Los estudios por imágenes en la evaluación del niño con estridor / Imaging studies in evaluating children with stridor

El estridor es un síntoma de obstrucción de la vía aérea superior y puede ser resultado de causas congénitas o adquiridas. El diagnóstico suele ser clínico. Si es necesaria una investigación adicional para el diagnóstico diferencial, la endoscopia es el método de elección en la mayoría de los casos. Los estudios por imágenes son complementarios a la endoscopia. Permiten evaluar la patología laríngea y traqueobronquial, las compresiones extrínsecas de la vía aérea por tumores o malformaciones vasculares y definir la localización, extensión y características de una lesión. Son útiles en casos de duda diagnóstica y cuando la endoscopia no está disponible. Es fundamental comprender la anatomía y fisiopatología del tracto respiratorio, y ser conscientes de las indicaciones y limitaciones de los exámenes complementarios para el diagnóstico adecuado. Se describen las diferentes modalidades de imágenes disponibles para evaluar el estridor en pediatría y se discuten sus ventajas.

Stridor is a symptom of upper airway obstruction and may result from congenital or acquired causes. The diagnosis is usually clinical. If further investigation is necessary for differential diagnosis, endoscopy is the method of choice in most cases. Imaging studies are complementary to endoscopy. They allow evaluation of laryngeal and tracheobronchial pathology and extrinsic airway compressions due to tumors or vascular malformations and define a lesion's location, extent, and characteristics. They are helpful in cases of diagnostic doubt and when endoscopy is unavailable. It is essential to understand the anatomy and pathophysiology of the respiratory tract and to be aware of the indications and limitations of complementary examinations for proper diagnosis. The different imaging modalities available to evaluate stridor in pediatrics are described, and their advantages are discussed.

Bronquitis plástica. Caso clínico interesante / Plastic Bronchitis. Interesting Case Report

La bronquitis plástica es una enfermedad infrecuente y poco estudiada. Se caracteriza por la obstrucción parcial o total de la vía aérea inferior por moldes o yesos gomosos y firmes, compuestos por múltiples sustancias como fibrina, mucina y otros, que se acumulan en la luz bronquial. En la actualidad, no hay un consenso de la fisiopatología real. Puede presentarse con síntomas leves como tos, sibilancias y disnea, hasta eventos fatales de insuficiencia respiratoria. Se clasifican en tipo I (inflamatorios) y tipo II (acelulares). La presencia de la bronquitis plástica es una complicación de varias enfermedades y está relacionada con procedimientos correctivos de cardiopatías congénitas (procedimiento de Fontan). El diagnóstico se hace a través de la identificación de los yesos bronquiales, ya sea cuando el paciente los expectora o por broncoscopía. Se han utilizado múltiples terapias que solo tienen evidencias anecdóticas. En los últimos años se han observado buenos resultados con el uso de heparinas, así como el alteplasa nebulizado e instilado por broncoscopia.

Plastic bronchitis is a rare and little-studied disease. It is characterized by partial or total obstruction of the lower airway by rubbery and firm molds or plasters, made up of multiple substances that accumulate in the bronchial lumen. Currently, there is no consensus on real pathophysiology. It can present itself with mild symptoms such as cough, wheezing and dyspnea, to fatal events of respiratory failure. They are classified into type I (inflammatory) and type II (acellular). The presence of plastic bronchitis is a complication of several diseases and in corrective procedures for congenital heart disease (Fontan procedure). Diagnosis is made by identifying bronchial casts, either by the patient expectorating them or by bronchoscopy. Multiple therapies have been used that only have anecdotal evidence. In recent years, good results have been observed with the use of heparins and tPA nebulized and instilled by bronchoscop.

Obstrucción laríngea inducible (OLI): una revisión actualizada de la literatura / Induced laryngeal obstruction (ILO): an updated literature review

La obstrucción laríngea inducible se ha descrito como un trastorno de la respiración que se presenta, habitualmente, como dificultad respiratoria aguda por aducción anormal de los pliegues vocales, típicamente, durante la inspiración. Es más frecuente en mujeres y adultos, que en adolescentes. Es difícil estimar la incidencia exacta dada la heterogeneidad de los criterios diagnósticos y nomenclatura, asociado al frecuente subdiagnóstico de esta entidad. Por ello, en la literatura se ha reportado la prevalencia de acuerdo con las subpoblaciones de pacientes, describiendo que alrededor de un 2,8% de los pacientes que consultan en el servicio de urgencia por disnea podría corresponder a esta patología. El diagnóstico es eminentemente clínico, con confirmación mediante laringoscopia flexible. Se apoya en exámenes de función respiratoria, especialmente para descartar otras patologías pulmonares que expliquen el cuadro. El tratamiento es sencillo y, suele ser exitoso, tanto en situaciones agudas como crónicas. Sin embargo, se ha descrito, frecuentemente, un retraso en el diagnóstico, debido a desconocimiento de esta patología.

Induced laryngeal obstruction has been described as a respiratory disorder, usually presenting as an acute respiratory distress due to abnormal adduction of the vocal folds, typically during inspiration. It is more frequent in women and adults, than adolescents. It is difficult to estimate its exact incidence given the heterogeneity of the diagnostic criteria and nomenclature, together with its common underdiagnosis. Hence, studies have reported its prevalence according to the subpopulations within this entity, with a prevalence of 2.8% in patients who consult in the emergency room for dyspnea. The diagnosis is based upon clinical presentation, confirmed by flexible laryngoscopy, and supported by respiratory function exams to rule out other pulmonary diseases with similar symptoms. Its treatment is simple and usually successful, in both acute and chronic situations. However, a delay in the diagnosis has been frequently described, due to unawareness of this disorder.

CHAOS: síndrome de obstrucción congénita de las vías aéreas superiores / CHAOS: congenital high airway obstruction syndrome

Resumen El síndrome de obstrucción congénita de vías áreas superiores (CHAOS) es una condición que se caracteriza por la existencia de una obstrucción en las vías áreas altas en el feto, la cual puede ser parcial o completa. Comúnmente es una situación incompatible con la vida, por lo que su diagnóstico prenatal es importante considerando el pronóstico y los diferentes manejos prenatales y posnatales que existen. Presentamos un caso de CHAOS diagnosticado en la semana 21, con una breve revisión de la literatura sobre su diagnóstico, pronóstico y alternativas terapéuticas.

Abstract Congenital high airway obstruction syndrome (CHAOS) is a condition characterized by the existence of an obstruction of the fetal upper airways, which may be partial or complete. It is commonly incompatible with life, so its prenatal diagnosis is important due to the prognosis and the recently described pre and postnatal management options. We present a case of CHAOS in a pregnancy of 21 weeks with a brief review of the current literature about its diagnosis, prognosis and therapeutic alternatives.

Spirometry for the diagnosis of airway obstruction in patients with risk factors for COPD: the GOLD and lower limit of normal criteria / Espirometria para o diagnóstico de obstrução das vias aéreas em pacientes com fatores de risco para DPOC: os critérios GOLD e limite inferior da normalidade

ABSTRACT Objective: The identification of persistent airway obstruction is key to making a diagnosis of COPD. The GOLD guidelines suggest a fixed criterion-a post-bronchodilator FEV1/FVC ratio < 70%-to define obstruction, although other guidelines suggest that a post-bronchodilator FEV1/FVC ratio < the lower limit of normal (LLN) is the most accurate criterion. Methods: This was an observational study of individuals ≥ 40 years of age with risk factors for COPD who were referred to our pulmonary function laboratory for spirometry. Respiratory symptoms were also recorded. We calculated the prevalence of airway obstruction and of no airway obstruction, according to the GOLD criterion (GOLD+ and GOLD−, respectively) and according to the LLN criterion (LLN+ and LLN−, respectively). We also evaluated the level of agreement between the two criteria. Results: A total of 241 individuals were included. Airway obstruction was identified according to the GOLD criterion in 42 individuals (17.4%) and according to the LLN criterion in 23 (9.5%). The overall level of agreement between the two criteria was good (k = 0.67; 95% CI: 0.52-0.81), although it was lower among the individuals ≥ 70 years of age (k = 0.42; 95% CI: 0.12-0.72). The proportion of obese individuals was lower in the GOLD+/LLN+ category than in the GOLD+/LLN− category (p = 0.03), as was the median DLCO (p = 0.04). Conclusions: The use of the GOLD criterion appears to be associated with a higher prevalence of COPD. The agreement between the GOLD and LLN criteria also appears to be good, albeit weaker in older individuals. The use of different criteria to define airway obstruction seems to identify individuals with different characteristics. It is essential to understand the clinical meaning of discordance between such criteria. Until more data are available, we recommend a holistic, individualized approach to, as well as close follow-up of, patients with discordant results for airway obstruction.

RESUMO Objetivo: A identificação de obstrução persistente das vias aéreas é fundamental para o diagnóstico de DPOC. As diretrizes da GOLD sugerem um critério fixo - relação VEF1/CVF pós-broncodilatador < 70% - para definir obstrução, embora outras diretrizes sugiram que a relação VEF1/CVF pós-broncodilatador < o limite inferior da normalidade (LIN) é o critério mais preciso. Métodos: Estudo observacional com indivíduos ≥ 40 anos de idade com fatores de risco para DPOC encaminhados ao nosso laboratório de função pulmonar para espirometria. Também foram registrados sintomas respiratórios. Calculamos a prevalência de obstrução e de ausência de obstrução das vias aéreas segundo o critério GOLD (GOLD+ e GOLD−, respectivamente) e segundo o critério LIN (LIN+ e LIN−, respectivamente). Avaliamos também o grau de concordância entre os dois critérios. Resultados: Foram incluídos 241 indivíduos. Obstrução das vias aéreas foi identificada segundo o critério GOLD em 42 indivíduos (17,4%) e segundo o critério LIN em 23 (9,5%). A concordância global entre os dois critérios foi boa (k = 0,67; IC95%: 0,52-0,81), embora tenha sido menor entre os indivíduos ≥ 70 anos de idade (k = 0,42; IC95%: 0,12-0,72). A proporção de obesos foi menor na categoria GOLD+/LIN+ do que na categoria GOLD+/LIN− (p = 0,03), assim como a mediana de DLCO (p = 0,04). Conclusões: A utilização do critério GOLD parece estar associada a uma maior prevalência de DPOC. A concordância entre os critérios GOLD e LIN também parece ser boa, embora seja mais fraca em indivíduos mais velhos. A utilização de diferentes critérios para definir obstrução das vias aéreas parece identificar indivíduos com diferentes características. É essencial compreender o significado clínico da discordância entre esses critérios. Até que mais dados estejam disponíveis, recomendamos uma abordagem holística e individualizada e também um acompanhamento cuidadoso dos pacientes com resultados discordantes para obstrução das vias aéreas.

El niño con estridor persistente / The child with persistent stridor

El estridor es un ruido respiratorio anormal generado por obstrucción o colapso de la vía aérea laringotraqueal, de manera aguda o de evolución crónica. Existen distintas causas tanto congénitas como adquiridas capaces de producir dificultad respiratoria, que puede llegar a ser grave y con potencial riesgo vital. El diagnóstico clínico del paciente con estridor persistente debe ser complementado con un estudio endoscópico de la vía aérea y en ocasiones con imágenes, para intentar determinar el o los sitios comprometidos y posibles malformaciones asociadas. La indicación de tratamiento debe ser individualizada, considerando el estado general del paciente, las etiologías responsables, el im pacto sobre la respiración y la deglución, el pronóstico y la capacidad técnica del equipo tratante, entre otras. Las alternativas pueden incluir observación, medidas no farmacológicas, medicamentos locales o sistémicos, procedimientos endoscópicos, cirugías abiertas, o bien la instalación de una traqueostomía de manera temporal o como manejo definitivo. El objetivo de esta revisión es entregar un adecuado conocimiento de la fisiopatología y la etiopatogenia del estridor pediátrico persistente, fundamental para el correcto manejo de estos pacientes complejos, que debiera realizarse idealmente en un contexto multidisciplinario.

Stridor is an abnormal respiratory sound caused by obstruction or collapse of the laryngotracheal airway, either acutely or chronically. There are different causes, both congenital and acquired, that can produce shortness of breath which may be severe and potentially life-threatening. The clini cal diagnosis must be complemented with an endoscopic airway assessment and sometimes with imaging, to try to determine the areas involved and possible associated malformations. Treatment should be individualized, considering the patient's overall condition, stridor etiology, its impact on breathing and swallowing, prognosis, and technical capacity of the managing team, among others. Alternatives may include observation, non-pharmacological measures, local or systemic medications, endoscopic and open surgeries, or a temporary or long-term tracheostomy. A thorough understan ding of the pathophysiology and etiopathogenesis of persistent pediatric stridor is essential for the correct management of these complex patients, ideally in a multidisciplinary manner.

"Ortoglossopelveplastia" e o algoritmo de sua utilização na sequência de Pierre-Robin / "Orthoglossopelveplasty" and the algorithm for its use in the Pierre Robin sequence

Introdução: Muitos pacientes portadores de sequência de Pierre Robin (micrognatia, glossoptose e obstrução de via aérea) apresentam o músculo genioglosso alterado, encurtado e retrátil, que impede a protração lingual, mantendo a parte anterior da língua verticalizada e seu volume deslocado em direção posterior. Isso pode corroborar para obstrução supraglótica, dificuldade alimentar e inversão das forças de estímulo do crescimento do corpo mandibular. Métodos: Estudo retrospectivo de pacientes com Pierre Robin tratados entre 2012 e 2017 pela equipe, com descrição da "ortoglossopelveplastia", que propõe uma modificação na glossopexia, soltando o genioglosso anômalo da sua inserção, liberando a língua para elevar seu terço anterior e avançar o volume de sua base, sendo auxiliada por ponto de tração da base lingual à sínfise mandibular. Apresentamos um algoritmo de tratamento proposto que prioriza a necessidade desta cirurgia, associada ou não à distração mandibular, de acordo com a gravidade da dificuldade respiratória e/ou alimentar. Resultados: São apresentados 12 casos de obstrução da orofaringe atendidos de 2012 a 2017, discutem-se suas prioridades, a ortoglossopelveplastia e se aplica o algoritmo proposto. Conclusão: A reorganização anatômica da musculatura em uma posição anteriorizada correta proporciona protração e funcionalidade à língua, com desobstrução da via aérea na orofaringe, melhora da função alimentar e do desenvolvimento mandibular, com baixa morbidade cirúrgica e poucas complicações.

Introduction: Several patients with the Pierre Robin sequence (micrognathia, glossoptosis, and airway obstruction) have an altered, shortened, and retractable genioglossus muscle that prevents protraction of the tongue and keeps the anterior part of the tongue vertical and its volume posteriorly displaced. This can contribute to supraglottic obstruction, feeding difficulty, and inversion of the growth stimulation forces of the mandibular body. Methods: A retrospective study of patients with the Pierre Robin sequence treated between 2012 and 2017 with "orthoglossopelveplasty," which includes modification of glossopexy, releasing the anomalous genioglossus of its insertion and releasing the tongue to raise its anterior third and advance the volume of its base using a traction suture of the tongue base to the mandible symphysis. We present a treatment algorithm that prioritizes the need for surgery associated, or not, with mandibular distraction in accordance with respiratory and/or feeding difficulty severity. Results: Twelve cases of oropharyngeal obstruction treated from 2012 to 2017 are presented, their priorities and orthoglossopleoplasty are discussed, and the proposed algorithm is applied. Conclusion: Anatomical reorganization of the musculature in a correct anterior position provides protraction and functionality to the tongue, clears the airway in the oropharynx, and improves the feeding function and mandibular development, with low surgical morbidity rates and few complications.

Controversies and limitations in the diagnosis of chronic obstructive pulmonary disease

Abstract Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality worldwide. While the cut-off point to define airflow obstruction has been controversial, it is widely accepted that the spirometry test is vital, as well as performing it after using a bronchodilator. The 6-second spirometry and the forced expiratory volume in 1 second/forced expiratory volume in 6 seconds (FEV1/FEV6) have demonstrated validity for defining obstruction, and it would be advisable to incorporate them in the definitions of obstruction. Another relevant issue is that spirometry with borderline obstruction can vary over time, changing to above or below the cut-off point. Thus, surveillance should be considered over time, repeating the spirometry to have a greater certainty in the diagnosis. The objective of this article was to conduct an in-depth review of the controversies in the diagnosis of COPD. During the past years, COPD definition has been updated in different times; however, it is now considered more as a complex syndrome with systemic participation, requiring a multidimensional assessment, and not only a spirometry.

Correlation between obstructive apnea syndrome and difficult airway in ENT surgery / Correlação entre síndrome da apneia obstrutiva e via aérea difícil na cirurgia otorrinolaringológica

Abstract Introduction: ENT patients with obstructive sleep apnea syndrome have a tendency of collapsing the upper airways in addition to anatomical obstacles. Obstructive sleep apnea syndrome is related to the increased risk of difficult airway and also increased perioperative complications. In order to identify these patients in the preoperative period, the STOP Bang questionnaire has been highlighted because it is summarized and easy to apply. Objectives: Evaluate through the STOP Bang questionnaire whether patients undergoing ENT surgery with a diagnosis of obstructive sleep apnea syndrome have a higher risk of complications, particularly the occurrence of difficult airway. Casuistry and methods: Measurements of anatomical parameters for difficult airway and questionnaire application for clinical prediction of obstructive sleep apnea syndrome were performed in 48 patients with a previous polysomnographic study. Results: The sample detected difficult airway in about 18.7% of patients, all of them with obstructive sleep apnea syndrome. This group had older age, cervical circumference > 40 cm, ASA II and Cormack III/IV. Patients with obstructive sleep apnea syndrome had higher body mass index, cervical circumference, and frequent apnea. In subgroup analysis, the group with severe obstructive sleep apnea syndrome showed a significantly higher SB score compared to patients without this syndrome or with a mild/moderate obstructive sleep apnea syndrome. Conclusions: The STOP Bang questionnaire was not able to predict difficult airway and mild obstructive sleep apnea syndrome, but it identified marked obstructive sleep apnea syndrome. All patients with difficult airway had moderate and marked obstructive sleep apnea syndrome, although this syndrome did not involve difficult airway. The variables Cormack III/IV and BMI greater than 35 kg.m−2 were able to predict difficult airway and obstructive sleep apnea syndrome, respectively.

Resumo Introdução: Os pacientes cirúrgicos otorrinolaringológicos portadores da síndrome da apneia obstrutiva do sono apresentam, além de obstáculos anatômicos, tendência ao colapso das vias aéreas superiores. Síndrome da apneia obstrutiva do sono está relacionada ao maior risco de via aérea difícil e também aumento de complicações perioperatórias. A fim de se identificar esses pacientes no período pré-operatório, tem se destacado o questionário STOP Bang, por ser resumido e de fácil aplicação. Objetivos: Avaliar se pacientes submetidos à cirurgia otorrinolaringológica com diagnóstico de síndrome da apneia obstrutiva do sono pelo questionário STOP Bang apresentariam maior risco de complicações, particularmente ocorrência de via aérea difícil. Casuística e métodos: Feitas medidas de parâmetros anatômicos para via aérea difícil e administrado questionário para predição clínica de síndrome da apneia obstrutiva do sono em 48 pacientes com estudo polissonográfico prévio. Resultados: A amostra detectou via aérea difícil em 18,7% dos pacientes, todos portadores de síndrome da apneia obstrutiva do sono. Esse grupo apresentava maior idade, circunferência cervical > 40 cm, ASA II e Cormack III/IV. Os pacientes com síndrome da apneia obstrutiva do sono apresentaram maior índice de massa corpórea, circunferência cervical e frequência de apneia observada. Na análise de subgrupos, o grupo com síndrome da apneia obstrutiva do sono acentuada mostrou significantemente maior pontuação no SB quando comparado com pacientes sem síndrome da apneia obstrutiva do sono ou com síndrome da apneia obstrutiva do sono leve/moderada. Conclusões: O questionário STOP Bang não foi capaz de predizer via aérea difícil e nem síndrome da apneia obstrutiva do sono leve e moderada, mas identificou síndrome da apneia obstrutiva do sono acentuada. Todos pacientes com via aérea difícil apresentaram síndrome da apneia obstrutiva do sono moderada e acentuada, apesar desta síndrome não implicar em via aérea difícil. As variáveis Cormack III/IV e IMC maior do que 35 Kg.m-2 foram capazes de predizer via aérea difícil e síndrome da apneia obstrutiva do sono respectivamente.

Evaluación de la disnea asociada al ejercicio / Exercise-induced dyspnea evaluation

Exercise-induced dyspnea is a common pediatric question but difficult to address since usually symptoms are described ambiguously by the child or parents. Most of times dyspnea is secondary to poor training but sometimes may be due to an underlying condition like exercise-induced bronchoconstriction or vocal cord dysfunction. To provide clinicians with a practical approach about exercise-induced dyspnea we have review pathogenesis and clinical characteristics of respiratory diseases and proposed an algorithm for study.

Frecuentemente nos vemos enfrentados a evaluar un niño con síntomas vagos asociados al ejercicio que el mismo paciente o sus padres describen como ahogo o sensación de pecho apretado. La mayoría de las veces se trata de cansancio atribuible al ejercicio normal que solo refleja pobre condicionamiento físico del individuo; sin embargo, este cansancio puede ser desproporcionado al esfuerzo, lo que obliga a considerar enfermedades comunes como asma o poco comunes como disfunción de cuerdas vocales. El objetivo de esta revisión es actualizar el conocimiento aquellas enfermedades respiratorias que forman parte del diagnóstico diferencial de la disnea asociada al ejercicio y proponer un algoritmo de estudio que permita un acercamiento práctico según causas de origen.

Estridor persistente / Persistent stridor

Stridor is a musical, often high-pitched sound produced by a rapid, turbulent flow of air through a narrowed segment of the large airways. The cause of stridor can be located anywhere in the extrathoracic airway (nose, pharynx, larynx, and trachea) or the intrathoracic airway (tracheobronchial tree). Stridor may be acute (caused by inflammation/infection or foreign body inhalation) or chronic. It may be congenital or acquired. Various congenital and acquired disorders prevail in neonates, infants, children, and adolescents, and need to be distinguished. Medical history and age of the child, together with physical examination, often allow a presumptive diagnosis. Further tests may be necessary to establish a definite diagnosis, and flexible airway endoscopy is the diagnostic procedure of choice in most circumstances

Estridor es un sonido musical, de alta frecuencia, generado por el paso de un flujo de aire turbulento en zonas con calibre disminuido de la vía aérea de mayor tamaño.La causa del estridor puede estar localizado en cualquier lugar de la vía aérea extratorácica (nariz, faringe, laringe y tráquea) o la vía aérea intratorácica (árbol traqueobronquial). El estridor puede ser agudo (causado por inflamación/infección o aspiración de cuerpos extraños) o crónica. Puede ser congénita o adquirida. Varios trastornos congénitos y adquiridos prevalecen en neonatos, lactantes, niños y adolescentes, y tienen que ser distinguidos. La historia clínica, edad del niño y examen físico a menudo permiten un diagnóstico presuntivo. Puede requerirse mayor estudio para establecer un diagnóstico definitivo, y la endoscopia flexible de la vía aérea es el procedimiento diagnóstico de elección en la mayoría de las circunstancias

Análisis factorial exploratorio de una escala de gravedad de obstrucción bronquial evaluada en menores de tres años, Chile, 2015 / Exploratory factor analysis of a score for grading the severity of bronchial obstruction evaluated in children younger than 3 years old, Chile, 2015

Introducción. La escala de Tal modificada es utilizada en Chile para determinar la gravedad de la obstrucción bronquial. Existen informes de su validez; sin embargo, carece de antecedentes del análisis de su estructura como escala para cuantificar de forma significativa la gravedad de la obstrucción bronquial. Objetivo. Identificar el patrón de relación entre los ítems de la escala y la dimensión gravedad de la obstrucción bronquial en una muestra de menores de tres años que consultan en dos centros de salud de la provincia de Concepción, Chile. Método. Análisis factorial exploratorio. Selección no aleatoria y voluntaria de participantes, menores de 36 meses, agosto-noviembre de 2015. Evaluados de manera independiente por médico y kinesiólogo, en tiempo seguido. Se aplican medidas de tendencia central, análisis factorial exploratorio, por subgrupo de menores y mayores de 6 meses, y consistencia interna. Resultados. 204 mediciones a 102 menores. Con una varianza explicada de 39%, los ítems se dirigen a dos conceptos diferentes, un factor que agrupa frecuencia respiratoria, sibilancia y retracción, y otro que solo lo determina cianosis, con alfa de Cronbach de 0, 5. Al extraer cianosis del análisis, muestra matriz monofactorial con 38% de varianza total explicada y consistencia interna de 0, 62. Conclusiones. Por medio de sus ítems, la estructura de la escala no se ajusta adecuadamente para esta muestra. Cianosis se muestra como un ítem disociado en la estructura. Al ajustar el modelo a solo tres ítems, la estabilidad del alfa como medida de consistencia interna aumenta, pero a un valor cuestionable, lo que, sin duda, variará al ser aplicada en otra muestra.

Introduction. The modified Tal's score has been used in Chile to determine the severity of bronchial obstruction. Its validity has been reported already; however, its structure as a scale to significantly quantify the severity of bronchial obstruction has not been analyzed. Objective. To identify the relationship pattern among the score's items and the severity of bronchial obstruction in a sample of children younger than 3 years seen in two health care centers in the province of Concepción, Chile. Method. Exploratory factor analysis. Nonrandom, voluntary selection of participants youngerthan36months, August-November 2015. Participants were assessed independently and subsequently by a physician and a physical therapist. The following measurements were applied: central tendency, exploratory factor analysis, subgroups of participants younger and older than 6 months, and internal consistency. Results. A total of 204 measurements were done in 102 children. With a 39% explained variance, items incline towards to two different concepts: one factor groups respiratory rate, wheezing, and retractions, and the other determines only cyanosis, with a Cronbach's alpha of 0.5. Once cyanosis is removed from the analysis, the original one-factor matrix sample shows a 38% total explained variance and a 0.62 internal consistency. Conclusions. Based on its items, the score's structure does not fit adequately to this sample. Cyanosis appears as a dissociated item within the structure. Once the model is adjusted to only 3 items, the stability of Chronbach's alpha as a measure of internal consistency increases but at an objectionable value, which will undoubtedly vary once it is applied to a different sample.

Procedimiento EXIT o terapia intraparto ex-útero: artículo de revisión / Exit procedure or Ex - Uterus intrapartum therapy: review

El compromiso obstructivo de la vía aérea en el recién nacido se asocia a hipoxia, acidosis, morbilidad neurológica y alta mortalidad. La causa más frecuente de obstrucción son los tumores cervicales y la obstrucción congénita de la vía aérea. Las lesiones cervicales más comunes son las malformaciones linfáticas, teratoma, higroma quístico, hemangiomas, bocio, quistes de plexo braquial, neuroblastomas y hemartomas. El preparar un nacimiento en el que obstetras, pediatras, neonatólogos, cardiólogos, anestesistas y cirujanos infantiles se coordinen con la intención de obtener una vía aérea permeable y segura, mientras permanece intacta la circulación placentaria, es lo que entendemos como terapia fetal intraparto ex útero o EXIT. Este manejo puede cambiar el pronóstico en pacientes críticos, en los que sin una adecuada preparación, la obstrucción de vía aérea se transformaría en una emergencia para el recién nacido.

The commitment obstructive airway in the newborn is associated with hypoxia, acidosis, neurologic morbidity and high mortality. The most common cause of obstruction are cervical tumors and congenital obstruction of the airway. The most common injuries are cervical lymphatic malformations, teratoma, cystic hygroma, hemangioma, goiter, brachial plexus cysts, neuroblastomas and hamartomas. Preparing a birth in which obstetricians, pediatricians, neonatologists, cardiologists, anesthesiologists and pediatrics surgeons are coordinated with the intention of obtaining a patent and safe airway, while remaining intact placental circulation, it is what we understand as intrapartum fetal therapy ex - uterus or EXIT. This management can change the prognosis in critically ill patients, in which without adequate preparation, airway obstruction would become an emergency for the newborn.

Cuerpos extraños en vía respiratoria: experiencia de 15 años. Universo estadístico de la provincia de Mendoza, Argentina / Foreign bodies in airway: experience of 15 years. Statistical universe of the province of Mendoza, Argentina

Objetivo. Presentar la experiencia de 15 años con extracción de cuerpos extraños. Se describen 277 procedimientos broncoscópicos realizados por sospecha de aspiración de cuerpo extraño desde diciembre de 1992 a diciembre de 2008. En 165 CE encontrados, se presentan las conclusiones derivadas de esa experiencia. Material y método. Rango de edades: 6 meses a 24 años. Se usó broncofibroscopio Pentax u Olympus, y broncoscopio rígido Storz. Resultados. El 69,70% de los pacientes tenía entre 6 a 25 meses; el 79% de los CE fueron extraídos antes de la semana de derivación por SP; el 40% correspondió a “semillas”; el síntoma más frecuente fue el SP: 91,5%, y la tos en el 85,5% de los casos; la radiología pulmonar fue normal en el 56,36%. Conclusiones. Debe ser un procedimiento centralizado por regiones que permita mantener la manualidad del operador. El centro de broncoscopía debe contar con la tecnología apropiada, en función de las edades que abarca. Deben ser más difundidas las características de la alimentación en los primeros 3 años de vida - edad más riesgosa- y los alimentos a evitar.

Objective. Experience of 15 years with bronchoscopic foreign bodies (FB) removal is presented 277 bronchoscopies for “probable foreign body aspiration” were per fomed from December 1992 to December 2008. In 165 cases a F.B. was found and conclusions are presented. Population. age range 6 mo to 24 yo. Results. 69,70% of patients were between 6 and 25 m.old.; 79% of F.B. were removed before 1 week of referral for suffocation event; 40% were classified as “seeds”; most frequent symptom was suffocation event in 91,5% and cough in 85,5% of cases; lung radiology was normal in 56%. F.B. successful extraction during first procedure was 154 cases out of 165 F.B. Complications were seen in 6,6%. Conclusions. F.B. extraction should be a procedure performed by geographic regions according to experience and population served. The F.B. extraction center should have instruments appropiate for ages and body sizes of its population. Feeding precautions and food preparation, during first 3 years of life, must be emphasized.

High-Sensitivity C-Reactive Protein Can Reflect Small Airway Obstruction in Childhood Asthma

PURPOSE: High-sensitivity assays enabled the identification of C-reactive protein (hs-CRP) at levels that were previously undetectable. We aimed to determine if hs-CRP could reflect airway inflammation in children, by comparing hs-CRP with spirometry and impulse oscillometry (IOS) parameters and symptomatic severities. MATERIALS AND METHODS: A total of 276 asthmatic children who visited Severance Children's Hospital from 2012-2014 were enrolled. Serum hs-CRP and pulmonary function tests were performed on the same day. Patients were divided into hs-CRP positive and negative groups (cut-off value, 3.0 mg/L). RESULTS: Of the 276 asthmatic children [median age 7.5 (5.9/10.1) years, 171 boys (62%)], 39 were hs-CRP positive and 237 were negative. Regarding spirometry parameters, we observed significant differences in maximum mid-expiratory flow, % predicted (FEF25-75) (p=0.010) between hs-CRP positive and negative groups, and a negative correlation between FEF25-75 and hs-CRP. There were significant differences in the reactance area (AX) (p=0.046), difference between resistance at 5 Hz and 20 Hz (R5-R20) (p=0.027), resistance at 5 Hz, % predicted (R5) (p=0.027), and reactance at 5 Hz, % predicted (X5) (p=0.041) between hs-CRP positive and negative groups. There were significant positive correlations between hs-CRP and R5 (r=0.163, p=0.008), and X5 (r=0.164, p=0.007). Spirometry and IOS parameters had more relevance in patients with higher blood neutrophil levels in comparison to hs-CRP. CONCLUSION: Hs-CRP showed significant correlation with FEF25-75, R5, and X5. It can reflect small airway obstruction in childhood asthma, and it is more prominent in neutrophil dominant inflammation.

Drug-induced sleep endoscopy in the identification of obstruction sites in patients with obstructive sleep apnea: a systematic review / Endoscopia do sono induzido por droga na identificação do(s) sítio(s) de obstrução em pacientes com apneia obstrutiva do sono: revisão sistemática

INTRODUCTION: Obstructive sleep apnea syndrome has multifactorial causes. Although indications for surgery are evaluated by well-known diagnostic tests in the awake state, these do not always correlate with satisfactory surgical results.OBJECTIVE: To undertake a systematic review on endoscopy during sleep, as one element of the diagnosis routine, aiming to identify upper airway obstruction sites in adult patients with OSAS.METHODS: By means of electronic databases, a systematic review was performed of studies using drug-induced sleep endoscopy to identify obstruction sites in patients with OSAS.RESULTS: Ten articles were selected that demonstrated the importance of identifying multilevel obstruction, especially in relation to retrolingual and laryngeal collapse in OSAS.CONCLUSION: DISE is an additional method to reveal obstruction sites that have not been detected in awake patients.

INTRODUÇÃO: A síndrome de apneia obstrutiva do sono (SAOS) apresenta causas multifatoriais com indicação cirúrgica avaliada por meio dos exames diagnósticos consagrados em vigília, que podem, porém, não assegurar resultados cirúrgicos satisfatórios.OBJETIVO: Realizar uma revisão sistemática sobre a endoscopia do sono, como parte da rotina diagnóstica, em pacientes adultos com SAOS a fim de identificar os sítios de obstrução da via aérea superior.MÉTODO: Revisão sistemática da literatura (RSL), a partir de bases de dados eletrônicas, dos estudos que identificaram os sítios de obstrução em pacientes com SAOS a partir da endoscopia do sono induzido por droga (DISE).RESULTADOS: Foram selecionados dez artigos que demonstraram relevância na identificação dos multiníveis de obstrução, principalmente em relação ao colapso retro-lingual e laríngeo na SAOS.CONCLUSÃO: DISE é um método adicional na identificação de sítios de obstrução não detectáveis no paciente em vigília.