Acute and chronic airway obstruction in children
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Airway obstruction
Airway emergencies, different from emergency airway management, occur rarely and often under unexpected circumstances. Due to the dependence of the vital organs on continuous supply of oxygen, airway emergencies have a potential to cause significant morbidity and mortality if not managed appropriately. Causes, recognition, and management of airway emergencies are discussed in this article.
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Emergency airway management has evolved tremendously since the onset of the specialty’s origin. Over the years, the importance of first-pass success and approach to the difficult airway were the primary challenges faced by emergency physicians. With the advent of video laryngoscopy, the rates of first-pass success continue to increase, and the effect of the anatomically difficult airway has begun to lessen. With advances in tools for airway management, the challenges have shifted to approaching optimal preoxygenation and correction of physiologic disturbances prior to any intubation attempt. This review discusses traditional rapid sequence intubation and advances in the field of emergency airway management. This review contains 6 figures, 6 tables and 74 references Key words: difficult airway, emergency airway management, preoxygenation, surgical airway
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Topicalisation of the airway by various techniques has routinely been recommended for awake fibre-optic bronchoscopy in cases of difficult airway. However, topicalisation by itself can cause airway obstruction by decreasing the tone of the laryngeal muscles and causing a dynamic air inflow obstruction. Two cases of difficult airway are illustrated where anaesthetising upper airway with nebulisation with 4% lignocaine (Xylocaine™) or 2% lignocaine (Xylocaine™) jelly resulted in stridor and upper airway obstruction. This is the first reported case of airway obstruction after lignocaine (Xylocaine™) jelly. We would like to highlight that topicalisation of airway, once thought as a relatively safe technique, can cause airway collapse if not detected and anticipated at the earliest. Pre-operative spirometry and airway ultrasonography can be useful in detecting the patients at risk of developing airway obstruction. Using a nasopharyngeal airway during topicalisation can serve as a valuable device in preventing total airway obstruction in susceptible patients.
Airway obstruction
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Airway management of patients with maxillofacial trauma remains a challenging task for an anesthesiologist in the emergency and perioperative settings due to anatomical distortion. Detailed knowledge of maxillofacial and airway anatomy is desired for the correct diagnosis of extent and severity of the injury. Basic principles of advanced trauma life support protocols should be followed while managing such patients. Establishing unobstructed airway remains the top priority while maintaining C-spine immobilization and preventing aspiration. Although multiple options exist for securing the airway, a universal technique of airway management may not be applicable to all the patients. Hence, a high index of suspicion along with timely and skillful management is warranted. In this brief review, issues affecting the airway management in cases of maxillofacial trauma are addressed with the possible uses of a wide range of airway management devices available in emergency and elective scenarios.
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The aim of the study was to evaluate noninvasive continuous positive airway pressure as first-line treatment for upper airway obstruction in neonates with Pierre Robin sequence. Forty-four neonates were enrolled and classified in 4 groups: ventilator-dependent patients (severe upper airway obstruction group), patients with clinical upper airway obstruction, an abnormal (moderate upper airway obstruction group) or normal polygraphy (mild upper airway obstruction group), and those with no clinical upper airway obstruction (no upper airway obstruction group). Five neonates in the severe upper airway obstruction group (n = 9) were successfully managed by noninvasive continuous positive airway pressure and 4 required a tracheotomy. The moderate upper airway obstruction group (n = 4) was successfully managed by noninvasive continuous positive airway pressure and the other patients by prone positioning. Continuous positive airway pressure represents an effective treatment of upper airway obstruction in Pierre Robin sequence and may be recommended in selected patients.Therapeutic, IV.
Airway obstruction
Pierre Robin syndrome
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Over the last decade there has been significant advancement in airway management and a recent closed claims analysis indicates a decrease in claims since the 1980s. Studies and new airway devices have focused on managing the difficult airway and the failed intubation, problems which are common to the trauma patient. Although new airway devices have improved our ability to ventilate these patients, they are not 100% reliable nor do they provide a definitive airway. Formal training in airway management and the use of these airway devices has much room for improvement. With increased emphasis on training and the development of improved intubating aids, modern management of the difficult airway may approach 100% success.
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The authors compared airway management in normogravity and simulated microgravity with and without restraints for laryngoscope-guided tracheal intubation, the cuffed oropharyngeal airway, the standard laryngeal mask airway, and the intubating laryngeal mask airway.Four trained anesthesiologist-divers participated in the study. Simulated microgravity during spaceflight was obtained using a submerged, full-scale model of the International Space Station Life Support Module and neutrally buoyant equipment and personnel. Customized, full-torso manikins were used for performing airway management. Each anesthesiologist-diver attempted airway management on 10 occasions with each device in three experimental conditions: (1) with the manikin at the poolside (poolside); (2) with the submerged manikin floating free (free-floating); and (3) with the submerged manikin fixed to the floor using a restraint (restrained). Airway management failure was defined as failed insertion after three attempts or inadequate device placement after insertion.For the laryngoscope-guided tracheal intubation, airway management failure occurred more frequently in the free-floating (85%) condition than the restrained (8%) and poolside (0%) conditions (both, P < 0.001). Airway management failure was similar among conditions for the cuffed oropharyngeal airway (poolside, 10%; free-floating, 15%; restrained, 15%), laryngeal mask airway (poolside, 0%; free-floating, 3%; restrained, 0%), and intubating laryngeal mask airway (poolside, 5%; free-floating, 5%; restrained, 10%). Airway management failure for the laryngoscope-guided tracheal intubation was usually caused by failed insertion (> 90%), and for the cuffed oropharyngeal airway, laryngeal mask airway, and intubating laryngeal mask airway, it was always a result of inadequate placement.The emphasis placed on the use of restraints for conventional tracheal intubation in microgravity is appropriate. Extratracheal airway devices may be useful when restraints cannot be applied or intubation is difficult.
Tracheal tube
Mascara
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I-gel is a supraglottic airway device that has been used for emergency airway management. In this report, we present a case in which airway management is facilitated using I-gel. Scar revision was planned in a 12-year-old male patient with limited ability to extend the neck and restricted oral opening because of post-burn contracture. The patient was ventilated successfully achieved using the supraglottic I-gel method. This new airway device may appropriate in cases with asymmetric airways in which airway management is difficult.
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Tracheal tube
Capnography
Nurse anesthetist
Supine position
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Airway management is one of the most important subjects in medicine. This article reviews the history, assessment of airway prior to anesthesia, techniques and equip-ment of airway management and management of patients with anticipated and unan-ticipated difficult airways. This article covers recent literature on airway appliances and devices and their use in different circumstances. Airway assessment methods especially the recent Iranian method have been reviewed and discussed briefly in this article. On the whole the article covers the etiology of difficult airway and offers guidelines for safe practice of anesthesia in patients in whom airway is anticipated to be difficult.
Review article
Etiology
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