Severe postoperative laryngeal oedema causing total airway obstruction immediately on extubation.
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We report a case of total upper airway obstruction occurring immediately after extubation after elective bi-maxillary osteotomy. The obstruction was caused by severe, progressive supraglottic oedema, which totally obscured the laryngeal inlet. No swelling had been present at initial laryngoscopy and intubation. Immediate re-intubation of the patient's trachea was difficult but life saving. Subsequent investigations revealed extensive soft tissue swelling, maximal at the level of the hyoid and extending downwards into the trachea. The cause of such severe oedema in this case is not certain, but may be related to vigorous submental liposuction carried out at the end of operation. We have found no other reports of total airway obstruction occurring immediately after extubation as a result of this cause. We review the appropriate literature, describe the postoperative management and suggest precautions in similar patients. (+info)
First results of a randomized clinical trial of fast neutrons compared with X or gamma rays in treatment of advanced tumours of the head and neck. Report to the Medical Research Council.
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Results of the first randomized clinical trial to compare the effects of fast neutrons and those of x or gamma rays (photons) in treating patients with advanced tumours of the head and neck are reported. In 37 out of 52 patients treated with neutrons and 16 out of 50 treated with photons the local tumour completely regressed; the tumour later recurred in nine of the 16 photon patients but in none of the 37 neutron patients. The advantages to the neutron-treated patients were seen in tumours of well and poorly differentiated histology and in each site. Complications after treatment did not differ significantly between the groups. Despite these substantial differences in local control of the tumour there were no significant differences in mortality between the series. A detailed study of the effective doses and the response of tumours and normal tissue in each series indicated that the improved results from neutron therapy were due to differences in the biological quality of the beam and not to the rather higher average effective dose in the neutron series. To assess the long-term effects of neutron treatment patients in earlier stages of disease and with smaller tumours should be included in the next phase of the trial. (+info)
The cuff-leak test: what are we measuring?
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Stridor is one of the most frequent causes of early extubation failure. The cuff-leak test may help to identify patients at risk to develop post-extubation laryngeal edema. However the discrimination power of the cuff-leak test is highly variable and can be use, at best, to detect patients at risk to develop edema but should not be used to postpone extubation as tracheal extubation can still be successful in many patients with a positive test. In this editorial, the author discuss the factors influencing the leak and hence its predictive value. (+info)
Percutaneous transtracheal jet ventilation as a guide to tracheal intubation in severe upper airway obstruction from supraglottic oedema.
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We report two cases of severe upper airway obstruction caused by supraglottic oedema secondary to adult epiglottitis and Ludwig's angina. In the former case, attempts to intubate with a direct laryngoscope failed but were successful once percutaneous transtracheal jet ventilation (PTJV) had been instituted. In the case with Ludwig's angina, PTJV was employed as a pre-emptive measure and the subsequent tracheal intubation with a direct laryngoscope was performed with unexpected ease. In both cases recognition of the glottic aperture was made feasible with PTJV by virtue of the fact that the high intra-tracheal pressure from PTJV appeared to lift up and open the glottis. The escape of gas under high pressure caused the oedematous edges of the glottis to flutter, which facilitated the identification of the glottic aperture. We believe that the PTJV should be considered in the emergency management of severe upper airway obstruction when this involves supraglottic oedema. (+info)
Evaluation of risk factors for laryngeal edema after tracheal extubation in adults and its prevention by dexamethasone. A placebo-controlled, double-blind, multicenter study.
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Because laryngeal edema (LE) after tracheal extubation is likely to result from an exudative response, corticosteroids often are given routinely as a preventive treatment. No adequate controlled study supports this strategy, however. A prospective, randomized, placebo-controlled, double-blind, multicenter trial that included 700 consecutive patients requiring tracheal intubation and mechanical ventilation was conducted to determine risk factors for LE occurrence after tracheal extubation in adults and to evaluate the efficacy of corticosteroids in its prevention. One hour before extubation, patients were given either an intravenous bolus of 8 mg dexamethasone or a placebo. Patients were divided into two groups: 1) those in whom short-duration intubation (SDI, less than 36 h) was administered; and 2) those in whom long-duration intubation (LDI, more than 36 h) was administered. Minor LE was diagnosed when either stridor or laryngeal dyspnea, or both, occurred; major LE was diagnosed when reintubation due to LE was required, with LE evidenced during direct laryngoscopy. The overall incidence of LE was 4.2% and varied among the six participating centers from 2.3 to 6.9% (not significant). In only seven patients (1%), all with LDI, was tracheal reintubation required for LE. Laryngeal edema occurred more frequently after LDI than after SDI (7.2 vs. 0.9%; P less than 0.001). It also was more frequent in female than in male patients (20/284 vs. 8/379; P less than 0.05), irrespective of intubation duration and treatment. There was no association between LE and either difficulty/route of intubation or admission diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS) (+info)
Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study.
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The cuff-leak test was widely used for the prediction of post-extubation stridor, but controversial results limit its clinical application. The current study used real-time ultrasonography to evaluate the air-leak and hypothesised that the air-column width, measured by ultrasonography, may be correlated to the development of post-extubation stridor. From June 1, 2001 to March 1, 2002, a total of 51 planned extubations in 51 consecutively intubated patients were included. All of the patients received ultrasonographical examinations of their vocal cords and larynx in addition to an air-column width measurement within 24 h prior to extubation. The overall post-extubation stridor rate was 7.8%. The air-leak volume presented as median (interquartile range) were 300 (350) mL and 25 (20) mL, respectively, for the nonstridor and stridor groups. The air-column width during cuff deflation was 6.4 (2) mm and 4.5 (0.8) mm, respectively. They were found to be statistically significant. In conclusion, the authors demonstrated that laryngeal ultrasonography could be a reliable, noninvasive method, in the evaluation of vocal cords, laryngeal morphology and the ease of airflow, which passed through vocal cords or subglottic area due to laryngeal oedema. The air-column width during cuff deflation was a potential predictor of post-extubation stridor. (+info)
Anaphylactoid reactions to Dextran 40 and 70: reports to the United States Food and Drug Administration, 1969 to 2004.
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BACKGROUND: Clinical dextrans, such as Dextran 40 and Dextran 70, are associated with anaphylactoid reactions caused by dextran-reactive immunoglobulin G antibodies. When infused immediately before clinical dextrans, dextran 1 significantly reduces the incidence of severe anaphylactoid reactions. The objective of the study was to describe the frequency and characteristics of reports submitted to the United States Food and Drug Administration (FDA) for anaphylaxis or anaphylactoid events after clinical dextran administration. METHODS: We searched the FDA's Adverse Event Reporting System for reports associated with a clinical dextran and describing anaphylaxis/anaphylactoid reactions. Our case definition for a probable anaphylaxis/anaphylactoid event required signs or symptoms from at least two body systems, with at least one sign or symptom being hypotension, vasodilation, or respiratory difficulty, and onset within 60 minutes. Other reports were considered possible cases if the reporter specifically described the reaction as anaphylaxis or an anaphylactoid reaction. Premier RxMarket Advisor provided estimates of total US hospitalizations with clinical dextran or dextran 1 administration from 2000 to 2004, based on discharge billing data from a sample of US hospitals. The IMS National Sales Perspective provided estimates of total doses of dextrans sold in the United States from 1999 to 2004, based on volumes of dextrans sold in a sample of retail and nonretail outlets. RESULTS: The FDA received 366 clinical dextran adverse event reports from 1969 to 2004, of which 90 (24.6%) were anaphylaxis/anaphylactoid events. The ratio of hospitalizations where clinical dextran was administered to hospitalizations where dextran 1 was administered was 28.4:1. The expected ratio would be 1:1 if all clinical dextran patients had received dextran 1 pretreatment. The ratio of clinical dextran doses sold to dextran 1 doses sold in the United States was 38.6:1. CONCLUSIONS: A high proportion of adverse event reports for clinical dextrans described anaphylaxis or anaphylactoid reactions. Hospital discharge and product sales data suggest that dextran 1 has not been used consistently before clinical dextran administration in recent years. To reduce the risk of anaphylactoid reactions, physicians should consider routine administration of dextran 1 before the infusion of a clinical dextran. (+info)
The role of the cuff leak test in predicting the effects of corticosteroid treatment on postextubation stridor.
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BACKGROUND: There is not enough evidence to determine the most appropriate treatment of postextubation stridor. Although the cuff leak test is a simple method to predict postextubation stridor, little is known about its use in monitoring the effects of steroid treatment for this complication. The aim of this study was to evaluate the effect of steroids on postextubation stridor based on the clinical response and the cuff leak test. METHODS: A cohort of 110 translaryngeal intubated patients in the medical intensive care unit (ICU) were enrolled. A cuff leak test was conducted before extubation. Patients developing postextubation stridor were intravenously given 5 mgs of dexamethasone every 8 hours for 3 days. The clinical response and cuff leak volume before and after steroid treatment were gathered for analysis. RESULTS: The incidence of postextubation stridor was 18.2% (20/110). Fifty-five percent of patients (11/20) with stridor needed reintubation. Overall, 80% of patients (16/20) with postextubation stridor improved with steroid treatment. The leak volume significantly increased after treatment (152.4 +/- 109.6 ml vs. 29.9 +/- 35.7 ml, p = 0.012); stridor did not recur in 64% of reintubated patients (7/11). A threshold leak volume of less than 88 ml predicted the occurrence of stridor (positive predictive value, 54.5%; negative predictive value, 90.9%). Postextubation stridor was associated with the female gender and lower leak volumes (p = 0.007 and 0.003, respectively). CONCLUSION: Corticosteroids improve postextubation stridor. The cuff leak test accurately predicts the absence of stridor and is a non-invasive method of monitoring for regression of laryngeal edema after steroid treatment. Steroid treatment should be considered for patients developing postextubation stridor. (+info)