Mitomycin C in the endoscopic treatment of tracheal stenosis: a prospective cohort study / Mitomicina C no tratamento endoscópico de estenose traqueal: estudo prospectivo de coorte

ABSTRACT Objective: To evaluate the efficacy of mitomycin C (MMC) in the endoscopic treatment of tracheal stenosis. Methods: Patients with laryngotracheal, tracheal, or tracheobronchial stenosis were treated with dilation and topical MMC. The inclusion criteria were as follows: being ineligible for surgery (for medical reasons) at the time of evaluation; membranous stenosis responding well to dilation; and postoperative stenosis at the anastomosis site. Etiology of stenosis and indication for treatment with MMC, as well as site, length, and percentage of stenosis, together with presence of tracheostomy and duration of follow-up, were analyzed. The outcomes evaluated were symptom-free interval ≥ 12 months, number of dilations with topical application of MMC, and complications. Results: Twenty-two patients (15 men and 7 women) were treated between 2003 and 2010. Stenosis was due to endotracheal intubation in 15 patients and surgery in 8. Pure tracheal stenosis was encountered in 13 patients, subglottic stenosis was encountered in 4, tracheobronchial stenosis was encountered in 3, and complex stenosis was encountered in 2. The length of stenosis ranged from 0.5 cm to 2.5 cm, and the percentage of stenosis ranged from 40% to 100%. Nine patients had undergone tracheostomy and had a Montgomery T-tube in situ. Treatment was successful in 14 patients, who remained free of symptoms for at least 12 months. The number of topical applications of MMC ranged from 1 to 5, and complications included fungal infection, keloid scarring, granuloma, and mediastinal emphysema. Conclusions: MMC appears to be effective in the endoscopic treatment of tracheal stenosis.

RESUMO Objetivo: Avaliar a eficácia da mitomicina C (MMC) no tratamento endoscópico de estenose traqueal. Métodos: Pacientes com estenose laringotraqueal, traqueal ou traqueobrônquica foram tratados por meio de dilatação e MMC tópica. Foram empregados os seguintes critérios de inclusão: pacientes inaptos para cirurgia (por motivos médicos) no momento da avaliação; estenose membranosa com boa resposta a dilatação e estenose pós-operatória no local da anastomose. Foram analisadas as seguintes variáveis: etiologia da estenose; indicação de tratamento com MMC; local e extensão da estenose, bem como a porcentagem de estenose; presença de traqueostomia e tempo de seguimento. Os desfechos avaliados foram 12 meses ou mais sem sintomas, número de dilatações com aplicação de MMC tópica e complicações. Resultados: Vinte e dois pacientes (15 homens e 7 mulheres) foram tratados entre 2003 e 2010. As causas da estenose foram intubação endotraqueal em 15 pacientes e cirurgia em 8. A estenose traqueal pura foi observada em 13 pacientes, a subglótica, em 4, a traqueobrônquica, em 3 e a complexa, em 2. A extensão da estenose variou de 0,5 a 2,5 cm, e a porcentagem de estenose variou de 40 a 100%. Nove pacientes haviam sido submetidos a traqueostomia e apresentavam tubo T de Montgomery in situ. O tratamento teve êxito em 14 pacientes, que permaneceram sem sintomas durante pelo menos 12 meses. O número de aplicações de MMC tópica variou de 1 a 5, e as complicações foram infecção fúngica, queloide, granuloma e enfisema mediastinal. Conclusões: A MMC é aparentemente eficaz no tratamento endoscópico de estenose traqueal.

Anesthetic management of a large mediastinal mass for tracheal stent placement / Manejo anestésico de grande massa mediastinal para a colocação de stent traqueal

ABSTRACT The anesthetic management of patients with large mediastinal masses can be complicated due to the pressure effects of the mass on the airway or major vessels. We present the successful anesthetic management of a 64-year-old female with a large mediastinal mass that encroached on the great vessels and compressed the trachea. A tracheal stent was placed to relieve the tracheal compression under general anesthesia. Spontaneous ventilation was maintained during the perioperative period with the use of a classic laryngeal mask airway. We discuss the utility of laryngeal mask airway for anesthetic management of tracheal stenting in patients with mediastinal masses.

RESUMO O manejo anestésico de pacientes com grandes massas situadas no mediastino pode ser complicado por causa dos efeitos da pressão da massa sobre as vias aéreas ou grandes vasos. Relatamos o manejo anestésico bem-sucedido de uma paciente de 64 anos com uma grande massa mediastinal que invadiu os grandes vasos e comprimiu a traqueia. Um stent traqueal foi colocado para aliviar a compressão da traqueia, sob anestesia geral. A ventilação espontânea foi mantida durante o período perioperatório com o uso de uma máscara laríngea clássica. Discutimos a utilidade da máscara laríngea para o manejo da colocação de stent traqueal em pacientes com massas situadas no mediastino.

Síndrome de compresión traqueal por arteria innominada: casos clínico-radiológicos / Syndrome of tracheal compression by the innominate artery: clinical-radiological cases

Innominate artery compression of the trachea, which is included within the vascular rings, although rare can cause serious respiratory disorders in childhood even putting at risk the child’s life. Most cases are asymptomatic but can also occur with cough, stridor, cyanosis and/or apneas. Diagnostic images play a fundamental role, specially computed tomography and magnetic resonance imaging that provide detailed anatomical information. Bronchoscopy allows confirmation of the diagnosis and assesses the severity of the disorder; moreover, this procedure is also used as support in surgery (aortopexy). Conservative treatment is indicated in less severe cases. Two cases of pediatric patients are presented, one a newborn with severe symptoms and an asymptomatic lactating infant.

La compresión traqueal por arteria innominada, que se incluye dentro de los anillos vasculares, aunque es poco frecuente puede provocar trastornos respiratorios graves en la infancia poniendo incluso en riesgo la vida del niño. La mayoría de los casos son asintomáticos aunque también pueden presentarse con tos, estridor, cianosis y/o apneas. Las imágenes diagnósticas cumplen un rol fundamental, destacando la tomografía computarizada y la resonancia magnética que otorgan información anatómica detallada. La fibrobroncoscopía permite confirmar el diagnóstico y estimar la severidad de la alteración; por otra parte, este procedimiento también se utiliza como apoyo en la cirugía (aortopexia). El manejo conservador está indicado en los casos menos severos. Se presentan 2 casos de pacientes pediátricos, un recién nacido con síntomas severos y un lactante menor asintomático.

Estenosis subglótica y granulomatosis con poliangeítis (Wegener) en dos casos: Report of two cases / Subglottic tracheal stenosis in Wegener disease

Granulomatosis with polyangiitis (GPA) or Wegener's disease is characterized by a granulomatous vasculitis of the upper and lower airways and kidney. It involves the lower respiratory tract causing subglottic tracheal stenosis, which occurs in approximately 22% of patients. We report two females aged 40 and 52 years, admitted to the hospital with a subglottic tracheal stenosis. Their symptoms and management are reviewed. The frst patient responded to rituximab. The second patient required a tracheostomy.

Tracheal resection and anastomosis: an 11 year management outcome

To evaluate the etiology, perioperative management and outcome of surgery in cases of tracheal stenosis. This was a retrospective analysis of patients with tracheal stenosis who underwent resection with anastomosis from January 2000 until December 2010. Ten patients, aged between 15 to 53 years old [mean of 34.4 years] were included. Post intubation injury was the major cause of tracheal stenosis [n=8], followed by external laryngeal trauma [n=2]. Using the Cotton-Myer classification, 60% of patients had Grade III stenosis whilst 40% had Grade IV stenosis. Intravenous corticosteroids were given 24 hours before extubation. Four patients were well post- operatively without complications. The most common complication in the other patients was granulation tissue in the anastomosis region [n=3], vocal cord paresis [n=2] and one restenosis [n=1]. Four of these patients underwent examination under anesthesia with removal of granulation tissue and/or laser dilatation. However, 2 cases needed Shian Lee operation and required T-tube until present. The success rate for tracheal resection and anastomosis is taken as the number of patients successfully decannulated, which was 80%. Tracheal resection with end-to-end anatomosis was a successful procedure for cervical tracheal stenosis, with low mortality and few complications related to it

role of tracheal stenting as an alternative treatment in cicatricial and non-operable tracheal stenosis

Tracheal stenosis is normally caused by trauma, infection, benign and malignant tumors, prolonged intubation or tracheostomy. The best treatment for tracheal stenosis is resection and anastomosis of trachea. Yet the major surgical complication of tracheal surgery is postoperative stenosis. The goal of this paper is to study the result of tracheal stenting as a replacement therapy for patients suffering from tracheal stenosis who are not good candidates for surgery. This study presents the results of stenting in patients with: Inoperable tumoral stenosis,Non-tumoral stenosis being complicated due to prior surgeries,Inability to undergo a major surgery. The study was performed between September 2002 and July 2011 and poly flex stents were used by means of rigid bronchoscopy. A total of 25 patients received stents during this study. Among them 15 patients suffered from benign and 10 suffered from malignant tracheal stenosis. The patients were followed up for at most 12 months after the stenting operation. The mean age of the patients was 35 years. The most common cause of stenosis was prolonged intubation [75%]. The most common indication for stenting was the history of multiple tracheal operations. The most common complication of stenting and cause of stent removal was formation of granulation tissue. 30% of patients with benign tracheal stenosis were cured and about 10% improved until they could stand a major operation. Ten patients in benign group and 2 patients in malignant group [20%] needed T-Tube insertion after stent removal but other patientcure by stenting. In benign cases stenting is associated with recurrence of symptoms which requires other therapeutic techniqus, so the stenting may not be named as a final solution in benign cases. However, this technique is the only method with approved efficacy for malignant cases with indication

Tracheal Wall Thickening Is Associated with the Granulation Tissue Formation Around Silicone Stents in Patients with Post-Tuberculosis Tracheal Stenosis

PURPOSE: Tracheal restenosis due to excessive granulation tissue around a silicone stent requires repeated bronchoscopic interventions in patients with post-tuberculosis tracheal stenosis (PTTS). The current study was conducted to identify the risk factors for granulation tissue formation after silicone stenting in PTTS patients. MATERIALS AND METHODS: A retrospective study was conducted between January 1998 and December 2010. Forty-two PTTS patients with silicone stenting were selected. Clinical and radiological variables were retrospectively collected and analyzed. RESULTS: Tracheal restenosis due to granulation tissue formation were found in 20 patients (47.6%), and repeated bronchoscopic interventions were conducted. In multivariate analysis, tracheal wall thickness, measured on axial computed tomography scan, was independently associated with granulation tissue formation after silicone stenting. Furthermore, the degree of tracheal wall thickness was well correlated with the degree of granulation tissue formation. CONCLUSION: Tracheal wall thickening was associated with granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis.

Anillos vasculares como diagnóstico diferencial del asma / Vascular rings in differential diagnosis of asthma

Aortic arch abnormalities and vascular rings are a rare cause of compression of trachea and esophagus causing respiratory and digestive symptoms in adults. We report a 64 years old woman with exercise induced asthma not resolving with adequate treatment. Flow/volume loop shape suggested an intrathoracic major airway obstruction. Chest X ray showed a right sided aortic notch and CT scan revealed a vascular ring composed by a right aortic arch with aberrant left subclavian artery and Kommerell's diverticulum compressing trachea and esophagus. Bronchoscopy confirmed posterior wall compression of trachea exacerbated by tachycardia as a cause of symptoms. We think that is important to consider vascular rings as a differential diagnostic entity in difficult to treat asthma.

Las anomalías del arco aórtico y sus ramas son infrecuentes. La presencia de un anillo vascular determina la aparición de sintomatología relacionada con compresión traqueal o esofágica. El diagnóstico en la edad adulta es extremadamente inusual. Se presenta el caso de una mujer de 64 años con diagnóstico de Asma inducida por ejercicio, refractaria a tratamiento, la cual presentó disnea sibilante en relación al ejercicio, que no cedió con tratamiento bien llevado. La curva flujo-volumen sugirió obstrucción variable de la vía aérea central intratorácica, la radiografía de tórax mostró botón aórtico situado a derecha, la tomografía computada del tórax demostró un anillo vascular formado por un arco aórtico derecho, con la arteria subclavia izquierda aberrante, divertículo de Kommerell comprimiendo el esófago y con la aorta descendente que en su trayecto comprime la pared posterior de la tráquea, lo que es corroborado por videobroncoscopía, describiéndose compresión pulsátil, que se exacerbaba con la taquicardia. Se concluye que la paciente tiene un anillo vascular causante de los síntomas descritos y nos orienta a establecer que en el esquema de estudio de pacientes con asma atípica o de difícil manejo, es necesario incluir las malformaciones del arco aórtico en el diagnóstico diferencial, realizando al menos radiografía de tórax y revisando atentamente la gráfica de la curva flujo-volumen.

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

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

Endotracheal tuberculous stenosis: Ventilation rescue and bronchography guided stenting.

We present the case of a 16-year-old female patient who presented with dyspnoea, cough and noisy breathing that progressed further in hospital with the development of stridor and severe respiratory compromise requiring mechanical ventilatory support. Investigations were consistent with a diagnosis of endotracheal tuberculosis with tracheal and bronchial stenosis. Despite adequate anti-tuberculous therapy and ventilation the patient had high airway pressures, low tidal volumes and hypercapnia, which prevented weaning from mechanical ventilation. Balloon dilatation and stenting of the 4.5cm long, 2.3mm diameter stenotic tracheal segment was performed under radiological guidance. The patient was weaned successfully from the ventilator post-procedure. This report illustrates the successful management of an uncommon presentation of a common disease with modern endoscopic therapy.

Surgical treatment of post-intubation tracheal stenosis

Incidence of post-intubation tracheal stenoses is relatively high in Iran and the majority of tracheal surgeries are performed to treat these strictures. Therefore, it is important to become familiar with the nature of tracheal stenoses and know their treatment methods. Most surgeons learn different methods of tracheal surgery through operating on cases of post-intubation tracheal stenoses and apply these methods for surgical operation of tracheal tumors. We mainly focused on the technique of tracheal surgery, patient selection, and pre-op and post-op equipments required. Other related fields such as anatomy of the trachea, bronchoscopy, imaging, laser therapy and stenting are mentioned when necessary

Intubation-induced tracheal stenosis - the urgent need for permanent solution

The most common site for the occurrence of intubation-induced tracheal damage is at the area in contact with the inflatable cuff. After the change from high-pressure to low-pressure cuffs, major tracheal lesions still continue to occur. This is a case of tracheal stenosis that occurred after 7 days of intubation with standard cuffed tube whose cuff pressure was assessed by subjective means. Three weeks later, patient was in need of reintubation, the trachea was found to be stenotic at the site of the previous tube cuff. Emergency tracheostomy had to be performed and computed axial tomography [CT] confirmed the tracheal stenosis. A month later, the patient had another cardiac arrest from which he did not recover. Our message in this report is to throw light and alert clinicians involved in tracheal intubation, of the presence of the Lanz endotracheal tube whose pilot balloon is designed to automatically regulate the intra-cuff pressure and thus prevent the occurrence of tracheal stenosis due to high pressure. We strongly recommend the presence of Lanz tracheal tubes as standard emergency equipment in intensive care settings and in any situation in which cuff pressure is likely to increase

Stomaplasty--anterior advancement flap and lateral splaying of trachea, a simple and effective technique.

BACKGROUND: Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. AIM: To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. SETTINGS AND DESIGN: Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. MATERIALS AND METHODS: A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. STATISTICAL ANALYSIS: Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. RESULTS: Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. CONCLUSIONS: This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

Endoprótese auto-expansível de malha de poliéster revestida por silicone (Polyflex®) no tratamento de estenoses traqueais não-cirúrgicas / Self-expanding stent made of polyester mesh with silicon coating (Polyflex®) in the treatment of inoperable tracheal stenoses

OBJETIVO: Avaliar a prótese Polyflex® quanto à sua eficácia, facilidade de implantação e complicações em pacientes com afecções traqueobrônquicas. MÉTODOS: Foram acompanhados, prospectivamente, dezesseis pacientes com estenoses traqueais secundárias à intubação orotraqueal (n = 12), neoplasia (n = 3) e granulomatose de Wegener (n = 1), não candidatos a tratamento cirúrgico. Desses, onze eram mulheres e cinco eram homens, com idade média de 42,8 anos (intervalo de 21 a 72 anos). Os pacientes foram submetidos à implantação de um total de 21 próteses Polyflex®. Os procedimentos foram realizados no centro cirúrgico, sob anestesia geral e as próteses implantadas através de laringoscopia de suspensão e aplicador próprio. RESULTADOS: Em todos os casos foi possível implantar a prótese e observamos resolução de sintomas. Os pacientes permaneceram com a prótese por tempo médio de 7,45 meses, variando entre 2 e 18 meses. As complicações pós-operatórias imediatas observadas foram disfonia em dois pacientes (12,5 por cento) e odinofagia em dois pacientes (12,5 por cento). As complicações tardias foram tosse em dez pacientes (62,5 por cento), migração em sete pacientes (43,75 por cento), formação de granulomas em dois pacientes (12,5 por cento) e pneumonia em um paciente (6,25 por cento). CONCLUSÃO: A prótese Polyflex® é fácil de implantar e retirar, é bem tolerada e efetiva na resolução dos sintomas, porém, está associada a alto índice de migração, principalmente em estenoses pós-intubação orotraqueal.

OBJECTIVE: To evaluate the Polyflex® stent in terms of its efficacy, ease of implantation, and complications in patients with tracheobronchial affections. METHODS: This was a prospective study, in which sixteen patients with inoperable tracheal stenosis secondary to orotracheal intubation (n = 12), neoplasia (n = 3), or Wegener's granulomatosis (n = 1) were monitored. Of these patients, eleven were women, and five were men. The mean age was 42.8 years (range, 21-72 years). Patients were submitted to implantation of a total of 21 Polyflex® stents. All procedures were carried out in the operating room under general anesthesia, and the stents were implanted via suspension laryngoscopy using the stent applicator. RESULTS: Stents were implanted and symptoms were resolved in all cases. The stents remained in place for a mean period of 7.45 months, ranging from 2 to 18 months. The complications observed in the immediate postoperative period were dysphonia (in two patients, 12.5 percent) and odynophagia (in two patients, 12.5 percent). Late complications were cough (in ten patients, 62.5 percent), migration (in seven patients, 43.75 percent), granuloma formation (in two patients, 12.5 percent), and pneumonia (in one patient, 6.25 percent). CONCLUSION: The Polyflex® stent is easily implanted, easily removed, well tolerated by patients and effective in resolving symptoms. However, its use is associated with a high rate of migration, especially in patients with post-orotracheal intubation stenosis.

Percutaneous dilational tracheostomy: an initial experience in community based teaching hospital.

Percutaneous dilational tracheostomy (PDT) is frequently performed in the intensive care unit to prevent the long term complications associated with prolonged endotracheal intubation. OBJECTIVE: To report the analysis of our experience with percutaneous dilation tracheostomy. STUDY DESIGN: A prospective documentation of 40 patients who received percutaneous dilational tracheostomy in a multidisciplinary intensive care unit during a 12-month period. METHOD: The patients demographic, indications of intubation and PDT, time required to perform the procedure, complications and the outcome of these patients in the intensive care unit were noted. RESULT: Among 425 patients, 40 underwent percutaneous dilational tracheostomy that included 22 females and 18 males with the median age of 35 years. Prolonged ventilatory support was the most common indication for tracheostomy. The average duration of intubation before PDT was 5 days. Median procedure time was 20 minutes. Complications included minor bleeding in two (5%), subcutaneous emphysema with pneumothorax in two patients (5%), tracheal stenosis in three (7.5%), tracheo-esophageal fistula and glottic granuloma in one patient each (2.5%). Among forty patients, 28 (70%) were discharged to the ward, 8 died in intensive care unit and 4 left hospital against medical advice. CONCLUSION: Percutaneous dilational tracheostomy is a safe, quick and effective way for long term airway management in critically ill patients.

Ventilatory management of severe tracheal stenosis.

We present here a 4 year old child with severe tracheal stenosis and respiratory failure. The patient was not responding to conventional ventilation settings and had significant hypercarbia. The difficulty in mechanical ventilation was handled successfully with specific ventilatory strategy: use of low respiratory rate, long inspiratory time and normal inspiratory time: expiratory time ratio. Thereafter the child was managed surgically and the stenosis was corrected. The child was discharged after a Montgomery T-tube placement.

[How postintubation tracheal stenosis could be prevented?]

Although it is assumed that appropriate care of endotracheal tubes and airway might prevent postintubation airway stenosis [PIAS], but this concept has not been investigated adequately. The purpose of the study was to investigate practical ways for prevention of PIAS in intubated patients. The study was implemented in 3 phases. First we collected information about methods of caring for airways and tubes in intensive care units in Tehran and other cities [control group] and data collection based on filling 10-20 questionnaires in each intensive care unit. Then we assessed patients who had PIAS and had been treated by us during a 6 year period [1994-2000] [study group]. In the final phase, collected data were analyzed and we looked for important pitfalls in caring for airways in intensive care units in our country and also looked for the practical measures to prevent PIAS. In phase I, 341 questionnaires were filled out in 18 intensive care units [12 in Tehran, 6 in other cities]. There were 133 females and 208 males aged 3 month to 98 years [mean 46.1]. Head injury was the commonest cause of intubations in 24%. of patients. Out of 356 tracheal tubes which had been used in these patients, 318 were high volume low pressure types [new tubes], and 32 were high pressure low volume types [old tubes]. In 179 patients [52.4%], there was not any type of care for tubes and airways by attending physicians, in 140 patients [41%] there was some kind of care although not organized or sufficient and in only 21 patients [6.1%] the care was organized and sufficient. Mean time of intubation was 8 days [1-45 days]. Tracheotomy had been undertaken without any established criteria and mostly by junior staff with low experience [usually junior residents]. In phase II, 120 patients were treated for PIAS [36 females, 84 males aging 1-83 years, mean 25.9 years]. Head injury was the cause of intubation in 78 [65%] patients, the site of stenosis was tracheal in 88 and laryngotracheal in 32 patients. More than half of the patients were intubated by inappropriate old tubes. Direct cause of stenosis was the cuff in 92, tip of the tubes in 15 and stoma in 10 patients. In 3 patients more than one factor were the causes. Mean time of intubation was 14.9 days [1-90] and mean length of stenosis was 3.2 cm [1-7]. Caring of tubes and airways was inappropriate and inorganized in all patients. Factors which were statistically different in study and control group were: time of intubation [14.9 day vs 8 days, P=0.000], suicide attempts [12 vs 5, P=0.000], head injuries [65% vs 24% P=0.000], Age [25.9y Vs 46y, P=0.05], using old tubes [50% vs 9% P=0.000], organized caring of tubes and airways [0.0%vs6.1%P=0.000]. The following measures are effective in decreasing the PIAS: decreasing time of intubation, using appropriate tubes, [including PVC tubes], continuous care of airway and tube, cuff monitoring and daily recording of information about tubes and cuff pressure, and special care for intubated young patients who had sustained head injury or had attempted suicide

Incidência e características endoscópicas de lesões das vias aéreas associadas à intubação traqueal em crianças / Incidence and endoscopic characteristics of airway injuries associated with endotracheal intubation in children

OBJETIVO: Descrever a incidência e características endoscópicas de lesões das vias aéreas em crianças submetidas à intubação. MÉTODOS: Durante o período de dois anos (outubro/99 a outubro/01) foi conduzido estudo prospectivo no qual todo paciente intubado, excetuando-se aqueles que evoluíram para óbito e recém-nascidos (RN) com peso inferior a 1.250g, foi submetido à endoscopia respiratória na extubação. Achados endoscópicos foram classificados em leves, moderados ou graves. Descrições foram realizadas por meio de proporções e medianas, comparações feitas por teste qui-quadrado para proporções. RESULTADOS: Foram estudados 61 RN e 154 crianças. Em 89,8 por cento dos pacientes, sendo 55 RN e 138 crianças (p=0,89), foi detectada pelo menos uma lesão somando 507. Pacientes com lesões leves corresponderam a 54,8 por cento (IC95 por cento: 48,1-61,5), aqueles com lesões moderadas foram 24,2 por cento (IC95 por cento: 18,5-30,0) enquanto as graves ocorreram em 10,7 por cento dos pacientes (IC95 por cento: 6,6-14,8). Locais principalmente acometidos foram glote (48,1 por cento das lesões) e subglote (34,9 por cento das lesões). Erosões foram as mais incidentes em ambos os grupos etários (p=0,88). Edema de prega vocal foi a principal lesão moderada em ambos os grupos (p=0,96), seguida por ulcerações (p=0,92). Nódulos fibrosos em pregas vocais e sinéqüias foram as principais lesões graves em ambos os grupos etários (p=0,12). Estenose subglótica foi detectada em 2,8 por cento da população sem diferença entre as faixas etárias (p=0,35). CONCLUSÕES: Verificou-se elevada incidência de lesões em vias aéreas, sem diferença significante entre os grupos etários com relação à incidência e características das lesões. Houve predomínio de lesões leves, lesões na glote e caracterizadas por erosões, edema e ulcerações.

Anillos vasculares: valor de las imágenes en 56 casos / Vascular rings: diagnostic imaging in a 56 patients series

El anillo vascular es una anomalía infrecuente de las grandes arterias y sus ramas, que comprimen la tráquea y/o el esófago produciendo estridor y/o disfagia en los niños. Analizamos retrospectivamente los pacientes con anillo vascular estudiados durante 10 años (1988-1998), correlacionando síntomas, Rx de tórax (F y P), esofagograma, endoscopia y angiografía. Utilizando base de datos Epi-6. De estos pacientes a 47 se les realizó arteriografía constatando: 20 DAA, 16 AISDur, 4 ADSlur, 3 AIA, 2 SAP y 2 DK. Se sometieron a tratamiento quirúrgico 39 pacientes. El diagnóstico de anillo vascular es efectivo en el esofagograma en un gran porcentaje de los casos, sobre todo en anillos completos. La endoscopía es útil en los pacientes sintomáticos con esofagograma normal. La clínica define la cirugía y la angiografía la anatomía puntual en los pacientes con indicación quirúrgica. La TC helicoidal con 3D y la RM podrían reemplazar en la actualidad los procedimientos endoscópicos y angiográficos en los pacientes sin cardiopatía asociada