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Byline: Maria Elena Ochoa (1), Maria del Carmen Marin (2), Fernando Frutos-Vivar (3,4), Federico Gordo (5), Jaime Latour-Perez (6), Enrique Calvo (5), Andres Esteban (3,4) Keywords: Upper airway obstruction; Reintubation; Cuff-leak test; Meta-analysis; Likelihood ratio Abstract: Purpose To evaluate, in adults, the diagnostic accuracy of the cuff-leak test for the diagnosis of upper airway obstruction secondary to laryngeal edema and for reintubation secondary to upper airway obstruction. Methods Systematic review without language restrictions based on electronic databases and manual review of the literature up to December 2008. When appropriate, a random-effects meta-analysis and meta-regression (Moses' method) were performed. Results Upper airway obstruction was the outcome in nine studies with an overall incidence of 6.9%. There was significant heterogeneity among studies. The pooled sensitivity was 0.56 (95% confidence interval: 0.48--0.63), the specificity was 0.92 (95% CI: 0.90--0.93), the positive likelihood ratio was 5.90 (95% CI: 4.00--8.69), the negative likelihood ratio was 0.48 (95% CI: 0.33--0.72), and the diagnostic odds ratio was 18.78 (95% CI: 7.36--47.92). The area under the curve of the summary receiver-operator characteristic (SROC) was 0.92 (95% CI: 0.89--0.94). Only three studies have evaluated the accuracy of the cuff-leak test for reintubation secondary to upper airway obstruction. Overall incidence was 7%. The pooled sensitivity was 0.63 (95% CI: 0.38--0.84), the specificity was 0.86 (95% CI: 0.81--0.90), the positive likelihood ratio was 4.04 (95% CI: 2.21--7.40), the negative likelihood ratio was 0.46 (95% CI: 0.26--0.82), and the diagnostic odds ratio was 10.37 (95% CI: 3.70--29.13). Conclusions A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction. Author Affiliation: (1) Fundacion Valle del Lili, Cali, Colombia (2) Hospital Regional 1Ao de Octubre, Mexico DF, Mexico (3) Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12,500, Getafe, Madrid, Spain (4) CIBER Enfermedades Respiratorias, Madrid, Spain (5) Hospital del Henares, Coslada, Madrid, Spain (6) Hospital General Universitario de Elche, Alicante, Spain Article History: Registration Date: 16/04/2009 Received Date: 03/03/2009 Accepted Date: 14/04/2009 Online Date: 28/04/2009

Byline: Samir Jaber (1), Gerald Chanques (1), Stefan Matecki (2), Michele Ramonatxo (2), Christine Vergne (3), Bruno Souche (1), Pierre-Francois Perrigault (1), Jean-Jacques Eledjam (1) Keywords: Post-extubation stridor Airway obstruction Laryngeal edema Extubation failure Cuff-leak test Helium-oxygen Unplanned extubation Abstract: Abstract Objective. To evaluate the incidence and identify factors associated with the occurrence of post-extubation stridor and to evaluate the performance of the cuff-leak test in detecting this complication. Design. Prospective, clinical investigation. Setting. Intensive care unit of a university hospital. Patients. Hundred twelve extubations were analyzed in 112 patients during a 14-month period. Intervention. A cuff-leak test before each extubation. Measurements and results.The incidence of stridor was 12%. When we chose the thresholds of 130 ml and 12% to quantify the cuff-leak volume, the sensitivity and the specificity of the test were, respectively, 85% and 95%. The patients who developed stridor had a cuff leak significantly lower than the others, expressed in absolute values (372+-170 vs 59+-92 ml, p Conclusion. A low cuff-leak volume ( Author Affiliation: (1) Department of Anesthesiology. Intensive Care and Transplantation Unit (DAR B), Chu de Montpellier Hopital Saint Eloi, 80, avenue Augustin Fliche, 34295 Montpellier Cedex 5, France (2) Service central de Physiologie Clinique, Chu de Montpellier Hopital Arnaud de Villeneuve, 371, avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France (3) Department of Biostatistics, Faculty of Medicine, Chu de Montpellier Hopital Arnaud de Villeneuve, 371, avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France Article History: Received Date: 25/04/2002 Accepted Date: 08/10/2002 Article note: Electronic Publication

Byline: S. Epstein (1) Keywords: Extubation failure Mechanical ventilation Outcome Non-invasive ventilation Respiratory secretions Upper airway obstruction Predictors Abstract: The need for reintubation within 24--72 h of planned extubation is a common event, occurring in 2--25% of extubated patients. Risk factors for extubation failure include being a medical, multidisciplinary or paediatric patient age >70 years a longer duration of mechanical ventilation use of continuous intravenous sedation and anaemia (haemoglobin Author Affiliation: (1) Medical Intensive Care Unit, Pulmonary and Critical Care Division, Box 369, New England Medical Center, Tufts University School of Medicine, 750 Washington St., Boston, MA 02111, USA Article History: Received Date: 22/11/2001 Accepted Date: 25/01/2002 Article note: Electronic Publication

Byline: Pankaj Kumar (1), Amit Roy (1), Daniel J. Penny (2), George Ladas (1), Peter Goldstraw (1) Keywords: Congenital cardiac defects Vascular compression Airway obstruction Ventilated children Stents Abstract: Objective: Young children with congenital cardiac defect and airway obstruction leading to ventilator dependency present a significant clinical challenge with uncertain outcome. Design: Retrospective review of our experience with self-expanding metal stents in these young children between 1996--2000. Results: Airway stenting has been undertaken in five such children (four boys, one girl) at our institution. Their mean age was 7.4 months (range 2--14 months), and four of the five had undergone congenital cardiac surgery and could not be weaned from the ventilator following surgery. These five children were ventilator dependent for a mean of 112 days (range 40--210 days, median 71). A total of ten self-expanding metal stents were inserted (4--11 mm in diameter and 15--33 mm in length). The sites stented included the trachea (two stents), the left main bronchus (three stents) and the bronchus intermedius (five stents). Four of these five children were successfully weaned from the ventilator and extubated after a mean time interval of 6 days (range 2--11 days, median 5.5) after stenting. One child failed to wean from the ventilator, required tracheostomy and is ventilator dependent after 8 months. There was one death 2 months after extubation but unrelated to the airway. Three children remain well and asymptomatic 24, 36 and 54 months after stenting. Conclusions: Airway stenting in such young children is an infrequent procedure often undertaken in dire circumstances. We have found it valuable in enabling ventilator-dependent children to be extubated with encouraging early results. Their long-term outlook remains uncertain and is dependent on the underlying cardiac status. Author Affiliation: (1) Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK (2) Paediatric Intensive Care, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK Article History: Received Date: 30/05/2001 Accepted Date: 05/11/2001 Article note: Electronic Publication