Pudendal nerve block for circumcision of pediatric patient with Pierre Robin Sequence: case report

Abstract Pierre Robin Sequence (PRS) is a congenital condition characterized by micrognathia, glossoptosis, and cleft palate that presents with airway obstruction and developmental delay with or without other congenital anomalies. These patients' anesthesia management is challenging because of difficult ventilation and intubation. Regional anesthesia methods should be considered for these patients on a case-by-case basis. This report presents primary use of regional anesthesia for circumcision of a 9-year-old boy with PRS.

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.

Dupilumabe no tratamento de rinossinusite crônica com pólipo nasal em adolescente / Dupilumab in the treatment of chronic rhinosinusitis with nasal polyps in adolescents

O uso do anticorpo monoclonal dupilumabe em adultos tem possibilitado o controle da inflamação crônica, reduzindo significativamente o tamanho e a recorrência de novos pólipos, melhorando os sintomas nasais e, consequentemente, a qualidade de vida desses indivíduos. Relatamos o caso de uma adolescente que evidencia a eficácia de dupilumabe no tratamento da rinossinusite crônica com pólipo nasal.

The use of the monoclonal antibody dupilumab in adults has allowed the control of chronic inflammation, significantly reducing the size and recurrence of new polyps, improving nasal symptoms, and, consequently, quality of life. We report a successful case of dupilumab use in an adolescent for the treatment of chronic rhinosinusitis with nasal polyps.

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.

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

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

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

Evaluación del miedo dental en niños atendidos en la Clínica Odontológica Universidad Franz Tamayo-Bolivia / Avaliação do medo dental em crianças atendidas na Clínica Odontológica da Universidade Franz Tamayo-Bolívia / Evaluation of dental fear in children attended at the Odontological clinic from Franz Tamayo University-Bolivia

El miedo dental en niños puede variar en su naturaleza, intensidad y persistencia, transformándose en un comportamiento negativo y problemático que el dentista debe identificar para proporcionar un apropiado tratamiento. El presente estudio tuvo por objetivo evaluar el miedo dental en 190 niños y niñas de 4 a 12 años de edad que asistieron al servicio odontológico en la ciudad de El Alto, utilizando la Escala de Evaluación de Miedo en niños ­ Subescala Dental; adicionalmente se recolectó información de experiencias odontológicas previas. Los resultados revelaron una media total de 30,7 ± 8,3 en la escala, lo cual indica que el miedo dental presente es bajo entre los niños evaluados. Tampoco se encontraron diferencias significativas en cuanto a género. En relación a la edad, el grupo de niños entre 10 a 12 años evidenciaron una proporción más elevada (41%) de miedo dental, que los otros grupos de niños de edades menores. La experiencia de visitas odontológicas previas está asociada más frecuentemente a niveles de miedo dental bajo a diferencia de los niveles moderados y altos encontrados en aquellos que asistieron por vez primera. Se identificó que asfixiarse, inyecciones y que un extraño los toque, son aspectos que causan más ansiedad en los niños. El presente estudio concluyó que la prevalencia de miedo dental en los niños de la ciudad de El Alto es bajo y no asociada al género, pero hay evidencia de que puede incrementarse en niños mayores y en aquellos que no tuvieron experiencias odontológicas previas.

Resumo: O medo ao tratamento odontológico pode variar em natureza, intensidade e persistência, provocando ansiedade, pensamentos obsessivos ou diminuição do umbral de dor, derivando num comportamento negativo e problemático, que não somente impede aos pacientes de procurar tratamento, mas também interfere com a eficácia do mesmo. Pelos motivos acima indicados é relevante a identificação do medo ao tratamento odontológico em população pediátrica. No presente estudo tivemos como objetivo avaliar ao tratamento odontológico em crianças de 4 a 12 anos de idade, que atenderam ao serviço odontológico na cidade de El Alto, utilizando a Escala de Avaliação de Medo em crianças ­ Subescala Dentaria, adicionalmente se coletou informação sobre experiências odontológicas previas. O presente estudo, ressalta a importância dequeosdentistasconsideremalémdacondiçãofísicaoestadopsicológicoeemocional. Osresultadosobtidosmostraram uma média de 30,7 ± 8,3 segundo a escala, indicando que o medo dentário foi baixo no grupo de 190 crianças avaliadas. Não se encontraram diferenças significativas em termos de gênero. Ao respeito da idade, o grupo de crianças entre 10 a 12 anos mostrou uma proporção mais alta (41%) de medo quando comparado com os outros grupos de crianças em faixas etárias menores. A experiência de visitas odontológicas previas encontra-se associada com níveis de medo ao tratamento odontológico mais baixos em comparação com níveis moderados e altos nas crianças que assistiram por primeira vez. Se identificou que o fato de se asfixiar, ter injeção aplicada e que contato com uma pessoa alheia, são os aspeitos que causam maior medo nas crianças. O presente estudo concluiu que a prevalência do medo ao tratamento odontológico em crianças da cidade de El Alto é baixa, não associado ao gênero, mas existe evidência de que pode incrementar em crianças maiores e em aqueles que não tiveram experiências odontológicas previas.

Abstract: Dental fear in children can vary in its nature, intensity and persistence, causing anxiety, obsessive thinking or decreasing the pain threshold, transforming into a negative and problematic behavior, that not only prevents patients from seeking treatment but also interferes with its efficacy. Due to the afore mentioned issues, the identification of dental fear in pediatric population is relevant and the dentist must identify to provide appropriate treatment. The objective of this study was to evaluate dental fear in boys and girls aged 4 to 12 who attended dental services in the city of El Alto, using the Scale for the Evaluation of Fear in Children - Dental Subscale. Additionally, information was collected from previous dental experiences. The present study highlights the importance that dentists not only consider the physical condition of the patients, but also the psychological and emotional state. The results obtained revealed a total mean of 30.7 ± 8.3 on the scale, which indicates that the dental fear is low among the 190 children evaluated. Neither were significant differences found in terms of gender. In relation to age, the group of children between 10 and 12 years old showed a higher proportion (41%) of dental fear than the other groups of children of younger ages. The experience of previous dental visits is more frequently associated with low levels of dental fear, as opposed to the moderate and high levels found in those who attended for the first time. Choking, injections, and being touched by a stranger have been identified as causing the most anxiety in children. The present study concluded that the prevalence of dental fear in children in the city of El Alto is low and not associated with gender, but there is evidence that it may increase in older children and in those who had no previous dental experiences.

Validade de conteúdo dos indicadores clínicos de desobstrução ineficaz de vias aéreas / Validez de contenido de los indicadores clínicos de desobstrucción ineficaz de las vías aéreas / Content validity of ineffective airway clearance clinical indicators

Resumo Objetivo Identificar os indicadores clínicos mais relevantes para o Diagnóstico de Enfermagem Desobstrução ineficaz de vias aéreas. Método Estudo metodológico de análise de conteúdo organizado em três fases: definição conceitual do fenômeno de interesse, construção da estrutura do fenômeno de interesse e análise dos juízes sobre a estrutura construída. Resultados Foram identificados 21 indicadores clínicos. Apenas Sons respiratórios aumentados e Retração subcostal não foram indicadores significativamente relevantes para o diagnóstico. Conclusão Os indicadores de maior relevância para o diagnóstico Desobstrução ineficaz de vias aéreas foram: Dispneia, Mudanças no ritmo respiratório, Ruídos adventícios respiratórios, Taquipneia, Acúmulo excessivo de muco, Tosse ineficaz, Sons respiratórios diminuídos, Ortopneia, Cianose, Inquietação, Dificuldade para verbalizar e Uso da musculatura acessória para respirar.

Resumen Objetivo Identificar a los indicadores clínicos más relevantes para el Diagnóstico de Enfermería Desobstrucción ineficaz de las vías aéreas. Métodos Estudio metodológico de análisis de contenido organizado em tres fases: definición conceptual del fenómeno de interés, construcción de la estructura del fenómeno de interés y análisis de los jueces sobre la estructura construida. Resultados Se identificaron 21 indicadores clínicos. Únicamente Sonidos respiratorios aumentados y Retracción subcostal no fueron indicadores significantemente relevantes para el diagnóstico. Conclusión Los indicadores de mayor relevancia para el diagnóstico Desobstrucción ineficaz de las vías aéreas fueron: Disnea, Cambios en el ritmo respiratorio, Ruidos adventicios respiratorios, Taquipnea, Acúmulo excesivo de mucosidad, Tos ineficaz, Sonidos respiratorios disminuidos, Ortopnea, Cianosis, Inquietud, Dificultad para verbalizar y Uso de la musculatura accesoria para respirar.

Abstract Objective To identify the most relevant clinical indicators for the Ineffective airway clearance Nursing Diagnosis. Method This is a methodological study of content analysis organized into a conceptual definition of the phenomenon of interest, construction of the phenomenon of interest structure and analysis by judges on the constructed structure. Results Twenty-one clinical indicators were identified. Only Increased breath sounds and Subcostal retraction were not significantly relevant for the diagnosis. Conclusion The most relevant indicators for the Ineffective airway clearance diagnosis were: Dyspnea, Alteration in respiratory rate, Adventitious respiratory noises, Tachypnea, Excessive sputum, Ineffective cough, Decreased breathing sounds, Orthopnea, Cyanosis, Restlessness, Difficulty verbalizing and Use of accessory muscles to breathe.

Clinical analysis of selective tracheostomy necessary for patients undergoing head and neck surgery with free flap reconstruction / 北京大学学报(医学版)

OBJECTIVE@#To discover the factors that may affect the use of selective tracheostomy among patients who have undergone head and neck surgeries with free flap reconstruction, so that the patients will not need tracheostomy nor receive the unnecessary treatment.@*METHODS@#Five hundred and thirty-three patients who had undergone head and neck surgery with free flap reconstruction operated by the same team of surgery at Department of Oral and Maxillofacial Surgery at Peking University School of Stomatology from 2015 to 2016 were reviewed. Three hundred and twenty-one (60.2%) of these patients underwent selective tracheostomy. All the patients' demographic information, operation-related information, prior treatments, comorbidities and complications were recorded and analyzed.@*RESULTS@#The patients with defects of the tongue, mouth floor, oropharynx and bilateral mandible, who underwent neck dissection and with previous radiotherapy and smoking habit were more likely to get selective tracheostomy. Usage of bulky soft tissue flap might also add to the risk of airway obstruction and the need of selective tracheostomy, while other factors were not significantly related to the risk of postoperative airway obstruction and the patients could be kept safe without selective tracheostomy. Most cases without tracheostomy were kept safe except one case, while 8.39% of the patients with tracheostomy suffered from tracheostomy related complications, mainly pneumonia and hemorrhage of the tracheostomy wound, yet none led to serious consequences or even death.@*CONCLUSION@#Selective tracheostomy is not necessary for patients who have undergone head and neck surgeries with free flap reconstruction except that there are defects at the tongue, oropharynx and mandible. Neck dissection, bulky soft tissue flap reconstruction, previous radiotherapy and smoking habit may also add to the risk of postoperative airway obstruction, while a favorable decision would involve a combination of all the above factors to assure the safety of the postoperative airway for the patients undergone head and neck surgeries with free flap reconstruction.

Clinical characteristics and outcomes of 111 neonates with upper airway obstruction admitted via transportation / 中华儿科杂志

Objectives: To analyze the clinical characteristics and outcomes of neonates with upper airway obstruction (UAO) who were admitted via transportation, hence to provide more evidence-based information for the clinical management of UAO. Methods: This was a single center retrospective study. Patients were hospitalized in Beijing Children's Hospital from January 1, 2016 to May 31, 2021 with age <28 days or postmenstrual age (PMA) ≤44 weeks, and UAO as the first diagnosis. The general information of patients, obstructed sites in the upper airway, treatment, complications and prognosis were analyzed. The outcomes of surgical UAO vs. non-surgical UAO were analyzed by 2 by 2 χ2 test. Results: A total of 111 cases were analyzed (2.3% of the total NICU hospitalized 4 826 infants in the same period), in which 62 (55.9%) were boys and 101 (91.0%) were term infants, and their gestational age was (38.7±2.0) weeks, birth weight (3 207±585) g, PMA on admission (40.8±2.5) weeks and weight on admission was (3 221±478) g. There were 92 cases (82.9%) with symptoms of UAO presenting on postnatal day 1, and 35 cases (31.5%) had extra-uterine growth retardation on admission. The diagnosis of UAO and the obstructive site was confirmed in 25 cases (22.5%) before transportation. There were 24 cases (21.6%), 71 cases (64.0%), and 16 cases (14.4%) who had UAO due to nasal, throat, and neck problems, respectively. The top 5 diagnosis of UAO were vocal cord paralysis (28 cases), bilateral choanal atresia (20 cases), laryngomalacia (15 cases), pharynx and larynx cysts (7 cases), and subglottic hemangioma (6 cases). The diagnosis and treatment of all the patients followed a multidisciplinary approach consisted of neonatal intensive care unit, ear-nose-throat department and medical image departments. A total of 102 cases (91.9%) underwent both bronchofiberscope and fiber nasopharyngoscope investigation. Seventy cases (63.1%) required ventilation. Among the 58 cases (52.3%) who required surgical intervention, 16 had tracheotomy. For cases with vs. without surgical intervention, the rate of cure and (or) improvement were 94.8% (55/58) vs. 54.7% (29/53), and the rate of being discharged against medical arrangement were 1.7% (1/58) vs. 45.3% (24/53) (χ²=24.21 and 30.11, both P<0.01). Conclusions: Neonatal UAO may locate at various sites of the upper airway. The overall prognosis of neonatal UAO is favorable. A multidisciplinary approach is necessary for efficient evaluation and appropriate surgical intervention.

Oxigenación apnéica para extracción de cuerpo extraño en vía aérea / Apneic oxygenation for extracting a foreign body in the airway

La oxigenación apnéica consiste en la administración de flujos altos de oxígeno a través de algún dispositivo supraglótico mientras el paciente se mantiene en apnea. Se explica por qué el alveolo desnitrogenizado con una composición en su mayor parte de oxígeno, permite la difusión alveolo capilar y genera una presión subatmosférica capaz de arrastrar el flujo de oxigeno existente en el árbol traqueobronquial hasta el mismo alveolo, siempre y cuando no hubiera obstrucción mecánica de la vía aérea. El tiempo aumenta considerablemente hasta que la saturación de oxígeno disminuya, lo que se conoce como tiempo de apnea segura. Se presenta la experiencia de emplear esta técnica en un escolar de 5 años sin antecedentes patológicos, que ingirió un cuerpo extraño (semilla de girasol), la cual se localizaba en vía aérea bronquio principal derecho. Este se extrajo por fibrobroncoscopía bajo anestesia total intravenosa, priorizando la ventilación espontánea hasta localizarlo, y luego, debido a la dificultad que presentó su extracción, se empleó relajación muscular y apnea para optimizar las condiciones de la extracción. Durante este periodo, se empleó la técnica de oxigenación apnéica, la cual se mantuvo durante 12 min. La saturación pulsátil de oxigeno fue mayor al 92 por ciento, tiempo suficiente para culminar la extracción con éxito y sin complicaciones(AU)

Apneic oxygenation consists in the administration of high flows of oxygen through a supraglottic device while the patient remains in apnea. It is explained because the alveolus with low nitrogen concertation/accumulation, with a composition mostly of oxygen, allows capillary alveolus to diffuse, as well as it generates a subatmospheric pressure capable of dragging the oxygen flow existing in the tracheobronchial tree to the alveolus itself, as long as there is no mechanical airway obstruction. The time increases considerably until oxygen saturation decreases, which is known as the safe apnea time. The experience of using this technique is presented is it was used with a five-year-old boy with no pathological history and who swallowed a foreign body (sunflower seed), which was located in the airway, specifically the right main bronchus. The foreign body was extracted by fiberoptic bronchoscopy under total intravenous anesthesia, prioritizing spontaneous ventilation until it was located; and then, due to the difficulty for its extraction, muscle relaxation and apnea were used to optimize the extraction conditions. During this period, the apneic oxygenation technique was used and maintained for twelve minutes. Pulsatile oxygen saturation was greater than 92 percent, enough time to complete the extraction successfully and without complications(AU)

Utilização do limite inferior da normalidade versus ponto de corte fixo na avaliação de crianças e adolescentes com doenças pulmonares / Use of the lower limit of normality versus fixed cut-off point in the assessment of children and adolescents with pulmonary diseases

RESUMO Introdução: A espirometria é um exame que avalia a função pulmonar,complementando a análise clínica.O objetivo do estudo foi avaliar a associação entre os valores do limite inferior de normalidade (LIN) e ponto de corte fixo na interpretação do distúrbio ventilatório obstrutivo (DVO), utilizando o volume expiratório forçado no 1º segundo (VEF1)/capacidade vital(CV) e VEF1/capacidade vital forçada (CVF) de crianças e adolescentes com doença pulmonar. Métodos: Estudo transversal com 358 testes espirométricos de crianças e adolescentes com doença pulmonar entre 7 e 18 anos de idade foram encaminhados ao Laboratório de Prova de Função Respiratória (LPFR) entre novembro de 2016 e dezembro de 2017. As espirometrias seguiram normas estabelecidas pela American Thoracic Society/European Respiratory Society Task Force (ATS/ERS, 2005). Na classificação do DVO foi utilizado dois critérios de interpretação da relação VEF1/CVF: ponto de corte fixos e o LIN do 50 percentil, considerado padrão ouro. Analisada a concordância através do índice Kappa de Cohen. Resultados: 316 espirometrias,mediana de idade de 12 anos(7-18) e 51,9% do sexo masculino. Observada fraca concordância entre os dois critérios (Kappa igual a 0,30). Pelo LIN do 50 percentil foi possível identificar mais casos de DVO em comparação ao ponto de corte fixo, com p<0,001. Conclusão: Identificamos fraca concordância entre os dois métodos e o LIN foi capaz de classificar mais casos de DVO quando comparados ao ponto de corte fixo. Novos estudos devem ser realizados para conclusão do assunto na faixa etária pediátrica. PALAVRA-CHAVE: Espirometria, obstrução das vias respiratórias, criança, adolescente, diagnóstico

ABSTRACT Introduction: Spirometry is a test that assesses lung function, complementing the clinical analysis. The aim of the study was to evaluate the association between the values of lower limit of normality (LLN) and fixed cut-off point in the interpretation of obstructive ventilatory disorder (OVD), using the forced expiratory volume in the 1st second (FEV1)/vital capacity (VC) and FEV1/forced vital capacity (FVC) of children and adolescents with lung disease. Methods: A cross-sectional study with 358 spirometric tests in children and adolescents with pulmonary disease between 7 and 18 years of age were referred to the Respiratory Function Test Laboratory (LPFR) between November 2016 and December 2017. Spirometry followed the standards established by the American Thoracic Society/European Respiratory Society Task Force (ATS/ERS, 2005). In the classification of OVD, two criteria were used for interpreting the FEV1/FVC ratio: fixed cutoff point and the LLN of the 50th percentile, considered the gold standard. Concordance analysis was through the Cohen's Kappa index. Through the LLN of the 50th percentile, it was possible to identify more cases of OVD compared to the fixed cutoff point, with p<0.001. Conclusion: We found a weak concordance between the two methods, and LLN was able to classify more cases of OVD as compared to the fixed cutoff point. New studies must be carried out to conclude the subject in the pediatric age group. KEYWORDS: Spirometry, airway obstruction, child, adolescent, diagnosis

Diagnóstico tardío de cuerpos extraños en vía aérea en pediatría en el ospital de Especialidades Carlos Andrade Marín / Late diagnosis of foreign bodies in pediatric airway in the Carlos Andrade Marín Specialties Hospital

La aspiración de cuerpos extraños es una de las principales causas de ingreso a urgencias y de morbi-mortalidad en Ecuador en pacientes pediátricos. El diagnóstico suele ser tardío, por falta de interés de los cuidadores, o por errores en la valoración. Es importante detectar el cuadro a tiempo, para evitar complicaciones. OBJETIVO. Demostrar la necesidad de un diagnóstico acertado ante la alta sospecha en un cuadro dudoso de aspiración de cuerpo extraño. SERIE DE CASOS. Evaluación de cuatro pacientes de ambos sexos, de entre 11 meses a 15 años de edad con antecedente de ingesta de cuerpo extraño, atendidos en la Unidad Técnica de Cirugía Pediátrica, del Hospital de Especialidades Carlos Andrade Marín, durante el periodo 2019-2020. Se realizó la extracción exitosa mediante broncoscopia rígida en tres de ellos. DISCUSIÓN. La mayoría de pacientes con aspiración de cuerpo extraño suelen ser menores de 5 años de edad, en contraste con éste estudio, donde sólo un paciente estuvo dentro de este rango, y el resto fueron escolares y adolescentes. El cuerpo extraño más común es de origen orgánico; el 50% de los casos observados fue de origen inorgánico. CONCLUSIÓN. El diagnóstico de aspiración de cuerpo extraño se condiciona a la obtención completa de datos sobre la Historia Clínica; requiere una valoración rápida y manejo adecuado por emergencias.

INTRODUCTION. Foreign body aspiration is one of the main causes of emergency room admissions and morbidity and mortality in pediatric patients in Ecuador. Diagnosis is usually late, due to lack of interest of caregivers, or due to errors in the assessment. It is important to detect the condition in time to avoid complications. OBJECTIVE. To demonstrate the need for an accurate diagnosis in the presence of high suspicion in a doubtful picture of foreign body aspiration. CASE SERIES. Evaluation of four patients of both sexes, between 11 months and 15 years of age with a history of foreign body ingestion, attended at the Pediatric Surgery Technical Unit of the Carlos Andrade Marin Specialties Hospital, during 2019-2020 period. Successful extraction by rigid bronchoscopy was performed in three of them. DISCUSSION. Most patients with foreign body aspiration are usually under 5 years of age, in contrast to this study, where only one patient was within this range, and the rest were schoolchildren and adolescents. The most common foreign body is of organic origin; 50% of the cases observed were of inorganic origin. CONCLUSION. The diagnosis of foreign body aspiration is conditioned to the complete collection of data on the Clinical History; it requires a rapid assessment and appropriate emergency management.

Utilização do limite inferior da normalidade versus ponto de corte fixo na avaliação de crianças e adolescentes com doenças pulmonares / Use of the lower limit of normality versus fixed cut-off point in the assessment of children and adolescents with pulmonary diseases

Resumo Introdução:A espirometria é um exame que avalia a função pulmonar,complementando a análise clínica.O objetivo do estudo foi avaliar a associação entre os valores do limite inferior de normalidade(LIN) e ponto de corte fixo na interpretação do distúrbio ventilatório obstrutivo(DVO),utilizando o volume expiratório forçado no 1º segundo(VEF1)/capacidade vital(CV) e VEF1/capacidade vital forçada(CVF) de crianças e adolescentes com doença pulmonar.Métodos:Estudo transversal com 358 testes espirométricos de crianças e adolescentes com doença pulmonar entre 7 e 18 anos de idade foram encaminhados ao Laboratório de Prova de Função Respiratória(LPFR) entre novembro de 2016 e dezembro de 2017. As espirometrias seguiram normas estabelecidas pela American Thoracic Society/European Respiratory Society Task Force(ATS/ERS, 2005).Na classificação do DVO foi utilizado dois critérios de interpretação da relação VEF1/CVF:ponto de corte fixos e o LIN do 50 percentil,considerado padrão ouro.Analisada a concordância através do índice Kappa de Cohen.Resultados:316 espirometrias,mediana de idade de 12 anos(7-18) e 51,9% do sexo masculino.Observada fraca concordância entre os dois critérios (Kappa igual a 0,30).Pelo LIN do 50 percentil foi possível identificar mais casos de DVO em comparação ao ponto de corte fixo, com p<0,001.Conclusão:Identificamos fraca concordância entre os dois métodos e o LIN foi capaz de classificar mais casos de DVO quando comparados ao ponto de corte fixo. Novos estudos devem ser realizados para conclusão do assunto na faixa etária pediátrica. Palavras-chave: Espirometria, Obstrução das Vias Respiratórias, Criança, Adolescente, Diagnóstico.

Summary Introduction: Spirometry is a test that evaluates pulmonary function, complementing the clinical analysis. The objective of the study was to evaluate the association between the values ​​of the lower limit of normality (LIN) and fixed cut-off point in the interpretation of obstructive respiratory disorder (OVD) ), using forced expiratory volume in 1 second (FEV1)/vital capacity (VC) and FEV1/forced vital capacity (FVC) of children and adolescents with lung disease.Methods:Cross-sectional study with 358 spirometric tests of children and adolescents with lung disease. between 7 and 18 years of age were referred to the Respiratory Function Testing Laboratory (LPFR) between November 2016 and December 2017. Spirometry followed standards established by the American Thoracic Society/European Respiratory Society Task Force (ATS/ERS, 2005). ).In the OVD classification, two interpretation criteria were used for the FEV1/FVC ratio: fixed cut-off point and the 50th percentile LIN, considered the gold standard. concordance through Cohen's Kappa index. Results: 316 spirometries, median age of 12 years (7-18) and 51.9% male. Weak agreement between the two criteria was observed (Kappa equal to 0.30). LIN of the 50th percentile, it was possible to identify more cases of OVD compared to the fixed cut-off point, with p<0.001.Conclusion: We identified weak agreement between the two methods and the LIN was able to classify more cases of OVD when compared to the cut-off point fixed. New studies must be carried out to conclude the matter in the pediatric age group. Keywords: Spirometry, Airway Obstruction, Child, Adolescent, Diagnosis.

Teratoma oral: la importancia del diagnóstico prenatal y el trabajo interdisciplinario: un caso clínico / Epignathus, the importance of prenatal diagnosis and interdisciplinary work: A case report

Gracias al avance de la tecnología, es posible realizar el diagnóstico prenatal de distintas malformaciones congénitas que ponen en riesgo la vida del recién nacido. Entre estas, el teratoma oral o epignathus es una forma poco frecuente de teratoma congénito entre los que se localizan en cabeza y cuello. Suelen ser benignos y abarcan el 4 % de los teratomas neonatales.A partir del desarrollo de la técnica de tratamiento intraparto extraútero (EXIT, por su sigla en inglés), que se implementó en los años 90 para mantener la circulación fetal hasta asegurar la vía aérea del recién nacido, se logra planificar una estrategia de manejo multidisciplinario que permite el abordaje correcto de estas patologías. Se presenta un caso de teratoma oral gigante en una paciente de sexo femenino de 35 semanas de gestación, en quien se aplicó la técnica EXIT, y su evolución posterior.

Thanks to technological advances, it has been possible to carry out the prenatal diagnosis of different life-threatening congenital malformations. Among these, oral teratoma, or epignathus, is a rare form of congenital teratoma within those located in the head and neck. They are generally benign and comprise 4 % of neonatal teratomas. From the development of the EXIT technique (ex utero intrapartum treatment), which has been implemented since the 90's to support fetal circulation until the newborn's airway is secured, it is possible to plan a multidisciplinary management strategy that enables the correct approach of these pathologies.We present a case of giant epignathus in a 35-week gestation female patient, whose airway was secured using the EXIT technique, and follow up.

Ultrasound-guided superior laryngeal nerve block -A description of the technique / Bloqueo de nervio laríngeo superior guiado por ecografia. Descripción de la técnica

Abstract Complications in airway management remain a common cause of anesthesia-associated mortality. When a patient is considered with anticipated difficult airway, the management depends on several variables, however, at present, the standard of management continues to be the patient awake approach. In scenarios of acute upper airway obstruction, the only way to guarantee adequate ventilation is to obtain a translaryngeal or transtracheal access, for which, it is necessary to use local anesthesia and grade I / II sedation, avoiding loss of spontaneous ventilation. For this purpose, we propose ultrasound-guided superior laryngeal nerve block, in order to standardize an ultrasound landmark that is reproduceable, with a high success rate, which allows limiting complications related to regional anatomic techniques and thus facilitating the securing of the airway in these patients.

Resumen Las complicaciones en el manejo de la vía aérea siguen siendo una causa frecuente de mortalidad relacionada con anestesia. Cuando un paciente se considera con vía aérea difícil anticipada, el manejo depende de diversas variables, sin embargo, en la actualidad, el estándar de manejo sigue siendo el abordaje con paciente despierto. En escenarios de obstrucción aguda de la vía aérea superior, la única forma de garantizar una adecuada ventilación es obtener un acceso translaríngeo o transtraqueal, para lo cual, es necesario el uso de anestesia local y de sedación grado I/II evitando la pérdida de ventilación espontánea. Con este propósito, planteamos el bloqueo del nervio laríngeo superior guiado por ultrasonografía, con el fin de estandarizar una referencia ecográfica reproducible, con alto índice de éxito, la cual permita limitar complicaciones relacionadas con las técnicas regionales anatómicas y así facilitar el aseguramiento de la vía aérea en estos pacientes.

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.

Caso clínico: aproximación a la vía aérea difícil en neonatología. Síndrome de Treacher-Collins / Clinical case: approach to the difficult airway in neonatology. Treacher-Collins syndrome

Cuando los recién nacidos presentan obstrucción de la vía aérea, requieren un manejo urgente y experto para evitar la mortalidad y la morbilidad. La definición de vía aérea difícil se relaciona con problemas en la intubación endotraqueal o en la ventilación a presión positiva con bolsa y máscara o reanimador de pieza en T. El manejo debe basarse en la comprensión del mecanismo fisiopatológico responsable de la vía aérea difícil. Las causas en el recién nacido pueden ser congénitas y/o adquiridas.Se presenta el caso de una recién nacida con síndrome de Treacher-Collins tipo 1 [OMIM #154500] con una disostosis mandibulofacial, micrognatia, hipoplasia malar, paladar hendido, sin cardiopatía congénita, asociado con intubación extremadamente difícil

f newborns have an airway obstruction, they require urgent and expert management to avoid mortality and morbidity. The definition of difficult airway includes problems in endotracheal intubation or positive pressure ventilation with bag and mask or T-piece resuscitator. Management should be based on an understanding of the pathophysiological mechanism responsible for difficult airway. The causes of difficult airway in the newborn can be congenital or acquired.We present the case of a newborn with Treacher-Collins syndrome Type 1 [OMIM # 154500] with a mandibulofacial dysostosis, micrognathia, malar hypoplasia, cleft palate, without congenital heart disease, associated with extremely difficult intubation

Conhecimentos de funcionários de creches sobre primeiros socorros com crianças antes e após treinamento ativo / Conocimientos de los empleados de guarderías sobre primeros auxilios a niños antes y después del entrenamiento activo / Knowledge of nursery workers about first aid measures with children before and after active training

RESUMO Objetivo: identificar mudanças no conhecimento de funcionários de creches após intervenção educacional ativa em primeiros socorros com crianças no ambiente escolar. Método: estudo quase-experimental, do tipo antes e depois, com grupo único de comparação composto por 134 funcionários das seis creches públicas de um município brasileiro, mediante adesão voluntária ofertada a toda população do estudo. O treinamento em primeiros socorros contou com 16 horas/aula e utilizou métodos ativos de aprendizagem. Um questionário fechado com nove situações simuladas avaliou o conhecimento antes/após. Utilizou-se o software R Core Team 2020, nível de significância 5% e o teste não paramétrico de McNemar para efeito da intervenção. Resultados: houve um aumento estatisticamente significativo de acertos após o treinamento nos seguintes assuntos: parada cardiorrespiratória; convulsão; engasgo; choque elétrico; trauma, queda; hemorragia; e intoxicação. As principais diferenças nos acertos antes e após foram engasgo (77,6% para 98,5%), trauma (75,3% para 94,7%), intoxicação por ingestão (70,8% para 86,5%) e convulsão (87,3% para 98,5%). C onclusões: o treinamento ampliou conhecimentos acerca de todas as temáticas, com exceção de queimaduras (p=0,248). O contexto sociocultural deve ser considerado, bem como a carga horária distribuída entre teoria e práticas. Os enfermeiros podem ser os profissionais de referência para ministrar tais cursos.

Resumen Objetivo: identificar cambios en el conocimiento de empleados de guarderías tras intervención educativa activa en primeros auxilios a niños en el ambiente escolar. Método: estudio casi-experimental, del tipo antes y después, con grupo único de comparación compuesto por 134 empleados de las seis guarderías públicas de un municipio brasileño, mediante adhesión voluntaria ofrecida a toda población del estudio. El entrenamiento en primeros auxilios contó con 16 horas/clasey utilizó métodos activos de aprendizaje. Un cuestionario cerrado con nueve situaciones simuladas evaluóel conocimiento antes/después. Se utilizó el softwareR Core Team 2020, nivel de significancia 5% y la prueba no paramétrica de McNemar para efecto de la intervención. Resultados: hubo un aumento estadísticamente significativo de aciertos después del entrenamiento en los siguientes asuntos: paro cardiorrespiratorio; convulsión; atragantamiento; choque eléctrico; trauma, caída; hemorragia; e intoxicación. Las principales diferencias en los aciertos antes y después fueron atragantamiento (77,6% para 98,5%), trauma (75,3% para 94,7%), intoxicación por ingestión (70,8% para 86,5%) y convulsión (87,3% para 98,5%). Conclusiones: el entrenamiento amplió conocimientos acerca de todas las temáticas, con excepción de quemaduras (p=0,248). El contexto sociocultural debe ser considerado, así como la carga horaria distribuida entre teoría y prácticas. Los enfermeros pueden ser los profesionales de referencia para dar tales cursos.

ABSTRACT Objective: to identify changes in the knowledge of nursery workers after active educational intervention in first aid measures with children in the school environment. Method: a quasi-experimental study of the before and after type with a single comparison group composed of 134 workers from the six public nursery centers in a Brazilian municipality, through voluntary adherence offered to the entire study population. First aid training consisted of 16 hours/class and used active learning methods. A closed questionnaire with nine simulated situations assessed the knowledge before and after the intervention. The R Core Team 2020 software was used in the analysis, and a significance level of 5% and the McNemar non-parametric test were used for the purpose of the intervention. Results: there was a statistically significant increase in correct answers after training in the following subjects: cardiorespiratory arrest; convulsion; choking; electric shock; trauma, fall; bleeding, and poisoning. The main differences in terms of correct answers before and after were found for choking (77.6% to 98.5%), trauma (75.3% to 94.7%), poisoning by ingestion (70.8% to 86.5%), and convulsion (87.3% to 98.5%). Conclusions: the training expanded the knowledge about all the themes, with the exception of burns (p = 0.248). The socio-cultural context must be considered, as well as the workload distributed between theory and practices. Nurses can be the reference professionals to teach such courses.