By Y. Mamuk. Colorado State University.
Other measures that may be of benefit in intubated patient include the use of a closed suctioning system to avoid generating infectious aerosols and the use of submicron filters for air exhausted from ventilators  buy discount zithromax 100 mg on-line antibiotic quotes. All health care workers who will be exposed to potentially infectious tuberculosis patients should use personal protective devices cheap zithromax 250 mg without a prescription hpv. Properly fitted masks capable of filtering at least 95% of particles 1 µm in size are recommended with fit-testing to ensure a face-seal leakage of less than 10% order genuine zithromax on line antibiotics z pack and alcohol. Powered air-purifying respirators with a helmet or hood are a more effective and more expensive option. These could be considered for certain high-risk situations such as an unavoidable bronchoscopy of an infectious case of tuberculosis. Public Health Aspects Presumptive and confirmed cases of tuberculosis should be promptly reported to the local public health department as required by law in every state. The function of this reporting is to provide the opportunity to conduct timely contact investigations, which may be critical to preventing life-threatening complications of tuberculosis among small children or immunocompromised household members. In addition, many health departments can assist in ensuring completion of outpatient therapy and thus prevent a hospital readmission for treatment failure or relapse with drug-resistant tuberculosis. Treatment recommendations for tuberculosis, based on randomized controlled trials, are summarized in Table 82. Isoniazid, rifampin, pyrazinamide and ethambutol 7 d/wk for 56 doses (8 wk)  Adjunctive corticosteroids are recommended for: 1. Erbes R, Oettel K, Raffenberg M, et al: Characteristics and outcome of patients with active pulmonary tuberculosis requiring intensive care. American Thoracic Society/Centers for Disease Control and Prevention: Diagnostic standards and classification of tuberculosis in adults and children. Lillebaek T, Dirksen A, Baess I, et al: Molecular evidence of endogenous reactivation of Mycobacterium tuberculosis after 33 years of latent infection. Centers for Disease Control and Prevention: Targeted tuberculin testing and treatment of latent tuberculosis infection. Greenaway C, Menzies D, Fanning A, et al: Delay in diagnosis among hospitalized patients with active tuberculosis—predictors and outcomes. Long R, Chong H, Hoeppner V, et al: Empirical treatment of community-acquired pneumonia and the development of fluoroquinolone-resistant tuberculosis. Penner C, Roberts D, Kunimoto D, et al: Tuberculosis as a primary cause of respiratory failure requiring mechanical ventilation. Sanyika C, Corr P, Royston D, et al: Pulmonary angiography and embolization for severe hemoptysis due to cavitary pulmonary tuberculosis. Brown M, Varia H, Bassett P, et al: Prospective study of sputum induction, gastric washing, and bronchoalveolar lavage for the diagnosis of pulmonary tuberculosis in patients who are unable to expectorate. A study of the relationship between these factors in patients with human immunodeficiency virus infection. Gachot B, Wolff M, Clair B, et al: Severe tuberculosis in patients with human immunodeficiency virus infection. Thwaites G, Fisher M, Hemingway C, et al: British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. Pai M, Zwerling A, Menzies D: Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update. Piersimoni C, Scarparo C: Relevance of commercial amplification methods for direct detection of Mycobacterium tuberculosis complex in clinical samples. Centers for Disease Control and Prevention: Updated guidelines for the use of nucleic acid amplification tests in the diagnosis of tuberculosis. Dinnes J, Deeks J, Kunst H, et al: A systematic review of rapid diagnostic tests for the detection of tuberculosis infection. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. However, these viruses cause respiratory illness after a phase of systemic viral replication and dissemination. Airborne virus-containing droplets 5 to 10 μm in diameter are filtered and deposited in the upper respiratory tract. Virus reaches the lower respiratory tract after efficient replication and spread within squamous epithelial cells, often in the setting of impaired mucociliary clearance (due to extremes of age, antecedent or concurrent infections, and drugs). Other viruses such as varicella and rubeola are transmitted via aerosols (particles 1 to 5 μm in diameter) that can deposit directly in the lower respiratory tract. As such, they are highly infectious and can be transmitted over greater distances and time than agents transmitted by droplets. Although deposited directly in alveoli, viral dissemination to the lung typically occurs hematogenously after a viremic phase [1,2]. Once in the lower respiratory tract, there are a limited number of ways that the lung can respond to a viral infection and produce respiratory illness. Viral invasion and replication can directly produce a necrotizing bronchopneumonia with highly inflammatory, purulent, and exudative reactions. Respiratory viral infections can impair host lung defenses in a way that leads to secondary bacterial pneumonias, particularly with Streptococcus pneumoniae or Staphylococcus aureus. Finally, viral infection of the lower respiratory tract may produce severe disease by triggering a common tissue response to acute lung injuries termed diffuse alveolar damage or acute respiratory distress syndrome. The clues to a specific viral etiology are often found in assessing host risk factors and epidemiology on presentation. A summary of the common clinical manifestations for specific viral pneumonias is presented in Table 83. Many of the viral infections discussed in this chapter are characterized by a “flu-like illness” prodrome. The presence or absence of upper respiratory symptoms at this stage may provide one clue to the specific viral etiology. The lower respiratory tract signs and symptoms in viral pneumonias are generally nonspecific and progress to dyspnea, tachypnea, and inspiratory crackles (rales). If the clinical course is biphasic (dyspnea and productive cough after improvement of a flu-like illness), then a secondary bacterial pneumonia should be suspected. Routine laboratory tests are generally of little help in distinguishing among the viruses that can produce severe respiratory illness. Electrolyte abnormalities and hepatic transaminase elevation can occur among any of the severe viral pneumonias. However, they are no better at defining particular radiographic patterns of specific viral or bacterial causes . Definitive serologic evidence of a viral infection requires a rise in virus- specific antibody titers between paired acute illness and convalescent sera. With a few exceptions, serologic assays are therefore not generally helpful for the clinician in the acute setting of a severe viral pneumonia. This section will focus on diagnostic tests that may assist the clinician faced with a critically ill patient and suspected viral pneumonia. Human Influenza A and B Rapid, direct, antigen-detection assays are commercially available for diagnosing human influenza A and B virus infections. These assays rely on detection of the influenza virus nucleoprotein in respiratory secretions, and results can be obtained within 1 hour.
While it Down’s syndrome screening order zithromax on line amex virus barrier, this too should be discussed would appear advantageous for women to be seen by the in detail and supplemented with written informa- same midwife throughout pregnancy and childbirth order zithromax 250 mg free shipping infection 2 hacked, tion cheap 100 mg zithromax fast delivery virus 068. Ideally another follow‐up appointment should be there are practical and economic considerations that arranged before the screening tests need to be performed need to be taken into account. Nevertheless, where to allow further questions and to arrange a time for the possible, care should be provided by a small group of tests following maternal consent. The next appointment needs to be around 16 weeks’ gestation to discuss the results of the screening tests. In addition, information about antenatal classes should be Documentation of antenatal care given and a plan of action made for the timing and fre- the antenatal record needs to document clearly the care quency of future antenatal visits, including who should the woman has received from all those involved. As with each antenatal visit, the blood also serve as a legal document, a source of useful infor- pressure should be measured and the urine tested for mation for the woman and a mechanism of communica- protein. The 20‐week anomaly scan should also be dis- tion between different healthcare professionals. There is cussed and arranged and women should understand its now good evidence that women should be allowed to limitations. Women feel more in control of At each visit the symphysis–fundal height is plotted, their pregnancy and do not lose the notes any more often the blood pressure measured and the urine tested for than the hospital! At 28 weeks’ gestation, blood should be taken available to clinicians should the woman require emer- for haemoglobin estimation and atypical red‐cell anti- gency care while away from home. Anti‐D prophylaxis should be offered to women are endeavouring to work towards a standard format for who are rhesus negative. This would be of benefit to those women weeks will allow the opportunity to discuss these results. If a breech is confirmed, ● At booking, women should be asked about history external cephalic version should be considered. For of significant mental illness, previous psychiatric women who have not given birth by 41 weeks, both a treatment or family history of perinatal mental membrane sweep and induction of labour should be illness. In summary, a total of 10 appointments is recom- ● Dating scan should be performed between 10 and mended for nulliparous women and seven appointments 13 weeks’ gestation by measuring the crown–rump for multiparous women, assuming they have uncompli- length. References 1 Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, 7 United Nations Children’s Fund. The non‐invasive test to improve screening for pregnant Investigation and Management of the Small‐for‐ women. Lau Fetal Medicine Centre, Paramount Medical Centre, Hong Kong A large part of normal obstetric care consists of a series 9) the cost of case‐finding (including diagnosis and of screening tests designed to identify those pregnant treatment of patients diagnosed) should be econom women who are at risk of various maternal, obstetric or ically balanced in relation to possible expenditure on fetal complications so that early interventions can be ini medical care as a whole. Many of these screen into a high‐risk (or test‐positive) group and a low‐risk (or ing tests have been discussed in other chapters in this test‐negative) group. Further investigations and diagnos book under specific conditions and therefore will not be tic tests should be considered for those in the high‐risk repeated here. There are four important parameters in assessing screening of chromosomal abnormalities. Specificity, or true negative rate, equals 1) the condition sought should be an important health (1 – false‐positive rate). A high sensitivity 2) There should be an accepted treatment for patients indicates a lower chance of missing an affected subject, with recognized disease. First Trimester Antenatal Screening 59 involving two chromosomes 21, there will be 100% risk Summary box 6. First‐trimester Down’s syndrome Other medical problems are common, including hearing loss (up to 70%), obstructive sleep apnoea (50%), con screening genital heart diseases (50%), hypothyroidism, otitis media, cataracts and visual problems. Screening for fetal Down’s syndrome has become part of In the past, the outcome of individuals with Down’s routine antenatal care in many countries. Down’s syn syndrome was poor, mostly due to the lack of medical drome has been considered the commonest genetic care and support. The prognosis of individuals with Down’s syndrome has incidence of Down’s syndrome increases with maternal improved significantly over the last century. Currently in age, being relatively stable before age 30 but increasing developed countries the average lifespan of affected indi exponentially after age 35. About 30% of affected preg viduals is already over 50, and many of them are living nancies result in miscarriage or intrauterine fetal death with their families or independently with varying degree and therefore the incidence of Down’s syndrome of support. Such improvement relies on the availability of In over 95% of individuals with Down’s syndrome the appropriate and adequate medical care, early interven condition is due to trisomy 21 – the presence of one tional programmes, education, financial support, extra chromosome 21 – which is typically due to an social support and employment opportunities. In developed countries with adequate medical and Although trisomy 21 is not an inherited condition, a his social support, most families with children with Down’s tory of an affected pregnancy increases the chance of syndrome are able to find enough resources to help having another affected pregnancy by about 0. This suggests that some individ Even with all necessary social and medical support, uals are more prone to non‐disjunction during meiosis, Down’s syndrome remains a condition with multiple or some trisomies are due to underlying maternal medical problems that poses significant stress and chal gonadal mosaicism. At present, it is medically possible to About 2–3% of Down’s syndrome cases are due to identify affected pregnancy in the antenatal period, and Robertsonian translocations, in which part of chromo pregnancy termination of affected pregnancies is legal some 21 is translocated to another chromosome, most in many countries. About two‐thirds of these confirmed that prenatal Down’s syndrome screening is cases are de novo events, while one‐third are inherited cost‐effective. On the other hand, Down’s syndrome is a from one of the parents who is a carrier of a balanced non‐lethal condition, and there is continuous debate translocation. If the mother is the carrier, there is about a about the ethics of terminating affected pregnancies. If beyond the scope of this chapter to elaborate on the the father is the carrier, the risk is much lower, estimated ethics of Down’s syndrome screening. The discussion to be at most 3% although some believe that the addi will therefore focus on the scientific basis and details of tional risk is negligible. If an individual is a carrier of a implementation of Down’s syndrome screening in the very special form of balanced Robertsonian translocation first trimester of pregnancy. Moving the cut‐off to 1 in 100 may reduce the sen sitivity to 65% but also increase the specificity to 98%. Not all women want to undergo screening so any pro These numbers are only hypothetical, and the true effect gramme must recognize those wishing to ‘opt out’. In this case cut‐off is therefore a compromise between high sensitivity these women can have an early scan but the fetal nuchal and high specificity. It is important to realize that using the same screening test with the same cut‐off in populations with different First‐trimester combined screening maternal age may result in different sensitivities and spe programmes cificities. The typi would probably be less confused with a suggested cut‐off cal changes associated with fetal Down’s syndrome are and a simple result of high or low risk. It is present in all fetuses in the late first are performed between 11 and 13 weeks of gestation, and early second trimester, and then gradually disap or at a crown–rump length of 45–84 mm. This starts with the estimation of the a priori the fetal nuchal skin but not fluid collection. The An individualized risk or post‐test odds is calculated most commonly used protocol is listed in Table 6. Moving the Most risk calculation algorithms provide adjustment for cut‐off will change the sensitivity and specificity at the these factors, to maximize the test performance. For example, assuming that the sensitivity oratories performing Down’s syndrome screening bio and specificity are 75% and 95%, respectively, at a cut‐off chemistry should have continuous internal and external of 1 in 250, moving the cut‐off to 1 in 400 may increase quality assurance programmes (such as the United the sensitivity to 85% but also reduce the specificity to Kingdom National External Quality Assessment Service, First Trimester Antenatal Screening 61 Table 6. Since the throughput of an accredited sonog the measurement must be taken at a gestation between 11 rapher is much lower than that of an accredited weeks and 13 weeks 6 days biochemical laboratory, an ultrasound‐only approach is the measurement must be taken when the fetal crown–rump more difficult to implement in populated‐based screen length is between 45 and 84 mm ing programmes. Only one individualized risk screenings to ensure that the biochemical laboratories is calculated when information from all markers is avail they are using are well qualified and have satisfactory able.
Riera J buy zithromax with a mastercard infection headache, Baldirà J zithromax 500 mg cheap infection 2 strategy, Ramirez S buy zithromax amex virus mers, et al: Gastroparesis following lung transplantation: risk factor for pneumonia. Ferdinande P, Bruyninckx F, Van Raemdonck D, et al; Leuven Lung Transplant Group: Phrenic nerve dysfunction after heart–lung and lung transplantation. Jacques F, El-Hamamsy I, Fortier A, et al: Acute renal failure following lung transplantation: risk factors, mortality, and long-term consequences. Raghavan D, Gao A, Ahn C, et al: Contemporary analysis of incidence of post-operative atrial fibrillation, its predictors, and association with clinical outcomes in lung transplantation. Fourteen years passed before the first successful heart–lung transplant was performed on March 9, 1981. Heart–lung transplantation established the potential for lung transplantation as a viable therapeutic option, and the first successful single-lung transplant was performed in 1983 . The waiting list for heart transplant has steadily grown because more patients are added than removed every year. Subsequently, the number of heart transplants has been increasing since 2004, with roughly 2,500 performed annually in the United States. It could also be an individual who has a mechanical assist device in place and either right or left ventricular support that is beginning to malfunction. It also includes individuals who are on continuous mechanical ventilation or on high-dose inotropic support that cannot be weaned. Status 2 candidates are individuals who need heart transplantation but have not been defined as being in the most urgent status. These patients typically are at home, still active, and taking heart- failure medications while awaiting transplantation. The number of transplantations increased for patients with cardiomyopathy and congenital heart disease, 34% and 28%, respectively. Cardiac retransplantation represents approximately 4% of the adult heart transplant population annually. Most patients who received a transplant had private insurance; however, the proportion of insured versus those on Medicare decreased between 2002 and 2012 . Patient Selection Many of the specific critical care problems seen in thoracic organ recipients can be reduced by careful patient selection. The other 10% to 20% are individuals who are critically ill and undergo an urgent transplant evaluation. The recipient assessment consists of a general evaluation, an assessment of the functional and hemodynamic status, and a psychosocial evaluation. For those patients who are capable of performing this test, there are excellent data which demonstrate that a peak oxygen consumption of less than 12 mL/kg/min is associated with a very poor 1-year survival rate without transplant. Individuals with a peak oxygen consumption of less than 15 mL/kg/min should be considered for listing [3,4]. The patient’s medical history is examined to try to determine the cause of the patient’s heart disease. Individuals who have a creatinine clearance of less than 50 mL per minute do have a significant increase in the need for postcardiac transplantation dialysis and have lower rates of survival than those with near-normal renal function. Individuals with severely abnormal creatinine clearance would be excluded from heart transplant or considered for heart-and-kidney transplantations. Individuals with diabetes need further end-organ evaluation prior to listing to understand the full scope of their risk. The hemodynamic evaluation consists of an echocardiogram to evaluate function and anatomy, and a cardiac catheterization. The cardiac catheterization includes evaluation of heart function by a right heart catheterization as well as a coronary angiogram. In this assessment, the patient’s coronary anatomy is examined for potential intervention, and any abnormalities in the filling pressures, pulmonary capillary occlusion pressure, or pulmonary vascular resistance are identified. Patients with heart failure and secondary pulmonary hypertension are a group who are of special interest. Pulmonary arterial and capillary wedge pressures are measured to determine the degree to which a patient has secondary pulmonary hypertension and whether or not it is reversible. The patient’s hemodynamics should be optimized in the catheterization laboratory in an attempt to decrease the pulmonary arterial pressures to normal levels, and 100% oxygen, nitric oxide, and other pulmonary vasodilators can be used to test the reactivity of the pulmonary vasculature. Individuals with values outside these values would then be listed for heart–lung transplant, or be given a trial of pulmonary vasodilators. The psychosocial evaluation should be centered on evaluating not only the transplant recipient, but also the family support for the patient. This needs to be performed by a qualified professional experienced in social work and, when indicated, other mental health professionals who have a keen understanding of the demands made on a postoperative cardiac transplantation patient. Patients need to be medically compliant, have adequate neurocognitive function for the postoperative regimen, and adequate social support. Once the evaluation has been completed, the patient is evaluated for any relative or absolute contraindication for heart transplantation. Those relative contraindications include: age greater than 70 years, previous chronic substance abuse, limited social support, limited adaptive ability, mild renal dysfunction, active peptic ulcer disease, cachexia, obesity, and cigarette smoking. It should be noted that to receive a heart transplantation, individuals who smoke are required to go through a smoking-cessation program, and many transplant programs require them to sign a contract stating that they will not resume smoking prior to or after the transplantation. Absolute contraindications to cardiac transplantation include: ongoing substance abuse, refractory psychiatric conditions, suicidal behavior, severe personality disorder, issues with ongoing medical noncompliance, inadequate neurocognitive ability, irreversible hepatic or renal dysfunction, severe peripheral or cerebral vascular disease, systemic disease that limits rehabilitation, insulin-dependent diabetes with severe end-organ damage, or evidence of severe, fixed, secondary pulmonary hypertension [8–10]. With an assist device implanted, patients who would otherwise not survive long enough to receive a heart transplantation are now living independently at home with reasonably good quality of life until a suitable organ becomes available. This has impacted the number of patients reliant on inotropes at the time of transplant, with a decrease from 43. There are two broad categories of devices in use based on pump mechanism: pulsatile devices that employ some type of pneumatic pump, and continuous, or axial flow devices that involve a spinning propeller. The cycles of the pulsatile device are measured in beats per minute (bpm) and that of the continuous-flow pumps in revolutions per minute (rpm). Each device has an inflow cannula through which the patient’s blood is drawn from the heart and into the pump and an outflow cannula that directs the blood back into the patient’s circulation. For both pulsatile pumps and continuous-flow pumps, there are two more classifications that can be described on the basis of the location of the pump when implanted: intracorporeal, wherein the entire pump is implanted inside the body with the exception of the drive-line that powers the device and passes through an exit site on the abdomen; the other is paracorporeal, or extracorporeal, wherein the pump sits outside the body and the inflow and outflow cannulae enter and exit the skin on the upper abdomen just below the costal margin. The Levitronix CentriMag (now owned by Thoratec) is approved for temporary right ventricular assistance up to 30 days and its inflow cannula may be placed in either the right atrium or the right ventricle. Bridge to recovery refers to the patient who is expected to recover from heart failure and the device is used to sustain life until the time when it can be weaned off and explanted. It will be important not to begin administration of plasma and cryoprecipitate until the plan to proceed with the transplant is certain. The local organ-procurement agency will obtain consent for donation from the family and proceed with the donor evaluation and support. The donor evaluation consists of taking a general history of any illnesses or risk factors such as heart disease, hypertension, diabetes, or cigarette smoking. Specifics are gathered surrounding the time and mode of death to determine whether there is any potential cardiac injury, down time, cardiopulmonary resuscitation, or cardioversion.
Further route and duration of therapy depend on the specific type and sensitivity of the identified organism and the patient’s clinical response cheap 250mg zithromax amex antimicrobial agents examples. Please refer to Chapter 73 for appropriate antibiotic treatment for presumptive or identified infectious organisms buy 500 mg zithromax free shipping antibiotic 1000mg. Drainage of the infected joint with either serial percutaneous needle aspiration or surgical intervention is also crucial purchase zithromax from india antibiotic 625mg. Because there are no prospective studies comparing these options, controversy exists regarding the optimal approach. The physical removal of inflammatory cells, cellular debris, lysosomal enzymes, and bacterial by-products reduces the potential damage to the joint. Prosthetic joints and other native joints such as hip, shoulder, wrist, finger, sacroiliac, or sternoclavicular joints require immediate surgical intervention, whereas native septic knees may respond to serial percutaneous needle aspiration. Arthroscopy or arthrotomy has the advantage of more complete debridement of fibrin, infected synovium, and loculations. However, percutaneous drainage may be the only option for a critically ill patient who is too unstable for surgery. Thus, the ideal approach is to consult both an orthopedic surgeon and a rheumatologist at the time of diagnosis to decide on optimal management. Once antibiotics are given and drainage has been performed, early physical therapy with passive range of motion and graduation to active range of motion will improve outcomes. Because septic arthritis usually occurs as a consequence of bacteremia from a distant primary source of infection, investigation for these sites must be pursued. Unless an obvious site of local inoculation is present, cultures from blood, urine, sputum, indwelling lines, and catheters should be obtained before the institution of antibiotics. Risk factors are similar for native joint septic arthritis discussed previously and also include prior infection of a prosthetic joint at the same site or revision arthroplasty. If aspiration is not done before surgery, then intraoperative sampling of multiple periprosthetic tissue sites will increase the yield of an organism. If the patient is a surgical candidate, options include: (1) resection arthroplasty, (2) one- or two-stage surgery with prosthesis removal and reimplantation, or (3) surgical debridement with retention of prosthesis with or without long-term oral antibiotic suppression. The first option is rarely performed unless the patient has failed previous surgical attempts at eradicating the infection or is likely to have minimal functional improvement after replacement. The latter usually entails removal of the infected prosthesis, treatment with antibiotics with or without an antibiotic-loaded spacer for a period of 6 to 12 weeks, and then subsequent reimplantation. Debridement with retention of the infected prosthesis is an option only if (i) age of the prosthesis is less than 3 months; (ii) symptoms have been present for less than 3 weeks; (iii) absence of sinus tract communicating with joint space; (iv) no radiographic evidence of prosthetic loosening; (v) infection not involving S. Prolonged oral antibiotics (3 months for hips and 6 months for knees) are recommended in patients treated with debridement with implant retention . Hemarthrosis In the absence of an underlying inherited disorder of coagulation, hemarthrosis in the intensive care setting is most likely a complication of anticoagulation therapy, most frequently described in patients receiving an oral anticoagulant. Because hemarthrosis may occur spontaneously in an anticoagulated patient, a history of trauma is often absent. Prolongation of coagulation parameters suggests the diagnosis, but diagnostic arthrocentesis is essential to confirm the diagnosis of hemarthrosis and exclude septic arthritis, crystalline disease, or other causes. When performed aseptically and carefully, arthrocentesis is safe and free of significant long-term morbidity. A precise definition of hemarthrosis has not been established, but the diagnosis is suggested by a synovial fluid hematocrit exceeding 3%. Despite the fact that hemophiliac patients with repeated hemarthrosis have significant joint abnormalities, an isolated episode of spontaneous hemarthrosis has a benign prognosis. Treatment of hemarthrosis from hemophilia or other bleeding diathesis is discussed elsewhere (see Chapters 88 and 89). Management of spontaneous hemarthrosis from anticoagulation consists of immobilization, analgesia, and, if possible, temporarily reducing or correcting clotting parameters with fresh frozen plasma or reversal agents when the patient is not at high risk of thrombotic complications. Involvement of the cervical spine, temporomandibular or cricoarytenoid joints, or oral aperture may limit adequate positioning, visualization, or successful endotracheal intubation with conventional direct laryngoscopy. Advanced airway techniques including fiberoptic intubation, video laryngoscopy, and nasotracheal intubation enable safe airway placement for most patients with difficult airways (see Chapter 8). Laryngeal mask airway is a possible rescue measure for patients who cannot be intubated but can be ventilated and is a good alternative to bag mask ventilation. A surgical airway, cricothyroidotomy or tracheostomy, is required in emergent situations when safe intubation is not possible and the patient cannot be adequately ventilated (see Chapters 8 and 9). Although the majority of patients with cervical spine involvement are asymptomatic, forced manipulation of the neck (e. Cervical instability and dislocations most commonly occur at the atlantoaxial (first and second cervical vertebrae) junction because of laxity or erosion of the transverse ligament caused by synovitis. Subsequently, the odontoid (superior peg of the axis) moves more freely and can protrude posteriorly, particularly during neck flexion, and compress the spinal cord, lower medulla, or vertebrobasilar arteries. Fracture or erosive destruction of the odontoid may allow the atlas to slide posteriorly on the axis, a process termed posterior atlantoaxial subluxation. Destruction of the lateral atlantoaxial joints and of the bones of the foramen magnum may allow the axis to sublux cephalad, so-called vertical subluxation. Symptoms suggestive of cervical myelopathy include Lhermitte’s sign, neck pain radiating up to the occiput, paresthesias in the hands or feet, loss of arm or leg strength, and urinary incontinence or retention. Atlantoaxial instability is identified with lateral cervical spine radiographs in flexed and extended views. If this distance is exceeded, care should be taken to avoid sudden or forced neck flexion during any intensive care procedure. A soft cervical collar to maintain the neck in slight extension helps prevent sudden forced flexion and is a reminder to all caregivers that any neck manipulation should proceed with caution. Thus, plain radiographic imaging with lateral views before any procedure can help establish potential barriers to endotracheal intubation and the need for advanced intubation techniques. In these situations, early awareness of the need for nasotracheal intubation or other advanced airway techniques will prevent potential complications in routine or emergency endotracheal intubation. Symptoms of cricoarytenoid involvement include throat pain, sensation of a foreign object in the throat, odynophagia, dysphagia, hoarseness, shortness of breath, and stridor. As a result of acute or chronic inflammation, the vocal cords may become fixed in adduction, resulting in upper airway obstruction and respiratory failure. The diagnosis may be distinguished from recurrent laryngeal nerve paralysis, tumor, and thyroiditis by visualizing the vocal cords by either direct laryngoscopy or fiberoptic nasopharyngoscopy. For the patient with chronically restricted motion of the cricoarytenoid joints, a superimposed insult, like an upper respiratory tract infection or trauma from intubation, may cause laryngospasm or soft tissue swelling with resultant airway obstruction. Treatment of life-threatening airway obstruction includes establishing an airway by cricothyroidotomy or tracheostomy, administration of high- dose systemic corticosteroids, systemic antirheumatic therapy, or topical aerosolized corticosteroids. The initial triggering antigen, whether exogenous or self, has not been identified, but the initial activation of innate immunity and the subsequent stimulation of T cells initiate the process of recruitment of other cells to the synovium, including macrophages, neutrophils, and B cells.