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Introduction: Angioedema, a swelling of the subcutaneous or submucosal layers of the skin or gastrointestinal tract, is a potential complication to thrombolytic therapy in the treatment of acute ischemic strokes. In these cases, angioedema develops due to increased levels of bradykinin as a result of the activation of the fibrinolytic pathway and contact activation system. Angioedema can involve the tongue, larynx, and vocal cords, leading to occlusion of the airway and death due to asphyxiation. It is vital for the emergency physician to know that this complication can occur to ensure appropriate monitoring for development of angioedema.Case Report: We report the case of a 65-year-old Black man who presented with signs of an acute ischemic stroke and was treated with tenecteplase. The patient’s stroke symptoms mostly resolved within 90 minutes; however, he developed swelling of his right upper lip consistent with angioedema. The patient was treated with steroids and antihistamines. He was closely monitored and did not require airway intervention. The angioedema was almost fully resolved by the following day.Conclusion: Angioedema is a known complication of thrombolytic therapy for acute ischemic stroke. Risk factors for alteplase-associated angioedema include use of angiotensin-converting enzyme inhibitors, female gender, diabetes, and infarcts of the insula and frontal cortex. As hospital systems switch from alteplase to tenecteplase for the treatment of acute ischemic strokes for reasons of cost and ease of administration, it is important to recognize that angioedema is also a potential complication of tenecteplase.

Bovine respiratory disease (BRD) is the leading cause of mortality and antimicrobial drug (AMD) use in weaned dairy heifers. Limited information is available regarding antimicrobial resistance (AMR) in respiratory bacteria in this population. This study determined AMR gene presence in 326 respiratory isolates (Pasteurella multocida, Mannheimia haemolytica, and Histophilus somni) from weaned dairy heifers using whole genome sequencing. Concordance between AMR genotype and phenotype was determined. Twenty-six AMR genes for 8 broad classes of AMD were identified. The most prevalent, medically important AMD classes used in calf rearing, to which these genes predict AMR among study isolates were tetracycline (95%), aminoglycoside (94%), sulfonamide (94%), beta-lactam (77%), phenicol (50%), and macrolide (44%). The co-occurrence of AMR genes within an isolate was common; the largest cluster of gene co-occurrence encodes AMR to phenicol, macrolide, elfamycin, β-lactam (cephalosporin, penam cephamycin), aminoglycoside, tetracycline, and sulfonamide class AMD. Concordance between genotype and phenotype varied (Matthews Correlation Coefficient ranged from -0.57 to 1) by bacterial species, gene, and AMD tested, and was particularly poor for fluoroquinolones (no AMR genes detected) and ceftiofur (no phenotypic AMR classified while AMR genes present). These findings suggest a high genetic potential for AMR in weaned dairy heifers; preventing BRD and decreasing AMD reliance may be important in this population.

Cardiac catheterization remains the gold standard for the diagnosis and management of pediatric pulmonary hypertension (PH). There is lack of consensus regarding optimal anesthetic and airway regimen. This retrospective study describes the anesthetic/airway experience of our single center cohort of pediatric PH patients undergoing catheterization, in which obtaining hemodynamic data during spontaneous breathing is preferential. A total of 448 catheterizations were performed in 232 patients. Of the 379 cases that began with a natural airway, 274 (72%) completed the procedure without an invasive airway, 90 (24%) received a planned invasive airway, and 15 (4%) required an unplanned invasive airway. Median age was 3.4 years (interquartile range [IQR] 0.7-9.7); the majority were either Nice Classification Group 1 (48%) or Group 3 (42%). Vasoactive medications and cardiopulmonary resuscitation were required in 14 (3.7%) and eight (2.1%) cases, respectively; there was one death. Characteristics associated with use of an invasive airway included age

Objective: This study aimed to develop a deep learning model to predict skeletal malocclusions with an acceptable level of accuracy using airway and cephalometric landmark values obtained from analyzing different CBCT images. Background: In orthodontics, multitudinous studies have reported the correlation between orthodontic treatment and changes in the anatomy as well as the functioning of the airway. Typically, the values obtained from various measurements of cephalometric landmarks are used to determine skeletal class based on the interpretation an orthodontist experiences, which sometimes may not be accurate. Methods: Samples of skeletal anatomical data were retrospectively obtained and recorded in Digital Imaging and Communications in Medicine (DICOM) file format. The DICOM files were used to reconstruct 3D models using 3DSlicer (slicer.org) by thresholding airway regions to build up 3D polygon models of airway regions for each sample. The 3D models were measured for different landmarks that included measurements across the nasopharynx, the oropharynx, and the hypopharynx. Male and female subjects were combined as one data set to develop supervised learning models. These measurements were utilized to build 7 artificial intelligence-based supervised learning models. Results: The supervised learning model with the best accuracy was Random Forest, with a value of 0.74. All the other models were lower in terms of their accuracy. The recall scores for Class I, II, and III malocclusions were 0.71, 0.69, and 0.77, respectively, which represented the total number of actual positive cases predicted correctly, making the sensitivity of the model high. Conclusion: In this study, it is observed that the Random Forest model was the most accurate model for predicting the skeletal malocclusion based on various airway and cephalometric landmarks. [ABSTRACT FROM AUTHOR]

Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams. [ABSTRACT FROM AUTHOR]

Environmental air pollution presents a considerable risk to global respiratory health. If critical levels are exceeded, inhaled pollutants can lead to the development of respiratory dysfunction and provoke exacerbation in those with pre‐existing chronic respiratory disease. Over 90% of the global population currently reside in areas where environmental air pollution is considered excessive—with adverse effects ranging from acute airway irritation to complex immunomodulatory alterations. This narrative review provides an up‐to‐date perspective concerning the impact of environmental air pollution on respiratory health and function and describes the underpinning mechanisms that contribute to the development and progression of chronic respiratory disease. [ABSTRACT FROM AUTHOR]

An application of CO2/HCO3−-free solution (Zero-CO2) did not increase intracellular pH (pHi) in ciliated human nasal epithelial cells (c-hNECs), leading to no increase in frequency (CBF) or amplitude (CBA) of the ciliary beating. This study demonstrated that the pHi of c-hNECs expressing carbonic anhydrase IV (CAIV) is high (7.64), while the pHi of ciliated human bronchial epithelial cells (c-hBECs) expressing no CAIV is low (7.10). An extremely high pHi of c-hNECs caused pHi, CBF and CBA to decrease upon Zero-CO2 application, while a low pHi of c-hBECs caused them to increase. An extremely high pHi was generated by a high rate of HCO3− influx via interactions between CAIV and Na+/HCO3− cotransport (NBC) in c-hNECs. An NBC inhibitor (S0859) decreased pHi, CBF and CBA and increased CBF and CBA in c-hNECs upon Zero-CO2 application. In conclusion, the interactions of CAIV and NBC maximize HCO3− influx to increase pHi in c-hNECs. This novel mechanism causes pHi to decrease, leading to no increase in CBF and CBA in c-hNECs upon Zero-CO2 application, and appears to play a crucial role in maintaining pHi, CBF and CBA in c-hNECs periodically exposed to air (0.04% CO2) with respiration. [ABSTRACT FROM AUTHOR]

Coffin-Lowry Syndrome (CLS) is a rare X-linked genetic disorder characterized by growth delays, facial dysmorphisms, and intellectual disabilities. Currently, there are limited published case reports regarding the anesthetic management of patients with CLS. Managing anesthesia for CLS patients can be complex due to difficult airway management. In this case report, we present a patient with CLS who underwent surgical intervention, highlighting the anesthetic considerations encountered throughout the perioperative period. We aim to summarize the difficulties involved in anesthetic management of rare conditions like CLS to improve clinical outcomes for affected individuals. [ABSTRACT FROM AUTHOR]

Background and Aims: The most important and lifesaving step of airway management and resuscitation of patients is rapid and accurate endotracheal tube placement. Any delay in confirmation of endotracheal tube placement can lead to potentially life-threatening complications. Capnography, which is considered the gold standard method, also can yield transiently false positive results. We aimed to detect the time taken and to compare the effectiveness of real-time trans-tracheal ultrasonography with waveform capnography to confirm the correct placement of the endotracheal tube. Methods: A prospective observational study was conducted at our tertiary care hospital for a period of six months on 100 patients requiring endotracheal intubation under general anaesthesia. Real-time transtracheal ultrasonography and waveform capnography were used to confirm the correct placement of the endotracheal tube. Time taken by both methods in seconds was noted down by two different observers. Results: The time taken to confirm the correct placement of ETT by ultrasonography was 19.82 ± 5.14s, 95% CI: 18.8 - 20.84 and for capnography was 32.69 ± 5.73s, 95% CI: 31.55 - 33.83, p < 0.001, with a mean difference of 12.87s, 95% CI: 13.61 to 12.069, p < 0.001. The Pearson’s correlation coefficient ‘r value’ was 0.822, 95% CI: 0.746 - 0.877, p < 0.001. The sensitivity, specificity, PPV, and NPV of ultrasonography against capnography were 100%. Conclusion: Transtracheal ultrasonography is a faster, equally accurate and safe technique for confirmation of the correct placement of ETT and can be a good alternative to capnography. [ABSTRACT FROM AUTHOR]

Tracheomalacia is a condition where the tracheal wall is abnormally soft and prone to collapse during increased respiratory efforts. Airway malacia can manifest as segmental conditions like laryngomalacia, tracheomalacia and bronchomalacia, or as diffuse conditions such as tracheobronchomalacia (TBM). Unlike long‐segment congenital tracheal stenosis, where surgery may be the preferred treatment, the management of long‐segment TBM remains controversial. [ABSTRACT FROM AUTHOR]

Emergence and extubation are critical transitional phases in the perioperative period. Evidence has shown that complications occur more at extubation than intubation and induction. A comprehensive understanding of the various factors influencing emergence and extubation, potential complications, essential steps and different techniques employed can maximize patient outcomes and satisfaction. Vigilant monitoring and assessment of the patient's readiness for extubation are required at emergence. Reasons for delay and delirium in emergence must be screened and investigated so that corresponding treatment can be pursued. Haemodynamic stability, continued oxygen delivery, adequate analgesia and anti-emesis are the general objectives. Extubation is an elective procedure with the potential for unanticipated challenges and mortalities. Should extubation be determined appropriate, individualized planning and methodical preparation must precede the performance of extubation to avoid complications and failures. Risk stratification, airway assessment and optimization of physiological parameters are some of the necessary processes. Different extubation techniques are selected and performed to address specific physiological consequences and airway concerns. Guidelines and systematic approaches regarding emergence and extubation should be followed. [ABSTRACT FROM AUTHOR]

Background: Early orthopaedic treatment with rapid maxillary expansion (RME) associated with facemask (FM) has been shown to be effective in correcting Class III malocclusions in children. Treatment with pushing splints 3 (PS3) has shown to correct skeletal discrepancies in Class III growing patients. However, the effects of orthopaedic treatment on the upper airways in children with Class III malocclusion is controversial. Objectives: The aim of this study was to evaluate the cephalometric changes in the airways of PS3 compared to the RME/FM protocol. Materials and Methods: In this study, 48 patients with Class III malocclusion (age range 5.5–8.5 years old) were selected for this study, and 24 were treated with PS3 appliance and 24 with RME/FM therapy. Lateral cephalograms before (T0) and at the end of the treatment (T1) were analysed to compare pharyngeal spaces. Paired and unpaired t tests were used for data analysis (P <.05). Results: A total of 41 patients (21 patients for the PS3 group, 11 males and 10 females, mean age 7.0 ± 1.2 years; 20 patients for the RME/FM group, 10 males and 10 females, mean age 7.2 ± 1.3 years) were included. The results showed a statistically significant (P <.05) increase in the nasopharyngeal space after both therapies. However, the effects were similar considering that there were no differences between groups for the assessed variables at T0–T1. Conclusions: Early treatment of Class III malocclusion with PS3 does not induce a statistically significant increase in the sagittal airway space compared to RME/FM. The absence of untreated group could not define the role of growth in the increase of space. [ABSTRACT FROM AUTHOR]

Background While inflammatory and immune responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in peripheral blood are extensively described, responses at the upper respiratory mucosal site of initial infection are relatively poorly defined. We sought to identify mucosal cytokine/chemokine signatures that distinguished coronavirus disease 2019 (COVID-19) severity categories, and relate these to disease progression and peripheral inflammation. Methods We measured 35 cytokines and chemokines in nasal samples from 274 patients hospitalized with COVID-19. Analysis considered the timing of sampling during disease, as either the early (0–5 days after symptom onset) or late (6–20 days after symptom onset) phase. Results Patients that survived severe COVID-19 showed interferon (IFN)-dominated mucosal immune responses (IFN-γ, CXCL10, and CXCL13) early in infection. These early mucosal responses were absent in patients who would progress to fatal disease despite equivalent SARS-CoV-2 viral load. Mucosal inflammation in later disease was dominated by interleukin 2 (IL-2), IL-10, IFN-γ, and IL-12p70, which scaled with severity but did not differentiate patients who would survive or succumb to disease. Cytokines and chemokines in the mucosa showed distinctions from responses evident in the peripheral blood, particularly during fatal disease. Conclusions Defective early mucosal antiviral responses anticipate fatal COVID-19 but are not associated with viral load. Early mucosal immune responses may define the trajectory of severe COVID-19. [ABSTRACT FROM AUTHOR]

Background Objective Materials and Methods Results Conclusion Some orthodontic devices used in children share similar design principles to appliances used to treat obstructive sleep apnoea in adults. As well as treating malocclusion, orthodontic appliances used in children may therefore also have effects on the upper airway.A review of the literature to assess the effects of orthodontic treatment on the upper airway dimensions in children assessed on CBCT.Following registration of the protocol (PROSPERO CRD42023439056), a systematic electronic search of published studies was performed using several databases (PubMed; Scopus, Web of Science and Science Direct) in accordance with the PRISMA guidelines. Inclusion criteria were as follows: age under 18 years, orthodontic treatment with any appliance, a control group who received no treatment or a non‐active alternative treatment and airway measurement using CBCT. RoB‐2 and ROBINS‐I tools were used to assess risk of bias and quality of the evidence.In total, 341 studies were identified following the initial search. Title and abstract screening resulted in 45 studies for further full‐text analysis. On completion of the screening process, a total of 23 studies met the inclusion criteria. Study interventions included functional appliances (10 studies), rapid maxillary expansion (RME) (9 studies), reverse‐pull headgear (1 study) and 4 premolar dental extractions (3 studies). The included studies had moderate to high risk of bias, and the quality of evidence was low.The scientific evidence shows that functional appliances are associated with significant improvements in both upper airway volume and constriction when used in children however, the effects on the nasal cavity are limited. RME was associated with a significant increase in nasal cavity and nasopharyngeal dimensions, but not the upper pharyngeal airway. Neither reverse‐pull headgear nor dental extractions were associated with any change in airway dimensions; however, the evidence is limited. Functional appliances may reduce the severity of obstructive sleep apnoea (OSA) in children. [ABSTRACT FROM AUTHOR]

Acute upper airway compromise is a rare but catastrophic complication after anterior cervical discectomy and fusion. This study aims to develop a score to identify patients at risk of acute postoperative airway compromise (PAC). Potential risk factors for acute PAC were selected by a modified Delphi process. Ten patients with acute PAC were identified of 1466 patients who underwent elective anterior cervical discectomy and fusion between July 2014 and May 2019. A comparison group was created by a randomized selection process (non-PAC group). Factors associated with PAC and a P value of < 0.10 were entered into a logistic regression model and coefficients contributed to each risk factor's overall score. Calibration of the model was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Quantitative discrimination was calculated, and the final model was internally validated with bootstrap sampling. We identified 18 potential risk factors from our Delphi process, of which 6 factors demonstrated a significant association with airway compromise: age >65 years, current smoking status, American Society of Anesthesiologists class >2, history of a bleeding disorder, surgery of upper subaxial cervical spine (above C4), and duration of surgery >179 minutes. The final prediction model included 5 predictors with very strong performance characteristics. These 5 factors formed the PAC score, with a range from 0 to 100. A score of 20 yielded the greatest balance of sensitivity (80%) and specificity (88%). The acute PAC score demonstrates strong performance characteristics. The PAC score might help identify patients at risk of upper airway compromise caused by surgical site abnormalities. [ABSTRACT FROM AUTHOR]

Advances in paediatric anaesthetic equipment and monitoring continue to be made. While the mainstay of airway intubating equipment currently is the direct laryngoscope, videolaryngoscopes and endoscopes are increasing in their use. These continue to evolve, generating better quality pictures, with more sophisticated yet easier to use equipment. Vascular access in paediatric anaesthesia can be challenging. Ultrasound has become an integral piece of equipment in the management of these children with difficult access. As the population increases in weight, so the management of the obese child is now a reality. This requires thought and careful planning of their perioperative care. Newer techniques such as high flow nasal oxygen are useful both to prevent hypoxia at induction, but also to facilitate surgery. Total intravenous anaesthesia will be discussed with reference to paediatric algorithms and equipment. Neurological monitoring in the form of near-infrared spectroscopy and depth of anaesthesia monitoring are discussed with evidence relevant to paediatric practice. [ABSTRACT FROM AUTHOR]

Airway management is undertaken to deliver oxygen, remove carbon dioxide and protect against pulmonary aspiration. This article describes the equipment utilized by airway providers in order to achieve these aims, aided by their relevant knowledge, skills and experience. The use of this equipment forms the basis of core airway management techniques, including facemask ventilation, use of supraglottic airway devices, laryngoscopy, awake tracheal intubation and front-of-neck access. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to develop and assess multidisciplinary advanced surgical planning (ASP) sessions using three dimensional (3D) printed models for cervicothoracic slide tracheoplasty (CST). We hypothesized that these sessions would improve surgeon confidence, streamline intraoperative planning, and highlight the utility of 3D modeling. Methods: 3D‐printed patient‐specific trachea models were used in pre‐operative ASP sessions consisting of a multidisciplinary case discussion and hands‐on slide tracheoplasty simulation. Participants completed a survey rating realism, utility, impact on the final surgical plan, and pre‐ and post‐session confidence. Statistical analysis was performed via Wilcoxon and Kruskal‐Wallis tests. Results: Forty‐eight surveys were collected across nine sessions and 27 different physicians. On a 5‐point Likert scale, models were rated as "very realistic", "very useful" (both median of 4, IQR 3–4 and 4–5, respectively). Overall confidence increased by 1.4 points (+/− 0.7, p < 0.0001), with the largest change seen in those with minimal prior slide tracheoplasty experience (p = 0.005). Participants felt that the sessions "strongly" impacted their surgical plan or anticipated performance (median 4, IQR 4–5), regardless of training level or experience. Conclusion: 3D‐printed patient‐specific models were successfully implemented in ASP sessions for CST. Models were deemed very realistic and very useful by surgeons across multiple specialties and training levels. Surgical planning sessions also strongly impacted the final surgical plan and increased surgeon confidence for CST. Level of Evidence: 4 Laryngoscope, 134:3395–3401, 2024 [ABSTRACT FROM AUTHOR]

Abstract Objective This study aimed to develop a deep learning model to predict skeletal malocclusions with an acceptable level of accuracy using airway and cephalometric landmark values obtained from analyzing different CBCT images. Background In orthodontics, multitudinous studies have reported the correlation between orthodontic treatment and changes in the anatomy as well as the functioning of the airway. Typically, the values obtained from various measurements of cephalometric landmarks are used to determine skeletal class based on the interpretation an orthodontist experiences, which sometimes may not be accurate. Methods Samples of skeletal anatomical data were retrospectively obtained and recorded in Digital Imaging and Communications in Medicine (DICOM) file format. The DICOM files were used to reconstruct 3D models using 3DSlicer (slicer.org) by thresholding airway regions to build up 3D polygon models of airway regions for each sample. The 3D models were measured for different landmarks that included measurements across the nasopharynx, the oropharynx, and the hypopharynx. Male and female subjects were combined as one data set to develop supervised learning models. These measurements were utilized to build 7 artificial intelligence-based supervised learning models. Results The supervised learning model with the best accuracy was Random Forest, with a value of 0.74. All the other models were lower in terms of their accuracy. The recall scores for Class I, II, and III malocclusions were 0.71, 0.69, and 0.77, respectively, which represented the total number of actual positive cases predicted correctly, making the sensitivity of the model high. Conclusion In this study, it is observed that the Random Forest model was the most accurate model for predicting the skeletal malocclusion based on various airway and cephalometric landmarks.

Abstract Coffin-Lowry Syndrome (CLS) is a rare X-linked genetic disorder characterized by growth delays, facial dysmorphisms, and intellectual disabilities. Currently, there are limited published case reports regarding the anesthetic management of patients with CLS. Managing anesthesia for CLS patients can be complex due to difficult airway management. In this case report, we present a patient with CLS who underwent surgical intervention, highlighting the anesthetic considerations encountered throughout the perioperative period. We aim to summarize the difficulties involved in anesthetic management of rare conditions like CLS to improve clinical outcomes for affected individuals.

Introduction: Tissue plasminogen activator (tPA), commonly used for treatment of acute ischemic stroke, is associated with life-threatening bleeding intracranially as well as surrounding the airway. Case Report: A 78-year-old year old male who presented with stroke symptoms and after tPA administration developed a retropharyngeal hematoma requiring intubation and surgical intervention. Conclusion: Numerous threats to the patient’s airway can develop after tPA administration. While angioedema is the most common cause, it is important to be prepared for other causes related to hemorrhage.

A 4.1 kg male neonate with a diagnosis of double-inlet left ventricle with dextro-transposition of the great arteries was intubated shortly after birth due to respiratory insufficiency. The initial management consisted of a successful Stage I hybrid procedure. Persistent respiratory insufficiency led to cross-sectional imaging and bronchoscopy that demonstrated severe airway compression from a dilated main pulmonary artery. A Norwood procedure with Blalock–Thomas–Taussig shunt was performed at 1 month of age to relieve the airway obstruction. The patient was discharged home on room air at 2 months of age. This case highlights a unique single-ventricle anatomic variant with airway compression, which was successfully managed with deferred Norwood palliation.

Background/purpose: The use of computed tomography (CT) for craniofacial measurements is common in medical imaging, but concerns about accuracy and reliability persist, especially with different CT technologies. This study assessed the accuracy of twenty-six common measurements on consecutive CT images from the same patients, using multidetector CT (MDCT) and cone-beam CT (CBCT) with two software programs (Amira and Dolphin). Materials and methods: Ten adult subjects with consecutive CBCT scans within one year were randomly selected. Another ten subjects with consecutive MDCT scans were paired with the CBCT group based on age, gender, race, occlusion, and craniofacial pattern. All digital imaging and communications in medicine (DICOM) files were randomly coded and analyzed using the two software programs. Intra-examiner reliability was assessed using the intraclass correlation coefficient. Successive measurement errors from consecutive scans for both imaging modalities and software programs were compared. Results: For most skeletal linear and angular measurements, Dolphin showed greater successive measurement errors compared to Amira. Eight of the 26 common measurements had errors greater than one unit (millimeter or degree). Despite almost perfect intra-examiner reliability for upper airway analysis, average successive measurement errors were notably high, particularly for intraoral and oropharyngeal airway volumes. The successive Dolphin measurement error for oropharyngeal airway volume on CBCT images was over three times that on MDCT images. Conclusion: Given the substantial successive measurement errors observed during consecutive CT scanning for the upper airway, this study does not support the quantitative use of CT for analyzing changes in airway dimensions for research purposes.

Airway ultrasound has been increasingly used in correct positioning of endotracheal tube. We hypothesize that a safe distance between endotracheal tube tip and carina can be achieved with the aid of ultrasound.

Obesity is associated with many significant physiological changes. These considerations are important to surgery, especially in urological procedures. Obese patients often undergo surgical procedures and are at higher risk of complications. This investigation reviews physiological and anaesthesia considerations for obese and morbidly obese patients. In addition, urological surgeries and procedures should be considered for these higher risk patients. Clinical anaesthesiologists must use detailed assessment and, when appropriate, consultation in developing safe anaesthesia plans for these patients. Newer technologies have improved safety related to airway management, advanced airway devices, and regional anaesthesia with ultrasound-guided nerve blocks, which can reduce the need for opioids postoperatively. Recent developments in drug and monitoring technologies have also been developed and can be effective for obese and morbidly obese patients undergoing urological procedures and perioperative surgery, thus improving the likelihood of safety in this higher risk population.

Systemic administration of opioids has been associated with aspiration and swallow dysfunction in humans. We speculated that systemic administration of codeine would induce dysfunctional swallowing and that this effect would have a peripheral component. Experiments were conducted in spontaneously breathing, anesthetized cats. The animals were tracheotomized and electromyogram (EMG) electrodes were placed in upper airway and chest wall respiratory muscles for recording swallow related motor activity. The animals were allocated into three groups: vagal intact (VI), cervical vagotomy (CVx), and supra-nodose ganglion vagotomy (SNGx). A dose response to intravenous codeine was performed in each animal. Swallowing was elicited by injection of 3 mL of water into the oropharynx. The number of swallows after vehicle was significantly higher in the VI group than in SNGx. Codeine had no significant effect on the number of swallows induced by water in any of the groups. However, the magnitudes of water swallow-related EMGs of the thyropharyngeus muscle were significantly increased in the VI and CVx groups by 2-4 fold in a dose-related manner. In the CVx group, the geniohyoid muscle EMG during water swallows was significantly increased. There was a significant dose-related increase in spontaneous swallowing in each group from codeine. The spontaneous swallow number at the 10 mg/kg dose of codeine was significantly larger in the CVx group than that in the SNGx group. During water-evoked swallows, intravenous codeine increased upper airway motor drive in a dose-related manner, consistent with dysregulation. The data support the existence of both central and peripheral actions of codeine on spontaneous swallowing. At the highest dose of codeine, the reduced spontaneous swallow number in the SNGx group relative to CVx is consistent with a peripheral excitatory action of codeine either on pharyngeal/laryngeal receptors or in the nodose ganglion itself. The higher number of swallows in the CVx group than the VI group supports disinhibition of this behavior by elimination of inhibitory vagal sensory afferents. [ABSTRACT FROM AUTHOR]

Cough is a powerful, protective expulsive behavior that assists in maintaining respiratory health by clearing foreign material, pathogens, and mucus from the airways. Therefore, cough is critical to survival in both health and disease. Importantly, cough protects the airways and lungs from both antegrade (e.g., food, liquid, saliva) and retrograde (e.g., bile, gastric acid) aspirate contents. Aspiration is often the result of impaired swallowing (dysphagia), which allows oral and/or gastric contents to enter the lung, especially in individuals who also have cough dysfunction (dystussia). Cough hyposensitivity, downregulation, or desensitization- collectively referred to as hypotussia- is common in individuals with dysphagia, and increases the likelihood that aspirated material will reach the lung. The consequence of hypotussia with reduced airway clearance can include respiratory tract infection, chronic inflammation, and long-term damage to the lung parenchyma. Despite the clear implications for health, the problem of managing hypotussia in individuals with dysphagia is frequently overlooked. Here, we provide an overview of the current interventions and treatment approaches for hypotussic cough. We synthesize the available literature to summarize research findings that advance our understanding of these interventions, as well as current gaps in knowledge. Further, we highlight pragmatic resources to increase awareness of hypotussic cough interventions and provide support for the clinical implementation of evidence-based treatments. In culmination, we discuss potential innovations and future directions for hypotussic cough research. [ABSTRACT FROM AUTHOR]

Introduction: Patients with sleep apnea, affecting up to 1 in 4 older men in the United States, may be at increased risk of postoperative complications after total knee arthroplasty (TKA), including increased thromboembolic and cerebrovascular events, as well as respiratory, cardiac, and digestive complications. However, the extent to which the use of CPAP in patients with sleep apnea has been studied in TKA is limited. Methods: A national, all-payer database was queried to identify all patients who underwent a primary TKA between 2010 and 2021. Patients who had any history of sleep apnea were identified and then stratified based on the use of CPAP. A propensity score match analysis was conducted to limit the influence of confounders. Medical complications, such as cardiac arrest, stroke, pulmonary embolism, transfusion, venous thromboembolism, and wound complications, were collected at 90-days, 1-year, and 2-years. Results: The bivariate analysis showed inferior outcomes for sleep apnea with CPAP use compared to sleep apnea with no CPAP use, in terms of length of stay (5.9 vs. 5.2, p < 0.001), PJI (1.31% vs. 1.14%, p < 0.001), stroke (0.97% vs. 0.82%, p < 0.001), VTE (1.04% vs. 0.82, p < 0.001), and all other complications at 90-days (p < 0.001) except cardiac arrest (0.14% vs. 0.11%, p = 0.052), and aseptic revision (0.40% vs. 0.39%, p = 0.832), PJI (1.81% vs. 1.55%, p < 0.001) and aseptic revision (1.25% vs. 1.06%, p < 0.001) at 1-year, and PJI (2.07 vs. 1.77, p < 0.001) and aseptic revision (1.98 vs. 1.17, p < 0.001) at 2-years. Conclusion: Patients with sleep apnea have increased postoperative complications after undergoing TKA in comparison to patients without sleep apnea. More severe sleep apnea, represented by CPAP usage in this study led to worse postoperative outcomes but further analysis is required signify the role of CPAP in this patient population. Patients with sleep apnea should be treated as a high-risk group. [ABSTRACT FROM AUTHOR]

Background: Respiratory viruses significantly impact global morbidity and mortality, causing more disease in humans than any other infectious agent. Beyond pathogens, various viruses and bacteria colonize the respiratory tract without causing disease, potentially influencing respiratory diseases' pathogenesis. Nevertheless, our understanding of respiratory microbiota is limited by technical constraints, predominantly focusing on bacteria and neglecting crucial populations like viruses. Despite recent efforts to improve our understanding of viral diversity in the human body, our knowledge of viral diversity associated with the human respiratory tract remains limited. Methods: Following a comprehensive search in bibliographic and sequencing data repositories using keyword terms, we retrieved shotgun metagenomic data from public repositories (n = 85). After manual curation, sequencing data files from 43 studies were analyzed using EVEREST (pipEline for Viral assEmbly and chaRactEriSaTion). Complete and high-quality contigs were further assessed for genomic and taxonomic characterization. Results: Viral contigs were obtained from 194 out of the 868 FASTQ files processed through EVEREST. Of the 1842 contigs that were quality assessed, 8% (n = 146) were classified as complete/high-quality genomes. Most of the identified viral contigs were taxonomically classified as bacteriophages, with taxonomic resolution ranging from the superkingdom level down to the species level. Captured contigs were spread across 25 putative families and varied between RNA and DNA viruses, including previously uncharacterized viral genomes. Of note, airway samples also contained virus(es) characteristic of the human gastrointestinal tract, which have not been previously described as part of the lung virome. Additionally, by performing a meta-analysis of the integrated datasets, ecological trends within viral populations linked to human disease states and their biogeographical distribution along the respiratory tract were observed. Conclusion: By leveraging publicly available repositories of shotgun metagenomic data, the present study provides new insights into viral genomes associated with specimens from the human respiratory tract across different disease spectra. Further studies are required to validate our findings and evaluate the potential impact of these viral communities on respiratory tract physiology. [ABSTRACT FROM AUTHOR]

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit. [ABSTRACT FROM AUTHOR]

Objective: Compare ventilation pressures of 2 endotracheal tube designs used in laser airway surgery in clinical practice and with a benchtop model to elucidate differences and understand the design elements that impact airflow dynamics. Methods: Ventilatory and aerodynamic characteristics of the laser resistant stainless-steel endotracheal tube (LRSS-ET) design and the laser resistant aluminum-wrapped silicone endotracheal tube (LRAS-ET) design were compared. Ventilatory parameters were collected for 32 patients undergoing laser-assisted airway surgery through retrospective chart review. An in vitro benchtop simulation measured average resistance and centerline turbulence intensity of both designs at various diameters and physiological frequencies. Results: Baseline patient characteristics did not differ between the 2 groups. Clinically, the median LRAS-ET peak inspiratory pressure (PIP; 21.00 cm H2O) was significantly decreased compared to LRSS-ET PIP (34.67 cm H2O). In benchtop simulation, the average PIP of the LRAS-ET was significantly lower at all sizes and frequencies. The LRSS-ET consistently demonstrated an increased resistance, although no patterns were observed in turbulence intensity data between both designs. Conclusion: The benchtop model demonstrated increased resistance in the LRSS-ET compared to the LRAS-ET at all comparable sizes. This finding is supported by retrospective ventilatory pressures during laser airway surgery, which show significantly increased PIPs when comparing identically sized inner diameters. Given the equivocal turbulence intensity data, these differences in resistance and pressures are likely caused by wall roughness and intraluminal presence of tubing, not inlet or outlet geometries. The decreased PIPs of the LRAS-ET should assist in following lung protective ventilator management strategies and reduce risk of pulmonary injury and hemodynamic instability to the patient. [ABSTRACT FROM AUTHOR]

A female patient, known to have hypermobile Ehlers-Danlos syndrome (hEDS), underwent several elective gastroscopies under sedation in different hospitals. Except for a single incident of mild laryngospasm during emergence, all procedures were uneventful. On that occasion, following the procedure in the postanesthesia care unit, the patient suffered severe airway obstruction, and standard airway rescue techniques exacerbated adequate ventilation. After the removal of all stimuli and maintaining only an indirect oxygen supply via a mask in front of her face, her airway improved, and the patient fully recovered after 17 minutes. After the gastroscopy, physical examination revealed that the patient had an extremely flexible trachea that could be completely moved outside the midline to the extreme right and left. For the subsequent procedures, an airway plan was developed in conjunction with the patient and resulted in uncomplicated perianesthetic care. This case report serves to alert readers to the risk of adverse airway events in patients with EDS and suggests an alternative approach to avoid such complications. When patients receive care in different hospitals, adequate documentation is essential and adequate preoperative assessment is crucial. This case study demonstrates the value of patient-coproduction care plans. [ABSTRACT FROM AUTHOR]

Background: Intubated preterm infants 326/7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 326/7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 326/7 weeks or less of gestation in a mid-Atlantic level IV NICU. Methods: This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked. Results: Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt. Implications for Practice and Research: Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 326/7 weeks or less of gestation. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to verify the correlation of the airway‐facial phenotype and visualize the morphological variation in Crouzon syndrome patients. Additionally, to develop a non‐radiation methodology for airway assessments. Method: In this study, 22 patients diagnosed with Crouzon syndrome (Age: 7.80 ± 5.63 years; Gender distribution: 11 females and 11 males) were analysed. The soft tissue surface and airway were three‐dimensionally reconstructed, and the entire facial phenotype was topologized and converted into spatial coordinates. Geometric morphometrics was employed to verify the correlation and visualize dynamic phenotypic variation associated with airway volume. A total of 276 linear variables were automatically derived from 24 anatomical landmarks, and principal component analysis (PCA) identified the 20 most significant parameters for airway evaluation. Correlation analyses between parameters and airway volume were performed. Then, patients were classified into three groups based on airway volume, and the differences among the groups were compared for evaluating the differentiating effectiveness of parameters. Results: The facial phenotype was strongly correlated with the airway (coefficient: 0.758). Morphological variation was characterized by (i) mandibular protrusion and anticlockwise rotation; (ii) midface retrusion; (iii) supraorbital frontward and (iv) lengthening of the facial height. All the anthropometric parameters were strongly associated with the airway, and the differences among the groups were statistically significant. Conclusion: This study confirmed the strong correlation between facial phenotype and airway parameters in Crouzon syndrome patients. Despite the development of the airway, pathological midface retrusion was still aggravated, suggesting that surgical intervention was inevitable. Three‐dimensional facial anthropometry has potential as a non‐radiation examination for airway evaluation. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to elucidate the association between cranial base (Bjork‐Jarabak analysis), midsagittal cross‐sectional area of the airway in the pharyngeal region (MCSA‐PR) data and pharyngeal‐airway volume (PAV) and develop a model that could help clinicians predict PAV using two‐dimensional (2D) data (Bjork polygon and MCSA‐PR). Materials and Methods: Pre‐treatment lateral cephalometric radiographs and magnetic resonance imaging (MRI) scans of 82 women were categorized into three anteroposterior skeletal groups based on ANB angle: Class I (n = 29), 1.5° ≤ ANB≤5.1°; Class II (n = 26), ANB >5.1°; Class III (n = 27), ANB <1.5°. The Bjork polygon, MCSA‐PR data from cephalograms and PAV data from MRI scans were examined. Intergroup comparisons were performed using the Kruskal–Wallis test and one‐way analysis of variance (ANOVA), with pairwise comparisons conducted using the Bonferroni‐corrected Mann–Whitney U‐test for the Kruskal–Wallis test and Bonferroni‐corrected multiple comparison test for one‐way ANOVA. Forward multiple linear regression was used to create model equations for predicting PAV. Results: MCSA‐PR and anterior (N‐S) and posterior (S‐Ar) cranial‐base lengths were positively correlated with the PAV. We developed four models; three operated at the group level, and one encompassed the entire sample. Notably, all models could effectively explain the variance in the PAV data. The model for the Class I group was the strongest (adjusted R2 = 0.77). Conclusion: Our findings indicate the remarkable potential of the MCSA‐PR, N‐S and Bjork sum angles (BSA) as predictors of the PAV and the relevance of 2D cephalometric and cranial‐base parameters in predicting the three‐dimensional (3D) pharyngeal‐airway size. [ABSTRACT FROM AUTHOR]

Objectives: Tracheal transplantation is an ideal option for the reconstruction of long‐segment circumferential tracheal defects. Our group performed the first successful vascularized single‐staged tracheal transplantation in January 2021. Although a rigid biocompatible structure is necessary for a functioning tracheal replacement, the importance of ciliated epithelium, which allows for critical mucociliary clearance, is now being appreciated. Here, we examined the histological changes of the first single‐staged human tracheal transplant from serial endoscopic biopsies. Methods: Biopsies of the tracheal mucosa were serially obtained since the time of the tracheal transplantation. Samples were examined via hematoxylin and eosin, electron microscopy, and immunohistochemistry. Results: One week after transplantation, there is loss of ciliated epithelium and seromucinous cells, with only a basal layer of epithelium remaining. By 2 weeks, however, the epithelium begins to recover, albeit differently depending on the location of the biopsy. Near the site of tracheal anastomosis, there is epithelial proliferation, with the appearance of early ciliated cells. However, in the midgraft, there appears to be evidence of squamous metaplasia. Over time, however, normal ciliated epithelium and mucous cells appear without signs of chronic inflammation. Conclusions: Critically, the tracheal allograft regained normal appearing respiratory epithelium after initial ischemic injury. The histologic differences at the midgraft versus anastomosis may suggest unique mechanisms of reepithelialization. At the recipient–donor interface, there may be a faster direct migration of recipient‐derived epithelial cells, in line with preclinical studies. The midgraft, in contrast, responds with epithelial proliferation from the donor basal cells or dedifferentiated mucous cells. Level of Evidence: N/A Laryngoscope, 134:2664–2671, 2024 [ABSTRACT FROM AUTHOR]

Background: Nitrous oxide (N2O) has been in industrial and recreational use since the 18th century and is commonly perceived as a safe substance. Despite its increasing uptake, there is a lack of data on N2O-related harm. This article explores the misuse of N2O associated with various complications, with a focus on frostbite as a novel phenomenon. We aimed to review the existing body of literature and describe the epidemiology, presentation, pathophysiology, and management of patients with N2O-related frostbite injuries in the upper aerodigestive tract. Methods: A literature search was conducted across PubMed, MEDLINE and Embase databases, focusing on English language articles related to N2O use patterns, associated injuries, pathophysiology, investigations, and management. Results: The search yielded 122 results, of which fifteen case reports and case series were included in the study. There are 54 total cases included in the analysis. There is an equal distribution of males and females among a young population with a median age of 27.5 years. Presentations of skin and mucosal injuries across different anatomical sites as well as their management approaches are described. Conclusions: The pathophysiology of frostbite involves both direct and indirect effects, leading to tissue ischaemia, inflammation, and immune responses. Complications, including airway obstruction, underscore the severity of N2O-related injuries. Management strategies include securing the airway, surgical debridement, and pharmacological interventions such as prophylactic corticosteroids and antibiotics. N2O is a documented causative agent of frostbite injuries. Awareness of its rising prevalence and potential complications is key in the treatment of patients with complications sustained from the use of N2O. Level of evidence: Not ratable [ABSTRACT FROM AUTHOR]

Cough is a common symptom of several respiratory diseases. However, frequent coughing from acute to chronic often causes great pain to patients. It may turn into cough variant asthma, which seriously affects people's quality of life. For cough treatment, it is dominated by over-the-counter antitussive drugs, such as asmeton, but most currently available antitussive drugs have serious side effects. Thus, there is a great need for the development of new drugs with potent cough suppressant. BALB/c mice were used to construct mice model with cough to investigate the pharmacological effects of pectolinarigenin (PEC). Hematoxylin-eosin and Masson staining were used to assess lung injury and airway remodeling, and ELISA was used to assess the level of inflammatory factor release. In addition, inflammatory cell counts were measured to assess airway inflammation. Airway hyperresponsiveness assay was used to assess respiratory resistance in mice. Finally, we used Western blotting to explore the potential mechanisms of PEC. We found that PEC could alleviate lung tissue injury and reduce the release of inflammatory factors, inhibit of cough frequency and airway wall collagen deposition in mice model with cough. Meanwhile, PEC inhibited the Ras/ERK/c-Fos pathway to exhibit antitussive effect. Therefore, PEC may be a potential drug for cough suppression. [ABSTRACT FROM AUTHOR]

Introduction: Video laryngoscope (VL) technology improves first‐pass success. The novel i‐view VL device is inexpensive and disposable. We sought to determine the first‐pass intubation success with the i‐view VL device versus the standard reusable VL systems in routine use at each site. Methods: We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i‐view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator‐initiated interim analysis was performed. Our primary outcome was a first‐pass success with a non‐inferiority margin of 10% based on the per‐protocol analysis. Results: There were 93 intubations using the reusable VL devices and 81 intubations using the i‐view. Our study was stopped early due to futility in reaching our predetermined non‐inferiority margin. Operator and patient characteristics were similar between the two groups. The first‐pass success rate for the i‐view group was 69.1% compared to 84.3% for the reusable VL group. A non‐inferiority analysis indicated that the difference (−15.1%) and corresponding 90% confidence limits (−25.3% to −5.0%) did not fall within the predetermined 10% non‐inferiority margin. Conclusions: The i‐view device failed to meet our predetermined non‐inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i‐view month. [ABSTRACT FROM AUTHOR]

Airway compromise is the second leading cause of potentially preventable death on the battlefield. Prehospital airway management is often unavoidable in a kinetic combat environment and expected to increase in future wars where timely evacuation will be unreliable and air superiority not guaranteed. We compared characteristics of survivors to non-survivors among combat casualties undergoing prehospital airway intubation. We requested all Department of Defense Trauma Registry (DODTR) encounters during 2007–2023 with documentation of any airway intervention or assessment within the first 72-h after injury. We conducted a retrospective cohort study of all casualties with intubation documented in the prehospital setting. We used descriptive and inferential statistical analysis to compare survivors through 7 days post injury versus non-survivors. We constructed 3 multivariable logistic regression models to test for associations between interventions and 7-day survival after adjusting for injury severity score, mechanism of injury, and receipt of sedatives, paralytics, and blood products. There were 1377 of 48,301 patients with documentation of prehospital intubation in a combat setting. Of these, 1028 (75%) survived through 7 days post injury. Higher proportions of survivors received ketamine, paralytic agents, parenteral opioids, and parenteral benzodiazepines; there was no difference in the proportions of survivors versus non-survivors receiving etomidate. The multivariable models consistently demonstrated positive associations between 7-day survival and receipt of non-depolarizing paralytics and opioid analgesics. We found an association between non-depolarizing paralytic and opioid receipt with 7-day survival among patients undergoing prehospital intubation. The literature would benefit from future multi-center randomized controlled trials to establish optimal pharmacologic strategies for trauma patients undergoing prehospital intubation. [ABSTRACT FROM AUTHOR]

Ex vivo lung perfusion has emerged as a platform for organ preservation, evaluation, and restoration. Gene delivery using a clinically relevant adeno-associated vector during ex vivo lung perfusion may be useful in optimizing donor allografts while the graft is maintained physiologically active. We evaluated the feasibility of adeno-associated vector–mediated gene delivery during ex vivo lung perfusion in a rat transplant model. Additionally, we assessed off-target effects and explored different routes of delivery. Rat heart-lung blocks were procured and underwent 1-hour ex vivo lung perfusion. Before ex vivo lung perfusion, 4e11 viral genome luciferase encoding adeno-associated vector 9 was administered via the left bronchus (Br group, n = 4), via the left pulmonary artery (PA group, n = 3), or directly into the circuit (Circuit group, n = 3). Donor lungs in the Control group (n = 3) underwent ex vivo lung perfusion without adeno-associated vector 9. Only the left lung was transplanted. Animals underwent bioluminescence imaging weekly before being killed at 2 weeks. Tissues were collected for luciferase activity measurement. All recipients tolerated the transplant well. At 2 weeks post-transplant, luciferase activity in the transplanted lung was significantly higher among animals in the Br group compared with the other 3 groups (Br: 1.1 × 106 RLU/g, PA: 8.3 × 104 RLU/g, Circuit: 3.8 × 103 RLU/g, Control: 2.5 × 103 RLU/g, P =.0003). No off-target transgene expression was observed. In this work, we demonstrate that a clinically relevant adeno-associated vector 9 vector mediates gene transduction during ex vivo lung perfusion in rat lung grafts when administered via the airway and potentially the pulmonary artery. Our preliminary results suggest a higher transduction efficiency when adeno-associated vector 9 was delivered via the airway, and delivery during ex vivo lung perfusion reduces off-target effects after graft implant. [Display omitted] [ABSTRACT FROM AUTHOR]