complex airway problems - paediatric perspective · complex airway problems - paediatric...
TRANSCRIPT
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Complex Airway problems - Paediatric Perspective
Dave Albert BACO
Liverpool 2009
www.albert.uk.com
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“Complex” Ξ not simple, multiple parts
• Multiple problems with airway
– Combined Web/stenosis/multiple levels
• Multiple problems with child
– Syndromic children
• “Difficult to treat”
– Poor outcomes
• Posterior laryngeal stenosis
• Multiple previous surgery
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Complex laryngeal stenosis – congenital
Severe congenital web/stenosis
Complete tracheal rings
High take off right upper lobe bronchus
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Complex laryngeal stenosis – syndromic
Velo cardio facial syndrome
Larsen’s syndrome
Epidermolysis bullosa
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Complex laryngeal stenosis – previous surgery
Stenosis following laser for
papillomatosis
Posterior scar bands with cricoarytenoid
fixation
Very scarred larynx from multiple laser
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What do we treat? Paeds vs adult
•UPPER AIRWAY •Laryngomalacia •Subglottic haemangiomas, webs and clefts •Difficult decannulation •Vocal Cord movement disorders •Subglottic stenosis •Complex stenosis •Tumours
•LOWER AIRWAY
•Tracheomalacia- intrinsic
•Extrinsic compression
•Tracheal stenosis
•Tumours
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What do we both treat?
•UPPER AIRWAY •Laryngomalacia •Subglottic haemangiomas, webs and clefts •Difficult decannulation •Vocal Cord movement disorders •Subglottic stenosis •Complex stenosis •Tumours
•LOWER AIRWAY •Tracheomalacia- intrinsic •Extrinsic compression •Tracheal stenosis •Tumours
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Paediatric Subglottis
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Techniques
•UPPER AIRWAY
•Cartilage grafting
•Resection
•Dilatation/stents
•Lateralisation
•Laryngeal transplant
•Pacing
•LOWER AIRWAY
•Tracheoplasty
•Dilatation/stents
•Tissue engineering
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Current paediatric techniques
•Endoscopic
•FESS style surgery
•Sharp rather than Laser
•Radial Dilatation
•Lateralisation
•Microdebrider
•Endoscopic Stents/keels
•T-Tubes
•Open
•Cricoid split
•Cartilage grafts
• single/2 stage
•Cricotracheal resection
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History
• 60’s Premature infants survive
– Acquired Subglottic Stenosis
– Tracheostomy
• 70’s Open laryngeal surgery, Rib graft repair
• 80’s Cricoid split to deal with early cases
• 90’s Single stage laryngeal reconstruction
• Partial cricotracheal resection
• 2000+ Endoscopic techniques
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0
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1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Year
Nu
mb
er o
f P
atie
nts
LTP LTR CTR
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Paediatric Subglottic stenosis
• Management
– Medical
– Endoscopic
– Open procedures
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Paediatric tube management
•Smallest stable tube
–Oral or nasal
–Shouldered or straight
•Steroids (pre extubation)
•Anti-reflux treatment
•Optimal status pre extubation
•Laryngeal rest
•Duration not main factor
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Endoscopic Treatment
•Sharp removal
• subglottic cysts
• granulations
•Division of thin webs
•Gentle radial dilatation –Mitomycin C
•Endoscopic cricoid split –(all with stenting and steroids)
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Sharp avulsion of cysts
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Endoscopic cricoid split
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Cut edges of cricoid
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Radial dilatation and Mitomycin C
• Antineoplastic antibiotic - acts as an alkylating agent by inhibiting DNA and protein synthesis
Angioplasty balloon – up to 16 Atmospheres!
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Endoscopic web division
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Failed extubation
with stridor
Re-intubate
Soft SGS Optimise extubation
MLB
Endoscopic Rx Mature SGS
Paediatric Tube
management
Granulations, cysts, edema
SGS
Success
Medical management
Cricoid split
Single stage
LTR
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Open procedures
Anterior Cricoid split- split and stent procedure for neonates with failed extubation due to early SGS
Laryngotracheal Reconstruction (LTR) – framework
expansion with cartilage grafts for mature stenosis
Cricotracheal resection – resection with end on end anastomosis
for total or near total stenosis
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Cricoid Split
–“Decompression”
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Cricoid Split
•Indications –Soft edema
–> 1.5 kg
–Fit
•Procedure
–Split-1° ring, cricoid and ½ thyroid
–Re-intubated-check length
–Drain
•Postoperative care
–Intubated for 5-7 days. Not
paralysed or ventilated
–Antibiotics
–Exubate under steroid cover
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Single stage LTR
• “Augmentation procedure that aims to combine all elements into one operation”
• .
• Period of intubation instead of stent
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Laryngofissure in intubated patient
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Rib graft harvest
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Graft placement
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SSLTR - Postoperative care
• Intubated for 7 days. Not paralysed or
ventilated
• Antibiotics
• Exubate under steroid cover
– Dexamethasone 0.25mg/kg then 0.1mg/kg
QDS
–
• Reintubate with care if needed **
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Conventional LTR with tracheostomy
• “Traditional Staged procedure using a stent”
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LTR
• “Augmentation”
• Rib cartilage
– Anterior
– Posterior
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LTR with stent - Indications
• Severe stenosis grade III-IV • Complicating medical conditions
• Child/parent not keen on ITU
• Still need to optimise medical conditions especially reflux
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Expose strap muscles
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Expose larynx
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Laryngofissure
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Posterior split
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Stent
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Anterior graft
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Endoscopic posterior graft
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Endoscopic posterior graft
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Results of LTR Cotton 1989
• Decannulation rate Patient Procedures (%)
•
• Grade 2 97% 95 129 (33%)
• Grade 3 91% 80 94 (17%)
• Grade 4 72% 25 28 (12%)
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Results of LTR - GOSH
• 266 procedures • (presented ESPO Helsinki Evans 1998)
• Grade 2 94%
• Grade 3 90%
• Grade 4 66%
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Partial Cricotracheal resection
• Grade III-IV
• Usually as a single stage
• Upper excision below cords
– preserve posterior cricoid
– cricoid plate drilled to reduce stenosis
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Cricotracheal resection
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Cricotracheal resection
• Intubate for 7-10 days
• Scope prior to extubation and downsize
• No longer use lateral tension sutures or neck sutures
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Cricotracheal resection
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Partial Cricotracheal Resection Monnier 1993
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Cricotracheal resection
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My current guidelines
Grade
I Conservative
II Endoscopic if soft LTR once established
III LTR CTR if severe and clear of cords
IV LTR CTR if clear of cords
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Complete Tracheal Cartilage Rings
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Slide Tracheoplasty
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Balloon dilatation of metal stents
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The Future
• Paediatric and adult laryngology will continue
to learn techniques from each other
• Laryngeal transplantation, laryngeal pacing
and tissue engineering are very exciting
developments
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•Lowry Hotel
•Manchester
•September 18th
•www.bapo.org.uk
BAPO Meeting 2009