Gaslini's tracheal team: preliminary experience after one year of paediatric airway reconstructive surgery.

Background: congenital and acquired airway anomalies represent a relatively common albeit challenging problem in a national tertiary care hospital. In the past, most of these patients were sent to foreign Centres because of the lack of local experience in reconstructive surgery of the paediatric airway. In 2009, a dedicated team was established at our Institute. Gaslini's Tracheal Team includes different professionals, namely anaesthetists, intensive care specialists, neonatologists, pulmonologists, radiologists, and ENT, paediatric, and cardiovascular surgeons. The aim of this project was to provide these multidisciplinary patients, at any time, with intensive care, radiological investigations, diagnostic and operative endoscopy, reconstructive surgery, ECMO or cardiopulmonary bypass. Aim of this study is to present the results of the first year of airway reconstructive surgery activity of the Tracheal Team.Methods: between September 2009 and December 2010, 97 patients were evaluated or treated by our Gaslini Tracheal Team. Most of them were evaluated by both rigid and flexible endoscopy. In this study we included 8 patients who underwent reconstructive surgery of the airways. Four of them were referred to our centre or previously treated surgically or endoscopically without success in other Centres.Results: Eight patients required 9 surgical procedures on the airway: 4 cricotracheal resections, 2 laryngotracheoplasties, 1 tracheal resection, 1 repair of laryngeal cleft and 1 foreign body removal with cardiopulmonary bypass through anterior tracheal opening. Moreover, in 1 case secondary aortopexy was performed. All patients achieved finally good results, but two of them required two surgeries and most required endoscopic manoeuvres after surgery. The most complex cases were the ones who had already been previously treated.Conclusions: The treatment of paediatric airway anomalies requires a dedicated multidisciplinary approach and a single tertiary care Centre providing rapid access to endoscopic and surgical manoeuvres on upper and lower airways and the possibility to start immediately cardiopulmonary bypass or ECMO.The preliminary experience of the Tracheal Team shows that good results can be obtained with this multidisciplinary approach in the treatment of complicated cases. The centralization of all the cases in one or few national Centres should be considered.

Prefabrication of composite grafts for long-segment tracheal reconstruction.

OBJECTIVE: To investigate the prefabrication of vascularized mucosa-lined composite grafts intended to replace circumferential tracheal defects. DESIGN: Plane grafts composed of ear cartilage and full-thickness oral mucosa were revascularized by the laterothoracic fascia. The use of meshed vs nonmeshed mucosa to improve the epithelial coverage was examined. We also investigated the creation of a vascular bed over the cartilage and the subsequent application of meshed mucosa. Macroscopic aspects, viability, and degree of mucosal lining were analyzed. SUBJECTS: Twenty male New Zealand white rabbits. INTERVENTIONS: Ten animals underwent placement of auricular cartilage under the laterothoracic fascia. Intact (group 1) or meshed mucosa (group 2) was applied over the fascia and protected by a silicone sheet. After 3 weeks, prefabricated grafts were removed for comparison. In 10 other animals, a sheet of perforated cartilage was placed under the laterothoracic fascia. Two weeks later, 5 grafts (group 3) were harvested. The remaining 5 grafts were reopened for mucosal application over the cartilage and revascularized for 3 additional weeks (group 4). RESULTS: Vascularized plane grafts were obtained in all groups. Mucosal lining increased significantly with meshed mucosa (14%-68%; mean, 40%) compared with nonmeshed mucosa (3%-15%; mean, 10%) (P = .008). Induction of a vascular bed over perforated cartilage was achieved, but survival of secondary implanted mucosa was variable. CONCLUSIONS: A reliable technique to prefabricate composite grafts with cartilaginous support and mucosal lining is presented. The use of meshed mucosa significantly improves epithelial coverage.

Evaluation of the GlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar

RAPPORT DE SYNTHÈSE : Chez les patients présentant une pathologie de la colonne cervicale, l'instrumentation des voies aériennes peut s'avérer délicate. En effet, l'impossibilité d'effectuer une extension de la nuque afin d'aligner correctement l'axe oro-pharyngo-trachéal, ainsi que l'ouverture de bouche limitée par la présence d'une minerve cervicale, rendent la laryngoscopie standard extrêmement difficile. Le but de cette étude est de démontrer que l'intubation oro-trachéale avec une minerve cervicale semi-rigide est possible à l'aide d'un vidéolaryngoscope récemment développé, le GlideScope®. Celui-ci est formé d'une lame courbe présentant une angulation accentuée à 60° à partir de son milieu, avec une petite caméra haute résolution et une source lumineuse enchâssées dans la partie inférieure au point d'inflexion. Différents travaux ont montré les avantages du GlideScope® par rapport à la lame de Macintosh standard "pour l'instrumentation des voies aériennes de routine ou en situation difficile. Après acceptation par la Commission d'Ethique, 50 patients, adultes consentants et programmés pour une intervention chirurgicale élective nécessitant une anesthésie générale ont été inclus dans cette étude. Malgré la présence d'une minerve cervicale semi-rigide Philadelphia® Patriot correctement positionnée et la tête fixée à la table d'opération, tous les patients ont pu être intubés a l'aide du GlideScope®. Aucune complication n'a été documentée pendant la procédure ou en post-opératoire. De plus, nous avons démontré que dans cette situation la visualisation des structures laryngées est significativement améliorée grâce au GlideScope®, par rapport à la lame de Macintosh utilisée lors de toute intubation standard. En conclusion, l'intubation oro-trachéale chez les patients ayant une minerve cervicale et la tête fixée est possible à l'aide du GlideScope®. La meilleure façon de sécuriser les voies aériennes chez les patients présentant une instabilité de la colonne cervicale est un sujet fortement débattu. L'utilisation du GlideScope® pourrait s'avérer une alternative intéressante, en particulier dans les situations d'urgence.

Evaluation of the GlideScope (R) for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar

Application of cervical collars may reduce cervical spine movements but render tracheal intubation with a standard laryngoscope difficult if not impossible. We hypothesised that despite the presence of a Philadelphia Patriot (R) cervical collar and with the patient's head taped to the trolley, tracheal intubation would be possible in 50 adult patients using the GlideScope (R) and its dedicated stylet. Laryngoscopy was attempted using a Macintosh laryngoscope with a size 4 blade, and the modified Cormack-Lehane grade was scored. Subsequently, laryngoscopy with the GlideScope was graded and followed by tracheal intubation. All patients' tracheas were successfully intubated with the GlideScope. The median (IQR) intubation time was 50 s (43-61 s). The modified Cormack-Lehane grade was 3 or 4 at direct laryngoscopy. It was significantly reduced with the GlideScope (p < 0.0001), reaching grade 2a in most patients. Tracheal intubation in patients wearing a semi-rigid collar and having their head taped to the trolley is possible with the help of the GlideScope.

Evaluation of the GlideScope (R) for tracheal intubation in patients with cervical spine immobilization by a semi-rigid collar

Background: In patients with cervical spine injury, a cervical collar may prevent cervical spine movements but renders tracheal intubation with a standard laryngoscope difficult if not impossible. We hypothesized that despite the presence of a semi-rigid cervical collar and with the patient's head taped to the trolley, we would be able to intubate all patients with the GlideScopeR and its dedicated stylet. Methods: 50 adult patients (ASA 1 or 2, BMI ≤35 kg/m2) scheduled for elective surgical procedures requiring tracheal intubation were included. After standardized induction of general anesthesia and neuromuscular blockade, the neck was immobilized with an appropriately sized semi-rigid Philadelphia Patriot® cervical collar, the head was taped to the trolley. Laryngoscopy was attempted using a Macintosh laryngoscope blade 4 and the modified Cormack Lehane grade was noted. Subsequently, laryngoscopy with the GlideScopeR was graded and followed by oro-tracheal intubation. Results: All patients were successfully intubated with the GlideScopeR and its dedicated stylet. The median intubation time was 50 sec [43; 61]. The modified Cormack Lehane grade was 3 or 4 at direct laryngoscopy. It was significantly reduced with the GlideScopeR (p <0.0001), reaching 2a in most of patients. Maximal mouth opening was significantly reduced with the cervical collar applied, 4.5 cm [4.5; 5.0] vs. 2.0 cm [1.8; 2.0] (p <0.0001). Conclusions: The GlideScope® allows oro-tracheal intubation in patients having their cervical spine immobilized by a semi-rigid collar and their head taped to the trolley. It furthermore decreases significantly the modified Cormack Lehane grade.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence.

BACKGROUND: We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). METHODS: We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. RESULTS: In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. CONCLUSIONS: Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

Comparison of the single-use Ambu(®) aScope? 2 vs the conventional fibrescope for tracheal intubation in patients with cervical spine immobilisation by a semirigid collar*.

Fibreoptic intubation remains a key technique for the management of difficult intubation. We randomly compared the second generation single-use Ambu(®) aScope? 2 videoscope with a standard re-usable flexible intubating fibrescope in 50 tracheal intubations in patients with a difficult airway simulated by a semirigid collar. All patients' tracheas were intubated successfully with the aScope 2 or the re-usable fibrescope. The median (IQR [range]) time to intubate was significantly longer with the aScope 2 70 (55-97 [41?-226]) s vs 50 (40-59 [27-175]) s, p = 0.0003) due to an increased time to see the carina. Quality of vision was significantly lower with the aScope 2 (excellent 24 (48%) vs 49 (98%), p = 0.0001; good 22 (44%) vs 1 (2%), p = 0.0001; poor 4 (8%) vs 0, p = 0.12) but with no difference in the subjective ease to intubate (easy score of 31 (62%) vs 38 (76%), p = 0.19; intermediate 12 (24%) vs 7 (14%), p = 0.31; difficult 7 (14%) vs 5 (5%), p = 0.76). The longer times to intubate and the poorer scores for quality of vision do not support the use of the single-use aScope 2 videoscope as an alternative to the re-usable fibrescope.

Metabolic and hemodynamic changes during recovery and tracheal extubation in neurosurgical patients: immediate versus delayed recovery.

Delayed recovery has been advocated to limit the postoperative stress linked to awakening from anesthesia, but data on this subject are lacking. In this study, we measured oxygen consumption (V(O2)) and plasma catecholamine concentrations as markers of postoperative stress. We tested the hypothesis that delayed recovery and extubation would attenuate metabolic changes after intracranial surgery. Thirty patients were included in a prospective, open study and were randomized into two groups. In Group I, the patients were tracheally extubated as soon as possible after surgery. In Group II, the patients were sedated with propofol for 2 h after surgery. V(O2), catecholamine concentration, mean arterial pressure (MAP), and heart rate (HR) were measured during anesthesia, at extubation, and 30 min after extubation. V(O2) and noradrenaline on extubation and mean V(O2) during recovery were significantly higher in Group II than in Group I (V(O2) for Group I: preextubation 215 +/- 46 mL/min, recovery 198 +/- 38 mL/min; for Group II: preextubation 320 +/- 75 mL/min, recovery 268 +/- 49 mL/min; noradrenaline on extubation for Group I: 207 +/- 76 pg/mL, for Group II: 374 +/- 236 pg/ mL). Extubation induced a significant increase in MAP. MAP, HR, and adrenaline values were not statistically different between groups. In conclusion, delayed recovery after neurosurgery cannot be recommended as a mechanism of limiting the metabolic and hemodynamic consequences from emergence from general anesthesia. IMPLICATIONS: In this study, we tested the hypothesis that delayed recovery after neurosurgery would attenuate the consequences of recovery from general anesthesia. As markers of stress, oxygen consumption and noradrenaline blood levels were higher after delayed versus early recovery. Thus, delayed recovery cannot be recommended as a mechanism of limiting the metabolic and hemodynamic consequences from emergence after neurosurgery.

Repair of tracheal aspergillosis perforation causing tension pneumothorax.

Tracheobronchial aspergillosis is a rare entity mainly observed in immune-compromised patients or those who have undergone transplantation. It may cause airway ulcerations or bleeding. We report the case of a 17-year-old patient receiving chemotherapy for acute lymphoblastic leukemia who presented with right-sided tension pneumothorax. Chest tube drainage revealed a massive air leak without reexpansion of the lung, and bronchoscopy showed a 15- × 15-mm defect of the distal trachea related to aspergillosis infection. The defect was closed by an intrathoracic transposition of a pedicled latissimus dorsi muscle flap, which was sutured into the debrided defect followed by temporary endotracheal stenting and antifungal medication.

Congenital tracheal anomalies.

Congenital tracheal lesions are rare, but important, causes of morbidity in infants and children. Consequently, experience in their management is limited and dispersed. Given its small diameter, the juvenile trachea is obstructed easily by various natural causes, or following a surgical intervention. The diagnosis of a congenital, tracheal, obstructive anomaly is based on a high degree of suspicion in infants and children with respiratory distress accompanied by retraction. In this article, the authors discuss the various causes of these conditions, their diagnostic features, and the treatment possibilities.

Videolaryngoscopy improves intubation condition in morbidly obese patients

Résumé : Contexte clinique et objectifs: l'intubation oro-trachéale peut être plus difficile chez les patients obèses morbides (index de masse corporelle BMI > 35 kg/m2) que chez les patients non-obèses. Récemment, de nouveaux instruments permettant une intubation assistée au moyen d'une caméra ont été développés. Notre expérience pratique avec la vidéolaryngoscopie nous a conduit à l'hypothèse que celle-ci pourrait améliorer la vision laryngoscopique chez cette population spécifique et de ce fait faciliter l'intubation. Le but de cette étude était donc d'évaluer le bénéfice du vidéolaryngoscope sur le grade de laryngoscopie chez le patient obèse morbide. Résultats : le grade laryngoscopique fut abaissé de manière significative avec le vidéolaryngoscope comparé à la vision directe avec un laryngoscope standard. Lorsque le grade laryngoscopique était plus grand que 1 à la laryngoscopie directe, il fut dans la grande majorité des cas (93% des patients) abaissé avec le vidéolaryngoscope. Chez les 7 % restant, le grade laryngoscopique resta identique. Conclusions : chez le patient obèse morbide, l'utilisation du vidéolaryngoscope améliore de manière significative la visualisation du larynx et de ce fait facilite l'intubation. Une application systématique de ce procédé pourrait donc permettre de réduire l'incidence d'une intubation difficile ainsi que ses conséquences chez cette population de patients. Summary : Background and objective: Tracheal intubation may be more difficult in morbidly obese patients (body mass index >35 kgM-2) than in the non-obese. Recently, new video-assisted intubation devices have been developed. After some experience with videolaryngoscopy, we hypothesized that it could improve the laryngoscopic view in this specific population and therefore facilitate intubation. The aim of this study was to assess the benefit of a videolaryngoscope on the grade of laryngoscopy in morbid obesity. Methods: We studied 80 morbidly obese patients undergoing bariatric surgery. They were randomly assigned to one of two groups. One group was intubated with the help of the videolaryngoscope and in the control group the screen of the videolaryngoscope was hidden to the intubating anaesthesiologist. The primary end-point of the study was to assess in both groups the Cormack and Lehane direct and indirect grades of laryngoscopy. The duration of intubation, the number of attempts needed as well as the minimal SPO2 reached during the intubation process were measured. Results: Grade of laryngoscopy was significantly lower with the videolaryngoscope compared with the direct vision (P < 0.001). When the grade of laryngoscopy was higher than one with the direct laryngoscopy (n = 30), it was lower in 28 cases with the videolaryngoscope and remained the same only in two cases (P < 0.001). The minimal SPO2 reached during the intubation was higher with the videolaryngoscope but it did not reach statistical significance. Conclusions: In morbidly obese patients, the use of the videolaryngoscope significantly improves the visualization of the larynx and thereby facilitates intubation.

Automatic Mallampati Classification Using Active Appearance Models

Difficult tracheal intubation assessment is an important research topic in anesthesia as failed intubations are important causes of mortality in anesthetic practice. The modified Mallampati score is widely used, alone or in conjunction with other criteria, to predict the difficulty of intubation. This work presents an automatic method to assess the modified Mallampati score from an image of a patient with the mouth wide open. For this purpose we propose an active appearance models (AAM) based method and use linear support vector machines (SVM) to select a subset of relevant features obtained using the AAM. This feature selection step proves to be essential as it improves drastically the performance of classification, which is obtained using SVM with RBF kernel and majority voting. We test our method on images of 100 patients undergoing elective surgery and achieve 97.9% accuracy in the leave-one-out crossvalidation test and provide a key element to an automatic difficult intubation assessment system.

Repair of non-circumferential cervical trachea defects by three different latissimus dorsi flaps. A comparative studyin an experimental setting.

BACKGROUND: Large intrathoracic airway defects may be closed using a pedicled latissimus dorsi (LD) flap, with rewarding results. This study addresses the question of whether this holds true for extrathoracic non-circumferential tracheal defects. METHODS: A cervical segment of the trachea of 4 x 1 cm was resected in 9 white male pigs. The defect was stented with a silicone stent for 3 months and closed either by an LD flap alone (group a, n = 3), an LD flap with an attached rib segment covered by pleura (group b, n = 3), or an LD flap reinforced by a perforated polylactide (MacroPore) plate (group c, n = 3). The trachea was assessed by rigid endoscopy at 3 and 4 months and histologically at 4 months postoperatively. RESULTS: The degree of stenosis at the level of the reconstruction at 4 months was 25, 50 and 75% in group a, 15, 50 and 60% in group b, and 20, 95 and 95% in group c, respectively. The percentage of the defect covered by columnar epithelium was 100% in all animals of group a, 60, 100 and 100% in group b, and 10, 0 and 0% in group c. Resorption of the rib was seen in all animals of group b and obstructive inflammatory polyps were found in 2 animals of group c. CONCLUSION: Pedicled LD flaps provided less satisfactory results for closure of large non-circumferential extrathoracic airway defects than observed after intrathoracic reconstruction. A pedicled rib segment added to the LD flap did not improve the results obtained from LD flap repair alone, and an embedded MacroPore prosthesis may result in severe airway stenosis due to plate migration and intense inflammatory reaction protruding into the tracheal lumen.