Bedside management of lung collapse in children on mechanical ventilation: saline lavage--simulated cough technique proves simple, effective.

We report a simple, four-step procedure for bedside treatment of infants on mechanical ventilation who have various degree of lung collapse unresponsive to conventional instillation of saline followed by chest percussion with endotracheal suctioning. The technique involves hyperoxygenation by bagging with 100% oxygen, deep endotracheal instillation of 0.25-0.5 mL/kg sterile saline, bagging with momentary inspiratory hold, followed by release of the hold and simultaneous forced exhalation and vibration to simulate cough, and endotracheal suctioning. This procedure was repeated three to five times on the affected side and at least once on the unaffected side; it resulted in notably improved lung expansion in 48 of 57 infants, documented by chest radiographs. The 57 infants included 48 (84%) whose chest radiographs showed airways occluded by mucus ("no air bronchograms") and 7 (16%) whose chest radiographs showed patent airways ("air bronchograms"). The technique is less successful in the latter group of patients in whom material obstructing proximal and intermediate airways has already been removed or displaced to distal airways, or a parenchymal infection has developed.

Arterial thrombosis and protein S deficiency.

A previously healthy boy had progressive painful discoloration of the lower extremities and was treated with exchange transfusion and anticoagulation, which were unsuccessful in arresting pedal ischemia; amputation of all of the child's toes was required. Studies of the patient and his parents resulted in a diagnosis of inherited protein S deficiency.

Adenosine in the treatment of paroxysmal supraventricular tachycardia in children.

Intravenous bolus adenosine was given to four pediatric patients aged 1 month to 8 years who had paroxysmal supraventricular tachycardia that had not responded to conventional medical therapy. Adenosine (one to three doses) was successful in converting the arrhythmia to normal sinus rhythm in all four cases, and no side effects of the drug were noted.

Esophagotracheal perforation during an emergency intubation.

The authors report the first known case of a simultaneous esophagotracheal perforation, which occurred during an emergency intubation of a patient with airway abnormalities. The perforation was suspected from the postintubation chest roentgenograph and confirmed by fiber optic bronchoscopy which showed that the endotracheal tube had entered through the posterior wall of the trachea after perforating the esophagus. The patient had a tracheostomy done and was placed on prophylactic antibiotic therapy; the esophageal tear was left to heal spontaneously. Risk factors for esophagotracheal perforation, means to avoid it, and diagnosis and treatment considerations are discussed.

Dexamethasone in the prevention of postextubation stridor in children.

To assess whether there is any advantage in the use of corticosteroid to prevent postextubation stridor in children, we conducted a prospective, randomized, double-blind trial of dexamethasone versus saline solution. The patients were evaluated and then randomly selected to receive either dexamethasone or saline solution according to a stratification based on risk factors for postextubation stridor: age, duration of intubation, upper airway trauma, circulatory compromise, and tracheitis. Dexamethasone, 0.5 mg/kg, was given every 6 hours for a total of six doses beginning 6 to 12 hours before and continuing after endotracheal extubation in a pediatric intensive care setting. There was no statistical difference in incidence of postextubation stridor in the two groups; 23 of 77 children in the placebo group and 16 of 76 in the dexamethasone group had stridor requiring therapy (p = 0.21). We conclude that the routine use of corticosteroids for the prevention of postextubation stridor during uncomplicated pediatric intensive care airway management is unwarranted.

Blunt cardiac injury in children.

Thirty-nine children admitted to the pediatric intensive care unit with multiple injuries from blunt trauma underwent serial EKGs, determination of creatinine phosphokinase (CPK) isoenzymes, echocardiography, and radionuclide angiography studies. Motor vehicle injuries were responsible for 83% (32 of 39) of admissions, the remainder (7 of 39) caused by falls from heights. Thirteen children sustained serious (Modified Injury Severity Score [MISS] greater than 25) multiple system injury. Chest injuries were sustained by 12 children, nine being serious thoracic injuries (MISS chest score greater than 2). Three children (7.7%) showed elevations of MB fraction of CPK isoenzymes in addition to EKG abnormalities and/or ejection fraction depression on radionuclide angiography and were considered to have sustained cardiac contusion. Eight other children (20%) had normal or borderline elevation of CPK-MB fraction and EKG abnormalities combined with abnormal echocardiograms or radionuclide angiograms, and were considered to have sustained cardiac concussion. An additional 14 children (36%) had EKG or radionuclide angiography abnormalities alone. Two children required lidocaine therapy for cardiac irritability manifesting as multifocal PVCs and ventricular tachycardia. Based on this study, a comprehensive diagnostic evaluation of the heart in all children sustaining multiple injuries from blunt trauma cannot be justified. Continuous cardiac monitoring should be initiated in the emergency room and maintained throughout intensive care unit confinement to identify transient dysrhythmias. In patients with significant dysrhythmias and in those with obvious thoracic injuries serial EKG and cardiac isoenzyme assay should be obtained. Dysrhythmias should be man-aged with appropriate anti-arrhythmic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary edema complicating relief of upper airway obstruction.

Treatment by endotracheal intubation or tracheostomy in children with severe and prolonged upper airway obstruction usually results in dramatic improvement; in some rare instances, it is complicated by the development of pulmonary edema. During an eight-year period, the author observed this complication in 20 children. The mechanism of this edema is complex and not yet fully understood. In addition to hypoxia, profound hemodynamic changes occur during the inspiratory phase of the obstruction; highly negative transpulmonary pressure may lead to an increase in pulmonary blood volume and biventricular dysfunction, and possibly disruption of integrity of the pulmonary endothelium. These hemodynamic changes appear to be counterbalanced by the positive pleural and alveolar pressures and decreased venous return during the expiratory component of the obstruction. Nevertheless, when an artificial airway is inserted, this compensation is disrupted abruptly, resulting in an increase in systemic venous return and thus pulmonary edema. Although this type of edema usually is observed in cases of severe obstruction, it may go unrecognized or misdiagnosed.

Perforation of the heart by central venous catheters in infants: guidelines to diagnosis and management.

The frequent use of central venous catheters has resulted in improved monitoring and parenteral nutrition. However, these catheters have also been a source of numerous complications, some of them lethal. Two cases of perforation of the heart that resulted in cardiac tamponade and death are reported. Early detection of this complication depends on a high index of suspicion, both clinical and radiographic. Measures such as securing the catheter tip in the superior vena cava can prevent this complication; immediate evacuation of the pericardial fluid by gentle aspiration or pericardiocentesis can prove life-saving.

Patent ductus arteriosus. Its occurrence with unequal pulmonary vascularity and hyperlucent left lung.

Twenty-four of 230 patients with patent ductus arteriosus had hypovascularity and hyperlucency in the left lung on preoperative chest roentgenograms. Two of the 24 patients died shortly after operation, and one was unavailable for follow-up. During the postoperative course (mean, three years), roentgenograms of eight of the remaining 21 patients showed persistent, unequal pulmonary vascularity and hyperlucent left lung, with no evidence of air trapping, and two patients had diminished volume of the hyperlucent left lung compared with that of the right lung.

Pulmonary edema following relief of acute upper airway obstruction.

Five children, aged one to five years, with severe upper airway obstruction, three of whom had epiglottitis and two of whom had laryngotracheobronchitis, developed acute pulmonary edema after the obstruction had been relieved by placement of an artificial airway. Although major physiologic changes, such as hypoxemia and massive sympathetic discharge, play a significant role in the development of acute pulmonary edema, we have postulated a possible etiological cause for the development of pulmonary edema in these children which involves a series of physiologic events. The generation of very high transpulmonary pressure gradients during inspiration is opposed by a decreased venous return due to the obstruction during exhalation. Airway pressures then fall abruptly with the insertion of the artifial airway, resulting in a sudden increase in venous return to the central circulation and marked increase in the intravascular hydrostatic pressures. The final result of this series of events is the development of pulmonary hyperemia and edema. The prevention of this situation must begin the moment the airway is inserted and involves the application of moderate amounts of continuous positive pressure to the airway, thus allowing time for circulatory adaption to take place.

Pulmonary hyperinflation in ventricular septal defect.

Pulmonary hyperinflation (PH) has frequently been seen in patients with ventricular septal defect (VSD). Mean age of patients at the time of cardiac catherization and operation was less in Group II (PHI) than in Group I (normal pulmonary inflation). There is a statistically significant difference in the ratio of mean pulmonary to mean systemic blood flow and the ratio of mean peak pulmonary to mean peak systemic systolic pressures, with the higher values recorded for Group II. There is no statistically significant difference in the pulmonary vascular resistance in the two groups. Thirty-five of the 44 patients with PHI developed normal inflation within a month after surgical correction of VSD. Possible mechanisms of PHI in VSD are discussed. PHI is prolong and perpetuate respiratory distress and can lead to progressive lung disease. PHI is therefore another indication for early surgical correction of VSD.

Clinical implications of postoperative unilateral phrenic nerve paralysis.

Unilateral phrenic nerve paralysis (PNP) folowed 32 (1.7 percent) of 1,891 consecutive cardiac surgical procedures during an 8 year peroid. Diagnosis was based on radiographic criteria with comparison of preoperative and postoperative chest radiographs and was confirmed in all 21 evaluated by fluoroscopy. Six had persistent radiographic abnormality more than 12 months postoperatively. PNP occurred most frequently in association with Blalock-Taussig shunts. These operations represented 22 percent of this series, and PNP complicated 7 percent of all Blalock-Taussig shunts. PNP was less well tolerated in the 14 infants than in the 18 older children. Eleven infants had serious difficulties during weaning from mechanical ventilatory support. Five infants required tracheostomy, one underwent diaphragmatic plication, and three died. Infants had a mean duration of mechanical ventilation of 24 days and required prolonged intensive care and long-term hospitalization. In comparison, older children had a more benign postoperative course. Diaphragmatic plication should be considered in infants with paradoxical motion of the hemidiaphragm who remain dependent on mechanical ventilatory support for more than 2 weeks postoperatively.