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Background and Objective: Upper airway surgery for obstructive sleep apnoea (OSA) is an alternative treatment for patients who are intolerant of continuous positive airway pressure (CPAP). However, upper airway surgery has variable treatment efficacy with no reliable predictors of response. While we now know that there are several endotypes contributing to OSA (i.e., upper airway collapsibility, airway muscle response/compensation, respiratory arousal threshold and loop gain), no study to date has examined: (i) how upper airway surgery affects all four OSA endotypes, (ii) whether knowledge of baseline OSA endotypes predicts response to surgery and (iii) whether there are any differences when OSA endotypes are measured using the CPAP dial-down or clinical polysomnographic (PSG) methods., Methods: We prospectively studied 23 OSA patients before and ≥3 months after multilevel upper airway surgery. Participants underwent clinical and research PSG to measure OSA severity (apnoea-hypopnoea index [AHI]) and endotypes (measured in supine non-rapid eye movement [NREM]). Values are presented as mean ± SD or median (interquartile range)., Results: Surgery reduced the AHI Total (38.7 [23.4 to 79.2] vs. 22.0 [13.3 to 53.5] events/h; p = 0.009). There were no significant changes in OSA endotypes, however, large but variable improvements in collapsibility were observed (CPAP dial-down method: ∆1.9 ± 4.9 L/min, p = 0.09, n = 21; PSG method: ∆3.4 [-2.8 to 49.0]%V eupnoea , p = 0.06, n = 20). Improvement in collapsibility strongly correlated with improvement in AHI (%∆AHI SupineNREM vs. ∆collapsibility: p < 0.005; R 2  = 0.46-0.48). None of the baseline OSA endotypes predicted response to surgery., Conclusion: Surgery unpredictably alters upper airway collapsibility but does not alter the non-anatomical endotypes. There are no baseline predictors of response to surgery., (© 2022 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

The use of high-flow nasal oxygen is gaining popularity in apneic and spontaneously breathing adult patients during anesthesia. This prospective observational study evaluated the effect of high-flow nasal oxygen in maintaining adequate oxygenation and ventilation in spontaneously breathing pediatric patients with dynamic airway obstruction, undergoing tubeless airway surgery. Oxygenation was provided via an age-appropriate, high-flow nasal cannula at a flow rate of 2 L kg-1 min-1. Propofol and remifentanil were used to maintain anesthesia while preserving spontaneous respiration. We sought to determine the incidence and risk factors of rescue ventilation. Rescue ventilation with a face mask was performed when the pulse oximetry oxygen saturation was <90% or transcutaneous carbon dioxide was >80 mm Hg. In total, 27 patients were included in the final analysis. Median (interquartile range) of pulse oximetry and transcutaneous carbon dioxide were 100% (99%-100%) and 58.4 mm Hg (51.4-70.3 mm Hg), respectively. Altogether, 9 (33.3%) patients needed rescue ventilation during anesthesia. Of these, 7 patients (25.9%) developed oxygen desaturation (<90%) and 2 patients (7.4%) developed hypercarbia. Patients who required rescue ventilation were significantly younger (8.2 vs 28.8 months, P = .02) and required a longer anesthesia time (55.7 vs 41.0 minutes, P = .04) than those who did not. In conclusion, High-flow nasal oxygen is an alternative technique to maintain oxygenation in children undergoing airway surgeries. However, younger age and longer anesthesia time are significant risk factors leading to the requirement of rescue ventilation in these patients. Further studies with large sample size are required for clinical application of these techniques., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: We examined rates of upper aerodigestive tract (UADT) procedures in a multi-institutional cohort of neonates with esophageal atresia/tracheoesophageal fistula (EA/TEF) to estimate secondary UADT pathology., Methods: A retrospective cohort study was performed using a previously-validated population of patients with EA/TEF within the Pediatric Health Information System (PHIS) between 2007 and 2015. ICD-9/10-CM codes for aerodigestive procedures were examined from 2007 to 2020: 1) diagnostic direct laryngoscopy and/or bronchoscopy (DLB), 2) DLB with intervention, 3) tracheostomy, 4) gastrostomy, 5) fundoplication, 6) aortopexy, 7) laryngotracheoplasty, and 8) esophageal dilation. Associations between procedures and demographics, length of gestation, and weight were estimated using generalized linear mixed models., Results: We identified 2,509 patients with EA/TEF from 47 hospitals, 56.7% male and 43.3% female. Median length of stay for the first admission was 24 days (interquartile range: 12-55). Of these patients, 1,943 (77.4%) had at least one aerodigestive procedure within 14 admissions. Specifically, 1,635 (65.2%) underwent diagnostic DLB, 85 (3.4%) DLB with intervention, 167 (6.7%) tracheostomy, 1,043 (41.2%) gastrostomy, 211 (11.0%) fundoplication, 52 (2.1%) aortopexy, 161 (6.4%) laryngotracheoplasty, and 207 (8.3%) esophageal dilation. Preterm gestation increased odds of tracheostomy (adjusted odds ratio (OR) 2.4, 95% confidence interval (CI) 1.5-3.7), gastrostomy (OR 2.1, CI 1.7-2.7), fundoplication (OR 1.7, CI 1.1-2.4), aortopexy (OR 5.8, CI 2.1-16.1), and esophageal dilation (OR 2.0, CI 1.4-3.0). Very low birth weight (<1,500 g) increased odds of gastrostomy (OR 2.5, CI 1.6-3.8)., Conclusion: Patients with EA/TEF frequently have aerodigestive sequelae. This work helps quantify aerodigestive needs in neonates with EA/TEF, suggesting early otolaryngology evaluation in their care., Level of Evidence: 3 Laryngoscope, 132:695-700, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Major airway surgery can pose a complex problem to perioperative central airway management. Adjuncts to advanced ventilation strategies have included cardiopulmonary bypass, veno-arterial, or veno-venous extracorporeal life support. We performed a systematic review to assess the existing evidence utilizing these strategies., Methods: An electronic search was conducted to identify studies written in English reporting the use of extracorporeal life support (ECLS) during central airway surgery. Thirty-six articles consisting of 78 patients were selected and patient-level data were analyzed., Results: Median patient age was 47 [IQR: 34-53] and 59.0% (46/78) were male. Indications for surgery included central airway or mediastinal cancer in 57.7% (45/78), lesion or injury in 15.4% (12/78), and stenosis in 12.8% (10/78). Support was initiated pre-operatively in 9.9% (7/71) and at the time of induction in 55.3% (42/76). It was most commonly used at the time of tracheal resection/repair [93.2% (68/73)], intubation of the tracheal stump [94.4% (68/72)], and re-anastomosis [94.2% (65/69)]; 13.7% (10/73) patients were supported post-operatively. The most commonly performed surgery was tracheal repair or resection in 70.3% (52/74). Median hospital stay was 12 [8, 25] days and in-hospital mortality was 7.9% (6/76). There was no significant difference in survival between the three groups (p = .54)., Conclusions: Extracorporeal membrane oxygenation offers versatility in timing, surgical approach, and ECLS runtime that makes it a viable addition to the surgical armamentarium for treating complex central airway pathologies., (© 2021 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.)

Central airway obstruction (CAO) can be attributed to several benign or malignant conditions. Although surgery is the preferred therapeutic option for the management of CAO, bronchoscopic treatment can be performed in scenarios where the surgical procedure is not possible. Recent years have witnessed several improvements in the field of bronchoscopic treatment, especially with regard to airway stents. Current research involves new attempts to overcome the existing shortcomings pertaining to the stents (migration, mucostasis, and granulation tissue formation). The authors have recently developed a new silicone airway stent (GINA stent) with an anti-migration design, dynamic structure that enables the reduction of stent cross-sectional area, and radio-opacity. The present study aimed to evaluate the mechanical characteristics and performance of the novel GINA stent using a porcine tracheal stenosis model. In the current study, all the tests involved the comparison of the GINA stent [outer diameter (OD, mm): 14; length (L, mm): 55] with the Dumon stent (OD: 14; L: 50). The mechanical tests were performed using a digital force gauge, in order to determine the anti-migration force, expansion force, and flexibility. The present study evaluated the short-term (3 weeks) performance of the two stents after implantation [GINA (n = 4) vs. Dumon (n = 3)] in the porcine tracheal stenosis model. The results pertaining to the comparison of the mechanical properties of the GINA and Dumon stents are stated as follows: anti-migration force (18.4 vs. 12.8 N, P = 0.008); expansion force (11.9 vs. 14.5 N, P = 0.008); and flexibility (3.1 vs. 4.5 N, P = 0.008). The results pertaining to the comparison of the short-term performance of the GINA and Dumon stents are stated as follows: mucus retention (0/4 vs. 0/3); granulation tissue formation (0/4 vs. 0/3); and migration (1/4 vs. 2/3). The GINA stent displayed better mechanical properties and comparable short-term performance, compared to the Dumon stent.

Purpose: While the prevalence of obstructive sleep apnea (OSA) is well documented in trisomy 21, there has been little published about the incidence in trisomy 13 (T13) and trisomy 18 (T18). Trisomies 13, 18, and 21 have overlapping clinical features that make patients prone to OSA. Because the literature regarding OSA in T13 and T18 children is limited, we performed a retrospective chart review to investigate the characteristics of these patients., Methods: We reviewed the medical records of children with T13 or T18 seen at seen at a single urban tertiary children's hospital for sleep disordered breathing from 1/1/10 to 5/1/18. Candidates were selected based on ICD-9 diagnosis and procedural codes., Results: We identified 21 T18 patients that had documented symptoms of SDB, of which 3 were diagnosed with OSA, 11 had clinical SDB, and 7 had snoring. Of the T13 patients, 10 had documented symptoms of SDB, of which 1 patient was diagnosed with OSA, 7 with clinical SDB, and 2 with snoring. In both T13 and T18 patients, anatomical features included micrognathia/mandibular hypoplasia, small mouth/small airway, midface hypoplasia, abnormal/difficult airway, glossoptosis, hypotonia, and GERD. Endoscopic findings included laryngomalacia and/or tracheomalacia, adenoid and lingual tonsil hypertrophy, and inferior turbinate hypertrophy. Surgical interventions performed in T13 and T18 patients included adenoidectomy, lingual tonsillectomy, and tracheostomy. Of the 32 T13 and T18 patients, 15 had to be intubated for respiratory insufficiency., Conclusion: The results of our study suggest that T13 and T18 patients are at increased risk for OSA due to common features found in this population. These findings indicate a need for otolaryngologist intervention to increase both survival and quality of life in this population., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy., Study Design: Consecutive case series with chart review., Setting: This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic., Methods: Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes., Results: A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded., Conclusion: This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.

Background: Airway stents are used to treat central airway stenosis or tracheal fistula caused by a variety of malignant and benign tracheal diseases as well as iatrogenic procedures. Airway stent placement has a satisfying effect in instantly relieving of symptoms, but the long-term survival of patients still depends on the individualized treatment of the primary diseases. Therefore, exploring the prognostic risk factors of patients who received airway stent placement can be beneficial to the optimization of the placement procedure and also the improvement of individualized clinical management of patients., Methods: Data of a total of 66 patients who underwent airway stent placement at the First Affiliated Hospital of Zhejiang University from January 2014 to June 2017 were retrospectively collected. Prognostic effects of the clinical characteristics as age, gender, Charlson comorbidity index (CCI) and procedure duration were analyzed., Results: Age and gender had no significant effect on the outcomes of the patients, while higher CCI (P=0.045) and procedure duration over 60 min (P=0.037) were both independent risk factors of poor prognosis. A prognostic nomogram was then constructed, of which the area under the curve of the receiver operating characteristic (ROC) curve and the concordance index (C-index) was 0.71 and 0.69, respectively., Conclusions: For patients receiving airway stent placement, the baseline CCI and the procedure duration had prognostic significance in clinical practice.

Background: Airway stents has been widely used in airway stenosis and fistula, yet clinical date of airway stents in reestablishment a complex airway is insufficient. The aim of this study is to evaluate the efficacy and safety to combine the silicon stent and the metal stent in reestablishment a complex malignant airway., Methods: Patients with non-operable complex malignant airway stenosis and fistula were recruited in this study. Silicon Y stent combined with covered metal stent (Hybrid stent) were inserted to reestablishment the airway. Clinical outcomes and complications were observed over six months., Results: A total of 23 silicon Y stents and 25 covered metal stents were inserted in 23 patients. Nineteen of 23 (19/23, 82.6%) patients felt a immediately relieving of current symptoms. The mean duration of stents placement in patients was (153.43±9.14) days. The modified British Medical Research Council, Karnofsky Performance Status and Performance Status scale were improved significantly after stenting. A total of 12 patients living with stent at 6 months. Others dead of tumor progression. There were no death or immediate complications related to hybrid stenting implication., Conclusions: Hybrid stenting proved to be useful and was well-tolerated in the management of complex malignant airway stenosis and fistula.

Anesthesia for pediatric airway procedures constitutes a true art form that requires training and experience. Communication between anesthetist and surgeon to establish procedure goals is essential in determining the most appropriate anesthetic management. But does the mode of anesthesia have an impact? Traditionally, inhalational anesthesia was the most common anesthesia technique used during airway surgery. Introduction of agents used for total intravenous anesthesia (TIVA) such as propofol, short-acting opioids, midazolam, and dexmedetomidine has driven change in practice. Ongoing debates abound as to the advantages and disadvantages of volatile-based anesthesia versus TIVA. This pro-con discussion examines both volatiles and TIVA, from the perspective of effectiveness, safety, cost, and environmental impact, in an endeavor to justify which technique is the best specifically for pediatric airway procedures., (© 2019 John Wiley & Sons Ltd.)

Shared airway surgery in children is a complex, high-risk undertaking that requires continuous communication and cooperation between the anesthetic and surgical teams. Airway abnormalities commonly seen in children, the surgical options, and the anesthetic techniques that can be used to care for this vulnerable population are discussed. Many of these procedures were traditionally carried out using jet ventilation, or intermittent tracheal intubation, but increasingly spontaneously breathing "tubeless" techniques are being used. This review has been written from both the surgical and anesthetic perspective, highlighting the concerns that both specialties have in relation to the maintenance of surgical access and operating conditions, and the need for the provision of anesthesia, oxygenation, and ventilation where the airway is the primary site of operation., (© 2019 John Wiley & Sons Ltd.)

High-flow nasal oxygenation (HFNO) is a promising new technique for anesthesiologists. The use of HFNO during the induction of anesthesia and during upper airway surgeries has been initiated, and its applications have been rapidly growing ever since. The advantages of this technique include its easy set-up, high tolerability, and its abilities to produce positive airway pressure and a high fraction of inspired oxygen and to influence the clearance of carbon dioxide to some extent. HFNO, via a nasal cannula, can provide oxygen both to patients who can breathe spontaneously and to those who are apneic; further, this technique does not interfere with bag-mask ventilation, attempts at laryngoscopy for tracheal intubation, and surgical procedures conducted in the airway. In this review, we describe the techniques associated with HFNO and the advantages and disadvantages of HFNO based on the current state of knowledge.

Introduction: Hypoxaemia during anaesthesia for tubeless upper airway surgery in children with abnormal airways is common due to the complexity of balancing adequate depth of anaesthesia with maintenance of spontaneous breathing and providing an uninterrupted field of view of the upper airway for the surgeon. High-flow nasal oxygenation (HIGH-FLOW) can prolong safe apnoea time and be used in children with abnormal airways but to date has not been compared with the alternative technique of low-flow nasal oxygenation (LOW-FLOW). The aim is to investigate if use of HIGH-FLOW can reduce the number of hypoxaemic events requiring rescue oxygenation compared with LOW-FLOW. METHODS AND ANALYSIS: H igh-flow oxygen for children's a irway surgery: rando m i s ed controll e d t r ial (HAMSTER) is a multicentre, unmasked, randomised controlled, parallel group, superiority trial comparing two oxygenation techniques during anaesthesia. Children (n=530) aged >37 weeks to 16 years presenting for elective tubeless upper airway surgery who fulfil inclusion but not exclusion criteria will be randomised prior to surgery to HIGH-FLOW or LOW-FLOW post induction of anaesthesia. Maintenance of anaesthesia with HIGH-FLOW requires Total IntraVenous Anaesthesia (TIVA) and with LOW-FLOW, either inhalational or TIVA at discretion of anaesthetist. The primary outcome is the incidence of hypoxaemic events requiring interruption of procedure for rescue oxygenation by positive pressure ventilation and the secondary outcome includes total hypoxaemia time, adverse cardiorespiratory events and unexpected paediatric intensive care admission admission. Hypoxaemia is defined as Sp0 2 <90%. Analysis will be conducted on an intention-to-treat basis., Ethics and Dissemination: Ethical approval has been obtained by Children's Health Queensland Human Research Ethics Committee (HREC/18/QRCH/130). The trial commenced recruitment in 2018. The primary manuscript will be submitted for publication in a peer-reviewed journal., Trial Registration Number: The HAMSTER is registered with the Australia and New Zealand Clinical TrialsRegistry: ACTRN12618000949280., Competing Interests: Competing interests: SH and AS have received support by Fisher & Paykel Health Care for travel and accommodation to attend conferences., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The early efforts of pediatric airway surgeons, gastroenterologists, and pulmonologists to optimize surgical outcomes involved evaluating multiple organ systems for diseases negatively affecting surgery. This resulted in coordinated clinics with multiple services, ancillary testing, and endoscopic procedures, known as aerodigestive programs. These programs have nationally increased the value of care, with multidisciplinary experts delivering organized and efficient care to children with complex needs. This article describes the origin and value of aerodigestive programs within the modern health care landscape, serving as a primer for providers and administrators investigating how to facilitate aerodigestive or similar programs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Tobacco smoke is the leading cause of chronic obstructive pulmonary disease. The aim of this study is to highlight the effectiveness of smoking cessation along with bronchial valve implantation in subjects with severe COPD., Methods: A sample of 25 patients, current smokers, affected by severe COPD and heterogeneous emphysema who quit smoking were compared with a group of 15 patients who did not quit smoking., Measurements and Main Results: Patients performed plethysmography, 6 minute walking test (WT), haemogasanalysis, exhaled CO test (eCO), COPD assessment test (CAT) together with the mMRC test. A clearer improvement of examined parameters was registered in the group of patients who quit smoking by varenicline and counselling. In particular, we observed a significant increase of FEV1 by 350 ml in the abstainers group compared with 100 ml increase in the non-abstainers(p < .05) group. We noticed that the RV% decreased by 30% compared with the 10% in the non-abstainers(p < .001). The CAT value decreased by 20 compared with 10 in current smokers(p < .001) as well as the mMRC score (p < .001) was more improved in abstainers. The total resistances were reduced by 30% versus 10% (p < .01)and notably there was a higher improvement of walking test (30 m versus 5) (p < .001). The eCO was clearly reduced in abstainers, 14 versus 8 (p < .002),. PaO2 increased by 4 mmHg versus 1(p < .0001)., Conclusions: Smoking cessation treatment by varenicline strengthens the effects of bronchial valve implantation and shows up its crucial therapeutic role in severe COPD., (Copyright © 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objectives: Spread through air spaces (STAS) as a pattern of invasion in lung adenocarcinomas had been recognized by WHO in 2015. Moreover, STAS was associated significantly with aggressive micropapillary or solid components when presented predominant pattern in lung adenocarcinomas, which had a poor prognostic significance. Small amounts of micropapillary or solid with components could also reduce overall survival and recurrence-free survival but its impact on STAS is unknown now. Some studies have demonstrated manipulations of surgeons and pathologists could affect STAS but the degree of these impacts is not clear., Materials and Methods: We reviewed resected small (≤ 2 cm) stage I invasive lung adenocarcinomas by thoracoscopic surgery at our institution from January 2017 to October 2018 (n = 277). Micropapillary or solid pattern was considered to be present when the subtype occupied at least 1% of the entire tumor. Lobectomy and segmentectomy were performed using three portals thoracoscopic surgery. Statistical analysis was performed to analyze the correlations of STAS and clinicopathological characteristics. Moreover, we also analyzed the correlated factors of STAS in solid nodules., Results: STAS was found in 59 of 163 (36.2%) lobectomy cases and 27 of 114 (23.7%) limited resection cases. Lobectomy group showed a higher incidence of STAS compared with limited resection group (p = 0.027), but the difference was disappeared in multivariate analysis, which showed that STAS was significantly correlated to solid nodules and presence of high grade histologic subtype (mircopapillary or solid). However, both lobectomy and presence of high grade histologic subtype were significantly correlated with STAS in solid nodules., Conclusions: The small amounts of high grade histologic subtypes were also associated with STAS. Thoracoscopic surgery could affect STAS to some degree.

Flexible fiberoptic bronchoscopy a vital diagnostic and therapeutic procedure for assessing the airway. Its logistics, clinical indications and utility need to be elucidated in pediatric context. Pediatric flexible fibreoptic bronchoscopy is useful for diagnosis of airway anomalies, bronchoalveolar lavage for diagnostic and therapeutic purposes, and interventions like foreign body removal. Newer ultra-thin bronchoscopes can be used to perform this procedure in children of all ages. Pediatric flexible bronchoscopy is a valuable diagnostic and therapeutic tool in the hands of skilled personnel when used judiciously.

Background: Endoscopic airway measurement (EAM) combines optical endoscopic instruments with open source image processing to accurately obtain airway dimensions. Preclinical models have demonstrated EAM as an accurate technique of airway measurement with the added advantage of characterizing multilevel stenosis, non-circular lesions, and distal obstruction. The aim of this prospective clinical study was to compare EAM to airway measurements obtained from endotracheal tube approximation (ETTA) during pediatric aerodigestive evaluation and to evaluate reproducibility of EAM across practitioners., Methods: Thirty-seven pediatric patients undergoing routine microlaryngoscopy and bronchoscopy at a single tertiary care children's hospital were prospectively recruited. Patients undergoing emergent procedures were excluded. Two blinded reviewers performed airway measurements using ImageJ (NIH) as previously described and average values were compared to ETTA measurements. Additional EAMs were obtained from an ex vivo airway model by 28 separate clinicians and were analyzed by the same reviewers to evaluate reproducibility., Results: EAM and ETTA measurements were themselves significantly different (p = 0.0003); however, the average absolute difference between the two methods was small (Mean: 0.5 mm, 95%CI: -2.6-1.6 mm). There were notable differences between raters such that estimates of raters with more experience were more similar to ETTA. Despite observed differences between EAM and ETTA, endoscopic airway measurement was highly correlated with ETTA (p = 0.0002, Spearman r = 0.4185), and strong agreement was observed (Bias: -0.4974 ± 1.083 mm, 95% LOA: -2.62-1.625 mm)., Conclusion: Clinical use of EAM is a valid and precise approach for quantification of airway luminal dimensions. This method may provide advantages over traditional ETTAs for evaluation of asymmetric airway morphology in the pediatric population., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Rationale: Foreign body (FB) aspiration in adults is occasionally encountered. The aspiration and impaction of a coin in the lower respiratory tract is an unusual accident. This report presents 2 rare adult cases of FB aspiration with coin impaction in larynx and trachea, respectively., Patient Concerns: Two patients presented to the emergency department separately. Both had a similar history of inadvertent ingestion of a 5-jiao coin that was accidentally enveloped in dumplings. The ingestion was immediately followed by violent cough., Diagnosis: The diagnosis of foreign body aspiration was confirmed by chest x-ray. In the first patient, chest computed tomography (CT) confirmed the shape of the coin and it was located in the laryngeal area, facing C5. In the second patient, CT revealed a metal-density FB located in the tracheal carina., Interventions: In the first patient, direct laryngoscopy was performed and the 5-Jiao coin was removed in a direction parallel to the vocal cords. In the second patient, rigid bronchoscopy was used to remove the coin., Outcomes: The postoperative period was uneventful in both the patients., Lessons: During FB removal, the coin should be positioned parallel to the vocal cords during its retrieval through the glottis. Due attention must be paid to avoid asphyxia due to positional changes of the coin in the trachea. Early diagnosis and intervention is the key in such cases as delay can cause catastrophic complications.

The thoracic surgeon occupies a unique position in the team of those who are involved in looking after surgical patients in need of airway operations. It may be for urgent and life-threatening situations as in tracheo-vascular fistula or critical airway obstruction. Or it may be semiurgent in the intensive care unit in patients on assisted ventilation requiring tracheostomy (open or percutaneous). It may be elective for patients with tracheal stricture (benign or malignant), cervical exenteration, anterior mediastinal tracheostomy, and tracheo-bronchomalacia., (Copyright © 2018 Elsevier Inc. All rights reserved.)

One of the most challenging tasks during airway surgery is ensuring adequate ventilation throughout the procedure. Because the airway is shared between surgeon and anesthesiologist, successful oxygenation and ventilation of the patient can only be accomplished through close collaboration during the various stages of the procedure. This includes periods in which surgical airway manipulation compromises adequate ventilation and periods in which ventilation interferes with the surgical environment. With continuous communication between surgeon and anesthesiologist, optimal outcomes can be achieved., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To highlight some of the legendary figures in the medical field who have paved the path of thoracic surgery today., Methods: We reviewed historical articles and landmark studies published in anesthesiology, pulmonology, and thoracic surgery, and summarized them as they pertain to current practice., Results: Throughout our article, we have attempted to chronologically depict how our field has evolved, starting from the development of the stethoscope to reconstructing the esophagus using an extracorporeal tube to minimally invasive complex surgeries that we practice today., Conclusions: We hope that our article can inspire the young minds to further grow the field and take it to higher levels., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Excessive dynamic airway collapse is a relatively new diagnosis separate from tracheobronchomalacia that is manifested by functional collapse of the large airways. Most commonly described in patients with underlying obstructive lung disease such as chronic obstructive pulmonary disease and asthma, it may contribute to increased dyspnea, cough, or exacerbations. There are few data published on the role of excessive dynamic airway collapse as related specifically to exercise. It was recently described as the cause for exertional dyspnea in individuals without underlying lung disease., (Published by Elsevier Inc.)

Objectives/hypothesis: To evaluate if upper airway surgery reduces blood pressure in patients with obstructive sleep apnea (OSA)., Study Design: Prospective series., Methods: A prospective series of 112 consecutive OSA patients with hypertension (HTN). All patients were > 18 years old, respiratory disturbance index >5, all levels of apnea-hypopnea index (AHI), with a history of HTN treated with medication for at least 6 months. Surgical procedures included septoplasty, turbinate reduction, palate surgery, and tongue base reduction., Results: There were 92 men and 20 women, with a mean age of 48.6 years, mean body mass index (BMI) was 27.5 (range, 19.7-34.7). Mean follow-up was 16.1 months. The mean preoperative AHI was 32.6 (range, 1.2-104), with the mean lowest oxygen saturation (LSAT) of 79.9% (range, 52%-93%). The mean adjusted preoperative and postoperative systolic blood pressure (SBP) was reduced from 146 ± 15.3 mm Hg to 122 ± 12.5 mm Hg (P < .001), and diastolic blood pressure (DBP) was reduced from 91 ± 10.2 mm Hg to 76 ± 7.8 mm Hg (P < .001). There was a decrease in overall BMI from 27.5 ± 3.6 to 25.5 ± 3.0 (P < .001); however, based on multivariate analysis, the reduction in SBP and DBP was not affected by this BMI reduction. Fifty-eight patients (51.8%) did not require their antihypertensive after surgery. There was poor correlation noted between HTN with AHI, LSAT, and oxygen duration <90%., Conclusions: Upper airway surgery does reduce SBP and DBP in patients with OSA., Level of Evidence: 4. Laryngoscope, 128:523-527, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To evaluate outcomes of foreign body aspiration (FBA) and to investigate surgeon and hospital volume as risk factors for a complicated course., Study Design: Retrospective case series., Methods: Children with FBA in a multihospital network were identified from January 2005 to September 2015. Demographic information, surgeon, and hospital location were reviewed. Mean operative time and hospital length of stay were recorded. Cases requiring intensive care unit admission, hospital stay greater than 24 hours, need for more than one bronchoscopy, operative time greater than 1 hour, or death were considered "complicated.", Results: A total of 450 cases of airway foreign body extraction were performed. Patient ages ranged from 0.6 to 18.8 years, with a median age of 1.9 years. Bronchoscopy with foreign body extraction was performed by 55 different surgeons at 11 different facilities. There were one to 24 surgeons for each facility, with an average number of 5.4 surgeons per facility. A total of 88 (19.6%) cases were considered complicated, including five (1.1%) deaths. Increased rates of complications were seen with unwitnessed aspiration (P = 0.008) and hyperlucency (P < 0.001) or infiltrates (P = 0.001) on chest radiographs. No significant association was found between surgeon type or facility as related to a complicated case., Conclusions: Unwitnessed aspiration events and abnormalities on chest radiograph may be associated with a more complicated course in children with FBA. This multihospital study identified a low number of procedures by many surgeons; however, surgeon and hospital volume did not significantly correlate with higher complication rates., Level of Evidence: 4. Laryngoscope, 128:490-495, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Simulation is an emerging and viable means to increase pediatric airway surgical training. A variety of simulators currently exist that may be used or modified for laryngoscopy, bronchoscopy, and endoscopic intervention, although anatomic realism and utility for complex procedures are limited. There is a need for further development of improved endoscopic and anatomic models. Innovative techniques are enabling small-scale manufacturing of generalizable and patient-specific simulators. The high acuity of the pediatric airway patient makes the use of simulation an attractive modality for training, competency maintenance, and patient safety quality-improvement studies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO 2 laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO 2 laser transoral microsurgery or CO 2 TOLMS or CO 2 laser transoral surgery only (with a handpiece) would be defined as CO 2 TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO 2 wave-guide with a handpiece would be a CO 2 TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.

Study Objectives: To test whether the integration of both anatomical and nonanatomical parameters (ventilatory control, arousal threshold, muscle responsiveness) in a physiology-based model will improve the ability to predict outcomes after upper airway surgery for obstructive sleep apnea (OSA)., Methods: In 31 patients who underwent upper airway surgery for OSA, loop gain and arousal threshold were calculated from preoperative polysomnography (PSG). Three models were compared: (1) a multiple regression based on an extensive list of PSG parameters alone; (2) a multivariate regression using PSG parameters plus PSG-derived estimates of loop gain, arousal threshold, and other trait surrogates; (3) a physiological model incorporating selected variables as surrogates of anatomical and nonanatomical traits important for OSA pathogenesis., Results: Although preoperative loop gain was positively correlated with postoperative apnea-hypopnea index (AHI) ( P = .008) and arousal threshold was negatively correlated ( P = .011), in both model 1 and 2, the only significant variable was preoperative AHI, which explained 42% of the variance in postoperative AHI. In contrast, the physiological model (model 3), which included AHI REM (anatomy term), fraction of events that were hypopnea (arousal term), the ratio of AHI REM and AHI NREM (muscle responsiveness term), loop gain, and central/mixed apnea index (control of breathing terms), was able to explain 61% of the variance in postoperative AHI., Conclusions: Although loop gain and arousal threshold are associated with residual AHI after surgery, only preoperative AHI was predictive using multivariate regression modeling. Instead, incorporating selected surrogates of physiological traits on the basis of OSA pathophysiology created a model that has more association with actual residual AHI., Commentary: A commentary on this article appears in this issue on page 1023., Clinical Trial Registration: ClinicalTrials.Gov; Title: The Impact of Sleep Apnea Treatment on Physiology Traits in Chinese Patients With Obstructive Sleep Apnea; Identifier: NCT02696629; URL: https://clinicaltrials.gov/show/NCT02696629., (© 2017 American Academy of Sleep Medicine)

Study Objectives: Upper airway surgery is often recommended to treat patients with obstructive sleep apnea (OSA) who cannot tolerate continuous positive airways pressure. However, the response to surgery is variable, potentially because it does not improve the nonanatomical factors (ie, loop gain [LG] and arousal threshold) causing OSA. Measuring these traits clinically might predict responses to surgery. Our primary objective was to test the value of LG and arousal threshold to predict surgical success defined as 50% reduction in apnea-hypopnea index (AHI) and AHI <10 events/hour post surgery., Methods: We retrospectively analyzed data from patients who underwent upper airway surgery for OSA (n = 46). Clinical estimates of LG and arousal threshold were calculated from routine polysomnographic recordings presurgery and postsurgery (median of 124 [91-170] days follow-up)., Results: Surgery reduced both the AHI (39.1 ± 4.2 vs. 26.5 ± 3.6 events/hour; p < .005) and estimated arousal threshold (-14.8 [-22.9 to -10.2] vs. -9.4 [-14.5 to -6.0] cmH2O) but did not alter LG (0.45 ± 0.08 vs. 0.45 ± 0.12; p = .278). Responders to surgery had a lower baseline LG (0.38 ± 0.02 vs. 0.48 ± 0.01, p < .05) and were younger (31.0 [27.3-42.5] vs. 43.0 [33.0-55.3] years, p < .05) than nonresponders. Lower LG remained a significant predictor of surgical success after controlling for covariates (logistic regression p = .018; receiver operating characteristic area under curve = 0.80)., Conclusions: Our study provides proof-of-principle that upper airway surgery most effectively resolves OSA in patients with lower LG. Predicting the failure of surgical treatment, consequent to less stable ventilatory control (elevated LG), can be achieved in the clinic and may facilitate avoidance of surgical failures., (© Sleep Research Society 2017. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Importance: Many adverse health outcomes are associated with obstructive sleep apnea (OSA)., Objective: To review primary care-relevant evidence on screening adults for OSA, test accuracy, and treatment of OSA, to inform the US Preventive Services Task Force., Data Sources: MEDLINE, Cochrane Library, EMBASE, and trial registries through October 2015, references, and experts, with surveillance of the literature through October 5, 2016., Study Selection: English-language randomized clinical trials (RCTs); studies evaluating accuracy of screening questionnaires or prediction tools, diagnostic accuracy of portable monitors, or association between apnea-hypopnea index (AHI) and health outcomes among community-based participants., Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles. When multiple similar studies were available, random-effects meta-analyses were conducted., Main Outcomes and Measures: Sensitivity, specificity, area under the curve (AUC), AHI, Epworth Sleepiness Scale (ESS) scores, blood pressure, mortality, cardiovascular events, motor vehicle crashes, quality of life, and harms., Results: A total of 110 studies were included (N = 46 188). No RCTs compared screening with no screening. In 2 studies (n = 702), the screening accuracy of the multivariable apnea prediction score followed by home portable monitor testing for detecting severe OSA syndrome (AHI ≥30 and ESS score >10) was AUC 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90), respectively, but the studies oversampled high-risk participants and those with OSA and OSA syndrome. No studies prospectively evaluated screening tools to report calibration or clinical utility for improving health outcomes. Meta-analysis found that continuous positive airway pressure (CPAP) compared with sham was significantly associated with reduction of AHI (weighted mean difference [WMD], -33.8 [95% CI, -42.0 to -25.6]; 13 trials, 543 participants), excessive sleepiness assessed by ESS score (WMD, -2.0 [95% CI, -2.6 to -1.4]; 22 trials, 2721 participants), diurnal systolic blood pressure (WMD, -2.4 points [95% CI, -3.9 to -0.9]; 15 trials, 1190 participants), and diurnal diastolic blood pressure (WMD, -1.3 points [95% CI, -2.2 to -0.4]; 15 trials, 1190 participants). CPAP was associated with modest improvement in sleep-related quality of life (Cohen d, 0.28 [95% CI, 0.14 to 0.42]; 13 trials, 2325 participants). Mandibular advancement devices (MADs) and weight loss programs were also associated with reduced AHI and excessive sleepiness. Common adverse effects of CPAP and MADs included oral or nasal dryness, irritation, and pain, among others. In cohort studies, there was a consistent association between AHI and all-cause mortality., Conclusions and Relevance: There is uncertainty about the accuracy or clinical utility of all potential screening tools. Multiple treatments for OSA reduce AHI, ESS scores, and blood pressure. Trials of CPAP and other treatments have not established whether treatment reduces mortality or improves most other health outcomes, except for modest improvement in sleep-related quality of life.

Objective: To investigate the early complication rate and identify patient-related independent clinical risk factors for early complications in patients following interventional pulmonology procedures., Methods: In the period from December 2014 to December 2015, sufficient data of Peking University First Hospital Respiratory and Critical Care Medicine Department for analysis were identified in 218 subjects. Interventional pulmonology procedures were performed in all the patients. Early complications after the procedures were defined as newly respiratory failure, arrhythmia requiring treatment, severe hemoptysis, pneumothorax, pneumomediastinum, pulmonary edema, tracheoesophageal fistulae, bronchopleural fistulae, acute coronary syndrome, acute cerebrovascular accident, and death. Patient-related clinical risk factors were defined as coronary atherosclerotic heart disease, cerebral infarction, diabetes mellitus, cirrhosis, chronic kidney disease, arrhythmia, asthma, chronic obstructive pulmonary disease, hypertension, and previous interventional pulmonology treatment. The patient-related independent clinical risk factors which had close relations to the occurrence of early complications were analyzed by multivariate statistical analysis with Logistic regression., Results: There were 56.4% male and 43.6% female subjects in this study. There were 10.6% current smokers, 26.6% former smokers, and 62.8% non-smokers. The overall early complication rate was 8.3%. In all the subjects groups, the patient-related independent clinical risk factors for the early complication rate were coronary atherosclerotic heart disease (B=1.545, P=0.006, OR=4.686, 95% CI 1.568-14.006), chronic obstructive pulmonary disease (B=1.037, P=0.049, OR=2.820, 95% CI 1.675-11.790), and current smoking status (B=1.412, P=0.032, OR=4.139, 95% CI 1.134-15.109); for the newly respiratory failure rates were coronary atherosclerotic heart disease (B=2.207, P=0.004, OR=9.087, 95% CI 2.028-40.714), chronic obstructive pulmonary disease (B=1.646, P=0.048, OR=5.188, 95% CI 1.783-34.375), and lesions involving three central airways (B=1.899, P=0.032, OR=6.680, 95% CI 1.182-37.740). In the malignant group, the patient-related independent clinical risk factor for the early complication rate was current smoking status (B=2.953, P=0.006, OR=19.161, 95% CI 2.360-155.572). In the benign group, the patient-related independent clinical risk factor for the early complication rate was only coronary atherosclerotic heart disease (B=1.976, P=0.022, OR=7.214, 95% CI 1.324-39.298)., Conclusion: Closer monitoring of patients with identified clinical risk factors is advisable prior and immediately after interventional pulmonology procedures. In order to avoid or minimize early complications, special attention should be directed toward patients who are current smokers, or patients with lesions involving three central airways, or with coronary atherosclerotic heart disease or chronic obstructive pulmonary disease.

Background: The aim of this study is to investigate the prevalence of central sleep apneas syndrome (CSAS) in children with obstructive sleep apnea syndrome (OSAS) and the effect of adenotonsillectomy (A)TE on CSAS., Methods: Retrospective analysis of polysomnographic data in children diagnosed with OSAS and without comorbidity. A central apnea index (CAI) ≥1/h is considered abnormal and central sleep apnea syndrome (CSAS) is diagnosed at a CAI >5/h. Data are presented as median (25-75 percentile)., Results: Data were available for 90 children, 35 girls and 55 boys, age 3.7 years (1.8-5.4), BMI-z score 0.20 (-0.85-0.90), oAHI 10.9/h (5.8-19.1). Sixty-four percent had an abnormal CAI and the prevalence of CSAS was 7.8%. There was a significant correlation between CAI and MinSat (r = -0.48, p = 0.01) and between CAI and age (r = -0.45, p = 0.01). Pre-postop PSG data were available for 41 children with a CAI ≥ 1/h. Central apnea index decreased from 2.2/h (1.7-3.8) to 1.3/h (0.8-2.6) (p < 0.001) following (A)TE along with an improvement in oAHI from 10.9/h (5.9-22.2) to 1.2/h (0.6-2.7) (p < 0.001). No patient had postoperative CSAS and a reduction in the CAI <1/h was observed in 11 patients (26,9%)., Conclusion: A central apnea index ≥1/h is common in children with OSAS but CSAS (CAI >5) is rare. We observed a significant decrease in the CAI and a resolution of CSAS after (adeno)tonsillectomy., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Introduction: Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns., Methods: A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763)., Results: A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns., Conclusions: The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety., (© Crown copyright 2016.)

Objective: To identify characteristics in patients who undergo positive and negative bronchoscopy for a suspected airway foreign body (AFB)., Methods: Review medical records between 2008 and 2012., Results: There were 145 patients who went to the operating room with the pre-bronchoscopy diagnosis of suspected AFB during the study period. There was an overall negative bronchoscopy rate of an average of 37%, with an annual range between 21% and 50%. The findings of history or suspicion of choking, asymmetric breath sounds, and wheezing were statistically more common in patients with an AFB. Chest roentograms (CXR) had a sensitivity and specificity of 62% and 57%. Twenty patients had a chest computed tomography (CT) scan, and 100% were clinically significant. Four CT scans were diagnostic of an AFB, and 16 patients avoided bronchoscopy after negative CT., Conclusions: In current clinical practice, it is difficult to identify patients with an AFB without performing bronchoscopy. This results in a significant number of negative bronchoscopes. Certain elements in the history and physical exam were more common in patients who were found to have an AFB. Our preliminary data suggest that chest CT scans may be useful to decrease the number of negative bronchoscopies., (© The Author(s) 2016.)

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 and mask ventilation. Papers 2 and 3 outline the methodology and the pre-trial calculations and considerations leading to the DIFFICAIR trial described in Paper 4. The trial was designed to randomise anaesthesia department to either thorough education in, and subsequent use of the SARI for preoperative airway assessment or to continue usual care. Registration of the SARI in DAD was made mandatory in SARI departments and impossible in usual care departments. Conditions regarding anticipation of difficulties and actual airway managements were recorded as for Paper 1. DAD data made it possible to estimate an appropriate sample size, considering the between cluster variation, and to construct a stratification variable based on 2011 baseline values of the primary outcome used in the DIFFICAIR trial. Paper 1 revealed that 1.86% of all patients who were intubated, but not planned for advanced intubation techniques (e.g. video laryngoscopy), were unanticipated difficult to intubate. However, 75 to 93% of all difficult intubations were unanticipated. Furthermore, 94% of all difficult mask ventilations were unanticipated. In Paper 4, 59,514 patients were included in the primary analyses. The proportion of unanticipated difficult intubations was 2.38% (696/29,209) in SARI departments and 2.39% (723/30,305) in usual care departments. The adjusted odds ratio was 1.03 (95% CI: 0.77-1.38), p = 0.84. No significant differences were detected in other adjusted outcome measures and neither a 58% increase in patients anticipated to have intubation difficulties nor an 84% increase in patients scheduled for advanced intubation techniques in SARI departments reached statistical significance, p = 0.29 and p = 0.06 respectively. The papers constituting this thesis demonstrate that at high proportion of airway management difficulties are unanticipated. In a cluster randomised trial it was not possible to reduce the proportion of unanticipated difficult intubation in daily clinical practice by implementing a systematic approach for airway assessment compared with usual care. However, implementation of the SARI may increase the anticipation of intubation difficulties and it may change practice towards advanced intubation techniques. This thesis underlines the continued challenge anaesthesiologists face in predicting airway management related difficulties.

Brachycephalic airway syndrome in dogs is typified by a variety of anatomical abnormalities causing a diverse spectrum of clinical signs of varying intensity. This variability makes the assessment of the surgical outcome after upper airway surgery difficult. Using a structured questionnaire, the present study investigated the dog owner-perceived severity and frequency of a broad spectrum of welfare-relevant impairments 2 weeks before and 6 months after brachycephalic dogs underwent a recently developed multi-level upper airway surgery. All dogs underwent surgical treatment of stenotic nares (ala-vestibuloplasty), the nasal cavity (laser-assisted turbinectomy, LATE), the pharynx (palatoplasty and tonsillotomy), and if indicated, laryngeal surgery (laser-assisted ablation of everted ventricles and partial cuneiformectomy). Owners of brachycephalic dogs (n = 102) referred for upper airway surgery were eligible to participate. Questionnaire data from owners of 37 Pugs and 25 French bulldogs were evaluated. In all dogs, the clinical signs associated with brachycephaly improved markedly after surgery. Most encouraging was the striking reduction in life-threatening events by 90% (choking fits decreased from 60% to 5% and collapse from 27% to 3%). The incidence of sleeping problems decreased from 55% to 3%, and the occurrence of breathing sounds declined by approximately 50%. There was a marked improvement in exercise tolerance and a modest improvement in heat tolerance. Dogs with severe brachycephaly benefitted substantially from multi-level surgery, and there were particular improvements in the incidences of severe impairment and life-threatening events. However, despite the marked improvement perceived by dog owners, these dogs remained clinically affected and continued to show welfare-relevant impairments caused by these hereditary disorders., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The Virtual Pediatric Airways Workbench (VPAW) is a patient-centered surgical planning software system targeted to pediatric patients with airway obstruction. VPAW provides an intuitive surgical planning interface for clinicians and supports quantitative analysis regarding prospective surgeries to aid clinicians deciding on potential surgical intervention. VPAW enables a full surgical planning pipeline, including importing DICOM images, segmenting the airway, interactive 3D editing of airway geometries to express potential surgical treatment planning options, and creating input files for offline geometric analysis and computational fluid dynamics simulations for evaluation of surgical outcomes. In this paper, we describe the VPAW system and its use in one case study with a clinician to successfully describe an intended surgery outcome.

In the article provides an analysis of own of clinical experience peculiarities of carrying out of anesthesia, when performing 466 various tracheo-bronhoplastiс of operations for the period from 1979 to 2014 the year a one team of surgeons. Preoperative preparation, anesthesia and postoperative management of patients are key to improving treatment outcomes. Full arsenal of modern methods of ventilation lets you choose for each stage of surgery is most convenient for the surgeon and patient-safe way to maintain gas exchange. Presented in this paper our anestiology experience allows you to discuss and elect the proposed management of patients through the selection and optimization of the method that best meets modern requirements.

Basic surgical instrumentation for avian soft tissue surgery includes soft tissue retractors, microsurgical instrumentation, surgical loupes, and head-mounted lights. Hemostasis is fundamental during the surgical procedures. The indications, approach, and complications associated with soft tissue surgeries of the integumentary (digit constriction repair, feather cyst excision, cranial wound repair, sternal wound repair, uropygial gland excision), gastrointestinal (ingluviotomy, crop biopsy, crop burn repair, celiotomy, coelomic hernia and pseudohernia repair, proventriculotomy, ventriculotomy, enterotomy, intestinal resection and anastomosis, cloacoplasty, cloacopexy), respiratory (rhinolith removal, sinusotomy, tracheotomy, tracheal resection and anastomosis, tracheostomy, pneumonectomy) and reproductive (ovocentesis, ovariectomy, salpingohysterectomy, cesarean section, orchidectomy, vasectomy, phallectomy) systems are reviewed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: Up to half of children have substantial dysphonia after airway reconstruction. Visual assessment of vocal function is valuable. Feasibility of flexible and rigid endoscopy has been reported; however, the clinical utility of stroboscopy has not been examined. Rating of vibratory characteristics, such as mucosal wave and amplitude of vibration, is essential for the development of interventions to improve voice outcomes., Objective: To examine (1) clinicians’ ratings of anatomical and physiological features in children following airway reconstruction on initial voice evaluation using videolaryngostroboscopy and (2) the relationship of age to the type of endoscopy used., Design, Setting, and Participants: Retrospective medical record review of 32 patients aged 3 to 21 years evaluated for post–airway reconstruction dysphonia between July 2011 and July 2012 at a quaternary care children’s hospital., Interventions: Clinical voice evaluation protocol including rigid and/or flexible endoscopy with stroboscopy., Main Outcomes and Measures: Demographic and voice quality characteristics were collected. The ability to complete endoscopy and ratings of anatomical and/or physiological features were assessed by a consensus of 4 clinicians. A t test was used to determine whether age was a significant factor in successful completion of videolaryngostroboscopy., Results: Of 31 children who underwent flexible videolaryngostroboscopy, 22 (71%) examinations were completed with a distal chip endoscope and 9 (29%) with a fiberoptic. Significant differences were found in age between children who completed the distal chip vs. fiberoptic examination (mean [SD], 7.3 [2.7] vs. 5.5 [6.2] years; P = .05). Rigid endoscopy was attempted for 14 (44%) of 32 patients; 9 examinations (64%) were successful. Significant differences were found in age between patients for whom a rigid endoscopy could be successfully completed vs. those for whom it was not (mean [SD], 12.9 [3.4] vs. 6.2 [2.1] years; P < .001). Eighteen (56%) were glottic phonators, 8 (25%) supraglottic, and 6 (19%) aphonic. Vibratory characteristics were visible in 10 of 37 examinations (27%); 6 (16%) had ratable characteristics., Conclusions and Relevance: Endoscopy can be successfully completed in most children who have undergone airway reconstruction, most often using a distal chip endoscope.We found that vibratory characteristics were often not assessed adequately using videolaryngostroboscopy. Further work identifying imaging modalities that better display vibratory characteristics, such as high-speed videoendoscopy, may provide new insight into vocal function and lead to a more thorough evaluation.

Abstract: Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects on both personal and public health. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and low morbidity; long-term adherence rates approach 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the results of a large multicenter, prospective trial were recently published. The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This novel approach is the first to combine sleep surgery techniques with a titratable medical device for the treatment of OSA. Further research is required to define optimal patient selection and device performance and to demonstrate long-term effectiveness., (© 2015 Associated Professional Sleep Societies, LLC.)

Due to the wealth of reagents and transgenic strains available, mice have become one of the most commonly used model organisms for the study of allergic airway inflammation. One of the major hallmarks of the asthma phenotype in humans is reversible airflow obstruction, or airway hyper-responsiveness. However, the ability to confidently obtain useful physiological responses from such a small animal has presented a large technological challenge in murine studies. Recent advances have provided the technology to obtain lung mechanics through either the forced oscillation technique or plethysmography. Here we describe the utility of these measurements in mouse models of allergic airway inflammation and anaphylaxis.

Background: Obstructive sleep apnea (OSA) is tightly linked to increased cardiovascular disease. Surgery is an important method to treat OSA, but its effect on serum lipid levels in OSA patients is unknown. We aimed to evaluate the effect of upper airway surgery on lipid profiles., Material and Methods: We performed a retrospective review of 113 adult patients with OSA who underwent surgery (nasal or uvulopalatopharyngoplasty [UPPP]) at a major, urban, academic hospital in Beijing from 2012 to 2013 who had preoperative and postoperative serum lipid profiles., Results: Serum TC (4.86±0.74 to 4.69±0.71) and LP(a) (median 18.50 to 10.90) all decreased significantly post-operatively (P<0.01, 0.01, respectively), with no changes in serum HDL, LDL, or TG (P>0.05, all). For UPPP patients (n=51), serum TC, HDL and LP(a) improved (P=0.01, 0.01,<0.01, respectively). For nasal patients (n=62), only the serum LP(a) decreased (P<0.01). In patients with normal serum lipids at baseline, only serum LP(a) decreased (P<0.01). In contrast, in patients with isolated hypertriglyceridemia, the serum HDL, TG and LP(a) showed significant improvements (P=0.02, 0.03, <0.01, respectively). In patients with isolated hypercholesterolemia, the serum LP(a) decreased significantly (P=0.01), with a similar trend for serum TC (P=0.06). In patients with mixed hyperlipidemia, the serum TC and LDL also decreased (P=0.02, 0.03, respectively)., Conclusions: Surgery may improve blood lipid levels in patients with OSA, especially in patients with preoperative dyslipidemia, potentially yielding a major benefit in metabolism and cardiovascular sequelae. Prospective studies should examine this potential metabolic effect of airway surgery for OSA.

A 79-year-old woman was prescribed bisphosphonates 3 years ago for osteoporosis. At the time of first prescription, she received counselling directions on how to take her medication, which she stringently adhered to. However, she accidentally aspirated an alendronic acid tablet and subsequently developed respiratory tract symptoms. An emergency bronchoscopy was performed. We describe the marked bronchoscopic changes following aspiration of alendronic acid.

The purpose of this article is to review the literature and personal experiences of equine surgeons so as to describe procedures that can be performed in the standing sedated horse to alleviate conditions that result in upper respiratory tract obstruction. Upper respiratory tract surgery requires attention to detail, meticulous planning, and careful dissection and execution with little room for error. This article describes a selection of standing upper airway procedures, the indications for and possible complications of these surgeries, and advantages and disadvantages of a particular method., (Copyright © 2014 Elsevier Inc. All rights reserved.)