducted between January 2009 to December 2014. Surgical patients (ASA physical status I-III) whom reported intraoperative awareness during this study period were interviewed and their medical records were reviewed. The potential risk factors for awareness were compared with the non-case matched controls, who were randomly selected from the database. A total of 61436 patients were included and 16 definite cases of intraoperative awareness were identified. Patients who received ETGA and TIVA had significantly higher incidence of developing awareness compared to those who were anesthetized using laryngeal masks (LMA) (P = 0.03). Compared with the matched controls (n = 80), longer anesthesia time was associated with increased incidence of awareness (odds ratio 2.04; 95% CI 1.30–3.20, per hour increase). Perioperative use of muscle relaxant was also associated with increased incidence of awareness, while significantly lower incidence of awareness was found in patients who were anesthetized with volatile anesthetics. Conclusions The overall incidence of awareness was 0.023% in the ASA≤ III surgical patients who received general anesthesia. Anesthesia with a laryngeal mask under spontaneous ventilation and supplemented with volatile anesthetics may be the preferred anesthesia technique in generally healthy patients in order to provide a lower risk of intraoperative awareness. PMID:29073151

Cuff leak test and laryngeal survey for predicting post-extubation stridor.

PubMed

Patel, Anit B; Ani, Chizobam; Feeney, Colin

2015-02-01

Evidence for the predictive value of the cuff leak test (CLT) for post-extubation stridor (PES) is conflicting. We evaluated the association and accuracy of CLT alone or combined with other laryngeal parameters with PES. Fifty-one mechanically ventilated adult patients in a medical-surgical intensive care unit were tested prior to extubation using; CLT, laryngeal ultrasound and indirect laryngoscopy. Biometric, laryngeal and endotracheal tube (ETT) parameters were recorded. PES incidence was 4%. CLT demonstrated 'no leak' in 20% of patients. Laryngeal oedema was present in 10% of the patients on indirect laryngoscopy, and 71% of the patients had a Grades 1-3 indirect laryngoscopic view. Mean air column width on laryngeal ultrasound was 0.66 ± 0.15 cm (cuff deflated), mean ratio of ETT to laryngeal diameter was 0.48 ± 0.07, and the calculated CLT and laryngeal survey composite was 0.86 ± 1.25 (range 0-5). CLT and the CLT and Laryngeal survey composite measure were not associated with or predict PES. Age, sex, peri-extubation steroid use, intubation duration and body mass index were not associated with PES. Even including ultrasonographic and indirect laryngoscopic examination of the airway, no single aspect of the CLT or combination with laryngeal parameters accurately predicts PES.

Anatomic and physiopathologic changes affecting the airway of the elderly patient: implications for geriatric-focused airway management

PubMed Central

Johnson, Kathleen N; Botros, Daniel B; Groban, Leanne; Bryan, Yvon F

2015-01-01

There are many anatomical, physiopathological, and cognitive changes that occur in the elderly that affect different components of airway management: intubation, ventilation, oxygenation, and risk of aspiration. Anatomical changes occur in different areas of the airway from the oral cavity to the larynx. Common changes to the airway include tooth decay, oropharyngeal tumors, and significant decreases in neck range of motion. These changes may make intubation challenging by making it difficult to visualize the vocal cords and/or place the endotracheal tube. Also, some of these changes, including but not limited to, atrophy of the muscles around the lips and an edentulous mouth, affect bag mask ventilation due to a difficult face-mask seal. Physiopathologic changes may impact airway management as well. Common pulmonary issues in the elderly (eg, obstructive sleep apnea and COPD) increase the risk of an oxygen desaturation event, while gastrointestinal issues (eg, achalasia and gastroesophageal reflux disease) increase the risk of aspiration. Finally, cognitive changes (eg, dementia) not often seen as related to airway management may affect patient cooperation, especially if an awake intubation is required. Overall, degradation of the airway along with other physiopathologic and cognitive changes makes the elderly population more prone to complications related to airway management. When deciding which airway devices and techniques to use for intubation, the clinician should also consider the difficulty associated with ventilating the patient, the patient’s risk of oxygen desaturation, and/or aspiration. For patients who may be difficult to bag mask ventilate or who have a risk of aspiration, a specialized supralaryngeal device may be preferable over bag mask for ventilation. Patients with tumors or decreased neck range of motion may require a device with more finesse and maneuverability, such as a flexible fiberoptic broncho-scope. Overall, geriatric-focused airway

Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics.

PubMed

Kheterpal, Sachin; Martin, Lizabeth; Shanks, Amy M; Tremper, Kevin K

2009-04-01

There are no existing data regarding risk factors for impossible mask ventilation and limited data regarding its incidence. The authors sought to determine the incidence, predictors, and outcomes associated with impossible mask ventilation. The authors performed an observational study over a 4-yr period. For each adult patient undergoing a general anesthetic, preoperative patient characteristics, detailed airway physical exam, and airway outcome data were collected. The primary outcome was impossible mask ventilation defined as the inability to exchange air during bag-mask ventilation attempts, despite multiple providers, airway adjuvants, or neuromuscular blockade. Secondary outcomes included the final, definitive airway management technique and direct laryngoscopy view. The incidence of impossible mask ventilation was calculated. Independent (P < 0.05) predictors of impossible mask ventilation were identified by performing a logistic regression full model fit. Over a 4-yr period from 2004 to 2008, 53,041 attempts at mask ventilation were recorded. A total of 77 cases of impossible mask ventilation (0.15%) were observed. Neck radiation changes, male sex, sleep apnea, Mallampati III or IV, and presence of beard were identified as independent predictors. The receiver-operating-characteristic area under the curve for this model was 0.80 +/- 0.03. Nineteen impossible mask ventilation patients (25%) also demonstrated difficult intubation, with 15 being intubated successfully. Twelve patients required an alternative intubation technique, including two surgical airways and two patients who were awakened and underwent successful fiberoptic intubation. Impossible mask ventilation is an infrequent airway event that is associated with difficult intubation. Neck radiation changes represent the most significant clinical predictor of impossible mask ventilation in the patient dataset.

Comparison of Ventilation With One-Handed Mask Seal With an Intraoral Mask Versus Conventional Cuffed Face Mask in a Cadaver Model: A Randomized Crossover Trial.

PubMed

Amack, Andrew J; Barber, Gary A; Ng, Patrick C; Smith, Thomas B; April, Michael D

2017-01-01

We compare received minute volume with an intraoral mask versus conventional cuffed face mask among medics obtaining a 1-handed mask seal on a cadaver model. This study comprised a randomized crossover trial of adult US Army combat medic volunteers participating in a cadaver laboratory as part of their training. We randomized participants to obtain a 1-handed mask seal during ventilation of a fresh unembalmed cadaver, first using either an intraoral airway device or conventional cuffed face mask. Participants obtained a 1-handed mask seal while a ventilator delivered 10 standardized 750-mL breaths during 1 minute. After a 5-minute rest period, they repeated the study with the alternative mask. The primary outcome measure was received minute volume as measured by a respirometer. Of 27 recruited participants, all completed the study. Median received minute volume was higher with the intraoral mask compared with conventional cuffed mask by 1.7 L (95% confidence interval 1.0 to 1.9 L; P<.001). The intraoral mask resulted in greater received minute volume received compared with conventional cuffed face mask during ventilation with a 1-handed mask seal in a cadaver model. The intraoral mask may prove a useful airway adjunct for ventilation. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Upper airway obstruction in Norwich Terriers: 16 cases.

PubMed

Johnson, L R; Mayhew, P D; Steffey, M A; Hunt, G B; Carr, A H; McKiernan, B C

2013-01-01

Norwich Terriers have grown increasingly popular as show animals and pets, and awareness of respiratory problems within the breed is growing. To describe components of obstructive upper airway syndrome in a nonbrachycephalic terrier breed. Sixteen Norwich Terriers; 12 with and 4 without clinical signs of respiratory disease. Prospective case series. Physical and laryngoscopic examinations were performed by 1 investigator in all dogs. Medical and surgical interventions were summarized and results of follow-up examination or owner reports were recorded. The study population was comprised of 9 females (6 intact) and 7 males (5 intact). Median age was 3.0 years (range, 0.5-11 years). Of 12 dogs presented for a respiratory complaint, physical examination was normal in 4 dogs. Laryngoscopic examination was abnormal in 11/12 dogs with redundant supra-arytenoid folds, laryngeal collapse, everted laryngeal saccules, and a narrowed laryngeal opening in most. Of 4 dogs lacking clinical signs, all had normal physical examination; however, 3/4 dogs had similar appearance of the larynx to dogs with clinical signs. Response to surgical intervention was minimal to moderate in all dogs. Norwich Terriers suffer from an upper airway obstructive syndrome that differs from that encountered in brachycephalic breeds. Affected dogs are difficult to identify without laryngoscopic examination because of the lack of clinical signs and abnormalities in physical examination findings, despite severe airway obstruction. Care is warranted when anesthetizing Norwich Terriers because of the small size of the laryngeal opening. Copyright © 2013 by the American College of Veterinary Internal Medicine.

An update on out-of-hospital airway management practices in the United States.

PubMed

Diggs, Leigh Ann; Yusuf, Juita-Elena Wie; De Leo, Gianluca

2014-07-01

We characterized out-of-hospital airway management interventions, outcomes, and complications using the 2012 NEMSIS Public-Release Research Data Set containing almost 20 million Emergency Medical Services activations from 40 states and two territories. We compared the outcomes with a previous study that used 2008 NEMSIS data containing 16 states with 4 million EMS activations. Patients who received airway management interventions including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and surgical) were identified. Using descriptive statistics, airway management success and complications were examined in the full cohort and key subsets including cardiac arrest, non-arrest medical, non-arrest injury, children<10 years, children 10-19 years, rapid sequence intubation (RSI), population setting, U.S. census region, and U.S. census division. Among 19,831,189 EMS activations, there were 74,993 ETIs, 21,990 alternate airways, and 1332 cricothyroidotomies. ETI success rates were: overall 63,956/74,993 (85.3%; 95% CI: 85.0-85.5), cardiac arrest 33,558/39,270 (85.5%), non-arrest medical 12,215/13,611 (89.7%), non-arrest injury (90.1%), children <10 years 2069/2468 (83.8%), children 10-19 years 1647/1900 (86.7%), adults >19 years 58,965/69,144 (85.3%), and rapid sequence intubation 5265/5658 (93.1%). Major complications included bleeding 677 (4.4 per 1000 interventions), vomiting 1221 (8 per 1000 interventions), esophageal intubation immediately detected 874 (5.7 per 1000 interventions), and esophageal intubations other 219 (1.4 per 1000 interventions). Low out-of-hospital ETI and alternate airway success rates were observed. These data may guide national efforts to improve out-of-hospital airway management quality leading efforts to better educate providers on ETI. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Laryngeal reinnervation for bilateral vocal fold paralysis.

PubMed

Marina, Mat B; Marie, Jean-Paul; Birchall, Martin A

2011-12-01

Laryngeal reinnervation for bilateral vocal fold paralysis (BVFP) patients is a promising technique to achieve good airway, although preserving a good quality of voice. On the other hand, the procedure is not simple. This review explores the recent literature on surgical technique and factors that may contribute to the success. Research and literature in this area are limited due to variability and complexity of the nerve supply. The posterior cricoarytenoid (PCA) muscle also receives nerve supply from the interarytenoid branch. Transection of this nerve at the point between interarytenoid and PCA branch may prevent aberrant reinnervation of adductor nerve axons to the PCA muscle. A varying degree of regeneration of injured recurrent laryngeal nerves (RLN) in humans of more than 6 months confirms subclinical reinnervation, which may prevent denervation-induced atrophy. Several promising surgical techniques have been developed for bilateral selective reinnervation for BVFP patients. This involves reinnervation of the abductor and adductor laryngeal muscles. The surgical technique aims at reinnervating the PCA muscle to trigger abduction during the respiratory cycle and preservation of good voice by strengthening the adductor muscles as well as prevention of laryngeal synkinesis.

The role of fiberoptic nasopharyngoscopy in the management of the acute airway in angioneurotic edema.

PubMed

Bentsianov, B L; Parhiscar, A; Azer, M; Har-El, G

2000-12-01

Angioneurotic edema of the upper aerodigestive tract (AEUAT) often challenges the otolaryngologist with the decision of surgical intervention versus observation. To develop a logical approach to the evaluation and management of the airway in patients with AEUAT, emphasizing fiberoptic examination (FOE) findings. A computer-based retrospective review of all patients diagnosed with AEUAT was performed. The charts were reviewed for demographics, etiology, medical history, presentation, physical examination, imaging studies, intervention, and outcome. Findings on FOE as well as other covariants were statistically compared. Seventy patients with AEUAT were identified. The etiologies consisted of 24 cases of angiotensin converting enzyme inhibitor use (33%), 10 allergic reactions (17%), 1 hereditary (1.5%), and 35 idiopathic cases (48%). Fourteen patients underwent airway intervention, including 6 tracheotomies and 8 intubations. Of the 14 patients, 5 underwent emergent intervention before fiberoptic examination, 4 had laryngeal edema only, and 5 had both laryngeal and base of tongue edema. No patients with both laryngeal and base of tongue edema were observed. The remaining 52 patients were observed in a monitored setting and required no subsequent intervention. FOE is an invaluable tool in the assessment of the compromised airway in patients with angioneurotic edema Laryngeal edema alone is an ominous physical finding. When laryngeal and pharyngeal edema are present together, the physician should consider immediate intervention. Our findings indicate that symptoms, including stridor, hoarseness, and dysphagia, do correlate with disease severity; however, they must be confirmed with fiberoptic visualization. Although sound clinical judgment should always be exercised, we present our results in the management of the acute airway in angioneurotic edema.

Using simulators to teach pediatric airway procedures in an international setting.

PubMed

Schwartz, Marissa A; Kavanagh, Katherine R; Frampton, Steven J; Bruce, Iain A; Valdez, Tulio A

2018-01-01

There has been a growing shift towards endoscopic management of laryngeal procedures in pediatric otolaryngology. There still appears to be a shortage of pediatric otolaryngology programs and children's hospitals worldwide where physicians can learn and practice these skills. Laryngeal simulation models have the potential to be part of the educational training of physicians who lack exposure to relatively uncommon pediatric otolaryngologic pathology. The objective of this study was to assess the utility of pediatric laryngeal models to teach laryngeal pathology to physicians at an international meeting. Pediatric laryngeal models were assessed by participants at an international pediatric otolaryngology meeting. Participants provided demographic information and previous experience with pediatric airways. Participants then performed simulated surgery on these models and evaluated them using both a previously validated Tissue Likeness Scale and a pre-simulation to post-simulation confidence scale. Participants reported significant subjective improvement in confidence level after use of the simulation models (p < 0.05). Participants reported realistic representations of human anatomy and pathology. The models' tissue mechanics were adequate to practice operative technique including the ability to incise, suture, and suspend models. The pediatric laryngeal models demonstrate high quality anatomy, which is easy manipulated with surgical instruments. These models allow both trainees and surgeons to practice time-sensitive airway surgeries in a safe and controlled environment. Copyright © 2017 Elsevier B.V. All rights reserved.

Effect of laryngeal anesthesia on pulmonary function testing in normal subjects.

PubMed

Kuna, S T; Woodson, G E; Sant'Ambrogio, G

1988-03-01

Pulmonary function tests (PFT) were performed on 11 normal subjects before and after topical anesthesia of the larynx. The PFT consisted of flow volume loops and body box determinations of functional residual capacity and airway resistance, each performed in triplicate. After the first set of tests, cotton pledgets soaked in 4% lidocaine were held in the pyriform sinuses for 2 min to block the superior laryngeal nerves. In addition, 1.5 ml of 10% cocaine was dropped on the vocal cords via indirect laryngoscopy. PFT were repeated 5 min after anesthesia. Besides routine analysis of the flow volume loops, areas under the inspiratory (Area I) and expiratory (Area E) portions of the loops were calculated by planimetry. Area I, peak inspiratory flow (PIF), as well as forced inspiratory flow at 25, 50, and 75% forced vital capacity (FVC), decreased after anesthesia. Peak expiratory flow decreased after anesthesia, but Area E and forced expiratory flow at 25, 50, and 75% FVC were unchanged. This protocol also was performed in 12 normal subjects with isotonic saline being substituted for the lidocaine and cocaine. In this group, no significant differences were observed when flow volume loop parameters were compared before and after topical application of saline. In 5 spontaneously breathing anesthetized dogs, posterior cricoarytenoid muscle and afferent superior laryngeal nerve activity were recorded before and after laryngeal anesthesia performed with the same procedure used in the human subjects. Laryngeal anesthesia resulted in a substantial decrease or a complete disappearance of afferent SLN activity recorded during unobstructed and obstructed respiration. The data suggest that laryngeal receptors help modulate upper airway patency in man.

Fiberoptic nasopharyngoscopy for evaluating a potentially difficult airway in a patient with elevated intracranial pressure.

PubMed

Kurnutala, Lakshmi N; Sandhu, Gurneet; Bergese, Sergio D

2016-11-01

A 62-year-old man with a left temporal lobe tumor was scheduled for a semiurgent craniotomy for tumor excision. Previously, the patient had a laryngeal carcinoma that was resected and treated with chemotherapy and radiotherapy and a history of laryngeal biopsy with awake fiberoptic intubation. Because a difficult airway was anticipated, awake fiberoptic nasopharyngoscopy of the airway was performed under topical anesthesia in the operating room. This revealed a narrow glottic opening with no supraglottic pathology or friable tissue. Based on these airway observations, we proceeded safely with intravenous induction and secured the airway in a controlled fashion, thereby minimizing the risk of increased intracranial pressure and catastrophic complications. Nasopharyngoscopy can be used safely to evaluate the upper airway to stratify airway management in patients with a history of head and neck cancer presenting for neurosurgical procedures in the setting of elevated intracranial pressure. Copyright © 2016 Elsevier Inc. All rights reserved.

Self-pressurized air-Q® intubating laryngeal airway versus the LMA® Classic™: a randomized clinical trial.

PubMed

Ha, Sang Hee; Kim, Min-Soo; Suh, Jiwoo; Lee, Jong Seok

2018-05-01

The self-pressurized air-Q® (air-Q SP) intubating laryngeal airway is a relatively new supraglottic airway (SGA) device. The intracuff pressure of air-Q dynamically equilibrates with the airway pressure and adjusts to the patient's pharyngeal and periglottic anatomy, potentially providing improved airway fit and seal. The aim of this prospective randomized study was to compare the clinical performance of air-Q to the LMA® Classic™ SGA. Adult patients requiring general anesthesia for elective surgery were prospectively enrolled and randomly assigned to either air-Q SP or the LMA Classic SGA. Oropharyngeal leak pressure (primary endpoint), success rate, insertion features (insertion time, ease of insertion, requirement for device manipulation), sealing function, gastric insufflation, bronchoscopic view, and oropharyngeal complications at device insertion and following its removal (sore throat, dysphagia, dysphonia) were compared. The mean (standard deviation [SD]) oropharyngeal leak pressure just after insertion was similar in the air-Q SP and LMA [16.8 (4.9) vs 18.6 (5.5) cm H 2 O, respectively; mean difference, 1.8 cm H 2 O; 95% CI, -0.5 to 4.2; P = 0.13] and did not differ at ten minutes following device insertion. Median [interquartile range (IQR)] peak inspiratory pressure just after insertion was lower in the air-Q SP (11.0 [10.0-13.0] vs 13.0 [11.0-14.0] cmH 2 O, median difference, 1.0 cm H 2 O; 95% CI, 0.0 to 2.0; P = 0.03) but no difference was observed at ten minutes. The median [IQR] insertion time was faster with the air-Q SP (15.9 [13.6-20.3] sec vs 24 [21.2-27.1] sec; median difference, 8.1 sec; 95% CI, 5.6 to 9.9; P < 0.001) and improved bronchoscopic viewing grade were seen with the air-Q SP immediately after insertion (P < 0.001). No differences between the groups were observed with respect to the rate of successful insertion at first attempt, overall insertion success rate, ease of insertion, and complications. The air-Q SP had similar leak

Comparison of face masks in the bag-mask ventilation of a manikin.

PubMed

Redfern, D; Rassam, S; Stacey, M R; Mecklenburgh, J S

2006-02-01

We conducted a study investigating the effectiveness of four face mask designs in the bag-mask ventilation of a special manikin adapted to simulate a difficult airway. Forty-eight anaesthetists volunteered to bag-mask ventilate the manikin for 3 min with four different face masks. The primary outcome of the study was to calculate mean percentage leak from the face masks over 3 min. Anaesthetists were also asked to rate the face masks using a visual analogue score. The single-use scented intersurgical face mask had the lowest mean leak (20%). This was significantly lower than the mean leak from the single-use, cushioned 7,000 series Air Safety Ltd. face mask (24%) and the reusable silicone Laerdal face mask (27%) but not significantly lower than the mean leak from the reusable anatomical intersurgical face mask (23%). There was a large variation in both performance and satisfaction between anaesthetists with each design. This highlights the importance of having a variety of face masks available for emergency use.

Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer

PubMed Central

Gupta, Babita; Kohli, Santvana; Farooque, Kamran; Jalwal, Gopal; Gupta, Deepak; Sinha, Sumit; Chandralekha

2014-01-01

Overview: Awake fiberoptic bronchoscope (FOB) guided intubation is the gold standard of airway management in patients with cervical spine injury. It is essential to sufficiently anesthetize the upper airway before the performance of awake FOB guided intubation in order to ensure patient comfort and cooperation. This randomized controlled study was performed to compare two methods of airway anesthesia, namely ultrasonic nebulization of local anesthetic and performance of airway blocks. Materials and Methods: A total of 50 adult patients with cervical spine injury were randomly allocated into two groups. Group L received airway anesthesia through ultrasonic nebulization of 10 ml of 4% lignocaine and Group NB received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) each with 2 ml of 2% lignocaine and viscous lignocaine gargles. FOB guided orotracheal intubation was then performed. Hemodynamic variables at baseline and during the procedure, patient recall, vocal cord visibility, ease of intubation, coughing/gagging episodes, and signs of lignocaine toxicity were noted. Results: The observations did not reveal any significant differences in demographics or hemodynamic parameters at any time during the study. However, the time taken for intubation was significantly lower in Group NB as compared with the Group L. Group L had an increased number of coughing/gagging episodes as compared with Group NB. Vocal cord visibility and ease of intubation were better in patients who received airway blocks and hence the amount of supplemental lignocaine used was less in this group. Overall patient comfort was better in Group NB with fewer incidences of unpleasant recalls as compared with Group L. Conclusion: Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate. PMID:25538514

The performances of standard and ResMed masks during bag-valve-mask ventilation.

PubMed

Lee, Hyoung Youn; Jeung, Kyung Woon; Lee, Byung Kook; Lee, Seung Joon; Jung, Yong Hun; Lee, Geo Sung; Min, Yong Il; Heo, Tag

2013-01-01

A tight mask seal is frequently difficult to obtain and maintain during single-rescuer bag-valve-mask (BVM) ventilation. The ResMed mask (Bella Vista, NSW, Australia) is a continuous-positive-airway-pressure mask (CM) designed for noninvasive ventilation. In this study, we compared the ventilation performances of a standard mask (SM) and a ResMed CM using a simulation manikin in an out-of-hospital single-rescuer BVM ventilation scenario. Thirty emergency medical technicians (EMTs) performed two 2-minute attempts to ventilate a simulation manikin using BVM ventilation, alternatively, with the SM or the ResMed CM in a randomized order. Ventilation parameters including tidal volume and peak airway pressure were measured using computer analysis software connected to the simulation manikin. Successful volume delivery was defined as delivery of 440-540 mL of tidal volume in accord with present cardiopulmonary resuscitation guidelines. BVM ventilation using the ResMed CM produced higher mean (± standard deviation) tidal volumes (452 ± 50 mL vs. 394 ± 113 mL, p = 0.014) and had a higher proportion of successful volume deliveries (65.3% vs. 26.7%, p < 0.001) than that using the SM. Peak airway pressure was higher in BVM ventilation using the ResMed CM (p = 0.035). Stomach insufflation did not occur during either method. Twenty-nine of the participants (96.7%) preferred BVM ventilation using the ResMed CM. BVM ventilations using ResMed CM resulted in a significantly higher proportion of successful volume deliveries meeting the currently recommended range of tidal volume. Clinical studies are needed to determine the value of the ResMed CM for BVM ventilation.

Effects of unilateral laser-assisted ventriculocordectomy in horses with laryngeal hemiplegia.

PubMed

Robinson, P; Derksen, F J; Stick, J A; Sullins, K E; DeTolve, P G; Robinson, N E

2006-11-01

Recent studies have evaluated surgical techniques aimed at reducing noise and improving airway function in horses with recurrent laryngeal neuropathy (RLN). These techniques require general anaesthesia and are invasive. A minimally invasive transnasal surgical technique for treatment of RLN that may be employed in the standing, sedated horse would be advantageous. To determine whether unilateral laser-assisted ventriculocordectomy (LVC) improves upper airway function and reduces noise during inhalation in exercising horses with laryngeal hemiplegia (LH). Six Standardbred horses were used; respiratory sound and inspiratory transupper airway pressure (Pui) measured before and after induction of LH, and 60, 90 and 120 days after LVC. Inspiratory sound level (SL) and the sound intensities of formants 1, 2 and 3 (Fl, F2 and F3, respectively), were measured using computer-based sound analysis programmes. In addition, upper airway endoscopy was performed at each time interval, at rest and during treadmill exercise. In LH-affected horses, Pui, SL and the sound intensity of F2 and F3 were increased significantly from baseline values. At 60 days after LVC, Pui and SL had returned to baseline, and F2 and F3 values had improved partially compared to LH values. At 90 and 120 days, however, SL increased again to LH levels. LVC decreases LH-associated airway obstruction by 60 days after surgery, and reduces inspiratory noise but not as effectively as bilateral ventriculocordectomy. LVC may be recommended as a treatment of LH, where reduction of upper airway obstruction and respiratory noise is desired and the owner wishes to avoid risks associated with a laryngotomy incision or general anaesthesia.

Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications.

PubMed

Greenland, K B; Edwards, M J; Hutton, N J; Challis, V J; Irwin, M G; Sleigh, J W

2010-11-01

The sniffing position is often considered optimal for direct laryngoscopy. Another concept of airway configuration involving a laryngeal vestibule axis and two curves has also been suggested. We investigated whether this theory can be supported mathematically and if it supports the sniffing position as being optimal for direct laryngoscopy. Magnetic resonance imaging scans were performed in 42 normal adult volunteers. The airway passage was divided into two curves-primary (oro-pharyngeal curve) and secondary (pharyngo-glotto-tracheal curve). Airway configuration was evaluated in the neutral, extension, head lift, and sniffing positions. The airway passage, point of inflection (where the two curves meet), its tangent, and the line of sight were plotted on each scan. The point of inflection lay within the laryngeal vestibule in all positions. The head lift and sniffing positions caused the tangent to the point of inflection to approximate the horizontal plane. The sniffing, extension, and head lift positions caused a reduction in the area between the line of sight and the airway curve compared with the neutral position. A two-curve theory is proposed as a basis for explaining airway configuration. The changes in these curves with head and neck positioning support the sniffing position as optimal for direct laryngoscopy. Application of this new concept to other forms of laryngoscopy should be investigated.

Laser vocal cordectomy fails to effectively reduce respiratory noise in horses with laryngeal hemiplegia.

PubMed

Brown, Jennifer A; Derksen, Frederik J; Stick, John A; Hartmann, William M; Robinson, N Edward

2005-01-01

To report the effect of unilateral laser vocal cordectomy on respiratory noise and airway function in horses with experimentally induced laryngeal hemiplegia (LH). Experimental study. Six Standardbred horses without upper airway abnormalities at rest or during high-speed treadmill exercise. Respiratory sounds and inspiratory trans-upper airway pressure (P(Ui)) were measured before (baseline) and 14 days after induction of LH by left recurrent laryngeal neurectomy, and again 30, 60, 90, and 120 days after endoscopically assisted laser cordectomy of the left vocal cord. Data were collected with the horses exercising on a treadmill at a speed producing maximum heart rate (HR(max)). In horses exercising at HR(max), induction of LH caused a significant increase in P(Ui), sound level (SL), and the sound intensity of formant 2 (F(2)) and 3 (F(3)). The sound intensity of formant 1 (F(1)) was unaffected by induction of LH. Laser vocal cordectomy had no effect on SL, or on the sound intensity of F(1) and F(3). At 30, 60, 90, and 120 days after surgery, P(Ui) and the sound intensity of F(2) were significantly reduced, but these variables remained significantly different from baseline values. Unilateral laser vocal cordectomy did not effectively improve upper airway noise in horses with LH. The procedure decreased upper airway obstruction to the same degree as bilateral ventriculocordectomy. Currently, laser vocal cordectomy cannot be recommended for the treatment of upper airway noise in horses with LH.

Analysis Of Laryngeal Biomechanics Of Deaf Speakers Utilizing High-Speed Cinematography

NASA Astrophysics Data System (ADS)

Metz, Dale E.; Whitehead, Robert L.

1982-02-01

Since the formalization of the myoelastic-aerodynamic theory of vocal fold vibration, it has been generally accepted that biomechanical and aerodynamic forces determine the nature of vocal fold vibration patterns, speaking fundamental frequency and vocal intensity. The speech of the deaf is frequently characterized by abnormal voice qualities and aberrant frequency and intensity variations suggesting mismanagement of the biomechanical and aerodynamic forces acting on the larynx. Unfortunately, efforts to remediate these abnormal laryngeal activities are frequently ineffective. It is reasonable to suggest that more effective remedial strategies could be developed if we had a better understanding of the underlying nature of the problems deaf persons experience when trying to control laryngeal functioning for speech purposes. Toward this end, we are employing high speed laryngeal filming procedures in conjunction with glottal impedance, respiratory kinematic and acous-tical measurement procedures to assess abnormal laryngeal functioning of deaf speakers. All data are collected simultaneously and are time-locked to facilitate analysis of specific laryngeal events. This unique combination of instrumentation has provided important insights regarding laryngeal functioning of the deaf. For example, we have observed that deaf speakers may assume abnormal glottal configurations during phonation that pro-hibit normal laryngeal functioning and disturb upper airway dynamics. Also, normal vibratory patterns are frequently disturbed. Instrumentation, data collection protocols, analysis procedures and selected findings will be discussed.

Impact of the type of mask on the effectiveness of and adherence to continuous positive airway pressure treatment for obstructive sleep apnea.

PubMed

Andrade, Rafaela Garcia Santos de; Piccin, Vivien Schmeling; Nascimento, Juliana Araújo; Viana, Fernanda Madeiro Leite; Genta, Pedro Rodrigues; Lorenzi-Filho, Geraldo

2014-01-01

Continuous positive airway pressure (CPAP) is the gold standard for the treatment of obstructive sleep apnea (OSA). Although CPAP was originally applied with a nasal mask, various interfaces are currently available. This study reviews theoretical concepts and questions the premise that all types of interfaces produce similar results. We revised the evidence in the literature about the impact that the type of CPAP interface has on the effectiveness of and adherence to OSA treatment. We searched the PubMed database using the search terms "CPAP", "mask", and "obstructive sleep apnea". Although we identified 91 studies, only 12 described the impact of the type of CPAP interface on treatment effectiveness (n = 6) or adherence (n = 6). Despite conflicting results, we found no consistent evidence that nasal pillows and oral masks alter OSA treatment effectiveness or adherence. In contrast, most studies showed that oronasal masks are less effective and are more often associated with lower adherence and higher CPAP abandonment than are nasal masks. We concluded that oronasal masks can compromise CPAP OSA treatment adherence and effectiveness. Further studies are needed in order to understand the exact mechanisms involved in this effect.

Impact of the type of mask on the effectiveness of and adherence to continuous positive airway pressure treatment for obstructive sleep apnea*

PubMed Central

de Andrade, Rafaela Garcia Santos; Piccin, Vivien Schmeling; Nascimento, Juliana Araújo; Viana, Fernanda Madeiro Leite; Genta, Pedro Rodrigues; Lorenzi-Filho, Geraldo

2014-01-01

Continuous positive airway pressure (CPAP) is the gold standard for the treatment of obstructive sleep apnea (OSA). Although CPAP was originally applied with a nasal mask, various interfaces are currently available. This study reviews theoretical concepts and questions the premise that all types of interfaces produce similar results. We revised the evidence in the literature about the impact that the type of CPAP interface has on the effectiveness of and adherence to OSA treatment. We searched the PubMed database using the search terms "CPAP", "mask", and "obstructive sleep apnea". Although we identified 91 studies, only 12 described the impact of the type of CPAP interface on treatment effectiveness (n = 6) or adherence (n = 6). Despite conflicting results, we found no consistent evidence that nasal pillows and oral masks alter OSA treatment effectiveness or adherence. In contrast, most studies showed that oronasal masks are less effective and are more often associated with lower adherence and higher CPAP abandonment than are nasal masks. We concluded that oronasal masks can compromise CPAP OSA treatment adherence and effectiveness. Further studies are needed in order to understand the exact mechanisms involved in this effect. PMID:25610507

The effect of esophagogastroduodenoscopy probe insertion on the intracuff pressure of airway devices in children during general anesthesia.

PubMed

Balaban, Onur; Kamata, Mineto; Hakim, Mumin; Tumin, Dmitry; Tobias, Joseph D

2017-04-01

Given the size of the esophagogastroduodenoscopy (EGD) probe and the compressibility of the pediatric airway, the EGD probe may increase the intracuff pressure (IP) of an airway device. The current study evaluated IP changes during EGD examination under general anesthesia in pediatric patients. Following the induction of anesthesia, a laryngeal mask airway (LMA) or endotracheal tube (ETT) was placed without neuromuscular blockade. The IP was measured at baseline, during EGD probe insertion, while the EGD probe was in place, and after probe removal. The study cohort included 101 patients (mean age 11.3 years). The airway was secured with an LMA and an ETT in 88 and 13 patients, respectively. The IP increased from 27 ± 15 cmH 2 O at baseline to 34 ± 17 cmH 2 O during probe insertion (p < 0.001), remained at 33 ± 16 cmH 2 O while the probe was in place, and decreased to 26 ± 14 cmH 2 O after probe removal. The IP of the LMA or ETT increased during EGD probe insertion and remained elevated while the probe was in place. High IP may compromise mucosal perfusion resulting in a sore throat when using an LMA or the potential for airway damage if an ETT is used. Removal of air from the cuff and titration of the IP should be considered after EGD insertion.

[Laryngeal papillomatosis: A rare cause of dysphonia in the child. Case series].

PubMed

Cuestas, Giselle; Rodríguez, Verónica; Doormann, Flavia; Bellia Munzón, Patricio; Bellia Munzón, Gastón

2018-06-01

Juvenile laryngeal papillomatosis is an uncommon disease caused by human papilloma virus, mainly types 6 and 11. It is the most common benign laryngeal tumor in children. This condition should be suspected in any children with persistent and progressive dysphonia with or without stridor and respiratory distress. Flexible laryngoscopy under local anesthesia allows to visualize the typical wart-like lesions. The diagnosis is confirmed by pathological anatomy. Existing treatment is palliative and consists mainly of the surgical excision of the papillomas to maintain the airway without obstruction and to improve the quality of the voice, but it has a high rate of relapse. We present 20 patients with juvenile laryngeal papillomatosis. We describe the clinical manifestations, the diagnostic methods and the treatment of this pathology. Sociedad Argentina de Pediatría.

Use of a Supraglottic Airway to Relieve Ventilation-Impeding Gastric Insufflation During Emergency Airway Management in an Infant.

PubMed

Dodd, Kenneth W; Strobel, Ashley M; Driver, Brian E; Reardon, Robert F

2016-10-01

Positive-pressure bag-valve-mask ventilation during emergency airway management often results in significant gastric insufflation, which may impede adequate ventilation and oxygenation. Current-generation supraglottic airways have beneficial features, such as channels for gastric decompression while ventilation is ongoing. A 5-week-old female infant required resuscitation for hypoxemic respiratory failure caused by rhinovirus with pneumonia. Bag-valve-mask ventilation led to gastric insufflation that compromised ventilation, thereby interfering with intubation because of precipitous oxygen desaturation during laryngoscopy. A current-generation supraglottic airway (LMA Supreme; Teleflex Inc, Morrisville, NC) was used to facilitate gastric decompression while ventilation and oxygenation was ongoing. After gastric decompression, ventilation was markedly improved and the pulse oxygen saturation improved to 100%. Intubation was successful on the next attempt, without oxygen desaturation. Current-generation supraglottic airways have 3 distinct advantages compared with first-generation supraglottic airways, which make them better devices for emergency airway management: gastric decompression ports, conduits for intubation, and higher oropharyngeal leak pressures. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

A comparison of 2 methods of endoscopic laryngeal sensory testing: a preliminary study.

PubMed

Kaneoka, Asako; Krisciunas, Gintas P; Walsh, Kayo; Raade, Adele S; Langmore, Susan E

2015-03-01

This study examined the association between laryngeal sensory deficits and penetration or aspiration. Two methods of testing laryngeal sensation were carried out to determine which was more highly correlated with Penetration-Aspiration Scale (PAS) scores. Healthy participants and patients with dysphagia received an endoscopic swallowing evaluation including 2 sequential laryngeal sensory tests-air pulse followed by touch method. Normal/impaired responses were correlated with PAS scores. Fourteen participants completed the endoscopic swallowing evaluation and both sensory tests. The air pulse method identified sensory impairment with greater frequency than the touch method (P<.0001). However, the impairment identified by the air pulse method was not associated with abnormal PAS scores (P=.46). The sensory deficits identified by the touch method were associated with abnormal PAS scores (P=.05). Sensory impairment detected by the air pulse method does not appear to be associated with risk of penetration/aspiration. Significant laryngeal sensory loss revealed by the touch method is associated with compromised airway protection. © The Author(s) 2014.

Mask ventilation with two different face masks in the delivery room for preterm infants: a randomized controlled trial.

PubMed

Cheung, D; Mian, Q; Cheung, P-Y; O'Reilly, M; Aziz, K; van Os, S; Pichler, G; Schmölzer, G M

2015-07-01

If an infant fails to initiate spontaneous breathing after birth, international guidelines recommend a positive pressure ventilation (PPV). However, PPV by face mask is frequently inadequate because of leak between the face and mask. Despite a variety of available face masks, none have been prospectively compared in a randomized fashion. We aimed to evaluate and compare leak between two commercially available round face masks (Fisher & Paykel (F&P) and Laerdal) in preterm infants <33 weeks gestational age in the delivery room. Infants born at the Royal Alexandra Hospital from April to September 2013 at <33 weeks gestational age who received mask PPV in the delivery room routinely had a flow sensor placed between the mask and T-piece resuscitator. Infants were randomly assigned to receive PPV with either a F&P or Laerdal face mask. All resuscitators were trained in the use of both face masks. We compared mask leak, airway pressures, tidal volume and ventilation rate between the two groups. Fifty-six preterm infants (n=28 in each group) were enrolled; mean±s.d. gestational age 28±3 weeks; birth weight 1210±448 g; and 30 (52%) were male. Apgar scores at 1 and 5 min were 5±3 and 7±2, respectively. Infants randomized to the F&P face mask and Laerdal face mask had similar mask leak (30 (25-38) versus 35 (24-46)%, median (interquartile range), respectively, P=0.40) and tidal volume (7.1 (4.9-8.9) versus 6.6 (5.2-8.9) ml kg(-1), P=0.69) during PPV. There were no significant differences in ventilation rate, inflation time or airway pressures between groups. The use of either face mask during PPV in the delivery room yields similar mask leak in preterm infants <33 weeks gestational age.

Computed tomography-guided tissue engineering of upper airway cartilage.

PubMed

Brown, Bryan N; Siebenlist, Nicholas J; Cheetham, Jonathan; Ducharme, Norm G; Rawlinson, Jeremy J; Bonassar, Lawrence J

2014-06-01

Normal laryngeal function has a large impact on quality of life, and dysfunction can be life threatening. In general, airway obstructions arise from a reduction in neuromuscular function or a decrease in mechanical stiffness of the structures of the upper airway. These reductions decrease the ability of the airway to resist inspiratory or expiratory pressures, causing laryngeal collapse. We propose to restore airway patency through methods that replace damaged tissue and improve the stiffness of airway structures. A number of recent studies have utilized image-guided approaches to create cell-seeded constructs that reproduce the shape and size of the tissue of interest with high geometric fidelity. The objective of the present study was to establish a tissue engineering approach to the creation of viable constructs that approximate the shape and size of equine airway structures, in particular the epiglottis. Computed tomography images were used to create three-dimensional computer models of the cartilaginous structures of the larynx. Anatomically shaped injection molds were created from the three-dimensional models and were seeded with bovine auricular chondrocytes that were suspended within alginate before static culture. Constructs were then cultured for approximately 4 weeks post-seeding and evaluated for biochemical content, biomechanical properties, and histologic architecture. Results showed that the three-dimensional molded constructs had the approximate size and shape of the equine epiglottis and that it is possible to seed such constructs while maintaining 75%+ cell viability. Extracellular matrix content was observed to increase with time in culture and was accompanied by an increase in the mechanical stiffness of the construct. If successful, such an approach may represent a significant improvement on the currently available treatments for damaged airway cartilage and may provide clinical options for replacement of damaged tissue during treatment of

A randomised controlled trial on the effect of mask choice on residual respiratory events with continuous positive airway pressure treatment.

PubMed

Ebben, Matthew R; Narizhnaya, Mariya; Segal, Alan Z; Barone, Daniel; Krieger, Ana C

2014-06-01

It has been found that mask style can affect the amount of continuous positive airway pressure (CPAP) required to reduce an apnoea/hyponoea index (AHI) to < 5/h on a titration study. However, it was not previously known whether switching from one CPAP mask style to another post titration could affect the residual AHI with CPAP. The purpose of this study was to investigate the differences in residual AHI with CPAP treatment between oronasal and nasal masks. Twenty-one subjects (age mean (M)=62.9, body mass index (BMI) M=29.6 kg/m2) were randomised (14 subjects completed the protocol) to undergo an in-laboratory CPAP titration with either a nasal mask or an oronasal mask. Subjects were then assigned this mask for 3weeks of at-home CPAP use with the optimal treatment pressure determined on the laboratory study (CPAP M=8.4 cm of H2O). At the end of this 3-week period, data were collected from the CPAP machine and the subject was given the other mask to use with the same CPAP settings for the next 3weeks at home (if the nasal mask was given initially, the oronasal one was given later and vice versa). On completion of the second 3-week period, data on residual AHI were again collected and compared with the first 3-week period on CPAP. A Wilcoxon Signed-Rank Test (two-tailed) revealed that residual AHI with CPAP treatment was significantly higher with the oronasal compared with the nasal mask (z = -3.296, p<0.001). All 14 subjects had a higher residual AHI with the oronasal versus nasal mask, and 50% of the subjects had a residual AHI >10/h in the oronasal mask condition, even though all of these subjects were titrated to an AHI of < 5/h in the laboratory. A higher residual AHI was seen in all patients with the use of an oronasal mask compared with a nasal mask. Switching to an oronasal mask post titration results in an increase in residual AHI with CPAP treatment, and pressure adjustment may be warranted. Copyright © 2014 Elsevier B.V. All rights reserved.

Anesthesia management in pediatric patients with laryngeal papillomatosis undergoing suspension laryngoscopic surgery and a review of the literature.

PubMed

Bo, Lin; Wang, Bing; Shu, Shi-Yu

2011-11-01

The excision of laryngeal papillomas poses a great challenge for both the anesthesiologist and the surgeon. The narrowness of the airways and the great variability of the pathological lesions necessitate close collaboration between the surgical and anesthesia teams to provide optimal operating conditions and ensure adequate ventilation and oxygenation. Our aim was to explore perioperative anesthesia management in pediatric patients during the excision of laryngeal papillomas with a suspension laryngoscope. Fifty-eight pediatric patients suffering from laryngeal papillomas were included in this retrospective study. These patients had degrees of laryngeal obstruction from I to III and underwent suspension laryngoscopic surgery to excise laryngeal papillomas between January 2007 and December 2010. The American Society of Anesthesiologists (ASA) physical status of the patients ranged from I to III. Anesthesia was induced by intravenous administration. Once the child was unconscious, a 2% lidocaine aerosol solution was sprayed over the laryngeal area directly under the laryngoscope. For patients to tolerate suspension laryngoscopy, it is necessary to maintain spontaneous breathing and ensure adequate anesthesia depth. The airway was secured, and sufficient ventilation was established throughout a tracheal tube (ID 2.5 or 3.0) which was placed close to glottis and connected to Jackson Rees system. Hemodynamic parameters and pulse oxygen saturation (SpO(2)) were closely monitored, and adverse events were recorded. Most of the patients 89% (52/58) were hemodynamically stable during the perioperative period. Laryngospasm and laryngeal edema occurred in several children during emergence from the anesthesia. Tracheal intubations were performed in six patients (10.3%). Tracheotomies were performed in two patients. One patient had to be sent to the ICU for comprehensive therapy. The most important consideration for anesthesia during suspension laryngoscopy is (1) the

Swallowing Mechanics Associated with Artificial Airways, Bolus Properties, and Penetration-Aspiration Status in Trauma Patients

ERIC Educational Resources Information Center

Dietsch, Angela M.; Rowley, Christopher B.; Solomon, Nancy Pearl; Pearson, William G., Jr.

2017-01-01

Purpose: Artificial airway procedures such as intubation and Sare common in the treatment of traumatic injuries, and bolus modifications may be implemented to help manage swallowing disorders. This study assessed artificial airway status, bolus properties (volume and viscosity), and the occurrence of laryngeal penetration and/or aspiration in…

Temporomandibular Joint Ankylosis: "A Pediatric Difficult Airway Management".

PubMed

Sharma, Anoop; Dwivedi, Deepak; Sharma, Ram Murti

2018-01-01

Intubating a pediatric patient with temporomandibular joint ankylosis is a daunting task, and it becomes more challenging with limited mouth opening. Fiberoptic nasotracheal intubation technique is considered a gold standard. We describe an improvised technique of securing airway in the absence of appropriate-sized fiberoptic scope. The endotracheal tube inserted in the left nostril for maintaining depth of anesthesia was advanced under vision by the fiberoptic scope inserted into the right nostril, and with external laryngeal manipulation, the airway was secured with no complications.

Spontaneous laryngeal reinnervation following chronic recurrent laryngeal nerve injury.

PubMed

Kupfer, Robbi A; Old, Matthew O; Oh, Sang Su; Feldman, Eva L; Hogikyan, Norman D

2013-09-01

To enhance understanding of spontaneous laryngeal muscle reinnervation following severe recurrent laryngeal nerve injury by testing the hypotheses that 1) nerve fibers responsible for thyroarytenoid muscle reinnervation can originate from multiple sources and 2) superior laryngeal nerve is a source of reinnervation. Prospective, controlled, animal model. A combination of retrograde neuronal labeling techniques, immunohistochemistry, electromyography, and sequential observations of vocal fold mobility were employed in rat model of chronic recurrent laryngeal nerve injury. The current study details an initial set of experiments in sham surgical and denervated group animals and a subsequent set of experiments in a denervated group. At 3 months after recurrent laryngeal nerve resection, retrograde brainstem neuronal labeling identified cells in the characteristic superior laryngeal nerve cell body location as well as cells in a novel caudal location. Regrowth of neuron fibers across the site of previous recurrent laryngeal nerve resection was seen in 87% of examined animals in the denervated group. Electromyographic data support innervation by both the superior and recurrent laryngeal nerves following chronic recurrent laryngeal nerve injury. Following chronic recurrent laryngeal nerve injury in the rat, laryngeal innervation is demonstrated through the superior laryngeal nerve from cells both within and outside of the normal cluster of cells that supply the superior laryngeal nerve. The recurrent laryngeal nerve regenerates across a surgically created gap, but functional significance of regenerated nerve fibers is unclear. Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

The temporal relationship between non-respiratory burst activity of expiratory laryngeal motoneurons and phrenic apnoea during stimulation of the superior laryngeal nerve in rat

PubMed Central

Sun, Qi-Jian; Bautista, Tara G; Berkowitz, Robert G; Zhao, Wen-Jing; Pilowsky, Paul M

2011-01-01

Abstract A striking effect of stimulating the superior laryngeal nerve (SLN) is its ability to inhibit central inspiratory activity (cause ‘phrenic apnoea’), but the mechanism underlying this inhibition remains unclear. Here we demonstrate, by stimulating the SLN at varying frequencies, that the evoked non-respiratory burst activity recorded from expiratory laryngeal motoneurons (ELMs) has an intimate temporal relationship with phrenic apnoea. During 1–5 Hz SLN stimulation, occasional absences of phrenic nerve discharge (PND) occurred such that every absent PND was preceded by an ELM burst activity. During 10–20 Hz SLN stimulation, more bursts were evoked together with more absent PNDs, leading eventually to phrenic apnoea. Interestingly, subsequent microinjections of isoguvacine (10 mm, 20–40 nl) into ipsilateral Bötzinger complex (BötC) and contralateral nucleus tractus solitarii (NTS) significantly attenuated the apnoeic response but not the ELM burst activity. Our results suggest a bifurcating projection from NTS to both the caudal nucleus ambiguus and BötC, which mediates the closely related ELM burst and apnoeic response, respectively. We believe that such an intimate timing between laryngeal behaviour and breathing is crucial for the effective elaboration of the different airway protective behaviours elicited following SLN stimulation, including the laryngeal adductor reflex, swallowing and cough. PMID:21320890

Temperature distribution in the upper airway after inhalation injury.

PubMed

Rong, Yan-hua; Liu, Wei; Wang, Cheng; Ning, Fang-gang; Zhang, Guo-an

2011-11-01

The aim of the study was to establish an animal model of laryngeal burn and to investigate the temperature distribution of heated air in the upper airway. The animal model was established by inhalation of dry heated air at 80, 160 and 320 °C in 18 healthy, male, adult hybrid dogs. Time for inducing injury was set at 20 min. The distribution of temperatures after heated-air inhalation was examined at different locations including the epiglottis, laryngeal vestibule, vocal folds and trachea. The temperatures of the heated air decreased to 47.1, 118.4 and 193.8 °C at the laryngeal vestibule and to 39.3, 56.6 and 137.9 °C at the lower margin of vocal folds in the 80, 160 and 320 °C groups, respectively. Due to its special anatomy and functions, the larynx has different responses to dry heated air at different temperatures. The air temperature decreases markedly when the air arrives at the larynx. By contrast, the larynx has a low capacity for blocking high-temperature air and retaining heat. As a result, high-temperature air often causes more severe injury to the larynx and the lower airway. Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.

Supraglottic Airway Devices: the Search for the Best Insertion Technique or the Time to Change Our Point of View?

PubMed

Sorbello, Massimiliano; Petrini, Flavia

2017-04-01

In the crowded world of supraglottic airway devices (SADs), many papers compare the easiness of insertion based on the different endpoints of an operator's satisfaction: first pass success, ventilation effectiveness, complications and morbidity. Proseal LMA ™ (Laryngeal Mask Airway, Teleflex Medical, Dublin, Ireland) has been extensively studied because on one hand it has a steeper learning curve and more complex insertion when compared with other SADs and on the other hand many alternative techniques are available to facilitate insertion. This research is part of a larger body of studies exploring the issue that some devices are more difficult to insert because of many features related to sizing, constructive material, airway conduit and cuff design, performance and last but not least experience. Nevertheless, the biggest question might be the search for a systematic categorization of insertion difficulty features and identification of criteria allowing the choice for the best device and consequently for the best insertion technique. Given that, as a result of many intrinsic characteristics of the device we are using, insertion might become the secondary issue to be considered only after we clearly identify what makes it difficult, and to be counterbalanced on the results we expect from the device, performance we can achieve and degree of airway protection it could grant. The aim of this narrative review is to consider which factors might affect or condition SAD insertion difficulty and to try identifying some criteria addressing physicians pertaining to the use of SADs in clinical practice.

Rates of initial acceptance of PAP masks and outcomes of mask switching.

PubMed

Bachour, Adel; Vitikainen, Pirjo; Maasilta, Paula

2016-05-01

Recently, we noticed a considerable development in alleviating problems related to positive airway pressure (PAP) masks. In this study, we report on the initial PAP mask acceptance rates and the effects of mask switching on mask-related symptoms. We prospectively collected all cases of mask switching in our sleep unit for a period of 14 months. At the time of the study, we used ResMed™ CPAP devices and masks. Mask switching was defined as replacing a mask used for at least 1 day with another type of mask. Changing to a different size but keeping the same type of mask did not count as mask switching. Switching outcomes were considered failed if the initial problem persisted or reappeared during the year that followed switching. Our patient pool was 2768. We recorded 343 cases of mask switching among 267 patients. Of the 566 patients who began new PAP therapy, 108 (39 women) had switched masks, yielding an initial mask acceptance rate of 81 %. The reason for switching was poor-fit/uncomfortable mask in 39 %, leak-related in 30 %, outdated model in 25 %, and nasal stuffiness in 6 % of cases; mask switching resolved these problems in 61 %. Mask switching occurred significantly (p = 0.037) more often in women and in new PAP users. The odds ratio for abandoning PAP therapy within 1 year after mask switching was 7.2 times higher (interval 4.7-11.1) than not switching masks. The initial PAP mask acceptance rate was high. Patients who switched their masks are at greater risk for abandoning PAP therapy.

An Uncommon Complication with a Supraglottic Airway: The King LT.

PubMed

Brown, Sara; Cherian, Verghese T; Greco, Katherine; Mets, Elbert; Budde, Arne

2016-02-15

General anesthesia was administered in an 18-year-old man for removal of hardware from his right knee using a King Laryngeal Tube supraglottic airway. An hour after extubation, he reported inability to swallow with no respiratory distress. Examination showed an edematous uvula, which took 3 days to subside with anti-inflammatory medication. During the positioning of the King Laryngeal Tube, it was pulled back to ensure adequate ventilation. The inflated cuff could have dragged the uvula and folded it on itself, leading to venous congestion and edema.

Management of Foreign Body Removal in Children by Flexible Bronchoscopy.

PubMed

Tenenbaum, Tobias; Kähler, Georg; Janke, Christoph; Schroten, Horst; Demirakca, Süha

2017-01-01

Rigid bronchoscopy remains the gold standard in many countries to remove airway foreign bodies (FBs). We aimed to analyze the feasibility of airway FB removal in children, primarily by flexible bronchoscopy through a laryngeal mask. Between 2008 and 2013, 62 children with suspected airway FB who underwent flexible bronchoscopy were analyzed in a retrospective chart review at a tertiary university hospital with respect to clinical presentation and medical management. In 28/62 children (45.2%) an airway FB could be found and in all patients removed by flexible bronchoscopy. Additional 19/34 children (55.8%), in which no FB was found, showed macroscopic evidence of prior FB aspiration. The most frequently removed airway FBs were nuts (13/28; 46.4%) followed by other organic airway FBs (9/28; 32.2%) and nonorganic airway FBs (6/28; 21.4%). All FBs were uneventfully removed with a grasping forceps (16/28; 57.1%), basket forceps (9/28; 32.2%), suction (2/28; 7.1%), or polypectomy snare (1/28; 3.6%). Children with proven airway FB were significantly younger than children without an airway FB (24 vs. 27 mo). Adjuvant antibiotic therapy was given in 15/28 (53.6%) children with proven airway FB and 13/34 (38.2%) without, steroids in 24/28 (85.7%) and 21/34 (61.8%), respectively. In 6/28 (9.7%) children epinephrine intrabronchial was used to mobilize the airway FB during bronchoscopy. In an optimized clinical setting, flexible bronchoscopy can be regarded as a feasible procedure to remove airway FB through a laryngeal mask. Short-term and long-term outcome is favorable.

Development of Sub-optimal Airway Protocols for the International Space Station (ISS) by the Medical Operation Support Team (MOST)

NASA Technical Reports Server (NTRS)

Polk, James D.; Parazynski, Scott; Kelly, Scott; Hurst, Victor, IV; Doerr, Harold K.

2007-01-01

Airway management techniques are necessary to establish and maintain a patent airway while treating a patient undergoing respiratory distress. There are situations where such settings are suboptimal, thus causing the caregiver to adapt to these suboptimal conditions. Such occurrences are no exception aboard the International Space Station (ISS). As a result, the NASA flight surgeon (FS) and NASA astronaut cohorts must be ready to adapt their optimal airway management techniques for suboptimal situations. Based on previous work conducted by the Medical Operation Support Team (MOST) and other investigators, the MOST had members of both the FS and astronaut cohorts evaluate two oral airway insertion techniques for the Intubating Laryngeal Mask Airway (ILMA) to determine whether either technique is sufficient to perform in suboptimal conditions within a microgravity environment. Methods All experiments were conducted in a simulated microgravity environment provided by parabolic flight aboard DC-9 aircraft. Each participant acted as a caregiver and was directed to attempt both suboptimal ILMA insertion techniques following a preflight instruction session on the day of the flight and a demonstration of the technique by an anesthesiologist physician in the simulated microgravity environment aboard the aircraft. Results Fourteen participants conducted 46 trials of the suboptimal ILMA insertion techniques. Overall, 43 of 46 trials (94%) conducted were properly performed based on criteria developed by the MOST and other investigators. Discussion The study demonstrated the use of airway management techniques in suboptimal conditions relating to space flight. Use of these techniques will provide a crew with options for using the ILMA to manage airway issues aboard the ISS. Although it is understood that the optimal method for patient care during space flight is to have both patient and caregiver restrained, these techniques provide a needed backup should conditions not present

Histoplasmosis laryngeal

PubMed Central

Moriones Robayo, Carlos Alberto

2014-01-01

Laryngeal histoplasmosis is a fungal infection that is frequent in Colombia. Laryngeal histoplasmosis usually occurs in immunocompromised patients through the dissemination of the fungus from the lungs to other organs. Histoplasmosis isolated laryngeal (primary) is rare. If a patient presents with a history of immunosuppression by renal transplant, primary laryngeal histoplasmosis with supraglottic granulomatous inflammation that was treated with amphotericin B and Itraconazole, with complete resolution of laryngeal lesions. PMID:25767308

A systematic review of variations of the recurrent laryngeal nerve.

PubMed

Ling, Xing Yao; Smoll, Nicolas Roydon

2016-01-01

With thyroid cancer fast becoming one of the most common endocrine cancers, the frequency of thyroid surgery has increased. A common and debilitating concern with thyroid surgery is recurrent laryngeal nerve (RLN) paralysis leading to glottal obstruction and airway compromise. A systematic review regarding the anatomical variation of the recurrent laryngeal nerve was performed to determine the position of anatomical variants of the RLN in relation to the inferior thyroid artery (ITA) as well as the prevalence of nonrecurrent laryngeal nerve (NRLN). MEDLINE, Web of Science, MEDITEXT, AMED, CINAHL, Cochrane, ProQuest, Pubmed, and ScienceDirect. Databases were searched using the search terms "inferior thyroid artery," "recurrent laryngeal nerve," "nonrecurrent laryngeal nerve," and "anatomical variation." The reference sections of the articles found were searched for additional reports. The references of all articles were searched to find articles missed in the database search. A total of 8,655 RLN sides were included in this study. One thousand eight hundred and thirteen (20.95%; 95% confidence interval (CI) 20.09, 2,182) showed a Type A configuration of RLN in relation to the ITA, 2,432 (28.10%; 95% CI 27.15, 29.06) showed a Type B configuration and 4,410 (50.95%; 95% CI 49.89, 52.01) showed a Type C configuration between the RLN and the ITA. The second search returned with 38,568 recurrent laryngeal sides and only 221 (0.57%; 95%CI 0.5, 0.65) NRLN documented. The RLN is most commonly found in the posterior position, relative to the ITA. The incidence of the NRLN is low, only occurring in 0.57% of people. © 2015 Wiley Periodicals, Inc.

Nasal mask ventilation is better than face mask ventilation in edentulous patients.

PubMed

Kapoor, Mukul Chandra; Rana, Sandeep; Singh, Arvind Kumar; Vishal, Vindhya; Sikdar, Indranil

2016-01-01

Face mask ventilation of the edentulous patient is often difficult as ineffective seating of the standard mask to the face prevents attainment of an adequate air seal. The efficacy of nasal ventilation in edentulous patients has been cited in case reports but has never been investigated. Consecutive edentulous adult patients scheduled for surgery under general anesthesia with endotracheal intubation, during a 17-month period, were prospectively evaluated. After induction of anesthesia and administration of neuromuscular blocker, lungs were ventilated with a standard anatomical face mask of appropriate size, using a volume controlled anesthesia ventilator with tidal volume set at 10 ml/kg. In case of inadequate ventilation, the mask position was adjusted to achieve best-fit. Inspired and expired tidal volumes were measured. Thereafter, the face mask was replaced by a nasal mask and after achieving best-fit, the inspired and expired tidal volumes were recorded. The difference in expired tidal volumes and airway pressures at best-fit with the use of the two masks and number of patients with inadequate ventilation with use of the masks were statistically analyzed. A total of 79 edentulous patients were recruited for the study. The difference in expiratory tidal volumes with the use of the two masks at best-fit was statistically significant (P = 0.0017). Despite the best-fit mask placement, adequacy of ventilation could not be achieved in 24.1% patients during face mask ventilation, and 12.7% patients during nasal mask ventilation and the difference was statistically significant. Nasal mask ventilation is more efficient than standard face mask ventilation in edentulous patients.

Oronasal masks require higher levels of positive airway pressure than nasal masks to treat obstructive sleep apnea.

PubMed

Bettinzoli, Michela; Taranto-Montemurro, Luigi; Messineo, Ludovico; Corda, Luciano; Redolfi, Stefania; Ferliga, Mauro; Tantucci, Claudio

2014-12-01

The purpose of this study was to compare the therapeutic pressure determined by an automated CPAP device (AutoCPAP) during the titration period, between nasal and oronasal mask and the residual apnea-hypopnea index (AHI) on a subsequent poligraphy performed with the established therapeutic CPAP. As a retrospective study, 109 subjects with moderate and severe obstructive sleep apnea-hypopnea (apnea-hypopnea index≥15 events/h) were studied. CPAP titration was performed using an auto-titrating device. There was significant difference in the mean pressure delivered with autoCPAP between the group of patients using the nasal mask (mean 10.0 cmH2O±2.0 SD) and the group which used the oronasal mask (mean 11.2 cmH2O±2.1) (p<0.05). Residual apneas were lower when using a nasal mask: average AHI of 2.6±2.5 compared to 4.5±4.0 using an oronasal mask (p<0.05). On multivariate analysis, the only independent predictor of the level of therapeutic pressure of CPAP was the type of mask used (r=0.245, p 0.008). Therapeutic CPAP level for OSAH is higher when administered via oronasal mask, leaving more residual events. These findings suggest that nasal mask should be the first choice for OSAH treatment.

The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation

PubMed Central

Prekker, Matthew E.; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D.

2016-01-01

Objective Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Design Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services (EMS) administrative database. Setting EMS system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e. rapid sequence intubation). Patients A total of 7,523 patients >12 years old in whom paramedics attempted prehospital endotracheal intubation. Interventions None Measurements and Main Results An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (N=1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, N=27) and bag-valve-mask ventilation (0.8%, N=60) were rarely performed by paramedics as final rescue airway strategies. Conclusions Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a

The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation.

PubMed

Prekker, Matthew E; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D

2014-06-01

Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database. Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation). A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation. None. An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies. Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.

Equivalence of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea syndrome.

PubMed

Teo, Ming; Amis, Terence; Lee, Sharon; Falland, Karina; Lambert, Stephen; Wheatley, John

2011-07-01

Continuous positive airway pressure (CPAP) titration studies are commonly performed using a nasal mask but some patients may prefer a full-face or oronasal mask. There is little evidence regarding the equivalence of different mask interfaces used to initiate treatment. We hypothesized that oronasal breathing when using an oronasal mask increases upper airway collapsibility and that a higher pressure may be required to maintain airway patency. We also assessed patient preferences for the 2 mask interfaces. Prospective, randomized, cross-over design with 2 consecutive CPAP titration nights. Accredited laboratory in a university hospital. Twenty-four treatment-naive subjects with obstructive sleep apnea syndrome and respiratory disturbance index of greater than 15 events per hour. CPAP titration was performed using an auto-titrating machine with randomization to a nasal or oronasal mask, followed by a second titration night using the alternate mask style. There was no significant difference in the mean pressures determined between nasal and oronasal masks, although 43% of subjects had nasal-to-oronasal mask-pressure differences of 2 cm H(2)O or more. Residual respiratory events, arousals, and measured leak were all greater with the oronasal mask. Seventy-nine percent of subjects preferred the nasal mask. Patients with obstructive sleep apnea syndrome can generally switch between nasal and oronasal masks without changing machine pressure, although there are individual differences that may be clinically significant. Measured leak is greater with the oronasal mask. Most patients with obstructive sleep apnea syndrome prefer a nasal mask as the interface for initiation of CPAP. Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN: ACTRN12611000243910. URL: http://www.ANZCTR.org.au/ACTRN12611000243910.aspx

Nasal mask ventilation is better than face mask ventilation in edentulous patients

PubMed Central

Kapoor, Mukul Chandra; Rana, Sandeep; Singh, Arvind Kumar; Vishal, Vindhya; Sikdar, Indranil

2016-01-01

Background and Aims: Face mask ventilation of the edentulous patient is often difficult as ineffective seating of the standard mask to the face prevents attainment of an adequate air seal. The efficacy of nasal ventilation in edentulous patients has been cited in case reports but has never been investigated. Material and Methods: Consecutive edentulous adult patients scheduled for surgery under general anesthesia with endotracheal intubation, during a 17-month period, were prospectively evaluated. After induction of anesthesia and administration of neuromuscular blocker, lungs were ventilated with a standard anatomical face mask of appropriate size, using a volume controlled anesthesia ventilator with tidal volume set at 10 ml/kg. In case of inadequate ventilation, the mask position was adjusted to achieve best-fit. Inspired and expired tidal volumes were measured. Thereafter, the face mask was replaced by a nasal mask and after achieving best-fit, the inspired and expired tidal volumes were recorded. The difference in expired tidal volumes and airway pressures at best-fit with the use of the two masks and number of patients with inadequate ventilation with use of the masks were statistically analyzed. Results: A total of 79 edentulous patients were recruited for the study. The difference in expiratory tidal volumes with the use of the two masks at best-fit was statistically significant (P = 0.0017). Despite the best-fit mask placement, adequacy of ventilation could not be achieved in 24.1% patients during face mask ventilation, and 12.7% patients during nasal mask ventilation and the difference was statistically significant. Conclusion: Nasal mask ventilation is more efficient than standard face mask ventilation in edentulous patients. PMID:27625477

How do paramedics manage the airway during out of hospital cardiac arrest?

PubMed Central

Voss, Sarah; Rhys, Megan; Coates, David; Greenwood, Rosemary; Nolan, Jerry P.; Thomas, Matthew; Benger, Jonathan

2014-01-01

Aim The best method of initial airway management during resuscitation for out of hospital cardiac arrest (OHCA) is unknown. The airway management techniques used currently by UK paramedics during resuscitation for OHCA are not well documented. This study describes the airway management techniques used in the usual practice arm of the REVIVE-Airways feasibility study, and documents the pathway of interventions to secure and sustain ventilation during OHCA. Method Data were collected from OHCAs attended by paramedics participating in the REVIVE-Airways trial between March 2012 and February 2013. Patients were included if they were enrolled in the usual practice arm of the study, fulfilled the main study eligibility criteria and did not receive either of the intervention supraglottic airway devices during the resuscitation attempt. Results Data from 196 attempted resuscitations were included in the analysis. The initial approach to airway management was bag-mask for 108 (55%), a supraglottic airway device (SAD) for 39 (20%) and tracheal intubation for 49 (25%). Paramedics made further airway interventions in 64% of resuscitations. When intubation was the initial approach, there was no further intervention in 76% of cases; this compares to 16% and 44% with bag-mask and SAD respectively. The most common reason cited by paramedics for changing from bag-mask was to carry out advanced life support, followed by regurgitation and inadequate ventilation. Inadequate ventilation was the commonest reason cited for removing a SAD. Conclusion Paramedics use a range of techniques to manage the airway during OHCA, and as the resuscitation evolves. It is therefore desirable to ensure that a range of techniques and equipment, supported by effective training, are available to paramedics who attend OHCA. PMID:25260723

Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway.

PubMed

Monclus, Enric; Garcés, Antonio; Artés, David; Mabrock, Maged

2008-07-01

For a predicted difficult airway, oral intubation techniques are well established in pediatric anesthesia, but nasotracheal intubation remains a problem. There are many reports concerning this, but the risk of bleeding, added to the lack of cooperation make this procedure difficult and hazardous. We describe a modification of the nasal intubation technique in two stages. First an oral intubation and then exchanging the oral for a nasal tube, in the case of a 13-year-old boy affected by an advanced stage of cherubism. Oral intubation using a laryngeal mask technique has already been reported, but problems appear during the exchange procedure and even more when direct laryngoscopy is impossible. Fiberscopic control of the exchange, and the introduction of a Cook Exchange Catheter into the trachea through the oral tube before withdrawal, permits oxygenation of the patient and acts as a guide for oral tube reintroduction if required.

Invited Article: Recommendations of the Neurolaryngology Study Group on Laryngeal Electromyography

PubMed Central

Blitzer, Andrew; Crumley, Roger L.; Dailey, Seth H.; Ford, Charles N.; Floeter, Mary Kay; Hillel, Allen D.; Hoffman, Henry T.; Ludlow, Christy L.; Merati, Albert; Munin, Michael C.; Robinson, Lawrence R.; Rosen, Clark; Saxon, Keith G.; Sulica, Lucian; Thibeault, Susan L.; Titze, Ingo; Woo, Peak; Woodson, Gayle E.

2009-01-01

The Neurolaryngology Study Group convened a multidisciplinary panel of experts in neuromuscular physiology, electromyography, physical medicine and rehabilitation, neurology, and laryngology to meet with interested members from the American Academy of Otolaryngology Head and Neck Surgery, the Neurolaryngology Subcommittee and the Neurolaryngology Study Group to address the use of laryngeal electromyography (LEMG) for electrodiagnosis of laryngeal disorders. The panel addressed the use of LEMG for: 1) diagnosis of vocal fold paresis, 2) best practice application of equipment and techniques for LEMG, 3) estimation of time of injury and prediction of recovery of neural injuries, 4) diagnosis of neuromuscular diseases of the laryngeal muscles, and, 5) differentiation between central nervous system and behaviorally based laryngeal disorders. The panel also addressed establishing standardized techniques and methods for future assessment of LEMG sensitivity, specificity and reliability for identification, assessment and prognosis of neurolaryngeal disorders. Previously an evidence-based review of the clinical utility of LEMG published in 2004 only found evidence supported that LEMG was possibly useful for guiding injections of botulinum toxin into the laryngeal muscles. An updated traditional/narrative literature review and expert opinions were used to direct discussion and format conclusions. In current clinical practice, LEMG is a qualitative and not a quantitative examination. Specific recommendations were made to standardize electrode types, muscles to be sampled, sampling techniques, and reporting requirements. Prospective studies are needed to determine the clinical utility of LEMG. Use of the standardized methods and reporting will support future studies correlating electro-diagnostic findings with voice and upper airway function. PMID:19467391

Laryngeal closure impedes non-invasive ventilation at birth

PubMed Central

Crawshaw, Jessica R; Kitchen, Marcus J; Binder-Heschl, Corinna; Thio, Marta; Wallace, Megan J; Kerr, Lauren T; Roehr, Charles C; Lee, Katie L; Buckley, Genevieve A; Davis, Peter G; Flemmer, Andreas; te Pas, Arjan B; Hooper, Stuart B

2018-01-01

Background Non-invasive ventilation is sometimes unable to provide the respiratory needs of very premature infants in the delivery room. While airway obstruction is thought to be the main problem, the site of obstruction is unknown. We investigated whether closure of the larynx and epiglottis is a major site of airway obstruction. Methods We used phase contrast X-ray imaging to visualise laryngeal function in spontaneously breathing premature rabbits immediately after birth and at approximately 1 hour after birth. Non-invasive respiratory support was applied via a facemask and images were analysed to determine the percentage of the time the glottis and the epiglottis were open. Hypothesis Immediately after birth, the larynx is predominantly closed, only opening briefly during a breath, making non-invasive intermittent positive pressure ventilation (iPPV) ineffective, whereas after lung aeration, the larynx is predominantly open allowing non-invasive iPPV to ventilate the lung. Results The larynx and epiglottis were predominantly closed (open 25.5%±1.1% and 17.1%±1.6% of the time, respectively) in pups with unaerated lungs and unstable breathing patterns immediately after birth. In contrast, the larynx and the epiglottis were mostly open (90.5%±1.9% and 72.3%±2.3% of the time, respectively) in pups with aerated lungs and stable breathing patterns irrespective of time after birth. Conclusion Laryngeal closure impedes non-invasive iPPV at birth and may reduce the effectiveness of non-invasive respiratory support in premature infants immediately after birth. PMID:29054974

Expression of taste receptors in Solitary Chemosensory Cells of rodent airways

PubMed Central

2011-01-01

Background Chemical irritation of airway mucosa elicits a variety of reflex responses such as coughing, apnea, and laryngeal closure. Inhaled irritants can activate either chemosensitive free nerve endings, laryngeal taste buds or solitary chemosensory cells (SCCs). The SCC population lies in the nasal respiratory epithelium, vomeronasal organ, and larynx, as well as deeper in the airway. The objective of this study is to map the distribution of SCCs within the airways and to determine the elements of the chemosensory transduction cascade expressed in these SCCs. Methods We utilized a combination of immunohistochemistry and molecular techniques (rtPCR and in situ hybridization) on rats and transgenic mice where the Tas1R3 or TRPM5 promoter drives expression of green fluorescent protein (GFP). Results Epithelial SCCs specialized for chemoreception are distributed throughout much of the respiratory tree of rodents. These cells express elements of the taste transduction cascade, including Tas1R and Tas2R receptor molecules, α-gustducin, PLCβ2 and TrpM5. The Tas2R bitter taste receptors are present throughout the entire respiratory tract. In contrast, the Tas1R sweet/umami taste receptors are expressed by numerous SCCs in the nasal cavity, but decrease in prevalence in the trachea, and are absent in the lower airways. Conclusions Elements of the taste transduction cascade including taste receptors are expressed by SCCs distributed throughout the airways. In the nasal cavity, SCCs, expressing Tas1R and Tas2R taste receptors, mediate detection of irritants and foreign substances which trigger trigeminally-mediated protective airway reflexes. Lower in the respiratory tract, similar chemosensory cells are not related to the trigeminal nerve but may still trigger local epithelial responses to irritants. In total, SCCs should be considered chemoreceptor cells that help in preventing damage to the respiratory tract caused by inhaled irritants and pathogens. PMID:21232137

Expression of taste receptors in solitary chemosensory cells of rodent airways.

PubMed

Tizzano, Marco; Cristofoletti, Mirko; Sbarbati, Andrea; Finger, Thomas E

2011-01-13

Chemical irritation of airway mucosa elicits a variety of reflex responses such as coughing, apnea, and laryngeal closure. Inhaled irritants can activate either chemosensitive free nerve endings, laryngeal taste buds or solitary chemosensory cells (SCCs). The SCC population lies in the nasal respiratory epithelium, vomeronasal organ, and larynx, as well as deeper in the airway. The objective of this study is to map the distribution of SCCs within the airways and to determine the elements of the chemosensory transduction cascade expressed in these SCCs. We utilized a combination of immunohistochemistry and molecular techniques (rtPCR and in situ hybridization) on rats and transgenic mice where the Tas1R3 or TRPM5 promoter drives expression of green fluorescent protein (GFP). Epithelial SCCs specialized for chemoreception are distributed throughout much of the respiratory tree of rodents. These cells express elements of the taste transduction cascade, including Tas1R and Tas2R receptor molecules, α-gustducin, PLCβ2 and TrpM5. The Tas2R bitter taste receptors are present throughout the entire respiratory tract. In contrast, the Tas1R sweet/umami taste receptors are expressed by numerous SCCs in the nasal cavity, but decrease in prevalence in the trachea, and are absent in the lower airways. Elements of the taste transduction cascade including taste receptors are expressed by SCCs distributed throughout the airways. In the nasal cavity, SCCs, expressing Tas1R and Tas2R taste receptors, mediate detection of irritants and foreign substances which trigger trigeminally-mediated protective airway reflexes. Lower in the respiratory tract, similar chemosensory cells are not related to the trigeminal nerve but may still trigger local epithelial responses to irritants. In total, SCCs should be considered chemoreceptor cells that help in preventing damage to the respiratory tract caused by inhaled irritants and pathogens.

A statistical analysis of cervical auscultation signals from adults with unsafe airway protection.

PubMed

Dudik, Joshua M; Kurosu, Atsuko; Coyle, James L; Sejdić, Ervin

2016-01-22

Aspiration, where food or liquid is allowed to enter the larynx during a swallow, is recognized as the most clinically salient feature of oropharyngeal dysphagia. This event can lead to short-term harm via airway obstruction or more long-term effects such as pneumonia. In order to non-invasively identify this event using high resolution cervical auscultation there is a need to characterize cervical auscultation signals from subjects with dysphagia who aspirate. In this study, we collected swallowing sound and vibration data from 76 adults (50 men, 26 women, mean age 62) who underwent a routine videofluoroscopy swallowing examination. The analysis was limited to swallows of liquid with either thin (<5 cps) or viscous (≈300 cps) consistency and was divided into those with deep laryngeal penetration or aspiration (unsafe airway protection), and those with either shallow or no laryngeal penetration (safe airway protection), using a standardized scale. After calculating a selection of time, frequency, and time-frequency features for each swallow, the safe and unsafe categories were compared using Wilcoxon rank-sum statistical tests. Our analysis found that few of our chosen features varied in magnitude between safe and unsafe swallows with thin swallows demonstrating no statistical variation. We also supported our past findings with regard to the effects of sex and the presence or absence of stroke on cervical ausculation signals, but noticed certain discrepancies with regards to bolus viscosity. Overall, our results support the necessity of using multiple statistical features concurrently to identify laryngeal penetration of swallowed boluses in future work with high resolution cervical auscultation.

Pressure-volume behavior of the upper airway.

PubMed

Fouke, J M; Teeter, J P; Strohl, K P

1986-09-01

The study was performed to investigate the relationship between force generation and upper airway expansion during respiratory efforts by upper airway muscles. In 11 anesthetized dogs we isolated the upper airway (nasal, oral, pharyngeal, and laryngeal regions) by transecting the cervical trachea and sealing the nasal and oral openings. During spontaneous respiratory efforts the pressure within the sealed upper airway, used as an index of dilating force, decreased during inspiration. On alternate breaths the upper airway was opened to a pneumotachograph, and an increase in volume occurred, also during inspiration. Progressive hyperoxic hypercapnia produced by rebreathing increased the magnitude of change in pressure and volume. At any level of drive, peak pressure or volume occurred at the same point during inspiration. At any level of drive, volume and pressure changes increased with end-expiratory occlusion of the trachea. The force-volume relationship determined from measurements during rebreathing was compared with pressure-volume curves performed by passive inflation of the airway while the animal was apneic. The relationship during apnea was 1.06 +/- 0.55 (SD) ml/cmH2O, while the force-volume relationship from rebreathing trials was -1.09 +/- 0.45 ml/cmH2O. We conclude that there is a correspondence between force production and volume expansion in the upper airway during active respiratory efforts.

Equivalence of Nasal and Oronasal Masks during Initial CPAP Titration for Obstructive Sleep Apnea Syndrome

PubMed Central

Teo, Ming; Amis, Terence; Lee, Sharon; Falland, Karina; Lambert, Stephen; Wheatley, John

2011-01-01

Study Objective: Continuous positive airway pressure (CPAP) titration studies are commonly performed using a nasal mask but some patients may prefer a full-face or oronasal mask. There is little evidence regarding the equivalence of different mask interfaces used to initiate treatment. We hypothesized that oronasal breathing when using an oronasal mask increases upper airway collapsibility and that a higher pressure may be required to maintain airway patency. We also assessed patient preferences for the 2 mask interfaces. Design: Prospective, randomized, cross-over design with 2 consecutive CPAP titration nights. Setting: Accredited laboratory in a university hospital. Patients or Participants: Twenty-four treatment-naive subjects with obstructive sleep apnea syndrome and respiratory disturbance index of greater than 15 events per hour. Interventions: CPAP titration was performed using an auto-titrating machine with randomization to a nasal or oronasal mask, followed by a second titration night using the alternate mask style. Measurements and Results: There was no significant difference in the mean pressures determined between nasal and oronasal masks, although 43% of subjects had nasal-to-oronasal mask-pressure differences of 2 cm H2O or more. Residual respiratory events, arousals, and measured leak were all greater with the oronasal mask. Seventy-nine percent of subjects preferred the nasal mask. Conclusions: Patients with obstructive sleep apnea syndrome can generally switch between nasal and oronasal masks without changing machine pressure, although there are individual differences that may be clinically significant. Measured leak is greater with the oronasal mask. Most patients with obstructive sleep apnea syndrome prefer a nasal mask as the interface for initiation of CPAP. Clinical Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN: ACTRN12611000243910. URL: http://www.ANZCTR.org.au/ACTRN12611000243910.aspx Citation: Teo M

Respiratory and laryngeal symptoms secondary to gastro-oesophageal reflux

PubMed Central

Rafferty, G; Mainie, I; McGarvey, L P A

2011-01-01

Gastro-oesophageal reflux may cause a range of laryngeal and respiratory symptoms. Mechanisms responsible include the proximal migration of gastric refluxate beyond the upper oesophageal sphincter causing direct irritation of the larynx and lower airway. Alternatively, refluxate entering the distal oesophagus alone may stimulate oesophageal sensory nerves and indirectly activate airway reflexes such as cough and bronchospasm. Recognising reflux as a cause for these extraoesophageal symptoms can be difficult as many patients do not have typical oesophageal symptoms (eg, heartburn) and clinical findings on laryngoscopy are not very specific. Acid suppression remains an effective treatment in the majority of patients but there is growing appreciation of the need to consider and treat non-acid and volume reflux. New opinions about the role of existing medical and surgical (laparoscopic techniques) treatment are emerging and a number of novel anti-reflux treatments are under development. PMID:28839612

Laryngeal closure impedes non-invasive ventilation at birth.

PubMed

Crawshaw, Jessica R; Kitchen, Marcus J; Binder-Heschl, Corinna; Thio, Marta; Wallace, Megan J; Kerr, Lauren T; Roehr, Charles C; Lee, Katie L; Buckley, Genevieve A; Davis, Peter G; Flemmer, Andreas; Te Pas, Arjan B; Hooper, Stuart B

2018-03-01

Non-invasive ventilation is sometimes unable to provide the respiratory needs of very premature infants in the delivery room. While airway obstruction is thought to be the main problem, the site of obstruction is unknown. We investigated whether closure of the larynx and epiglottis is a major site of airway obstruction. We used phase contrast X-ray imaging to visualise laryngeal function in spontaneously breathing premature rabbits immediately after birth and at approximately 1 hour after birth. Non-invasive respiratory support was applied via a facemask and images were analysed to determine the percentage of the time the glottis and the epiglottis were open. Immediately after birth, the larynx is predominantly closed, only opening briefly during a breath, making non-invasive intermittent positive pressure ventilation (iPPV) ineffective, whereas after lung aeration, the larynx is predominantly open allowing non-invasive iPPV to ventilate the lung. The larynx and epiglottis were predominantly closed (open 25.5%±1.1% and 17.1%±1.6% of the time, respectively) in pups with unaerated lungs and unstable breathing patterns immediately after birth. In contrast, the larynx and the epiglottis were mostly open (90.5%±1.9% and 72.3%±2.3% of the time, respectively) in pups with aerated lungs and stable breathing patterns irrespective of time after birth. Laryngeal closure impedes non-invasive iPPV at birth and may reduce the effectiveness of non-invasive respiratory support in premature infants immediately after birth. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Airway difficulty in Mallampati 'class zero' patients: a prospective double-blind observational study.

PubMed

Hegde, Harihar V; Prasad, Kothegala C; Bhat, Manjunath T; Hegde, Jyothirmay S; Santhosh Mysore, C b; Yaliwal, Vijay G; Raghavendra Rao, P

2012-07-01

Assessment of Mallampati class is an integral part of preoperative airway evaluation. Increasing Mallampati class is known to be associated with greater difficulty with intubation, but some cases of airway difficulty in Mallampati 'class zero' patients have been reported. We undertook this study to evaluate intubation difficulty and to correlate this with indirect laryngoscopy findings in Mallampati class zero patients. The incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation were also evaluated. Prospective double-blind observational study. A tertiary care medical college hospital in Karnataka, India. September 2010 to April 2011. Patients of either sex, 18 years and older, presenting for preanaesthetic examination for elective surgery were evaluated. All patients with Mallampati class zero airway undergoing general anaesthesia with tracheal intubation were included. Exclusion criteria were upper airway disorder, unstable cervical spine, increased risk for aspiration, ischaemic heart disease, increased intracranial pressure, respiratory distress, those unable to sit upright, or infected with hepatitis B, hepatitis C, HIV or pulmonary tuberculosis, or requiring emergency surgery. All underwent indirect laryngoscopy performed by the otorhinolaryngologist and subsequently, direct laryngoscopy performed by the anaesthesiologist. Intubation difficulty was assessed by the Cormack & Lehane grades. Evaluation of intubation difficulty and correlation with indirect laryngoscopy findings in Mallampati class zero patients. Estimation of the incidence of Mallampati class zero airway in Indian patients and the difficulty in mask ventilation. Twenty women and thirteen men, aged 18-65 years, of Mallampati class zero were identified out of 1937 (incidence, 1.7%). The data of 27 patients were analysed. Two patients had 'difficult' mask ventilation. All had a 'predicted easy' airway on indirect laryngoscopy and 'easy' (Cormack & Lehane

Use of i-gel for laser ablation of a bronchial lesion.

PubMed

Garg, Rakesh; Thakore, Sakshi; Madan, Karan; Mohan, Anant

2017-10-24

The use of laser for airway lesions requires airway management. Usual options include special laser-resistant endotracheal tubes. The use of supraglottic devices have been described in the literature. Laryngeal mask airway carries the risk of cuff damage during the use of laser. i-gel is made of thermoplastic material and does not require air inflation and thus potentially reduce the risk of cuff rupture. i-gel use in laser surgeries has not been described in the literature. We present successful airway management in laser surgery for bronchial tumour using i-gel. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Laryngeal fracture due to blunt trauma presenting with pneumothorax and pneumomediastinum.

PubMed

Narcı, Adnan; Embleton, Didem Baskın; Ayçiçek, Abdullah; Yücedağ, Fatih; Cetinkurşun, Salih

2011-01-01

Injuries due to traffic accidents are frequent in childhood, and they have high mortality and morbidity. Laryngeal injury due to a traffic accident is a rare pathology and might be missed if not suspected. Here we present a laryngeal fracture in a child after a blunt chest trauma during a traffic accident that presented with pneumomediastinum and pneumothorax. A 14-year-old girl was referred for pneumomediastinum. Her physical examination was normal except subcutaneous emphysema, edema and tenderness in the cervical area, hoarseness, facial and extremity abrasions and ecchymoses. Chest tomography revealed pneumothorax and pneumomediastinum, and cranial tomography revealed maxillofacial fractures. Upper airway damage was suspected, flexible endoscopy revealed right vocal cord paralysis and cervical tomography revealed thyroid cartilage fracture. The fracture was repaired and tracheotomy was performed. She was discharged on postoperative day 6. Facial fractures were repaired in another center. Tracheotomy was removed on postoperative day 20. Her hoarseness, although decreased, still persists. Pneumomediastinum is a rare result of a laryngeal fracture and if not suspected, the fracture can easily be missed. It should be kept in mind after blunt cervical trauma with pneumomediastinum and/or pneumothorax. Direct endoscopy and cervical tomography may be necessary for the differential diagnosis. Copyright © 2011 S. Karger AG, Basel.

Cricothyrotomy training increases adherence to the ASA difficult airway algorithm in a simulated crisis: a randomized controlled trial.

PubMed

You-Ten, Kong Eric; Bould, M Dylan; Friedman, Zeev; Riem, Nicole; Sydor, Devin; Boet, Sylvain

2015-05-01

Non-adherence to airway guidelines in a 'cannot intubate-cannot oxygenate' (CICO) crisis situation is associated with adverse patient outcomes. This study investigated the effects of hands-on training in cricothyrotomy on adherence to the American Society of Anesthesiologists difficult airway algorithm (ASA-DAA) during a simulated CICO scenario. A total of 21 postgraduate second-year anesthesia residents completed a pre-test teaching session during which they reviewed the ASA-DAA, became familiarized with the Melker cricothyrotomy kit, and watched a video on cricothyrotomy. Participants were randomized to either the intervention 'Trained' group (n = 10) (taught and practiced cricothyrotomy) or the control 'Non-Trained' group (n = 11) (no extra training). After two to three weeks, performances of the groups were assessed in a simulated CICO scenario. The primary outcome measure was major deviation from the ASA-DAA. Secondary outcome measures were (1) performance of the four categories of non-technical behaviours using the validated Anaesthetists' Non-Technical Skills scale (ANTS) and (2) time to perform specific tasks. Significantly more non-trained than trained participants (6/11 vs 0/10, P = 0.012) committed at least one major ASA-DAA deviation, including failure to insert an oral airway, failure to call for help, bypassing the laryngeal mask airway, and attempting fibreoptic intubation. ANTS scores for all four categories of behaviours, however, were similar between the groups. Trained participants called for help faster [26 (2) vs 63 (48) sec, P = 0.012] but delayed opening of the cricothyrotomy kit [130 (50) vs 74 (36) sec, P = 0.014]. Hands-on training in cricothyrotomy resulted in fewer major ASA-DAA deviations in a simulated CICO scenario. Training in cricothyrotomy may play an important role in complying with the ASA-DAA in a CICO situation but does not appear to affect non-technical behaviours such as decision-making.

Face mask ventilation--the dos and don'ts.

PubMed

Wood, Fiona E; Morley, Colin J

2013-12-01

Face mask ventilation provides respiratory support to newly born or sick infants. It is a challenging technique and difficult to ensure that an appropriate tidal volume is delivered because large and variable leaks occur between the mask and face; airway obstruction may also occur. Technique is more important than the mask shape although the size must appropriately fit the face. The essence of the technique is to roll the mask on to the face from the chin while avoiding the eyes, with a finger and thumb apply a strong even downward pressure to the top of the mask, away from the stem and sloped sides or skirt of the mask, place the other fingers under the jaw and apply a similar upward pressure. Preterm infants require continuous end-expiratory pressure to facilitate lung aeration and maintain lung volume. This is best done with a T-piece device, not a self-inflating or flow-inflating bag. Copyright © 2013 Elsevier Ltd. All rights reserved.

Outcomes and Resource Utilization of Endoscopic Mass-Closure Technique for Laryngeal Clefts.

PubMed

Balakrishnan, Karthik; Cheng, Esther; de Alarcon, Alessandro; Sidell, Douglas R; Hart, Catherine K; Rutter, Michael J

2015-07-01

To compare resource utilization and clinical outcomes between endoscopic mass-closure and open techniques for laryngeal cleft repair. Case series with chart review. Tertiary academic children's hospital. Pediatric patients undergoing repair for Benjamin-Inglis type 1-3 laryngeal clefts over a 15-year period. All 20 patients undergoing endoscopic repair were included. Eight control patients undergoing open repair were selected using matching by age and cleft type. Demographic, clinical, and resource utilization data were collected. Twenty-eight patients were included (20 endoscopic, 8 open). Mean age, rates of tracheostomy and vocal fold immobility, and distribution of cleft types were not different between the 2 groups (all P > .2). Mean operative time (P = .004) and duration of hospital stay (P < .001) were significantly shorter in the endoscopic group. All repairs were intact in both groups at final postoperative endoscopy. Rates of persistent laryngeal penetration or aspiration on swallow study were not different between groups (P = 1.000), although results were available for only 11 patients. Endoscopic laryngeal cleft repair using a mass-closure technique provides a durable result while requiring significantly shorter operative times and hospital stays than open repair and avoiding the potential morbidity of laryngofissure. However, open repair may allow the simultaneous performance of other airway reconstructive procedures and may be a useful salvage technique when endoscopic repair fails. Postoperative swallowing results require further study. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

Effect of Medialization Thyroplasty on Glottic Airway Anatomy: Cadaver Model.

PubMed

Shinghal, Tulika; Anderson, Jennifer; Chung, Janet; Hong, Aaron; Bharatha, Aditya

2016-11-01

The purpose of this study was to investigate the change in airway dimensions after medialization thyroplasty (MT) using a cadaveric model. Helical computerized tomography (CT) was performed before and after placement of a silastic block in human larynges to investigate the effect on airway anatomy at the level of the glottis. Tissue density (TD) of the medialized vocal fold (VF) was documented to understand the effect on tissue displacement. This is a cadaveric study. Thirteen human cadaveric larynges underwent fine-cut CT scan before and after MT was performed using carved blocks in two sizes (small block and large block [LB]). Clientstream software was used to measure laryngeal dimensions: intraglottic volume (IGV), cross-sectional area (CSA), posterior-glottic diameter (PGD), VF density (in Hounsfield units [HUs]), and anterior-posterior diameter (APD). Eight sequential axial sections 0.625 mm cuts) at the level of the true VFs were analyzed. There was a significant decrease between the three conditions for IGV (P < 0.0001) and CSA (P < 0.0001). TD of the VF was increased after MT as indicated by HU increase (P = 0.0003). APD was not significantly changed. PGD was significantly different between the no block to LB placement (P = 0.0012). MT significantly changes the IGV and CSA at the level of the glottis. Density in the true VF was significantly increased. These findings have important implications for understanding volumetric effects of MT. Copyright © 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Propofol-induced violent coughing in a patient with Becker's muscular dystrophy

PubMed Central

Jain, Amit

2011-01-01

Propofol anesthesia is often associated with decreased incidence of gagging, coughing or laryngospasm, and provides intense suppression on airway reflex during tracheal intubation and laryngeal mask airway insertion. Propofol pretreatment is also effective in reducing the occurrence of opioid-induced coughing. These benefits are often attributed to bronchodilator and sedative effects of propofol. However, severe coughing following sedative doses of 1% propofol has not been reported so far. We report a rare case of violent coughing following low-dose propofol infusion in a patient with Becker's muscular dystrophy. PMID:21845012

Relationship between gastro-oesophageal reflux and airway diseases: the airway reflux paradigm.

PubMed

Pacheco-Galván, Adalberto; Hart, Simon P; Morice, Alyn H

2011-04-01

Our understanding of the relationship between gastro-oesophageal reflux and respiratory disease has recently undergone important changes. The previous paradigm of airway reflux as synonymous with the classic gastro-oesophageal reflux disease (GORD) causing heartburn has been overturned. Numerous epidemiological studies have shown a highly significant association of the acid, liquid, and gaseous reflux of GORD with conditions such as laryngeal diseases, chronic rhinosinusitis, treatment resistant asthma, COPD and even idiopathic pulmonary fibrosis. However, it has become clear from studies on cough hypersensitivity syndrome that much reflux of importance in the airways has been missed, since it is either non- or weakly acid and gaseous in composition. The evidence for such a relationship relies on the clinical history pointing to symptom associations with known precipitants of reflux. The tools for the diagnosis of extra-oesophageal reflux, in contrast to the oesophageal reflux of GORD, lack sensitivity and reproducibility. Unfortunately, methodology for detecting such reflux is only just becoming available and much additional work is required to properly delineate its role. Copyright © 2011 SEPAR. Published by Elsevier Espana. All rights reserved.

Fabrication technique for a custom face mask for the treatment of obstructive sleep apnea.

PubMed

Prehn, Ronald S; Colquitt, Tom

2016-05-01

The development of the positive airway pressure custom mask (TAP-PAP CM) has changed the treatment of obstructive sleep apnea. The TAP-PAP CM is used in continuous positive airway pressure therapy (CPAP) and is fabricated from the impression of the face. This mask is then connected to a post screwed into the mechanism of the TAP3 (Thornton Anterior Positioner) oral appliance. This strapless CPAP face mask features an efficient and stable CPAP interface with mandibular stabilization (Hybrid Therapy). A technique with a 2-stage polyvinyl siloxane face impression is described that offers improvements over the established single-stage face impression. This 2-stage impression technique eliminates problems inherent in the single-stage face impression, including voids, compressed tissue, inadequate borders, and a rushed experience due to the setting time of the single stage. The result is a custom mask with an improved seal to the CPAP device. Copyright © 2016 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.

High-flow oxygen therapy: pressure analysis in a pediatric airway model.

PubMed

Urbano, Javier; del Castillo, Jimena; López-Herce, Jesús; Gallardo, José A; Solana, María J; Carrillo, Ángel

2012-05-01

The mechanism of high-flow oxygen therapy and the pressures reached in the airway have not been defined. We hypothesized that the flow would generate a low continuous positive pressure, and that elevated flow rates in this model could produce moderate pressures. The objective of this study was to analyze the pressure generated by a high-flow oxygen therapy system in an experimental model of the pediatric airway. An experimental in vitro study was performed. A high-flow oxygen therapy system was connected to 3 types of interface (nasal cannulae, nasal mask, and oronasal mask) and applied to 2 types of pediatric manikin (infant and neonatal). The pressures generated in the circuit, in the airway, and in the pharynx were measured at different flow rates (5, 10, 15, and 20 L/min). The experiment was conducted with and without a leak (mouth sealed and unsealed). Linear regression analyses were performed for each set of measurements. The pressures generated with the different interfaces were very similar. The maximum pressure recorded was 4 cm H(2)O with a flow of 20 L/min via nasal cannulae or nasal mask. When the mouth of the manikin was held open, the pressures reached in the airway and pharynxes were undetectable. Linear regression analyses showed a similar linear relationship between flow and pressures measured in the pharynx (pressure = -0.375 + 0.138 × flow) and in the airway (pressure = -0.375 + 0.158 × flow) with the closed mouth condition. According to our hypothesis, high-flow oxygen therapy systems produced a low-level CPAP in an experimental pediatric model, even with the use of very high flow rates. Linear regression analyses showed similar linear relationships between flow and pressures measured in the pharynx and in the airway. This finding suggests that, at least in part, the effects may be due to other mechanisms.

Increased respiratory neural drive and work of breathing in exercise-induced laryngeal obstruction.

PubMed

Walsted, Emil S; Faisal, Azmy; Jolley, Caroline J; Swanton, Laura L; Pavitt, Matthew J; Luo, Yuan-Ming; Backer, Vibeke; Polkey, Michael I; Hull, James H

2018-02-01

Exercise-induced laryngeal obstruction (EILO), a phenomenon in which the larynx closes inappropriately during physical activity, is a prevalent cause of exertional dyspnea in young individuals. The physiological ventilatory impact of EILO and its relationship to dyspnea are poorly understood. The objective of this study was to evaluate exercise-related changes in laryngeal aperture on ventilation, pulmonary mechanics, and respiratory neural drive. We prospectively evaluated 12 subjects (6 with EILO and 6 healthy age- and gender-matched controls). Subjects underwent baseline spirometry and a symptom-limited incremental exercise test with simultaneous and synchronized recording of endoscopic video and gastric, esophageal, and transdiaphragmatic pressures, diaphragm electromyography, and respiratory airflow. The EILO and control groups had similar peak work rates and minute ventilation (V̇e) (work rate: 227 ± 35 vs. 237 ± 35 W; V̇e: 103 ± 20 vs. 98 ± 23 l/min; P > 0.05). At submaximal work rates (140-240 W), subjects with EILO demonstrated increased work of breathing ( P < 0.05) and respiratory neural drive ( P < 0.05), developing in close temporal association with onset of endoscopic evidence of laryngeal closure ( P < 0.05). Unexpectedly, a ventilatory increase ( P < 0.05), driven by augmented tidal volume ( P < 0.05), was seen in subjects with EILO before the onset of laryngeal closure; there were however no differences in dyspnea intensity between groups. Using simultaneous measurements of respiratory mechanics and diaphragm electromyography with endoscopic video, we demonstrate, for the first time, increased work of breathing and respiratory neural drive in association with the development of EILO. Future detailed investigations are now needed to understand the role of upper airway closure in causing exertional dyspnea and exercise limitation. NEW & NOTEWORTHY Exercise-induced laryngeal obstruction is a prevalent cause of exertional dyspnea in young

Periorbital Edema Secondary to Positive Airway Pressure Therapy

PubMed Central

Dandekar, Francesco; Camacho, Macario; Valerio, Jason

2015-01-01

Two patients developed bilateral, periorbital edema after initiating positive airway pressure (PAP) therapy with a full face mask. The periorbital edema was more pronounced in the morning and would dissipate throughout the day. This phenomenon seemed to be correlated with the direct pressure of the full face mask, which may have impaired lymphatic and venous drainage. To test this hypothesis, each patient was changed to a nasal pillow interface with subsequent improvement in the periorbital edema. PMID:25767727

Periorbital edema secondary to positive airway pressure therapy.

PubMed

Dandekar, Francesco; Camacho, Macario; Valerio, Jason; Ruoff, Chad. M.

2015-01-01

Two patients developed bilateral, periorbital edema after initiating positive airway pressure (PAP) therapy with a full face mask. The periorbital edema was more pronounced in the morning and would dissipate throughout the day. This phenomenon seemed to be correlated with the direct pressure of the full face mask, which may have impaired lymphatic and venous drainage. To test this hypothesis, each patient was changed to a nasal pillow interface with subsequent improvement in the periorbital edema.

Airway physical examination tests for detection of difficult airway management in apparently normal adult patients.

PubMed

Roth, Dominik; Pace, Nathan L; Lee, Anna; Hovhannisyan, Karen; Warenits, Alexandra-Maria; Arrich, Jasmin; Herkner, Harald

2018-05-15

The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear. The objective of this review was to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway abnormalities. We performed this individually for each of the four descriptors of the difficult airway: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. We searched major electronic databases including CENTRAL, MEDLINE, Embase, ISI Web of Science, CINAHL, as well as regional, subject specific, and dissertation and theses databases from inception to 16 December 2016, without language restrictions. In addition, we searched the Science Citation Index and checked the references of all the relevant studies. We also handsearched selected journals, conference proceedings, and relevant guidelines. We updated this search in March 2018, but we have not yet incorporated these results. We considered full-text diagnostic test accuracy studies of any individual index test, or a combination of tests, against a reference standard. Participants were adults without obvious airway abnormalities, who were having laryngoscopy performed with a standard laryngoscope and the trachea intubated with a standard tracheal tube. Index tests included the Mallampati test, modified Mallampati test, Wilson risk score, thyromental distance, sternomental distance, mouth opening test, upper lip bite test, or any combination of these. The target condition was difficult airway, with one of the following reference

Surgical fires in laser laryngeal surgery: are we safe enough?

PubMed

Roy, Soham; Smith, Lee P

2015-01-01

Laser surgery of the larynx and airway remains high risk for the formation of operating room fire. Traditional methods of fire prevention have included use of "laser safe" tubes, inflation of a protective cuff with saline, and wet pledgets to protect the endotracheal tube from laser strikes. We tested a mechanical model of laser laryngeal surgery to evaluate the fire risk. Mechanical model. Laboratory. An intubation mannequin was positioned for suspension microlaryngoscopy. A Laser-Shield II cuffed endotracheal tube was placed through the larynx and the cuff inflated using saline. Wet pledgets covered the inflated cuff. A CO2 laser created an inadvertent cuff strike at varying oxygen concentrations. Risk reduction measures were implemented to discern any notable change in the outcome after fire. At 100% FiO2 an immediate fire with sustained flame was created and at 40% FiO2 a near immediate sustained flame was created. At 29% FiO2, a small nonsustained flame was noted. At room air, no fire was created. There was no discernible difference in the severity of laryngeal damage after the fire occurred whether the tube was immediately pulled from the mannequin or if saline was poured down the airway as a first response. While "laser safe" tubes provide a layer of protection against fires, they are not fire proof. Inadvertent cuff perforation may result in fire formation in low-level oxygen enriched environments. Placement of wet pledgets do not provide absolute protection. Endotracheal tube (ETT) cuffs should be placed distally well away from an inadvertent laser strike while maintaining the minimum supplemental oxygen necessary. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.

Face mask removal is safer than helmet removal for emergent airway access in American football.

PubMed

Swartz, Erik E; Mihalik, Jason P; Beltz, Nora M; Day, Molly A; Decoster, Laura C

2014-06-01

In cases of possible cervical spine injury, medical professionals must be prepared to achieve rapid airway access while concurrently restricting cervical spine motion. Face mask removal (FMR), rather than helmet removal (HR), is recommended to achieve this. However, no studies have been reported that compare FMR directly with HR. The purpose of this study was to compare motion, time, and perceived difficulty in two commonly used American football helmets between FMR and HR techniques, and when helmet air bladders were deflated before HR compared with inflated scenarios. The study incorporated a repeated measures design and was performed in a controlled laboratory setting. Participants included 22 certified athletic trainers (15 men and seven women; mean age, 33.9±10.5 years; mean experience, 11.4±10.0 years; mean height, 172±9.4 cm; mean mass, 76.7±14.9 kg). All participants were free from upper extremity or central nervous system pathology for 6 months and provided informed consent. Dependent variables included head excursion in degrees (computed by subtracting the minimum position from the maximum position) in each of the three planes (sagittal, frontal, transverse), time to complete the required task, and ratings of perceived exertion. To address our study purposes, we used two-by-two repeated-measures analysis of variance (removal technique×helmet type, helmet type×deflation status) for each dependent variable. Independent variables consisted of removal technique (FMR and HR), helmet type (Riddell Revolution IQ [RIQ] and VSR4), and helmet deflation status (deflated [D], inflated, [I]). After familiarization, participants conducted two successful trials for each of six conditions in random order (RIQ-FMR, VSR4-FMR, RIQ-HR-D, VSR4-HR-D, RIQ-HR-I, and VSR4-HR-I). Face masks, helmets, and shoulder pads were removed from a live model wearing a properly fitted helmet and shoulder pads. The participant and an investigator stabilized the model's head. A six

Prehospital airway management on rescue helicopters in the United Kingdom.

PubMed

Schmid, M; Mang, H; Ey, K; Schüttler, J

2009-06-01

Adequate equipment is one prerequisite for advanced, out of hospital, airway management. There are no data on current availability of airway equipment on UK rescue helicopters. An internet search revealed all UK rescue helicopters, and a questionnaire was sent to the bases asking for available airway management items. We identified 27 helicopter bases and 26 (96%) sent the questionnaire back. Twenty-four bases (92%) had at least one supraglottic airway device; 16 (62%) helicopters had material for establishing a surgical airway (e.g. a cricothyroidotomy set); 88% of the helicopters had CO(2) detection; 25 (96%) helicopters carried automatic ventilators; among these, four (15%) had sophisticated ventilators and seven (27%) helicopters carried special face masks suitable for non-invasive ventilation. We found a wide variation in the advanced airway management equipment that was carried routinely on air ambulances. Current guidelines for airway management are not met by all UK air ambulances.

Undiagnosed light chain systemic amyloidosis: does it matter to anesthesiologists? -a case report-

PubMed Central

Kim, Gwan Ho; Lee, Woo Kyung; Na, Se Hee

2013-01-01

Light chain systemic amyloidosis is rare but may accompany laryngeal or pulmonary involvement, which may increase the risk in airway management. We present a case of a patient planned for resection of cervical epidural mass. The patient had face and neck ecchymoses and purpuras with an unknown cause. Mask ventilation and intubation were successful, but the operation was cancelled to evaluate bleeding from facial skin lesions. A diagnosis of light chain systemic amyloidosis prompted evaluation of involvement of other organs and treatment. This case shows the importance of preoperative evaluation and careful airway management in patients with systemic amyloidosis. PMID:24363850

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults.

PubMed

Myatra, Sheila Nainan; Shah, Amit; Kundra, Pankaj; Patwa, Apeksh; Ramkumar, Venkateswaran; Divatia, Jigeeshu Vasishtha; Raveendra, Ubaradka S; Shetty, Sumalatha Radhakrishna; Ahmed, Syed Moied; Doctor, Jeson Rajan; Pawar, Dilip K; Ramesh, Singaravelu; Das, Sabyasachi; Garg, Rakesh

2016-12-01

The All India Difficult Airway Association (AIDAA) guidelines for management of the unanticipated difficult airway in adults provide a structured, stepwise approach to manage unanticipated difficulty during tracheal intubation in adults. They have been developed based on the available evidence; wherever robust evidence was lacking, or to suit the needs and situation in India, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. We recommend optimum pre-oxygenation and nasal insufflation of 15 L/min oxygen during apnoea in all patients, and calling for help if the initial attempt at intubation is unsuccessful. Transnasal humidified rapid insufflations of oxygen at 70 L/min (transnasal humidified rapid insufflation ventilatory exchange) should be used when available. We recommend no more than three attempts at tracheal intubation and two attempts at supraglottic airway device (SAD) insertion if intubation fails, provided oxygen saturation remains ≥ 95%. Intubation should be confirmed by capnography. Blind tracheal intubation through the SAD is not recommended. If SAD insertion fails, one final attempt at mask ventilation should be tried after ensuring neuromuscular blockade using the optimal technique for mask ventilation. Failure to intubate the trachea as well as an inability to ventilate the lungs by face mask and SAD constitutes 'complete ventilation failure', and emergency cricothyroidotomy should be performed. Patient counselling, documentation and standard reporting of the airway difficulty using a 'difficult airway alert form' must be done. In addition, the AIDAA provides suggestions for the contents of a difficult airway cart.

The efficacy and safety of the flexible fiber CO2 laser delivery system in the endoscopic management of pediatric airway problems: Our long term experience.

PubMed

Lee, Gi Soo; Irace, Alexandra; Rahbar, Reza

2017-06-01

To report the use of flexible fiber CO2 laser in the endoscopic management of pediatric airway cases. A retrospective review was conducted of patients who underwent CO2 laser-assisted airway procedures between September 2007 and January 2014 at a tertiary pediatric hospital. Sixty-eight patients underwent 80 procedures utilizing flexible fiber CO2 laser. Procedures included supraglottoplasty (n = 32), laryngeal cleft repair (type I [n = 10], type II [n = 7], type III [n = 6]), suprastomal granuloma excision (n = 6), cordotomy (n = 4), laryngeal neurofibroma excision (n = 4), laryngeal granulomatous mass excision (n = 1), subglottic stenosis excision (n = 6), division of glottic web (n = 2), subglottic cyst excision (n = 1), and supraglottic biopsy (n = 1). Ages ranged from 8 days to 21 years (median 11 months). No intraoperative or postoperative complications related to the use of laser were noted. The flexible fiber CO2 laser can be safely and effectively used to address a variety of pediatric airway lesions. Previously, the use of CO2 laser in minimally invasive airway surgery has been limited due to the articulating arm carrier, absence of a hand piece, and the direct line-of sight view required. The fiber allows the cutting beam to be directed at the site of the lesion and bypasses limitations posed by other laser systems. Copyright © 2017 Elsevier B.V. All rights reserved.

Extralaryngeal division of the recurrent laryngeal nerve: a new description for the inferior laryngeal nerve.

PubMed

Yalcin, Bulent; Tunali, Selcuk; Ozan, Hasan

2008-05-01

Extralaryngeal division of the recurrent laryngeal nerve was contradictory in the literature. We aimed to investigate extralaryngeal division of the nerve, and also propose a new description for the inferior laryngeal nerve. Sixty specimens (120 sides) were examined for this project, including 41 men and 19 women cadavers between the ages of 40 and 89 years at death. In one right side, terminal segment of the nerve gave off many small branches surrounding the inferior thyroid artery then reaching the larynx, trachea, thyroid gland and esophagus. In eight sides, terminal segment of the nerve had no extralaryngeal division and entered the larynx as a single trunk. In 110 sides, the nerve had extralaryngeal division. One hundred and three nerves had two laryngeal and one to three extralaryngeal branches. Two types were described in this group. In type I (66 nerves), both branches arose from the same level of nerve. Type I had two subtypes: type Ia, the origin of the branches was just below the inferior constrictor muscle; type Ib, the origin of the branches was 15-35 mm below the muscle. In type II (37 nerves), the laryngeal branches arose just 3-5 mm above the extralaryngeal branches. We observed that the laryngeal and extralaryngeal branches arose generally from the same point of the recurrent laryngeal nerve. The inferior laryngeal nerve is thus very short, or even nonexistent. Therefore, we suggest that if the term "superior laryngeal nerve" is a given, standard, and accepted term, then the term "inferior laryngeal nerve" should also be accepted instead of the term "recurrent laryngeal nerve."

Oronasal Masks Require a Higher Pressure than Nasal and Nasal Pillow Masks for the Treatment of Obstructive Sleep Apnea.

PubMed

Deshpande, Sheetal; Joosten, Simon; Turton, Anthony; Edwards, Bradley A; Landry, Shane; Mansfield, Darren R; Hamilton, Garun S

2016-09-15

Oronasal masks are frequently used for continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). The aim of this study was to (1) determine if CPAP requirements are higher for oronasal masks compared to nasal mask interfaces and (2) assess whether polysomnography and patient characteristics differed among mask preference groups. Retrospective analysis of all CPAP implementation polysomnograms between July 2013 and June 2014. Prescribed CPAP level, polysomnography results and patient data were compared according to mask type (n = 358). Oronasal masks were used in 46%, nasal masks in 35% and nasal pillow masks in 19%. There was no difference according to mask type for baseline apnea-hypopnea index (AHI), body mass index (BMI), waist or neck circumference. CPAP level was higher for oronasal masks, 12 (10-15.5) cm H2O compared to nasal pillow masks, 11 (8-12.5) cm H2O and nasal masks, 10 (8-12) cm H2O, p < 0.0001 (Median [interquartile range]). Oronasal mask type, AHI, age, and BMI were independent predictors of a higher CPAP pressure (p < 0.0005, adjusted R(2) = 0.26.). For patients with CPAP ≥ 15 cm H2O, there was an odds ratio of 4.5 (95% CI 2.5-8.0) for having an oronasal compared to a nasal or nasal pillow mask. Residual median AHI was higher for oronasal masks (11.3 events/h) than for nasal masks (6.4 events/h) and nasal pillows (6.7 events/h), p < 0.001. Compared to nasal mask types, oronasal masks are associated with higher CPAP pressures (particularly pressures ≥ 15 cm H2O) and a higher residual AHI. Further evaluation with a randomized control trial is required to definitively establish the effect of mask type on pressure requirements. A commentary on this article appears in this issue on page 1209. © 2016 American Academy of Sleep Medicine.

Laryngitis (For Kids)

MedlinePlus

... First Aid & Safety Doctors & Hospitals Videos Recipes for Kids Kids site Sitio para niños How the Body Works ... for Educators Search English Español Laryngitis KidsHealth / For Kids / Laryngitis What's in this article? How Your Voice ...

Neurotrophin expression and laryngeal muscle pathophysiology following recurrent laryngeal nerve transection

PubMed Central

WANG, BAOXIN; YUAN, JUNJIE; XU, JIAFENG; XIE, JIN; WANG, GUOLIANG; DONG, PIN

2016-01-01

Laryngeal palsy often occurs as a result of recurrent laryngeal or vagal nerve injury during oncological surgery of the head and neck, affecting quality of life and increasing economic burden. Reinnervation following recurrent laryngeal nerve (RLN) injury is difficult despite development of techniques, such as neural anastomosis, nerve grafting and creation of a laryngeal muscle pedicle. In the present study, due to the limited availability of human nerve tissue for research, a rat model was used to investigate neurotrophin expression and laryngeal muscle pathophysiology in RLN injury. Twenty-five male Sprague-Dawley rats underwent right RLN transection with the excision of a 5-mm segment. Vocal fold movements, vocalization, histology and immunostaining were evaluated at different time-points (3, 6, 10 and 16 weeks). Although vocalization was restored, movement of the vocal fold failed to return to normal levels following RLN injury. The expression of brain-derived neurotrophic factor and glial cell line-derived neurotrophic factor differed in the thyroarytenoid (TA) and posterior cricoarytenoid muscles. The number of axons did not increase to baseline levels over time. Furthermore, normal muscle function was unlikely with spontaneous reinnervation. During regeneration following RLN injury, differences in the expression levels of neurotrophic factors may have resulted in preferential reinnervation of the TA muscles. Data from the present study indicated that neurotrophic factors may be applied for restoring the function of the laryngeal nerve following recurrent injury. PMID:26677138

Neurotrophin expression and laryngeal muscle pathophysiology following recurrent laryngeal nerve transection.

PubMed

Wang, Baoxin; Yuan, Junjie; Xu, Jiafeng; Xie, Jin; Wang, Guoliang; Dong, Pin

2016-02-01

Laryngeal palsy often occurs as a result of recurrent laryngeal or vagal nerve injury during oncological surgery of the head and neck, affecting quality of life and increasing economic burden. Reinnervation following recurrent laryngeal nerve (RLN) injury is difficult despite development of techniques, such as neural anastomosis, nerve grafting and creation of a laryngeal muscle pedicle. In the present study, due to the limited availability of human nerve tissue for research, a rat model was used to investigate neurotrophin expression and laryngeal muscle pathophysiology in RLN injury. Twenty-five male Sprague-Dawley rats underwent right RLN transection with the excision of a 5-mm segment. Vocal fold movements, vocalization, histology and immunostaining were evaluated at different time-points (3, 6, 10 and 16 weeks). Although vocalization was restored, movement of the vocal fold failed to return to normal levels following RLN injury. The expression of brain‑derived neurotrophic factor and glial cell line-derived neurotrophic factor differed in the thyroarytenoid (TA) and posterior cricoarytenoid muscles. The number of axons did not increase to baseline levels over time. Furthermore, normal muscle function was unlikely with spontaneous reinnervation. During regeneration following RLN injury, differences in the expression levels of neurotrophic factors may have resulted in preferential reinnervation of the TA muscles. Data from the present study indicated that neurotrophic factors may be applied for restoring the function of the laryngeal nerve following recurrent injury.

[Immediate recurrent laryngeal nerve reconstruction in the treatment of thyroid cancer invading the recurrent laryngeal nerve].

PubMed

Feng, Yun; Yang, Dazhang; Liu, Dandan; Chen, Jian; Bi, Qingling; Luo, Keqiang

2014-08-01

To explore the application of immediate recurrent laryngeal nerve reconstruction in the treatment of thyroid cancer invading the recurrent laryngeal nerve. Ten patients with thyroid cancer invading unilateral recurrent laryngeal nerve underwent radical surgery and immediate recurrent laryngeal nerve reconstruction. The reconstructive surgical approach included recurrent laryngeal nerve decompression surgery, end-to-end anastomosis of the recurrent laryngeal nerve, anastomosis of ansa cervicalis nerve to the recurrent laryngeal nerve, and nerve-muscle pedicle (NMP) technique. Among the ten patients, one underwent nerve decompression, one underwent end-to-end anastomosis of the recurrent laryngeal nerve, seven had anastomosis of ansa cervicalis to recurrent laryngeal nerve, and one case had anastomosis of ansa cervicalis to recurrent laryngeal nerve combined with nerve-muscle pedicle (NMP) technique. The effect of surgery was evaluated by videolaryngoscopy, maximum phonation time (MPT), phonation efficiency index (PEI) and voice assessment. T-test was used in the statistical analysis. All of the 10 patients had no complications including tumor recurrence and hypoparathyroidism after the surgery. Their hoarseness symptoms were improved, and the patients returned to normal or near-normal voice. Postoperative videolaryngoscopy showed that paralyzed vocal cord returned to normal muscle tone and volume, and the vocal cord vibration and mucosal wave were symmetric and the patients got good glottal closure. The pre- and post-operative maximum phone times of the patients were (4.52 ± 0.89) s and (11.91 ± 1.87) s, respectively (P < 0.01). The pre- and post-operative phonation efficiency indices were (1.37 ± 0.43) s/L and (4.02 ± 1.33) s/L, respectively (P < 0.05). In patients with thyroid cancer invading unilateral recurrent laryngeal nerve, immediate recurrent laryngeal nerve reconstruction following radical surgery of thyroid cancer can effectively achieve recovery in

The epidemiology of upper airway injury in patients undergoing major surgical procedures.

PubMed

Hua, May; Brady, Joanne; Li, Guohua

2012-01-01

Airway injury is a potentially serious and costly adverse event of anesthesia care. The epidemiologic characteristics of airway injury have not been well documented. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a multicenter, prospective, outcome-oriented database for patients undergoing major surgical procedures. Using the NSQIP data for the years 2005 to 2008, we examined the incidence of, and risk factors for, airway injury. Of the 563,190 patients studied, 1202 (0.2%) sustained airway injury. The most common airway injury was lip laceration/hematoma (61.4%), followed by tooth injury (26.1%), tongue laceration (5.7%), pharyngeal laceration (4.7%), and laryngeal laceration (2.1%). Multivariable logistic modeling revealed an increased risk of airway injury in patients with Mallampati class III (adjusted odds ratio [OR], 1.69; 99% confidence interval [CI], 1.36-2.11, relative to patients with Mallampati classes I and II) or class IV (adjusted OR, 2.6; 99% CI, 1.52-4.02), and in patients aged 80 years or older (adjusted OR, 1.50; 99% CI, 1.02-2.19, relative to patients aged 40 to 49 years). The risk of airway injury for patients undergoing major surgical procedures is approximately 1 in 500. Patients with difficult airways as indicated by Mallampati classes III and IV are at significantly increased risk of sustaining airway injury during anesthesia for major surgical procedures.

Asphyxia due to laryngeal spasm as a severe complication of awake deep brain stimulation for Parkinson's disease: a case report.

PubMed

von Eckardstein, Kajetan L; Sixel-Döring, Friederike; Kazmaier, Stephan; Trenkwalder, Claudia; Hoover, Jason M; Rohde, Veit

2016-11-08

In accordance with German neurosurgical and neurological consensus recommendations, lead placements for deep brain stimulation (DBS) in patients with Parkinson's disease (PD) are usually performed with the patient awake and in "medication off" state. This allows for optimal lead position adjustment according to the clinical response to intraoperative test stimulation. However, exacerbation of Parkinsonian symptoms after withdrawal of dopaminergic medication may endanger the patient by inducing severe "off" state motor phenomena. In particular, this can be a problem in awake craniotomies utilizing intraoperative airway management and resuscitation. We report the case of a PD patient with progressive orofacial and neck muscle dystonia resulting in laryngeal spasm during DBS lead placement. This led to upper airway compromise and asphyxia, requiring resuscitation. Laryngeal spasms may occur as a rare "off" state motor complication in patients with PD. Other potential causes of intraoperative difficulties breathing include bilateral vocal cord palsy, positional asphyxia, and silent aspiration. In our practice, we have adjusted our medication regimen and now allow patients to receive their standard dopaminergic medication until the morning of surgery. Neurologists and neurosurgeons performing lead placement procedures for PD should be aware of this rare but unsafe condition to most optimized treatment.

Current evidence for the use of C-MAC videolaryngoscope in adult airway management: a review of the literature

PubMed Central

Xue, Fu-Shan; Li, Hui-Xian; Liu, Ya-Yang; Yang, Gui-Zhen

2017-01-01

The C-MAC videolaryngoscope is the first Macintosh-typed videolaryngoscope. Since the advent of its original version video Macintosh system in 1999, this device has been modified several times. A unique feature of C-MAC device is its ability to provide the 2 options of direct and video laryngoscopy with the same device. The available evidence shows that in patients with normal airways, C-MAC videolaryngoscope compared with direct laryngoscopy can provide comparable or better laryngeal views and exerts less force on maxillary incisors, but does not offer conclusive benefits with regard to intubation time, intubation success, number of intubation attempts, the use of adjuncts, and hemodynamic responses to intubation. In patients with predicted or known difficult airways, C-MAC videolaryngoscope can achieve a better laryngeal view, a higher intubation success rate and a shorter intubation time than direct laryngoscopy. Furthermore, the option to perform direct and video laryngoscopy with the same device makes C-MAC videolaryngoscope exceptionally useful for emergency intubation. In addition, the C-MAC videolaryngoscope is a very good tool for tracheal intubation teaching. However, tracheal intubation with C-MAC videolaryngoscope may occasionally fail and introduction of C-MAC videolaryngoscope in clinical practice must be accompanied by formal training programs in normal and difficult airway managements. PMID:28740393

Oral mask ventilation is more effective than face mask ventilation after nasal surgery.

PubMed

Yazicioğlu, Dilek; Baran, Ilkay; Uzumcugil, Filiz; Ozturk, Ibrahim; Utebey, Gulten; Sayın, M Murat

2016-06-01

To evaluate and compare the face mask (FM) and oral mask (OM) ventilation techniques during anesthesia emergence regarding tidal volume, leak volume, and difficult mask ventilation (DMV) incidence. Prospective, randomized, crossover study. Operating room, training and research hospital. American Society of Anesthesiologists physical status I and II adult patients scheduled for nasal surgery. Patients in group FM-OM received FM ventilation first, followed by OM ventilation, and patients in group OM-FM received OM ventilation first, followed by FM ventilation, with spontaneous ventilation after deep extubation. The FM ventilation was applied with the 1-handed EC-clamp technique. The OM was placed only over the mouth, and the 1-handed EC-clamp technique was used again. A child's size FM was used for the OM ventilation technique, the mask was rotated, and the inferior part of the mask was placed toward the nose. The leak volume (MVleak), mean airway pressure (Pmean), and expired tidal volume (TVe) were assessed with each mask technique for 3 consecutive breaths. A mask ventilation grade ≥3 was considered DMV. DMV occurred more frequently during FM ventilation (75% with FM vs 8% with OM). In the FM-first sequence, the mean TVe was 249±61mL with the FM and 455±35mL with the OM (P=.0001), whereas in the OM-first sequence, it was 276±81mL with the FM and 409±37mL with the OM (P=.0001). Regardless of the order used, the OM technique significantly decreased the MVleak and increased the TVe when compared to the FM technique. During anesthesia emergence after nasal surgery the OM may offer an effective ventilation method as it decreases the incidence of DMV and the gas leak around the mask and provides higher tidal volume delivery compared with FM ventilation. Copyright © 2016 Elsevier Inc. All rights reserved.

Exercise-associated Excessive Dynamic Airway Collapse in Military Personnel.

PubMed

Weinstein, Daniel J; Hull, James E; Ritchie, Brittany L; Hayes, Jackie A; Morris, Michael J

2016-09-01

Evaluation of military personnel for exertional dyspnea can present a diagnostic challenge, given multiple unique factors that include wide variation in military deployment. Initial consideration is given to common disorders such as asthma, exercise-induced bronchospasm, and inducible laryngeal obstruction. Excessive dynamic airway collapse has not been reported previously as a cause of dyspnea in these individuals. To describe the clinical and imaging characteristics of military personnel with exertional dyspnea who were found to have excessive dynamic collapse of large airways during exercise. After deployment to Afghanistan or Iraq, 240 active U.S. military personnel underwent a standardized evaluation to determine the etiology of persistent dyspnea on exertion. Study procedures included full pulmonary function testing, impulse oscillometry, exhaled nitric oxide measurement, methacholine challenge testing, exercise laryngoscopy, cardiopulmonary exercise testing, and fiberoptic bronchoscopy. Imaging included high-resolution computed tomography with inspiratory and expiratory views. Selected individuals underwent further imaging with dynamic computed tomography. A total of five men and one woman were identified as having exercise-associated excessive dynamic airway collapse on the basis of the following criteria: (1) exertional dyspnea without resting symptoms, (2) focal expiratory wheezing during exercise, (3) functional collapse of the large airways during bronchoscopy, (4) expiratory computed tomographic imaging showing narrowing of a large airway, and (5) absence of underlying apparent pathology in small airways or pulmonary parenchyma. Identification of focal expiratory wheezing correlated with bronchoscopic and imaging findings. Among 240 military personnel evaluated after presenting with postdeployment exertional dyspnea, a combination of symptoms, auscultatory findings, imaging, and visualization of the airways by bronchoscopy identified six individuals

Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve

PubMed Central

Hydman, Jonas; Svensson, Mikael

2015-01-01

Loss of function in the recurrent laryngeal nerve (RLN) during thyroid/parathyroid surgery, despite a macroscopically intact nerve, is a challenge which highlights the sensitivity and complexity of laryngeal innervation. Furthermore, the uncertain prognosis stresses a lack of capability to diagnose the reason behind the impaired function. There is a great deal of literature considering risk factors, surgical technique and mechanisms outside the nerve affecting the incidence of RLN paresis during surgery. To be able to prognosticate recovery in cases of laryngeal dysfunction and voice changes after thyroid surgery, the surgeon would first need to define the presence, location, and type of laryngeal nerve injury. There is little data describing the events within the nerve and the neurobiological reasons for the impaired function related to potential recovery and prognosis. In addition, very little data has been presented in order to clarify any differences between the transient and permanent injury of the RLN. This review aims, from an anatomical and neurobiological perspective, to provide an update on the current understandings of surgically-induced injury to the laryngeal nerves. PMID:25713777

[Taste disturbance after general anesthesia with classic laryngeal mask airway (CLM)].

PubMed

Arimune, Mutsuaki

2007-07-01

A 27-year-old man underwent the right knee joint operation under general anesthesia with CLM. After the operation, he complained of taste disturbance of the left side of the tongue. We measured electrical taste threshold and the serum level of zinc, copper and iron. The taste threshold was elevated in the two nerve areas of the left side of the tongue (chorda tympani, N. glossopharyngeus) and the serum levels of zinc and iron were low. We concluded that he had been short of zinc and iron and the insertion of CLM had triggered taste disturbance.

Laryngeal response patterns influence the efficacy of mechanical assisted cough in amyotrophic lateral sclerosis

PubMed Central

Andersen, Tiina; Sandnes, Astrid; Brekka, Anne Kristine; Hilland, Magnus; Clemm, Hege; Fondenes, Ove; Tysnes, Ole-Bjørn; Heimdal, John-Helge; Halvorsen, Thomas; Vollsæter, Maria; Røksund, Ola Drange

2017-01-01

Background Most patients with amyotrophic lateral sclerosis (ALS) are treated with mechanical insufflation–exsufflation (MI-E) in order to improve cough. This method often fails in ALS with bulbar involvement, allegedly due to upper-airway malfunction. We have studied this phenomenon in detail with laryngoscopy to unravel information that could lead to better treatment. Methods We conducted a cross-sectional study of 20 patients with ALS and 20 healthy age-matched and sex-matched volunteers. We used video-recorded flexible transnasal fibre-optic laryngoscopy during MI-E undertaken according to a standardised protocol, applying pressures of ±20 to ±50 cm H2O. Laryngeal movements were assessed from video files. ALS type and characteristics of upper and lower motor neuron symptoms were determined. Results At the supraglottic level, all patients with ALS and bulbar symptoms (n=14) adducted their laryngeal structures during insufflation. At the glottic level, initial abduction followed by subsequent adduction was observed in all patients with ALS during insufflation and exsufflation. Hypopharyngeal constriction during exsufflation was observed in all subjects, most prominently in patients with ALS and bulbar symptoms. Healthy subjects and patients with ALS and no bulbar symptoms (n=6) coordinated their cough well during MI-E. Conclusions Laryngoscopy during ongoing MI-E in patients with ALS and bulbar symptoms revealed laryngeal adduction especially during insufflation but also during exsufflation, thereby severely compromising the size of the laryngeal inlet in some patients. Individually customised settings can prevent this and thereby improve and extend the use of non-invasive MI-E. PMID:27174631

Central nervous system integration of sensorimotor signals in oral and pharyngeal structures: oropharyngeal kinematics response to recurrent laryngeal nerve lesion.

PubMed

Gould, Francois D H; Ohlemacher, Jocelyn; Lammers, Andrew R; Gross, Andrew; Ballester, Ashley; Fraley, Luke; German, Rebecca Z

2016-03-01

Safe, efficient liquid feeding in infant mammals requires the central coordination of oropharyngeal structures innervated by multiple cranial and spinal nerves. The importance of laryngeal sensation and central sensorimotor integration in this system is poorly understood. Recurrent laryngeal nerve lesion (RLN) results in increased aspiration, though the mechanism for this is unclear. This study aimed to determine the effect of unilateral RLN lesion on the motor coordination of infant liquid feeding. We hypothesized that 1) RLN lesion results in modified swallow kinematics, 2) postlesion oropharyngeal kinematics of unsafe swallows differ from those of safe swallows, and 3) nonswallowing phases of the feeding cycle show changed kinematics postlesion. We implanted radio opaque markers in infant pigs and filmed them pre- and postlesion with high-speed videofluoroscopy. Markers locations were digitized, and swallows were assessed for airway protection. RLN lesion resulted in modified kinematics of the tongue relative to the epiglottis in safe swallows. In lesioned animals, safe swallow kinematics differed from unsafe swallows. Unsafe swallow postlesion kinematics resembled prelesion safe swallows. The movement of the tongue was reduced in oral transport postlesion. Between different regions of the tongue, response to lesion was similar, and relative timing within the tongue was unchanged. RLN lesion has a pervasive effect on infant feeding kinematics, related to the efficiency of airway protection. The timing of tongue and hyolaryngeal kinematics in swallows is a crucial locus for swallow disruption. Laryngeal sensation is essential for the central coordination in feeding of oropharyngeal structures receiving motor inputs from different cranial nerves. Copyright © 2016 the American Physiological Society.

Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest.

PubMed

Hasegawa, Kohei; Hiraide, Atsushi; Chang, Yuchiao; Brown, David F M

2013-01-16

It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation. To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA. Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649,654 consecutive adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010. Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2. Of the eligible 649,359 patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for

The efficacy of three different mask styles on a PAP titration night.

PubMed

Ebben, Matthew R; Oyegbile, Temitayo; Pollak, Charles P

2012-06-01

This study compared the efficacy of three different masks, nasal pillows, nasal masks and full face (oronasal) masks, during a single night of titration with continuous positive airway pressure (CPAP). Fifty five subjects that included men (n=33) and women (n=22) were randomly assigned to one of three masks and underwent a routine titration with incremental CPAP applied through the different masks. CPAP applied through the nasal pillows and nasal mask was equally effective in treating mild, moderate, and severe sleep apnea. However, CPAP applied through the oronasal mask required a significantly higher pressure compared to nasal masks to treat moderately severe (2.8 cm of H(2)O ± 2.1 SD) and severe (6.0 cm of H(2)O ± 3.2 SD) obstructive sleep apnea. CPAP applied with either nasal mask was effective in treating mild, moderate, and severe sleep apnea. The oronasal mask required significantly higher pressures in subjects with moderate to severe disease. Therefore, when changing from a nasal to an oronasal mask, a repeat titration is required to ensure effective treatment of sleep apnea, especially in patients with moderate to severe disease. Copyright © 2012 Elsevier B.V. All rights reserved.

Oronasal Masks Require a Higher Pressure than Nasal and Nasal Pillow Masks for the Treatment of Obstructive Sleep Apnea

PubMed Central

Deshpande, Sheetal; Joosten, Simon; Turton, Anthony; Edwards, Bradley A.; Landry, Shane; Mansfield, Darren R.; Hamilton, Garun S.

2016-01-01

Study Objectives: Oronasal masks are frequently used for continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). The aim of this study was to (1) determine if CPAP requirements are higher for oronasal masks compared to nasal mask interfaces and (2) assess whether polysomnography and patient characteristics differed among mask preference groups. Methods: Retrospective analysis of all CPAP implementation polysomnograms between July 2013 and June 2014. Prescribed CPAP level, polysomnography results and patient data were compared according to mask type (n = 358). Results: Oronasal masks were used in 46%, nasal masks in 35% and nasal pillow masks in 19%. There was no difference according to mask type for baseline apnea-hypopnea index (AHI), body mass index (BMI), waist or neck circumference. CPAP level was higher for oronasal masks, 12 (10–15.5) cm H2O compared to nasal pillow masks, 11 (8–12.5) cm H2O and nasal masks, 10 (8–12) cm H2O, p < 0.0001 (Median [interquartile range]). Oronasal mask type, AHI, age, and BMI were independent predictors of a higher CPAP pressure (p < 0.0005, adjusted R2 = 0.26.). For patients with CPAP ≥ 15 cm H2O, there was an odds ratio of 4.5 (95% CI 2.5–8.0) for having an oronasal compared to a nasal or nasal pillow mask. Residual median AHI was higher for oronasal masks (11.3 events/h) than for nasal masks (6.4 events/h) and nasal pillows (6.7 events/h), p < 0.001. Conclusions: Compared to nasal mask types, oronasal masks are associated with higher CPAP pressures (particularly pressures ≥ 15 cm H2O) and a higher residual AHI. Further evaluation with a randomized control trial is required to definitively establish the effect of mask type on pressure requirements. Commentary: A commentary on this article appears in this issue on page 1209. Citation: Deshpande S, Joosten S, Turton A, Edwards BA, Landry S, Mansfield DR, Hamilton GS. Oronasal masks require a higher pressure than nasal and

Neonatal mannequin comparison of the Upright self-inflating bag and snap-fit mask versus standard resuscitators and masks: leak, applied load and tidal volumes.

PubMed

Rafferty, Anthony Richard; Johnson, Lucy; Davis, Peter G; Dawson, Jennifer Anne; Thio, Marta; Owen, Louise S

2017-11-30

Neonatal mask ventilation is a difficult skill to acquire and maintain. Mask leak is common and can lead to ineffective ventilation. The aim of this study was to determine whether newly available neonatal self-inflating bags and masks could reduce mask leak without additional load being applied to the face. Forty operators delivered 1 min episodes of mask ventilation to a mannequin using the Laerdal Upright Resuscitator, a standard Laerdal infant resuscitator (Laerdal Medical) and a T-Piece Resuscitator (Neopuff), using both the Laerdal snap-fit face mask and the standard Laerdal size 0/1 face mask (equivalent sizes). Participants were asked to use pressure sufficient to achieve 'appropriate' chest rise. Leak, applied load, airway pressure and tidal volume were measured continuously. Participants were unaware that load was being recorded. There was no difference in mask leak between resuscitation devices. Leak was significantly lower when the snap-fit mask was used with all resuscitation devices, compared with the standard mask (14% vs 37% leak, P<0.01). The snap-fit mask was preferred by 83% of participants. The device-mask combinations had no significant effect on applied load. The Laerdal Upright Resuscitator resulted in similar leak to the other resuscitation devices studied, and did not exert additional load to the face and head. The snap-fit mask significantly reduced overall leak with all resuscitation devices and was the mask preferred by participants. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Difference between continuous positive airway pressure via mask therapy and incentive spirometry to treat or prevent post-surgical atelectasis.

PubMed

Al-Mutairi, Fouad H; Fallows, Stephen J; Abukhudair, Waleed A; Islam, Baharul B; Morris, Michael M

2012-11-01

To assess the effect of early use of continuous positive airway pressure (CPAP) therapy to treat or prevent acute atelectasis in post-operative cardiac patients particularly smokers and elderly patients. A pilot study suggested enrolling at least 32 participants in each group to be significant. One hundred and eight patients from King Fahd Armed Forces Hospital, Jeddah, Kingdom of Saudi Arabia who met the inclusion criteria participated in this study conducted between March 2010 and March 2011. The participants were divided randomly into 3 groups, incentive spirometry (IS) therapy, and CPAP therapy every 2 (CPAP 2 hrs), or 4 hours (CPAP 4 hrs). Inspiratory capacity (IC) was used to compare the 3 therapy regimes. Simultaneously, respiratory rate (RR), heart rate (HR) and oxygen saturation (SpO2) were measured for all groups. Failure was defined as requiring intubation, bi-level positive airway pressure, or added chest physiotherapy. Thirty-six patients participated in each group (98 male and 10 female, with a mean age of 62+/-9.3 years). The IC increased significantly in the CPAP 2 hrs group when compared with the control group or the CPAP 4hrs group. The SpO2 decreased significantly in the control group and the CPAP 4 hrs groups when compared with the CPAP 2 hrs group. Also, there were no significant differences in RR and HR between all groups. Early use of CPAP via mask therapy for half an hour every 2 hours had better outcomes to re-open collapsed alveoli after cardiac surgery.

Management of adult recurrent respiratory papillomatosis with oral acyclovir following micro laryngeal surgery: a case series.

PubMed

Chaturvedi, Jagdish; Sreenivas, V; Hemanth, V; Nandakumar, R

2014-01-01

To demonstrate the role of oral acyclovir in monthly regimes after microdebrider assisted excision in 3 patients with adult recurrent respiratory papillomatosis (ARRP). Three patients with ARRP who presented to a tertiary referral hospital in stridor were initially treated with a tracheostomy in order to secure airway. On further evaluation by videolaryngoscopy extensive bilateral laryngeal papillomatosis was noted with history of similar conditions in the past for which they were repeatedly operated. They were admitted and underwent Microlaryngeal surgery and laryngeal microdebrider assisted surgery under general anesthesia. Post operatively a course of oral acyclovir at 800 mg/5 times/day for 5 days was administered. On repeat assessment with videolaryngoscopy at monthly intervals a complete remission of the disease was noted with no residual disease at the end of 1 year in 2 cases. One case had a recurrence. Renal parameters were monitored periodically. It may be concluded that the action of anti viral drugs at regular intervals in addition to a short course of oral steroids lead to rapid recovery and prevented latent virus activation within the laryngo tracheal system hence maintaining long term improvement. This can avoid multiple laryngeal surgeries, repeated respiratory emergencies and risk for malignant transformation in the future thereby reducing morbidity and effect on quality of life.

Positive airway pressure adherence and mask interface in the setting of sinonasal symptoms.

PubMed

Schell, Amy E; Soose, Ryan J

2017-10-01

Despite reports of lower positive pressure adherence rates with oronasal masks, patients with sinonasal problems are often prescribed this interface over a nasal interface. The aim of this study was to characterize the relationship between mask type and therapy adherence in the setting of sinonasal symptoms. Retrospective case series with chart review. We reviewed 328 patients who underwent positive pressure titration between January 2012 and May 2015. Follow-up adherence data were available for 218 patients (66.5%). Multivariate analysis examined whether patients with sinonasal symptoms have improved adherence with oronasal masks compared to nasal or nasal pillow interfaces. At a median follow-up of 95 days, positive pressure adherence in patients with sinonasal symptoms was highest with the nasal pillow interface. When compared with oronasal interfaces, the odds of adequate therapy adherence were >5 times greater with nasal pillow interfaces (odds ratio [OR] = 5.20, 95% confidence interval [CI] = 1.61-16.80, P = .006) and >3 times greater with nasal interfaces (OR = 3.67, 95% CI = 1.20-11.26, P = .02) in these symptomatic patients. The presence of nasal problems does not predict the need for an oronasal mask. Positive pressure adherence rates are higher with nasal and nasal pillow interfaces compared to oronasal masks, even in patients with sinonasal complaints. 4. Laryngoscope, 127:2418-2422, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Comparison of the Pentax AirwayScope and McGrath MAC videolaryngoscope for endotracheal intubation in patients with a normal airway

PubMed Central

Lee, Jiyoung; Kwak, Hyun Jeong; Lee, Ji Yeon; Chang, Min Young; Lee, Sook Young; Kim, Jong Yeop

2017-01-01

Abstract Various videolaryngoscopes (VLs) have been developed to provide a better laryngeal view and facilitate difficult intubations. The goal of this study was to compare 2 VLs, the Pentax AWS and the McGrath VL, with respect to intubation time and ease of intubation. One hundred forty patients aged 19 to 65 years (American Society of Anesthesiologists classification I or II), who required tracheal intubation for elective surgery, were randomly assigned to 1 of the 2 groups: the Pentax AWS (n = 70) or the McGrath VL (n = 70). The primary outcome was time to intubation (TTI) measured by a blind observer. The intubation difficulty scale (IDS), percentage of glottic opening (POGO) scale, glottic grade, use of optimal external laryngeal manipulation (OELM), and ease of intubation were also recorded. The Pentax AWS provided a better laryngeal view than the McGrath VL with respect to the Cormack-Lehane (CL) glottic grade (1/2a/2b) (63/7/0 vs 43/24/3, P < .001) and the POGO scale (median [interquartile range, IQR]) (100 [100–100] vs 100 [80–100], P < .001). The IDS was significantly lower in the Pentax AWS group compared with the McGrath VL group (median [IQR]) (0 [0–0] vs 0 [0–1], P < .001). However, the TTI was similar in both the Pentax AWS and McGrath VL groups (median [IQR]) (30 [27–34] vs 32 [27–35] seconds, P = .440). OELM and ease of intubation were also similar between the 2 groups. The Pentax AWS offered a superior laryngeal view compared with the McGrath VL. There was no significant difference in either the intubation time or ease of intubation using these 2 devices in patients with normal airways. PMID:29145308

Brachycephalic airway obstructive syndrome in dogs: 90 cases (1991-2008).

PubMed

Fasanella, Frank J; Shivley, Jacob M; Wardlaw, Jennifer L; Givaruangsawat, Sumalee

2010-11-01

To determine the prevalence of individual anatomic components of brachycephalic airway obstructive syndrome (BAOS), including everted tonsils, and analyze the frequency with which each component occurs with 1 or more other components of BAOS in brachycephalic dogs. Retrospective case series. 90 dogs with BAOS. Medical records were reviewed for signalment, clinical signs at time of admission, historical and physical examination findings, BAOS components found on laryngoscopic examination of the pharynx and larynx, surgical procedures performed, and perioperative complications. English Bulldogs (55/90 [61%]), Pugs (19/90 [21%]), and Boston Terriers (8/90 [9%]) were the most common breeds with BAOS. The most common components of BAOS were elongated soft palate (85/90 [94%]), stenotic nares (69/90 [77%]), everted laryngeal saccules (59/90 [66%]), and everted tonsils (50/90 [56%]). Dogs most commonly had 3 or 4 components of BAOS, with the most common combination being stenotic nares, elongated soft palate, everted laryngeal saccules, and everted tonsils. Dogs with stenotic nares were significantly more likely to have everted laryngeal saccules (50/69 [72%]), and dogs with everted laryngeal saccules were significantly more likely to have everted tonsils (39/59 [66%]). Postoperative surgical complications occurred in 12% (10/83) of dogs that received corrective surgery. No specific BAOS component made dogs more likely to have complications. The prevalence of components of BAOS in brachycephalic dogs of this study differed from that reported previously, especially for everted tonsils. Thorough examination of the pharynx and larynx is necessary for detection of BAOS components.

A child with a difficult airway: what do I do next?

PubMed

Engelhardt, Thomas; Weiss, Markus

2012-06-01

Difficulties in pediatric airway management are common and continue to result in significant morbidity and mortality. This review reports on current concepts in approaching a child with a difficult airway. Routine airway management in healthy children with normal airways is simple in experienced hands. Mask ventilation (oxygenation) is always possible and tracheal intubation normally simple. However, transient hypoxia is common in these children usually due to unexpected anatomical and functional airway problems or failure to ventilate during rapid sequence induction. Anatomical airway problems (upper airway collapse and adenoid hypertrophy) and functional airway problems (laryngospasm, bronchospasm, insufficient depth of anesthesia and muscle rigidity, gastric hyperinflation, and alveolar collapse) require urgent recognition and treatment algorithms due to insufficient oxygen reserves. Early muscle paralysis and epinephrine administration aids resolution of these functional airway obstructions. Children with an 'impaired' normal (foreign body, allergy, and inflammation) or an expected difficult (scars, tumors, and congenital) airway require careful planning and expertise. Training in the recognition and management of these different situations as well as a suitably equipped anesthesia workstation and trained personnel are essential. The healthy child with an unexpected airway problem requires clear strategies. The 'impaired' normal pediatric airway may be handled by anesthetists experienced with children, whereas the expected difficult pediatric airway requires dedicated pediatric anesthesia specialist care and should only be managed in specialized centers.

Role of upper airway in ventilatory control in awake and sleeping dogs.

PubMed

Stradling, J R; England, S J; Harding, R; Kozar, L F; Andrey, S; Phillipson, E A

1987-03-01

We examined the role of the upper airway in the regulation of the pattern of breathing in six adult dogs during wakefulness and sleep. The dogs breathed through a fenestrated endotracheal tube inserted through a tracheostomy. The tube was modified to allow airflow to be directed either through the nose or through the tracheostomy. When airflow was diverted from nose to tracheostomy there was an abrupt increase in the rate of expiratory airflow, resulting in prolongation of the end-expiratory pause but no change in overall expiratory duration or respiratory frequency. Furthermore, electromyogram recordings from implanted diaphragmatic and laryngeal muscle electrodes did not show any changes that could be interpreted as an attempt to delay expiratory airflow or increase end-expiratory lung volume. The effects of switching from nose to tracheostomy breathing could be reversed by adding a resistance to the endotracheal tube so as to approximate upper airway resistance. The findings indicate that under normal conditions in the adult dog upper airway receptors play little role in regulation of respiratory pattern and that the upper airway exerts little influence on the maintenance of end-expiratory lung volume.

Neopuff T-piece resuscitator mask ventilation: Does mask leak vary with different peak inspiratory pressures in a manikin model?

PubMed

Maheshwari, Rajesh; Tracy, Mark; Hinder, Murray; Wright, Audrey

2017-08-01

The aim of this study was to compare mask leak with three different peak inspiratory pressure (PIP) settings during T-piece resuscitator (TPR; Neopuff) mask ventilation on a neonatal manikin model. Participants were neonatal unit staff members. They were instructed to provide mask ventilation with a TPR with three PIP settings (20, 30, 40 cm H 2 O) chosen in a random order. Each episode was for 2 min with 2-min rest period. Flow rate and positive end-expiratory pressure (PEEP) were kept constant. Airway pressure, inspiratory and expiratory tidal volumes, mask leak, respiratory rate and inspiratory time were recorded. Repeated measures analysis of variance was used for statistical analysis. A total of 12 749 inflations delivered by 40 participants were analysed. There were no statistically significant differences (P > 0.05) in the mask leak with the three PIP settings. No statistically significant differences were seen in respiratory rate and inspiratory time with the three PIP settings. There was a significant rise in PEEP as the PIP increased. Failure to achieve the desired PIP was observed especially at the higher settings. In a neonatal manikin model, the mask leak does not vary as a function of the PIP when the flow rate is constant. With a fixed rate and inspiratory time, there seems to be a rise in PEEP with increasing PIP. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Mask pressure effects on the nasal bridge during short-term noninvasive ventilation

PubMed Central

Brill, Anne-Kathrin; Pickersgill, Rachel; Moghal, Mohammad; Morrell, Mary J.; Simonds, Anita K.

2018-01-01

The aim of this study was to assess the influence of different masks, ventilator settings and body positions on the pressure exerted on the nasal bridge by the mask and subjective comfort during noninvasive ventilation (NIV). We measured the pressure over the nasal bridge in 20 healthy participants receiving NIV via four different NIV masks (three oronasal masks, one nasal mask) at three different ventilator settings and in the seated or supine position. Objective pressure measurements were obtained with an I-Scan pressure-mapping system. Subjective comfort of the mask fit was assessed with a visual analogue scale. The masks exerted mean pressures between 47.6±29 mmHg and 91.9±42.4 mmHg on the nasal bridge. In the supine position, the pressure was lower in all masks (57.1±31.9 mmHg supine, 63.9±37.3 mmHg seated; p<0.001). With oronasal masks, a change of inspiratory positive airway pressure (IPAP) did not influence the objective pressure over the nasal bridge. Subjective discomfort was associated with higher IPAP and positively correlated with the pressure on the skin. Objective measurement of pressure on the skin during mask fitting might be helpful for mask selection. Mask fitting in the supine position should be considered in the clinical routine. PMID:29637077

Recurrent laryngeal nerve reinnervation for management of aspiration in a subset of children.

PubMed

Zur, Karen B; Carroll, Linda M

2018-01-01

Pediatric aspiration is a multifactorial process that is often complex to manage. Recurrent laryngeal nerve (RLN) injury can cause glottic insufficiency and aspiration. We describe three cases of unilateral vocal fold paralysis resulting in aspiration and the successful use of the RLN reinnervation for its treatment. The theory for utilizing the reinnervation procedure is that when glottic closure improves and a less breathy vocalization occurs, then the larynx is better equipped to protect the lower airway and avoid aspiration. Our cases demonstrate stronger voice and improved swallow function, with normalization of modified barium swallow evaluation, at approximately 6-months post reinnervation. Copyright © 2017. Published by Elsevier B.V.

Equipment for pre-hospital airway management on Helicopter Emergency Medical System helicopters in central Europe.

PubMed

Schmid, M; Schüttler, J; Ey, K; Reichenbach, M; Trimmel, H; Mang, H

2011-05-01

For advanced out-of-hospital airway management, skilled personnel and adequate equipment are key prerequisites. There are little data on the current availability of airway management equipment and standards of medical staff on Helicopter Emergency Medical System (HEMS) helicopters in central Europe. An internet search identified all HEMS helicopters in Austria, Switzerland and Luxembourg. We identified 15 HEMS helicopter bases in Switzerland, 28 in Austria and three in Luxembourg. A questionnaire was sent to all bases, asking both for the details of the clinical background and experience of participating staff, and details of airway management equipment carried routinely on board. Replies were received from 14 helicopter bases in Switzerland (93%), 25 bases in Austria (89%) and all three bases in Luxembourg. Anaesthesiologists were by far the most frequent attending physicians (68-85%). All except one bases reported to have at least one alternative supraglottic airway device. All bases had capnometry and succinylcholine. All bases in the study except two in Austria had commercial pre-packed sets for a surgical airway. All helicopters were equipped with automatic ventilators, although not all were suitable for non-invasive ventilation (NIV; Switzerland: 43%, Austria: 12%, Luxembourg: 100%). Masks for NIV were rarely available in Switzerland (two bases; 14%) and in Austria (three bases; 12%), whereas all three bases in Luxembourg carried those masks. Most HEMS helicopters carry appropriate equipment to meet the demands of modern advanced airway management in the pre-hospital setting. Further work is needed to ensure that appropriate airway equipment is carried on all HEMS helicopters.

Recurrent laryngeal nerve landmarks during thyroidectomy.

PubMed

Ngo Nyeki, A-R; Njock, L-R; Miloundja, J; Evehe Vokwely, J-E; Bengono, G

2015-11-01

This study was designed to describe the various anatomical relations of the recurrent laryngeal nerve (RLN) during thyroid surgery in a Central African population. A prospective study was conducted between January 2012 and December 2012 in 5 otorhinolaryngology and head and neck surgery departments in Cameroon and Gabon. All patients undergoing total or subtotal thyroidectomy or loboisthmectomy with recurrent laryngeal nerve dissection, with no history of previous thyroid surgery, RLN dissection or tumour infiltration of the RLN, were included. Fifty-six patients were included, corresponding to 36 loboisthmectomies and 20 total or subtotal thyroidectomies. A total of 62 recurrent laryngeal nerves were identified: 32 on the right and 30 on the left. The course of the recurrent laryngeal nerve in relation to branches of the inferior thyroid artery (ITA) was retrovascular in 53.1% of cases on the right and 76.6% of cases on the left; transvascular in 15.6% of cases on the right and 13.4% of cases on the left. The course of the recurrent laryngeal nerve was modified by thyroid disease in 12.9% of cases. Six cases (9.7%) of extralaryngeal division of the recurrent laryngeal nerve were observed. No case of non-recurrent nerve was observed in this series. The anatomical relations of the recurrent laryngeal nerve with the inferior thyroid artery were very inconstant in this series and were predominantly retrovascular or transvascular in relation to the branches of the artery. The presence of extralaryngeal branches and modification of the course of the nerve by thyroid disease also introduced additional difficulties during recurrent laryngeal nerve dissection. The anatomical relations of the right recurrent laryngeal nerve in this African population differ from the classically described prevascular course. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Diclofenac vs oxybuprocaine eyedrops for analgesia in paediatric strabismus surgery.

PubMed

Morton, N S; Benham, S W; Lawson, R A; McNicol, L R

1997-01-01

Forty children undergoing strabismus surgery as day patients were randomly allocated to receive oxybuprocaine 0.4% eyedrops or 0.1% diclofenac eyedrops for perioperative analgesia. A non-invasive anaesthetic technique using the reinforced laryngeal mask airway was used. The study demonstrated that both topical analgesics provided good to excellent analgesia and the anaesthetic technique was associated with a relatively low incidence of nausea and vomiting. Complications were limited to two children who were admitted with persistent postoperative nausea and vomiting.

The usefulness of design of experimentation in defining the effect difficult airway factors and training have on simulator oral-tracheal intubation success rates in novice intubators.

PubMed

Thomas, Frank; Carpenter, Judi; Rhoades, Carol; Holleran, Renee; Snow, Gregory

2010-04-01

This exploratory study examined novice intubators and the effect difficult airway factors have on pre- and posttraining oral-tracheal simulation intubation success rates. Using a two-level, full-factorial design of experimentation (DOE) involving a combination of six airway factors (curved vs. straight laryngoscope blade, trismus, tongue edema, laryngeal spasm, pharyngeal obstruction, or cervical immobilization), 64 airway scenarios were prospectively randomized to 12 critical care nurses to evaluate pre- and posttraining first-pass intubation success rates on a simulator. Scenario variables and intubation outcomes were analyzed using a generalized linear mixed-effects model to determine two-way main and interactive effects. Interactive effects between the six study factors were nonsignificant (p = 0.69). For both pre- and posttraining, main effects showed the straight blade (p = 0.006), tongue edema (p = 0.0001), and laryngeal spasm (p = 0.004) significantly reduced success rates, while trismus (p = 0.358), pharyngeal obstruction (p = 0.078), and cervical immobilization did not significantly change the success rate. First-pass intubation success rate on the simulator significantly improved (p = 0.005) from pre- (19%) to posttraining (36%). Design of experimentation is useful in analyzing the effect difficult airway factors and training have on simulator intubation success rates. Future quality improvement DOE simulator research studies should be performed to help clarify the relationship between simulator factors and patient intubation rates.

Acromegaly and papillomatosis: difficult intubation and use of the airway exchange catheter.

PubMed

Hulme, G J; Blues, C M

1999-08-01

We describe the anaesthetic management of a patient with acromegaly scheduled for transsphenoidal resection of a pituitary tumour who was found at intubation to have coexisting laryngeal papillomatosis. Oral intubation was impossible using both direct and fibreoptic techniques. Nasal fibreoptic intubation was successful but precluded the transsphenoidal approach to surgery. A Cook Airway Exchange Catheter [Cook (UK) Ltd, Monroe House, Letchworth SG6 1LN] was used with a Negus bronchoscope to convert to oral intubation and allow completion of surgery without resort to tracheostomy.

General Information about Laryngeal Cancer

MedlinePlus

... Laryngeal Cancer Treatment (Adult) (PDQ®)–Patient Version General Information About Laryngeal Cancer Go to Health Professional Version ... the PDQ Adult Treatment Editorial Board . Clinical Trial Information A clinical trial is a study to answer ...

Palliative Airway Stenting Performed Under Radiological Guidance and Local Anesthesia

DOE Office of Scientific and Technical Information (OSTI.GOV)

Profili, Stefano; Manca, Antonio; Feo, Claudio F.

2007-02-15

Purpose. To assess the effectiveness of airway stenting performed exclusively under radiological guidance for the palliation of malignant tracheobronchial strictures. Methods. We report our experience in 16 patients with malignant tracheobronchial stricture treated by insertion of 20 Ultraflex self-expandable metal stents performed under fluoroscopic guidance only. Three patients presented dysphagia grade IV due to esophageal malignant infiltration; they therefore underwent combined airway and esophageal stenting. All the procedures were performed under conscious sedation in the radiological room; average procedure time was around 10 min, but the airway impediment never lasted more than 40 sec. Results. We obtained an overall technicalmore » success in 16 cases (100%) and clinical success in 14 patients (88%). All prostheses were successfully placed without procedural complications. Rapid clinical improvement with symptom relief and normalization of respiratory function was obtained in 14 cases. Two patients died within 48 hr from causes unrelated to stent placement. Two cases (13%) of migration were observed; they were successfully treated with another stent. Tumor overgrowth developed in other 2 patients (13%); however, no further treatment was possible because of extensive laryngeal infiltration. Conclusions. Tracheobronchial recanalization with self-expandable metal stents is a safe and effective palliative treatment for malignant strictures. Airway stenting performed exclusively under fluoroscopic view was rapid and well tolerated.« less

Management of the difficult airway.

PubMed

Schwartz, D E; Wiener-Kronish, J P

1991-09-01

For clinicians involved in airway management, a plan of action for dealing with the difficult airway or a failed intubation should be developed well in advance of encountering a patient in whom intubation is not routine. When difficulty is anticipated, the equipment necessary for performing a difficult intubation should be immediately available. It also is prudent to have a surgeon skilled in performing a tracheotomy and a criothyroidotomy stand by. The intubation should be attempted in the awake state, preferably using the fiberoptic bronchoscope. The more challenging situation is when the difficult airway is confronted unexpectedly. After the first failed attempt at laryngoscopy, head position should be checked and the patient ventilated with oxygen by mask. A smaller styletted tube and possibly a different laryngoscope blade should be selected for a second attempt at intubation. The fiberoptic bronchoscope and other equipment for difficult intubation should be obtained. A second attempt should then be made. If this is unsuccessful, the patient should be reoxygenated, and assistance including a skilled anesthesiologist and surgeon should be summoned. On a third attempt, traction to the tongue can be applied by an assistant, a tube changer could be used to enter the larynx, or one of the other special techniques previously described can be used. If this third attempt fails, it may be helpful to have a physician more experienced in airway management attempt intubation after oxygen has been administered to the patient. If all attempts are unsuccessful, then invasive techniques to secure the airway will have to be performed.

Laryngeal amyloidosis: diagnosis, pathophysiology and management.

PubMed

Phillips, N M; Matthews, E; Altmann, C; Agnew, J; Burns, H

2017-07-01

Laryngeal amyloidosis represents approximately 1 per cent of all benign laryngeal lesions, and can cause variable symptoms depending on anatomical location and size. Treatment ranges from observation through to endoscopic microsurgery, laser excision and laryngectomy. To highlight the diversity of presentations, increase awareness of paediatric amyloidosis and update the reader on current management. Five cases are illustrated. Four adult patients were female, and the one child, the second youngest in the literature, was male. Amyloid deposits were identified in all laryngeal areas, including the supraglottis, glottis and subglottis. Treatment consisted of balloon dilatation, endoscopic excision, laser cruciate incision, and resection with carbon dioxide laser, a microdebrider and coblation wands. Laryngeal amyloidosis remains a rare and clinically challenging condition. Diagnosis should be considered for unusual appearing submucosal laryngeal lesions. Treatment of this disease needs to be evaluated on a case-by-case basis and managed within an appropriate multidisciplinary team.

[Laryngeal electromyography in diagnosis and treatment of voice disorders].

PubMed

García-López, Isabel; Santiago-Pérez, Susana; Peñarrocha-Teres, Julio; del Palacio, Antonio J; Gavilan, Javier

2012-01-01

Laryngeal electromyography, together with clinical evaluation, is a valuable tool in voice disorder management. It assesses the integrity of laryngeal nerves and muscles, contributing to the diagnosis of many diseases, especially laryngeal movement disorders. Our purpose was to describe the experience of the first Spanish series with laryngeal electromyography in evaluating voice disorders. A prospective study was designed to evaluate laryngeal movement disorders with laryngeal electromyography. Both the cricothyroid and thyroarytenoid muscles were tested routinely and, in some cases, the posterior cricoarytenoid muscle. The laryngeal electromyography technique and result interpretation were performed by a laryngologist and a neurophysiologist. We included 110 patients, with the most common symptom being dysphonia. Laryngeal electromyography was performed in 85% of cases. Primary diagnosis before electromyography was laryngeal immobility. Positive predictive value for diagnosis in cases of paralysis was 88%. Laryngeal electromyography is a useful adjunct, together with clinical evaluation, for diagnosis and management of motion abnormalities in the larynx in patients who present with dysphonia. Copyright © 2012 Elsevier España, S.L. All rights reserved.

Obstructive sleep apnea as a risk factor associated with difficult airway management - A narrative review.

PubMed

Leong, Siaw May; Tiwari, Akhilesh; Chung, Frances; Wong, David T

2018-03-01

The association between obstructive sleep apnea (OSA) and difficult airway had been studied in various clinical trials but the relationship between the two conditions has not been clearly established. The objective of this narrative review is to determine if OSA is a risk factor associated with difficult airway. The OVID Medline in process, Medline (vis Pub Med), EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science and SCOPUS were searched up to April 2016 using specific keywords. Inclusion criteria were: [1] airway management in patients with a diagnosis of OSA, [2] comparison of airway management between OSA and non-OSA patients, [3] publications or abstracts in the English language. The incidence of difficult airway between OSA and non-OSA patients was compared using Chi-square analysis or Fisher's exact test. Ten studies were included in the final review. Overall, the incidence of difficult tracheal intubation was higher in OSA patients versus non-OSA patients [56/386 (14.5%) vs. 69/897 (7.7%); P=0.0002]. OSA patients also have a higher incidence of difficult mask ventilation [115/4626 (2.5%) vs. 471/64,684 (0.7%); P<0.0001]. Compared to non-OSA patients, OSA was not associated with difficulty in the use of a supraglottic airway (SGA) device [10/663 (1.5%) vs. 162/15,171 (1.1%); P=0.38]. No studies compared difficult surgical airway in OSA and non-OSA patients. OSA was found to be a risk factor associated with difficult tracheal intubation and difficult mask ventilation. There was no association between OSA and difficult SGA use. Copyright © 2017 Elsevier Inc. All rights reserved.

Isolated laryngeal myasthenia gravis for 26 years.

PubMed

Renard, Dimitri; Hedayat, Amir; Gagnard, Corinne

2015-02-01

Laryngeal myasthenia gravis is a relatively rare variant of myasthenia gravis. A vast portion of patients with initial laryngeal myasthenia gravis develop involvement of ocular and/or extra-ocular muscles during the years after symptom onset although a minority of laryngeal myasthenia gravis patients continues to have isolated laryngeal muscle involvement for several years. We present a 58-year-old woman with recurrent episodic isolated dysphonia (associated with diffuse bilateral vocal cord paresis on laryngoscopy) since the age of 32. Dysphonia became permanent since 6 months. A diagnosis of laryngeal myasthenia gravis was made based on abnormal single-fiber electromyography and spectacular response to pyridostigmine treatment. Repetitive nerve stimulation was normal and anti-acetylcholine receptor and anti-muscle specific tyrosine kinase antibodies were absent. This case shows that laryngeal myasthenia gravis can be isolated during 26 years of follow-up. We propose that even when myasthenia gravis seems unlikely as underlying mechanism of isolated dysphonia (because of lack of antibodies, normal repetitive nerve stimulation, and absence of extra-laryngeal involvement after years of follow-up), single-fiber electromyography should be performed and myasthenia gravis treatment should be tried. Copyright © 2014 Elsevier B.V. All rights reserved.

Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis.

PubMed

Ahn, Eun Jin; Choi, Geun Joo; Kang, Hyun; Baek, Chong Wha; Jung, Yong Hun; Woo, Young Cheol; Bang, Si Ra

2016-01-01

Air-Q® (air-Q) is a supraglottic airway device which can be used as a guidance of intubation in pediatric as well as in adult patients. We evaluated the efficacy and safety of air-Q compared to other airway devices during general anesthesia in pediatric patients by conducting a systematic review and meta-analysis. A total of 10 studies including 789 patients were included in the final analysis. Compared with other supraglottic airway devices, air-Q showed no evidence for a difference in leakage pressure and insertion time. The ease of insertion was significantly lower than other supraglottic airway devices. The success rate of intubation was significantly lower than other airway devices. However, fiberoptic view was better through the air-Q than other supraglottic airway devices. Therefore, air-Q could be a safe substitute for other airway devices and may provide better fiberoptic bronchoscopic view.

Diclofenac vs oxybuprocaine eyedrops for analgesia in paediatric strabismus surgery.

PubMed

Morton, N; Benham, S; Lawson, R; McNICOL, L

1997-05-01

Forty children undergoing strabismus surgery as day patients were randomly allocated to receive oxybuprocaine 0.4% eyedrops or 0.1% diclofenac eyedrops for perioperative analgesia. A non-invasive anaesthetic technique using the reinforced laryngeal mask airway was used. The study demonstrated that both topical analgesics provided good to excellent analgesia and the anaesthetic technique was associated with a relatively low incidence of nausea and vomiting. Complications were limited to two children who were admitted with persistent postoperative nausea and vomiting. 1997 Blackwell Science Ltd.

Cyclooxygenase-2 expression and clinical parameters in laryngeal squamous cell carcinoma, vocal fold nodule, and laryngeal atypical hyperplasia.

PubMed

Sayar, Cağdaş; Sayar, Hamide; Özdemir, Süleyman; Selçuk, Tahsin; Görgülü, Orhan; Akbaş, Yücel; Kemal Olgun, Mustafa

2013-01-01

The diagnostic role of cyclooxygenase-2 (COX-2) expression in laryngeal atypical hyperplasia, vocal fold nodule, and laryngeal squamous cell carcinoma was examined. Specimens obtained from patients diagnosed with vocal fold nodule (n = 35), atypical hyperplasia (n = 35), laryngeal squamous cell carcinoma (n = 35), and clinical parameters were evaluated retrospectively. Although no staining was observed in patients with vocal fold nodules, staining was noted in laryngeal atypical hyperplasia and squamous cell carcinoma. The percentage of COX-2 staining was the highest in the carcinoma group. It was determined that COX-2 staining was significantly associated with laryngeal squamous cell carcinoma. It should be noted that overexpression of COX-2, a potentially important factor in the evolution of carcinogenesis in precancerous lesions, might be an indicator of the development of carcinoma. Copyright © 2012 Wiley Periodicals, Inc.

Increased airway reactivity in a neonatal mouse model of Continuous Positive Airway Pressure (CPAP)

PubMed Central

Mayer, Catherine A.; Martin, Richard J.; MacFarlane, Peter M.

2015-01-01

Background Continuous positive airway pressure (CPAP) is a primary form of respiratory support used in the intensive care of preterm infants, but its long-term effects on airway (AW) function are unknown. Methods We developed a neonatal mouse model of CPAP treatment to determine whether it modifies later AW reactivity. Un-anesthetized spontaneously breathing mice were fitted with a mask to deliver CPAP (6cmH2O, 3hrs/day) for 7 consecutive days starting at postnatal day 1. Airway reactivity to methacholine was assessed using the in vitro living lung slice preparation. Results One week of CPAP increased AW responsiveness to methacholine in male, but not female mice, compared to untreated control animals. The AW hyper-reactivity of male mice persisted for 2 weeks (at P21) after CPAP treatment ended. 4 days of CPAP, however, did not significantly increase AW reactivity. Females also exhibited AW hyper-reactivity at P21, suggesting a delayed response to early (7 days) CPAP treatment. The effects of 7 days of CPAP on hyper-reactivity to methacholine were unique to smaller AWs whereas larger ones were relatively unaffected. Conclusion These data may be important to our understanding of the potential long-term consequences of neonatal CPAP therapy used in the intensive care of preterm infants. PMID:25950451

Laryngeal juvenile xanthogranuloma: Imaging finding.

PubMed

Wang, L M; Chen, Q H; Zhang, Y X; Fang, Y Q

2010-08-01

Laryngeal juvenile xanthogranuloma is rare and there were only four cases have been reported previously in English literature. We report a case of isolated JXG of larynx in the superglottic region. The mass was well-defined and homogeneous hypoechoic in ultrasonography while presented indistinct boundary and soft tissue density in Computed Tomography images. Radiological findings are nonspecific but could help to understand the extent of the lesion. We suggest that JXG should be considered as differential diagnosis for laryngeal stridor. Laryngeal ultrasound is safe and reliable, which could be considered a useful diagnostic tool for supplementing laryngoscopy.

A new suction mask to reduce leak during neonatal resuscitation: a manikin study.

PubMed

Lorenz, Laila; Maxfield, Dominic A; Dawson, Jennifer A; Kamlin, C Omar F; McGrory, Lorraine; Thio, Marta; Donath, Susan M; Davis, Peter G

2016-09-01

Leak around the face mask is a common problem during neonatal resuscitation. A newly designed face mask using a suction system to enhance contact between the mask and the infant's face might reduce leak and improve neonatal resuscitation. The aim of the study is to determine whether leak is reduced using the suction mask (Resusi-sure mask) compared with a conventional mask (Laerdal Silicone mask) in a manikin model. Sixty participants from different professional categories (neonatal consultants, fellows, registrars, nurses, midwives and students) used each face mask in a random order to deliver 2 min of positive pressure ventilation to a manikin. Delivered airway pressures were measured using a pressure line. Inspiratory and expiratory flows were measured using a flow sensor, and expiratory tidal volumes and mask leaks were derived from these values. A median (IQR) leak of 12.1 (0.6-39.0)% was found with the conventional mask compared with 0.7 (0.2-4.6)% using the suction mask (p=0.002). 50% of the participants preferred to use the suction mask and 38% preferred to use the conventional mask. There was no correlation between leak and operator experience. A new neonatal face mask based on the suction system reduced leak in a manikin model. Clinical studies to test the safety and effectiveness of this mask are needed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Neurological Complications in Thyroid Surgery: A Surgical Point of View on Laryngeal Nerves

PubMed Central

Varaldo, Emanuela; Ansaldo, Gian Luca; Mascherini, Matteo; Cafiero, Ferdinando; Minuto, Michele N.

2014-01-01

The cervical branches of the vagus nerve that are pertinent to endocrine surgery are the superior and the inferior laryngeal nerves: their anatomical course in the neck places them at risk during thyroid surgery. The external branch of the superior laryngeal nerve (EB) is at risk during thyroid surgery because of its close anatomical relationship with the superior thyroid vessels and the superior thyroid pole region. The rate of EB injury (which leads to the paralysis of the cricothyroid muscle) varies from 0 to 58%. The identification of the EB during surgery helps avoiding both an accidental transection and an excessive stretching. When the nerve is not identified, the ligation of superior thyroid artery branches close to the thyroid gland is suggested, as well as the abstention from an indiscriminate use of energy-based devices that might damage it. The inferior laryngeal nerve (RLN) runs in the tracheoesophageal groove toward the larynx, close to the posterior aspect of the thyroid. It is the main motor nerve of the intrinsic laryngeal muscles, and also provides sensory innervation to the larynx. Its injury finally causes the paralysis of the omolateral vocal cord and various sensory alterations: the symptoms range from mild to severe hoarseness, to acute airway obstruction, and swallowing impairment. Permanent lesions of the RNL occur from 0.3 to 7% of cases, according to different factors. The surgeon must be aware of the possible anatomical variations of the nerve, which should be actively searched for and identified. Visual control and gentle dissection of RLN are imperative. The use of intraoperative nerve monitoring has been safely applied but, at the moment, its impact in the incidence of RLN injuries has not been clarified. In conclusion, despite a thorough surgical technique and the use of intraoperative neuromonitoring, the incidence of neurological complications after thyroid surgery cannot be suppressed, but should be maintained in a low range. PMID

Laryngitis

MedlinePlus

... laryngitis: Try to avoid people who have upper respiratory infections during cold and flu season. Wash your hands often. DO NOT strain your voice. Stop smoking. This can help prevent tumors of the head and neck or lungs, which can lead to hoarseness.

Sedation with detomidine and acepromazine influences the endoscopic evaluation of laryngeal function in horses.

PubMed

Lindegaard, C; Husted, L; Ullum, H; Fjeldborg, J

2007-11-01

Endoscopy of the upper airways of horses is used as a diagnostic tool and at purchase examinations. On some occasions it is necessary to use sedation during the procedure and it is often speculated that the result of the examination might be influenced due to the muscle-relaxing properties of the most commonly used sedatives. To evaluate the effect of detomidine (0.01 mg/kg bwt) and acepromazine (0.05 mg/kg bwt) on the appearance of symmetry of rima glottidis, ability to abduct maximally the arytenoid cartilages and the effect on recurrent laryngeal neuropathy (RLN) grade. Forty-two apparently normal horses underwent endoscopic examination of the upper airways on 3 different occasions, under the influence of 3 different treatments: no sedation (control), sedation with detomidine and sedation with acepromazine. All examinations were performed with a minimum of one week apart. The study was performed as an observer-blind cross-over study. Sedation with detomidine had a significant effect on the RLN grading (OR = 2.91) and ability maximally to abduct the left arytenoid cartilages (OR = 2.91). Sedation with acepromazine resulted in OR = 2.43 for the RLN grading and OR = 2.22 for the ability to abduct maximally. The ability to abduct maximally the right arytenoid cartilage was not altered. Sedating apparently healthy horses with detomidine or acepromazine significantly impairs these horses' ability to abduct fully the left but not the right arytenoid cartilage. This resulted in different diagnosis with respect to RLN when comparing sedation to no sedation. Since the ability to abduct the right arytenoid cartilage fully is not altered by sedation, it is speculated that horses changing from normal to abnormal laryngeal function when sedated, might be horses in an early stage of the disease. To confirm or reject these speculations, further studies are needed. Until then sedation during endoscopy should be used with care.

Retrograde air escape via the nasolacrimal system: a previously unrecognized complication of continuous positive airway pressure in the management of obstructive sleep apnea.

PubMed

Singh, Narinder Pal; Walker, Robbie James Eades; Cowan, Fiona; Davidson, Arthur Craig; Roberts, David Newton

2014-05-01

Continuous positive airway pressure (CPAP) is the gold standard treatment for moderate to severe obstructive sleep apnoea (OSA). Eye-related side effects of CPAP are commonly attributed to a poorly sealed mask, allowing leaked air to blow over the eye. We present 3 cases where attended polysomnography (A-PSG) demonstrated CPAP-associated retrograde air escape via the nasolacrimal system (CRANS) in the absence of any mask leaks. Symptoms included dry eye, epiphora, air escape from the medial canthus, and eyelid flutter. Symptoms were controlled with a variety of surgical and nonsurgical techniques. CRANS represents a previously undescribed clinical entity. CRANS may be responsible for some CPAP-related eye side effects and possibly for rarer secondary eye complications, including conjunctivitis and corneal ulceration. CRANS should be suspected in any patient on CPAP complaining of eye symptoms. CRANS may be diagnosed through careful observation during A-PSG and confirmed by performing a "saline bubble test." Management options include nonsurgical (mask alternatives, humidification, nasopharyngeal airway) and surgical techniques (nasal airway surgery, inferior turbinate out-fracture and adhesion, injection of bulking agent around Hasner's valve).

Comparison of 3 airway access techniques during suspected spine injury management in American football.

PubMed

Toler, Julianne D; Petschauer, Meredith A; Mihalik, Jason P; Oyama, Sakiko; Halverson, S Doug; Guskiewicz, Kevin M

2010-03-01

To determine how head movement and time to access airway were affected by 3 emergency airway access techniques used in American football. Prospective counterbalanced design. University research laboratory. Eighteen certified athletic trainers (ATCs) and 18 noncertified students (NCSs). Each participant performed 1 trial of each of the 3 after airway access techniques: quick release mechanism (QRM), cordless screwdriver (CSD), and pocket mask insertion (PMI). Time to task completion in seconds, head movement in each plane (sagittal, frontal, and transverse), maximum head movement in each plane, helmet movement in each plane, and maximum helmet movement in each plane. We observed a significant difference between all 3 techniques with respect to time required to achieve airway access (F(2,68) = 263.88; P < 0.001). The PMI allowed for the quickest access followed by the QRM and CSD techniques, respectively. The PMI technique also resulted in significantly less head movement (F(2,68) = 9.06; P = 0.001) and less maximum head movement (F(2,68) = 13.84; P < 0.001) in the frontal plane compared with the QRM and CSD techniques. The PMI technique should be used to gain rapid airway access when managing a football athlete experiencing respiratory arrest in the presence of a suspected cervical spine injury. In the event the athlete does not present with respiratory arrest, the facemask may be removed carefully with a pocket mask ready. Medical professionals must be familiar with differences in equipment and the effects these may have on the management of the spine-injured athlete.

Laryngeal electromyography as a diagnostic tool for Parkinson's disease.

PubMed

Zarzur, Ana P; Duprat, André de Campos; Cataldo, Berenice O; Ciampi, Daniel; Fonoff, Erich

2014-03-01

To study the laryngeal electromyography pattern in patients with Parkinson's disease (PD) and vocal complaints at different stages of the disease. Cross-sectional cohort study. Ninety-four adults with PD and vocal complaints at different stages of the disease (according to the Hoehn and Yahr scale) underwent laryngeal electromyography. Tremors were not detected on laryngeal electromyography of the cricothyroid and thyroarytenoid muscles even in patients with clinical tremor. Laryngeal electromyography hypercontractility during voice rest was the typical result observed in 91.5% of patients regardless of disease severity. Gender and age of subjects did not correlate with laryngeal electromyography results. Patients with PD presented spontaneous intrinsic laryngeal muscle activity during voice rest, regardless of disease severity. This study was significant because it reported on the use of laryngeal electromyography in a large number of patients with PD and vocal complaints grouped according to PD severity. The patterns observed suggest that laryngeal electromyography is a valuable diagnostic tool for PD even at early phases of the disease. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Laryngeal Motor Cortex and Control of Speech in Humans

PubMed Central

Simonyan, Kristina; Horwitz, Barry

2011-01-01

Speech production is one of the most complex and rapid motor behaviors and involves a precise coordination of over 100 laryngeal, orofacial and respiratory muscles. Yet, we lack a complete understanding of laryngeal motor cortical control during production of speech and other voluntary laryngeal behaviors. In recent years, a number of studies have confirmed the laryngeal motor cortical representation in humans and provided some information about its interactions with other cortical and subcortical regions that are principally involved in vocal motor control of speech production. In this review, we discuss the organization of the peripheral and central laryngeal control based on neuroimaging and electrical stimulation studies in humans and neuroanatomical tracing studies in non-human primates. We hypothesize that the location of the laryngeal motor cortex in the primary motor cortex and its direct connections with the brainstem laryngeal motoneurons in humans, as oppose to its location in the premotor cortex with only indirect connections to the laryngeal motoneurons in non-human primates, may represent one of the major evolutionary developments in humans towards the ability to speak and vocalize voluntarily. PMID:21362688

Anaesthetic Management in a Child with Goldenhar Syndrome.

PubMed

Khan, Waqas Ahmed; Salim, Bushra; Khan, Ausaf Ahmed; Chughtai, Shakaib

2017-03-01

Goldenhar syndrome is a congenital disorder involving deformities of the face. It usually affects one side of the face only and poses significant challenges in the airway management. We herein, report an 8-year boy, known case of Goldenhar syndrome, who presented to our radiology suite for a magnetic resonance imaging (MRI) brain, followed by a computed tomography (CT) scan brain. The boy had various features of Goldenhar syndrome, e.g. cleft palate, absent right eye and ear, right mandibular hypoplasia, micrognathia, and preauricular tags. His developmental milestones were delayed. Airway evaluation showed Mallampati class II with limited movements of head and neck, which suggested possibility of difficult laryngoscopy and intubation. He had no vertebral anomalies or cardiac disease. A difficult airway continues to be a major cause of anaesthesia-related morbidity and mortality; and maintaining spontaneous breathing remains a vital technique in its management. Lack of anaesthesia-related complications with supraglottic devices encouraged us to present the advantage of utilising a laryngeal mask airway (LMA) under anaesthesia for successful management of predicted difficult airway.

Trauma-induced schwannoma of the recurrent laryngeal nerve after thyroidectomy.

PubMed

Kennedy, William P; Brody, Robert M; LiVolsi, Virginia A; Wang, Amber R; Mirza, Natasha A

2016-06-01

Laryngeal schwannomas are rare, benign tumors, most often arising from the superior laryngeal nerve. We describe a case of a 68-year-old female with a laryngeal schwannoma of the recurrent laryngeal nerve after traumatic injury. We postulate that trauma to the recurrent laryngeal nerve during thyroidectomy or thyroplasty incited growth of a nerve sheath tumor. This is the first reported case of a trauma-induced schwannoma of the recurrent laryngeal nerve and second case of a recurrent laryngeal nerve schwannoma. Although rare, this case demonstrates that these tumors should be considered during workup of vocal cord paresis after surgery or failed thyroplasty. Laryngoscope, 126:1408-1410, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Laryngeal Electromyography Techniques and Clinical Use.

PubMed

Kimaid, Paulo Andre Teixeira; Crespo, Agrício Nubiato; Moreira, Ana Lucila; Wolf, Aline Epiphanio; França, Marcondes Cavalcante

2015-08-01

Laryngeal electromyography is considered a valuable diagnostic tool for voice disorders. The technique, described almost 70 years ago, evolved 3 decades later, mainly because of the growing interest of laryngologists and speech pathologists. In the authors' opinion, the reduced number of neurophysiologists involved in laryngeal electromyography groups is, at some instance, related to the difficulty to start the learning process and the multidisciplinary approach the field requires. This review highlights the anatomy and physiology needed to perform laryngeal electromyography and its clinical usefulness in the new field known as neurolaryngology.

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis.

PubMed

Caruana, Emmanuel; Chevret, Sylvie; Pirracchio, Romain

2017-03-01

The benefit of cricoid pressure during tracheal intubation is still debated and, due to its potential negative impact on laryngeal views, its routine use is questioned. The goal of this study was to estimate its impact on laryngeal view. All patients intubated in the prehospital setting were included. Three different propensity score (PS) models were used and compared in terms of the balance achieved between those patients who received cricoid pressure and those who did not. The PS model that optimised the balance was retained in order to estimate the relationship between cricoid pressure and the following outcomes: difficult laryngoscopy, intubation-related complications and difficult intubation. Among the 1195 patients included, 499 (41.7%) received cricoid pressure. The optimal PS included seven variables (cardiac arrest, altered neurological status, shock, respiratory distress, gender, obesity, patient's position). After PS matching, no significant risk difference (RD) in the rate of difficult laryngoscopy was found between the patients who received cricoid pressure and those who did not (RD=0.001, 95% CI -0.07 to 0.08, p=0.50). No significant difference was found in terms of difficult intubation (RD=0.06, 95% CI -0.13 to 0.25, p=0.28) and in terms of prevalence of complications, except for airway trauma that were more frequent in cricoid pressure group (RD=0.03, 95% CI 0.002 to 0.05, p=0.01). No significant relationship was found between the use of cricoid pressure for prehospital intubation and difficult laryngoscopy. Cricoid pressure was found to be associated with more airway trauma. This finding could question its routine use. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Isolated laryngeal leishmaniasis in an immunocompetent patient: a case report.

PubMed

Bajraktari, A; Seccia, V; Casani, A P; Franceschini, S S

Isolated laryngeal leishmaniasis in an immunocompetent patient: a case report. Isolated laryngeal Leishmaniasis presents neither explicit laryngeal lesions nor specific symptoms. In fact, it may mimic many inflammatory and neoplastic diseases. Considering the low incidence of this atypical localization, laryngeal Leishmaniasis, is rarely contemplated by physicians in differential diagnoses of laryngeal tumour lesions. We present the case of a 62-year-old immunocompetent subject who developed a single Leishmania mucosal lesion on the left vocal cord, simulating a laryngeal cancer. A case report and discussion of the clinical case by referring to the literature. Specific therapy with miltefosine led to clinical and endoscopic improvement. We had no relapse after three years of follow-up. This clinical case highlights the need to consider isolated laryngeal Leishmaniasis in the differential diagnoses of laryngeal tumour lesions, even in immunocompetent subjects who live in endemic zones, in order to ensure an early and correct therapeutic approach.

What's in a mask? Information masking with forward and backward visual masks.

PubMed

Davis, Chris; Kim, Jeesun

2011-10-01

Three experiments tested how the physical format and information content of forward and backward masks affected the extent of visual pattern masking. This involved using different types of forward and backward masks with target discrimination measured by percentage correct in the first experiment (with a fixed target duration) and by an adaptive threshold procedure in the last two. The rationale behind the manipulation of the content of the masks stemmed from masking theories emphasizing attentional and/or conceptual factors rather than visual ones. Experiment 1 used word masks and showed that masking was reduced (a masking reduction effect) when the forward and backward masks were the same word (although in different case) compared to when the masks were different words. Experiment 2 tested the extent to which a reduction in masking might occur due to the physical similarity between the forward and backward masks by comparing the effect of the same content of the masks in the same versus different case. The result showed a significant reduction in masking for same content masks but no significant effect of case. The last experiment examined whether the reduction in masking effect would be observed with nonword masks--that is, having no high-level representation. No reduction in masking was found from same compared to different nonword masks (Experiment 3). These results support the view that the conscious perception of a rapidly displayed target stimulus is in part determined by high-level perceptual/cognitive factors concerned with masking stimulus grouping and attention.

Laryngeal Reflexes: Physiology, Technique and Clinical Use

PubMed Central

Ludlow, Christy L.

2015-01-01

This review examines the current level of knowledge and techniques available for the study of laryngeal reflexes. Overall, the larynx is under constant control of several systems (including respiration, swallowing and cough) as well as sensory-motor reflex responses involving glossopharyngeal, pharyngeal, laryngeal and tracheobronchial sensory receptors. Techniques for the clinical assessment of these reflexes are emerging and need to be examined for sensitivity and specificity in identifying laryngeal sensory disorders. Quantitative assessment methods for the diagnosis of sensory reductions as well as sensory hypersensitivity may account for laryngeal disorders such as chronic cough, paradoxical vocal fold disorder and muscular tension dysphonia. The development of accurate assessment techniques could improve our understanding of the mechanisms involved in these disorders. PMID:26241237

Clinical evaluation of laryngeal sensation in horses.

PubMed

Gaughan, E M; Hackett, R P; Ducharme, N G; Rakestraw, P C

1990-01-01

Sensory innervation of the larynx was examined by tactile stimulation with a blunt biopsy forceps passed through a flexible videoendoscope. Twenty horses with no evidence of laryngeal motor deficit were stimulated on 10 sites by touch with the forceps. Unilateral neurectomies of the internal branch of the left cranial laryngeal nerve were performed on 5 other horses. These horses were stimulated by touch on the same sites preoperatively and up to 1 week postoperatively. In all 25 horses the motor response of the larynx was recorded on videotape and evaluated by 2 observers blind as to treatment and time of evaluation. Normal horses responded to touch by adduction of both arytenoid cartilages, swallowing or both. This response was not altered by sedation with xylazine hydrochloride. Left cranial laryngeal neurectomized horses failed to respond to tactile stimulation of the left side, while adduction of both cartilages, swallowing or both was observed following stimulation on the right side. Laryngeal stimulation by touch with a biopsy forceps was accurate in identifying horses with complete deficits of the internal branch of the cranial laryngeal nerve.

Swallowing Mechanics Associated With Artificial Airways, Bolus Properties, and Penetration-Aspiration Status in Trauma Patients.

PubMed

Dietsch, Angela M; Rowley, Christopher B; Solomon, Nancy Pearl; Pearson, William G

2017-09-18

Artificial airway procedures such as intubation and tracheotomy are common in the treatment of traumatic injuries, and bolus modifications may be implemented to help manage swallowing disorders. This study assessed artificial airway status, bolus properties (volume and viscosity), and the occurrence of laryngeal penetration and/or aspiration in relation to mechanical features of swallowing. Coordinates of anatomical landmarks were extracted at minimum and maximum hyolaryngeal excursion from 228 videofluoroscopic swallowing studies representing 69 traumatically injured U.S. military service members with dysphagia. Morphometric canonical variate and regression analyses examined associations between swallowing mechanics and bolus properties based on artificial airway and penetration-aspiration status. Significant differences in swallowing mechanics were detected between extubated versus tracheotomized (D = 1.32, p < .0001), extubated versus decannulated (D = 1.74, p < .0001), and decannulated versus tracheotomized (D = 1.24, p < .0001) groups per post hoc discriminant function analysis. Tracheotomy-in-situ and decannulated subgroups exhibited increased head/neck extension and posterior relocation of the larynx. Swallowing mechanics associated with (a) penetration-aspiration status and (b) bolus properties were moderately related for extubated and decannulated subgroups, but not the tracheotomized subgroup, per morphometric regression analysis. Specific differences in swallowing mechanics associated with artificial airway status and certain bolus properties may guide therapeutic intervention in trauma-based dysphagia.

Differential suppression of upper airway motor activity during carbachol-induced, REM sleep-like atonia.

PubMed

Fenik, V; Davies, R O; Pack, A I; Kubin, L

1998-10-01

Microinjections of carbachol into the pontine tegmentum of decerebrate cats have been used to study the mechanisms underlying the suppression of postural and respiratory motoneuronal activity during the resulting rapid eye movement (REM) sleep-like atonia. During REM sleep, distinct respiratory muscles are differentially affected; e.g., the activity of the diaphragm shows little suppression, whereas the activity of some upper airway muscles is quite strong. To determine the pattern of the carbachol-induced changes in the activity of different groups of upper airway motoneurons, we simultaneously recorded the efferent activity of the recurrent laryngeal nerve (RL), pharyngeal branch of the vagus nerve (Phar), and genioglossal branch of the hypoglossal (XII) and phrenic (Phr) nerves in 12 decerebrate, paralyzed, vagotomized, and artificially ventilated cats. Pontine carbachol caused a stereotyped suppression of the spontaneous activity that was significantly larger in Phar expiratory (to 8.3% of control) and XII inspiratory motoneurons (to 15%) than in Phr inspiratory (to 87%), RL inspiratory (to 79%), or RL expiratory motoneurons (to 72%). The suppression in upper airway motor output was significantly greater than the depression caused by a level of hypocapnia that reduced Phr activity as much as carbachol. We conclude that pontine carbachol evokes a stereotyped pattern of suppression of upper airway motor activity. Because carbachol evokes a state having many neurophysiological characteristics similar to those of REM sleep, it is likely that pontine cholinoceptive neurons have similar effects on the activity of upper airway motoneurons during both states.

Aberrant laryngeal location of Onchocerca lupi in a dog.

PubMed

Alho, Ana Margarida; Cruz, Luís; Coelho, Ana; Martinho, Filipe; Mansinho, Mário; Annoscia, Giada; Lia, Riccardo P; Giannelli, Alessio; Otranto, Domenico; de Carvalho, Luís Madeira

2016-06-01

Onchocerca lupi (Spirurida, Onchocercidae) is an emerging vector-borne helminth that causes nodular lesions associated with acute or chronic ocular disease in dogs and cats. Since its first description in dogs in 1991, this zoonotic filarioid has been increasingly reported in Europe and the United States. An 8-year-old outdoor mixed-breed female dog from the Algarve (southern Portugal) was presented with a history of severe dyspnoea. Cervical and thoracic radiographs revealed a slight reduction in the diameter of the cervical trachea and a moderate increase in radiopacity of the laryngeal soft tissue. An exploratory laryngoscopy was performed, revealing filiform worms associated with stenosis of the thyroid cartilage and a purulent necrotic tissue in the larynx lumen. A single sessile nodule, protruding from the dorsal wall of the laryngeal lumen caused a severe reduction of the glottis and tracheal diameter. Fragments of the worms were morphologically and molecularly identified as O. lupi. Histological examination of the nodule showed a granulomatous reaction with sections of coiled gravid female nematodes. Following laryngoscopy, a tracheostomy tube was inserted to relieve dyspnoea and ivermectin (300 μg/kg, once a week, for 8 weeks) combined with prednisolone was prescribed. The dog showed a complete recovery. Although O. lupi has been isolated in human patients from the spinal cord, this is the first report of an aberrant migration of O. lupi in a dog. The veterinary medical community should pay attention to aberrant location of O. lupi and consider onchocercosis as a differential diagnosis for airway obstruction in dogs. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Two-Stage Technique Used to Manage Severe Upper Airway Obstruction and Avoid Surgical Tracheostomy: A Case Report.

PubMed

Onwochei, Desire N; El-Boghdadly, Kariem; Ahmad, Imran

2018-03-01

Severe upper airway obstruction is commonly managed with surgical tracheostomy under local anesthesia. We present a 49-year-old woman with postradiotherapy laryngeal fixation and transglottic stenosis for dilation of a pharyngeal stricture who refused elective tracheostomy. A 2-stage technique was used, which involved an awake fiberoptic intubation, followed by the transtracheal insertion of a Cricath needle and ventilation using an ejector-based Ventrain device. We discuss management aspects of this clinical scenario and the principles by which the Ventrain works.

[A web-based integrated clinical database for laryngeal cancer].

PubMed

E, Qimin; Liu, Jialin; Li, Yong; Liang, Chuanyu

2014-08-01

To establish an integrated database for laryngeal cancer, and to provide an information platform for laryngeal cancer in clinical and fundamental researches. This database also meet the needs of clinical and scientific use. Under the guidance of clinical expert, we have constructed a web-based integrated clinical database for laryngeal carcinoma on the basis of clinical data standards, Apache+PHP+MySQL technology, laryngeal cancer specialist characteristics and tumor genetic information. A Web-based integrated clinical database for laryngeal carcinoma had been developed. This database had a user-friendly interface and the data could be entered and queried conveniently. In addition, this system utilized the clinical data standards and exchanged information with existing electronic medical records system to avoid the Information Silo. Furthermore, the forms of database was integrated with laryngeal cancer specialist characteristics and tumor genetic information. The Web-based integrated clinical database for laryngeal carcinoma has comprehensive specialist information, strong expandability, high feasibility of technique and conforms to the clinical characteristics of laryngeal cancer specialties. Using the clinical data standards and structured handling clinical data, the database can be able to meet the needs of scientific research better and facilitate information exchange, and the information collected and input about the tumor sufferers are very informative. In addition, the user can utilize the Internet to realize the convenient, swift visit and manipulation on the database.

Evaluation of chest compression effect on airway management with air-Q, aura-i, i-gel, and Fastrack intubating supraglottic devices by novice physicians: a randomized crossover simulation study.

PubMed

Komasawa, Nobuyasu; Ueki, Ryusuke; Kaminoh, Yoshiroh; Nishi, Shin-Ichi

2014-10-01

In the 2010 American Heart Association guidelines, supraglottic devices (SGDs) such as the laryngeal mask are proposed as alternatives to tracheal intubation for cardiopulmonary resuscitation. Some SGDs can also serve as a means for tracheal intubation after successful ventilation. The purpose of this study was to evaluate the effect of chest compression on airway management with four intubating SGDs, aura-i (aura-i), air-Q (air-Q), i-gel (i-gel), and Fastrack (Fastrack), during cardiopulmonary resuscitation using a manikin. Twenty novice physicians inserted the four intubating SGDs into a manikin with or without chest compression. Insertion time and successful ventilation rate were measured. For cases of successful ventilation, blind tracheal intubation via the intubating SGD was performed with chest compression and success or failure within 30 s was recorded. Chest compression did not decrease the ventilation success rate of the four intubating SGDs (without chest compression (success/total): air-Q, 19/20; aura-i, 19/20; i-gel, 18/20; Fastrack, 19/20; with chest compression: air-Q, 19/20; aura-i, 19/20; i-gel, 16/20; Fastrack, 18/20). Insertion time was significantly lengthened by chest compression in the i-gel trial (P < 0.05), but not with the other three devices. The blind intubation success rate with chest compression was the highest in the air-Q trial (air-Q, 15/19; aura-i, 14/19; i-gel, 12/16; Fastrack, 10/18). This simulation study revealed the utility of intubating SGDs for airway management during chest compression.

Repeated General Anesthesia in a Patient With Noonan Syndrome.

PubMed

Asahi, Yoshinao; Fujii, Ryosuke; Usui, Naoko; Kagamiuchi, Hajime; Omichi, Shiro; Kotani, Junichiro

2015-01-01

Noonan syndrome (NS) is an autosomal dominant disorder characterized by facial anomalies, short stature, chest deformity, congenital heart diseases, and other comorbidities. The challenges faced during anesthetic management of patients with NS could be due to congenital heart diseases, hemostatic disorders, and airway anomalies. Here we describe dental treatment under general anesthesia performed for a 28-year-old man with NS. He had characteristic features of NS along with mild pulmonary valve stenosis. Dental treatment under general anesthesia was performed successfully on 13 occasions with nasotracheal intubation under curve-tipped suction catheter guidance or insertion of a reinforced laryngeal mask airway. This case suggests that for patients with NS, who might present several challenges, dental anesthesiologists should consider the extent of the patient's disorders to enable them to perform dental treatment safely under general anesthesia.

Supplemental Carbon Dioxide Stabilizes the Upper Airway in Volunteers Anesthetized with Propofol.

PubMed

Ruscic, Katarina Jennifer; Bøgh Stokholm, Janne; Patlak, Johann; Deng, Hao; Simons, Jeroen Cedric Peter; Houle, Timothy; Peters, Jürgen; Eikermann, Matthias

2018-05-10

Propofol impairs upper airway dilator muscle tone and increases upper airway collapsibility. Preclinical studies show that carbon dioxide decreases propofol-mediated respiratory depression. We studied whether elevation of end-tidal carbon dioxide (PETCO2) via carbon dioxide insufflation reverses the airway collapsibility (primary hypothesis) and impaired genioglossus muscle electromyogram that accompany propofol anesthesia. We present a prespecified, secondary analysis of previously published experiments in 12 volunteers breathing via a high-flow respiratory circuit used to control upper airway pressure under propofol anesthesia at two levels, with the deep level titrated to suppression of motor response. Ventilation, mask pressure, negative pharyngeal pressure, upper airway closing pressure, genioglossus electromyogram, bispectral index, and change in end-expiratory lung volume were measured as a function of elevation of PETCO2 above baseline and depth of propofol anesthesia. PETCO2 augmentation dose-dependently lowered upper airway closing pressure with a decrease of 3.1 cm H2O (95% CI, 2.2 to 3.9; P < 0.001) under deep anesthesia, indicating improved upper airway stability. In parallel, the phasic genioglossus electromyogram increased by 28% (23 to 34; P < 0.001). We found that genioglossus electromyogram activity was a significant modifier of the effect of PETCO2 elevation on closing pressure (P = 0.005 for interaction term). Upper airway collapsibility induced by propofol anesthesia can be reversed in a dose-dependent manner by insufflation of supplemental carbon dioxide. This effect is at least partly mediated by increased genioglossus muscle activity.

Retention of pediatric bag-mask ventilation efficacy skill by inexperienced medical student resuscitators using standard bag-mask ventilation masks, pocket masks, and blob masks.

PubMed

Kitagawa, Kory H; Nakamura, Nina M; Yamamoto, Loren

2006-03-01

To measure the ventilation efficacy with three single-sized mask types on infant and child manikin models. Medical students were recruited as study subjects inasmuch as they are inexperienced resuscitators. They were taught proper bag-mask ventilation (BMV) according to the American Heart Association guidelines on an infant and a child manikin. Subjects completed a BMV attempt successfully using the adult standard mask (to simulate the uncertainty of mask selection), pocket mask, and blob mask. Each attempt consisted of 5 ventilations assessed by chest rise of the manikin. Study subjects were asked which mask was easiest to use. Four to six weeks later, subjects repeated the procedure with no instructions (to simulate an emergency BMV encounter without immediate pre-encounter teaching). Forty-six volunteer subjects were studied. During the first attempt, subjects preferred the standard and blob masks over the pocket mask. For the second attempt, the blob mask was preferred over the standard mask, and few liked the pocket mask. Using the standard, blob, and pocket masks on the child manikin, 39, 42, and 20 subjects, respectively, were able to achieve adequate ventilation. Using the standard, blob, and pocket masks on the infant manikin, 45, 45, and 11 subjects, respectively, were able to achieve adequate ventilation. Both the standard and blob masks are more effective than the pocket mask at achieving adequate ventilation on infant and child manikins in this group of inexperienced medical student resuscitators, who most often preferred the blob mask.

Laryngeal Cysts in Adults: Simplifying Classification and Management.

PubMed

Heyes, Richard; Lott, David G

2017-12-01

Objective Laryngeal cysts may occur at any mucosa-lined location within the larynx and account for 5% to 10% of nonmalignant laryngeal lesions. A number of proposed classifications for laryngeal cysts exist; however, no previously published classification aims to guide management. This review analyzes contemporary laryngeal cyst management and proposes a framework for the terminology and management of cystic lesions in the larynx. Data Sources PubMed/Medline. Review Methods A primary literature search of the entire Medline database was performed for all titles of publications pertaining to laryngeal cysts and reviewed for relevance. Full manuscripts were reviewed per the relevance of their titles and abstracts, and selection into this review was according to their clinical and scientific relevance. Conclusion Laryngeal cysts have been associated with rapid-onset epiglottitis, dyspnea, stridor, and death; therefore, they should not be considered of little significance. Symptoms are varied and nonspecific. Laryngoscopy is the primary initial diagnostic tool. Cross-sectional imaging may be required, and future use of endolaryngeal ultrasound and optical coherence tomography may revolutionize practice. Where possible, cysts should be completely excised, and there is growing evidence that a transoral approach is superior to transcervical excision for nearly all cysts. Histology provides definitive diagnosis, and oncocytic cysts require close follow-up. Implications for Practice A new classification system is proposed that increases clarity in terminology, with the aim of better preparing surgeons and authors for future advances in the understanding and management of laryngeal cysts.

Correlation between laryngeal sensitivity and penetration/aspiration after stroke.

PubMed

Onofri, Suely Mayumi Motonaga; Cola, Paula Cristina; Berti, Larissa Cristina; da Silva, Roberta Gonçalves; Dantas, Roberto Oliveira

2014-04-01

Stroke is the most common neurological disease in adults that is associated with deglutition disorders. The presence of laryngeal sensitivity is very important in developing safe swallowing without risk of pulmonary complications. The aim of this study was to correlate laryngeal sensitivity with laryngeal penetration and tracheal aspiration after swallows of three food consistencies (puree, thickened liquid, and liquid) in poststroke individuals in the late phase. A cross-sectional clinical study was performed with 91 post-ischemic stroke individuals, with oropharyngeal dysphagia, who were in rehabilitation center treatment from 2009 to 2011. They had a mean age of 68.1 years and average time since injury was 22.6 months; 39 had injury to the right hemisphere and 52 had injury to the left hemisphere. All underwent fiberoptic endoscopic evaluation of swallowing and evaluation of laryngeal sensitivity by touching the tip of the endoscope to the arytenoids and aryepiglottic folds. The linear correlation coefficient of Spearman was applied to evaluate the correlation between laryngeal penetration and tracheal aspiration and the presence/absence of laryngeal sensitivity. There was a negative correlation between the observation of penetration and tracheal aspiration and laryngeal sensitivity, with all bolus consistencies (p < 0.001 for aspiration and p ≤ 0.01 for penetration). The absence of laryngeal sensitivity determines the more frequent findings of penetration and tracheal aspiration. This sensory stimulus in the mucosa of the pharynx and larynx is an essential element for safe swallowing and its deficiency associated with altered motor activity can cause laryngeal penetration and aspiration in poststroke individuals regardless of food consistency.

Upper Airway Injury in Dogs Secondary to Trauma: 10 Dogs (2000-2011).

PubMed

Basdani, Eleni; Papazoglou, Lysimachos G; Patsikas, Michail N; Kazakos, Georgios M; Adamama-Moraitou, Katerina K; Tsokataridis, Ioannis

2016-01-01

Ten dogs that presented with trauma-induced upper airway rupture or stenosis were reviewed. Tracheal rupture was seen in seven dogs, tracheal stenosis in one dog, and laryngeal rupture in two dogs. Clinical abnormalities included respiratory distress in five dogs, subcutaneous emphysema in eight, air leakage through the cervical wound in seven, stridor in three dogs, pneumomediastinum in four and pneumothorax in one dog. Reconstruction with simple interrupted sutures was performed in four dogs, tracheal resection and end-to-end anastomosis in five dogs, and one dog was euthanized intraoperatively. Complications were seen in three dogs including aspiration pneumonia in one and vocalization alterations in two dogs.

Efficacy of a new device to optimize positive pressure ventilation via face mask in edentulous patients: a randomized trial.

PubMed

Niño, Maria C; Pauwels, Andres; Raffan, Fernando; Arango, Enrique; Romero, David J; Benitez, Daniel

2017-04-01

Mask ventilation is routinely performed during anesthesia. Under some circumstances, it might be difficult to perform, such as in edentulous patients, due to inadequate mask seal. We developed a new device called NIPARA and studied its use For ventilation optimization in edentulous patients. This randomized controlled trial included edentulous adults who had no other predictors of difficult airway, scheduled to undergo general anesthesia. Patients were assigned either to the NIPARA device group or to the control group (oral airway only). The primary outcomes were peak inspiratory pressure and tidal volume values of the first 14 breaths. The secondary outcome was the incidence of complications. Data from 37 patients were collected during a one-year period (twenty in the NIPARA device group and 17 in the control group). The difference in mean PIP was not statistically significant. The tidal volume was 1.5 times greater in the NIPARA group than in the control group. One patient from the intervention group had minimal oral trauma. In the administration of face mask ventilation, NIPARA is an effective device that significantly improves the tidal volume administered in edentulous patients.

Ultrasonic scissors-assisted 'open-book' thyroidectomy in massive goiter compressing airway and causing unilateral vocal cord paralysis.

PubMed

M, Irfan; Yaroko, Ali Ango; S M, Najeb; Periasamy, Centilnathan

2013-04-01

A massive goiter may constrict the trachea resulting in shortness of breath. Recurrent laryngeal nerve compression may cause vocal cord paralysis. We highlight a case of a 62- year-old female with a 30 year history of an anterior neck swelling gradually increasing in size. She presented with acute symptoms of upper airway obstruction and voice changes. Emergency thyroidectomy was performed by dividing the middle part of the gland using ultrasonic scissors. The recovery was uneventful and the patient regained normal vocal cord function post operatively.

Complications following recurrent laryngeal nerve lymph node dissection in oesophageal cancer surgery.

PubMed

Taniyama, Yusuke; Miyata, Go; Kamei, Takashi; Nakano, Toru; Abe, Shigeo; Katsura, Kazunori; Sakurai, Tadashi; Teshima, Jin; Hikage, Makoto; Ohuchi, Norikaki

2015-01-01

The recurrent laryngeal nerve lymph node is one of the most common metastatic sites in oesophageal cancer, and dissection of this lymph node is considered beneficial. Although the risk of complications from this procedure, such as recurrent laryngeal nerve palsy, is well known, few reports have detailed those risks in a large number of cases. Our study examined the risks of recurrent laryngeal nerve lymph node dissection, with a special focus on recurrent laryngeal nerve palsy. Retrospectively collected data from 661 patients, who underwent transthoracic oesophagectomy for oesophageal cancer, were analysed. Recurrent laryngeal nerve palsy occurred in 36% of the patients. Among these patients, except those in whom recurrent laryngeal nerve was intentionally excised due to metastatic lymph node, permanent palsy was detected in 12%. Bilateral recurrent laryngeal nerve lymph node dissection, cervical anastomosis and upper oesophageal cancer were independent risk factors for recurrent laryngeal nerve palsy. Although recurrent laryngeal nerve palsy was a risk factor for aspiration, tracheostomy and postoperative pneumonia, it did not directly correlate with death caused by pneumonia. Among postoperative complications, only recurrent laryngeal nerve palsy correlated with bilateral recurrent laryngeal nerve lymph node dissection. Recurrent laryngeal nerve palsy is a complication that should be avoided but does not seem to be severe enough to affect patient survival after surgery. Although bilateral recurrent laryngeal nerve lymph node dissection can induce recurrent laryngeal nerve palsy in patients who undergo transthoracic oesophagectomy, this procedure did not correlate with aspiration and pneumonia. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Non-recurrent inferior laryngeal nerve identification during robotic thyroidectomy.

PubMed

Wang, C-C; Wu, C-H

2014-02-01

A non-recurrent inferior laryngeal nerve is a rare anomaly in which the nerve enters the larynx directly off the cervical vagus nerve, without descending to the thoracic level. It is very susceptible to damage during surgery. This report describes the important pre-operative radiological evaluations and surgical landmarks in a case of a non-recurrent inferior laryngeal nerve, identified during the recently developed technique of robotic thyroidectomy. A 38-year-old woman presented with suspected papillary microcarcinoma, as indicated by aspiration cytology. Pre-operative computed tomography showed a right aberrant subclavian artery that indicated a possible right non-recurrent inferior laryngeal nerve. Using robotic thyroidectomy methods, it was possible to carefully dissect along the thyroid capsule. The laryngeal entrance point of the right non-recurrent inferior laryngeal nerve (a constant anatomical landmark) was successfully identified via the three-dimensional, high-magnification views provided by the robotic endoscope. With proper knowledge of radiological and surgical anatomy, and the benefits of high-magnification endoscopic views, a non-recurrent inferior laryngeal nerve can be safely preserved during robotic surgery.

Difficulty in tracheal extubation followed by tracheal collapse after balloon dilatation for tracheal stenosis therapy: A case report.

PubMed

Li, Nana; Zhu, Linjia; Sun, Jie; Pan, Yinbing; Gao, Mei

2018-06-01

Tracheobronchomalacia (TBM) refers to the weakening trachea or the trachea loss of structural integrity of airway cartilaginous structures. It causes tracheal stenosis, resulting in significantly high rates of mortality. Bronchoplasty by high-pressure balloon dilation under general anesthesia is a simple but effective and safe method to treat tracheobronchial stenosis. However, recurrent postoperative dyspnea after extubation due to tracheal collapse is still a challenge for anesthetists. A 52-year-old man weighing 72 kg was scheduled for balloon dilatation surgery under general anesthesia because of breathing difficulties caused by tracheal stenosis. His previous medical history included rheumatoid arthritis, obstructive sleep apnea syndrome (OSAS), chronic bronchitis and a history of tracheal intubation. Laryngeal computerized tomography confirmed the stenosis at the level of thyroid gland. The tracheal collapse after balloon dilatation for tracheal stenosis therapy. Postoperatively, the patient presented with more serious and repetitive symptoms of dyspnea after extubation when compared to that before treatment. So, we had to re-insert the laryngeal mask airway (LMA), and exclude some anesthesia-associated factors, such as laryngospasm, bronchospasm and so on. After a series of treatments, we ultimately found the cause in time (the airway collapsed), and succeeded in tracheal extubation after the stent was inserted. The patient recovered well and reported high satisfaction with anesthesia management. In such an emergency even, the anesthesiologist should take valuable treatments to ensure the patient's effective ventilation. If the anesthesia-related factors can be eliminated, tracheomalacia or airway collapse should be considered whenever dyspnea occurs in the patients who unexpectedly fail to be extubated.

Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury.

PubMed

Shen, Chenling; Xiang, Mingliang; Wu, Hao; Ma, Yan; Chen, Li; Cheng, Lan

2013-06-15

To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury.

Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury★

PubMed Central

Shen, Chenling; Xiang, Mingliang; Wu, Hao; Ma, Yan; Chen, Li; Cheng, Lan

2013-01-01

To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury. PMID:25206452

Diesel exhaust, diesel fumes, and laryngeal cancer.

PubMed

Muscat, J E; Wynder, E L

1995-03-01

A hospital-based, case-control study of 235 male patients with laryngeal cancer and 205 male control patients was conducted to determine the effects of exposure to diesel engine exhaust and diesel fumes and the risk of laryngeal cancer. All patients were interviewed directly in the hospital with a standardized questionnaire that gathered information on smoking habits, alcohol consumption, employment history, and occupational exposures. Occupations that involve substantial exposure to diesel engine exhaust include mainly truck drivers, as well as mine workers, firefighters, and railroad workers. The odds ratio for laryngeal cancer associated with these occupations was 0.96 (95% confidence interval, 0.5 to 1.8). The odds ratio for self-reported exposure to diesel exhaust was 1.47 (95% confidence interval, 0.5 to 4.1). An elevated risk was found for self-reported exposure to diesel fumes (odds ratio, 6.4; 95% confidence interval, 1.8 to 22.6). No association was observed between jobs that entail exposure to diesel fumes, such as automobile mechanics, and the risk of laryngeal cancer. These results show that diesel engine exhaust is unrelated to laryngeal cancer risk. The different findings for self-reported diesel fumes and occupations that involve exposure to diesel fumes could reflect a recall bias.

The groningen laryngomalacia classification system--based on systematic review and dynamic airway changes.

PubMed

van der Heijden, Martijn; Dikkers, Frederik G; Halmos, Gyorgy B

2015-12-01

Laryngomalacia is the most common cause of dyspnea and stridor in newborn infants. Laryngomalacia is a dynamic change of the upper airway based on abnormally pliable supraglottic structures, which causes upper airway obstruction. In the past, different classification systems have been introduced. Until now no classification system is widely accepted and applied. Our goal is to provide a simple and complete classification system based on systematic literature search and our experiences. Retrospective cohort study with literature review. All patients with laryngomalacia under the age of 5 at time of diagnosis were included. Photo and video documentation was used to confirm diagnosis and characteristics of dynamic airway change. Outcome was compared with available classification systems in literature. Eighty-five patients were included. In contrast to other classification systems, only three typical different dynamic changes have been identified in our series. Two existing classification systems covered 100% of our findings, but there was an unnecessary overlap between different types in most of the systems. Based on our finding, we propose a new a classification system for laryngomalacia, which is purely based on dynamic airway changes. The groningen laryngomalacia classification is a new, simplified classification system with three types, based on purely dynamic laryngeal changes, tested in a tertiary referral center: Type 1: inward collapse of arytenoids cartilages, Type 2: medial displacement of aryepiglottic folds, and Type 3: posterocaudal displacement of epiglottis against the posterior pharyngeal wall. © 2015 Wiley Periodicals, Inc.

Evidence and evidence gaps of laryngeal cancer surgery

PubMed Central

Wiegand, Susanne

2016-01-01

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal. PMID:28025603

An iterative method for airway segmentation using multiscale leakage detection

NASA Astrophysics Data System (ADS)

Nadeem, Syed Ahmed; Jin, Dakai; Hoffman, Eric A.; Saha, Punam K.

2017-02-01

There are growing applications of quantitative computed tomography for assessment of pulmonary diseases by characterizing lung parenchyma as well as the bronchial tree. Many large multi-center studies incorporating lung imaging as a study component are interested in phenotypes relating airway branching patterns, wall-thickness, and other morphological measures. To our knowledge, there are no fully automated airway tree segmentation methods, free of the need for user review. Even when there are failures in a small fraction of segmentation results, the airway tree masks must be manually reviewed for all results which is laborious considering that several thousands of image data sets are evaluated in large studies. In this paper, we present a CT-based novel airway tree segmentation algorithm using iterative multi-scale leakage detection, freezing, and active seed detection. The method is fully automated requiring no manual inputs or post-segmentation editing. It uses simple intensity based connectivity and a new leakage detection algorithm to iteratively grow an airway tree starting from an initial seed inside the trachea. It begins with a conservative threshold and then, iteratively shifts toward generous values. The method was applied on chest CT scans of ten non-smoking subjects at total lung capacity and ten at functional residual capacity. Airway segmentation results were compared to an expert's manually edited segmentations. Branch level accuracy of the new segmentation method was examined along five standardized segmental airway paths (RB1, RB4, RB10, LB1, LB10) and two generations beyond these branches. The method successfully detected all branches up to two generations beyond these segmental bronchi with no visual leakages.

Preoperative airway assessment - experience gained from a multicentre cluster randomised trial and the Danish Anaesthesia Database.

PubMed

Nørskov, Anders Kehlet

2016-05-01

Difficulties with airway management in relation to general anaesthesia have been a challenge for the anaesthesiologist since the birth of anaesthesia. Massive landmark improvements have been made and general anaesthesia is now regarded as a safe procedure. However, rare, difficult airway management still occurs and it prompts increased risk of morbidity and mortality - especially when not anticipated. Several preoperative risk factors for airway difficulties have been identified, yet none have convincing diagnostic accuracy as stand alone tests. Combining several risk factors increase the predictive value of the test and multivariable risk models have been developed. The Simplified Airway Risk Index (SARI) is a predictive model developed for anticipation of a difficult direct laryngoscopy. However, neither the diagnostic accuracy of the SARI nor of any other model has been tested prospectively and compared with existing practice for airway assessment in a randomised trial setting. The first objective of this thesis was to quantify the proportion of unanticipated difficult intubation and difficult mask ventilation in Denmark. The second objective was to design a cluster randomised trial, using state of the art methodology, in order to test the clinical impact of using the SARI for preoperative airway assessment compared with a clinical judgement based on usual practice for airway assessment. Finally, to test if implementation of the SARI would reduce the proportion of unanticipated difficult intubation compared with usual care for airway assessment. This thesis is based on data from the Danish Anaesthesia Database (DAD). Paper 1 presents an observational cohort study on 188,064 patients who underwent tracheal intubation from 2008 to 2011. Data on the anaesthesiologists' preoperative anticipations of airway difficulties was compared with actual airway management conditions, thus enabling an estimation of the proportion of unanticipated difficulties with intubation

The human laryngeal microbiome: effects of cigarette smoke and reflux.

PubMed

Jetté, Marie E; Dill-McFarland, Kimberly A; Hanshew, Alissa S; Suen, Garret; Thibeault, Susan L

2016-10-24

Prolonged diffuse laryngeal inflammation from smoking and/or reflux is commonly diagnosed as chronic laryngitis and treated empirically with expensive drugs that have not proven effective. Shifts in microbiota have been associated with many inflammatory diseases, though little is known about how resident microbes may contribute to chronic laryngitis. We sought to characterize the core microbiota of disease-free human laryngeal tissue and to investigate shifts in microbial community membership associated with exposure to cigarette smoke and reflux. Using 454 pyrosequencing of the 16S rRNA gene, we compared bacterial communities of laryngeal tissue biopsies collected from 97 non-treatment-seeking volunteers based on reflux and smoking status. The core community was characterized by a highly abundant OTU within the family Comamonadaceae found in all laryngeal tissues. Smokers demonstrated less microbial diversity than nonsmokers, with differences in relative abundances of OTUs classified as Streptococcus, unclassified Comamonadaceae, Cloacibacterium, and Helicobacter. Reflux status did not affect microbial diversity nor community structure nor composition. Comparison of healthy laryngeal microbial communities to benign vocal fold disease samples revealed greater abundance of Streptococcus in benign vocal fold disease suggesting that mucosal dominance by Streptococcus may be a factor in disease etiology.

Botulinum toxin injection in laryngeal dyspnea.

PubMed

Woisard, Virginie; Liu, Xuelai; Bes, Marie Christine Arné; Simonetta-Moreau, Marion

2017-02-01

Data, regarding the use of botulinum toxin (BT-A) in laryngeal dyspnea, are scarce, coming from some cases reports in the literature, including Vocal fold paralysis, laryngeal dystonia, vocal cord dysfunction also called paradoxical motion of the vocal fold (PMVF), and post-neuroleptic laryngeal dyskinesia. There is no consensus regarding the muscles and the doses to inject. The aim of this study is to present a retrospective review of patients treated in our ENT Department by BT-A injection in this indication. This study is a retrospective study describing patients who underwent an injection of botulinum toxin for laryngeal dyspnea in the ENT Department from 2005 to 2015 years. The inclusion criteria were a dyspnea associated with a laryngeal dysfunction, confirmed by flexible fiberoptic nasopharyngolaryngoscopy. Information concerning the causes of the dyspnea, the botulinum toxin BT-A injections procedure, post-injection follow-up, and respiratory outcome were collected for all patients included. In the group of 13 patients included, the main cause identified as principal factor linked with the short breath was: a bilateral VF paralysis (Patel et al., Otolaryngol Head Neck Surg 130:686-689, 7), laryngeal dystonia (Balkissoon and Kenn, Semin Respir Crit Care Med 33:595-605, 2), Anxiety syndrome associated with unilateral vocal fold paralysis or asthma (Marcinow et al., Laryngoscope 124:1425-1430, 3), and an isolated asthma (Zwirner et al., Eur Arch Otorhinolaryngol 254:242-245, 1). Nine out of the thirteen patients were improved by the injections. A BT-A-induced stable benefit for four patients led them to stop the injections in the follow-up. Good outcome was observed in five other patients (main cause: bilateral VP paralysis), allowing a progressive lengthening of the delay between BT-A injections. Four patients did not report a positive risk/benefit ratio after BT-A injections; two of them (with bilateral VF paralysis), because of respiratory side effects and

[Current status and prospect of photodynamic therapy in laryngeal diseases].

PubMed

Zhang, C; Jiang, J Q

2018-04-07

Laryngeal diseases are closely related to the swallowing and speech function of the patients.Protecting and restoring laryngeal function, while curing lesions, is vital to patients' quality of life.Photodynamic therapy (PDT) is a minimally invasive method which is widely used in the treatment of tumor, precancerous lesions, and inflammatory diseases.In recent years, it has been shown to have a protective effect on normal structures. This article reviews the clinical outcomes of laryngeal diseases treated with PDT since 1990 in order to evaluate its efficacy and significance. The complete remission rate of early-stage laryngeal tumors and precancerous lesions after PDT is 77.6%(249/321), and a promising effect on recurrent laryngeal papillomatosis has been observed thus far. The prolonged adverse effects of the first-generation photosensitizers have limited the application of PDT. With the improvement of photosensitizers and treatment strategies, PDT promises to be a safe, effective, and minimally invasive treatment method for laryngeal diseases.

Factors Associated With Infectious Laryngitis: A Retrospective Review of 15 Cases.

PubMed

Thomas, Carissa M; Jetté, Marie E; Clary, Matthew S

2017-05-01

To identify the culturable microbes associated with infectious laryngitis and outline effective treatment strategies. This is a retrospective chart review of adult patients with persistent dysphonia plus evidence of laryngeal inflammation who underwent biopsy for culture at a tertiary care medical center. Demographic factors, symptoms as reported on validated patient assessment tools, past medical history, social history, culture results, and treatment duration and response were reviewed. Fifteen patients with infectious laryngitis were included in this study. Culture results demonstrated Methicillin-sensitive Staphylococcus aureus (MSSA), Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Serratia marcescens, and "normal respiratory flora." In most patients, multiple courses of prolonged antibiotics were needed to treat MSSA or MRSA. Infections associated with other microbes resolved with a single course of antibiotics. In this population, infectious laryngitis is defined as colonization with bacteria not found in the previously characterized laryngeal microbiome of benign vocal fold lesions. In suspected cases of infectious laryngitis, culture is recommended, by biopsy if needed. For MSSA- and MRSA-associated laryngitis, an extended course of antibiotics may be necessary for symptom improvement and resolution of laryngeal inflammation. However, the optimal treatment regimen has yet to be defined and will require larger, prospective studies.

Effects of Asymmetric Superior Laryngeal Nerve Stimulation on Glottic Posture, Acoustics, Vibration

PubMed Central

Chhetri, Dinesh K.; Neubauer, Juergen; Bergeron, Jennifer L.; Sofer, Elazar; Peng, Kevin A.; Jamal, Nausheen

2013-01-01

Objectives Evaluate the effects of asymmetric superior laryngeal nerve stimulation on the vibratory phase, laryngeal posture, and acoustics. Study Design Basic science study using an in vivo canine model. Methods The superior laryngeal nerves were symmetrically and asymmetrically stimulated over eight activation levels to mimic laryngeal asymmetries representing various levels of superior laryngeal nerve paresis and paralysis conditions. Glottal posture change, vocal fold speed, and vibration of these 64 distinct laryngeal activation conditions were evaluated by high speed video and concurrent acoustic and aerodynamic recordings. Assessments were made at phonation onset. Results Vibratory phase was symmetric in all symmetric activation conditions but consistent phase asymmetry towards the vocal fold with higher superior laryngeal nerve activation was observed. Superior laryngeal nerve paresis and paralysis conditions had reduced vocal fold strain and fundamental frequency. Superior laryngeal nerve activation increased vocal fold closure speed, but this effect was more pronounced for the ipsilateral vocal fold. Increasing asymmetry led to aperiodic and chaotic vibration. Conclusions This study directly links vocal fold tension asymmetry with vibratory phase asymmetry; in particular the side with greater tension leads in the opening phase. The clinical observations of vocal fold lag, reduced vocal range, and aperiodic voice in superior laryngeal paresis and paralysis is also supported. PMID:23712542

Effect of Very-High-Flow Nasal Therapy on Airway Pressure and End-Expiratory Lung Impedance in Healthy Volunteers.

PubMed

Parke, Rachael L; Bloch, Andreas; McGuinness, Shay P

2015-10-01

Previous research has demonstrated a positive linear correlation between flow delivered and airway pressure generated by high-flow nasal therapy. Current practice is to use flows over a range of 30-60 L/min; however, it is technically possible to apply higher flows. In this study, airway pressure measurements and electrical impedance tomography were used to assess the relationship between flows of up to 100 L/min and changes in lung physiology. Fifteen healthy volunteers were enrolled into this study. A high-flow nasal system capable of delivering a flow of 100 L/min was purpose-built using 2 Optiflow systems. Airway pressure was measured via the nasopharynx, and cumulative changes in end-expiratory lung impedance were recorded using the PulmoVista 500 system at gas flows of 30-100 L/min in increments of 10 L/min. The mean age of study participants was 31 (range 22-44) y, the mean ± SD height was 171.8 ± 7.5 cm, the mean ± SD weight was 69.7 ± 10 kg, and 47% were males. Flows ranged from 30 to 100 L/min with resulting mean ± SD airway pressures of 2.7 ± 0.7 to 11.9 ± 2.7 cm H2O. A cumulative and linear increase in end-expiratory lung impedance was observed with increasing flows, as well as a decrease in breathing frequency. Measured airway pressure and lung impedance increased linearly with increased gas flow. Observed airway pressures were in the range used clinically with face-mask noninvasive ventilation. Developments in delivery systems may result in this therapy being an acceptable alternative to face-mask noninvasive ventilation. Copyright © 2015 by Daedalus Enterprises.

Non-chemosensitive parafacial neurons simultaneously regulate active expiration and airway patency under hypercapnia in rats.

PubMed

de Britto, Alan A; Moraes, Davi J A

2017-03-15

Hypercapnia or parafacial respiratory group (pFRG) disinhibition at normocapnia evokes active expiration in rats by recruitment of pFRG late-expiratory (late-E) neurons. We show that hypercapnia simultaneously evoked active expiration and exaggerated glottal dilatation by late-E synaptic excitation of abdominal, hypoglossal and laryngeal motoneurons. Simultaneous rhythmic expiratory activity in previously silent pFRG late-E neurons, which did not express the marker of ventral medullary CO 2 -sensitive neurons (transcription factor Phox2b), was also evoked by hypercapnia. Hypercapnia-evoked active expiration, neural and neuronal late-E activities were eliminated by pFRG inhibition, but not after blockade of synaptic excitation. Hypercapnia produces disinhibition of non-chemosensitive pFRG late-E neurons to evoke active expiration and concomitant cranial motor respiratory responses controlling the oropharyngeal and upper airway patency. Hypercapnia produces active expiration in rats and the recruitment of late-expiratory (late-E) neurons located in the parafacial respiratory group (pFRG) of the ventral medullary brainstem. We tested the hypothesis that hypercapnia produces active expiration and concomitant cranial respiratory motor responses controlling the oropharyngeal and upper airway patency by disinhibition of pFRG late-E neurons, but not via synaptic excitation. Phrenic nerve, abdominal nerve (AbN), cranial respiratory motor nerves, subglottal pressure, and medullary and spinal neurons/motoneurons were recorded in in situ preparations of juvenile rats. Hypercapnia evoked AbN active expiration, exaggerated late-E discharges in cranial respiratory motor outflows, and glottal dilatation via late-E synaptic excitation of abdominal, hypoglossal and laryngeal motoneurons. Simultaneous rhythmic late-E activity in previously silent pFRG neurons, which did not express the marker of ventral medullary CO 2 -sensitive neurons (transcription factor Phox2b), was also evoked

Graded activation of the intrinsic laryngeal muscles for vocal fold posturing

PubMed Central

Chhetri, Dinesh K.; Neubauer, Juergen; Berry, David A.

2010-01-01

Previous investigations using in vivo models to study the role of intrinsic laryngeal muscles in phonation have used neuromuscular stimulation to study voice parameters. However, these studies used coarse stimulation techniques using limited levels of neuromuscular stimulation. In the current investigation, a technique for fine control of laryngeal posturing was developed using graded stimulation of the laryngeal nerves. Vocal fold strain history to graded stimulation and a methodology for establishing symmetric laryngeal activation is presented. This methodology has immediate applications for the study of laryngeal paralysis and paresis, as well as general questions of neuromuscular control of the larynx. PMID:20369979

Childhood Laryngeal Tumors Treatment (PDQ®)—Patient Version

Cancer.gov

Childhood laryngeal (throat) tumor treatment options include laser surgery, radiation therapy, chemotherapy, immunotherapy, and targeted therapy. Learn more about the symptoms, prognosis, and treatment of newly diagnosed and recurrent childhood laryngeal tumors in this expert-reviewed summary.

Repeated General Anesthesia in a Patient With Noonan Syndrome

PubMed Central

Asahi, Yoshinao; Fujii, Ryosuke; Usui, Naoko; Kagamiuchi, Hajime; Omichi, Shiro; Kotani, Junichiro

2015-01-01

Noonan syndrome (NS) is an autosomal dominant disorder characterized by facial anomalies, short stature, chest deformity, congenital heart diseases, and other comorbidities. The challenges faced during anesthetic management of patients with NS could be due to congenital heart diseases, hemostatic disorders, and airway anomalies. Here we describe dental treatment under general anesthesia performed for a 28-year-old man with NS. He had characteristic features of NS along with mild pulmonary valve stenosis. Dental treatment under general anesthesia was performed successfully on 13 occasions with nasotracheal intubation under curve-tipped suction catheter guidance or insertion of a reinforced laryngeal mask airway. This case suggests that for patients with NS, who might present several challenges, dental anesthesiologists should consider the extent of the patient's disorders to enable them to perform dental treatment safely under general anesthesia. PMID:26061577

[Hypothyroidism incidence after multimodal treatment for laryngeal cancer].

PubMed

Ortega-Gutiérrez, César; Luna-Ortiz, Kuauhyama; Villavicencio-Valencia, Verónica; Herrera Gómez, Angel; Téllez-Palacios, Daniela; Contreras-Buendía, Marlen

2012-01-01

Hypothyroidism following total laryngectomy or radiotherapy treatment for laryngeal cancer is not a rare event, especially in advanced stages. There are no reports on the incidence of hypothyroidism in patients who received chemotherapy and radiotherapy. The objective of this study is to determine the incidence of thyroid dysfunction in a group of patients with laryngeal cancer who underwent surgery as sole treatment, total laryngectomy or radiotherapy alone, and patients with combined treatment: surgery plus radiotherapy, concomitant chemoradiation therapy and chemoradiation therapy plus salvage surgery. A prospective study of patients diagnosed with laryngeal cancer whose serum TSH and T4 levels were evaluated in a serial fashion. 70 patients with laryngeal cancer were studied; the average age at diagnosis was 70.2 years. Male patients were more affected, with a men-women ratio of 3.6:1. Glottic localization was the most frequent (44%). 64% of tumors were locally advanced carcinomas and 51% received multimodal treatment. 45 patients (63%) were diagnosed with hypothyroidism; 49% of the patients with subclinical hypothyroidism, and 51% with clinical hypothyroidism. Hypothyroidism is a complication following treatment for laryngeal cancer. It is recommended to evaluate the thyroid function periodically for timely detection.

Safety and Efficacy of a Fully Covered Self-Expandable Metallic Stent in Benign Airway Stenosis.

PubMed

Fortin, Marc; Lacasse, Yves; Elharrar, Xavier; Tazi-Mezalek, Rachid; Laroumagne, Sophie; Guinde, Julien; Astoul, Philippe; Dutau, Hervé

2017-01-01

The use of self-expandable metallic stents (SEMS) in benign airway disease was the object of a boxed warning from the United States Food and Drug Administration in 2005 due to the risk of stent-related complications and difficulties associated with their removal. Third-generation fully covered SEMS have been commercialized since this warning and theoretically should not present the same difficulties associated with removal as they cannot become embedded in the airway mucosa. We aimed to examine the safety and efficacy of a specific third-generation SEMS, the Silmet stent. We reviewed the records of all patients treated for benign airway stenosis with third-generation Silmet SEMS from January 2011 to December 2015 at the North Hospital of Marseilles, France. Forty SEMS were inserted in 30 patients over this period. Twenty (50.0%) stents were removed because of stent-related complications after a median of 77.0 ± 96.6 days (migration 32.5%, granulation tissue formation 7.5%, subjective intolerance 5.0%, mucus plugging 2.5%, laryngeal edema 2.5%). There were no cases of stent-related mortality. All complications were managed successfully endoscopically. Thirty-six stents (90.0%) were removed successfully after a median of 122.0 ± 113.2 days without any complications. The clinical success rate of stent treatment was 40.7%. Third-generation SEMS are a safe treatment option for complex benign airway stenosis, but complications requiring stent removal are frequent. Further studies are needed to compare the performance of third-generation SEMS and silicone stents in benign airway stenosis. © 2017 S. Karger AG, Basel.

Topological leakage detection and freeze-and-grow propagation for improved CT-based airway segmentation

NASA Astrophysics Data System (ADS)

Nadeem, Syed Ahmed; Hoffman, Eric A.; Sieren, Jered P.; Saha, Punam K.

2018-03-01

Numerous large multi-center studies are incorporating the use of computed tomography (CT)-based characterization of the lung parenchyma and bronchial tree to understand chronic obstructive pulmonary disease status and progression. To the best of our knowledge, there are no fully automated airway tree segmentation methods, free of the need for user review. A failure in even a fraction of segmentation results necessitates manual revision of all segmentation masks which is laborious considering the thousands of image data sets evaluated in large studies. In this paper, we present a novel CT-based airway tree segmentation algorithm using topological leakage detection and freeze-and-grow propagation. The method is fully automated requiring no manual inputs or post-segmentation editing. It uses simple intensity-based connectivity and a freeze-and-grow propagation algorithm to iteratively grow the airway tree starting from an initial seed inside the trachea. It begins with a conservative parameter and then, gradually shifts toward more generous parameter values. The method was applied on chest CT scans of fifteen subjects at total lung capacity. Airway segmentation results were qualitatively assessed and performed comparably to established airway segmentation method with no major visual leakages.

Use of Lasers in Laryngeal Surgery

PubMed Central

Yan, Yan; Olszewski, Aleksandra E.; Hoffman, Matthew R.; Zhuang, Peiyun; Ford, Charles N.; Dailey, Seth H.; Jiang, Jack J.

2012-01-01

Lasers are a relatively recent addition to laryngeal surgery. Since their invention, laser use and applications have expanded rapidly. In this paper, we discuss the benefits and disadvantages of lasers for different procedures, as well as ways to overcome commonly faced clinical problems. The use of lasers in surgery has offered a time- and cost-efficient alternative to cold surgical techniques, and has been employed in the treatment of numerous laryngeal pathologies, including stenoses, recurrent respiratory papillomatosis, leukoplakia, nodules, malignant laryngeal disease, and polypoid degeneration (Reinke’s edema). However, lasers can incur adjacent tissue damage and vocal fold scarring. These problems can be minimized through understanding the mechanisms by which lasers function and correctly manipulating the parameters under a surgeon’s control. By varying fluence, power density, and pulsation, tissue damage can be decreased and lasers can be used with greater confidence. The various types of lasers and their applications to the treatment of specific pathologies are reviewed with the intention of helping surgeons select the best tool for a given procedure. Recent applications of lasers to treat benign laryngeal lesions and severe laryngomalacia demonstrate that additional research must be conducted in order to realize the full potential of this surgical tool. PMID:19487102

[Study on the correlation between EGFR-STAT3 signal pathway and laryngeal papilloma].

PubMed

Wang, Xinhua; Sun, Jingwu

2009-09-01

To explore the relationship between the expression of EGFR and STAT3 in human laryngeal papilloma and its biological behavior. Reverse transcription polymerase chain reaction(RT-PCR), immunohistochemical staining and Western blot were used to evaluate the mRNA and protein expression of EGFR and STAT3 (p-STAT3) in 42 laryngeal papilloma tissues and 15 samples of normal laryngeal tissue, and the relationship between the protein expression of them and clinic pathological parameters was also analyzed. The mRNA expression levels of EGFR and STAT3 in laryngeal papilloma tissue were significantly higher than that in normal laryngeal tissue (P < 0.05, P < 0.01). Protein positive expression of EGFR and p-STAT3 were also detected in a significantly greater proportion of laryngeal papilloma than normal laryngeal tissue by immunohistochemistry and western blot (P < 0.01, P < 0.05). There was relationship between EGFR and p-STAT3 overexpression in laryngeal papilloma (P < 0.05). The expression p-STAT3 was correlated with the recurrence and canceration of laryngeal papilloma (P < 0.05). The EGFR-STAT3 signal transduction pathway may be involved in the pathogenesis of laryngeal papilloma,, and the persistent activation of STAT3 gene plays an important role in the recurrence and canceration of laryngeal papilloma.

Laryngeal dislocation after ventral fusion of the cervical spine

PubMed Central

Krauel, Jenny; Winkler, Dietrich; Münscher, Adrian; Tank, Sascha

2013-01-01

We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery – laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment. PMID:23983289

Laryngeal Cancer Treatment (PDQ®)—Health Professional Version

Cancer.gov

Laryngeal cancer treatment options depend on the location and extent of disease, often includes surgery and/or radiation, and sometimes chemotherapy. Get detailed information about the diagnosis and treatment of newly diagnosed and recurrent laryngeal cancer in this summary for clinicians.

Association Between Laryngeal Cancer and Asbestos Exposure: A Systematic Review.

PubMed

Ferster, Ashley P O'Connell; Schubart, Jane; Kim, Yesul; Goldenberg, David

2017-04-01

It has been debated whether a link exists between laryngeal cancer and asbestos exposure. Prior systematic reviews have been conducted on this topic, but no updates have been performed on the most recent literature since 2000. To provide an updated systematic review of the association between laryngeal cancer and asbestos exposure. A search of electronic databases, including PubMed and the Cochrane Library, was performed for articles published between January 1, 2000, and April 30, 2016. Search terms, including laryngeal cancer and asbestos, were used to identify publications reviewing the risk of laryngeal cancer in association with asbestos exposure. Studies analyzing this association that were published in any language and translated reliably were included. Two independent reviewers assessed articles based on predetermined eligibility criteria. Each study was reviewed for quality using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and assessed for their findings of support for or against a correlation between asbestos exposure and laryngeal cancer. A total of 160 studies were retrieved from all databases, and 2 additional articles were identified by cross-references. Of the 162 articles screened, 15 articles comprising 438 376 study participants were included in this review. Of these 15 studies, 10 showed no correlation between asbestos exposure and laryngeal cancer. The remaining 5 studies claimed a correlation between asbestos exposure and incidence of laryngeal cancer, although only 1 accounted for smoking or alcohol exposure while 3 others did not, and 1 study included only 2 patients. Although asbestos is considered hazardous and carcinogenic, current evidence is lacking to support a correlation between asbestos exposure and laryngeal cancer. Few studies have been able to definitively conclude a causal association between asbestos exposure and laryngeal cancer, and those that found an association often did not account for the

Creation and Validation of a Novel Mobile Simulation Laboratory for High Fidelity, Prehospital, Difficult Airway Simulation.

PubMed

Bischof, Jason J; Panchal, Ashish R; Finnegan, Geoffrey I; Terndrup, Thomas E

2016-10-01

Introduction Endotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI. Hypothesis/Problem The availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance. The MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis. Nineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts. The MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of

The Effects of Treadmill Running on Aging Laryngeal Muscle Structure

PubMed Central

Kletzien, Heidi; Russell, John A.; Connor, Nadine P.

2015-01-01

Levels of Evidence NA (animal study) Objective Age-related changes in laryngeal muscle structure and function may contribute to deficits in voice and swallowing observed in elderly people. We hypothesized that treadmill running, an exercise that increases respiratory drive to upper airway muscles, would induce changes in thyroarytenoid muscle myosin heavy chain (MHC) isoforms consistent with a fast-slow transformation in muscle fiber type. Study Design Randomized parallel group controlled trial. Methods Fifteen young adult and 14 old Fischer 344/Brown Norway rats received either treadmill running or no exercise (5 days/week/8 weeks). Myosin heavy chain isoform composition in the thyroarytenoid muscle was examined at the end of 8 weeks. Results Significant age and treatment effects were found. The young adult group had the greatest proportion of superfast contracting MHCIIL. The treadmill running group had the lowest proportion of MHCIIL and the greatest proportion of MHCIIx. Conclusion Thyroarytenoid muscle structure was affected both by age and treadmill running in a fast-slow transition that is characteristic of exercise manipulations in other skeletal muscles. PMID:26256100

Immunological responses against human papilloma virus and human papilloma virus induced laryngeal cancer.

PubMed

Chitose, Shun-ichi; Sakazaki, T; Ono, T; Kurita, T; Mihashi, H; Nakashima, T

2010-06-01

This study aimed to clarify the local immune status in the larynx in the presence of infection or carcinogenesis associated with human papilloma virus. Cytological samples (for human papilloma virus detection) and laryngeal secretions (for immunoglobulin assessment) were obtained from 31 patients with laryngeal disease, during microscopic laryngeal surgery. On histological examination, 12 patients had squamous cell carcinoma, four had laryngeal papilloma and 15 had other benign laryngeal disease. Cytological samples were tested for human papilloma virus DNA using the Hybrid Capture 2 assay. High risk human papilloma virus DNA was detected in 25 per cent of patients (three of 12) with laryngeal cancer. Low risk human papilloma virus DNA was detected only in three laryngeal papilloma patients. The mean laryngeal secretion concentrations of immunoglobulins M, G and A and secretory immunoglobulin A in human papilloma virus DNA positive patients were more than twice those in human papilloma virus DNA negative patients. A statistically significant difference was observed between the secretory immunoglobulin A concentrations in the two groups. Patients with laryngeal cancer had higher laryngeal secretion concentrations of each immunoglobulin type, compared with patients with benign laryngeal disease. The study assessed the mean laryngeal secretion concentrations of each immunoglobulin type in the 12 laryngeal cancer patients, comparing human papilloma virus DNA positive patients (n = 3) and human papilloma virus DNA negative patients (n = 9); the mean concentrations of immunoglobulins M, G and A and secretory immunoglobulin A tended to be greater in human papilloma virus DNA positive cancer patients, compared with human papilloma virus DNA negative cancer patients. These results suggest that the local laryngeal immune response is activated by infection or carcinogenesis due to human papilloma virus. The findings strongly suggest that secretory IgA has inhibitory activity

Incidence of laryngeal cancer and exposure to acid mists.

PubMed Central

Steenland, K; Schnorr, T; Beaumont, J; Halperin, W; Bloom, T

1988-01-01

To determine the relation between exposure to acid mist and laryngeal cancer, the smoking habits, drinking habits, and incidence of laryngeal cancer of 879 male steelworkers exposed to acid mists during pickling operations was ascertained. Sulphuric acid mist was the primary exposure for most men in this cohort. These men had all worked in a pickling operation for a minimum of six months before 1965, with an average duration of exposure of 9.5 years. Exposures to sulphuric acid in the 1970s averaged about 0.2 mg/m3, and earlier exposures were probably similar. Interviews were conducted with all cohort members or their next of kin in 1986 and medical records of decedents were reviewed. Nine workers were identified who had been diagnosed as having laryngeal cancer, using a conservative case definition that required medical record confirmation for any case among decedents and confirmation by a physician for any case among live individuals. Using data from national surveys of cancer incidence as referent rates, 3.44 laryngeal cancers would have been expected. Excess smoking by the exposed cohort compared with the United States population resulted in an upward adjustment of the expected number of cases of laryngeal cancer to 3.92. The standardised incidence rate ratio for laryngeal cancer was 2.30 (9/3.92), with a one sided p value of 0.01 (assuming a Poisson distribution). The finding of excess laryngeal cancer in this cohort is consistent with four other studies published since 1981. PMID:3203082

Impact of different nasal masks on CPAP therapy for obstructive sleep apnea: a randomized comparative trial.

PubMed

Neuzeret, Pierre-Charles; Morin, Laurent

2017-11-01

Patient interface is important for the success of continuous positive airway pressure (CPAP), but few trials have examined the influence of mask choice on CPAP adherence. To compare the impact of different nasal masks on CPAP in patients with newly-diagnosed obstructive sleep apnea (OSA). OSA patients were randomized in a 2:3 ratio to receive CPAP via different first-line nasal masks: ResMed Mirage FX® (MFX) or control mask (Fisher & Paykel Zest ® , HC407 ® or Philips EasyLife ® ). Mask acceptance, CPAP compliance and Home Care Provider (HCP) interventions were compared between groups after 3 months of CPAP therapy using modified intent-to-treat (mITT; after exclusion of patients with mouth leaks during CPAP initiation) and on-treatment (OT; CPAP adherent) analyses. Of 285 randomized patients, 90 requiring a full-face mask were excluded, leaving 195 and 151 in the mITT and OT analyses, respectively. Mask acceptance rate was higher in the MFX versus control group (mITT: 79% vs 68%, P = 0.067; OT: 90% vs 76%, P = 0.022). CPAP compliance was higher (5.9 ± 1.8 vs 5.1 ± 1.6 h/night, P = 0.011) and nasal mask issue-related HCP visits lower (3% vs 17%, P = 0.006) in the MFX group. Nasal mask failures due to mask discomfort (5% vs 1%) or unintentional leakage (5% vs 0%) were higher in control vs MFX group. Mask acceptance was significantly associated with fewer mask leaks (P = 0.002) and higher pressure therapy (P = 0.042). This study highlights differences between nasal masks for CPAP delivery and shows that initial mask selection can influence adherence and healthcare utilization during CPAP. © 2016 ResMed Germany Inc. The Clinical Respiratory Journal published by John Wiley & Sons Ltd.

Delivery of helium–oxygen mixture during spontaneous breathing: evaluation of three high-concentration face masks.

PubMed

Roche-Campo, Ferran; Vignaux, Laurence; Galia, Fabrice; Lyazidi, Aissam; Vargas, Frédéric; Texereau, Joëlle; Apiou-Sbirlea, Gabriela; Jolliet, Philippe; Brochard, Laurent

2011-11-01

To evaluate the efficacy of delivering a mixture of helium and oxygen gas (He–O2) in spontaneous ventilation. Three high oxygen flow reservoir masks were tested: the Heliox21, specifically designed for helium; the Hi-Ox80 mask, with an inspiratory and an expiratory valve; and a standard high-concentration face mask. This prospective randomized crossover study was performed in six healthy volunteers in a laboratory setting. Volunteers breathed a mixture of 78% He/22% O2 through each of the masks under two different breathing conditions (rest and hyperventilation: minute ventilation of 14.9 ± 6.1 and 26.7 ± 8.7 L min(−1), respectively) and four different He–O2 flow rates (7, 10, 12, and 15 L min(−1)). A nasopharyngeal catheter was used to estimate He pharyngeal concentration (Fp [He]) in the airways in order to determine the percentage of contamination with room air (% air cont) at end-expiration. Under all testing conditions, the Hi-Ox80 mask presented a significantly lower % air cont. During resting breathing pattern, a Fp [He] higher than 50% was achieved in 54% of the tests performed with the Hi-Ox80 mask compared to 29% for the Heliox21 mask and only 17% for the standard mask. At hyperventilation, a Fp [He] higher than 50% was achieved in 17% of the tests performed with the Hi-Ox mask compared to 4% for the other two masks. He–O2 administration via the usual high-concentration reservoir masks results in significant dilution by room air. The Hi-Ox80 mask minimized room air contamination and much more frequently achieved a pharyngeal He concentration higher than 50%.

Redesign of an Open-System Oxygen Face Mask With Mainstream Capnometer for Children.

PubMed

Napolitano, Natalie; Nishisaki, Akira; Buffman, Hayley S; Leffelman, Jessica; Maltese, Matthew R; Nadkarni, Vinay M

2017-01-01

Partial pressure of end-tidal carbon dioxide (P ETCO 2 ) monitoring in children is important to detect apnea or hypopnea early to intervene before hypoxemia develops. Monitoring P ETCO 2 in children without a tracheal tube is challenging. To improve P ETCO 2 measurement accuracy in a commercially available mask with a mainstream CO 2 detector, we implemented design changes with deform-and-hold shaping technology and anterior-posterior adjustment of the expiratory gas flow cup. Two sizes of redesigned face masks (small for 7-20 kg, medium for 10-40 kg) were evaluated. Initial bench testing used a simulator modeling a spontaneously breathing infant and child with a natural airway. An infant/child manikin head was connected to the breathing lung simulator. A mass flow controller provided expiratory CO 2 . Mask fit was then evaluated on healthy human subjects to identify anatomical features associated with good fit, defined as square shape capnography waveform during expiration. A 3-dimensional digital scan was used to quantify anatomical features. The gaps between face mask rims and facial surface were manually measured. Bench testing revealed a P ETCO 2 difference of 3.4 ± 1.5 mm Hg between a measured P ETCO 2 by the redesigned mask and CO 2 concentration at trachea, as compared with 6.7 ± 6.2 mm Hg between P ETCO 2 measured by nasal cannula and trachea (P < .001). In the human mask fit study, 35 children (13 ± 4 kg) with the small mask and 38 (24 ± 8 kg) with the medium mask were evaluated. Capnography tracing was successfully obtained in 86% of the small and 100% of the medium masks. In children with small-size masks, the gap between the face mask rim and the child's face was not statistically different among those with good mask fit and without (1.0 ± 1.5 mm vs 1.4 ± 1.9 mm, P = .73). P ETCO 2 measurement by a redesigned open-system face mask with a mainstream CO 2 detector was accurate in the bench setting. The redesigned face mask can attain good mask fit

Mask Ventilation during Induction of General Anesthesia: Influences of Obstructive Sleep Apnea.

PubMed

Sato, Shin; Hasegawa, Makoto; Okuyama, Megumi; Okazaki, Junko; Kitamura, Yuji; Sato, Yumi; Ishikawa, Teruhiko; Sato, Yasunori; Isono, Shiroh

2017-01-01

Depending on upper airway patency during anesthesia induction, tidal volume achieved by mask ventilation may vary. In 80 adult patients undergoing general anesthesia, the authors tested a hypothesis that tidal volume during mask ventilation is smaller in patients with sleep-disordered breathing priorly defined as apnea hypopnea index greater than 5 per hour. One-hand mask ventilation with a constant ventilator setting (pressure-controlled ventilation) was started 20 s after injection of rocuronium and maintained for 1 min during anesthesia induction. Mask ventilation efficiency was assessed by the breath number needed to initially exceed 5 ml/kg ideal body weight of expiratory tidal volume (primary outcome) and tidal volumes (secondary outcomes) during initial 15 breaths (UMIN000012494). Tidal volume progressively increased by more than 70% in 1 min and did not differ between sleep-disordered breathing (n = 42) and non-sleep-disordered breathing (n = 38) patients. In post hoc subgroup analyses, the primary outcome breath number (mean [95% CI], 5.7 [4.1 to 7.3] vs. 1.7 [0.2 to 3.2] breath; P = 0.001) and mean tidal volume (6.5 [4.6 to 8.3] vs. 9.6 [7.7 to 11.4] ml/kg ideal body weight; P = 0.032) were significantly smaller in 20 sleep-disordered breathing patients with higher apnea hypopnea index (median [25th to 75th percentile]: 21.7 [17.6 to 31] per hour) than in 20 non-sleep disordered breathing subjects with lower apnea hypopnea index (1.0 [0.3 to 1.5] per hour). Obesity and occurrence of expiratory flow limitation during one-hand mask ventilation independently explained the reduction of efficiency of mask ventilation, while the use of two hands effectively normalized inefficient mask ventilation during one-hand mask ventilation. One-hand mask ventilation is difficult in patients with obesity and severe sleep-disordered breathing particularly when expiratory flow limitation occurs during mask ventilation.

An Overview of Laryngeal Muscle Single Fiber Electromyography.

PubMed

Bertorini, Tulio E; Sharaf, Aboubakar G

2015-08-01

Needle electromyography is an important tool in the diagnosis of neuromuscular diseases and has also been applied successfully in the evaluation of the vocal cord paralysis. Laryngeal electromyography, initially described by Weddell, is used to determine the cause of vocal cord paralysis and to differentiate organic from nonorganic causes of speech disorders. This test allows the diagnosis of lower motor neuron and nerve paralysis as well as myopathies. Laryngeal electromyography also helps to determine the prognosis of paralysis caused by traumatic injury of the laryngeal nerves and is used for guidance during botulinum toxin injection in spasmodic dysphonias. Single fiber electromyography is used to diagnose abnormalities of neuromuscular transmission and is applied in the study the architecture of the motor unit in muscles. This article reviews the techniques of laryngeal muscles single fiber electromyography, provides limited informative data, and discusses its potential value in the evaluation of patients with dysphonia.

Microarray Analysis Gene Expression Profiles in Laryngeal Muscle After Recurrent Laryngeal Nerve Injury.

PubMed

Bijangi-Vishehsaraei, Khadijeh; Blum, Kevin; Zhang, Hongji; Safa, Ahmad R; Halum, Stacey L

2016-03-01

The pathophysiology of recurrent laryngeal nerve (RLN) transection injury is rare in that it is characteristically followed by a high degree of spontaneous reinnervation, with reinnervation of the laryngeal adductor complex (AC) preceding that of the abducting posterior cricoarytenoid (PCA) muscle. Here, we aim to elucidate the differentially expressed myogenic factors following RLN injury that may be at least partially responsible for the spontaneous reinnervation. F344 male rats underwent RLN injury (n = 12) or sham surgery (n = 12). One week after RLN injury, larynges were harvested following euthanasia. The mRNA was extracted from PCA and AC muscles bilaterally, and microarray analysis was performed using a full rat genome array. Microarray analysis of denervated AC and PCA muscles demonstrated dramatic differences in gene expression profiles, with 205 individual probes that were differentially expressed between the denervated AC and PCA muscles and only 14 genes with similar expression patterns. The differential expression patterns of the AC and PCA suggest different mechanisms of reinnervation. The PCA showed the gene patterns of Wallerian degeneration, while the AC expressed the gene patterns of reinnervation by adjacent axonal sprouting. This finding may reveal important therapeutic targets applicable to RLN and other peripheral nerve injuries. © The Author(s) 2015.

Congenital high airway obstruction syndrome in the breech presentation managed by ex utero intrapartum treatment procedure after intraoperative external cephalic version.

PubMed

Miwa, Ichiro; Sase, Masakatsu; Nakamura, Yasuhiko; Hasegawa, Keiko; Kawasaki, Masahiro; Ueda, Kazuyuki

2012-05-01

Congenital high airway obstruction syndrome (CHAOS) caused by laryngeal atresia was diagnosed by prenatal ultrasound in a male fetus at 26 weeks of gestation. Findings included massive ascites, subcutaneous edema, enlarged hyperechogenic lungs with diaphragmatic inversion, dilated trachea, polyhydramnios, and breech presentation. Those findings of CHAOS spontaneously returned to normal by 33 weeks of gestation. However, the placenta was localized to the anterior uterine wall. In addition, the fetal position had been breech until delivery. At 36 weeks of gestation, a planned ex utero intrapartum treatment (EXIT) procedure was performed following intraoperative external cephalic version (ECV) in which the fetus was approached from the posterior wall of the uterus. Laryngoscopy revealed the predicted laryngeal obstruction, and tracheostomy was placed. Intraoperative ECV may be a useful technique in breech presentation before EXIT procedure. © 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology.

Comparison of Aerosol Delivery by Face Mask and Tracheostomy Collar.

PubMed

Bugis, Alaa A; Sheard, Meryl M; Fink, James B; Harwood, Robert J; Ari, Arzu

2015-09-01

The purpose of this study was to compare the performance of a tracheostomy collar, Wright mask, and aerosol mask attached to a jet nebulizer in facilitating aerosolized medication delivery to the lungs. We also compared albuterol delivery with open versus closed fenestration and determined the effect of inspiratory-expiratory ratio (I:E) on aerosol delivery. Albuterol (2.5 mg/3 mL) was administered to an in vitro model consisting of an adult teaching mannequin extrathoracic and upper airway with stoma intubated with an 8-mm fenestrated tracheostomy tube. The cuff was deflated. A collecting filter at the level of the bronchi was connected to a breathing simulator at a tidal volume of 400 mL, breathing frequency of 20 breaths/min, and I:E of 2:1 and 1:2. A jet nebulizer was operated with O2 at 8 L/min. Each interface was tested in triplicate. The flow was discontinued at the end of nebulization. For each test, the nebulizer was attached to a tracheostomy collar with the fenestration open or closed, a Wright mask, or an aerosol mask. Drug was analyzed by spectrophotometry (276 nm). A paired t test and analysis of variance were performed (P < .05). The mean ± SD percent albuterol dose delivered distal to the bronchi was greater with the tracheostomy collar with a closed fenestration (9.4 ± 1.5%) compared with an open fenestration (7.0 ± 0.8%). The doses delivered with the Wright mask (4.1 ± 0.6%) and aerosol mask (3.5 ± 0.04%) were both less than with the tracheostomy collar under either condition (P < .05). Increasing the I:E from 1:2 to 2:1 increased aerosol delivery by 2.5-4%, with significance for the tracheostomy collar with an open fenestration (11.6 ± 1.4%), Wright mask (7.2 ± 0.6%), and aerosol mask (6.1 ± 0.5%). In an adult tracheostomy model, the tracheostomy collar delivered more aerosol to the bronchi than the Wright or aerosol mask. An I:E of 2:1 caused greater aerosol deposition compared with an I:E of 1:2. During aerosol administration via a

Laryngeal Electromyography for Prognosis of Vocal Fold Paralysis.

PubMed

Pardo-Maza, Adriana; García-Lopez, Isabel; Santiago-Pérez, Susana; Gavilán, Javier

2017-01-01

This study aimed to determine the value of laryngeal electromyography in the prognosis of vocal fold paralysis. This is a retrospective descriptive study. This study included 80 patients diagnosed with unilateral or bilateral vocal fold paralysis on flexible laryngoscopy between 2002 and 2014 in a tertiary medical center. Laryngeal electromyography using a standardized protocol was performed; the outcome measures were classified and analyzed into two groups according to the degree of injury. Group 1 included patients with mild to moderate injury, and group 2 included patients with severe to complete injury. Prognosis was correlated with vocal fold motion recovery status with a minimum of 6 months of follow-up since the symptoms onset using positive and negative predictive values. Sixty patients showed acute or chronic recurrent laryngeal neuropathy in laryngeal electromyography. Twelve of 41 patients included in group 1 recovered motion, and 30 of 35 patients included in group 2 did not recover, resulting in 88.2% of positive predictive value and 35.7% of negative predictive value. Our data confirm that laryngeal electromyography is a useful clinical tool in predicting poor recovery in patients with vocal fold paralysis. It allows identification of candidates for early intervention. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Comparing the Efficacy, Mask Leak, Patient Adherence, and Patient Preference of Three Different CPAP Interfaces to Treat Moderate-Severe Obstructive Sleep Apnea.

PubMed

Rowland, Sharn; Aiyappan, Vinod; Hennessy, Cathy; Catcheside, Peter; Chai-Coezter, Ching Li; McEvoy, R Doug; Antic, Nick A

2018-01-15

To determine if the type of continuous positive airway pressure (CPAP) mask interface influences CPAP treatment efficacy, adherence, side effects, comfort and sleep quality in patients with moderate-severe obstructive sleep apnea (OSA). This took place in a hospital-based tertiary sleep disorders unit. It is a prospective, randomized, crossover trial comparing three CPAP interfaces: nasal mask (NM), nasal mask plus chinstrap (NM-CS) and oronasal mask (ONM) each tried in random order, for 4 weeks. After each 4-week period, patient outcomes were assessed. Participants had a new diagnosis of obstructive sleep apneas. Forty-eight patients with moderate-severe OSA (32 males, mean ± standard deviation apnea-hypopnea index (AHI) 55.6 ± 21.1 events/h, age 54.9 ± 13.1 years, body mass index 35.8 ± 7.2 kg/m 2 ) were randomized. Thirty-five participants completed the full study, with complete data available for 34 patients. There was no statistically significant difference in CPAP adherence; however, residual AHI was higher with ONM than NM and NM-CS (residual AHI 7.1 ± 7.7, 4.0 ± 3.1, 4.2 ± 3.7 events/h respectively, main effect P = .001). Patient satisfaction and quality of sleep were higher with the NM and NM-CS than the ONM. Fewer leak and mask fit problems were reported with NM (all chi-square P < .05), which patients preferred over the NM-CS and ONM options (n = 22, 9 and 4 respectively, P = .001). The CPAP adherence did not differ between the three different mask interfaces but the residual AHI was lower with NM than ONM and patients reported greater mask comfort, better sleep, and overall preference for a NM. A nasal mask with or without chinstrap should be the first choice for patients with OSA referred for CPAP treatment. Registry: Australian and New Zealand Clinical Trials Registry, URL: https://www.anzctr.org.au, title: A comparison of continuous positive airway pressure (CPAP) interface in the control of leak, patient compliance and patient preference

Object Substitution Masking: When Does Mask Preview Work?

ERIC Educational Resources Information Center

Lim, Stephen Wee Hun; Chua, Fook K.

2008-01-01

When a target is enclosed by a 4-dot mask that persists after the target disappears, target identification is worse than it is when the mask terminates with the target. This masking effect is attributed to object substitution masking (OSM). Previewing the mask, however, attenuates OSM. This study investigated specific conditions under which mask…

Asbestos exposure and laryngeal cancer mortality.

PubMed

Peng, Wen-Jia; Mi, Jing; Jiang, Yu-Hong

2016-05-01

Occupational exposure to asbestos occurs in many workplaces and is well known to cause asbestosis, lung cancer, and mesothelioma. However, the link between asbestos exposure and other malignancies was not confirmed. The aim of the current meta-analysis was to provide a summary measure of risk for laryngeal cancer associated with occupational asbestos exposure. Systematic review and meta-analysis. Electronic databases were searched for studies characterizing the association between asbestos and laryngeal cancer. Standardized mortality rate (SMR) with its 95% confidence interval (CI) of each study was combined using a fixed or random effect model. Significantly increased SMR for laryngeal cancer was observed when subjects were exposed to asbestos (SMR = 1.69, 95% CI = 1.45-1.97, P < .001), with little evidence of heterogeneity among studies (Q = 15.39, P = .803, I(2) = 0.0%). Effect estimates were larger for cohorts controlling for male subjects, Europe and Oceania, mining and textile industries, exposure to crocidolite, long study follow-up (>25 years), and SMR for lung cancer > 2.0. Publication bias was not detect by Begg test (P = .910) and Egger test (P = .340). Our study supports the association of exposure to asbestos with an increased risk of laryngeal cancer mortality among male workers. NA Laryngoscope, 126:1169-1174, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

[Research of expression of L-DOPA decarboxylase in laryngeal cancer].

PubMed

Lai, Shisheng; Wan, Zhili

2014-12-01

This study aimed to investigate the expression levels of L-DOPA decarboxylase (DDC) mRNA and protein in laryngeal cancer, and to determine the clinical significance of DDC in diagnosis and prognosis of laryngeal cancer. Total RNA was isolated from 106 tissue samples surgically removed from 53 laryngeal cancer patients. A quantitative real-time polymerase chain reaction (RT-PCR) methodology based on SYBR Green I fluorescent dye was developed for the quantification of mRNA levels. In addition, Western Blot analysis was performed to detect the expression level of DDC protein. DDC mRNA expression in both primary (P= 0. 000) and recurrent (P=0. 033) laryngeal cancer samples downregulated significantly compared with their nonmalignant counterparts. Moreover, expression of DDC mRNA was not associated with age and histologic grade, but the significantly decreased mRNA were correlated with early TMN stage (P=0. 021). Additionally, DDC protein was detected in both cancerous and noncancerous tissues. Expression levels of DDC may play a vital role in the progression of laryngeal cancer, which can be served as a promising biomarker for the future clinical management of laryngeal cancer patients.

Pathological classification of equine recurrent laryngeal neuropathy.

PubMed

Draper, Alexandra C E; Piercy, Richard J

2018-04-24

Recurrent Laryngeal Neuropathy (RLN) is a highly prevalent and predominantly left-sided, degenerative disorder of the recurrent laryngeal nerves (RLn) of tall horses, that causes inspiratory stridor at exercise because of intrinsic laryngeal muscle paresis. The associated laryngeal dysfunction and exercise intolerance in athletic horses commonly leads to surgical intervention, retirement or euthanasia with associated financial and welfare implications. Despite speculation, there is a lack of consensus and conflicting evidence supporting the primary classification of RLN, as either a distal ("dying back") axonopathy or as a primary myelinopathy and as either a (bilateral) mononeuropathy or a polyneuropathy; this uncertainty hinders etiological and pathophysiological research. In this review, we discuss the neuropathological changes and electrophysiological deficits reported in the RLn of affected horses, and the evidence for correct classification of the disorder. In so doing, we summarize and reveal the limitations of much historical research on RLN and propose future directions that might best help identify the etiology and pathophysiology of this enigmatic disorder. Copyright © 2018 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Using Laryngeal Electromyography to Differentiate Presbylarynges from Paresis

ERIC Educational Resources Information Center

Stager, Sheila V.; Bielamowicz, Steven A.

2010-01-01

Purpose: Differential diagnosis of patients over 64 years of age reporting hoarseness is challenging. Laryngeal electromyography (LEMG) was used to determine the status of the recurrent and superior laryngeal nerves. The authors hypothesized that individuals with hoarseness but normal LEMG would have measures similar to those of patients from…

Relationship Between Laryngeal Electromyography and Video Laryngostroboscopy in Vocal Fold Paralysis.

PubMed

Maamary, Joel A; Cole, Ian; Darveniza, Paul; Pemberton, Cecilia; Brake, Helen Mary; Tisch, Stephen

2017-09-01

The objective of this study was to better define the relationship of laryngeal electromyography and video laryngostroboscopy in the diagnosis of vocal fold paralysis. Retrospective diagnostic cohort study with cross-sectional data analysis METHODS: Data were obtained from 57 patients with unilateral vocal fold paralysis who attended a large tertiary voice referral center. Electromyographic findings were classified according to recurrent laryngeal nerve, superior laryngeal nerve, and high vagal/combined lesions. Video laryngostroboscopy recordings were classified according to the position of the immobile fold into median, paramedian, lateral, and a foreshortened/hooded vocal fold. The position of the paralyzed vocal fold was then analyzed according to the lesion as determined by electromyography. The recurrent laryngeal nerve was affected in the majority of cases with left-sided lesions more common than right. Vocal fold position differed between recurrent laryngeal and combined vagal lesions. Recurrent laryngeal nerve lesions were more commonly associated with a laterally displaced immobile fold. No fold position was suggestive of a combined vagal lesion. The inter-rater reliability for determining fold position was high. Laryngeal electromyography is useful in diagnosing neuromuscular dysfunction of the larynx and best practice recommends its continued implementation along with laryngostroboscopy. While recurrent laryngeal nerve lesions are more likely to present with a lateral vocal fold, this does not occur in all cases. Such findings indicate that further unknown mechanisms contribute to fold position in unilateral paralysis. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Development of a nerve conduction technique for the recurrent laryngeal nerve.

PubMed

J Kim, Sang; G Lee, Dae; Kwon, Jeong-Yi

2014-12-01

To develop a reliable and safe laryngeal nerve conduction technique and to obtain consistent parameters as normal reference values. A prospective single-arm study. A nerve conduction test was performed on the contralateral normal side in 42 patients with unilateral vocal fold palsy. The recording was performed in the intact thyroarytenoid muscle using a monopolar needle. The electrical stimulation using a 37-mm monopolar needle was applied 3 cm below the lower margin of the cricoid cartilage, just lateral to the trachea and medial to the carotid artery, and its intensity was gradually increased until the amplitude of the electrical response reached the maximum level. The latency of the evoked muscle response was acquired at the first evoked waveform deflection from the baseline. The average latency of the recurrent laryngeal nerves was 1.98 ± 0.26 ms. The latencies showed normal distribution according to the quantile-quantile plot and Kolmogorov-Smirnov test (P = .098). There was no significant difference in latencies between the right and left recurrent laryngeal nerves. Anthropometric factors including height and weight did not show any correlation with the latencies. We developed a reliable and safe laryngeal nerve conduction technique and obtained normal reference values for the recurrent laryngeal nerve conduction study. This laryngeal nerve conduction study can be an additional tool for detecting recurrent laryngeal nerve injury if it is performed in combination with the conventional laryngeal electromyography. 4. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.

Mobile Apps for Teaching Intubation: Scoping Review and Critical Analysis in eLearning

PubMed Central

2017-01-01

Background Airway management is a core skill in anesthesia ensuring adequate oxygenation and delivery of inhalational agents for the patient. Objective The goals of this study were to critically evaluate the quality of airway management apps and target revised Bloom's Taxonomy cognitive levels. Methods An electronic search using the keywords “airway” and “airway management” was conducted in May 2015 across the App Store, Google Play, BlackBerry World, and Windows Store. Apps were included in the study if their content was related to airway management. App content and characteristics were extracted into a standard form and evaluated. Results A total of 65 apps met the inclusion criteria, and 73% (47/65) of apps were developed by companies or industry. Anesthesiology trainees were the target audience in only 20% (13/65) of apps. Bag mask ventilation and laryngeal mask airways were covered in only 20% (13/65) of apps. Only 2 apps were supported in the scientific literature. For Bloom’s Taxonomy, 37% (24/65) of apps targeted knowledge, 5% (3/65) comprehension, 22% (14/65) application, 28% (18/65) analysis, 9% (6/65) evaluation, and 0% synthesis. Multivariate analysis identified cost of apps, size of apps (MB), and apps targeting trainees and paramedics to be associated with higher levels of cognitive processing of revised Bloom’s Taxonomy. Conclusions Apps developed for teaching intubation target lower levels of cognitive processing and are largely not validated by research. Cost, app size, and targeted user are associated with higher cognitive levels. Trainees and all users should be aware of the paucity of the published evidence behind the efficacy of some of these apps. PMID:28874335

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults†

PubMed Central

Frerk, C.; Mitchell, V. S.; McNarry, A. F.; Mendonca, C.; Bhagrath, R.; Patel, A.; O'Sullivan, E. P.; Woodall, N. M.; Ahmad, I.

2015-01-01

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team. PMID:26556848

Quantitative PCR Analysis of Laryngeal Muscle Fiber Types

ERIC Educational Resources Information Center

Van Daele, Douglas J.

2010-01-01

Voice and swallowing dysfunction as a result of recurrent laryngeal nerve paralysis can be improved with vocal fold injections or laryngeal framework surgery. However, denervation atrophy can cause late-term clinical failure. A major determinant of skeletal muscle physiology is myosin heavy chain (MyHC) expression, and previous protein analyses…

Central nervous system control of the laryngeal muscles in humans

PubMed Central

Ludlow, Christy L.

2005-01-01

Laryngeal muscle control may vary for different functions such as: voice for speech communication, emotional expression during laughter and cry, breathing, swallowing, and cough. This review discusses the control of the human laryngeal muscles for some of these different functions. Sensori-motor aspects of laryngeal control have been studied by eliciting various laryngeal reflexes. The role of audition in learning and monitoring ongoing voice production for speech is well known; while the role of somatosensory feedback is less well understood. Reflexive control systems involving central pattern generators may contribute to swallowing, breathing and cough with greater cortical control during volitional tasks such as voice production for speech. Volitional control is much less well understood for each of these functions and likely involves the integration of cortical and subcortical circuits. The new frontier is the study of the central control of the laryngeal musculature for voice, swallowing and breathing and how volitional and reflexive control systems may interact in humans. PMID:15927543

Mobile Apps for Teaching Intubation: Scoping Review and Critical Analysis in eLearning.

PubMed

Matava, Clyde; Leo, Anne-Marie; Alam, Fahad

2017-09-05

Airway management is a core skill in anesthesia ensuring adequate oxygenation and delivery of inhalational agents for the patient. The goals of this study were to critically evaluate the quality of airway management apps and target revised Bloom's Taxonomy cognitive levels. An electronic search using the keywords "airway" and "airway management" was conducted in May 2015 across the App Store, Google Play, BlackBerry World, and Windows Store. Apps were included in the study if their content was related to airway management. App content and characteristics were extracted into a standard form and evaluated. A total of 65 apps met the inclusion criteria, and 73% (47/65) of apps were developed by companies or industry. Anesthesiology trainees were the target audience in only 20% (13/65) of apps. Bag mask ventilation and laryngeal mask airways were covered in only 20% (13/65) of apps. Only 2 apps were supported in the scientific literature. For Bloom's Taxonomy, 37% (24/65) of apps targeted knowledge, 5% (3/65) comprehension, 22% (14/65) application, 28% (18/65) analysis, 9% (6/65) evaluation, and 0% synthesis. Multivariate analysis identified cost of apps, size of apps (MB), and apps targeting trainees and paramedics to be associated with higher levels of cognitive processing of revised Bloom's Taxonomy. Apps developed for teaching intubation target lower levels of cognitive processing and are largely not validated by research. Cost, app size, and targeted user are associated with higher cognitive levels. Trainees and all users should be aware of the paucity of the published evidence behind the efficacy of some of these apps. ©Clyde Matava, Anne-Marie Leo, Fahad Alam. Originally published in JMIR Medical Education (http://mededu.jmir.org), 05.09.2017.

Innovative Application of a Microlaryngeal Surgery Tube for difficult Airway Management in a Case of Down's Syndrome.

PubMed

Gulabani, Michell; Gupta, Akhilesh; Bannerjee, Neerja Gaur; Sood, Rajesh; Dass, Prashant

2016-04-01

An 11-year-old male child, known case of down's syndrome with congenital oesophageal stricture was posted for oesophageal dilatation. Preoperative airway assessment revealed a high arched palate, receding mandible and Mallampati Score of 2. During surgery, after loss of consciousness which was described as loss of eyelash reflex and adequate jaw relaxation, direct laryngoscopy and endotracheal intubation was attempted with a cuffed endotracheal tube number 5.0mm ID (internal diameter). The endotracheal tube could not be negotiated smoothly, so 5.0mm ID uncuffed endotracheal tube was used which passed through easily, but on auscultation revealed a significant leak. Later, intubation via a Micro Laryngeal Surgery (MLS) cuffed tube 4.0mm ID was attempted. The MLS tube advanced smoothly and there was no associated leak on positive pressure ventilation. Thus by innovative thinking and avant-garde reasoning, a definitive airway device could be positioned with no other suitable alternative at hand.

Aspecific membranous laryngitis after infectious mononucleosis.

PubMed

Di Girolamo, S; Anselmi, M; Piccini, A; De Lauretis, A; Passàli, D

1996-01-01

Aspecific membranous laryngitis is an unusual but very serious complication of viral infections. Here, we report the uncommon finding of infectious mononucleosis characterized by aspecific membranous laryngitis with fever, dysphonia and severe dyspnea in a 12-year-old girl. Endoscopy showed mucopus and sloughed epithelium forming a pseudomembrane covering almost all the supraglottal region and a supraglottal swelling including the epiglottis and arytenoids. The importance of suspecting diphtheria, epiglottitis, viral or bacterial croup and laringo-tracheo-bronchitis and including them in the differential diagnosis is emphasized.

Influence of Netrin-1 on reinnervation of laryngeal muscles following recurrent laryngeal nerve injury.

PubMed

Hernandez-Morato, Ignacio; Koss, Shira; Sharma, Sansar; Pitman, Michael J

2017-07-13

Following recurrent laryngeal nerve (RLN) injury, recovery results in poor functional restitution of the paralyzed vocal fold. Netrin-1 has been found to be upregulated in the rat posterior cricoarytenoid muscle (PCA) during nerve regeneration. We evaluated the effect of ectopic Netrin-1 in the PCA during RLN reinnervation. The right RLN was transected and Netrin-1 was injected into the PCA (2.5, 5, 10, 15, 20μg/ml). At 7 days post injury fluorescent retrograde tracer was injected into the PCA and Thyroarytenoid (TA) muscles. At 9 days tissues were harvested. Immunostaining showed reinnervation patterns in the laryngeal muscles and labelled motoneurons in the nucleus ambiguus. Lower concentrations of Netrin-1 (2.5 and 5μg/ml) showed no significant changes in laryngeal muscles reinnervation. Higher concentrations of Netrin-1 significantly reduced motor end plate innervation. The most effective dose was 10μg/ml showing reduced number of innervated motor endplates in the PCA. The somatotopic organization of the nucleus ambiguus was altered in all concentrations of Netrin-1 injection. These findings indicate that injection of Netrin-1 into the PCA changes the reinnervation pattern of the RLN. Copyright © 2017. Published by Elsevier B.V.

Childhood Laryngeal Tumors Treatment (PDQ®)—Health Professional Version

Cancer.gov

Laryngeal tumors in children are rare and can be benign (papillomatosis) or malignant. Rhabdomyosarcoma is the most common cancer of the larynx in children. Get comprehensive information about childhood laryngeal tumors, including histology, presentation, and treatment in this summary for clinicians.

21 CFR 874.3730 - Laryngeal prosthesis (Taub design).

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Laryngeal prosthesis (Taub design). 874.3730 Section 874.3730 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES EAR, NOSE, AND THROAT DEVICES Prosthetic Devices § 874.3730 Laryngeal prosthesis (Taub design). (a) Identification. A...

Some etio-pathogenetic factors in laryngeal carcinogenesis.

PubMed

Sugár, J; Vereczkey, I; Tóth, J

1996-01-01

Chemical influences, mainly heavy tobacco smoking, chewing snuff, excessive alcohol consumption, and some occupational hazards, are known to be important etiologic factors in laryngeal carcinogenesis. The synergistic or cooperative interaction of human papilloma virus (HPV) infection with these chemical factors are serious considerations in the development of laryngeal carcinoma. With the development during the last decade of Southern blot hybridization and polymerase chain reaction (PCR), extensive and comprehensive studies have been conducted to determine the presence and biological (etiologic) significance of HPV. Developed cancer, as well as juvenile and adult multiple and single papilloma of the larynx, have been the subject of clinical and molecular-pathological investigation. Our previous study showed that cancer may develop on the basis of leukoplakia and adult-onset papilloma. Extensive kilocytes, an indication of HPV infection, can be seen by histological examination in papillomas and carcinoma. Literary data suggest that in laryngeal squamous cell carcinoma, including varicoses carcinoma, HPV 16, HPV 18, and HPV 33 DNA have been detected. Both in juvenile and adult-onset respiratory papillomatosis, patients could have either HPV type 6 or 11 DNA sequences. Molecular biological and PCR studies indicate that HPV may play an etiologic role in the development of human malignancies of the upper aerodigestive tract and uterine (cervical) origin. However, evidence that unequivocally links HPV infection with laryngeal squamous cell carcinoma is still lacking. In laryngeal cancer, p53 abnormalities are related to smoking-induced mutagenesis rather than HPV. Studies have postulated an interaction between HPV infection and chemical carcinogens and have concluded that HPV possibly are co-adjuvants during the multistage process of neoplastic transformation.

Effects of a Semioccluded Vocal Tract on Laryngeal Muscle Activity and Glottal Adduction in a Single Female Subject

PubMed Central

Laukkanen, Anne-Maria; Titze, Ingo R.; Hoffman, Henry; Finnegan, Eileen

2015-01-01

Voice training exploits semiocclusives, which increase vocal tract interaction with the source. Modeling results suggest that vocal economy (maximum flow declination rate divided by maximum area declination rate, MADR) is improved by matching the glottal and vocal tract impedances. Changes in MADR may be correlated with thyroarytenoid (TA) muscle activity. Here the effects of impedance matching are studied for laryngeal muscle activity and glottal resistance. One female repeated [pa:p:a] before and immediately after (a) phonation into different-sized tubes and (b) voiced bilabial fricative [β:]. To allow estimation of subglottic pressure from the oral pressure, [p] was inserted also in the repetitions of the semiocclusions. Airflow was registered using a flow mask. EMG was registered from TA, cricothyroid (CT) and lateral cricoarytenoid (LCA) muscles. Phonation was simulated using a 7 × 5 × 5 point-mass model of the vocal folds, allowing inputs of simulated laryngeal muscle activation. The variables were TA, CT and LCA activities. Increased vocal tract impedance caused the subject to raise TA activity compared to CT and LCA activities. Computer simulation showed that higher glottal economy and efficiency (oral radiated power divided by aerodynamic power) were obtained with a higher TA/CT ratio when LCA activity was tuned for ideal adduction. PMID:19011306

[Expression and clinical significance of CD45RO in laryngeal carcinoma tissue].

PubMed

Li, Manyi; Liu, Jishengi; Zhou, Hui; Wu, Wenying; Xiao, Gensheng; Yu, Yafeng; Guo, Lingchuan

2014-03-01

To investigate the role and significance of CD45RO in occurance and development in laryngeal squamous carcinoma, and to provide some valuable clues for searching new approaches to assess prognosis and theoretical basis for tumor biotherapy. The expression of CD45RO protein in 50 cases of laryngeal squamous carcinoma and 10 cases normal mucos was detected by immunohistochemical S-P method. The positive rate of CD45RO was 30% and 86% respectively in normal tissue and laryngeal squamous cell carcinoma tissue. The expresion of CD45RO was significantly and negatively associated with local metastatic of lymph nodes 0.713, P < 0.05) and tumor sites (r = -0.750, P < 0.05), but it have no notable difference with pathology differentiation, age, infiltrating depth and clinical stages in 50 cases of laryngeal squamous cell cancer. (1) The expresion of CD45RO in laryngeal squamous cell cancer is more than that in normal tissue. (2) It is possible that overexpresion of CD45RO in laryngeal squamous cell carcinoma cut local metastatic lymph nodes. (3) It is probable that overexpresion of CD45RO in laryngeal squamous cell cancer made for prognosis of patients. (4) Other than UICC-TNM stage, pathology differentiation, it provide valuable clues for searching new approaches to assess prognosis of laryngeal squamous cell carcinoma.

Effects of Voice Therapy on Laryngeal Motor Units During Phonation in Chronic Superior Laryngeal Nerve Paresis Dysphonia.

PubMed

Kaneko, Mami; Hitomi, Takefumi; Takekawa, Takashi; Tsuji, Takuya; Kishimoto, Yo; Hirano, Shigeru

2017-09-26

Injury to the superior laryngeal nerve can result in dysphonia, and in particular, loss of vocal range. It can be an especially difficult problem to address with either voice therapy or surgical intervention. Some clinicians and scientists suggest that combining vocal exercises with adjunctive neuromuscular electrical stimulation may enhance the positive effects of voice therapy for superior laryngeal nerve paresis (SLNP). However, the effects of voice therapy without neuromuscular electrical stimulation are unknown. The purpose of this retrospective study was to demonstrate the clinical effectiveness of voice therapy for rehabilitating chronic SLNP dysphonia in two subjects, using interspike interval (ISI) variability of laryngeal motor units by laryngeal electromyography (LEMG). Both patients underwent LEMG and were diagnosed with having 70% recruitment of the cricothyroid muscle, and 70% recruitment of the cricothyroid and thyroarytenoid muscles, respectively. Both patients received voice therapy for 3 months. Grade, roughness, breathiness, asthenia, and strain (GRBAS) scale, stroboscopic examination, aerodynamic assessment, acoustic analysis, and Voice Handicap Index-10 were performed before and after voice therapy. Mean ISI variability during steady phonation was also assessed. After voice therapy, both patients showed improvement in vocal assessments by acoustic, aerodynamic, GRBAS, and Voice Handicap Index-10 analysis. LEMG indicated shortened ISIs in both cases. This study suggests that voice therapy for chronic SLNP dysphonia can be useful for improving SLNP and voice quality. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Experimental Assessment of the Laryngeal Jet Effect on the Fluid Flow Pattern within the Trachea

NASA Astrophysics Data System (ADS)

Salehi, Mehran

Drug aerosol inhalation is a modern way to combat lung diseases. It is also becoming the preferred route for insulin delivery, pain management, cancer therapy and nanotherapetutics. The specific airflow characteristics within the central human airways, however, have a major influence on aerosol delivery and particle deposition. In this study the association of human inspiratory laryngeal function on the unique transitional turbulence this creates in the central airways and its association to particle deposition were investigated. The true vocal cords expand with increasing inspiratory flow rates and independently, with enlarging lung volumes. This creates a specific constriction to the inspiratory airstream and subsequent vortex formation below each vocal cord. The study compares triangular vocal cord shapes (physiologic) to rectangular (symmetric) shapes over a range of inspiratory directed flows. Disturbances below the laryngeal obstruction were visualized and the turbulence intensities as a function of distance below the vocal cord constriction in scale models under similitude flow conditions for a human trachea was also measured using laser Doppler anemometry in both primary (axial) and secondary (tangential) directions in a simplified larynx-trachea model. The turbulence length scale and energy spectrum were also calculated using hot-wire anemometer data to determine the size distribution of eddies and the rate of energy decay along the trachea for different larynx geometries and Reynolds numbers. Both visualizations and measurements were made at Reynolds numbers between 1000 and 4000 which represent mild to severe breathing conditions. The larynx geometry is modeled by a constriction inside a straight tube. The group of constrictions consists of 2 rectangular and triangular shapes at apex angles of 45°, 60° and 75° degrees. The base circular tube was 5 cm in diameter (D) and 30 cm in length (L) (to keep the relative ratio of L/D=6). The inlet area created

Effective EUVL mask cleaning technology solutions for mask manufacturing and in-fab mask maintenance

NASA Astrophysics Data System (ADS)

Dietze, Uwe; Dress, Peter; Waehler, Tobias; Singh, Sherjang; Jonckheere, Rik; Baudemprez, Bart

2011-03-01

Extreme Ultraviolet Lithography (EUVL) is considered the leading lithography technology choice for semiconductor devices at 16nm HP node and beyond. However, before EUV Lithography can enter into High Volume Manufacturing (HVM) of advanced semiconductor devices, the ability to guarantee mask integrity at point-of-exposure must be established. Highly efficient, damage free mask cleaning plays a critical role during the mask manufacturing cycle and throughout the life of the mask, where the absence of a pellicle to protect the EUV mask increases the risk of contamination during storage, handling and use. In this paper, we will present effective EUVL mask cleaning technology solutions for mask manufacturing and in-fab mask maintenance, which employs an intelligent, holistic approach to maximize Mean Time Between Cleans (MBTC) and extend the useful life span of the reticle. The data presented will demonstrate the protection of the capping and absorber layers, preservation of pattern integrity as well as optical and mechanical properties to avoid unpredictable CD-linewidth and overlay shifts. Experiments were performed on EUV blanks and pattern masks using various process conditions. Conditions showing high particle removal efficiency (PRE) and minimum surface layer impact were then selected for durability studies. Surface layer impact was evaluated over multiple cleaning cycles by means of UV reflectivity metrology XPS analysis and wafer prints. Experimental results were compared to computational models. Mask life time predictions where made using the same computational models. The paper will provide a generic overview of the cleaning sequence which yielded best results, but will also provide recommendations for an efficient in-fab mask maintenance scheme, addressing handling, storage, cleaning and inspection.

Intraoperative recurrent laryngeal nerve monitoring: a useful method for patients with esophageal cancer.

PubMed

Zhong, D; Zhou, Y; Li, Y; Wang, Y; Zhou, W; Cheng, Q; Chen, L; Zhao, J; Li, X; Yan, X

2014-07-01

It is well accepted that recurrent laryngeal nerve paralysis is a severe complication of esophagectomy or lymphadenectomy performed adjacent to the recurrent laryngeal nerves. Herein, determination of the effectiveness of implementing continuous recurrent laryngeal nerve monitoring to reduce the incidence of recurrent laryngeal nerve paralysis after esophagectomy was sought. A total of 115 patients diagnosed with esophageal cancer were enrolled in the thoracic section of the Tangdu Hospital of the Fourth Military Medical University from April 2008 to April 2009. Clinical parameters of patients, the morbidity, and the mortality following esophageal resection were recorded and compared. After the surgery, a 2-year follow up was completed. It was found that recurrent laryngeal nerve paralysis and postoperative pneumonia were more frequently diagnosed in the patients that did not receive continuous recurrent laryngeal nerve monitoring (6/61 vs. 0/54). Furthermore, positive mediastinal lymph nodes (P = 0.015), total mediastinal lymph nodes (P < 0.001), positive total lymph nodes (P = 0.027), and total lymph nodes (P < 0.001) were more often surgically removed in the patients with continuous recurrent laryngeal nerve monitoring. These patients also had a higher 2-year survival rate (P = 0.038) after surgery. It was concluded that continuous intraoperative recurrent laryngeal nerve monitoring is technically safe and effectively identifies the recurrent laryngeal nerves. This may be a helpful method for decreasing the incidence of recurrent laryngeal nerve paralysis and postoperative pneumonia, and for improving the efficiency of lymphadenectomy. © 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Economic analysis of routine neuromonitoring of recurrent laryngeal nerve in total thyroidectomy.

PubMed

Sanabria, Álvaro; Ramírez, Adonis

2015-01-01

Thyroidectomy is a common surgery. Routine searching of the recurrent laryngeal nerve is the most important strategy to avoid palsy. Neuromonitoring has been recommended to decrease recurrent laryngeal nerve palsy. To assess if neuromonitoring of recurrent laryngeal nerve during thyroidectomy is cost-effective in a developing country. We designed a decision analysis to assess the cost-effectiveness of recurrent laryngeal nerve neuromonitoring. For probabilities, we used data from a meta-analysis. Utility was measured using preference values. We considered direct costs. We conducted a deterministic and a probabilistic analysis. We did not find differences in utility between arms. The frequency of recurrent laryngeal nerve injury was 1% in the neuromonitor group and 1.6% for the standard group. Thyroidectomy without monitoring was the less expensive alternative. The incremental cost-effectiveness ratio was COP$ 9,112,065. Routine neuromonitoring in total thyroidectomy with low risk of recurrent laryngeal nerve injury is neither cost-useful nor cost-effective in the Colombian health system.

Influence of total face, facial and nasal masks on short-term adverse effects during noninvasive ventilation.

PubMed

Holanda, Marcelo Alcantara; Reis, Ricardo Coelho; Winkeler, Georgia Freire Paiva; Fortaleza, Simone Castelo Branco; Lima, José Wellington de Oliveira; Pereira, Eanes Delgado Barros

2009-02-01

Failure of noninvasive ventilation (NIV) has been associated with short-term adverse effects related to the use of masks. The aim of this study was to compare the incidence, type and intensity of adverse effects, as well as the comfort, of total face masks (TFMs), facial masks (FMs) and nasal masks (NMs) during NIV. This was a randomized crossover trial involving 24 healthy volunteers submitted to six sessions of NIV in bilevel positive airway pressure mode using the TFM, FM and NM masks at low and moderate-to-high pressure levels. A written questionnaire was applied in order to evaluate eleven specific adverse effects related to the use of the masks. Comfort was assessed using a visual analog scale. The CO2 exhaled into the ventilator circuit was measured between the mask and the exhalation port. The performance of the TFM was similar to that of the NM and FM in terms of comfort scores. Higher pressure levels reduced comfort and increased adverse effects, regardless of the mask type. When the TFM was used, there were fewer air leaks and less pain at the nose bridge, although there was greater oronasal dryness and claustrophobia. Air leaks were most pronounced when the FM was used. The partial pressure of exhaled CO2 entering the ventilator circuit was zero for the TFM. The short-term adverse effects caused by NIV interfaces are related to mask type and pressure settings. The TFM is a reliable alternative to the NM and FM. Rebreathing of CO2 from the circuit is less likely to occur when a TFM is used.

9 CFR 310.15 - Disposition of thyroid glands and laryngeal muscle tissue.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 9 Animals and Animal Products 2 2010-01-01 2010-01-01 false Disposition of thyroid glands and laryngeal muscle tissue. 310.15 Section 310.15 Animals and Animal Products FOOD SAFETY AND INSPECTION... of thyroid glands and laryngeal muscle tissue. (a) Livestock thyroid glands and laryngeal muscle...

9 CFR 310.15 - Disposition of thyroid glands and laryngeal muscle tissue.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 9 Animals and Animal Products 2 2014-01-01 2014-01-01 false Disposition of thyroid glands and laryngeal muscle tissue. 310.15 Section 310.15 Animals and Animal Products FOOD SAFETY AND INSPECTION... of thyroid glands and laryngeal muscle tissue. (a) Livestock thyroid glands and laryngeal muscle...

9 CFR 310.15 - Disposition of thyroid glands and laryngeal muscle tissue.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 9 Animals and Animal Products 2 2011-01-01 2011-01-01 false Disposition of thyroid glands and laryngeal muscle tissue. 310.15 Section 310.15 Animals and Animal Products FOOD SAFETY AND INSPECTION... of thyroid glands and laryngeal muscle tissue. (a) Livestock thyroid glands and laryngeal muscle...

9 CFR 310.15 - Disposition of thyroid glands and laryngeal muscle tissue.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 9 Animals and Animal Products 2 2012-01-01 2012-01-01 false Disposition of thyroid glands and laryngeal muscle tissue. 310.15 Section 310.15 Animals and Animal Products FOOD SAFETY AND INSPECTION... of thyroid glands and laryngeal muscle tissue. (a) Livestock thyroid glands and laryngeal muscle...

9 CFR 310.15 - Disposition of thyroid glands and laryngeal muscle tissue.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 9 Animals and Animal Products 2 2013-01-01 2013-01-01 false Disposition of thyroid glands and laryngeal muscle tissue. 310.15 Section 310.15 Animals and Animal Products FOOD SAFETY AND INSPECTION... of thyroid glands and laryngeal muscle tissue. (a) Livestock thyroid glands and laryngeal muscle...

Identification of key target genes and pathways in laryngeal carcinoma

PubMed Central

Liu, Feng; Du, Jintao; Liu, Jun; Wen, Bei

2016-01-01

The purpose of the present study was to screen the key genes associated with laryngeal carcinoma and to investigate the molecular mechanism of laryngeal carcinoma progression. The gene expression profile of GSE10935 [Gene Expression Omnibus (GEO) accession number], including 12 specimens from laryngeal papillomas and 12 specimens from normal laryngeal epithelia controls, was downloaded from the GEO database. Differentially expressed genes (DEGs) were screened in laryngeal papillomas compared with normal controls using Limma package in R language, followed by Gene Ontology (GO) enrichment analysis and pathway enrichment analysis. Furthermore, the protein-protein interaction (PPI) network of DEGs was constructed using Cytoscape software and modules were analyzed using MCODE plugin from the PPI network. Furthermore, significant biological pathway regions (sub-pathway) were identified by using iSubpathwayMiner analysis. A total of 67 DEGs were identified, including 27 up-regulated genes and 40 down-regulated genes and they were involved in different GO terms and pathways. PPI network analysis revealed that Ras association (RalGDS/AF-6) domain family member 1 (RASSF1) was a hub protein. The sub-pathway analysis identified 9 significantly enriched sub-pathways, including glycolysis/gluconeogenesis and nitrogen metabolism. Genes such as phosphoglycerate kinase 1 (PGK1), carbonic anhydrase II (CA2), and carbonic anhydrase XII (CA12) whose node degrees were >10 were identified in the disease risk sub-pathway. Genes in the sub-pathway, such as RASSF1, PGK1, CA2 and CA12 were presumed to serve critical roles in laryngeal carcinoma. The present study identified DEGs and their sub-pathways in the disease, which may serve as potential targets for treatment of laryngeal carcinoma. PMID:27446427

A pilot study to examine the effect of the Tulip oropharyngeal airway on ventilation immediately after mask ventilation following the induction of anaesthesia.

PubMed

Robinson, P N; Shaikh, A; Sabir, N M; Vaughan, D J A; Kynoch, M; Hasan, M

2014-07-01

The Tulip airway is an adult, disposable, single-sized oropharyngeal airway, that is connectable to an anaesthetic circuit. After a standardised induction of anaesthesia in 75 patients, the ease of insertion, intracuff pressure and intracuff volume were measured, as were the end-tidal carbon dioxide levels, airway pressures and tidal volumes over three breaths. Successful first-time insertion was achieved in 72 patients (96%, CI 88.8-99.2%) and after two attempts in 74 patients (99%, CI 92.8-100%). There was outright failure only in one patient. In 60 patients (80%, CI 72.2-90.4%), the Tulip airway provided a patent airway without additional manoeuvres, but in 14 patients, jaw thrust or head extension was necessary for airway patency. The main need for these adjuncts appeared to be an initial under-inflation of the cuff. These promising results are consistent with recent manikin studies using this device. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

[Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway].

PubMed

Corso, Ruggero M; Cattano, Davide; Buccioli, Matteo; Carretta, Elisa; Maitan, Stefano

2016-01-01

Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway.

PubMed

Corso, Ruggero M; Cattano, Davide; Buccioli, Matteo; Carretta, Elisa; Maitan, Stefano

2016-01-01

Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Muscle Bioenergetic Considerations for Intrinsic Laryngeal Skeletal Muscle Physiology

ERIC Educational Resources Information Center

Sandage, Mary J.; Smith, Audrey G.

2017-01-01

Purpose: Intrinsic laryngeal skeletal muscle bioenergetics, the means by which muscles produce fuel for muscle metabolism, is an understudied aspect of laryngeal physiology with direct implications for voice habilitation and rehabilitation. The purpose of this review is to describe bioenergetic pathways identified in limb skeletal muscle and…

Serotonin in the solitary tract nucleus shortens the laryngeal chemoreflex in anesthetized neonatal rats

PubMed Central

Donnelly, William T.; Bartlett, Donald; Leiter, J.C.

2017-01-01

The laryngeal chemoreflex (LCR), an airway protective reflex that causes apnea and bradycardia, has long been suspected as an initiating event in the sudden infant death syndrome (SIDS). Serotonin (5-HT) and 5-HT receptors may be deficient in the brainstems of babies who die of SIDS, and 5-HT seems to be important in terminating apneas directly or in causing arousals or as part of the process of autoresuscitation. We hypothesized that 5-HT in the brainstem would limit the duration of the LCR. We studied anesthetized rat pups between 7 and 21 days of age and made microinjections into the cisterna magna or into the nucleus of the solitary tract (NTS). Focal, bilateral microinjections of 5-HT into the caudal NTS significantly shortened the LCR. The 5-HT 1a receptor antagonist, WAY 100635, did not affect the LCR consistently, nor did a 5-HT2 receptor antagonist, ketanserin, alter the duration of the LCR. The 5-HT3 specific agonist, 1-(3-chlorophenyl)-biguanide, microinjected bilaterally into the caudal NTS significantly shortened the LCR. Thus, endogenous 5-HT released within the NTS may curtail the respiratory depression that is part of the LCR, and serotonergic shortening of the LCR may be attributed to activation of 5-HT3 receptors within the NTS. 5-HT3 receptors are expressed presynaptically on C-fiber afferents of the superior laryngeal nerve, and serotonergic shortening of the LCR may be mediated presynaptically by enhanced activation of inhibitory interneurons within the NTS that terminate during the LCR. PMID:27121960

The Icatibant Outcome Survey: treatment of laryngeal angioedema attacks

PubMed Central

Aberer, Werner; Bouillet, Laurence; Caballero, Teresa; Maurer, Marcus; Fabien, Vincent; Zanichelli, Andrea

2016-01-01

Objective To characterize the management and outcomes of life-threatening laryngeal attacks of hereditary angioedema (HAE) treated with icatibant in the observational Icatibant Outcome Survey (NCT01034969) registry. Methods This retrospective analysis was based on data from patients with HAE type I/II who received healthcare professional-administered or self-administered icatibant to treat laryngeal attacks between September 2008 and May 2013. Results Twenty centers in seven countries contributed data. Overall, 42 patients with HAE experienced 67 icatibant-treated laryngeal attacks. Icatibant was self-administered for 62.3% of attacks (healthcare professional-administered, 37.7%). One icatibant injection was used for 87.9% of attacks, with rescue or concomitant medication used for 9.0%. The median time to treatment was 2.0 h (n=31 attacks) and the median time to resolution was 6.0 h (n=35 attacks). Conclusions This analysis describes successful use of icatibant for the treatment of laryngeal HAE attacks in a real-world setting. PMID:27116379

Influence of mask type and mask position on the effectiveness of bag-mask ventilation in a neonatal manikin.

PubMed

Deindl, Philipp; O'Reilly, Megan; Zoller, Katharina; Berger, Angelika; Pollak, Arnold; Schwindt, Jens; Schmölzer, Georg M

2014-01-01

Anatomical face mask with an air cushion rim might be placed accidentally in a false orientation on the newborn's face or filled with various amounts of air during neonatal resuscitation. Both false orientation as well as variable filling may reduce a tight seal and therefore hamper effective positive pressure ventilation (PPV). We aimed to measure the influence of mask type and mask position on the effectiveness of PPV. Twenty neonatal staff members delivered PPV to a modified, leak-free manikin. Resuscitation parameters were recorded using a self-inflatable bag PPV with an Intersurgical anatomical air cushion rim face mask (IS) and a size 0/1 Laerdal round face mask. Three different positions of the IS were tested: correct position, 90° and 180° rotation in reference to the midline of the face. IS masks in each correct position on the face but with different inflation of the air cushion (empty, 10, 20 and 30 mL). Mask leak was similar with mask rotation to either 90° or 180° but significantly increased from 27 (13-73) % with an adequate filled IS mask compared to 52 (16-83) % with an emptied air cushion rim. Anatomical-shaped face mask had similar mask leaks compared to round face mask. A wrongly positioned anatomical-shaped mask does not influence mask leak. Mask leak significantly increased once the air cushion rim was empty, which may cause failure in mask PPV.

Peptidase modulation of airway effects of neuropeptides.

PubMed

Lilly, C M; Drazen, J M; Shore, S A

1993-09-01

SP and NKA are potent endogenous bronchoconstrictors, whereas VIP is a potent endogenous bronchodilator. There is abundant evidence that these neuropeptides are released in the lung in a variety of conditions and that they have the capacity to modulate the bronchoactivity of the same stimuli that release them. On many occasions, their bronchoactive effects are masked by their degradation at or near the site of their release. However, when the microenvironment is modified to decrease their cleavage, they can express enhanced physiologic effects. Although it appears that the human asthmatic lung may be an environment in which the effects of neuropeptides can be amplified, the role of neuropeptides in the pathogenesis of airway obstruction remains speculative.

The role of laryngeal electromyography in vagus nerve stimulation-related vocal fold dysmotility.

PubMed

Saibene, Alberto M; Zambrelli, Elena; Pipolo, Carlotta; Maccari, Alberto; Felisati, Giovanni; Felisati, Elena; Furia, Francesca; Vignoli, Aglaia; Canevini, Maria Paola; Alfonsi, Enrico

2017-03-01

Vagus nerve stimulation (VNS) is a useful tool for drug-resistant epilepsy, but it induces known laryngeal side effects, with a significant role on patients' quality of life. VNS patients may show persistent left vocal fold (LVF) palsy at rest and/or recurrent LVF adduction during stimulation. This study aims at electromyographically evaluating laryngeal muscles abnormalities in VNS patients. We compared endoscopic laryngeal evaluation data in six VNS patients with laryngeal muscle electromyography (LMEMG) carried out on the thyroarytenoid, cricothyroid, posterior cricoarytenoid, and cricopharyngeal muscles. Endoscopy showed LVF palsy at rest in 3/6 patients in whom LMEMG documented a tonic spastic activity with reduced phasic modulation. In four out of six patients with recurrent LVF adduction during VNS activation, LMEMG showed a compound muscle action potential persisting for the whole stimulation. This is the first LMEMG report of VNS-induced motor unit activation via recurrent laryngeal nerve and upper laryngeal nerve stimulation. LMEMG data were could, therefore, be considered consistent with the endoscopic laryngeal examination in all patient.

Complications of laryngeal framework surgery (phonosurgery).

PubMed

Tucker, H M; Wanamaker, J; Trott, M; Hicks, D

1993-05-01

The rising popularity of surgery involving the laryngeal framework (surgical medialization of immobile vocal folds, vocal fold tightening, pitch variation, etc.) has resulted in increasing case experience. Little has appeared in the literature regarding complications or long-term results of this type of surgery. Several years' experience in a major referral center with various types of laryngeal framework surgery has led to a small number of complications. These have included late extrusion of the prosthesis and delayed hemorrhage. A review of these complications and recommendations for modification of technique to minimize them in the future are discussed.

A novel variation of the recurrent laryngeal nerve.

PubMed

Wu, Gaosong; Wang, Kun

2017-06-02

Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery. Several anatomic variations of the nerve increase the likelihood of iatrogenic damage. A 50-year-old woman was presented to our department with a nodule in the right thyroid lobe, and she reported no voice changes. She had no history of surgery or radiation to the head or neck. Fine-needle aspiration was recorded as papillary thyroid carcinoma. The preoperative laryngoscopy revealed left vocal cord paralysis. Right thyroid lobectomy was performed. A scarce course of the left recurrent laryngeal nerve was found during the operation that ascended along the medial edge of the superior thyroid pole and finally disappeared beneath the superior cornu of the thyroid cartilage without any tracheal, esophageal, or laryngeal branches. The patient was discharged on the third postoperative day with the diagnoses of papillary thyroid carcinoma and congenital left vocal cord paralysis. The novel variation of the recurrent laryngeal nerve may challenge the current concept of the anatomy of the nerve. The vocal folds mobility should be examined routinely before surgery in patients undergoing thyroid operation.

Recurrent Laryngeal Nerve Injury In Total Versus Subtotal Thyroidectomy.

PubMed

Sajid, Tahira; Qamar Naqvi, Syeda Rifaat; Qamar Naqvi, Syeda Saima; Shukr, Irfan; Ghani, Rehman

2016-01-01

Both Total and Subtotal Thyroidectomy are correct treatment options for symptomatic Euthyroid Multinodular Goitre. The choice depends upon surgeon's preference due to consideration of disadvantages like permanent hypothyroidism in Total Thyroidectomy and high chances of recurrence in Subtotal Thyroidectomy. Many surgeons believe that there is a higher incidence of Recurrent Laryngeal nerve injury in Total Thyroidectomy which affects their choice of surgery. This study aimed to compare the incidence of recurrent laryngeal nerve injury in total versus subtotal thyroidectomy. This non randomized controlled trial was carried out at Department of Surgery and ENT of Ayub Teaching Hospital Abbottabad, and Combined Military Hospital Rawalpindi from 1st September 2013 to 30th August 2014. During the period of study, patients presenting in surgical outpatient department with euthyroid multinodular goitre having pressure symptoms requiring thyroidectomy were divided into two groups by convenience sampling with 87 patients in group 1 and 90 patients in group 2. Group-1 was subjected to total thyroidectomy and Group -2 underwent subtotal thyroidectomy. All the patients had preoperative Indirect Laryngoscopy examination and it was repeated postoperatively to check for injury to the recurrent laryngeal nerve. A total of 177 patients were included in the study. Out of these, 87 patients underwent total thyroidectomy (Group-1). Two of these patients developed recurrent laryngeal nerve injury (2.3%). In group-2 subjected to subtotal thyroidectomy, three of the patients developed recurrent laryngeal nerve injury (3.3%). The p-value was 0.678. The overall risk of injury to this nerve in both surgeries combined was 2.8%. There is no significant difference in the risk of recurrent laryngeal nerve damage in patients undergoing total versus subtotal thyroidectomy.