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Background: Post-extubation stridor indicates the presence of laryngeal edema. The documented occurrence of post-extubation airway blockage ranges from 4 to 37%. Aim: To evaluate the effectiveness of sonar assessment of laryngeal air column width difference to predict post-extubation upper airway obstruction and its relation to cuff leak volume. Patients and methods: This was an observational, descriptive cross-sectional study, conducted on 48 mechanically ventilated patients fulfilling weaning criteria at the ICU of Chest Department, Faculty of Medicine, Zagazig University, from July 2022 to March 2023. Results: A statistically insignificant variance was observed among COPD, ILD, overlap (OSA-COPD), pneumonia, aspiration pneumonia, and PE regarding laryngeal air column width difference (LACWD), while a statistically significant variance was observed among COPD, ILD, overlap (OSA-COPD), pneumonia, aspiration pneumonia, and PE regarding CLV; there was no correlation among cuff leak volume and LACWD, and there were 40 patients (83.3%) who had no post-intubation upper air way obstruction and 8 patients (16.7%) had post-intubation upper airway obstruction: 4 of them (8.3%) had success weaning, and 4 (8.3%) had failed weaning; and at cutoff value 140 ml, cuff leak volume had sensitivity of 100% and specificity of 97.5% with significance for prediction of stridor, and at cutoff value 1.15 mm, LACWD had sensitivity of 87.5% and specificity of 67.5% with significance for prediction of stridor. Conclusion: Cuff leak volume and ultrasound-guided LACWD effectively predict post-extubation upper airway obstruction, suggesting their integration into institutional extubation protocols. [ABSTRACT FROM AUTHOR]

Abstract Introduction Addressing acquired laryngotracheal stenosis presents a complex healthcare dilemma. Results We present a case series of 48 acquired post-intubation laryngotracheal stenosis cases managed within our Department of ENT Surgery at Farhat Hached Tunisia. Diagnosis relied on imaging and endoscopic findings. Among these cases, 28 exhibited tracheal stenosis, with 60% falling into grade 2–3 severity. Management approaches included sole endoscopic dilation for 17 patients, surgical intervention for 19 patients, and T-tube placement for 10 patients. Conclusions The management of laryngotracheal stenosis poses a challenge for ENT surgeons. Prevention is paramount, encompassing various measures such as employing high-volume, high tracheostomy, and extended intubation practices.

The aim of our study is to analyze the efficacy of nasal septal cartilage as cap-graft in laryngo-tracheoplasty in cases of Laryngotracheal stenosis. This was a prospective observational study carried out at a tertiary care hospital from March 2020 to March 2023. Total 8 patients who underwent laryngo-tracheoplasty using nasal septal cartilage as anterior Cap-graft were included in the study. Detailed history and clinical evaluation followed by diagnostic Flexible Fiber-optic Laryngoscopy and radiological investigations were done for all patients with post operative follow up for at least 1 year. Our study had maximum patients in age group of 11–30 years with male predominance, unknown compound ingestion being most common cause of intubation which was followed by tracheostomy. All patients had Cotton Mayer Grade III or IV subglottic stenosis. Out of 8 patients, 5 patients are decannulated, 1 patients still have T-tube in-situ whereas 2 patients didn't tolerate decannulation and required re-exploration. No donor site complication was seen during the study period. Nasal septal cartilage is a viable option for being used as anterior cap graft in laryngo-tracheoplasty. It can be a game changer, as can be done by E.N.T surgeon himself. No separate learning skills are required. It's cosmetically better with minimal complications; compared to life threatening complications like pneumothorax on using costal cartilage. Laryngeal framework is preserved as opposed to thyroid alar cartilage graft. Faster healing along with better postoperative donor site recovery are significant advantages. [ABSTRACT FROM AUTHOR]

Introduction: Addressing acquired laryngotracheal stenosis presents a complex healthcare dilemma. Results: We present a case series of 48 acquired post-intubation laryngotracheal stenosis cases managed within our Department of ENT Surgery at Farhat Hached Tunisia. Diagnosis relied on imaging and endoscopic findings. Among these cases, 28 exhibited tracheal stenosis, with 60% falling into grade 2–3 severity. Management approaches included sole endoscopic dilation for 17 patients, surgical intervention for 19 patients, and T-tube placement for 10 patients. Conclusions: The management of laryngotracheal stenosis poses a challenge for ENT surgeons. Prevention is paramount, encompassing various measures such as employing high-volume, high tracheostomy, and extended intubation practices. [ABSTRACT FROM AUTHOR]

Introduction: Adequate post-intubation sedation and analgesia (PISA) practices are important in the pre-hospital setting where vibration and noise of the transport vehicle may contribute to anxiety and pain in the patient. These practices are poorly described in the pre-hospital setting. This study aims to describe the current pre-hospital PISA practices in a private South African (SA) emergency medical service. Methodology: Patient report forms (PRF) of intubated patients between 1 Jan 2017 and 31 Dec 2017 from a private ambulance service were reviewed. The data were analysed descriptively. Correlations between receiving PISA and various predictive factors were calculated with Spearman's Rank correlations and differences between intubation method were calculated with independent t-tests and Mann-Whitney U tests. A binomial regression model was used to determine predictive factors of receiving PISA. Results: The number of PRFs included for analysis was 437. Of these, 69% of patients received PISA. The estimated time from intubation to 1st PISA ranged from 9 to 12 min. There were statistically significantly more PISA interventions in patients who had received Rocuronium (p < 0.01). There was weak correlation between the number of interventions and the mean arterial pressure, (p < 0.05) and with the transport time to hospital (rs = -0.77, p < 0.01). Conclusion: Sixty nine percent of patients who are intubated pre-hospital receive PISA, which leaves up to 30% without PISA. The time to 1st PISA appears to be shorter in the SA setting. There is an increased number of interventions in the patients who received Rocuronium, which may indicate practitioners being mindful of wakeful paralysis. Patients intubated with RSI are more likely to receive PISA and practitioners take the blood pressure prior to and after intubation into account when administering PISA. Longer transport times attribute to patients receiving more PISA interventions.

Adequate post-intubation sedation and analgesia (PISA) practices are important in the pre-hospital setting where vibration and noise of the transport vehicle may contribute to anxiety and pain in the patient. These practices are poorly described in the pre-hospital setting. This study aims to describe the current pre-hospital PISA practices in a private South African (SA) emergency medical service. Patient report forms (PRF) of intubated patients between 1 Jan 2017 and 31 Dec 2017 from a private ambulance service were reviewed. The data were analysed descriptively. Correlations between receiving PISA and various predictive factors were calculated with Spearman's Rank correlations and differences between intubation method were calculated with independent t-tests and Mann-Whitney U tests. A binomial regression model was used to determine predictive factors of receiving PISA. The number of PRFs included for analysis was 437. Of these, 69% of patients received PISA. The estimated time from intubation to 1st PISA ranged from 9 to 12 min. There were statistically significantly more PISA interventions in patients who had received Rocuronium (p < 0.01). There was weak correlation between the number of interventions and the mean arterial pressure, (p < 0.05) and with the transport time to hospital (r s = -0.77, p < 0.01). Sixty nine percent of patients who are intubated pre-hospital receive PISA, which leaves up to 30% without PISA. The time to 1st PISA appears to be shorter in the SA setting. There is an increased number of interventions in the patients who received Rocuronium, which may indicate practitioners being mindful of wakeful paralysis. Patients intubated with RSI are more likely to receive PISA and practitioners take the blood pressure prior to and after intubation into account when administering PISA. Longer transport times attribute to patients receiving more PISA interventions. [ABSTRACT FROM AUTHOR]

BackgroundPost-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients.MethodsThis retrospective analysis is based on a prospectively collected series (2003–2020) of 62 patients with PITL, staged and treated according to our revised morphological classification.ResultsFifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity.ConclusionsOur previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.

Introduction: Tracheoesophageal fistula (TEF) is a rare condition, which could be life-threatening if diagnosed late or mismanaged. Post-intubation TEF is the most common form of acquired, non-malignant TEF and is usually associated with tracheal stenosis, which makes the treatment more challenging. Here, we present our experience of managing 21 patients with post-intubation TEF. Materials & Methods: Twenty one patients including seven women and fourteen men with mean age of 38.05 years, who had post-intubation TEF were managed in our center (Massih Daneshvari Hospital, Tehran, Iran) during 2004-2013. None of the patients were operated before weaning from mechanical ventilation. Single division and closure of the fistula was performed in one patient who did not have accompanying tracheal stenosis. One-stage surgical repair including tracheal resection, anastomosis, primary closure of the esophageal defect, and muscle flap Interposition was the main treatment method in all other cases. Patients were followed up for at least two years. Results: Excellent and good results achieved in 85.7% of our patients. Major complications including permanent vocal cord paralysis and recurrence of tracheal stenosis necessitating T-tube insertion occurred in two patients (9.5%). Severe cachexia and sepsis secondary to sputum retention resulted in one mortality (4.8%). Conclusion: Surgery might provide the best treatment results along with low mortality and morbidity rates in post-intubation TEFs if performed within the proper time.

Tracheal stenosis is an uncommon but known complication of endotracheal intubation and tracheostomy. Surgery is currently the definitive treatment for tracheal stenosis but carries a significantly higher risk for adverse events as it often involves complex procedures. Here we present our experience using topical application of mitomycin C, along with various bronchoscopic interventions, as a treatment for tracheal stenosis. The patients in our series developed tracheal stenosis post-intubation or post-tracheostomy. Each patient in our series underwent the same basic procedures involving rigid bronchoscopy and balloon dilation, ablation of granulation tissue with cryotherapy and argon plasma coagulation, and finally application of topical mitomycin C. Our experience with these four cases shows a good initial success rate with topical mitomycin C application for the treatment of tracheal stenosis. Most patients required a repeat intervention a few weeks later. Our results suggest that success with topical mitomycin C is more likely in post-intubation rather than post-tracheostomy tracheal stenosis. Bronchoscopic therapy and topical application of mitomycin C may work better as a bridge to definitive surgery rather than as a stand-alone therapy.

Introduction: Tracheoesophageal fistula (TEF) is a rare condition, which could be life-threatening if diagnosed late or mismanaged. Post-intubation TEF is the most common form of acquired, non-malignant TEF and is usually associated with tracheal stenosis, which makes the treatment more challenging. Here, we present our experience of managing 21 patients with post-intubation TEF. Materials & Methods: Twenty one patients including seven women and fourteen men with mean age of 38.05 years, who had post-intubation TEF were managed in our center (Massih Daneshvari Hospital, Tehran, Iran) during 2004-2013. None of the patients were operated before weaning from mechanical ventilation. Single division and closure of the fistula was performed in one patient who did not have accompanying tracheal stenosis. One-stage surgical repair including tracheal resection, anastomosis, primary closure of the esophageal defect, and muscle flap Interposition was the main treatment method in all other cases. Patients were followed up for at least two years. Results: Excellent and good results achieved in 85.7% of our patients. Major complications including permanent vocal cord paralysis and recurrence of tracheal stenosis necessitating T-tube insertion occurred in two patients (9.5%). Severe cachexia and sepsis secondary to sputum retention resulted in one mortality (4.8%). Conclusion: Surgery might provide the best treatment results along with low mortality and morbidity rates in post-intubation TEFs if performed within the proper time. [ABSTRACT FROM AUTHOR]

Introduction: Tapia's syndrome is a rare condition that manifest due to unilateral extracranial nerve extension of cranial nerve 10 and 12 which occurred as a rare complication of Orotracheal Intubation in patient undergoing Laparoscopic appendectomy., Case Presentation: A 30 year old male, a known case of normal variant Right bundle branch block and Gilbert syndrome underwent orotracheal intubation prior to general anesthesia for emergency laparoscopic appendectomy. Postoperatively while assessing the patient there was deviation of tongue on left side., Clinical Findings and Investigations: On examination of throat, atrophic and deviated uvula toward the right side was found. While protruding his tongue, tongue was deviated towards left side.Neurological examination revealed sluggish Gag Reflex. Brain Ct was done, which showed normal scan., Interventions and Outcome: Tablet Prednisolone and logopedic therapy in combination helped in early recovery; which is almost 8 weeks. Patient was completely recovered in 2 month with gradual improvement of phonation, tongue tone and mobility., Relevance and Impact: The intent of this report is to show how important it is for anesthesia providers and surgeons to understand Tapia's syndrome, its causes, and the fact that it can occur despite seemingly normal airway care and neck posture. We believe that by raising awareness of this uncommon issue, practitioners will be able to early identify this complication., Competing Interests: There is no any conflicts of interest with this article., (© 2022 The Authors.)

The current global COVID-19 pandemic is caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Currently, acquired tracheoesophageal fistulas are mainly iatrogenic lesions produced by prolonged tracheal intubation. We present a case of tracheoesophageal fistula with severe tracheal stenosis following tracheal intubation in a patient with SARS-CoV-2 infection.

Post-intubation tracheal laceration (PITL) is a rare and potential life-threatening condition requiring prompt diagnosis and treatment. A conservative treatment is indicated in patients with laceration <2 cm in length while surgery is the treatment of choice for laceration >4 cm. For laceration between 2-4 cm, the best treatment is debate; some authors recommend surgery while others do not definitely exclude endoscopic treatment. Herein, we reported the endoscopic treatment with fibrin glue of PITL. The procedure is performed using a standard video-bronchoscopy in operating room; the patient is in spontaneous breathing and deep sedation. After identification of tracheal laceration, the fibrin glue is injected through a dedicated double lumen catheter into the lesion. After mixing both components of fibrin glue, polymerization of fibrin occurs resulting in an elastic and opaque clot that closes the lesion. The key success of the procedure is based on accurate patient selection. Patients are eligible if (I) they are clinically stable and in spontaneous respiration; (II) with a small and superficial tracheal laceration (≤4 cm in length and without oesophageal injury); (III) localized at level of the upper or middle trachea; and (IV) without clinical and/or radiological signs of mediastinal collection, of emphysema or pneumomediastinum progression, and of infection., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objectives: Injuries to the tracheobronchial region are rare, but have the potential for rapid progression and can become life-threatening. Etiologies of non-penetrating tracheobronchial injuries include blunt cervical trauma, endotracheal intubation, and other iatrogenic causes. Several options for treatment ranging from conservative to surgical exist, but no single treatment has been implemented with consensus. While early surgical repair was once considered the cornerstone of therapy, evidence supporting conservative treatment continues to gain strength., Methods: All pediatric patients who suffered from non-penetrating injuries to the tracheobronchial tree who were treated by the Otolaryngology Service at a tertiary children's hospital from May 2012 through March 2014 were recorded. A total of 8 patients were identified. The cases were collected from the patients treated by the Otolaryngology Department based on retrospective review. The available electronic medical records were reviewed for each patient. Data including type of injury, endoscopic assessment of injury, treatment received, and follow-up were collected., Results: The ages ranged from 2 to 15 years old, with a mean of 9.25 years old. Six of the eight patients had injuries related to endotracheal intubation. Each patient was taken to the operating suite for diagnostic direct laryngoscopy and bronchoscopy, and treated with initial conservative management. All but one of the patients was treated with endotracheal intubation, and the average length of intubation was 11.71 days. All of the injuries healed spontaneously without requiring initial open surgery. Five patients (62.5%) developed some degree of tracheal stenosis. Three patients (37.5%) required further surgery; one received a tracheostomy and two patients required balloon dilation., Conclusions: This case series is the largest to date documenting the outcomes of conservative treatment of non-penetrating traumatic tracheal injuries in children. By using initial conservative therapy, we were able to avoid open surgical procedures in many of our patients. We believe that this case series provides further support for conservative management for children with tracheobronchial injuries., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)