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Patients with a history of difficult ventilation or intubation and patients with anatomic or abnormal conditions associated with a complex airway fall into the category of known difficult airway.44 The causes of the expected difficult airway may be grouped into congenital or acquired conditions and be further classified on the basis of the location of involvement or disease.
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Increased frequency of ventilation, chest retractions, increased use of accessory muscles, stridor, voice weakness, or hoarseness, alone or in combination, may indicate a potential airway problem (Table 10-2). Stridor is a particularly important sign and may provide evidence of the site and severity of airway obstruction related to severe oropharyngeal, glottic, and/or upper tracheal occlusion. Stridor during inspiration generally indicates obstruction at or above the larynx. Expiratory stridor is most often associated with intrathoracic or subglottic obstructions. Obstruction associated with the larynx or glottic region may produce biphasic stridor, although either inspiratory or expiratory sounds may predominate. In the adult, stridor at rest indicates a serious degree of obstruction with a cross-sectional airway opening of less than 4 mm or an irregularly narrowed airway several centimeters in length.
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Airway assessment of the obese patient should be performed with the patient in both the sitting and supine positions. Respiratory function and airway patency can be significantly altered by this change in position.45 A large neck circumference is associated with obstructive sleep apnea (OSA) in obese patients. In evaluating 123 patients with thick necks for OSA, Katz et al found that the sleep apnea-hypopnea index correlated with external neck circumference, BMI, and the internal circumference of the distal pharynx.46 Men more commonly have sleep-disordered breathing than women, and the sleep-disordered breathing tends to be more severe.47 In an evaluation of 3942 OSA patients, the frequency and severity of OSA in the sleep clinic population was found to be greater in men than women, with unknown factors other than neck circumference, age, and BMI contributing to the gender differences.48 In a prospective study of 100 morbidly obese patients (BMI >40 kg/m2), preoperative measurements of height, weight, neck circumference, width of mouth opening, sternomental distance, TMD, and Mallampati score were recorded.49 The view during direct laryngoscopy was graded, and the number of attempts at tracheal intubation was recorded. Neither absolute obesity nor BMI was associated with intubation difficulties. Large neck circumference and high Mallampati score were the only predictors of potential intubation problems.
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In the supine position, changes in chest compliance and vital capacity may interfere with adequate spontaneous ventilation. The incidence of hiatal hernia, gastric pH of 2.5 or lower, and reduced functional residual capacity found in obese patients places these patients at increased risk for the consequences of aspiration of gastric contents.50,51 To minimize the risk of aspiration, a rapid sequence induction is commonly performed in obese patients.
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There is consensus that airway management is more difficult in the morbidly obese patients. Opinions differ, however, on the difficulty of endotracheal intubation. Wilson and coworkers regarded obesity as a weak predictor of difficult intubation.6 Buckley et al reported a 13% rate of difficult intubation using a rapid sequence technique in the obese patient.51 Rocke et al excluded obesity as a risk factor in intubation.8 Bond found no correlation between BMI and difficulty of laryngoscopy.50 Juvin et al compared difficulty in tracheal intubation in obese to lean patients using the IDS and patient vital signs.52 A Mallampati score of III-IV was the only independent risk factor for difficult intubation in obese patients. Difficult tracheal intubation was more frequent in obese (15.5%) than lean (2.2%) patients. The use of the IDS score demonstrated that tracheal intubation, not laryngoscopy, was more difficult in obese than lean patients.
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Body weight may not be as critical as the location of excess weight. Massive weight in the lower abdomen and hip area may be less important than when the weight is in the upper body area. A short, thick, immobile neck caused by cervical spine fat pads will interfere with rigid laryngoscopy. Furthermore, the redundancy of soft tissue structures inside the oropharyngeal and supralaryngeal area may also make visualization of the laryngeal structures difficult.
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Mask ventilation may prove difficult in the obese patient. When high positive pressure is required to ventilate the patient, the chance of inflating the stomach is increased. Rapid oxygen desaturation during apnea, secondary to reduced functional residual capacity, limits available intubation time. In the case of the cannot intubate, cannot ventilate situation, access to the neck for transtracheal jet ventilation or establishing a surgical airway (eg, emergency tracheostomy or cricothyroidotomy) will also be more complex.
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The incidence of failed intubation is predicted as 1 in 300 patients undergoing cesarean delivery.4 Airway-related problems account for a third of all anesthetic-related maternal mortality.53 During pregnancy, mucosal vascular engorgement, laryngeal edema, immobility of the floor of the mouth related to tongue engorgement, enlarged breasts, and general weight gain contribute to difficult intubation.53-55
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Airway anatomy may become distorted during prolonged labor or toxemia, leading to edematous soft tissue encroachment of the upper airway.54,55 Nasal intubation in these patients should be avoided because the mucous membranes become increasingly engorged and friable during late pregnancy. Similar to the obese patient, the obstetric patient should be considered to have a full stomach and at increased risk for gastric aspiration.
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The physical changes created by pregnancy may lead to marked alteration in cardiovascular and respiratory function when the patient changes from a sitting to a supine position. Furthermore, in cases of fetal distress or maternal hemorrhage, the emergency nature of the circumstances compounds airway management problems.
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The airway management of these patients should be based on an understanding of the pathologic changes affecting the airway. In patients with advanced rheumatoid arthritis and spondylosis, airway management may be extremely difficult. Rheumatoid arthritis may involve any joint of the body, including the cervical spine, TMJ, and cricoarytenoid joint. A change in voice, the presence of dysphagia, dysarthria, stridor, or a sense of fullness in the oropharynx may indicate laryngeal involvement. A careful fiberoptic examination of the larynx and glottic structures may be informative when such signs and symptoms are present. An edematous larynx with hyperemic arytenoids and/or mucosa with swollen aryepiglottic folds and false cords may be observed. Changes in phonation may be associated with decreased mobility of the vocal cords. In the case of a narrowed glottic opening, endotracheal intubation frequently requires a smaller sized endotracheal tube. TMJ ankylosis may prevent orotracheal intubation because of limited mouth opening.
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Physical examination of the patient with rheumatoid arthritis should include flexion, extension, and rotation of the head with palpation of the larynx and trachea for evidence of deviation and/or limitation. Upper-extremity radiculopathy suggests cervical spine arthritis. Progressive cervical spondylosis associated with rheumatoid arthritis leads to severe flexion deformity of the cervical spine, which complicates airway management.56 Synovial destruction and vertebral erosion, along with ligamentous changes, lead to instability of the cervical spine.57 Instability of the atlas and odontoid or of subaxial vertebral alignments may lead to subluxation of the cervical spine and cord compression. Cervical spine flexion and extension radiographs may be required for evaluation of instability and potential spinal cord compression. Although chin lift and jaw thrust are commonly used to improve mask ventilation and oxygenation, these maneuvers may increase the possibility of spinal cord compression and damage.58 If a head and neck stabilizing device is used by the patient, it generally should be left in place to prevent unintended movement of the cervical spine.59 Chest wall distortion in patients with rheumatoid arthritis may produce a major decrease in total lung volume and vital capacity. Pulmonary function tests may be helpful in determining a patient's ventilatory status in some cases.
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Anomalies of the cardiovascular, nervous, musculocutaneous, endocrine, or excretory systems may produce abnormalities of the head, neck, or upper airway. Rosenberg and Rosenberg have tabulated the syndromes most often accompanied by aberrations of the upper airway.44 These include Crouzon, Goldenhar, Pierre Robin, and Treacher Collins syndromes, which are known for their grossly abnormal head and neck anatomy. Patients with congenital malformations associated with micrognathia, retrognathia, and macroglossia have a smaller oropharyngeal cross section and are prone to soft-tissue upper-airway obstruction.54,60 Children with craniocarpotarsal dysplasia have severe microstomia that becomes more inadequate as they grow older and develop teeth. These children often require repeated anesthetics for correction of their musculoskeletal and soft tissue deformities and can pose a significant problem for the anesthesiologist.
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The most significant vascular malformations related to airway compromise are vascular rings, usually of aortic arch origin, encircling the trachea. Tracheomalacia, congenital tracheal stenosis, shortened trachea, and bronchogenic cysts can contribute to difficult airway management (Fig. 10-4).61 Wells et al reported that a significant percentage of infants with congenital malformation syndromes associated with cardiovascular anomalies and skeletal dysplasia have a shortened trachea.62 These infants may benefit from fiberoptic evaluation of endotracheal tube position to avoid unrecognized bronchial intubation.
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Acromegaly, the syndrome that results from the pituitary gland producing excess growth hormone after epiphyseal plate closure at puberty, requires careful airway evaluation. This condition is seldom seen today in the United States due to early diagnosis and management. Most patients with acromegaly have poor Mallampati grade due to soft tissue overgrowth and macroglossia. The practitioner may also wish to include evaluation of growth hormone levels and duration of disease symptoms in evaluation of cases with this condition.63,64 Congenital malformation syndromes also may be associated with varying degrees of acute, progressive, or chronic airway obstruction. Congenital tumors or cysts may invade or obstruct the airway. Preoperative assessment should include determination of the site of the tumor and the extent of obstruction or distortion of the airway.
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Inflammation and edema can distort anatomy, fix soft tissues, and compress the airway, interfering with ventilation and intubation.65,66 Airway compromise by infection poses a major airway management problem in patients younger than 10 years. Of 90 deaths resulting from upper airway obstruction in children, 36 were related to airway infections (Fig. 10-5).67,68 Anesthetists are most often involved in the management of urgent conditions such as peritonsillar abscess, retropharyngeal abscess, submandibular abscess, Ludwig angina, croup, and epiglottitis. Each of these infections presents in a specific manner, which then dictates airway management.
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Peritonsillar Space Infections
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The peritonsillar space is a potential space located at the junction of the oral cavity and oropharynx. It is formed by the palatine tonsil, as well as the palatoglossus, palatopharyngeal, and superior pharyngeal constrictor muscles. Clinical findings of peritonsillar abscess include acute onset of fever, pain, dysphagia, and cervical adenopathy. As the infection spreads, it may involve the muscles of mastication, producing trismus secondary to pain and spasm. On examination, there is displacement of the uvula to the contralateral side, tonsillar enlargement, and fetid breath. At times, surgical drainage of the peritonsillar space is indicated. Management of the airway in this subset of patients is generally accomplished with orotracheal intubation. Rapid sequence intubation is generally possible. Reduced interdental distance that may be noted on preoperative evaluation of these patients is due to pain and usually resolves on administering anesthetic agents.
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Retropharyngeal Space Infections/Prevertebral Space Infections
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The retropharyngeal space is a midline compartment located between the middle and deep cervical fascia. The prevertebral space is a bilateral space located posterior to the deep cervical fascia. Infection of the retropharyngeal space most commonly occurs in children and presents with irritability, fever, dysphagia, muffled speech or cry, noisy breathing, stiff neck, and cervical adenopathy.69 Prevertebral space infection is much less common and is seen after spread of retropharyngeal abscess or more rarely primary infection of the prevertebral space. Airway management in these infections typically uses endotracheal intubation or tracheotomy. During laryngoscopy after induction, the posterior pharyngeal wall appears displaced anteriorly. Care must be taken to avoid lacerating and draining a posterior pharyngeal wall abscess with subsequent aspiration before the airway is controlled.
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Ludwig Angina/Submandibular Space
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Infection that arises in this space may be odontogenic in origin or due to chronic sialadenitis. The submandibular space is divided by the mylohyoid muscle. Infection localized above the mylohyoid muscle creates edema and distortion of the floor of the mouth. Upper airway endoscopy with a standard or videolaryngoscope and/or fiberoptic bronchoscope is useful in defining anatomic challenges in patients with upper airway pathology before induction of general anesthesia.
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An infection inferior to the mylohyoid muscle may displace the base of tongue posteriorly. Ludwig angina is typically seen in patient with poor oral hygiene and presents as a bilateral neck cellulitis with displacement and swelling of the tongue base and floor of mouth. (Figs. 10-6 and 10-7). Both submandibular space infection and Ludwig angina present with acute onset of fever, dysphagia, pain, and swelling. The airway is best managed in these cases in a collaborative manner with the surgical team.
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With the advent of the haemophilus influenza B vaccine in 1991, the incidence of epiglottitis has precipitously decreased by 90%. Although uncommon today, acute epiglottitis does occasionally present, particularly in the pediatric population, with a rapid onset of high fever, respiratory distress, drooling, and painful swallowing. On examination patients are noted to have tachycardia, tachypnea, and appear toxic. On phonation, a muffled quality may be appreciated.70 This classic presentation was often seen in the pediatric population before the introduction of the Hib vaccine. In the adult population, acute epiglottitis may be preceded by a viral upper respiratory infection. Noninfectious causes of epiglottitis may also be seen after thermal injury or caustic ingestion. Thermal injury after crack cocaine abuse is not infrequent. Once again, the airway is best managed in these cases in a collaborative manner with the surgical team. Any manipulation of the airway prior to intubation should generally be avoided.
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Acute croup, or laryngotracheobronchitis, is often caused by the parainfluenza virus in children between the ages of 1 and 3, particularly in the spring and fall. Children typically present with low-grade fever, increased respiratory rate, barky cough, and hoarseness.70 Most children can be managed without intubation. When retraction or oxygen desaturation is noted, orotracheal intubation is indicated with an appropriate-size endotracheal tube.
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Trauma to the head and neck may produce major acute or chronic anatomic changes. These changes may affect airway accessibility, making tracheal intubation or mask ventilation difficult. Blunt or penetrating trauma to the larynx, trachea, hyoid structure, and facial bones can result in a complex, difficult-to-manage airway.71,72 Subcutaneous emphysema, hoarseness, stridor, and tracheal deviation are warning signs of airway injury. Such patients should be observed closely because progression of the condition may lead to airway obstruction.
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The signs and symptoms of laryngeal trauma may be quite subtle. Patients with laryngeal trauma are often hoarse or short of breath, although this clinical presentation may not correlate with the severity of injury. Dysphagia is not a common symptom of laryngotracheal injury. Nevertheless, esophageal injury should be strongly considered in patients with laryngotracheal trauma. On physical examination, the presence of hemoptysis may indicate laryngeal or tracheal injury. External palpation of the neck should include evaluation of the hyoid bone, and thyroid and cricoid cartilages (Fig. 10-8). The skin should be examined for abrasions and subcutaneous air. Open wounds should not be probed, but entrance and exit wounds should be noted to better understand the trajectory of the injury, particularly with bullet wounds. Cricotracheal separation should be suspected when the mechanism of injury is via a "clothesline" or hanging injury. In these patients, stridor and subcutaneous emphysema should prompt immediate evaluation. Orotracheal intubation is contraindicated because it may cause more harm than good. In these cases, an endotracheal tube can migrate through a perforation into the cervical soft tissues or mediastinum, creating a tenuous and possibly dangerous airway for the patient.73 Thus awake tracheostomy below the site of injury remains the mainstay of airway management in these cases.
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The trauma patient should also be examined for cervical spine injuries because movement of the neck during intubation may lead to irreversible paralysis. Maintaining cervical collar placement or applying axial traction may minimize spinal cord injury during intubation.74 The anesthetist should also be aware that mouth opening may be limited in the patient with facial trauma. Improvement in the ability to open the patient's mouth after induction of anesthesia and paralysis cannot be guaranteed. Therefore, a fiberoptic bronchoscope and a tracheostomy tray should be available for awake management of the airway.
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Head and neck tumors, both benign and malignant, may make intubation difficult. Mouth opening and proper positioning of the head and neck for rigid laryngoscopy can be limited by tumors, surgical scars, or radiation fibrosis of head and neck tissues (Table 10-3).2,57
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Tumors of the oral cavity and oropharynx may create trismus due to invasion of the muscles of mastication. This trismus can often be overcome after induction with muscle relaxants. Anesthesiologists should work collaboratively with the otolaryngology service to perform safe laryngoscopy for intubation, diagnosis, and staging biopsies. Care should be taken to avoid trauma of these tumors, which will cause bleeding. This is especially true of friable tumors of the base of tongue and tonsil that, in addition to trismus, prevent proper mask ventilation and preclude the use of a supraglottic airway.
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Tumors of the larynx create significant difficulty during orotracheal intubation. Exophytic tumors above the vocal cords may prolapse into and block the airway when even the slightest bit of sedation is administered.75,76 Once again, consultation with the otolaryngology service is indicated to avoid an emergently obstructed upper airway. In these cases, the airway can be managed with closed laryngoscopes such as a Dedo or anterior commissure (Holinger) laryngoscope (Fig. 10-9). Preparation for an awake tracheostomy under local anesthetic may be required in this subset of patients.
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The presence of cancerous goiters is also a concern. Difficult tracheal intubation is reported in 17 (5.3%) of 320 patients undergoing thyroidectomy.77 In this study, multivariate analysis suggests that the presence of a cancerous goiter and Cormack and Lehane grade III or IV laryngoscopic view are independently associated with difficult intubation. However, the same study reported that the size of goiter was not associated with increased difficulty with intubation. In any case, it is important to be aware that a goiter can narrow the airway due to extrinsic compression (Fig.10-10). Last, although infrequent, vocal cord paralysis due to malignant thyroid disease or due to surgical trauma may complicate extubation.
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Radiologic studies are indicated in the presence of trauma or tumors in or near the airway.78 Lateral cervical spine films, computed tomography (CT), or magnetic resonance imaging (MRI) may be used to assess the degree of airway compression and the involvement of associated structures. Topical anesthesia with fiberoptic laryngoscopy and bronchoscopy may prove beneficial in airway inspection.59
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The purpose of an airway stent is to prevent obstruction caused by malacia, stricture, or extrinsic compression that is not suitable for surgical correction either due to location or morbidity (Figs. 10-11 and 10-12).79,80 Conditions treated by stent placement include tracheomalacia, postintubation stricture, stricture related to lobectomy, tuberculosis, traumatic injury or compression secondary to malignancy, multinodular goiter, or an intrathoracic process. Tracheostomy and Montgomery T tubes are used extensively in the management of glottic, subglottic, or tracheal stenosis due to benign or malignant disease. More recently, tracheobronchial stents have been developed to help manage malacia, extrinsic compression, and stenosis of the distal airway (Figs. 10-13 and 10-14).
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Preoperative evaluation requires communication with the otolaryngologist to verify the underlying diagnosis, position of the stent, and the best method of airway management. Presence of a stent may complicate or prevent traditional endotracheal intubation. Also, attempted orotracheal intubation with a stent in place can damage the airway or dislodge the stent. Laryngeal mask airways, however, can often be used to safely manage the airways of such patients.
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Frequently, laryngectomy patients wear a silastic stent or a heat-moisture exchange system over the stoma. These "lary" tubes or buttons are uncuffed and often used in conjunction with a speaking valve or prosthesis placed across the tracheoesophageal wall (Figs. 10-15, 10-16, and 10-17). Given that these patients are "neck breathers" with potentially confusing surgically altered anatomy, their airway is best managed by collaborating with an otolaryngologist. Typically direct intubation of the stoma after removal of the laryngectomy tube is the best method of airway management. The speaking valve should not be removed during intubation because this is an indwelling device and will not obstruct placement of a tracheal tube.
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Intrathoracic Lesions
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Intrathoracic lesions can compromise airway integrity through compression of the tracheobronchial tree or by invasion of the trachea or bronchi. Mediastinal lesions leading to life-threatening airway obstructions may be found in neonates, infants, children, or adults.66,81-84 Congenital tumors or tumors arising in early infancy include hemangiomas, lymphangiomas, cystic hygromas, teratomas, dermoids, rhabdomyosarcomas, neurofibromas, neuromas, and thymic hyperplasia. Adults with mediastinal masses, commonly lymphomas and thymic tumors, appear to be less at risk for perioperative complications than children.85,86
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By nature of their anatomic location, these lesions may produce compression of the heart, compression of the large vessels, primarily the vena cava, and compression of the trachea and main bronchi. Anterior mediastinal tumors that are undiagnosed or underestimated as to degree of airway obstruction may completely block the airway on induction of anesthesia and induced muscle relaxation.82,87 Evaluation focuses on an estimate of the presence and degree of obstruction of the tracheobronchial tree and the possibility of avoiding general anesthesia if possible.
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Evaluation to assess the patency of the airway at the tracheal and the bronchial level is necessary to formulate an anesthetic plan. By history, symptoms of airway obstruction including dyspnea at rest, on exertion, and in different positions require additional evaluation. The presence of stridor, wheezing, rhonchi, and diminished breath sounds should be reviewed with the patient in different positions. Careful analysis of chest radiographs, CT, and MRI studies may prove essential for planning airway control in the patient with a mediastinal mass. Chest radiographs in the posteroanterior position allow measurement of the tracheal diameter at the level of the clavicles.88 A lateral chest view shows the degree of compression of the trachea in an anteroposterior position. A CT scan of the chest permits accurate measurements of airway diameters and indicates the exact level and extent of compression of the tracheobronchial tree.
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Pericardial effusion on preoperative CT scan was the only variable associated with intraoperative complications in a review of 98 patients with mediastinal mass.85 In this population, postoperative respiratory complications were related to tracheal compression of greater than 50% on a preoperative CT scan and a finding of mixed restrictive and obstruction disease on pulmonary function testing. A review of 29 pediatric patients with mediastinal masses who were undergoing general anesthesia concluded that CT evidence of superior vena compression along with symptoms and signs of superior vena cava syndrome (SVCS) were associated with potential development of life-threatening situations.86 In this review, SVCS was the only nonrespiratory sign or symptom that was associated with increased anesthetic risk. All 4 children with SVCS developed acute airway compromise with general anesthesia.
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Pulmonary flow volume loop studies performed in the upright and supine positions may sometimes assist in defining the severity of position-related airway compromise. Maximal inspiratory and expiratory flow volume curves may help to quantify the degree of impairment and differentiate extrathoracic from intrathoracic obstruction.66,82 In an evaluation of 37 patients with anterior mediastinal masses by Hnatiuk and Corcoran, however, the incidence of perioperative surgical complications was found to be low. The results of upright and supine spirometry did not always alter the anesthetic technique, and normal spirometry results did not exclude the occurrence perioperative complications.89 In a review of 77 mediastinal mass in patients who underwent pulmonary function tests prior to general anesthesia, airway collapse did not occur in any patient.85 This patient population included 10 cases with a peak expiratory flow rate (PEFR) that was less than 50% of the predicted rate and 6 cases with a PEFR that was 40% or less of the predicted rate. A PEFR of 40% or less of predicted, however, was associated with a more than 10-fold increase in the risk of postoperative respiratory complications.
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In general, patients with mediastinal masses are considered at high risk for perioperative complications if they have cardiorespiratory signs and symptoms, tracheal compression more than 50%, pericardial effusion on CT scan, or combined obstructive and restrictive patterns on pulmonary function testing.85 General anesthesia and the use of neuromuscular blocking agents may reduce lung volume, relax bronchial smooth muscle leading to greater compressibility of the airway from the overlying mass, and reduce the transmural pressure gradient across the airway that helps maintain airway diameter.82 A conservative management strategy may be necessary in such patients because mask ventilation may not be possible. Tracheostomy may not relieve airway obstruction because the obstruction may occur at or below the level of the carina. Some clinicians have advocated femoral vessel cannulation in high-risk patients so that cardiopulmonary bypass can immediately be initiated in a crisis.87
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Foreign bodies in the upper aerodigestive tract are an important cause of morbidity and mortality for patients at both age extremes. Both the elderly and children younger than 3 years are at risk for foreign body ingestion. Impacted food in the upper aerodigestive tract tends to be a problem in the elderly. These patients may have dentures that prevent the detection of a small bone fragments or proper mastication of food. In addition, elderly patients are more likely to suffer from esophageal dysmotility, Zenker diverticulum, malignancy, or stricture, all of which predispose to esophageal foreign bodies. Symptoms of an impacted bone include stabbing pain on swallowing. Typically the bone protrudes from the lingual or palatine tonsil. Generally, when a foreign body is lodged in the upper esophagus, the patient can point to the level of obstruction. Dysphagia, regurgitation of food, bloody secretions, and an inability to tolerate secretions may be noted. Removal of an impacted foreign body may be performed under general anesthesia depending on the patient's age, material that is impacted, and location. In these situations, it is imperative to control the airway to prevent aspiration. Even if the foreign body is noted on laryngoscopy, unless it is obstructing the airway, tracheal intubation should be achieved before removal.
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Children, particularly those younger than 3 years, can also present with an upper airway foreign body in addition to the more common esophageal foreign body. Airway foreign bodies may involve the larynx, trachea, or bronchi. Most inhaled foreign bodies enter the right mainstem bronchus, which is larger and has a straighter takeoff from the carina than the left. The symptoms associated with aspiration can include gagging, coughing, spasmodic choking, stridor, wheezing, tachypnea, tachycardia, and decreased breath sounds on auscultation.90 Removal of an inhaled foreign body may involve a general anesthetic depending on the patient's age, as well as the location and material of the foreign body. Careful control of the airway in these situations is imperative. The anesthetist should work closely with the otolaryngologist to perform laryngoscopy and bronchoscopy for removal of the foreign body.