Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report

Abstract Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

Algoritmo para el manejo de la obstrucción laríngea en pediatría / Algorithm for the management of laryngeal obstruction in pediatrics

La laringe se localiza en la encrucijada aerodigestiva; cualquier patología que la comprometa tendrá repercusión en la respiración, la deglución y/o la voz. Se divide en tres regiones: la supraglotis (comprende la epiglotis, las bandas ventriculares y los ventrículos laríngeos), la glotis (espacio limitado por las cuerdas vocales) y la subglotis (zona más estrecha de la vía aérea pediátrica y único punto rodeado en su totalidad por cartílago: el anillo cricoides). La obstrucción laríngea se puede presentar como una condición aguda potencialmente fatal o como un proceso crónico. El síntoma principal es el estridor inspiratorio o bifásico. La etiología varía mucho según la edad y puede ser de origen congénito, inflamatorio, infeccioso, traumático, neoplásico o iatrogénico. Se describen las patologías que ocasionan obstrucción laríngea con más frecuencia o que revisten importancia por su gravedad, sus síntomas orientadores para el diagnóstico presuntivo, los estudios complementarios y el tratamiento.

The larynx is at the aerodigestive crossroads; any pathology that involves it will have an impact on breathing, swallowing and/or the voice. It`s divided into three regions: supraglottis (includes epiglottis, ventricular bands and laryngeal ventricles), glottis (space limited by the vocal cords) and subglottis (narrowest area of pediatric airway and the only point of larynx completely surrounded by cartilage: the cricoid ring). Laryngeal obstruction can present as a potentially fatal acute condition or as a chronic process. The main symptom is inspiratory or biphasic stridor. The etiology varies widely according to age and it may be of congenital, inflammatory, infectious, traumatic, neoplastic or iatrogenic origin. We describe the pathologies that cause laryngeal obstruction, either those that occur very often or those which are important for their severity, their guiding symptoms to the presumptive diagnosis, additional studies and treatment.

Debulking obstructing laryngeal cancers to avoid tracheotomy / Redução de volume tumoral em câncer obstrutivo de laringe para evitar traqueotomia

Abstract Introduction: Upper airway obstruction, secondary to neoplasms presenting with stridor, is traditionally treated by tracheostomy. However, this common procedure can potentially have an impact on the long-term outcome, with tumor implantation into the tracheostomized wound leading to peristomal recurrence after laryngectomy, with the risk of stomal recurrence. Objective: To describe our clinical experience with tumor debulking as an alternative treatment choice of tracheotomy in patients with advanced larynx cancer at a tertiary referral center. Methods: A retrospective chart review of 87 subjects who had advanced larynx cancer (T3/4) with airway obstruction from our institutional database was conducted. Medical records including demographics, daily notes during hospitalization, and operative notes were used for clinical data of patients. The strategy for maintaining the airway patency was tracheotomy (emergency or awake) and tumor debulking (laser or coblation). Endophytic and exophytic laryngeal tumors were also noted. Results: In 41/87 (47.1%) patients, a tracheotomy was performed as an initial treatment (11 were emergency, 30 were planned) to maintain airway patency. Tumor debulking was performed in 28 exophytic and 18 endophytic lesions by laser or coblation (17 and 29 patients, respectively). Tracheotomy was performed in 5 patients (4 endophytic, 1 exophytic) who could not tolerate debulking surgery due to aspiration, edema and dyspnea. Three of the them who required subsequent tracheotomy was in the laser group and two in the coblation group. The success rate of laser debulking was 82.35% (14/17) and 93.1% (27/29) for coblation. Conclusion: Tumor debulking is a safe and effective method to avoid awake tracheotomy in patients suffering from airway obstruction due to advanced larynx cancer.

Resumo Introdução: A obstrução das vias aéreas superiores com estridor, secundária a neoplasias, é tradicionalmente tratada com traqueotomia. No entanto, este procedimento comum pode potencialmente ter um impacto sobre o desfecho a longo prazo, com a implantação do tumor na ferida cirúrgica da traqueotomia, o que leva à recorrência peristomal após laringectomia, com o risco de recorrência do estoma. Objetivo: Descrever nossa experiência clínica com a redução do volume tumoral como tratamento alternativo à traqueotomia em pacientes com câncer avançado de laringe em um centro de referência terciário. Método: Foi realizada uma revisão retrospectiva de prontuários de 87 indivíduos com câncer avançado de laringe (T3/T4) com obstrução das vias aéreas em nosso banco de dados institucional. Registros médicos incluindo dados demográficos, anotações diárias durante a hospitalização e anotações operacionais foram utilizados como dados clínicos dos pacientes. A estratégia para manter a patência das vias aéreas foi a traqueotomia (emergência ou em pacientes acordados) e redução do volume tumoral (por laser ou coblation). Tumores endofíticos e exofíticos da laringe também foram anotados. Resultados: Uma traqueotomia foi realizada como tratamento inicial em 41/87 (47,1%) pacientes (11 foram de emergência, 30 foram eletivas) para manter a patência das vias aéreas. A redução do volume tumoral foi realizada em 28 lesões exofíticas e 18 endofíticas por laser ou coblation (17 e 29 pacientes, respectivamente). A traqueotomia foi realizada em 5 pacientes (4 endofíticos, 1 exofítico) que não podiam tolerar a cirurgia de redução de volume devido à aspiração, edema e dispneia. Três deles que necessitaram de uma traqueotomia subsequente estavam no grupo de laser e dois no grupo coblation. A taxa de sucesso da redução tumoral foi de 82,35% (14/17) para o laser e 93,1% (27/29) para coblation. Conclusão: A redução do volume tumoral é um método seguro e eficaz para evitar a traqueotomia com paciente acordado, nos casos de obstrução das vias aéreas devido ao câncer de laringe avançado.

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.

Neuroblastoma cervical: presentación de casos y revisión actualizada del tema / Cervical neuroblastoma: presentation of cases and updated review of the topic

El neuroblastoma es uno de los tumores sólidos extracraneales más comunes en la edad pediátrica, y se origina en células precursoras del sistema nervioso simpático. La ubicación cervical corresponde a un 2-5% del total de los neuroblastomas y puede tener distintas manifestaciones clínicas, tales como masa cervical, disnea, estridor, síndrome de Horner o disfagia. Esta entidad debe ser considerada dentro del diagnóstico diferencial de una masa cervical pediátrica, especialmente ante la presencia de masas sólidas, laterales o paramedianas, palpables o no al examen físico. El tratamiento específico del neuroblastoma depende de la clasificación de riesgo del paciente, pudiendo ser expectante en casos específicos, exclusivamente quirúrgico, o bien requerir complementarse con otras terapias. En este artículo se presentan 2 casos clínicos de pacientes pediátricos con neuroblastoma cervical tratados de forma exclusiva y exitosa con cirugía, y una revisión del tema.

Neuroblastoma is one of the commonest extracranial solid tumors at pediatric age, originating from sympathetic nervous system precursor cells. Cervical position stands for 2-5% of all neuroblastomas, with variable clinical expression that includes cervical mass, dyspnea, stridor, Horner syndrome and dysphagia. This condition must be considered in the differential diagnosis of a pediatric cervical mass, specially in those solid, lateral/paramedian masses that could be palpable or not at physical examination. The specific treatment in neuroblastoma depends on patient´s risk group, including conservative follow-up in selected cases, surgery alone, or complementary perioperative therapy with chemotherapy and others. In this article, the group report two cases of cervical neuroblastoma exclusively treated with surgery with good results, and a literature review.

Manejo anestésico de resección de quiste de vallécula en neonato. A propósito de un caso / Anesthetic management of vallecular cyst resection in neonate. A case report

Difficult airway management is one of the most important challenges an anesthesiologist faces. It is due to the high morbidity and mortality that it entails. The challenge is even greater if the patient is a newborn. For this reason, we should have different strategies that allow us to anticipate and treat possible complications derived from the procedure. In this case, we present a newborn with vallecular cyst and respiratory distress who is admitted for cyst resection. The gold-standard in anticipated difficult airway management is the fibrobronchoscope. We decided to perform an alternative management by means of orotracheal intubation with videolaryngoscope (Glydescope®) in spontaneous ventilation

El manejo de una vía aérea difícil es uno de los retos más importantes a los que puede enfrentarse un anestesiólogo debido a la elevada morbimortalidad que conlleva. El reto aún es mayor si el paciente es un neonato. Por este motivo, debemos contar con diferentes estrategias que permitan anticipar y poder tratar las posibles complicaciones derivadas del procedimiento. En este caso, presentamos un neonato con quiste de vallécula con clínica de trabajo respiratorio que es admitido para cirugía de exéresis del quiste. El gold standard en el manejo de una vía aérea difícil conocida es el fibrobroncoscopio. Nosotros decidimos realizar un manejo anestésico alternativo mediante intubación orotraqueal con videolaringoscopio (Glydescope®) en ventilación espontánea.

Split cricoídeo posterior endoscópico con injerto de cartílago costal / Endoscopic posterior cricoid split with costal cartilage graft

RESUMEN A pesar de los avances en cirugía de vía aérea, tanto abierta como endoscópica, la inmovilidad bilateral de cuerdas vocales continúa representando un desafio significativo para los cirujanos de vía aérea. Entre las alternativas quirúrgicas existen tanto abordajes endoscópicos como transcervicales, no obstante, la mayoría de estas técnicas modifican estructuralmente regiones de la cuerda vocal y/o aritenoides de manera permanente. La traqueostomía ha sido el tratamiento de elección en niños con inmovilidad bilateral de cuerdas vocales severamente sintomática, sin embargo, el procedimiento ideal debiese establecer una vía aérea adecuada evitando la necesidad de realizar una traqueostomía, y a la vez no generar un deterioro de la función fonatoria. La capacidad de expandir el aspecto glótico posterior sin modificación estructural de aritenoides y/o ligamento vocal ha convertido a la sección cricoidea posterior endoscópica con injerto de cartílago costal en una alternativa quirúrgica atractiva para estos casos. En este trabajo se realiza una revisión de la literatura y presenta un caso tratado mediante esta técnica en el Hospital Guillermo Grant Benavente de Concepción, Chile.

ABSTRACT Despite advances in both open and endoscopic airway surgery, bilateral vocal cord immobility still poses a significant challenge for airway surgeons. Among the surgical alternatives there are both endoscopic and transcervical approaches. However, most of these techniques structurally modify certain regions of the vocal cord and/or arytenoids permanently. Tracheostomy has been the treatment of choice in severely symptomatic children with bilateral immobility of vocal cords. Nevertheless, the ideal procedure should establish an adequate airway, avoiding the need to perform a tracheostomy, and at the same time not causing a deterioration of the phonatory function. The ability to expand the posterior glottis without structural modification of the arytenoids and/or vocal ligament has converted the posterior endoscopic cricoid split with costal cartilage graft into an attractive surgical alternative for these cases. In this article we review the literature and present a case treated by this technique in the Guillermo Grant Benavente Hospital in Concepción, Chile.

Association of bone mineral density with chronic obstructive pulmonary disease in postmenopausal women

Abstract Background Osteoporosis (OP) is common in patients with chronic obstructive pulmonary disease (COPD). The relationship between OP and COPD has been primarily studied in male patients, and few reports are available in postmenopausal women. Objective The purpose of this study was to investigate the association between bone mineral density (BMD) and COPD in postmenopausal women. Methods This cross-sectional study included 133 clinically stable female ex-smokers with confirmed COPD, and 31 age-matched “ex-smoker” female controls. We analyzed groups according to their airway obstruction category. BMD was measured on dual-energy X-ray absorptiometry images of the left femoral neck. Results Patients with COPD had lower T-scores and higher prevalence of osteopenia/OP than the control group. In the COPD group, the airway obstruction category was significantly associated with the T-score after adjustment for confounders. Multivariate logistic regression analysis showed COPD was an independent marker for increased risk of osteopenia/OP in postmenopausal women. Conclusions COPD and airway obstruction category were strongly related to BMD. Postmenopausal women with COPD, especially those with severe airway obstruction, had a higher prevalence rate and a higher risk of osteopenia and OP than female controls without COPD.

Tratamiento de la estenosis traqueobronquial con prótesis: factores de buena respuesta / Treatment of tracheobronchial stenosis with stents: good response factors

OBJETIVO: Determinar predictores de buena respuesta con el uso de prótesis en la estenosis traqueobronquial. MATERIALES Y MÉTODO: Estudio retrospectivo descriptivo de una serie de casos entre junio de 2014 y junio de 2016. Se revisaron registros clínicos, protocolos operatorios, estudios histopatológicos y de imagen. Se consignaron antecedentes demográficos y clínicos al ingreso y luego del procedimiento, etiología de la estenosis traqueal, necesidad de oxígeno en litros, estadía hospitalaria, morbilidad asociada al procedimiento, indicación de terapia complementaria posterior y sobrevida. Se analizaron los datos con estadística descriptiva y analítica. RESULTADOS: Se realizaron 68 procedimientos, en 44 pacientes, 24 mujeres, el diagnóstico principal fue estenosis traqueal con 40 casos. La etiología neoplásica fue el 88% de los casos. El Performance status (PS) de ingreso fue mayor o igual a 2 en el 68% y posterior al procedimiento disminuyó a 22% p < 0,05. En 36 casos los pacientes requerían al menos 1 L de oxígeno lo que disminuyó en 13 casos posterior a la intervención p < 0,05. El tiempo de hospitalización promedio fue 6,2 días (1-60). En 13 pacientes con patología neoplásica se indicó terapia paliativa complementaria. La morbilidad asociada al procedimiento fue de 2,9% dado por prótesis desplazada y lesión iatrogénica. La sobrevida fue de 27% a un año. CONCLUSIONES: La etiología benigna, el PS previo a la intervención menor o igual a 3, requerimiento de oxígeno de 1 litro y obstrucción tumoral menor al 70% del lumen fueron elementos de buena respuesta.

AIM: Determine good response predictors in use of stent in benign and malignant tracheobronchial stenosis. MATERIAL AND METHODS: We retrospectively reviewed medical records of patients submitted to the procedure in the period 2014 to 2016. Clinical records, operative protocols, and histopathological and imaging studies were reviewed. Demographic and clinical data, performance status (PS) at admission and after the procedure, etiology of tracheal stenosis, need for oxygen in liters (L) Post-intervention, hospital stay, procedure-related morbidity, indication of therapy (Chemotherapy and/or Radiotherapy) and survival. Data were analyzed with descriptive and analytics statistics. RESULTS: A total of 68 procedures were performed in 44 patients, 24 women. Tracheal stenosis 40 cases were diagnosed. The malignant etiology was 88%. The admission PS was greater than or equal to 2 in 68% and 22% after the procedure. The oxygen requirements prior to the procedure were at least 1 L in 36 cases and decreased in 13 cases after the procedure. The average hospitalization period was 6.2 days (1-60). Complementary therapy was indicated in 13 patients; the morbidity associated with the procedure was 2.9%, displaced installation and iatrogenic injury. The one year survival was 27%. CONCLUSIONS: Benign etiology, el PS minor than or equal to 3, oxygen requirements prior to the procedure of 1 L and tumoral obstruction less than 75% were good response predictors in our study.

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.

Intervención del enfermero intensivista ante un paciente con atelectasia. Reporte de un caso / The intervention of the intensive care nurse in front of a patient with atelectasis. A case report

RESUMEN En la aspiración por cuerpo extraño en vías respiratoria, los síntomas van desde el paro cardiorrespiratorio, tos de intensidad y características variables como obstrucción bronquial difusa o localizada. Como complicación puede aparecer la neumonía y atelectasias. La atelectasia es el colapso de una parte periférica del pulmón o de todo el pulmón, debido a la obstrucción de la vía aérea en bronquios o bronquiolos. El objetivo de este trabajo es presentar un caso clínico y la importancia de la intervención de Enfermería en una Transicional, de 1 año y 9 meses de edad, sexo femenino. Ingresó en la Unidad de Terapia Intensiva del Hospital Pediátrico Provincial de Matanzas, con diagnóstico de aspiración de cuerpo extraño en vías aéreas. El desarrollo de las habilidades prácticas del enfermero intensivista fomenta el razonamiento crítico en aras de brindar cuidados con calidad y enfoque científico que repercuten en la mejoría de los pacientes (AU).

ABSTRACT This paper´s aim is to present a clinical case and the importance of the nursing interventions in a female transitional patient, aged 1 years and 9 months. She entered the Intensive Care Unit of the Provincial Pediatric Hospital of Matanzas, with a diagnosis of foreign body aspiration in the airways. The development of the intensive care nurses´ practical skills promotes the critical reasoning for the sake of giving qualitative care with a scientific approach striking on the improvement of the patients (AU).

Anillos vasculares en pediatria: presentación de 2 casos / Pediatric vascular rings: case reports

Vascular rings are uncommon congenital anomalies that result from anomalous embryological development of the mediastinum main arteries (aortic arch and its branches, pulmonary artery). Such anomalous vascular structures may produce compression of the trachea and / or esophagus, with consequent obstructive respiratory and digestive symptoms. Vascular rings can be complete or incomplete. They can be asymptomatic or manifest with persistent or recurrent respiratory and / or digestive symptoms. The study should include chest X-ray, barium swallow, flow-volume loop, fiberoptic bronchoscopy, chest computed tomography, angiotomography or magnetic resonance. Symptomatic patients often need surgery

Los anillos vasculares son el resultado de anomalías del desarrollo embrionario de grandes troncos vasculares del mediastino, tanto del cayado aórtico y sus ramas, como de la arteria pulmonar. Dichas estructuras vasculares anómalas pueden producir compresión de la tráquea y/o del esófago, con la consiguiente sintomatología obstructiva respiratoria y digestiva. En algunas ocasiones forman un anillo completo y en otras incompleto. El diagnóstico puede ser casual cuando son silentes o resultado del estudio de síntomas respiratorios y/o digestivos persistentes o recurrentes. El estudio debe incluir radiografía de tórax, esofagograma, curva flujo/volumen, fibrobroncoscopía, angiotomografía computada o angioresonancia magnética de tórax. En pacientes sintomáticos se debe recurrir a la cirugía, en cambio los asintomáticos u oligosintomáticos deben ser observados

Indicaciones, hallazgos broncoscópicos y mortalidad en pacientes pediátricos con traqueostomía en un hospital de México / Indications, bronchoscopic findings and mortality in pediatric patients with tracheostomy in a Mexican hospital

INTRODUCTION. Tracheostomy is an old surgical procedure, wich is currwently performed, in pediatric patients. Bronchoscopy is an effective procedure to follow these patients as it reveals data that can not be obtained with other methods. The aim of this study was to determine indications, bronchoscopic findings and mortality in patients with tracheostomy at the Hospital del Niño Morelense (HNM). in addiction, we sought to detail the role of bronchoscopy in patients follow-up. METHODS. Observational, descriptive and transversal study. We reviewed the records of the patients with tracheostomy during 5 years looking for bronchoscopic findings. RESULTS: The main indication for tracheostomy was prolonged ventilation (74.4 percent). The main bronchoscopic diagnoses were subglottic stenosis (20 percent), granulomas in the trachea (70 percent), and in bronchi abnormal secretions (70 percent) mortality was 32.5 percent. CONCLUSIONS: The main indication for tracheostomy is prolonged ventuilation. Mortality in children with tracheostomy depends mainly on the underlying pathology. Bronchospy is useful for monitoring the child with a tracheostomy

INTRODUCCIÓN. La traqueostomía es un procedimiento quirúrgico antiguo, que se realiza en pediatría cada vez con mayor frecuencia. La broncoscopía es un procedimiento efectivo para el seguimiento del paciente con traqueostomía ya que nos revela datos que no se pueden obtener con otros métodos. Se tuvo como objetios determinar indicaciones, hallazgos broncoscópicos y mortalidad en pacientes con traqueostomía, en el Hospital del Niño Morelense (HNM). MÉTODOS. Estudio observacional, descriptivo y transversal. Se revisaron los expedientes de los pacientes a quienes se les realizó traqueostomía durante 5 años buscando hallazgos broncoscópicos. RESULTADOS. La principal indicación de traqueostomía fue la ventilación prolongada (74 por ciento). Los principales diagnósticos broncoscópicos fueron: estenosis subglótica (20 por ciento), granulomas en tráquea (70 por ciento) y en bronquios secreciones anormales (70 por ciento). La mortalidad fue de 32.5 por ciento. CONCLUSIONES. la principal indicación para traqueostomía fue la ventilación prolongada. la mortalidad en niños con traqueostomía depende principalmente de la patología subyacente. La broncoscopía es útil para el seguimiento del niño con traqueostomía

Congenital vallecular cyst: a rare and potentially lethal condition

Congenital vallecular cyst is a rare laryngeal lesion, accounting for 10-20% of all laryngeal cysts, with a potential to cause severe upper airway obstruction, which can be fatal. It can cause stridor, apnea, cyanosis, respiratory distress, and feeding difficulties. Diagnosis requires a high level of clinical suspicion and helps in timely intervention. Direct laryngoscopy is gold standard for definitive diagnosis. Treatment options include aspiration, marsupialization, and surgical excision. Here, we report a case of 7-week-old infant with complain of recurrent episodes of cyanosis when agitated, since the age of 3 weeks, admitted with impression of apparent life-threatening events [ALTEs]

Extensive investigations were non-conclusive, which were done in local hospital. Direct laryngoscopy was performed in our hospital and showed presence of a vallecular cyst. Thus complete excision of cyst was done in the same setting with dramatic relief of symptoms

Electrocauterio y broncoscopia flexible como primera medida en la obstrucción central de la vía aérea y hemoptisis asociada / Electrocautery and bronchoscopy as a first step for the management of central airway obstruction and associated hemoptysis

Background: Central airway obstruction caused by malignant or benign lesions, associated in some cases with hemoptysis, is a condition with high morbidity and mortality. The use of electrocautery by flexible bronchoscopy is an initial treatment option with immediate improvement of obstruction symptoms. It is as effective as Nd: YAG laser. Aim: To describe the usefulness of electrocautery in the management of central obstruction of the airway and hemoptysis. Material and Methods: A retrospective, descriptive study of patients referred for management of central airway obstruction or associated hemoptysis. Diagnoses, symptoms (dyspnea, cough, and hemoptysis) and radiology before and after the procedures were analyzed. Results: Eighteen patients aged 59 ± 12 years (66% males) were evaluated, registering 25 endoscopic procedures. Three conditions were found: partial or complete airway obstruction, hemoptysis and post lung transplant bronchial stenosis. Seventy two percent presented with dyspnea, 61% with cough and 33% with hemoptysis. Sixty six percent of patients had airway obstruction caused by malignant metastatic lesions. After electrocautery, 17 patients (94.4%) improved their symptoms and achieved complete airway clearing. Three patients had significant bronchial stenosis after lung transplant achieving subsequent clearing after electrocautery. Conclusions: Electrocautery during flexible bronchoscopy is an effective and safe procedure for the management of central airway obstruction and associated hemoptysis.

Quiste de vallécula como causa de estridor congénito: reporte de un caso y revisión de la literatura / Vallecula cyst as a cause of congenital stridor: case report and literature review

El quiste de vallécula congénito es una malformación de vía aérea poco frecuente que se manifiesta principalmente con estridor laríngeo y que puede plantear problemas diagnósticos y terapéuticos complejos, a menudo en situaciones de riesgo vital. Se presenta el caso de un recién nacido de pretérmino (RNPT) de 36 semanas pequeño edad gesta-cional (PEG), portador de un estridor laríngeo congénito y mal incremento pondoestatural que en relación a una infección respiratoria baja, presentó empeoramiento del estridor laríngeo a los 48 días de edad cronológica. Por insuficiencia respiratoria aguda requirió de intubación orotraqueal que no resultó dificultosa. La extubación fue fallida por presentar estridor inspiratorio franco. La nasofibroscopía demostró una lesión de aspecto quístico en base de lengua que desplazaba la epiglotis hacia posterior obstruyendo parcialmente el lumen de la vía aérea. Por laringoscopía directa se realizó marsupialización. Se realiza la revisión bibliográfica y se analiza el caso y su tratamiento.

Congenital vallecular cyst is a rare airway malformation mainly manifested by laryngeal stridor and could generate complex diagnostic and therapeutic problems, often in life-threatening situations. We present the case of a pre-term newborn of 36 weeks small for gestational age, who at 48 days of chronological age showed worsening of a congenital laryngeal stridor in the context of a lower respiratory tract infection associated to low weight gain from birth. For reasons of acute respiratory failure, orotracheal intubation was executed which was not difficult. Extubation was failed because the child presents significant inspiratory stridor. Nasofibroscopy showed a cystic lesion of the tongue base that pushed backward the epiglottis obstructing partially the airway lumen. Marsupialization was performed by direct laryngoscopy. A Bibliographic review was done and the case and its treatment are discuss.

Malformaciones craneofaciales y obstrucción de vía aérea superior: ¿qué y cómo corregir? / Craniofacial malformations and upper airway obstruction: what and how to correct?

Objetivos: revisión de las principales causas de obstrucción de la vía aérea superior relacionadas a malformaciones del territorio craneofacial. Método: Revisión de la literatura, según nivel obstructivo; de origen nasofaríngeo, orofaríngeo, glóticas o subglóticas y según la condición desindrómica o no. Resultados: Se consideran las principales características clínicas de las distintas patologías, especialmente las relacionadas con el compromiso de la vía aérea superior y el procedimiento terapéutico en cada una de ellas.Se destaca dentro del manejo quirúrgico descrito la utilidad de la distracción osteogénica, sus indicaciones, la descripción de la técnica y sus resultados. Conclusiones: La obstrucción de la vía aérea respiratoria, resulta de una condición morfológica y/o funcional presente en distintas malformaciones craneofaciales, tanto en el contexto de Síndromes como en forma aislada. Su adecuado diagnóstico y posterior manejo resulta fundamental en la sobrevida de los pacientes que presentan esta compleja condición.

Objectives: review article of the main causes obstruction of the upper airway related to craniofacial malformations. Method: Literature review, according the obstructive level; nasopharyngeal origin, oropharyngeal, glottal or subglottic and depending on the condition of syndromic or not. Results: Considered the main clinical features of various diseases, especially those related to the engagement of the upper airway and therapeutic procedure in each. The usefulness of distraction osteogenesis indications, the description of the technique and its results emerged within the described surgical management. Conclusions: Obstruction of the respiratory airway, resulting from a morphological condition and / or functional present in different craniofacial malformations, both in the context of Syndromes and isolation. Proper diagnosis and subsequent management is essential to the survival of patients with this complex condition.

Rotura de la cánula de traqueostomía: una causa rara de dificultad respiratoria en el nino traqueotomizado. Caso clínico / Fractured tracheostomy tube: a rare cause of respiratory distress in the tracheotomized child. Case report

La fractura y migración de la cánula de traqueostomía en el árbol traqueobronquial es una complicación poco frecuente de la traqueostomía. El diagnóstico precoz y el tratamiento adecuado son esenciales debido al riesgo potencial de obstrucción respiratoria fatal. El diagnóstico se debe sospechar en todo niño traqueotomizado que presenta dificultad respiratoria. Se confirma mediante radiografía de tórax y examen endoscópico. El tratamiento de elección es la remoción endoscópica de la cánula aspirada a través del estoma traqueal. Describimos la presentación clínica y el manejo de la rotura de cánula de traqueostomía que se presentó como cuerpo extrano en la vía aérea de un niño de 18 meses. También incluimos recomendaciones para el cuidado de la traqueostomía.

Fracture and migration of the tracheotomy tube in the tracheobronchial tree is an uncommon complication of tracheotomy. Early diagnosis and proper treatment are essential because of the potential risk of fatal respiratory obstruction. Diagnosis should be suspected in all tracheotomized children undergoing breathing difficulties. It is confirmed by chest x-ray and endoscopic examination. The recommended treatment includes the endoscopic removal of the aspirated cannula through the tracheal stoma. We describe the clinical presentation and the management of a broken tracheotomy tube which was presented as a foreign body in the airway of a 18-month-old child. Recommendations for tracheostomy care are listed.

Assessment of upper airways measurements in patients with mandibular skeletal Class II malocclusion

Objective: Mandibular Class II malocclusions seem to interfere in upper airways measurements. The aim of this study was to assess the upper airways measurements of patients with skeletal Class II malocclusion in order to investigate the association between these measurements and the position and length of the mandible as well as mandibular growth trend, comparing the Class II group with a Class I one.Methods:A total of 80 lateral cephalograms from 80 individuals aged between 10 and 17 years old were assessed. Forty radiographs of Class I malocclusion individuals were matched by age with forty radiographs of individuals with mandibular Class II malocclusion. McNamara Jr., Ricketts, Downs and Jarabak's measurements were used for cephalometric evaluation. Data were submitted to descriptive and inferential statistical analysis by means of SPSS 20.0 statistical package. Student's t-test, Pearson correlation and intraclass correlation coefficient were used. A 95% confidence interval and 5% significance level were adopted to interpret the results.Results:There were differences between groups. Oropharynx and nasopharynx sizes as well as mandibular position and length were found to be reduced in Class II individuals. There was a statistically significant positive correlation between the size of the oropharynx and Xi-Pm, Co-Gn and SNB measurements. In addition, the size of the nasopharynx was found to be correlated with Xi-Pm, Co-Gn, facial depth, SNB, facial axis and FMA.Conclusion: Individuals with mandibular Class II malocclusion were shown to have upper airways measurements diminished. There was a correlation between mandibular length and position and the size of oropharynx and nasopharynx.

Introdução: as más oclusões de Classe II mandibulares parecem interferir nas dimensões das vias aéreas superiores. Assim, o objetivo do presente estudo foi avaliar as vias aéreas superiores de pacientes com Classe II esquelética, verificando a associação entre essas dimensões e a posição mandibular, o comprimento mandibular e a tendência de crescimento, comparando-os com um grupo pareado de pacientes com Classe I.Métodos: foram avaliadas 80 telerradiografias de perfil de 80 pacientes com 10 a 17 anos de idade, sendo 40 com má oclusão de Classe I e 40 com Classe II mandibular, pareados por idade. Para a avaliação cefalométrica, foram utilizadas medidas de McNamara Jr, Ricketts, Downs e Jarabak. Os dados foram submetidos à análise estatística descritiva e inferencial, por meio dosoftware SPSS 20.0, utilizando-se os testest de Student, coeficiente de correlação de Pearson e coeficiente de correlação intraclasse. Para interpretação dos resultados, adotou-se um intervalo de confiança de 95% e nível de significância de 5%.Resultados: houve diferença entre os grupos, e as medidas da orofaringe e nasofaringe foram menores no grupo de Classe II, assim como as medidas de comprimento e posição mandibular. Houve correlação positiva estatisticamente significativa entre a orofaringe e as medidas Xi-Pm, Co-Gn e SNB; já a nasofaringe apresentou correlação com as medidas Xi-Pm, Co-Gn, profundidade facial, SNB, eixo facial e FMA.Conclusão: indivíduos portadores de Classe II mandibular apresentaram as medidas das vias aéreas superiores diminuídas. Observou-se uma correlação entre o comprimento mandibular e a posição mandibular e as dimensões da orofaringe e da nasofaringe.