[Intermittent asphyxia syndrome caused by a bronchial cast in the subglottic region]. / Síndrome asfíctico intermitente provocado por molde bronquial en zona subglótica.

We report the case of an intensive care unit patient with acute respiratory failure caused by severe community-acquired pneumonia with empyema. She required orotracheal intubation and mechanical ventilation. Following extubation the patient s condition improved until the onset of several choking episodes caused by a dislodged laryngotracheal cast in the subglottic region. We discuss the differential diagnosis of upper airway obstructions and of the entities related to bronchial cast formation, in particular the clinical and pathophysiological features of plastic bronchitis and the treatment options available.

Síndrome asfíctico intermitente provocado por molde bronquial en zona subglótica / Intermittent asphyxia syndrome caused by bronchial cast in the subglottic region

Se presenta el caso de una paciente ingresada en la unidad de cuidados intensivos por insuficiencia respiratoria aguda secundaria a una neumonía comunitaria grave con empiema, que requirió intubación orotraqueal y ventilación mecánica. Tras su extubación cursó con buena evolución hasta presentar varios episodios de crisis asfícticas intermitentes secundarias a una obstrucción por el desplazamiento de un molde laringotraqueal en la zona subglótica. Se discute el diagnóstico diferencial de las obstrucciones respiratorias de la vía aérea superior, así como el de las entidades relacionadas con la formación de moldes bronquiales, con especial atención a las bronquitis plásticas, sus características clínicas, fisiopatológicas y posibilidades terapéuticas

We report the case of an intensive care unit patient with acute respiratory failure caused by severe community-acquired pneumonia with empyema. She required orotracheal intubation and mechanical ventilation. Following extubation the patient´s condition improved until the onset of several choking episodes caused by a dislodged laryngotracheal cast in the subglottic region. We discuss the differential diagnosis of upper airway obstructions and of the entities related to bronchial cast formation, in particular the clinical and pathophysiological features of plastic bronchitis and the treatment options available

[The indications for and results of video thoracoscopic surgery. Reflections on 152 procedures]. / Indicaciones y resultados de la cirugía videotoracoscópica. Consideraciones sobre 152 procedimientos.

Since thoracoscopy was first described in 1910, its application has been confined mainly to diagnosis and symptomatic treatment of pleural diseases. Recent technological advances in endoscopy and the refinement of surgical technique have brought wider applications, giving rise to video-assisted thoracoscopy (VAT). VAT surgery allows us to view, access and act upon internal thoracic organs without recourse to thoracotomy, thus circumventing inherent risk. We have reviewed our experience from April 1994 through November 1998 in 152 procedures with 141 consecutive patients. Diagnoses were pneumothorax in 94 cases, sympathetic nervous system alteration in 10, diffuse lung disease in 10, lung tumors in 9, pulmonary metastasis in 4, pleural tumors in 5, mediastinal tumors in 2, pericardial effusion in 2, spinal disease in 2 and chronic pancreatitis in 1. No deaths associated with the procedure occurred. The incidence of non-fatal postoperative complication was 11%. The most common complications were prolonged air leak (5%) and bloody pleural effusion (3.5%). The mean length of postoperative hospital care was 3.8 days (range 1 to 18 days). Our experience indicates that VAT is increasingly used to diagnose and treat a variety of chest lesions. Complications are fewer than in procedures in which thoracotomy is needed. Prolonged air leakage does not occur significantly more often with VAT than with thoracotomy. VAT is apparently safe and is particularly useful in some situations, as postoperative morbidity is low and clinical tolerance good.

[Benign acquired tracheoesophageal fistulas]. / Fístulas traqueoesofágicas benignas adquiridas.

Benign acquired tracheoesophageal fistula (TEF) is a rare though serious occurrence associated with a high degree of morbidity and mortality. We review 18 cases of TEF treated over 16 years in our hospital. The variables analyzed descriptively were demographic (age, sex and others), clinical (etiology, time of intubation, time and symptoms leading to clinical suspicion, diagnostic techniques, and others), and therapeutic (dependence on mechanical ventilation, location of tissues, tracheal resection, tissue interposition, postoperative course of disease, and others). Fifteen of the 18 patients required surgery. The rate of success (80%) was high in terms of respiration, swallowing and phonation. Surgery involved simple closure of the TEF, with half the patients requiring a second operation to correct tracheal stenosis. Resection and anastomosis were performed in the remaining 11 cases, with only one requiring a second operation for recurrence of stenosis. Two cases of perioperative mortality and one TEF recurrence related to assisted ventilation were recorded. Tracheoscopy was the most effective diagnostic technique, complemented by computerized tomography of the trachea. Presurgical evaluation of tracheal stenosis, the absence of mechanical ventilation, preoperative preparation and postoperative care are the factors that determine success in this type of surgery. When tracheal stenosis is associated with TEF, resection and anastomosis should be performed in the affected zone.

[Cardiac hernia after intrapericardial pneumonectomy]. / Hernia Cardíaca tras neumonectomía intrapericárdica.

Cardiac herniation secondary to intrapericardial pneumonectomy is a rare complication, although its real incidence has surely been underestimated. We describe a patient with left cardiac herniation presenting after intrapericardial pulmonectomy for primary lung cancer. The signs were severe hemodynamic shock requiring additional surgery involving a wide opening in the pericardium. The outcome after surgery was fully satisfactory.

[1990-1996: the experience of the La Fe Lung Transplant Group (Valencia)]. / 1990-1996: experiencia del Grupo de Trasplante Pulmonar La Fe (Valencia).

Objective to review the experience of the lung transplantation unit at Hospital La Fe (Valencia). Between February 1990 and March 1996 we performed 40 lung transplants. The following causes were most common: cystic fibrosis (9 cases), emphysema (8), pulmonary fibrosis (8) and bronchiectasis (7). Types of intervention were 27 double lung transplants (25 sequential and 9 blocked), 9 single lung transplants, and 4 heart-lung transplants. We then reviewed the 36 single and double lung transplants. The main exclusion criteria were age over 65 years, malignant disease, kidney or liver disease, severe or non reversible central nervous system disease, and drug addiction. Prior surgery, mechanical ventilation and the presence of Aspergillus were considered lower-order contraindications. Mean patient age was 37.7 years (14-59). Six patients were colonized by Aspergillus before transplantation. Five had undergone earlier surgery and two were mechanically ventilated before the transplant. The most common complication was respiratory infection, which was present in 6 of the 7 patients who died. Other complications in order of frequency were dehiscence and/or bronchial stenosis, corticoid myopathy and postoperative bleeding. The actuarial survival rate of single and double lung transplants was 67.85 after 3 years, and 87.5% in patients with cystic fibrosis. Lung transplantation is a well-established procedure that is gradually being extended to treat more conditions. The main obstacle is the scarcity of donors. The main challenge at present is bronchiolitis obliterans.

[Tracheal stenosis as the presenting form of follicular thyroid carcinoma]. / Estenosis traqueal como forma de presentación de un carcinoma folicular de tiroides.

Follicular carcinoma of the thyroid is an uncommon neoplasm, whose diagnosis is usually established upon evaluating a thyroid nodule. However, on occasions it can be presented with symptoms derived from the adjacent structures' compression, as the trachea, since only it is presented in reduced number of patients with substernal goiter. We present a rare case of a woman 73 years-old, with follicular carcinoma of the thyroid, that consulted for 5 years-old evolution dyspnea and wheezing, without finding alterations in the initial roentgenogram of the chest. We comment the difficulty in the diagnosis of the upper airway obstruction when the roentgenogram of the chest is normal, and we comment the clinical and pulmonary function data that can lead us to suspect this disease.