laryngotracheal complications of intubation...case - history •urgent aortic valve replacement and...
TRANSCRIPT
![Page 1: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/1.jpg)
Laryngotracheal
Complications of
Intubation
Samuel A. Schechtman, MD
Clinical Assistant Professor of Anesthesiology
Director of Head and Neck Anesthesiology &
Airway Management
![Page 2: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/2.jpg)
Disclosure Statement
NONE
![Page 4: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/4.jpg)
Learning Objectives
• Laryngotracheal injuries following
intubation
• Anesthetic management
• Surgical treatment
• Tracheostomy and airway safety
practices
![Page 5: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/5.jpg)
Lecture OutlineI. Case presentation
II. Background
III. Treatment of laryngotracheal
complications
• Posterior glottic stenosis
IV. Considerations post tracheostomy
![Page 6: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/6.jpg)
Procedural ComplicationsI. Intubation
– Acute
• Nasal complications
• Oral cavity and oropharynx
• Laryngeal: mucosal injury, arytenoid subluxation/dislocation
– Chronic
• Laryngotracheal stenosis: glottic / posterior glottic, subglottic
• Vocal process granuloma
• Tracheal
II. Videolaryngoscopy
III. Airway exchange catheters
![Page 7: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/7.jpg)
Uncommon Complications
From: Horellou MF, Mathe D, Feiss P: A hazard of
naso-tracheal intubation. Anaesthesia 33:73, 1978.
![Page 8: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/8.jpg)
Case Presentation
• 59 yo ASA III, male with posterior
glottic stenosis (PGS) presenting for:
• Elective awake tracheostomy
• Microdirect laryngoscopy
• CO2 laser excision
• Steroid injection
• Mitomycin C application
![Page 9: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/9.jpg)
Case - History• Urgent aortic valve replacement and mitral valve
repair 1 year prior
• Complicated post op course: 3 weeks of
endotracheal intubation
• Presented several months later with dysphonia,
dyspnea, & stridor
• Diagnosed with posterior glottic
stenosis (PGS)
![Page 10: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/10.jpg)
Laryngeal Videostroboscopy
Posterior
Anterior
![Page 11: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/11.jpg)
History of Laryngotracheal
Stenosis• 1858-1900: laryngotracheal stenosis associated with croup,
diphtheria, syphilis, leprosy, smallpox, measles, pertussis,
& blastomycosis
• 1900s: trauma to trachea and larynx identified as a
common cause
• 1900-1920s: Jackson associated stenosis with emergent
tracheotomies
• 1940s: Endotracheal intubation became most common
cause
![Page 12: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/12.jpg)
Lefferts, 1890:
“The management of chronic
laryngeal stenosis, so varying in
it’s nature and indications for
treatment, will always require
patience, perseverance and
ingenuity”
![Page 13: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/13.jpg)
Weiser et al. 2008.
• Estimated 234.2 million surgeries each year
worldwide
• Countries spending < US $100 per person on health
care: 295 per 100,000
• Those spending > US $1,000: 11,110 per 100,000
• Estimated > 30 million surgeries per year in the U.S.
![Page 14: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/14.jpg)
Intubation Injury: Epidemiology
Domino et al. 1999.
![Page 15: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/15.jpg)
• ASA Closed Claims database
– 1961-1996:
– 4460 claims
– 6% for airway injury (n=266)
– Most frequent sites of injury:
• Larynx (33%)
• Pharynx (19%)
• Esophagus (18%)
• Trachea (15%)
![Page 16: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/16.jpg)
– Laryngeal injury (n=87)
• Vocal fold paralysis (n=30, 34%)
• Granuloma (n=15, 17%)
• Cricoarytenoid dislocation (n=7, 8%)
• Hematoma (n=3, 3%)
– Tracheal injury (n=39)
• Surgical tracheotomy (n=25, 64%)
• Tracheal perforation (n=13, 33%)
• Infection (n=1, 3%)
• 21 of 25 tracheostomies were emergent
4 for subglottic or tracheal stenosis
![Page 17: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/17.jpg)
Epidemiology• Injuries to TMJ & larynx routine
intubation
• Injuries to the esophagus were more
severe
• Pharyngoesophageal perforation with:
- Difficult intubation
- Age > 60
- Female gender
![Page 18: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/18.jpg)
Epidemiology
• “80% of laryngeal claims were
associated with routine (non-difficult)
tracheal intubation”
• “Most (85%) of laryngeal injuries
were associated with short-term
tracheal intubation”
![Page 19: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/19.jpg)
Hua et al. 2012.
![Page 20: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/20.jpg)
• American College of Surgeons National
Surgical Quality Improvement Program
(NSQIP) database
• 563,190 patients included (n = 1202 injured,
0.20%)
• Lip laceration / hematoma (61.4%)
• Tooth injury (26.1%)
• Tongue laceration (5.7%)
• Pharyngeal laceration (4.7%)
• Laryngeal laceration (2.1%)
![Page 21: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/21.jpg)
• Increased risk with Mallampati III and
Mallampati IV
• Increased risk in patients > 80 years
• 1 in 500 for patients undergoing
major surgery
![Page 22: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/22.jpg)
• 4.9 cases per million per year
using greater London population
Nouraei et al. 2007
![Page 23: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/23.jpg)
• Retrospective cohort: Johns Hopkins University 34
patients
• Mean cost $4,080.09 annually
• Intubation-related stenosis significantly greater cost
- $5,286.56 intubation related
- $2,873.62 idiopathic
Yin et al. 2018.
![Page 24: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/24.jpg)
Greer et al. 2016.
![Page 25: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/25.jpg)
2018. Annals of Otology, Rhinology, and
Laryngology.
![Page 26: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/26.jpg)
Factors in Intubation Injury
• Abnormal larynx
• Emergency intubation
• Impairment of mucocilliary clearing
• Gastric aspiration
• Bacterial infection
• Acute or chronic disease states
• Duration of intubation
• Endotracheal tube size
• Endotracheal tube cuff pressure
![Page 27: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/27.jpg)
Specific Injuries
• Tongues of granulation tissue
• Ulcerated troughs
• Healed furrows
• Healed fibrous nodule
• Intubation granuloma
• Interarytenoid adhesion
• Posterior glottic stenosis
• Subglottic stenosis
• Ductal retention cysts
• Vocal fold paralysis
• Arytenoid dislocation
![Page 28: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/28.jpg)
![Page 29: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/29.jpg)
![Page 30: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/30.jpg)
![Page 31: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/31.jpg)
Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of
Intubation, Tracheotomy, and Tracheal Surgery". In: Complications in
surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
![Page 32: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/32.jpg)
Keys to Prevention
• Endotracheal tube (ETT) choice
• Treatment of reflux
• Minimize secretions
• Antibiotic treatment with
tracheostomy
• Minimize intubation time
• Manage comorbidities
![Page 33: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/33.jpg)
Prevention (back to basics)• Monitor ETT cuff pressures
• Caution with blind procedures (AFOI, AECs) –
McLean et al. 2013.
• Optimize intubating conditions
• Neuromuscular blockade (Pacheco-Lopez et
al. 2014)
• Positioning
• Lubricated ETT
![Page 34: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/34.jpg)
Laryngotracheal Anatomy
• Larynx - vital component of respiratory system
– Swallowing
– Breathing coordination
– Intrathoracic pressure regulation
– Vocalization
• Laryngotracheal stenosis
– Anterior or posterior glottic stenosis (PGS)
– Subglottic stenosis or tracheal stenosis
(SGS/TS)
![Page 35: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/35.jpg)
Anatomy of posterior glottis
• Posterior 1/3 of vocal folds
• Posterior commissure and
interarytenoid muscle
• Cricoid lamina
• Cricoarytenoid joints
• Arytenoids
• Overlying mucosae
![Page 36: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/36.jpg)
Posterior glottis susceptibility• Anatomy
– Posterior & subglottis: respiratory vs
squamous epithelium
• ETTs displaced by base of tongue onto
posterior glottis
• Proliferative fibrotic process
• Arytenoid contracture, possible ankylosis
Impairment of glottic airflow
![Page 37: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/37.jpg)
Perfectly positioned ETT
Right in the posterior glottis
![Page 38: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/38.jpg)
PGS: Development
Initial mucosal ulceration and inflammation (A)
Posterior laryngeal granulation tissue (B)
Contracts the arytenoids forcing the vocal folds into a
bilateral midline position (C)
From Hillel et al. 2016
![Page 39: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/39.jpg)
Posterior Glottic Stenosis
Posterior vocal folds
Vocal processes of the arytenoids
Interarytenoid region
Cricoarytenoid Joints
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation, Tracheotomy, and Tracheal
Surgery". In: Complications in surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
- Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765–
772.
- Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or
micro-trapdoor flap. Laryngoscope. 1984 Apr;94(4):445-50.
![Page 40: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/40.jpg)
SGS & PGS – Location Matters
Hatcher et al. 2015.
![Page 41: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/41.jpg)
Surgical Management Goals
• Balance airway & voice
• ↑Airway → ↓voice
• Tracheostomy placement may
be best
• No surgery can correct fixed
cricoarytenoid joints
• PGS can permanently alter QOL
Hatcher et al. 2015.
![Page 42: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/42.jpg)
PGS: Risk Factors
• 28 PGS patients (14 ♂, 14 ♀) ≥ 24hrs intubated in
ICU
• PGS risk factors included:
- Ischemic condition (374% ↑ OR)
- Diabetes (888% ↑ OR)
- Length of intubation (21% ↑ OR/day)
- ETT (≥ 8)Hillel et al. 2016.
![Page 43: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/43.jpg)
Posterior Glottic Stenosis
• As high as 14% in patients intubated > 10 days
• Increased risk:
- Traumatic intubation
- Prolonged intubation
- Multiple management maneuvers - motion
- Large ETT size
- Local infection
• Can present with co-existing subglottic
stenosis
![Page 44: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/44.jpg)
Other Etiologies of PGS
• Radiation
• Autoimmune disease
• External laryngeal trauma
• Caustic ingestion
![Page 45: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/45.jpg)
PGS: Typical Presentation
• Complex patient & prolonged intubation
• Progressive dyspnea and noisy
breathing
• May be mistaken as COPD or asthma
• Inspiratory vs biphasic stridor- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation, Tracheotomy, and Tracheal Surgery".
In: Complications in surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
- Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765–772.
Cummings
- Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or micro-
trapdoor flap. Laryngoscope. 1984 Apr;94(4):445-50.
![Page 46: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/46.jpg)
Flexible Laryngoscopy - PGS
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation, Tracheotomy, and Tracheal Surgery". In: Complications in
surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery. Philadelphia, PA: Elsevier, Saunders; 2015.
- Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765–772.
I: Vocal Process
Adhesion
II. Posterior
Commissure or
interarytenoid scar
III: Unilateral CA fixation IV: Bilateral CA fixation
Bogdasarian Grades of PGS
May mimic bilateral true vocal fold
paralysis, depending on degree of
CA joint fixation
![Page 47: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/47.jpg)
Surgical Management
of Posterior Glottic
Stenosis
![Page 48: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/48.jpg)
Preoperative Evaluation
• Subjective/objective impairment
• Goals of preoperative examination:
– Anatomic location(s)
– Dimensions
– Quality
– Vocal fold / cricoarytenoid joint mobility
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
![Page 49: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/49.jpg)
Evaluation• Indirect laryngotracheoscopy/stroboscopy
• Direct laryngoscopy
• Laryngeal EMG
- Equivocal cases VF motion impairment
• CT Scan with 2 mm cuts +/- 3D renderings
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
![Page 50: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/50.jpg)
Surgical Management• Elective: Non-critical lesions
• Urgent: Acute distress
SECURE AIRWAY
– Temporizing measures
• Elevate head of bed
• Cool humidified air
• Racemic epinephrine
• Corticosteroids
• Heliox
Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
![Page 51: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/51.jpg)
Goals of Definitive Operations • Establish SAFE airway
• Eventual decannulation with
tracheostomy
• Preserve other laryngeal functions – Airway protection
– Phonation
– Swallowing- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
![Page 52: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/52.jpg)
PGS: Surgical Management
• Difficult to manage
• Success difficult to predict
• No definitive therapy for
cricoarytenoid mobility after
fixation
![Page 53: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/53.jpg)
Surgical Techniques
• Endoscopic laser excision and
adjuncts
• Posterior cricoid split with cartilage
grafting
– Open
– Endoscopic
• Arytenoidectomy for grade IV
![Page 54: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/54.jpg)
CO2 Laser Excision• CO2 laser excision of synechiae/scar tissue
• Injection of Kenalog and topical mitomycin application
Meyer TK, Wolf J. Lysis of interarytenoid synechia (Type I Posterior Glottic Stenosis): vocal fold
mobility and airway results. Laryngoscope. 2011 Oct;121(10):2165-71.
![Page 55: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/55.jpg)
Suspension Laryngoscopy
• May be difficult without
tracheostomy
• University of Michigan:
– High frequency high pressure jet
ventilation without tracheostomy
– Low threshold for tracheostomy
Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
![Page 56: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/56.jpg)
Anesthetic Considerations
• Preoperative evaluation
• Awake tracheostomy is common
• Shared, unprotected airway
• Bed 90 degrees
• Total intravenous anesthesia with NMB
• COMMUNICATION AND TEAMWORK
![Page 57: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/57.jpg)
![Page 58: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/58.jpg)
![Page 59: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/59.jpg)
From Abdelmalak B and Doyle JD (Eds). 2013.
Anesthetic Management: Ventilation Methods
![Page 60: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/60.jpg)
High Frequency Jet
Ventilation (HFJV)
![Page 61: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/61.jpg)
High Frequency Jet
Ventilation (HFJV)
![Page 62: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/62.jpg)
Supraglottic Jet Ventilation
![Page 63: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/63.jpg)
Subglottic Jet Ventilation
![Page 64: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/64.jpg)
Microlaryngeal ETT &
Intermittent Apnea
![Page 65: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/65.jpg)
• Adequate oxygenation/ventilation in
1512
• 623 ABGs
• Mean PaO2 133.8 mmHg
• Mean PaCO2 of 42.3 mmHg
• No barotrauma
• 312 laser treatment – no complication
Rezaie-Majd et al. 2006.
![Page 66: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/66.jpg)
Knights et al. 2013.
![Page 67: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/67.jpg)
![Page 68: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/68.jpg)
Philips et al. 2018
• 46 patients - 70 procedures
• 29 obese
• Jet ventilation successful in 28/29 of obese cases
• No significant differences in chest rise, need for
intubation, and length of surgery or ventilation
![Page 69: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/69.jpg)
A New Use for an Old
Technology
![Page 70: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/70.jpg)
Transnasal Humidified Rapid
Insufflation Ventilatory
Exchange (THRIVE)
![Page 72: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/72.jpg)
T - Tube
Accessed On-Line:
https://www.intechopen.com/books/en
doscopy/endoscopy-of-larynx-and-
trachea-with-rigid-laryngo-
tracheoscopes-under-superimposed-
high-frequency-j
Accessed On-Line:
https://www.bosmed.com/safe-t-
tubestm.html
![Page 73: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/73.jpg)
Dhillon et al. 2018.
• Maintain airway clearance and support tracheal wall
• 13 patients with laryngotracheal stenosis and
aphonia/dysphonia
• Significant improvement in VRQOL after T tube placement
• Most common complication: granulation tissue
![Page 74: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/74.jpg)
T - Tube Management
• Under GA
- Remove and an armored ETT placed
- Small 4.0 ETT placed through T - tube
- Connector from ETT fit into end of T - tube
• If ETT through T - tube, must be directed
downward
• Manipulations WITH surgical service
![Page 75: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/75.jpg)
T – Tube Removal
• Clamp with a hemostat - pull with firm
pressure
• Only replaced with DL & bronchoscopy
• Standard tracheostomy tube used
temporarily
![Page 76: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/76.jpg)
![Page 77: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/77.jpg)
PGS Highlights
• Common and costly
• Complication of airway management
• Difficult to diagnose
• Challenging to treat
![Page 78: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/78.jpg)
System Based Practices
McGrath et al. 2012.
![Page 79: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/79.jpg)
National Tracheostomy Safety
Project (NTSP)• Several airway management specialties & governing
societies
• In England in 2009-2010:
- 5700 surgical tracheostomies
- 5000-8000 percutaneous tracheostomies
- 570 laryngectomies
• Guidelines developed for tracheostomy-related
emergencies:– Training
– Distinct bedside signs and algorithms
– Emergency equipment
![Page 80: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/80.jpg)
Specialized Airway Algorithms
Tracheostomy Laryngectomy
![Page 81: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/81.jpg)
NTSP
![Page 82: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/82.jpg)
![Page 83: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/83.jpg)
National Tracheostomy Safety Project – Accessed On-Line:
http://tracheostomy.org.uk/http://tracheostomy.org.uk/
![Page 84: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/84.jpg)
Michigan Medicine MiChart
Difficult Airway Navigator
![Page 85: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/85.jpg)
Summary
Intubation NOT WITHOUT RISK
![Page 86: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/86.jpg)
Anesthetic considerations for
management of laryngotracheal
complications
![Page 87: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/87.jpg)
Importance of airway risk assessment
and planning
![Page 88: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/88.jpg)
Team communication
![Page 89: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/89.jpg)
Optimizing safe airway
management
![Page 90: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/90.jpg)
THANK YOU
????
![Page 91: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/91.jpg)
ReferencesAbdelmalak B and Doyle JD (Eds). 2013. Anesthesia for Otolaryngologic Surgery. New York, NY: Cambridge University Press.
Aloy A and Grasl M. Endoscopy of Larynx and Trachea with Rigid Laryngo- Tracheoscopes Under Superimposed High-Frequency Jet Ventilation (SHFJV). In Endoscopy; Amornyotin S (ed.). 2013. Accessed On-Line January 14, 2018: https://www.intechopen.com/books/endoscopy/endoscopy-of-larynx-and-trachea-with-rigid-laryngo-tracheoscopes-under-superimposed-high-frequency-j
Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by theAmerican Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118(2): 251-70.
Benjamin B. Prolonged Intubation Injuries Of The Larynx: Endoscopic Diagnosis, Classification, And Treatment. Annals of Otology, Rhinology & Laryngology 2018, Vol. 127(8) 492 –507.
Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765–772.
Cummings
Bonvento B, Wallace S, Lynch J, Coe B, McGrath BA. Role of the multidisciplinary team in the care of the tracheostomy patient. Journal of Multidisciplinary Healthcare, 2017; 10:391-398.
Boston Medical Products. Montgomery ® Safe T TubesTM. Accessed On-Line January 14, 2018: https://www.bosmed.com/safe-t-tubestm.html
Brook I. Stoma care, aspiration prevention, and swimming after laryngectomy. Accessed On-Line January 14, 2018: http://dribrook.blogspot.com/p/stoma-care.html
Choussy O, Hibon R, Bon Mardion N, and Dehesdin D. Management of voice prosthesis leakage with Blom-Singer large esophageal and tracheal flange voice prostheses. European Annals of Otorhinolaryngology, Head and Neck Diseases. 2013; 130(2):49-53.
COCLIA Pediatrics: Glottic and Subglottic Stenosis Samuel Ostrower March 24, 2008
Cook TM, Woodall N, Frerk C, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. British Journal of Anaesthesia. 2011; 106(5): 632-42.
Cramer JD, Graboyes EM, Brenner MJ. Mortality associated with tracheostomy complications in the United States: 2007-2016. Laryngoscope. 2018 Nov 19. doi: 10.1002/lary.27500. [Epub ahead of print]
Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or micro-trapdoor flap. Laryngoscope. 1984 Apr;94(4):445-50.
Dhillon VK, Akst LM, Best SR, Hillel AT. Voice Outcomes in Laryngotracheal Stenosis: Impact of the Montgomery T-tube.Clin Surg. 2018 Jan;3. pii: 1855. Epub 2018 Jan 10.
Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anesthesia: a closed claims analysis. Anesthesiology. 1999 Dec;91(6):1703-11.
Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery. Philadelphia, PA: Elsevier, Saunders; 2015.
Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anesthesia. 2015; 115(6): 827-48.
Gerber ME, Modi VK, Ward RF, Gower VM, Thomsen J. Endoscopic posterior cricoid split and costal cartilage graft placement in children. Otolaryngol Head Neck Surg. 2013 Mar;148(3):494-502
![Page 92: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/92.jpg)
ReferencesGreer D, Marshall KE, Bevans S, Standlee A, McAdams P, Harsha W. Review of videolaryngoscopy pharyngeal wall injuries. Laryngoscope
2017;127(2):349-53.
The Global Tracheostomy Collaborative. Accessed On-Line: http://www.globaltrach.org/
Gustafsson IM, Lodenius A, Tunelli J, Ullman J, Jonsson Fagerulund M. Apnoeic oxygenation in adults under general anaesthesia using TransnasalHumidified Rapid-Insufflation Ventilatory Exchange (THRIVE) - a physiological study. British Journal of Anaesthesia. 2017; 118(4): 610-617.
Hatcher JL, Dao AM, Simpson CB. Voice outcomes after endoscopic treatment of laryngotracheal stenosis. Ann Otol Rhinol Laryngol. 2015 Mar;124(3):235-9.
Healthcare Supply Pros. Blom Singer Laryngectomy Tubes. Accessed On-Line January 14, 2018: Accessed On-Line: http://respiratory.healthcaresupplypros.com/ihbe6303
Hillel AT, Karatayli-Ozgursoy S, Samad I, Best SR, Pandian V, Giraldez L, Gross J, Wootten C, Gelbard A, Akst LM, Johns MM; North American Airway Collaborative (NoAAC). Predictors of Posterior Glottic Stenosis: A Multi-Institutional Case-Control Study. Ann Otol Rhinol Laryngol. 2016 Mar;125(3):257-63.
Horellou MF, Mathe D, Feiss P: A hazard of naso-tracheal intubation. Anaesthesia 33:73, 1978.
Hua M, Brady J, Li G. The epidemiology of upper airway injury in patients undergoing major surgical procedures. Anesth Analg. 2012 Jan;114(1):148-51.
Jackson C. Tracheotomy. Laryngoscope 1909;19:285–290.
Jackson C. High tracheotomy and other errors: the chief causes of chronic laryngeal stenosis. Surg Gynecol Obstet. 1921;32:392-8.
Johns Hopkins Medicine. Tracheostomy Service. Accessed On-Line January 14, 2018: https://www.hopkinsmedicine.org/tracheostomy/about/types.html.
Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation with combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology 2013; 119(6): 1360-9.
Knights RM, Clements S, Jewell E, Tremper K, Healy D. Airway Management in Patients with Subglottic Stenosis: Experience at an Academic Institution. Anesthesia & Analgesia. 117(6):1352–1354, DEC 2013
Lack HL (1909) Discussion on the treatment of cicatricial stenosis of the larynx. Br Med J 2:1140–1141
Lefferts GM (1890) Intubation of the larynx in acute and chronic syphilitic stenosis. Med Rec 38:369–373
Mark LJ, Herzer KR, Cover R, Pandian V, Bhatti NI, Berkow LC, Haut ER, Hillel AT, Miller CR, Feller-Kopman DJ, Schiavi AJ, Xie YJ, Lim C, Holzmueller C, Ahman M, Thomas P, Flint PW, Mirski MA. Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg. 2015 Jul; 121(1):127-39.
McGrath BA, Bates L, Atkinson D, et al. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012; 67: 1025-41.
McGrath BA, Calder N, Laha S, Perks A, Chaudry I, Bates L, Moore JA, Atkinson D. Reduction in harm from tracheostomy related patient safety incidents following introduction of the National Tracheostomy Safety Project: Our experience from two hundred and eighty seven incidents. Clinical Otolaryngology, 2013; 38:533-558.
McGrath BA, Wilkinson K. The NCEPOD study: on the right trach? Lessons for the anaesthetist. British Journal of Anaesthesia, 2015; 115(2): 155-8.
McLean S, Lanam CR, Benedict W, Kirkpatrick N, Kheterpal S, Ramachandran SK. Airway exchange failure and complications with the use of the Cook Airway Exchange Catheter®: a single center cohort study of 1177 patients. Anesth Analg. 2013 Dec;117(6):1325-7.
Mencke T, Echternach M, Plinkert PK, Johann U, Afan N, Rensing H, Noeldge-Schomburg G, Knoll H, Larsen R. Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial. Anesth Analg. 2006 Jan;102(1):306-12.
Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, Plinkert PK, Fuchs-Buder T. Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology. 2003 May;98(5):1049-56.
Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation, Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
![Page 93: Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and mitral valve repair 1 year prior •Complicated post op course: 3 weeks of endotracheal](https://reader034.vdocument.in/reader034/viewer/2022042121/5e9adfefbc322708f33c8138/html5/thumbnails/93.jpg)
ReferencesMeyer TK, Wolf J. Lysis of interarytenoid synechia (Type I Posterior Glottic Stenosis): vocal fold mobility and airway results. Laryngoscope. 2011
Oct;121(10):2165-71.
Nouraei SA, Ma E, Patel A, Howard DJ, Sandhu GS. Estimating the population incidence of adult post-intubation laryngotracheal stenosis. Clin Otolaryngol 2007;32:411–2
Passy Muir. The Passy Muir Valve. 2018. Accessed On-Line January 14, 2018: http://www.passy-muir.com/sites/default/files/trachtube_pmv2001_1a_0.jpg
Pacheco-Lopez PC, Berkow LC, Hillel AT, Lee M, Akst M. Complications of Airway Management. Respiratory Care, 2014; 59(6): 1006-1021.
Patel A and Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoeatime in patients with difficult airways. Anaesthesia, 2015; 70: 323-29.
Philips R, deSilva B, Matrka L. Jet ventilation in obese patients undergoing airway surgery for subglottic and tracheal stenosis. Laryngoscope 2018; 128(8):1887-1892.
Rahbar R, Shapshay SM, Healy GB. Mitomycin: effects on laryngeal and tracheal stenosis, benefits, and complications. Ann Otol Rhinol Laryngol. 2001 Jan;110(1):1-6.
Rezaie-Maid A, Bigenzahn W, Denk DM, Burian M, Kornfehl J, Grasl MCh, Ihra G, Aloy A. Superimposed high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients. Br J Anaesth; 2006: 96(5):650-9
Rutter MJ, Cotton RT. The use of posterior cricoid grafting in managing isolated posterior glottic stenosis in children. Arch Otolaryngol Head Neck Surg. 2004;130:737-739.
Tack JW. Springer Science and Business Media: Annals of Biomedical Engineering, 34, 2006, p. 1897, Figure 15.1.
Tsai A, Reich JA, Schumann R, Ludington J. Resident rarely completely document urgent intubations. Anesthesiology News, 2018. Accessed On-Line: https://www.anesthesiologynews.com/Clinical-Anesthesiology/Article/07-18/Residents-Rarely-Completely-Document-Urgent-Intubations/50068
Ward RF, Gordon M, Rabkin D, April MM. Modifications of airway reconstruction in children. Ann Otol Rhinol Laryngol.
1998;107:365-369.
Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA: An estimation of the global volume of surgery: a modelling strategy based on available data. The Lancet. 2008; 372:139–44.
Wilson WC. Trauma: Airway Management ASA Difficult Airway Algorithm Modified for Trauma — and Five Common Trauma Intubation Scenarios. American Society of Anesthesiologists Article 2005; 69(11). Accessed On-line January 26, 2016: http://www.asahq.org/resources/publications/newsletter-articles/2005/november2005/trauma-airway-management
Yilmaz T. Endoscopic total arytenoidectomy for bilateral abductor vocal fold paralysis: a new flap technique and personal experience with 50 cases. Laryngoscope. 2012 Oct;122(10):2219-26.
Yin LX, Padula WV, Gadkaree S, Motz K, Rahman S, Predmore Z, Gelbard A, Hillel AT. Health Care Costs and Cost-effectiveness in laryngotracheal stenosis. Otolaryngol Head Neck Surg. 2018. Nov 27. [Epub ahead of Print]