Guia Prático de Atualização no tratamento da exacerbação de asma na criança e no adolescente ­ Posicionamento conjunto da Associação Brasileira de Alergia e Imunologia e Sociedade Brasileira de Pediatria / Practical Update Guide on the treatment of asthma exacerbation in children and adolescents ­ Joint position of the Brazilian Association of Allergy and Immunology and the Brazilian Society of Pediatrics

Exacerbação aguda de asma é uma condição frequente na criança e no adolescente e uma das causas mais comuns de procura aos pronto atendimentos e de internações. Pode ocorrer em pacientes que ainda não foram diagnosticados como asmáticos, e mesmo naqueles cujo controle da doença não se encontre adequado. Reconhecer a exacerbação e iniciar seu tratamento desde o domicílio até o adequado manejo inicial em ambiente hospitalar é fundamental para evitar sua evolução para complicações que coloquem o paciente em risco de vida. O tratamento compreende o reconhecimento e tratamento da hipoxemia, da obstrução e do processo inflamatório, além de fornecer orientações na alta hospitalar e encaminhamentos para continuidade do tratamento.

Acute exacerbation of asthma is a frequent condition in children and adolescents and one of the most common causes of seeking emergency care and hospitalization. It can occur in patients who have not yet been diagnosed with asthma, and even in those whose disease control is not adequate. Recognizing the exacerbation and starting its treatment from home until proper initial management in a hospital environment is essential to avoid its evolution to complications that put the patient at risk of life. Treatment comprises the recognition and treatment of hypoxemia, obstruction, and the inflammatory process, in addition to providing guidance at hospital discharge and referrals for continued treatment.

Incidence of post-anesthetic respiratory complications in pediatrics. Observational, single-center study in Medellin, Colombia / Incidencia de complicaciones respiratorias postanestésicas en pacientes pediátricos. Estudio observacional en un hospital en Medellín, Colombia

Abstract Introduction: Post-anesthetic complications, particularly respiratory complications, continue to be a source of concern due to their high frequency, particularly in pediatrics. Objective: To describe the incidence of respiratory complications in the post-anesthesia care unit of an intermediate complexity center during a six-month period, and to explore the variables associated with major respiratory complications. Materials and Methods: Retrospective cohort study based on clinical record reviews. The records of the post-anesthesia care unit of an intermediate complexity pediatric institution located in Medellin, Colombia, were reviewed. This center uses a nursing-based care model that includes patient extubation in the post-anesthesia care unit. Results: The records of 1181 patients were analyzed. The cumulative incidences of major complications were bronchospasm 1.44%, laryngospasm 0.68% and respiratory depression 0.59%. There were no cases of cardiac arrest or acute pulmonary edema. A history of respiratory infection less than 15 days before the procedure, rhinitis and female sex were associated with major respiratory complications. Conclusions: A low frequency of respiratory complications was found during care provided by nursing staff trained in anesthesia recovery and pediatric airway in the post-anesthesia care unit.

Resumen Introducción: Las complicaciones postanestésicas, especialmente las respiratorias, siguen siendo causa de preocupación por su alta frecuencia, en particular, en la población pediátrica. Objetivo: Describir la incidencia de complicaciones respiratorias en la unidad de cuidados postanestésicos de una institución de mediana complejidad, en un período de seis meses y explorar las variables relacionadas con las complicaciones respiratorias mayores. Materiales y métodos: Estudio de cohorte retrospectivo, basado en la valoración de historias clínicas. Se revisaron los registros de la unidad de cuidados postanestésicos de una institución pediátrica de mediana complejidad ubicada en Medellín. Esta institución utiliza un modelo de atención -basado en enfermería- que incluye la extubación del paciente en la unidad de cuidados postanestésicos. Resultados: Se analizaron los registros de 1181 pacientes. La incidencia acumulada de complicaciones mayores fue: broncoespasmo 1,44 %, laringoespasmo 0,68 % y depresión respiratoria 0,59 %. No se presentaron casos de paro cardiaco ni de edema agudo de pulmón. El antecedente de infección respiratoria menor a 15 días, rinitis y sexo femenino se asociaron con complicaciones respiratorias mayores. Conclusiones: Durante la atención en la unidad de cuidados postanestésicos por parte del personal de enfermería entrenado en la recuperación de la anestesia y de la vía aérea de los pacientes pediátricos, se encontró una baja frecuencia de complicaciones respiratorias.

Controversias de la ventilación mecánica no invasiva en el asma grave / Controversies of the non-invasive mechanical ventilation in severe asthma

RESUMEN El asma es una enfermedad obstructiva en la que, las resistencias respiratorias se encuentran aumentadas. Los hechos responsables de este aumento de resistencias son el propio broncoespasmo, la inflamación y el remodelado de la vía aérea con reducción de su diámetro. Todavía falta mucho por conocer y estudiar, pero sabemos que la ventilación mecánica no invasiva, como nueva forma de soporte ventilatorio que ha venido tomando auge en las últimas décadas, tiene numerosos beneficios en la práctica médica. A pesar de que algunas investigaciones plantean la controversialidad del empleo de la ventilación no invasiva en el asma grave, queremos realizar con el presente trabajo un acercamiento a varios de los estudios que se han llevado a cabo donde justifican totalmente el empleo de la misma como una medida de éxito en el manejo del asma, con resultados positivos y exitosos. Donde ha probado mejorar la situación funcional y reducir las necesidades de ingreso hospitalario, aliviando el agotamiento muscular y de esta manera mejorando el trabajo respiratorio. Aún queda bastante camino por recorrer con esta variante de ventilación que ha surgido y tomado auge por todos los logros y expectativas que ha venido a cumplir (AU).

SUMMARY Asthma is an obstructive disease in which, respiratory resistances are increased. The factors responsible for this increase in resistance are bronchospasm, inflammation and remodeling of the airway with reduction of its diameter. Much remains to be known and studied, but we know that noninvasive ventilation (NIV), as a new form of ventilatory support that has been growing in recent decades, has numerous benefits in medical practice. Although some research raises the controversy about the use of NIV in severe asthma, we want to do with the present work an approach to several of the studies that have been carried out where they totally justify the use of it as a measure of success in managing asthma, with positive and successful results. Where he has tried to improve the functional situation and reduce the need for hospital admission, alleviating muscle exhaustion and thus improving breathing work. There is still enough way to go with this variant of ventilation that has emerged and taken shape for all the achievements and expectations it has come to fulfill (AU).

Impact of climate variability on exercise-induced bronchospasm in adolescents living in a semi-arid region / Influência de alterações climáticas sobre a ocorrência do broncoespasmo induzido por exercício em adolescentes de uma região semiárida

ABSTRACT Objective: To examine the impact of climate variability on the occurrence of exercise-induced bronchospasm in the rainy and dry seasons of a Brazilian semi-arid region. Methods: This sample comprised 82 adolescents aged 15 to 18 years, who were submitted to exercise-induced bronchospasm assessment on a treadmill and outdoors, during the rainy and the dry season. Anthropometric variables, sexual maturity and forced expiratory volume in the first second were analyzed. Air temperature and humidity, decline in forced expiratory volume in the first second (%) and frequency of bronchospasm were compared between seasons using the independent Student's t test, the Wilcoxon and McNemar tests, respectively. The level of significance was set at p<0.05. Results: The mean age was 15.65±0.82 years. Air temperature, air humidity and decline in forced expiratory volume in the first second (%) differed between seasons, with higher air temperature and humidity in the rainy season (29.6ºC±0.1 and 70.8%±0.6 versus 28.5ºC±0.2 and 48.5%±0.6; p<0.05). The decline in forced expiratory volume in the first second (%) was greater in the dry season (9.43%±9.97 versus 12.94%±15.65; p<0.05). The frequency of bronchospasm did not differ between seasons. Conclusion: The dry season had a negative impact on forced expiratory volume in the first second in adolescents, with greater decrease detected during this period. Findings of this study suggested bronchospasm tends to be more severe under low humidity conditions.

RESUMO Objetivo: Verificar a influência das alterações climáticas sobre o broncoespasmo induzido por exercício, nos períodos chuvoso e seco de uma região do semiárido brasileiro. Métodos: Foram submetidos à avaliação do broncoespasmo em esteira ergométrica, em ambiente externo, nos períodos chuvoso e seco, 82 adolescentes, com idades de 15 a 18 anos. Foram avaliadas as variáveis antropométricas, a maturação sexual e o volume expiratório forçado no primeiro segundo. Para comparação da temperatura e umidade, queda do volume expiratório forçado no primeiro segundo (%) e frequência do broncoespasmo entre os períodos, foram utilizados o teste t de Student independente, o teste de Wilcoxon e o teste de McNemar, respectivamente. O nível de significância adotado foi p<0,05. Resultados: A média de idade foi 15,65±0,82 anos. A temperatura, a umidade e a queda do volume expiratório forçado no primeiro segundo (%) diferiram entre os períodos, com valores de temperatura e umidade maiores no período chuvoso (29,6ºC±0,1 e 70,8%±0,6 versus 28,5ºC±0,2 e 48,4%±0,6; p<0,05). A queda do volume expiratório forçado no primeiro segundo (%) foi maior no período seco (9,43%±9,97 versus 12,94%±15,65; p<0,05), e não foi encontrada diferença da frequência do broncoespasmo entre os períodos. Conclusão: O período seco influenciou negativamente no volume expiratório forçado no primeiro segundo de adolescentes, observando maior percentual de queda dessa variável nesse período. De acordo com os achados, propõe-se uma maior gravidade do broncoespasmo induzido por exercício em condições de baixa umidade.

Evaluación del sulfato de magnesio en el tratamiento del broncoespasmo / Assessment of magnesium sulfate in bronchospasm treatment

Introducción: Una de las urgencias más temidas durante la instrumentación de la vía respiratoria es el broncoespasmo. El sulfato de magnesio, administrado por vía endovenosa, tiene un efecto broncodilatador al antagonizar los canales del calcio, inhibir la contracción muscular mediada por el calcio y favorecer la relajación del músculo liso bronquial. Objetivo: Evaluar la eficacia del sulfato de magnesio endovenoso en pacientes con broncoespasmo durante broncoscopias. Métodos: Estudio observacional, descriptivo y transversal en 20 pacientes, con broncoespasmo, desencadenado por manipulación de la vía respiratoria con broncoscopio flexible, tratados con sulfato de magnesio 50 mg/kg, (máximo 2 g), por vía endovenosa durante 5 min. Resultados: Predominaron los hombres entre 50-59 años (75 por ciento), todos los pacientes eran fumadores, 15 pacientes fueron clasificados como estado físico ASA III. Sufrieron broncoespasmo de intensidad moderada 60 por ciento, clasificado según la clínica y monitorización de SpO2. En 75 por ciento de los pacientes cedió el broncoespasmo tras el tratamiento sin administrar otro medicamento. No se registraron efectos adversos. Ningún paciente necesitó intubación orotraqueal para ventilación ni requirió hospitalización por más de 8 h. Conclusiones: El sulfato de magnesio es una buena opción farmacológica para el tratamiento de urgencia del broncoespasmo desencadenado por manipulación de la vía respiratoria(AU)

Introduction: One of the most feared emergencies during the instrumentation of the respiratory tract is bronchospasm. Magnesium sulfate, administered intravenously, has a bronchodilation effect by antagonizing calcium channels, inhibiting muscle contraction mediated by calcium and promoting bronchial smooth muscle relaxation. Objective: To evaluate the efficacy of magnesium sulfate administered intravenously in patients with bronchospasm during bronchoscopy. Methods: Observational, descriptive and cross-sectional study carried out with 20 patients, with bronchospasm, triggered by airway manipulation with flexible bronchoscope, treated with 50 mg/kg of magnesium sulfate, (maximum 2 g), administered intravenously for 5 min. Results: Men between 50-59 years (75 percent) predominated. All patients were smokers. 15 patients were classified with physical state ASA III. They suffered bronchospasm of mild intensity 60 percent, classified according to the clinic and monitoring of oxygen saturation. In 75 percent of the patients, the bronchospasm ceased after the treatment without administering any other medication. No adverse effects were recorded. No patient needed orotracheal intubation for ventilation or required hospitalization for more than 8 hours. Conclusions: Magnesium sulfate is a good pharmacological option for the emergency treatment of bronchospasm triggered by manipulation of the respiratory tract(AU)

Hiperclaridad pulmonar unilateral en un niño: Síndrome de Swyer-James-Macleod / A pediatric clinical case of unilateral hyperlucency of the lung: Swyer-James-Macleod syndrome

El síndrome de Swyer-James-MacLeod es un cuadro pulmonar muy infrecuente que se caracteriza radiológicamente por hiperclaridad pulmonar lobar o multilobar, producido por la disminución de la vascularización pulmonar, por lo general, por un proceso infeccioso previo. En ocasiones, es un hallazgo casual en el estudio por infecciones respiratorias o crisis asmáticas repetidas. Se presenta el caso de un paciente de 6 años de edad que, en el contexto de probable neumonía persistente, se realizó un amplio estudio que permitió el diagnóstico del síndrome de Swyer-James-MacLeod. Se desarrolló un abordaje terapéutico multidisciplinar con el que, hasta la fecha, la evolución ha sido satisfactoria, con tratamiento médico y fisioterapia respiratoria.

Swyer-James-MacLeod syndrome is a rare pulmonary disorder that is characterized radiologically by pulmonary lobar or multilobar hyperlucency produced by decreased pulmonary vascularization usually due to a previous infectious process. It is frequently a casual finding in recurrent pulmonary infections or in the study of asthma symptoms. We present the case of a 6-year-old patient who was diagnosed with Swyer-James-MacLeod syndrome after a persistent pneumoniae. A multidisciplinary approach was conducted, with a satisfactory progress up to date, combining medical treatment with respiratory physiotherapy.

Severe Anaphylaxis without Key Signs Such as Urticaria and Bronchospasm Suspected to Be Induced by Rocuronium

Perioperative hypersensitivity reaction have been reported to have a variable degree of the incidence from differ countries and to be 1/353–18,600 approximately and its mortality has been reported to be 4%–4.76% in the United States and Japan, respectively. A 65-year-old male patient with hypertension, rheumatoid arthritis, and history of amoxicillin allergy was scheduled for laparoscopic radical prostatectomy due to prostate cancer. Lidocaine, propofol, and rocuronium were administered sequentially to induce general anesthesia. Twenty minutes after the rocuronium administration, severe hypotension and tachycardia developed. But key signs of hypersensitivity such as urticaria and bronchospasm were not appeared. The operation was canceled and we evaluated the cause of severe hypotension and could confirm hypersensitivity for rocuronium with intradermal test after 4 weeks.

The KAAACI Standardization Committee Report on the procedure and application of the bronchial provocation tests

Bronchial provocation tests are of value in the evaluation of airway hyperresponsiveness. Nonspecific bronchial challenge (methacholine, mannitol, exercise, etc.) is used when the symptoms, physical examination, and measurements of pulmonary function are unremarkable in the diagnosis of asthma, when a patient is suspected of having occupational asthma or exercise-induced bronchoconstriction (EIB), and when a screening test for asthma or EIB is required for some occupational groups in whom bronchospasm would pose an unacceptable hazard. Methacholine inhalation challenge is most widely used pharmacologic challenge and highly sensitive. For appropriate interpretation of the results of methacholine provocation, it is important to perform the test with the standardized protocol and to recognize that inhalation methods significantly influence the sensitivity of the procedure. Indirect challenges (e.g., mannitol and exercise) correlate with airway inflammation and are more specific but less sensitive for asthma. Indirect provocation tests are used to confirm asthma, to differentiate asthma from other airway diseases, and to evaluate EIB.

Helium-oxygen mixture: clinical applicability in an intensive care unit / Mistura hélio-oxigênio: aplicabilidade clínica em unidade de terapia intensiva

ABSTRACT Objective To evaluate if distress respiratory decreases after using helium-oxygen mixture in pediatric patients diagnosed with bronchospasm. Methods This is a retrospective, non-randomized study that included patients diagnosed with bronchospasm, who received a helium-oxygen mixture at three time points (30, 60, and 120 minutes) according to the organization protocol singular, and were admitted to the intensive care unit, from January 2012 to December 2013. This protocol includes patients with bronchospasm who sustained a modified Wood score of moderate to severe, even after one hour of conventional treatment. Results Twenty children were included in the study. The mean score of severity of the disease at the initial moment was 5.6 (SD:2.0), and at moment 120 minutes, it was 3.4 (SD: 2.0). The severity score showed a significant improvement as of 30 minutes (p<0.001). Conclusion The use of helium-oxygen mixture proved to be effective in diminishing the respiratory distress score for children with airway obstructions; it should be considered a supplementary therapeutic option, together with drug therapy, in specific clinical situations.

RESUMO Objetivo Avaliar se o desconforto diminui após o uso da mistura hélio-oxigênio em pacientes pediátricos com diagnóstico de broncoespasmo. Métodos Estudo retrospectivo, não randomizado, no qual foram incluídos pacientes com diagnóstico de broncoespasmo que utilizaram a mistura hélio-oxigênio em três momentos (30, 60 e 120 minutos), seguindo o protocolo institucional, internados em unidade de terapia intensiva pediátrica de janeiro de 2012 a dezembro 2013. Este protocolo incluía pacientes com diagnóstico de broncoespasmo que mantivessem escore de Wood modificado de moderado a grave, mesmo após 1 hora de tratamento convencional. Resultados Foram incluídas 20 crianças neste estudo. A média do escore de gravidade da doença no momento zero foi de 5,6 (DP:2,0) e, no momento 120 minutos, 3,4 (DP: 2,0). O escore de gravidade apresentou melhora significante a partir dos 30 minutos (p<0,001). Conclusão A utilização da mistura hélio-oxigênio mostrou-se eficaz na redução do escore de desconforto respiratório de crianças com doenças obstrutivas e deve ser considerada recurso terapêutico complementar à terapia medicamentosa em situações clínicas específicas.

Residential NO₂ exposure is associated with urgent healthcare use in a thunderstorm asthma cohort

BACKGROUND: There is increasing interest in the role of traffic-related air pollution (TRAP) in allergic airway diseases. Few studies investigate the relationship between TRAP exposure and acute exacerbations of asthma. OBJECTIVE: The 2016 Melbourne thunderstorm asthma epidemic provided an opportunity to investigate the relationship between proxies of TRAP exposure and asthma exacerbation requiring urgent healthcare in the previous 12 months. METHODS: Current asthmatics who presented to the 3 Emergency Departments of Melbourne's second-largest health service with epidemic thunderstorm asthma in November 2016 were identified and completed a standard questionnaire. Their residential addresses were geocoded and the annual average nitrogen dioxide (NO2) exposure for each patient was assigned using a validated satellite-based land use regression model. Residential distance to the nearest major road was calculated using ArcGIS. Multivariate logistic regression was used to investigate the relationship between each TRAP proxy and healthcare use, adjusting for potential confounders. RESULTS: From 263 thunderstorm asthma patients, 88 patients identified with current asthma were analysed. Those with higher mean annual residential NO2 exposure had greater odds of urgent healthcare use in the previous year (odds ratio [OR], 3.45 per one interquartile-range increase; 95% confidence interval [CI], 1.31–9.10; p = 0.01), however distance from major road (OR, 0.95 per 100-m increase; 95% CI, 0.80–1.13; p = 0.57) and living < 200 m from a major road (OR, 1.47; 95% CI, 0.29–7.45; p = 0.64) were not significantly associated. CONCLUSION: In current asthmatics who presented during an epidemic thunderstorm asthma event, greater exposure to residential NO2 was significantly associated with greater odds of asthma exacerbations requiring urgent healthcare in the previous 12 months.

Anaphylaxis occurred immediately after prophylactic antibiotics injection with negative intradermal skin test during laparoscopic cholecystectomy / 고신대학교의과대학학술지

Prophylactic antibiotics that are used to prevent post-operative infection can commonly cause anaphylactic reactions during anesthesia. It is therefore necessary to perform a skin test before antibiotics are administered in order to diagnose and prevent anaphylactic reactions. However, the results of the antibiotic skin test can differ according to the drug, dose, and reagent concentration. We report a case of anaphylactic shock with bronchospasm and cardiovascular collapse immediately following administration of the prophylactic cefazedone after induction of general anesthesia for laparoscopic cholecystectomy.

Avaliação dos fatores de risco associados ao broncoespasmo induzido pelo exercício em crianças e adolescentes sem diagnóstico prévio de asma / Assessment of risk factors associated with exercise-induced bronchospasm in children and adolescents without prior diagnosis of asthma

Objetivo: Avaliar os fatores de risco associados ao broncoespasmo induzido pelo exercício (BIE) em crianças e adolescentes sem diagnóstico prévio de asma por meio dos parâmetros espirométricos. Métodos: 90 voluntários acima do percentil 85th do peso (EP) e 30 eutróficos (EU) participaram deste estudo. Foi realizado teste de broncoprovocação de acordo com o protocolo de Del Rio-Navarro et al. (2000), utilizando-se esteira ergométrica. O BIE foi considerado positivo quando o voluntário apresentou redução ≥ 10% do volume expiratório forçado no primeiro segundo (VEF1) basal, ou redução ≥ 26% do fluxo expiratório forçado entre 25 e 75% da capacidade vital forçada (FEF25-75%). Resultados: Houve associação do excesso de massa corpórea com o BIE demonstrado nas crianças e adolescentes, o que não foi observado com o nível de atividade física. Além disso, o diagnóstico positivo de BIE apresentou reduções significativas da função pulmonar até uma hora pós-exercício avaliado pelos métodos VEF1 e FEF25-75% da espirometria. Conclusão: O excesso de massa corporal pode influenciar no aumento da frequência de BIE em crianças e adolescentes sem o diagnóstico prévio de asma quando comparado a eutróficos por diferentes parâmetros na espirometria.

Objective: To assess risk factors associated with exercise-induced bronchospasm (EIB) in children and adolescents without prior diagnosis of asthma using spirometric parameters. Methods: 90 volunteers above the 85th percentile for weight (overweight) and 30 eutrophic participants were included in this study. EIB testing was performed according to the protocol proposed in 2000 by Del Rio-Navarro et al., using a treadmill. The EIB test was considered positive when there was a decrease of 10% or more in forced expiratory volume in one second (FEV1) or a reduction of 26% or more in forced expiratory flow between 25 and 75% of the forced vital capacity (FEF25-75%). Results: There was an association between EIB and excess body mass in children and adolescents, but not between EIB and level of physical activity. Furthermore, the diagnosis of EIB was associated with prolonged significant reductions in pulmonary function parameters FEV1 and FEF 25­75%.Conclusion: Excess body weight may increase the frequency of BIE in children and adolescents without prior diagnosis of asthma when compared with eutrophic subjects, based on different spirometric parameters.

Broncoespasmo intraoperatorio en una paciente con asma crítica y estenosis traqueal / Intraoperatory bronchospasms in a patient with critical asthma and tracheal stenosis

Introducción: el asma grave es una de las pocas enfermedades que mantiene tasas de mortalidad iguales desde hace décadas. Objetivo: presentar la evolución clínico-anestesiológica de una paciente con antecedentes de asma bronquial grave y obesidad mórbida, propuesta para resección de una estenosis traqueal. Caso clínico: se presenta el caso de una paciente con asma grave y estenosis traqueal admitida para cirugía abdominal de gran envergadura. Se administró anestesia regional combinada. Presentó un evento de broncoespasmo severo intraoperatorio con atrapamiento aéreo y caída de la oxigenación. Se utilizó ventilación no invasiva con hipoventilación controlada y mezcla de oxígeno y halotano. Se calculó la presión media de la vía aérea y la hiperinsuflación dinámica. Conclusiones: la estratificación del riesgo es imprescindible en la conducta anestesiológica de un paciente con asma grave mediante la realización de pruebas funcionales respiratorias que permiten evaluar globalmente la función pulmonar. La preparación preoperatoria B2 agonistas, esteroides y cromoglicato de sodio puede ser un elemento importante en el control perioperatorio del paciente. La anestesia regional combinada, a pesar de los efectos adversos en la musculatura intercostal, con nivel sensitivo adecuado es muy útil en el intraoperatorio del paciente con asma grave. El uso de ventilación con parámetros prefijados para minimizar la hiperinsuflación dinámica unido al uso de anestésicos volátiles es de extraordinaria ayuda. Además de la monitorización estándar se debe incorporar el cálculo de la presión media de la vía aérea en el manejo de este tipo de pacientes en situaciones de urgencia(AU)

Introduction: Severe asthma is one of the few diseases that has maintained the same mortality rates for decades. Objective: To present the clinical-anesthesiological evolution of a patient with history of severe bronchial asthma and morbid obesity, candidate for a tracheal stenosis resection. Clinical case: The case is presented of a patient with severe asthma and tracheal stenosis, admitted for large-scale abdominal surgery. Combined regional anesthesia was administered. She presented an intraoperative severe bronchospasm event with air trapping and oxygenation decrease. Non-invasive ventilation with controlled hypoventilation and oxygen-halothane mixture was used. Mean airway pressure and dynamic hyperinflation were calculated. Conclusions: Risk stratification is essential in the anesthesiological behavior of a patient with severe asthma through the performance of respiratory functional tests that allow a global assessment of pulmonary function. The preoperative preparation (B2 agonists, steroids and cromolyn sodium) can be an important element in the perioperative control of the patient. Combined regional anesthesia, despite the adverse effects on the intercostal musculature, with adequate sensory level, is very useful in the intraoperative period of the patient with severe asthma. The use of ventilation with preset parameters to minimize dynamic hyperinflation together with the use of volatile anesthetics is of extraordinary support. In addition to standard monitoring, the calculation of mean airway pressure should be included in the management of this type of patient in emergency situations(AU)

The roles of mast cells in allergic inflammation and mast cell-related disorders

Mast cells, which are major effector cells in allergic reactions, are found in the perivascular spaces of most tissues and contain pro-inflammatory and vasoactive mediators. These mediators are released after IgE receptor cross-linking induced by allergens or other stimuli, including anaphylatoxins (C3a and C5a), aggregated IgG, certain drugs, venoms, and physical stimuli (pressure and temperature changes), as well as cytokines and neuropeptides. The excess release of these mediators can cause variable allergic symptoms and signs, such as bronchospasm, itching, flushing, nausea, vomiting, diarrhea, abdominal pain, vascular instability, and anaphylaxis. Furthermore, mast cell disorders may involve either excessive proliferation of mast cells or abnormal mast cell reactivity. Mast cell disorders can be broadly divided into 3 types: primary, secondary, and idiopathic. All of these disorders present with signs and symptoms of mast cell activation and differ in severity and involvement of various organ systems. The best characterized primary disorder is mastocytosis. Systemic and cutaneous forms of the disease are well described. Secondary disorders include typical allergic diseases and some types of urticarial diseases. In this article, the biochemical characteristics of mast cells and the role of mast cells in allergic inflammation, as well as the classification, diagnosis, and management of mast cell-related disorders, will be reviewed.

Immediate hypersensitivity reaction to steroids: a case report

Steroids are widely used for the treatment of a variety of diseases, including autoimmune and allergic diseases. Immediate hypersensitivity reactions can occur within 1 hour after administration of steroids and are regarded as IgE-mediated hypersensitivity presenting as urticaria, angioedema, bronchospasm, and anaphylaxis. Steroid hypersensitivity is rare, but can be life-threatening. Therefore, it is important to find implicated drugs and to choose safe alternative agents. A 44-year-old female was diagnosed with steroid hypersensitivity after intralesional steroid injection. She underwent a skin prick test and an intradermal test for methylprednisolone, triamcinolone, hydrocortisone, and dexamethasone. The results were positive to triamcinolone and methylprednisolone. The patient was educated to avoid culprit agents in order to prevent recurrence. Herein, we report a rare case of steroid hypersensitivity that showed positive reactions to triamcinolone and methylprednisolone. A review of the literature for steroid hypersensitivity is also provided.

The effect of tulobuterol patches on the respiratory system after endotracheal intubation

BACKGROUND: Endotracheal intubation during anesthesia induction may increase airway resistance (R(aw)) and decrease dynamic lung compliance (Cdyn). We hypothesized that prophylactic treatment with a transdermal β2-agonist tulobuterol patch (TP) would help to reduce the risk of bronchospasm after placement of the endotracheal tube. METHODS: Eighty-two American Society of Anesthesiologists (ASA) category I or II adult patients showing obstructive patterns were divided randomly into a control and a TP group (n = 41 each). The night before surgery, a 2-mg TP was applied to patients in the TP group. Standard monitors were recorded, and target controlled infusion (TCI) with propofol and remifentanil was used for anesthesia induction and maintenance. Simultaneously, end-tidal carbon dioxide, R(aw), and Cdyn were determined at 5, 10, and 15 min intervals after endotracheal intubation. RESULTS: There was no significant difference in demographic data between the two groups. The TP group was associated with a lower R(aw) and a higher Cdyn, as compared to the control group. R(aw) was significantly lower at 10 min (P < 0.05) and 15 min (P < 0.01), and Cdyn was significantly higher at 5 min (P < 0.05) and 15 min (P < 0.01) in the TP group. A trend towards a lower R(aw) was observed showing a statistically significant difference 5 min after endotracheal intubation (P < 0.01) in each group. CONCLUSIONS: Prophylactic treatment with TP showed a bronchodilatory effect through suppressing an increase in R(aw) and a decrease in C(dyn) after anesthesia induction without severe adverse effects.

Airway obstruction during general anesthesia in a premature infant suspecting bronchospasm and/or airway malacia: A case report

Airway management is challenging during general anesthesia particularly in small infants. Airway obstruction is prone to occur in premature infants during general anesthesia due to several reasons. We report a case of airway obstruction occurred during the induction of general anesthesia in a 2-month-old infant. Several attempts at endotracheal intubation with positive pressure ventilation resulted in repeated patterns of no end-tidal carbon dioxide output after each trial of endotracheal intubation, but it was reappeared after extubation. However, anesthetic induction with self-respiration and gentle assistance with manual bagging led to a successful intubation. This case was explained by hydromechanics in a collapsible premature airway.

Postoperative negative pressure pulmonary edema following repetitive laryngospasm even after reversal of neuromuscular blockade by sugammadex: a case report / 대한마취과학회지

Laryngospasm, an occlusion of the glottis, can occur at any time during anesthesia, and is associated with serious perioperative complications such as hypoxia, hypercabia, aspiration, bronchospasm, arrhythmia, prolonged recovery, cardiac collapse, and eventually catastrophic death. Importantly, postoperative negative pressure pulmonary edema (NPPE) is a rare, but well described life-threatening complication related to acute and chronic upper airway obstruction. Sugammadex well known for affirmatively reducing the postoperative pulmonary complications associated with residual neuromuscular blockade may have an indirect role in triggering the negative intrathoracic pressure by raising a rapid and efficacious respiratory muscle strength in acute upper airway obstruction. Herein, we report a case of postoperative NPPE following repetitive laryngospasm even after reversal of rocuronium-induced neuromuscular blockade using sugammadex.

Cuerpo extraño en vía aérea con lesión en Arteria Subclavia: caso clínico único / Foreign object in airway with lesion in Subclavian Artery: an only clinical case

Introducción: La aspiración por vía aérea de cuerpo extraño es una complicación común de las personas en los extremos de la vida, que pueden llegar a comprometer la vida, debido principalmente a obstrucción de la vía aérea. En ocasiones más graves y dependiendo del tipo de cuerpo extraño aspirado puede causar síntomas: hemoptisis, broncoespasmo, accesos de tos, disnea etc. Caso: Paciente de 67 años de edad, con antecedentes de ulcera duodenal, evaluado por dos ocasiones en urgencias por cuadros de melenas y hematemesis. Acudió nuevamente por sangrado digestivo y debido a descompensación hemodinámica y marcado descenso del hematocrito fue intervenido quirúrgicamente. Hallazgos operatorios: aneurisma de la arteria subclavia izquierda y cuerpo extraño de madera en la vía aérea. En el postoperatorio fue atendido en la UCI, donde luego de presentar múltiples complicaciones falleció al cabo de 12 días. Discusión: La importancia de este caso radica en la extraña lesión ocurrida por la migración de un cuerpo extraño que viajó desde la vía aérea, produciendo una hemorragia masiva que comprometió la vida del paciente.

Introducción: Airway foreing body aspiration is a common complication in both extremes of life, that might lead to death due to airway obstruction. In severe cases, depending on the foreign body kind, symptoms are: hemoptysis, bronchospasm, coughing, breathlessness etc. Case: A 67 male patient was admitted to the emergency room because of an upper gastrointestinal bleeding. Due to a new bleeding, surgery was performed to control the bleeding. Findings: left subclavian artery aneurism and a wooden foreign body in the midle airway tract. In the postoperative period, he was treated in the ICU, though, he passed away 12 days later due to several complications. Discusion: The importance of this case is the incrdthe odd subclavian artery injury caused by a foreign body that traveled from the airway, causing massive bleeding that put patient's life at risk.

Catastrophic Bronchial Spasm Due to a Severe Anaphylactic Reaction to Protamine

Fatal anaphylactic reactions to protamine sulfate during cardiac surgery are very rare. We report a case of catastrophic bronchial spasm due to an anaphylactic reaction to protamine. The patient was managed successfully using a bronchodilator, steroid treatment, and extracorporeal membrane oxygenation.