Novel Therapy for Acquired Tracheomalacia with a Tissue-Engineered Extraluminal Tracheal Splint and Autologous Mesenchymal-Derived Chondrocytes

Abstract Introduction Acquired tracheomalacia (ATM) is characterized by a loss of structural strength of the tracheal framework, resulting in airway collapse during breathing. Near half of the patients undergoing prolonged invasive mechanical ventilation will suffer tracheal lesions. Treatment for ATM includes external splinting with rib grafts, prosthetic materials, and tracheal resection. Failure in the use of prosthetic materials has made reconsidering natural origin scaffolds and tissue engineering as a suitable alternative. Objective To restore adequate airway patency in an ovine model with surgicallyinduced ATM employing a tissue-engineered extraluminal tracheal splint (TE-ETS). Methods In the present prospective pilot study, tracheal rings were partially resected to induce airway collapse in 16 Suffolk sheep (Ovis aries). The TE-ETS was developed with autologous mesenchymal-derived chondrocytes and allogenic decellularized tracheal segments and was implanted above debilitated tracheal rings. The animals were followed-up at 8, 12, and 16 weeks and at 1-year postinsertion. Flexible tracheoscopies were performed at each stage. After sacrifice, a histopathological study of the trachea and the splint were performed. Results The TE-ETS prevented airway collapse for 16 weeks and up to 1-year postinsertion. Tracheoscopies revealed a noncollapsing airway during inspiration. Histopathological analyses showed the organization of mesenchymal-derived chondrocytes in lacunae, the proliferation of blood vessels, and recovery of epithelial tissue subjacent to the splint. Splints without autologous cells did not prevent airway collapse. Conclusion It is possible to treat acquired tracheomalacia with TE-ETS without further surgical removal since it undergoes physiological degradation. The present study supports the development of tissue-engineered tracheal substitutes for airway disease.

Uso prolongado de cánula nasal de alto flujo en niños con problemas respiratorios / Prolonged use of high flow nasal cannula in children with respiratory problems

La cánula nasal de alto flujo (CNAF) es una modalidad ventilatoria no invasiva segura y efectiva, usada ampliamente en patología respiratoria aguda en adultos y niños. Objetivo: presentar casos clínicos pediátricos que utilizaron CNAF por tiempo prolongado por problemas respiratorios crónicos. Descripción de casos clínicos, revisión de fichas clínicas de 5 pacientes que utilizaron CNAF por más de 1 mes, entre los años 2017-2020 en el Complejo Asistencial Dr. Sótero del Río. Aprobado por Comité de Ética. Resultados: 5 pacientes varones de mediana 61 (44 a 212) días de edad al inicio del uso de CNAF. Diagnóstico de base: displasia broncopulmonar (2/5), síndrome de Treacher Collins (1/5), síndrome de cimitarra con hipoplasia pulmonar derecha (1/5) y traqueobroncomalacia severa (1/5). Todos requirieron previamente uso de ventilación invasiva o no invasiva con mediana de 59 (4 a 78) días. A todos se les realizó broncoscopia, saturometría contínua o poligrafía para diagnóstico y titulación de CNAF y oxígeno. Todos mejoraron clínicamente, la SpO2 y el número de apneas. Dos pacientes se enviaron a domicilio con uso de Airvo2 nocturno. La mediana de uso de CNAF fue 165 (34 a 445) días. Conclusiones: el uso prolongado de CNAF es útil en pacientes pediátricos seleccionados, bien tolerado y factible de utilizar en domicilio.

The high-flow nasal cannula (HFNC) is a safe and effective non-invasive ventilation support widely used in acute respiratory pathology in adults and children. Objective: To present pediatric clinical cases that used HFNC for an extended period due to chronic respiratory disease. Description of clinical cases, review of medical records of 5 patients who used HFNC for more than 1 month, between the years 2017-2020 at Complejo Asistencial Dr. Sótero del Río. Approved by the Ethics Committee. Results: 5 male patients with a median age of 61 (44 to 212) days at the start of HFNC use. Underlying diagnoses: bronchopulmonary dysplasia (2/5), Treacher Collins syndrome (1/5), Scimitar syndrome with right pulmonary hypoplasia (1/5), and severe tracheobronchomalacia (1/5). All of them previously required invasive or non-invasive ventilation for a median of 59 (4 to 78) days. All patients underwent bronchoscopy, continuous pulse oximetry or polygraphy for diagnosis and titration of HFNC and oxygen. All showed clinical improvement, including SpO2 levels and the number of apneas. Two patients were discharged with nocturnal use of Airvo 2 at home. The median duration of HFNC use was 165 (34 to 445) days. Conclusions: Prolonged use of HFNC is useful in selected pediatric patients, well tolerated, and feasible for home use.

Management of Bronchomalacia in Infants Post?Cardiac Surgery Using Synchronized Nasal DuoPAP: A Novel Technology

Background:Tracheo?bronchomalacia (TBM) is the weakness in the structural integrity of the cartilaginous ring and arch. It may occur in isolation with prematurity or secondarily in association with various congenital anomalies. Bronchomalacia is more commonly associated with congenital heart diseases. The conventional treatment options include positive pressure ventilation with or without tracheostomy, surgical correction of external compression and airway stenting. Aim: To use “synchronized” nasal Dual positive airway pressure (DuoPAP), a non?invasive mode of ventilation as an alternative treatment option for bronchomalacia to avoid complications associated with conventional treatment modalities. Study Design: Prospective observational study conducted in Army Hospital Research and Referral from Jul 2019 to Dec 2020. Material and Methods: We diagnosed seven cases of TBM post?cardiac surgery at our institute, incidence of 4.2%. Four infants were diagnosed with left sided bronchomalacia, 2 were diagnosed with right sided bronchomalacia and one with tracheomalacia. Those infants were managed by “synchronized” nasal DuoPAP, a first in ventilation technology by Fabian Therapy Evolution ventilator (Acutronic, Switzerland). Results: All seven infants showed significant improvement with synchronized nasal DuoPAP both clinically as well as radiologically. None of the infant required tracheostomy and discharged to home successfully. Conclusion: The synchronized nasal DuoPAP is a low cost and effective treatment option for infants with TBM. It could be attributed to synchronization of the breaths leading to better tolerance and compliance in paediatric age group

Traqueobroncoplastia por malacia / Tracheobronchoplasty for malacia

RESUMEN La traqueobroncomalacia es una enfermedad de la vía aérea central caracterizada por una debilidad de la pared, con disminución dinámica de la luz de la tráquea y grandes bronquios principalmente durante la espiración. Genera síntomas crónicos que pueden evolucionar hasta la falla respiratoria grave, frecuentemente diagnosticados de forma errónea como asma o enfermedad pulmonar obstructiva crónica (EPOC). Presentamos el caso de una paciente femenina de 70 años, con antecedente de artritis reumatoide y múltiples internaciones por cuadros respiratorios infecciosos en los 3 años previos.

ABSTRACT Tracheobroncomalacia is a disease of the central airway due to weakness of the wall with dynamic narrowing of the lumen of the trachea and mainstem bronchi during exhalation. It produces chronic symptoms that can progress to severe respiratory failure, often misdiagnosed as asthma or chronic obstructive pulmonary disease (COPD). We report the case of a 70-year-old female patient with a history of rheumatoid arthritis and multiple hospitalizations for recurrent respiratory infections over the past 3 years.

Clinical analysis of 176 children with congenital tracheobronchial malformation / 中华实用儿科临床杂志

Objective:To investigate the clinical characteristics of congenital tracheobronchial malformation in children.Methods:Retrospective analysis was performed on the data of 176 children with congenital tracheobronchial malformation who were diagnosed by bronchoscopy at Children′s Hospital of Chongqing Medical University from January 2016 to October 2016, and were followed up by telephone for the presence of dyspnea, operation and death within 3 years after discharge.Results:(1) Among the 176 cases, there were 156 cases less than 3 years old, accounting for 88.64%.(2) Among the 176 cases, there were 54 cases with congenital tracheobronchial stenosis, 42 cases with congenital tracheomalacia, 26 cases with abnormal bronchial openings, 3 cases with airway diverticulum, 1 case with tracheoesophageal fistula, 1 case with bridging bronchus, and 49 cases with mixed type (2 or more malformations). (3) The most common clinical manifestations included recurrent or persistent dyspnea (86 cases), chronic cough (61 cases), and recurrent respiratory infection (34 cases) with the most frequent occurrence.Other manifestations included laryngeal stridor (14 cases), pulmonary atelectasis (29 cases), localized emphysema (6 cases), and difficulty extubation after endotracheal intubation (6 cases). (4) Among the 139 patients who underwent chest CT examination and airway reconstruction, only 44 cases were diagnosed correctly.(5) All 176 patients received routine medical treatment and bronchoscopy during hospitalization, among which 17 cases received surgical treatment.One hundred and seventy cases were improved in their condition and discharged, and 6 cases did not respond well.A total of 47 patients were followed up by telephone for 3 years.The proportion of children with dyspnea after 1 year, 2 years and 3 years were 59.57%, 51.06% and 38.30%, respectively.Among the follow-up patients, 4 patients received surgical treatment and 2 patients died.Conclusions:Congenital tracheobronchial malformation in children often occurs in infants, and their clinical manifestations are not typical.Therefore, suspected patients should receive chest CT and airway reconstruction as early as possible, and bronchoscopy can be employed in time if the diagnosis is unclear.The majority of children can obtain a favorable prognosis, with few death cases.Partial patients would present with a risk of recurrent or persistent dyspnea, and some critically ill children shall receive the airway stent implantation or surgical intervention.

Traqueomalacia: diagnóstico y alternativas terapéuticas / Tracheomalacia: diagnosis and treatment options

La traqueomalacia (TM) consiste en una excesiva colapsabilidad traqueal debida a una anomalía estructural del cartílago y/o de la pared membranosa posterior. Cuando se extiende a uno o ambos bronquios principales se denomina traqueobroncomalacia (TBM). Considerando diferentes clasificaciones, la mayoría de las TM son adquiridas, localizadas e intratorácicas. El diagnóstico clínico es difícil porque los síntomas son inespecíficos y se superponen con los de otras enfermedades respiratorias crónicas. Los síntomas más frecuentes incluyen estridor espiratorio, tos perruna e infecciones respiratorias recurrentes, en los casos más graves se presentan episodios de dificultad respiratoria severa, cianosis e incluso muerte súbita. La fibrobroncoscopía sigue siendo el método diagnóstico estándar de oro, complementándose con la tomografía computarizada que es esencial en la visualización de las estructuras adyacentes a la vía aérea. En los casos leves el tratamiento es conservador, considerando la resolución espontánea de la mayoría de los casos hacia los 2 años de edad. En los pacientes más sintomáticos la estrategia terapéutica se debe evaluar caso a caso, siendo la presión positiva contínua en vía aérea (no invasiva o invasiva por traqueostomía) el tratamiento más utilizado. En las TM-TBM más severas, entre posibles tratamientos que incluyen cirugía traqueal y prótesis en la vía aérea, lo más usado es aortoarteriopexia y traqueopexia, a la espera de resultados promisorios de mallas endoluminales biodegradables y prótesis reabsorbibles personalizadas impresas en 3D.

Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the cartilaginous rings and/or the posterior membrane. When the main bronchi is also affected this condition is termed as tracheobronchomalacia (TBM). According classifications TM is mostly acquired, localized and intrathoracic. Diagnosing TM is challenging because symptoms are nonspecific and overlap with those of other chronic respiratory disorders. The most common symptoms include expiratory stridor, barking cough and recurrent respiratory tract infections, in severe cases, severe respiratory distress episodes and acute life threatening events can occur. While flexible bronchoscopy is still considered as the gold standard diagnostic method, computed tomography is essential in assessing the surrounding structures. Conservative therapy is preferred in milder cases since the outcome is usually favorable within the first 2 years of life. Treatment of more symptomatic children should be discussed on an individual basis, continuous positive airway pressure (non invasive o invasive via tracheostomy) being the most widely used therapy. For more severe TM-TBM, amongst possible treatments including tracheal surgery and airway stenting, aortoarteriopexy and tracheopexy are mostly used, nevertheless absorbable stent and 3D printed customed prosthesis are being developed with promising results.

Posterior Plication of the Ascending Aorta to Relieve Tracheal Compression after Aorto-Left Ventricular Tunnel Repair / 日本心臓血管外科学会雑誌

A nine-month-old boy with a prenatal diagnosis of aorto-left ventricular tunnel (ALVT) and aortic valve disease underwent an urgent ALVT patch closure approximately 2 h after birth. The patient subsequently developed airway compression due to the progressive dilatation of the ascending aorta postoperatively associated with aortic regurgitation and stenosis. After 9 months of prolonged respiratory symptoms following the ALVT repair, he underwent a posterior plication of the ascending aorta. After plication, the tracheal compression and respiratory symptoms improved. A computed tomography (CT) scan 1 month after surgery revealed significant free space between the aorta and the trachea, which relieved the aortic compression. Posterior plication of the ascending aorta is achieved by resecting the posterior aortic wall adjacent to the airway. It is the procedure of choice for longer and more effective relief of airway compression compared to other procedures such as anterior aortopexy, the lateral sliding technique, and side clamp plication.

Establishment of experimental model of tracheomalacia in beagle dogs / 中国胸心血管外科临床杂志

@#Objective    To establish a model of tracheomalacia in beagle dogs. Methods    Six healthy male beagles were selected with a weight of 12-15 kg and age of 12-18 months. The dog was placed in supine position after being anesthetized. Then midline incision was performed on dogs' cervical skin and main trachea was dissected. Six continuous cartilage rings separated from the tracheal wall were removed. Finally, the endotracheal mucosal was examined and the wound was sutured layer by layer. Different degrees of cartilage were removed to simulate different degrees of tracheomalacia. The beagle dogs were classified into two groups (n=3 in each group): a mild tracheomalacia (MTM) group (part of the cartilage near the trachea membrane was retained) and a severe tracheomalacia (STM) group (cartilage was removed as much as possible). Results    The dogs in the MTM group survived for a long time after the operation, showing symptoms of airway stenosis such as wheezing and coughing. The dogs were killed at postoperative week 2, and the pathological examination was performed. In the STM group, severe asphyxia occurred in the experimental animals after tracheal intubation removed, and all dogs died within 1 hour after surgery. Postoperative bronchoscopy revealed that the trachea of the MTM group dogs collapsed in the phase of inhalation, but it could maintain a certain patency. The trachea of the STM group dogs collapsed completely in the phase of inhalation. Postoperative X-ray showed that the diameter of the airway in the MTM group was reduced and trachea did not completely collapse. In the STM group, the trachea collapsed completely at the cartilage removed segment. Pathological examination showed that the cartilage in the MTM group was partially removed and tracheomalacia was obvious in the cartilage removed segment. In the STM group, most of the cartilage was removed with only few cartilages left. Conclusion    The clinical symptoms of tracheomalacia in different degrees can be simulated and repeatable. Animal models can be established by controlling the degree of removal of tracheal cartilage ring in dogs. This method provides a simple, repeatable and standardized large animal model for the treatment and transformation of tracheomalacia.

Traqueomalacia pediátrica / Pediatric tracheomalacia

RESUMEN La malacia de la vía aérea central puede afectar la tráquea y/o los bronquios, haciéndola susceptible al colapso de sus paredes durante el ciclo respiratorio. Puede clasificarse como primaria o secundaria y clínicamente se manifiesta por síntomas respiratorios recurrentes o persistentes (especialmente en espiración), infecciones recurrentes y en casos severos, episodios de hipoventilación con cianosis. El diagnóstico se establece mediante broncoscopía flexible o rígida. Los estudios de imágenes se consideran complementarios, siendo especialmente útiles en casos de duda diagnóstica, estudio de causas secundarias o para la planificación preoperatoria. Su tratamiento depende de distintos factores como la severidad de los síntomas, su etiología, ubicación y extensión. En casos leves, una observación activa y tratamiento médico en espera de la resolución espontánea en los primeros 2 años, suelen ser suficientes. En casos moderados, la ventilación a presión positiva podría ser de utilidad. En casos severos está indicado el tratamiento quirúrgico, mediante distintas técnicas que buscan dar soporte a la estructura traqueobronquial debilitada, incluyendo traqueostomía, suspensiones directas (traqueopexias) o indirectas (aortopexia), tutores externos o stents intraluminales. En este articulo se revisarán las principales causas y tratamientos disponibles para la traqueomalacia pediátrica. Ya que su diagnóstico y manejo son complejos, es fundamental el trabajo de equipos médicos multidisciplinarios familiarizados con esta patología.

ABSTRACT Central airway malacia can affect the trachea and/or the main bronchi, making their walls susceptible to collapse during the respiratory cycle. It can be classified as primary or secondary, and clinically presents with recurrent or persistent respiratory symptoms (especially on expiration), recurrent infections and in severe cases, episodes of hypoventilation with cyanosis. The diagnosis is established by flexible or rigid bronchoscopy; imaging studies are considered as complementary, especially in cases of unclear diagnosis, secondary causes or for preoperative planning. Treatment depends on different factors such as the severity of the symptoms, their etiology, location and extension. In mild cases, active observation and medical treatment waiting for spontaneous resolution may be enough, which usually occurs in the first 2 years of age. In moderate cases, positive pressure ventilation could be useful. In severe cases, surgical treatment is indicated. Different techniques aiming to provide support to the weakened tracheobronchial structures are available, including tracheostomy, direct (tracheopexies) or indirect suspensions (aortopexy), external splints and intraluminal stents. In this article we present the main etiologies and available treatments for pediatric tracheomalacia. Given that diagnosis and management of these patients is complex, the work of multidisciplinary teams familiar with this pathology is of paramount importance.

Traqueomalacia, complicación de la exéresis de un bocio difuso endotorácico bilateral / Tracheomalacia: a complication after removal of bilateral endothoracic diffuse goiter

Introducción: En cirugía de la glándula tiroides la mortalidad es nula en algunas series por lo que la morbilidad es la mayor preocupación del cirujano. Objetivo: Presentar la evolución clínica de una paciente con tiroidectomía total por bocio endotorácico bilateral. Caso clínico: Paciente que se le realizó tiroidectomía total por bocio endotorácico bilateral, técnicamente difícil, biopsia por congelación negativa de malignidad, bocio coloide. Nervios recurrentes visualizados. Debido al tamaño de la glándula y lo complejo que resultó la extracción se decidió trasladar a la paciente a la sala de recuperación intubada y ventilada para proceder a la recuperación de la ventilación espontánea y la extubación en un período más prolongado. Fue extubada una primera vez que fue fallida. Fue reintubada y ocurrió en una segunda ocasión después de ser reintervenida por un posible hematoma de la herida. En la TAC preoperatoria se observó una glándula tiroides grande con prolongación endotorácia bilateral y estenosis alta de la tráquea. Conclusión: Las complicaciones de obstrucción de la vía aérea después de una tiroidectomía no son frecuentes. Generalmente, después de una tiroidectomía total o parcial se trata de recuperar al paciente en el quirófano para después de la extubación realizar una laringoscopia que descarte la parálisis de las cuerdas vocales. La traqueomalacia como complicación después de una tiroidectomía no es frecuente, por lo que se alerta que de no haber diagnosticado y tratado rápidamente la paciente podría tener un desenlace fatal(AU)

Introduction: In surgery of the thyroid gland, mortality is null in some series, so morbidity is the surgeon's greatest concern. Objective: To present the clinical evolution of a patient with total thyroidectomy due to bilateral endothoracic goiter. Clinical case: This patient underwent total thyroidectomy due to bilateral endothoracic goiter, technically difficult, negative freeze biopsy of malignancy, colloid goiter. Visualized recurrent nerves. Due to the size of the gland and how complex the extraction was, it was decided to transfer the patient to the intubated and ventilated recovery room to proceed with the recovery of spontaneous ventilation and extubation in a longer period. She was extubated the first time it failed. She was re-intubated and it occurred on a second occasion after being re-operated due to a possible hematoma of the wound. In the preoperative CT scan, a large thyroid gland with bilateral endothoracic prolongation and high stenosis of the trachea was observed. Conclusion: Complications of airway obstruction after thyroidectomy are not frequent. Generally, after a total or partial thyroidectomy, it is a matter of recovering the patient in the operating room, in order to perform, after extubation, a laryngoscopy to rule out paralysis of the vocal cords. Tracheomalacia as a complication after thyroidectomy is not frequent, so it is warned that failure to diagnose and treat the patient quickly could have a fatal outcome(AU)

Airway management during general anesthesia in an intellectually disabled patient with undiagnosed tracheomalacia

In cases of intellectually disabled patients, there is sometimes difficult to obtain sufficient information due to the intellectual disorder, even though the patient has significant medical problems. Herein, we report a case of decreased oxygen saturation and inadequate air exchange during general anesthesia in an intellectually disabled patient. We also describe the subsequent management, including the diagnosis of tracheomalacia (TM) using bronchoscopy, and the management of airway compromise with manual and/or controlled respiration, which led to the prevention of complications.

Successful Management of Acquired Tracheomalacia of Patients With Amyotrophic Lateral Sclerosis: A Report of Three Cases

Tracheomalacia is characterized by weakness of the tracheal walls and supporting cartilage. It results in dynamic compression of the airway, where the cross-sectional area of the trachea is reduced by expiratory compression. Acquired tracheomalacia results from complications associated with the use of endotracheal or tracheostomy tubes. In this report, we present three cases of patients with amyotrophic lateral sclerosis (ALS) successfully treated for tracheomalacia, including one case where the patient underwent surgery for combined tracheoesophageal fistula. We discuss the appropriate management strategies for tracheomalacia in patients with ALS. Through these case reports, we note the results of ALS patients who will have tracheostomy, and who are therefore at risk of sustaining a long term high cuff pressure, this study provides an evaluation for tracheomalacia and therapeutic management which should be considered for improving patient care outcomes.

Dynamic multi-detector computer tomography with volume helical shuttle technique for diagnosis of congenital heart disease with tracheomalacia in children / 第二军医大学学报

Objective To explore the diagnostic value of dynamic multi-detector computer tomography (MDCT) with volume helical shuttle (VHS) technique in children with congenital heart disease (CHD) combined with tracheomalacia. Methods We retrospectively analyzed the imaging and clinical data of 26 patients (16 males, 10 females) with CHD who underwent both MDCT with VHS technique and fiber bronchoscope between Oct 2014 and Aug. 2016. According to the results of fiber bronchoscope, the patients were divided into tracheomalacia (n = 7) and non­tracheomalacia (n=19) groups. The intracardiac structures and the anatomy of the great arteries were demonstrated by maximum intensity projection (MIP) and volume render (VR) reconstruction. The patterns of the tracheobronchial tree were demonstrated using minimum intensity projection (MinIP) reconstruction. The Mimics 17. 0 software was employed to automatically segment the CT images of different respiratory phases of each patient and to measure the cross sectional area of the airway. According to the golden-standard of fiber bronchoscopic findings and operative results, we calculated the diagnostic accuracy of VHS for CHD and the sensitivity, specificity and accuracy for tracheomalacia Results Compared with nontracheomalacia group, the patients in tracheomalacia group showed significantly greater cross-sectional area change of the trachea (34.23%-74. 95% vs 13. 73%-78. 87%, P= 0. 02). The diagnostic sensitivity, specificity and accuracy of VHS technique for tracheomalacia were 85.71%(6/7), 84. 21%(16/19) and 84. 62%(22/26), respectively. VHS showed accuracies of 100%(12/12) and 91. 67%(11/12) in diagnosing extracardiac and intracardiac defects, respectively. Conclusion Dynamic MDCT with VHS technique can provide a one-step diagnosis of tracheomalacia with CHI) in children.

Vascular airway compression management in a case of aortic arch and descending thoracic aortic aneurysm.

Airway compression due to distal aortic arch and descending aortic aneurysm repair has been documented. This case of tracheal and left main stem bronchus compression due to aortic aneurysm occurred in a 42‑year‑old man. The airway compression poses a challenge for the anesthesiologist in airway management during aortic aneurysm repair surgery. The fiber‑optic bronchoscope is very helpful in decision‑making both preoperatively and postoperatively in such cases. We report a case of airway compression in a 42‑year‑old patient who underwent elective distal aortic arch and descending aortic aneurysm repair.

Atelectasia lobar. Manifestación infrecuente de traqueobroncomalacia en adultos / Lobar atelectasis unusual presentation of tracheobronchomalacia in adults

Resumen Las alteraciones dinámicas del sistema respiratorio que condicionan colapso del lumen traqueobronquial durante la espiración favorecen síntomas inespecíficos o no atribuibles a una enfermedad respiratoria en particular. El diagnóstico preciso de la entidad clínica tiene implicaciones terapéuticas y pronosticas. La traqueobroncomalacia se diagnostica cuando existe una disminución en el lumen traqueobronquial mayor al 50% visible mediante exploración con broncoscopía. La etiología más frecuente en adultos es la forma adquirida y es rara la asociación con atelectasia.

Abstract Respiratory dynamic abnormalities that contributes with collapse of the airway luminal during expiration can cause nonspecific symptoms or not related to a respiratory disease. Accurate diagnosis of the clinical entity has therapeutic implications and is important for the prognosis. Tracheobronchomalacia is diagnosed when there is a decrease in the lumen tracheobronchial greater than 50% visible through exploration with Bronchoscopy. The main etiology in adults was the acquired form and association with lung atelectasis was rare.

Traqueobroncomalacia / Tracheobronchomalacia

A 10-years-old girl with recurrent wheezing was diagnosed as asthmatic. Her spirometry showed variable central airway intrathoracic obstruction. The bronchoscopy confirmed the presence of bronchomalacia.

Se presenta el caso de una paciente de edad escolar, quien por sibilancias recurrentes se trataba como asmática. Al realizar espirometría forzada se detectó un compromiso variable de vía central intratorácica. La fibrobroncoscopía confirmó la presencia de broncomalacia.

Importance of flexible bronchoscopy in decannulation of tracheostomy patients / Importância da broncoscopia flexível na decanulação dos pacientes traqueostomizados

OBJECTIVE: To evaluate the importance of flexible bronchoscopy in tracheostomy patients in the process of decannulation to assess the incidence and types of laryngotracheal injury and compare the presence of such lesions with clinical criteria used for decannulation. METHODS: We studied 51 tracheostomized patients aged between 19 and 87 years, with tracheal stent for a mean of 46 ± 28 days and with clinical criteria for decannulation. They were submitted to tracheostomy tube occlusion tolerance testfor 24 hours, and then to flexible bronchoscopy. We described and classified the diagnosed laryngotracheal changes. We compared the clinical criteria for decannulation indication with the bronchoscopy-diagnosed laryngotracheal injuries that contraindicated decannulation. We identified the factors that could interfere in decannulation and evaluated the importance of bronchoscopy as part of the process. RESULTS: Forty (80.4%) patients had laryngotracheal alterations. Of the 40 patients considered clinically fit to decannulation, eight (20%) (p = 0.0007) presented with laryngotracheal injuries at bronchoscopy that contraindicated the procedure. The most frequent laryngeal alteration was vocal cords lesion, in 15 (29%) individuals, and granuloma, the most prevalent tracheal lesion, in 14 (27.5%) patients. CONCLUSION: flexible bronchoscopy showed a large number of laryngotracheal injuries, the most frequent being the vocal cords injury in the larynx and the granuloma in the trachea, which contributed to increase the decannulation procedure safety.

OBJETIVO: Avaliar a importância do emprego, da broncoscopia flexível nos pacientes traqueostomizados em vias de decanulação para conhecer a incidência e os tipos de lesões laringotraqueais e comparar a presença destas lesões com os critérios clínicos utilizados para a decanulação. MÉTODOS: foram estudados 51 pacientes, com idade entre 19 e 87 anos, traquestomizados, com critérios clínicos de decanulação e com tempo médio de órtese traqueal de 46 ± 28 dias. Foram submetidos ao teste de tolerância à oclusão da cânula de traqueostomia por 24 horas, seguida da realização da broncoscopia flexível. As alterações laringotraqueais diagnosticadas foram descritas e classificadas. Comparou-se a indicação de decanulação por critérios clínicos com o diagnóstico de lesões laringotraqueais à broncoscopia que contraindicavam a decanulação. Identificaram-se os fatores que poderiam interferir na decanulação e avaliou-se a importância da broncoscopia como parte do processo. RESULTADOS: Apresentaram alterações laringotraqueais, 40 pacientes (80,4%). Dos 40 pacientes considerados clinicamente aptos à decanulação, oito (20%) (p=0,0007) apresentaram lesões laringotraqueais à broncoscopia que contraindicaram o procedimento. A alteração laríngea mais frequente foi lesão de pregas vocais em 15 (29%) e o granuloma, a lesão traqueal mais prevalente em 14 (27,5%) pacientes. CONCLUSÃO: a broncoscopia flexível evidenciou um número elevado de lesões laringotraqueais, sendo mais prevalentes a lesão de pregas vocais na laringe e o granuloma na traqueia, que contribuiu para aumentar a segurança do procedimento de decanulação.

Frecuencia de lesión de la vía aérea identificada por broncoscopia en recién nacidos con intubación endotraqueal prolongada en una unidad de cuidados intensivos neonatales de tercer nivel / Frequency and type of airway injury identified by bronchoscopic examination in newborns with prolonged endotracheal intubation in a neonatal intensive care unit

Introducción. La intubación endotraqueal y la ventilación mecánica son recursos que se utilizan frecuentemente en la Unidad de Cuidados Intensivos Neonatales. Sin embargo, se ha observado que elevan significativamente la mortalidad, dado que se presentan complicaciones. Por tanto, el objetivo de este trabajo fue reportar la frecuencia y el tipo de lesiones de la vía aérea en recién nacidos con intubación endotraqueal prolongada a quienes se les realizó broncoscopia. Métodos. Se incluyeron 150 recién nacidos con tiempo de intubación endotraqueal ≥ 5 días a quienes se les realizó broncoscopia. Se registraron las siguientes variables: edad gestacional, peso al nacer, indicación de la intubación, tamaño del tubo endotraqueal, número de reintubaciones, tiempo de intubación, indicación de la broncoscopia, hallazgos de la broncoscopia, tipo de tratamiento y número de broncoscopias. Resultados. La principal indicación de la broncoscopia fue la atelectasia persistente o recidivante. Del total de los pacientes, 96% presentaron alguna alteración de la vía aérea. Predominaron las lesiones inflamatorias (67.3%), seguidas de malacia (39.3%) y estenosis (28.7%). Las estructuras anatómicas más afectadas fueron los bronquios (31.6%), la laringe (24%) y la tráquea (22%). En 126 pacientes se indicó tratamiento médico; los esteroides se utilizaron con mayor frecuencia. Además del tratamiento médico, a 21 pacientes (14%) se les realizó dilatación bajo broncoscopia y a 7 (4.6%), traqueostomía. Conclusiones. Las lesiones más frecuentes fueron de tipo inflamatorio. La atelectasia persistente fue la principal manifestación clínica, por lo que se sugiere considerarla para que, durante la exploración broncoscópica, se descarte lesión de la vía aérea en recién nacidos con intubación endotraqueal prolongada.

Background. Endotracheal intubation and mechanical ventilation are frequently use resources in the Neonatal Intensive Care Unit. Higher mortality has been observed as a result of complications. We undertook this study to report the frequency and type of airway injury in newborns with prolonged endotracheal intubation who underwent bronchoscopy examination. methods. Newborns (n = 150) who were intubated endotracheally for ≥ 5 consecutive days and who underwent bronchoscopy were included. We recorded the following variables: gestational age, birth weight, indications for intubation, size of endotracheal tube, number of reintubations, intubation length, indication for bronchoscopy, bronchoscopic findings, type of treatment for airway injury, and number of bronchoscopies. Results. The main indication for bronchoscopy was atelectasis (persistent and/or recurrent); 96% of newborns had at least one injury. The most frequent were inflammatory type (67.3%), malacia (39.3%), and stenosis (28.7%). The most injured anatomic structures were the bronchi (31.6%), larynx (24%), and trachea (22%). For 126 patients, primary medical treatment was steroids. For 21 patients (14%), dilatation was performed under bronchoscopy; and for 7 (4.6%) patients, tracheostomy was performed. Conclusions. The most frequent injuries were inflammatory-type. Persistent atelectasis was the principal clinical manifestation; therefore, it should be considered as an indication of bronchoscopic exploration to identify airway injury in newborns with prolonged endotracheal intubation.

Tracheobronchial compression by right-sided aortic arch in a middle aged male.

Exertional dyspnoea is a common symptom among middle-aged population. Diagnostic evaluation of such patients is often challenging and confusing. We report a patient presenting with exertional dyspnoea and an obstructive ventilatory defect on spirometry that was refractory to bronchodilator therapy. Careful review of the chest radiograph and spirometry pointed towards variable intra-thoracic airways obstruction as a cause of dyspnoea. Contrast enhanced computed tomography (CECT) of the thorax and bronchoscopy established the diagnosis of a right-sided aortic arch resulting in tracheobronchial compression and tracheomalacia.

Progress in etiology, diagnosis and treatment of neonatal tracheal stenosis / 国际儿科学杂志

Tracheal stenosis is defined as a narrowing of the tracheal lumen,commonly caused by different factors.The etiology are not clear,but are closely linked with vascular tings compressed tracheal,tracheomalacia and tracheal remolding.About the diagnosis and treatment in infants with tracheal stenosis,imaging techniques,especially bronchoscopy and CT,play an important role,and surgery is often choosed.Currently,stent is a development direction of medicine.