Kent L. Christopher

ERS/ELS/ACCP 2013 international consensus conference nomenclature on inducible laryngeal obstructions

Individuals reporting episodes of breathing problems caused by re-occurring variable airflow obstructions in the larynx have been described in an increasing number of publications, with more than 40 different terms being used without consensus on definitions. This lack of an international consensus on nomenclature is a serious obstacle for the development of the area, as knowledge from different centres cannot be matched, pooled or readily utilised by others. Thus, an international Task Force has been created, led by the European Respiratory Society/European Laryngological Society/American College of Chest Physicians. This review describes the methods used to reach an international consensus on the subject and the resulting nomenclature, the 2013 international consensus conference nomenclature. The condition leading to episodes of feeling like you cannot breathe now has a name: inducible laryngeal obstructions http://ow.ly/OMaNl

Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery

Exercise-induced laryngeal obstruction (E-ILO) causes exertional dyspnoea. There is no standardised methodology which characterises laryngeal obstruction in relation to exercise or links laryngeal obstruction and dyspnoea severity. Continuous laryngoscopy during exercise (CLE) may improve diagnostic sensitivity by enabling laryngeal visualisation at peak work capacity in patients with rapidly resolving obstruction. The time course of laryngeal obstruction across exercise and recovery has not been quantitated until this report. Adolescents and young adults referred for CLE were laryngoscopically monitored across rest, maximal cycle ergometry exercise, and recovery. Three reviewers, blinded to time sequencing, rated inspiratory glottic and supraglottic obstruction during 10 windows of 15-s corresponding to rest, 25%, 50%, 75%, 90% and 100% of individual symptom-limited peak work capacity (expressed in Watts), and four consecutive recovery windows. 85 patients were screened and 71 included. Over 96% of time windows were interpretable. Laryngeal obstruction severity reached observed maximal levels at peak work capacity, and rapidly resolved. A spectrum of observed maximal obstruction was measured. CLE provides interpretable data demonstrating laryngeal obstruction in patients with suspected E-ILO that is more severe at peak work capacity than during rest, submaximal exercise, or recovery. Observed maximal obstruction was infrequently severe and rapidly resolved. Maximal laryngeal obstruction occurs at peak work capacity in suspected exercise-induced laryngeal obstruction http://ow.ly/pHER300eiU9

Otolaryngologist's role in transtracheal oxygen therapy: The minitrach procedure

The modified Seldinger technique for transtracheal oxygen catheter insertion is relatively straightforward, but tract problems during subsequent oxygen therapy are not uncommon. With the modified Seldinger technique method, transtracheal oxygen is not initiated until 1 week after the procedure. Six to 8 weeks are required for tract epithelialization, which allows routine catheter removal and cleaning by the patient. Without removal, mucus tends to collect and form balls on the catheter tip, creating a management problem. Previous studies suggest a significant incidence of tracheal chondritis, keloid formation, and inadvertent catheter dislodgment. In 7% to 10% of patients, the epithelial tract cannot be recovered by medical personnel, and complete closure occurs. We have developed a surgical technique for the creation of a controlled tracheocutaneous tract. Highlights of the minitrach include skin flap elevation, cervical lipectomy, resection of a small window of tracheal cartilage, and approximation of the skin flaps to the window. We evaluated 33 patients who underwent the minitrach procedure as an access method for receiving transtracheal oxygen. When compared with results from 64 patients followed up for a similar period with the modified Seldinger technique, results with minitrach showed that transtracheal oxygen could be instituted sooner (<24 hours), and symptomatic mucus balls were reduced because the tract matured more quickly (approximately 14 days). With the minitrach there were no inadvertent catheter dislodgments, as compared with 41% of modified Seldinger technique patients who had one or more episodes of catheter dislodgment. Twelve percent of minitrach patients had a single episode of chondritis, as compared with 25% of the modified Seldinger technique patients, who had one or more episodes. The minitrach was well tolerated in this group of patients with severe pulmonary and/or cardiovascular disease. In 12 of these patients, a minitrach revision of their previous modified Seldinger technique tracts resolved recurrent problems with chondritis, lost tracts, and keloids. We conclude that the minitrach promotes early institution of transtracheal oxygen, simplifies an intense postprocedure educational and management process, facilitates tract maturation, and reduces the incidence of problems related to mucus balls, lost tracts, chondritis, and keloids. The minitrach can be used as a revision procedure to resolve tract problems encountered with modified Seldinger technique. We are now using the minitrach as the preferred procedure for the institution of transtracheal oxygen. The minitrach greatly improves and simplifies the transtracheal oxygen program, and the otolaryngologist becomes an important member of the transtracheal oxygen team.

The flow-volume loop in inducible laryngeal obstruction: one component of the complete evaluation

The flow-volume loop in inducible laryngeal obstruction: one component of the complete evaluation

Transtracheal Oxygen Catheter Placement and Management

Transtracheal oxygen therapy (TTO) is a technology for administration of continuous supplemental oxygen to patients with chronic hypoxemia. It is an alternative to nasal cannula therapy. The multiple potential benefits of TTO are outlined in this publication. Two very different techniques for creation of the transtracheal tract have been developed to allow oxygen administration through the catheter. However, core to the success of TTO is the patient management program. Within the program are two pathways that are tailored to meet the specific needs of their respective companion insertion methods. The two methods are a modified Seldinger technique (MST) and the surgical approach developed by Dr. Alan Lipkin. In addition to benefits, potential complications of TTO are identified; they are generally minor in nature. Outcomes vary subject to the method of tract creation, patient selection, and experience of the team. Indications and contraindications as well as patient evaluation and selection are discussed. In addition, preprocedure management to address specific precautions and minimize complications is outlined. Both the surgical approach and MST for tract creation are reviewed. Patient management during the immature and mature tract phases is presented. Finally, specific advantages of the Lipkin procedure over the MST are summarized. The interventional pulmonologist, as team leader, plays a critical role in TTO. Trained respiratory therapists and nurses facilitate program implementation. A surgical colleague adds value to the team.