Description of a Novel Pathogenic Variant in the ARPC1B and a Severe Allergy in Two Infants.

Actinrelated protein 2/3 complex subunit 1B (ARPC1B) deficiency is an inborn error of immunity (IEI) characterized by a combination of immunodeficiency and immune dysregulation and classified as an IEI with allergic manifestations. Here, we describe two patients with pathogenic variants in the ARPC1B gene. The first patient presented with eczema and bronchospasm at six months of age. The second patient presented with eczema and milk protein allergy at five months of age. The c.899_944 (p.Glu300Glyfs*7) pathogenic variant was previously described, whereas the c.863del (p.Pro288Leufs*9) variant was novel. ARPC1B deficiency should be considered because of the severe allergic manifestations at an early age.

Evaluation of the classifications of severity in acute respiratory distress syndrome in childhood by the Berlin Consensus and the Pediatric Acute Lung Injury Consensus Conference / Avaliação das classificações de gravidade na síndrome do desconforto respiratório agudo na infância pelo Consenso de Berlim e pelo Pediatric Acute Lung Injury Consensus Conference

ABSTRACT Objective To compare two methods for defining and classifying the severity of pediatric acute respiratory distress syndrome: the Berlin classification, which uses the relationship between the partial pressure of oxygen and the fraction of inspired oxygen, and the classification of the Pediatric Acute Lung Injury Consensus Conference, which uses the oxygenation index. Methods This was a prospective study of patients aged 0 - 18 years with a diagnosis of acute respiratory distress syndrome who were invasively mechanically ventilated and provided one to three arterial blood gas samples, totaling 140 valid measurements. These measures were evaluated for correlation using the Spearman test and agreement using the kappa coefficient between the two classifications, initially using the general population of the study and then subdividing it into patients with and without bronchospasm and those with and without the use of neuromuscular blockers. The effect of these two factors (bronchospasm and neuromuscular blocking agent) separately and together on both classifications was also assessed using two-way analysis of variance. Results In the general population, who were 54 patients aged 0 - 18 years a strong negative correlation was found by Spearman's test (ρ -0.91; p < 0.001), and strong agreement was found by the kappa coefficient (0.62; p < 0.001) in the comparison between Berlin and Pediatric Acute Lung Injury Consensus Conference. In the populations with and without bronchospasm and who did and did not use neuromuscular blockers, the correlation coefficients were similar to those of the general population, though among patients not using neuromuscular blockers, there was greater agreement between the classifications than for patients using neuromuscular blockers (kappa 0.67 versus 0.56, p < 0.001 for both). Neuromuscular blockers had a significant effect on the relationship between the partial pressure of oxygen and the fraction of inspired oxygen (analysis of variance; F: 12.9; p < 0.001) and the oxygenation index (analysis of variance; F: 8.3; p = 0.004). Conclusion There was a strong correlation and agreement between the two classifications in the general population and in the subgroups studied. Use of neuromuscular blockers had a significant effect on the severity of acute respiratory distress syndrome.

RESUMO Objetivo Comparar dois métodos para definição e classificação de gravidade na síndrome do desconforto respiratório agudo pediátrica: a classificação de Berlim, que utiliza a relação entre pressão parcial de oxigênio e fração inspirada de oxigênio e a classificação do Pediatric Acute Lung Injury Consensus Conference, que utiliza o índice de oxigenação. Métodos Estudo prospectivo com pacientes de 0 - 18 anos com diagnóstico de síndrome do desconforto respiratório agudo e ventilados mecanicamente de forma invasiva, que forneceram de uma a três amostras de gasometria arterial, totalizando 140 medidas válidas. Essas medidas foram avaliadas quanto à correlação pelo teste de Spearman e à concordância pelo coeficiente kappa entre as duas classificações, inicialmente usando a população geral do estudo e, depois, subdividindo-a em pacientes com e sem broncoespasmo e com e sem o uso do bloqueador neuromuscular. Também foi verificado o efeito desses dois fatores (broncoespasmo e bloqueador neuromuscular) de forma separada e conjunta sobre ambas as classificações por meio da análise de variância para dois fatores. Resultados Na população geral, composta de 54 pacientes com idades de 0 - 18 anos, foi encontrada forte correlação negativa pelo teste de Spearman (ρ -0,91; p < 0,001) e forte concordância pelo coeficiente kappa (0,62; p < 0,001) na comparação entre Berlim e Pediatric Acute Lung Injury Consensus Conference. Nas populações com e sem broncoespasmo e com e sem o uso do bloqueador neuromuscular, os coeficientes de correlação mantiveram valores semelhantes aos da população geral. Entretanto, para os pacientes sem uso do bloqueador neuromuscular, houve maior concordância entre as classificações em relação aos pacientes com uso do bloqueador neuromuscular (kappa 0,67 versus 0,56 com p < 0,001 em ambos). Acrescenta-se ainda o efeito significativo do uso do bloqueador neuromuscular sobre a relação entre pressão parcial de oxigênio e fração inspirada de oxigênio (análise de variância; F: 12,9; p < 0,001) e o índice de oxigenação (análise de variância; F: 8,3; p = 0,004). Conclusão Houve forte correlação e concordância entre as duas classificações na população geral e nos subgrupos estudados, entretanto, há efeito significativo do uso do bloqueador neuromuscular sobre as classificações de gravidade da síndrome do desconforto respiratório agudo.

Sugammadex-induced bronchospasm: a case report.

Sugammadex has shown faster reversal of steroidal neuromuscular blockade (NMB) than neostigmine, a traditional reversal agent for NMB, even in the intense block phase. This efficiency is possible because of the unique mechanism of action by encapsulating the NMB molecules. Therefore, with the use of sugammadex, we can also expect to avoid direct interactions with the cholinergic system and its subsequent side effects, which are disadvantages of traditional drugs. However, despite these benefits and US Food and Drug Administration (FDA) approval in 2015, rare adverse events associated with sugammadex have been reported. Herein, we report a case of bronchospasm that developed immediately after sugammadex administration.

The Effect of Albuterol Spray on Hypoxia and Bronchospasm in Patients with Chronic Obstructive Pulmonary Disease (COPD) under General Anesthesia: A bouble-Blind Randomized Clinical Trial.

Background: Patients with chronic obstructive pulmonary disease (COPD) experience an increased risk of perioperative pulmonary complications. The aim of this study was to evaluate the effect of albuterol spray on hypoxia and bronchospasm in patients with COPD under general anesthesia. Methods: This single-center, double-blind, parallel-group, randomized clinical trial was performed on 120 smoking patients with COPD who were referred to 5 Azar Educational Hospital in Gorgan, Northern Iran, in 2021. Twenty minutes before general anesthesia and also after completion of surgery and before extubation, 60 patients in the intervention group were inhaled with 2 puffs of albuterol spray. In the control group, patients were inhaled with 2 puffs of placebo spray. In perioperative period, the occurrence of wheezing, bronchospasm, coughing, hemodynamic changes, postoperative shivering, dyspnea, and nausea and vomiting were evaluated in all patients. The Consolidated Standards of Reporting Trials (CONSORT) checklist was used to report important aspects of this study. Results: The mean age of the patients was 52.34 ±8.95 years, and 115 (95.8%) of them were males while the rest were females. The difference between systolic blood pressure before induction of anesthesia (after administration of albuterol spray) between the group receiving albuterol spray and the group not receiving it was statistically significant (p=0.04). Also, the difference between the mean arterial oxygen saturation before tracheal extubation (after re-administration of albuterol spray) between the albuterol spray group and the non-albuterol group was statistically significant (p = 0.03). Wheezing and recurrent cough after induction of anesthesia and after extubation (after albuterol spray administration) was lower in the albuterol group than in the control group (p<0.05). No significant side effects were detected in the albuterol-treated group. Conclusion: According to the results of this study, it seems that the prophylactic use of albuterol spray is useful in reducing the incidence of wheezing and recurrent cough before induction of anesthesia in COPD patients with smoking.

[Ketamine as a treatment of bronchospasm due to an anaphylaxis. A case report]. / Ketamina como tratamiento de broncoespasmo asociado a anafilaxia. Reporte de un caso.

Background: Ketamine is used in intravenous anesthesia for the maintenance in the general anesthesia. It has characteristics to prevent the difficult of breathing due to bronchospasm, as well as the delivery of histamine associated with asthmatic attack. These effects come from the direct action in the bronchial muscle, as well as from the potentiation of its catecholamines, which is why its use is very controversial, given that there are not enough trials to back it up. Moreover, the effect of ketamine on bronchospasm due to anaphylactic reaction has not been studied. The election treatment is epinephrine and there are factors associated with its use. The objective was to present the case of a patient with a history of allergic reaction to midazolam, who presented bronchospasm due to the administration of this drug, and who received unconventional treatment with positive outcomes. Clinical case: We present the case of a young female with a history of allergies to medicines, specifically to benzodiazepines, who presented bronchospasm and oxygen saturation drop after receiving a dose of midazolam into her eye while she was working. The use of ketamine was proposed after adrenaline, a beta-agonist, inhaled anticholinergics, a steroid and antihistamine drugs were used. Conclusion: Trials are needed in order to demonstrate the efficacy of ketamine in this particular context; however, the outcome in this case was positive.

Introducción: la ketamina es utilizada en anestesia intravenosa en el mantenimiento en la anestesia general. Su efecto cuenta con propiedades para prevenir la dificultad respiratoria asociada a broncoconstricción y la secreción de histamina asociada a crisis asmática. Estos efectos derivan de la acción directa en el músculo bronquial, así como de la potencialización de las catecolaminas, por lo que su uso muy controversial, ya que hasta el día de hoy no hay suficientes estudios que lo sustenten. Además, el efecto de la ketamina en el broncoespasmo debido a anafilaxia no está estudiado. El tratamiento de elección es la epinefrina y hay factores que están asociados en el éxito de esta. El objetivo fue presentar el caso de una paciente con antecedente de alergia a midazolam, que presentó broncoespasmo al estar en contacto con este y a la que se le administró tratamiento no convencional con resultados favorables. Caso clínico: presentamos el caso de una mujer joven con antecedentes de alergias a medicamentos, específicamente a benzodiacepinas, la cual presentó broncoespasmo y caída de la saturación posteriores al contacto con midazolam intraocular mientras laboraba. Se propuso la utilización de ketamina posterior a adrenalina, betaagonista y anticolinérgicos inhalados, esteroide y antihistamínico. Conclusión: es necesario hacer estudios que demuestren la eficacia de la ketamina en este contexto en particular; en este caso, los resultados fueron positivos.

Manejo perioperatorio de niños con infección respiratoria superior / Perioperative management of children with upper respiratory tract infection

Resumen Introducción. Es frecuente que muchos niños sometidos a procedimientos con anestesia general tengan historia de infección viral respiratoria superior reciente o activa. Objetivo. Realizar una revisión narrativa acerca de las pautas de manejo anestésico para los niños con infección reciente o activa de la vía aérea superior. Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO y Cochrane Library con los términos Anesthesia AND Respiratory Tract Infections AND Complications; Anesthesia AND Upper respiratory tract infection AND Complications; Anesthesia, General AND Respiratory Tract Infections AND Complications; Anesthesia, General AND Upper respiratory tract infection AND Complications; Anesthesia AND Laryngospasm OR Bronchospasm. La búsqueda se hizo en inglés con sus equivalentes en español. Resultados. Se encontraron 56 artículos con información relevante para el desarrollo de la presente revisión. Conclusiones. Una menor manipulación de la vía aérea tiende a disminuir la frecuencia de aparición y severidad de eventos adversos respiratorios perioperatorios. No existe evidencia suficiente para recomendar la optimización medicamentosa en pacientes con infección respiratoria superior.

Abstract Introduction: History of recent or active upper respiratory tract infection is common in many children undergoing general anesthesia procedures. Objective: To conduct a narrative review of anesthetic management guidelines for children with recent or active upper respiratory tract infection. Materials and methods: A structured literature search was conducted in ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO and Cochrane Library databases with the terms Anesthesia AND Respiratory Tract Infections AND Complications; Anesthesia AND Upper respiratory tract infection AND Complications; Anesthesia, General AND Respiratory Tract Infections AND Complications; Anesthesia, General AND Upper respiratory tract infection AND Complications; Anesthesia AND Laryngospasm OR Bronchospasm. The search was done in English with its equivalents in Spanish. Results: 56 articles had information relevant to meet the objective of this review. Conclusions: Minimizing manipulation of the airway tends to decrease the frequency and severity of perioperative adverse respiratory events. There is not sufficient evidence to recommend drug optimization in patients with upper respiratory tract infection.

Safety of aerosol therapy in children during noninvasive ventilation with helmet and total face mask.

PURPOSE: To evaluate the consequences of using nebulized drugs in patients subjected to noninvasive ventilation (NIV) with total face mask (TFM) and helmet. DESIGN: A descriptive analytical study of a prospective patient cohort was carried out. AMBIT: Pediatric intensive care unit (PICU) of a tertiary hospital. PATIENTS: Consecutive sampling was used to include all patients admitted to the PICU and requiring NIV with helmet or TFM over a period of 29 months. No patients were excluded. INTERVENTIONS: Nebulized treatment was added according to medical criteria. VARIABLES OF INTEREST: Independent variables were age, sex, diagnosis, disease severity, ventilation parameters and nebulized drugs (if administered). Secondary outcomes were duration and failure of NIV, and length of PICU stay. RESULTS: The most frequent diagnoses were bronchiolitis (60.5%) and asthma (23%). Patients received NIV for a median of 43h. Nebulized drugs were administered in 40% of the cases during NIV, and no adverse effects were registered. Using Bayesian statistics, the calculated probability of suffering an adverse effect was 1.3% with helmet and 0.5% with TFM (high density 95% probability intervals). Patients with helmet and nebulized therapy were in more serious condition than those who did not receive nebulization; nevertheless, no differences were observed regarding the need to change to bilevel modality. With TFM, PICU stay was shorter for the same degree of severity (p=0.033), and the NIV failure rate was higher in patients who did not receive inhaled drugs (p=0.024). CONCLUSIONS: The probability of suffering an adverse effect related to nebulization is extremely low when using a helmet or TFM. Inhaled therapy with TFM may shorten PICU stay in some patients.

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.

[Diving and asthma: Literature review]. / Plongée sous-marine et asthme : revue de littérature.

INTRODUCTION: Scuba diving has long been contraindicated for asthmatics. Recommendations are evolving towards authorisation under certain conditions. Our objective was to review the literature on the risks associated with scuba diving among asthmatics and about recommendations on this subject. MATERIALS AND METHODS: We used the MEDLINE and LiSSa databases, until June 2018, in French, English or Spanish language, with the keywords "asthma AND diving" and "asthme plongée" respectively. References to the first degree were analyzed. RESULTS: We have included 65 articles. Risk of bronchospasm is well documented, particularly in cold and/or deep water, or in the event of exposure to allergens (compressor without filter). Nonasthmatic atopic divers may be at greater risk of developing bronchial hyper-reactivity. Although the theoretical risk exists, epidemiological studies do not seem to show an over-risk of barotrauma, decompression sickness or arterial gas embolism in asthmatics. French, British, American, Spanish and Australian societies agreed on the exclusion of patients with moderate to severe persistent asthma, FEV1<80%, active asthma in the last 48hours, exercise/cold asthma and poor physical fitness. CONCLUSION: A diver's examination should include a triple assessment: asthma control, number of exacerbations and treatment compliance. Homogenizing the recommendations would improve the framework for the practice of diving among asthmatics and allow larger studies in this population. Communicating the current recommendations remains important to divers, dive instructors and doctors in the context of the development of scuba diving.

Bronchospasm During Induction of Anesthesia: A Case Report and Literature Review.

BACKGROUND: Bronchospasm (spasm of bronchial muscles) in general anesthesia caused by many reasons. Untreated bronchospasm can cause hypoxia, hypotension and increased morbidity and mortality. CASE REPORT: A 28 years old female scheduled for tonsillectomy surgery. Immediately after induction of anesthesia patient developed with drop in oxygen saturation and difficulty in mechanical ventilation. CONCLUSIONS: Bronchospasm should be considered in differential diagnosis of oxygen saturation drop during general anesthesia. This situation is more common in patients without specific respiratory disorder. Tracheal irritants like sputum and blood can cause bronchospasm. Other causes include histamine or serotonin release.

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.

ECMO for intractable status asthmaticus following atracurium.

Intraoperative allergic reactions are rare but serious events associated with increased morbidity and mortality. We report the salvage of intraoperative anaphylaxis leading to extreme hypercapnic respiratory failure by veno-venous extracorporeal membrane oxygenation (ECMO). A 38-year-old woman undergoing thyroidectomy developed intractable bronchospasm after administration of atracurium, leading to extreme hypercapnic respiratory failure (PaCO2 > 250 mmHg, pH 6.773). After the failure of conventional medical therapy and ventilatory optimization, the patient was connected to a veno-venous ECMO circuit. PaCO2 of 45.6 mmHg and pH of 7.25 were achieved in 1 h, by slowly increasing sweep gas flows up to 3.5 L/min and using continuous end-tidal CO2 monitoring to gauge the procedure. After extubation and disconnection from ECMO, the patient was discharged on the 6th day without sequelae. Rapid reversal of extreme hypercapnic acidosis by ECMO was feasible, without any neurologic sequelae. Veno-venous ECMO support may be a valuable option for the salvage of intraoperative anaphylaxis.

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.

Overweight effect on spirometric parameters in adolescents undergoing exercise / Efeito do excesso de peso sobre parâmetros espirométricos de adolescentes submetidos ao exercício

ABSTRACT Objective To evaluate effects of overweight on spirometric parameters in adolescents who underwent bronchial provocation test for exercise. Methods We included 71 male adolescents. The diagnosis of asthma was done based on participants’ clinical history and on the International Study Questionnaire Asthma and Allergies in Childhood, and the diagnosis of obesity was based on body mass index above 95th percentile. The bronchospasm induced by exercise was assessed using the run-walk test on a treadmill for eight minutes. The decrease in forced expiratory volume in one second > or equal to 10% before exercise was considered positive, and to calculate the intensity in exercise-induced bronchospasm we measured the maximum percentage of forced expiratory volume in one second and above the curve area. Data analysis was carried out using the Mann-Whitney U test and Friedman test (ANOVA), followed by Wilcoxon test (p<0.05). In addition, we used Fisher’s exact test to analyze the exercise-induced bronchospasm frequency. Results Significant differences were observed among obese adolescents in exercise-induced bronchospasm frequency (p=0,013) and in relation to time required for recovery after exercise (p=0,007). Conclusion Overweight can influence the increase in the exercise-induced bronchospasm frequency in non-asthmatic adolescents compared with eutrophic adolescents.

RESUMO Objetivo Avaliar o efeito do excesso de peso sobre parâmetros espirométricos em adolescentes submetidos ao teste de broncoprovocação por exercício. Métodos Participaram do estudo 71 adolescentes do sexo masculino. O diagnóstico de asma foi obtido por meio de histórico clínico e do questionário International Study of Asthma and Allergies in Childhood, e o de obesidade, pelo índice de massa corporal acima do percentil 95. Para avaliar o broncoespasmo induzido pelo exercício, utilizou-se o teste correr/caminhar em esteira ergométrica, com duração de 8 minutos, considerando positivo se diminuição do volume expiratório forçado no primeiro segundo >10% do valor pré-exercício e, para a intensidade do broncoespasmo induzido pelo exercício, foram utilizados o cálculo da queda percentual máxima do volume expiratório forçado no primeiro segundo e a área acima da curva. A análise dos dados foi realizada pelo teste U Mann-Whitney e pela ANOVA de Friedman, seguido do teste de Wilcoxon (p<0,05). O teste de Fisher foi empregado para analisar a frequência de broncoespasmo induzido pelo exercício. Resultados Foram encontradas diferenças significativas quanto à frequência de broncoespasmo induzido pelo exercício (p=0,013) e ao tempo de recuperação pós-exercício (p=0,007) nos adolescentes obesos. Conclusão O excesso de peso pode influenciar no aumento da frequência de broncoespasmo induzido pelo exercício em adolescentes não asmáticos, quando comparados a eutróficos.

Broncoespasmo desencadenado por anestesia espinal. Informe de caso y revisión de la literatura / Bronchospasm triggered by spinal anaesthesia. Case report and review of the literature

Bronchospasm is a clinical condition that can occur unexpectedly during general anaesthesia, but is extremely rare after spinal anaesthesia. The following is a case presentation of a patient who developed bronchospasm after undergoing spinal anaesthesia not attributable to other causes, and that adds another case to the limited literature. Most publications allude to asthmatic patients, and this is probably the first description about a patient with emphysema-type COPD. Our case shows that although spinal anaesthesia is considered safe for patients with respiratory disease, specifically in asthmatic patients there is a possibility of bronchospasm in susceptible patients.

El broncoespasmo es una condición clínica que puede aparecer inesperadamente durante la anestesia general, pero es extremadamente rara tras la anestesia espinal. Presentamos un paciente que desarrolló broncoespasmo tras ser sometido a anestesia espinal, no atribuible a otras causas y que añade un caso más a la escasa literatura al respecto. La mayoría de las publicaciones se refieren a pacientes asmáticos, y esta sea probablemente la primera descripción en un paciente con EPOC tipo enfisematoso. Nuestro caso muestra que aunque la anestesia espinal se considere más segura para pacientes con patología respiratoria, en concreto en pacientes asmáticos, existe la posibilidad de que ésta produzca broncoespasmo en pacientes susceptibles.

General Anesthesia for a Posttonsillectomy and Adenoidectomy Bleed.

INTRODUCTION: Providers at all levels should have some understanding of the pathophysiology and be able to manage such a patient in the operating room. In addition, any anesthetists providing pediatric care should be able to identify and understand the importance of other comorbid conditions in these patients. This simulation on posttonsillectomy and adenoidectomy hemorrhage in the pediatric patient presents a challenging case usually encountered in some form by most anesthesia residents during training. This simulation's objective is to challenge and further reinforce the knowledge of anesthesiology resident physicians who have completed 1 year of clinical anesthesia and at least 1 month of pediatric anesthesia. METHODS: The simulation can be delivered in a single session of 1 hour or less. Materials in this simulation include a case template designed to provide facilitators with a general overview, a checklist of critical actions each learner should perform during the scenario, a brief summary to be provided to the learner to reinforce knowledge gained through the activity, and an evaluation form to assess the learner's view of the activity's educational value. RESULTS: Learner comments were almost unanimously positive. All learners who returned surveys answered the questions "This simulation enhanced my understanding of how to manage critically ill patients in the perioperative period" and "The content was current and relevant to my practice" with either agree or strongly agree. DISCUSSION: The module offers various points to practice troubleshooting skills in the management of difficult IV line placement as well as difficult airway management. In reality, this case could be modified in multiple ways, including management of a more severe hemorrhage with a much more hypovolemic patient.

Therapeutic effect of ipratropium bromide on bronchial spasm in asthma and COPD / 中国生化药物杂志

Objective To investigate the therapeutic effect of ipratropium bromide on bronchial spasm of patients with asthma and chronic obstructive pulmonary disease (COPD).Methods 174 patients with asthma and COPD were selected and divided into two groups, 87 cases in the control group treated with budesonide and formoterol fumarate powder for inhalation , 87 cases in the experimental group received ipratropium bromide on the basis of the control group, pulmonary ventilation function, airway resistance and cytokine levels in induced sputum, the clinical effect and incidence of adverse reactions were compared after the treatment.Results The effective rate in the control group(81.61%)was lower than the experimental group (93.11%), with significant difference (P<0.05); compared with the control group, levels of peak expiratory flow (PEF), maximum midexpiratory flow (MMEF), forced expiratory volume in one second to forced vital capacity ratio (FEV1%), forced vital capacity (FVC) were higher in the experimental group after treatment, levels of airway resistance (Raw), Raw% were lower, level of specific airway conductance (Gsp) was higher after treatment, induced sputum levels of vascular endothelial growth factor (VEGF), intercellular adhesion molecular-1 (ICAM-1), interleukin-13 (IL-13), IL-17 were lower after treatment, with significant difference (P<0.05);there was no significant difference in the incidence of adverse reactions between the two groups.Conclusion The clinical effect of ipratropium bromide in the treatment of asthma and COPD was exactly , ipratropium bromide can significantly improve the pulmonary ventilation function in patients, relieve bronchial spasm, reduce airway resistance, inhibit airway inflammation, and the safety is higher.

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.

A retrospective analysis of severe intraoperative respiratory compliance changes during ophthalmic arterial chemosurgery for retinoblastoma.

BACKGROUND AND OBJECTIVES: Ophthalmic arterial chemosurgery for retinoblastoma has been associated with intraoperative decreases in respiratory compliance. Through the analysis of data from computerized records, we objectively defined severe respiratory compliance events and correlated them with demographic and clinical information in patients undergoing this procedure. METHODS: Data were collected from ophthalmic arterial chemosurgery cases from 2006 to 2013. Intraoperative PIP, PEEP, TV, SpO2 , and EtCO2 were analyzed. Compliance changes, desaturations, decreases in EtCO2 , and clinical outcomes were assessed. RESULTS: Respiratory compliance decreases with a bimodal distribution. Severe events were defined as exhibiting a minimum compliance decrease of 40%. Seventy-eight of 122 children (64%) experienced a severe compliance event during at least one treatment, and it occurred in 137/468 cases (29%). A subset of 94 children had complete or at least the first three records. The incidence of a severe respiratory compliance event in this subgroup was 17/94 (18%) on the first and 84/261 (32%) on subsequent procedures. The probability of developing a severe respiratory compliance event on a subsequent procedure was 0.40 if the child developed it on the first procedure, 0.30 if he did not; this difference was not significant. The incidence of desaturation below 90% with severe respiratory compliance events was 0.20; the incidence of a 30% drop in EtCO2 was 0.34. No morbidity, no extended recovery, and no admissions were associated with intraoperative severe respiratory compliance events. We found no correlation between history, age, sex, weight or allergies, and intraoperative severe respiratory compliance events. CONCLUSIONS: Here, most patients experienced a severe respiratory compliance event during at least one of their procedures. Overall incidence was 29% and was more likely on subsequent procedures. A severe respiratory compliance event at the initial procedure was poorly predictive of its occurrence on subsequent procedures. No morbidity was associated with intraoperative severe respiratory compliance events.