Uso prolongado de cánula nasal de alto flujo en niños con problemas respiratorios / Prolonged use of high flow nasal cannula in children with respiratory problems

La cánula nasal de alto flujo (CNAF) es una modalidad ventilatoria no invasiva segura y efectiva, usada ampliamente en patología respiratoria aguda en adultos y niños. Objetivo: presentar casos clínicos pediátricos que utilizaron CNAF por tiempo prolongado por problemas respiratorios crónicos. Descripción de casos clínicos, revisión de fichas clínicas de 5 pacientes que utilizaron CNAF por más de 1 mes, entre los años 2017-2020 en el Complejo Asistencial Dr. Sótero del Río. Aprobado por Comité de Ética. Resultados: 5 pacientes varones de mediana 61 (44 a 212) días de edad al inicio del uso de CNAF. Diagnóstico de base: displasia broncopulmonar (2/5), síndrome de Treacher Collins (1/5), síndrome de cimitarra con hipoplasia pulmonar derecha (1/5) y traqueobroncomalacia severa (1/5). Todos requirieron previamente uso de ventilación invasiva o no invasiva con mediana de 59 (4 a 78) días. A todos se les realizó broncoscopia, saturometría contínua o poligrafía para diagnóstico y titulación de CNAF y oxígeno. Todos mejoraron clínicamente, la SpO2 y el número de apneas. Dos pacientes se enviaron a domicilio con uso de Airvo2 nocturno. La mediana de uso de CNAF fue 165 (34 a 445) días. Conclusiones: el uso prolongado de CNAF es útil en pacientes pediátricos seleccionados, bien tolerado y factible de utilizar en domicilio.

The high-flow nasal cannula (HFNC) is a safe and effective non-invasive ventilation support widely used in acute respiratory pathology in adults and children. Objective: To present pediatric clinical cases that used HFNC for an extended period due to chronic respiratory disease. Description of clinical cases, review of medical records of 5 patients who used HFNC for more than 1 month, between the years 2017-2020 at Complejo Asistencial Dr. Sótero del Río. Approved by the Ethics Committee. Results: 5 male patients with a median age of 61 (44 to 212) days at the start of HFNC use. Underlying diagnoses: bronchopulmonary dysplasia (2/5), Treacher Collins syndrome (1/5), Scimitar syndrome with right pulmonary hypoplasia (1/5), and severe tracheobronchomalacia (1/5). All of them previously required invasive or non-invasive ventilation for a median of 59 (4 to 78) days. All patients underwent bronchoscopy, continuous pulse oximetry or polygraphy for diagnosis and titration of HFNC and oxygen. All showed clinical improvement, including SpO2 levels and the number of apneas. Two patients were discharged with nocturnal use of Airvo 2 at home. The median duration of HFNC use was 165 (34 to 445) days. Conclusions: Prolonged use of HFNC is useful in selected pediatric patients, well tolerated, and feasible for home use.

Extraluminal nitinol prosthesis in the treatment of intrathoracic tracheal collapse in a dog / Uso de prótese extraluminal de nitinol no tratamento de colapso traqueal intratorácico em um cão

A six-month-old male Brazilian Terrier with persistent cough and dyspnea was diagnosed with intrathoracic tracheal collapse and pneumonia after chest radiographics. The medical treatment was performed, and an extraluminal nitinol prosthesis was placed through thoracic access. The dog did not presented recurrence of dyspnea or pneumonia for four years after the surgical procedure. Placement of the extraluminal prosthesis with the thoracic approach effectively stabilized intrathoracic tracheal collapse without causing any structural damage in the thoracic region. Therefore, this is the first report of a successful use of this prosthesis with an intercostal approach in dogs for intrathoracic trachea collapse.

Um cão macho, da raça Terrier Brasileiro de seis meses de idade, com dispnéia e tosse persistente foi diagnosticado com colapso traqueal intratorácico e pneumonia após estudo radiográfico de tórax. Foi instituído tratamento médico e realizada toracotomia para a implantação de prótese traqueal extraluminal de nitinol. O animal não manifestou dispneia ou pneumonia durante os quatro anos posteriores ao procedimento. A implantação da prótese extraluminal através da toracotomia foi eficaz para o tratamento do colapso traqueal intratorácico, sem provocar danos estruturais na região torácica. Desta forma, este é primeiro relato da utilização bem-sucedida deste tipo de prótese, a partir da abordagem intercostal, no tratamento de cães com colapso traqueal intratorácico.

Traqueobroncoplastia por malacia / Tracheobronchoplasty for malacia

RESUMEN La traqueobroncomalacia es una enfermedad de la vía aérea central caracterizada por una debilidad de la pared, con disminución dinámica de la luz de la tráquea y grandes bronquios principalmente durante la espiración. Genera síntomas crónicos que pueden evolucionar hasta la falla respiratoria grave, frecuentemente diagnosticados de forma errónea como asma o enfermedad pulmonar obstructiva crónica (EPOC). Presentamos el caso de una paciente femenina de 70 años, con antecedente de artritis reumatoide y múltiples internaciones por cuadros respiratorios infecciosos en los 3 años previos.

ABSTRACT Tracheobroncomalacia is a disease of the central airway due to weakness of the wall with dynamic narrowing of the lumen of the trachea and mainstem bronchi during exhalation. It produces chronic symptoms that can progress to severe respiratory failure, often misdiagnosed as asthma or chronic obstructive pulmonary disease (COPD). We report the case of a 70-year-old female patient with a history of rheumatoid arthritis and multiple hospitalizations for recurrent respiratory infections over the past 3 years.

Traqueomalacia: diagnóstico y alternativas terapéuticas / Tracheomalacia: diagnosis and treatment options

La traqueomalacia (TM) consiste en una excesiva colapsabilidad traqueal debida a una anomalía estructural del cartílago y/o de la pared membranosa posterior. Cuando se extiende a uno o ambos bronquios principales se denomina traqueobroncomalacia (TBM). Considerando diferentes clasificaciones, la mayoría de las TM son adquiridas, localizadas e intratorácicas. El diagnóstico clínico es difícil porque los síntomas son inespecíficos y se superponen con los de otras enfermedades respiratorias crónicas. Los síntomas más frecuentes incluyen estridor espiratorio, tos perruna e infecciones respiratorias recurrentes, en los casos más graves se presentan episodios de dificultad respiratoria severa, cianosis e incluso muerte súbita. La fibrobroncoscopía sigue siendo el método diagnóstico estándar de oro, complementándose con la tomografía computarizada que es esencial en la visualización de las estructuras adyacentes a la vía aérea. En los casos leves el tratamiento es conservador, considerando la resolución espontánea de la mayoría de los casos hacia los 2 años de edad. En los pacientes más sintomáticos la estrategia terapéutica se debe evaluar caso a caso, siendo la presión positiva contínua en vía aérea (no invasiva o invasiva por traqueostomía) el tratamiento más utilizado. En las TM-TBM más severas, entre posibles tratamientos que incluyen cirugía traqueal y prótesis en la vía aérea, lo más usado es aortoarteriopexia y traqueopexia, a la espera de resultados promisorios de mallas endoluminales biodegradables y prótesis reabsorbibles personalizadas impresas en 3D.

Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the cartilaginous rings and/or the posterior membrane. When the main bronchi is also affected this condition is termed as tracheobronchomalacia (TBM). According classifications TM is mostly acquired, localized and intrathoracic. Diagnosing TM is challenging because symptoms are nonspecific and overlap with those of other chronic respiratory disorders. The most common symptoms include expiratory stridor, barking cough and recurrent respiratory tract infections, in severe cases, severe respiratory distress episodes and acute life threatening events can occur. While flexible bronchoscopy is still considered as the gold standard diagnostic method, computed tomography is essential in assessing the surrounding structures. Conservative therapy is preferred in milder cases since the outcome is usually favorable within the first 2 years of life. Treatment of more symptomatic children should be discussed on an individual basis, continuous positive airway pressure (non invasive o invasive via tracheostomy) being the most widely used therapy. For more severe TM-TBM, amongst possible treatments including tracheal surgery and airway stenting, aortoarteriopexy and tracheopexy are mostly used, nevertheless absorbable stent and 3D printed customed prosthesis are being developed with promising results.

Thoracoscopic aortopexy to treat severe tracheomalacia in children. Cases report.

OBJECTIVE: To present our experience in the treatment of the severe tracheomalacia by thoracoscopic approach, as well as its diagnostic methodology, surgical technique, post-operatory evolution and complications. CLINICAL CASES: From 2016 to 2017, three patients, 3, 9 and 12 months old, were treated. They showed multiple near sudden death events and had an absolute dependence to assisted ventilation. Pre-operatory bronchoscopy evinced tracheal severe malacia. Thoracic angiotomography discarded other extrinsic tracheal compression causes. A left thoracoscopic aortopexy was practiced with a bronchoscopical trans-operatory control; with improvement in tracheal space. Just one patient is still awaiting cannula removal, without symptomatology recurrence in a 3-20 months follow up. CONCLUSIONS: The thoracoscopic aortopexy is a safe and effective technique to treat primary and severe tracheomalacia in children.

OBJETIVO: Presentar nuestra experiencia en el tratamiento de la traqueomalacia grave por abordaje toracoscópico, la metodología diagnóstica, la técnica quirúrgica, la evolución postoperatoria y las complicaciones. CASOS CLÍNICOS: De 2016 a 2017 se trataron tres pacientes, dos de ellos con traqueomalacia grave y uno con traqueobronquiomalacia grave, de 3 a 12 meses de edad, con peso de 3 a 6 kg, múltiples eventos de casi muerte súbita y dependencia absoluta de ventilación asistida; en otro hospital practicaron traqueostomía, funduplicación y gastrostomía. La broncoscopia preoperatoria mostró malacia traqueal y bronquial grave, y la angiotomografía de tórax descartó otras causas de compresión. Se practicó aortopexia toracoscópica izquierda sin complicaciones, con control broncoscópico transoperatorio que mostró mejoría en la luz traqueal en los tres pacientes y sin recidiva de la sintomatología respiratoria en un seguimiento de 3 a 20 meses. CONCLUSIONES: La aortopexia toracoscópica es una técnica segura y efectiva para el tratamiento de la traqueomalacia primaria grave en los niños.

Traqueomalacia pediátrica / Pediatric tracheomalacia

RESUMEN La malacia de la vía aérea central puede afectar la tráquea y/o los bronquios, haciéndola susceptible al colapso de sus paredes durante el ciclo respiratorio. Puede clasificarse como primaria o secundaria y clínicamente se manifiesta por síntomas respiratorios recurrentes o persistentes (especialmente en espiración), infecciones recurrentes y en casos severos, episodios de hipoventilación con cianosis. El diagnóstico se establece mediante broncoscopía flexible o rígida. Los estudios de imágenes se consideran complementarios, siendo especialmente útiles en casos de duda diagnóstica, estudio de causas secundarias o para la planificación preoperatoria. Su tratamiento depende de distintos factores como la severidad de los síntomas, su etiología, ubicación y extensión. En casos leves, una observación activa y tratamiento médico en espera de la resolución espontánea en los primeros 2 años, suelen ser suficientes. En casos moderados, la ventilación a presión positiva podría ser de utilidad. En casos severos está indicado el tratamiento quirúrgico, mediante distintas técnicas que buscan dar soporte a la estructura traqueobronquial debilitada, incluyendo traqueostomía, suspensiones directas (traqueopexias) o indirectas (aortopexia), tutores externos o stents intraluminales. En este articulo se revisarán las principales causas y tratamientos disponibles para la traqueomalacia pediátrica. Ya que su diagnóstico y manejo son complejos, es fundamental el trabajo de equipos médicos multidisciplinarios familiarizados con esta patología.

ABSTRACT Central airway malacia can affect the trachea and/or the main bronchi, making their walls susceptible to collapse during the respiratory cycle. It can be classified as primary or secondary, and clinically presents with recurrent or persistent respiratory symptoms (especially on expiration), recurrent infections and in severe cases, episodes of hypoventilation with cyanosis. The diagnosis is established by flexible or rigid bronchoscopy; imaging studies are considered as complementary, especially in cases of unclear diagnosis, secondary causes or for preoperative planning. Treatment depends on different factors such as the severity of the symptoms, their etiology, location and extension. In mild cases, active observation and medical treatment waiting for spontaneous resolution may be enough, which usually occurs in the first 2 years of age. In moderate cases, positive pressure ventilation could be useful. In severe cases, surgical treatment is indicated. Different techniques aiming to provide support to the weakened tracheobronchial structures are available, including tracheostomy, direct (tracheopexies) or indirect suspensions (aortopexy), external splints and intraluminal stents. In this article we present the main etiologies and available treatments for pediatric tracheomalacia. Given that diagnosis and management of these patients is complex, the work of multidisciplinary teams familiar with this pathology is of paramount importance.

Traqueomalacia, complicación de la exéresis de un bocio difuso endotorácico bilateral / Tracheomalacia: a complication after removal of bilateral endothoracic diffuse goiter

Introducción: En cirugía de la glándula tiroides la mortalidad es nula en algunas series por lo que la morbilidad es la mayor preocupación del cirujano. Objetivo: Presentar la evolución clínica de una paciente con tiroidectomía total por bocio endotorácico bilateral. Caso clínico: Paciente que se le realizó tiroidectomía total por bocio endotorácico bilateral, técnicamente difícil, biopsia por congelación negativa de malignidad, bocio coloide. Nervios recurrentes visualizados. Debido al tamaño de la glándula y lo complejo que resultó la extracción se decidió trasladar a la paciente a la sala de recuperación intubada y ventilada para proceder a la recuperación de la ventilación espontánea y la extubación en un período más prolongado. Fue extubada una primera vez que fue fallida. Fue reintubada y ocurrió en una segunda ocasión después de ser reintervenida por un posible hematoma de la herida. En la TAC preoperatoria se observó una glándula tiroides grande con prolongación endotorácia bilateral y estenosis alta de la tráquea. Conclusión: Las complicaciones de obstrucción de la vía aérea después de una tiroidectomía no son frecuentes. Generalmente, después de una tiroidectomía total o parcial se trata de recuperar al paciente en el quirófano para después de la extubación realizar una laringoscopia que descarte la parálisis de las cuerdas vocales. La traqueomalacia como complicación después de una tiroidectomía no es frecuente, por lo que se alerta que de no haber diagnosticado y tratado rápidamente la paciente podría tener un desenlace fatal(AU)

Introduction: In surgery of the thyroid gland, mortality is null in some series, so morbidity is the surgeon's greatest concern. Objective: To present the clinical evolution of a patient with total thyroidectomy due to bilateral endothoracic goiter. Clinical case: This patient underwent total thyroidectomy due to bilateral endothoracic goiter, technically difficult, negative freeze biopsy of malignancy, colloid goiter. Visualized recurrent nerves. Due to the size of the gland and how complex the extraction was, it was decided to transfer the patient to the intubated and ventilated recovery room to proceed with the recovery of spontaneous ventilation and extubation in a longer period. She was extubated the first time it failed. She was re-intubated and it occurred on a second occasion after being re-operated due to a possible hematoma of the wound. In the preoperative CT scan, a large thyroid gland with bilateral endothoracic prolongation and high stenosis of the trachea was observed. Conclusion: Complications of airway obstruction after thyroidectomy are not frequent. Generally, after a total or partial thyroidectomy, it is a matter of recovering the patient in the operating room, in order to perform, after extubation, a laryngoscopy to rule out paralysis of the vocal cords. Tracheomalacia as a complication after thyroidectomy is not frequent, so it is warned that failure to diagnose and treat the patient quickly could have a fatal outcome(AU)

Síndrome de Mounier Kuhn en una paciente de 78 años con fibrosis pulmonar / Mounier Kuhn syndrome in a 78-year-old patient with pulmonary fibrosis

Resumen Se presenta el caso de una mujer de 78 años de edad con fibrosis pulmonar idiopàtica, quien consultó por exacerbación de sus síntomas respiratorios, a quien se le realizan estudios radiológicos, donde se evidencia dilatación de la vía aérea, previamente no descrita, y se realiza diagnóstico de síndrome de Mounier Kuhn. Hasta donde el conocimiento alcanza, es el primer caso reportado en Colombia y la tercera persona de mayor edad reportada en el mundo. Este es un hallazgo incidental, dado que desde el punto de vista fisiopatológico no hay ninguna relación causal entre la fibrosis pulmonar idiopática y el síndrome de Mounier Kuhn. Sin embargo, su presencia puedo afectar aún más el compromiso funcional, dado el eventual colapso de la vía aérea, lo cual puede llevar a intervenciones terapéuticas adicionales, como colocación de stent. (Acta Med Colomb 2017: 42-198-201).

Abstract The case of a 78-year-old woman with idiopathic pulmonary fibrosis who consulted for exacerbation of her respiratory symptoms is presented. Radiologic studies showed dilation of the airway that was not previously described, and for this reason the diagnosis of Mounier Kuhn Syndrome was made. To our knowledge, this is the first case reported in Colombia and the third oldest person reported in the world. This is an incidental finding, since from the pathophysiological point of view there is no causal relationship between idiopathic pulmonary fibrosis and Mounier Kuhn's syndrome. However, its presence may further affect the functional compromise, given the eventual collapse of the airway, which may lead to additional therapeutic interventions, such as stent placement. (Acta Med Colomb 2017: 42-198-201).

Atelectasia lobar. Manifestación infrecuente de traqueobroncomalacia en adultos / Lobar atelectasis unusual presentation of tracheobronchomalacia in adults

Resumen Las alteraciones dinámicas del sistema respiratorio que condicionan colapso del lumen traqueobronquial durante la espiración favorecen síntomas inespecíficos o no atribuibles a una enfermedad respiratoria en particular. El diagnóstico preciso de la entidad clínica tiene implicaciones terapéuticas y pronosticas. La traqueobroncomalacia se diagnostica cuando existe una disminución en el lumen traqueobronquial mayor al 50% visible mediante exploración con broncoscopía. La etiología más frecuente en adultos es la forma adquirida y es rara la asociación con atelectasia.

Abstract Respiratory dynamic abnormalities that contributes with collapse of the airway luminal during expiration can cause nonspecific symptoms or not related to a respiratory disease. Accurate diagnosis of the clinical entity has therapeutic implications and is important for the prognosis. Tracheobronchomalacia is diagnosed when there is a decrease in the lumen tracheobronchial greater than 50% visible through exploration with Bronchoscopy. The main etiology in adults was the acquired form and association with lung atelectasis was rare.

Traqueobroncomalacia / Tracheobronchomalacia

A 10-years-old girl with recurrent wheezing was diagnosed as asthmatic. Her spirometry showed variable central airway intrathoracic obstruction. The bronchoscopy confirmed the presence of bronchomalacia.

Se presenta el caso de una paciente de edad escolar, quien por sibilancias recurrentes se trataba como asmática. Al realizar espirometría forzada se detectó un compromiso variable de vía central intratorácica. La fibrobroncoscopía confirmó la presencia de broncomalacia.

Importance of flexible bronchoscopy in decannulation of tracheostomy patients / Importância da broncoscopia flexível na decanulação dos pacientes traqueostomizados

OBJECTIVE: To evaluate the importance of flexible bronchoscopy in tracheostomy patients in the process of decannulation to assess the incidence and types of laryngotracheal injury and compare the presence of such lesions with clinical criteria used for decannulation. METHODS: We studied 51 tracheostomized patients aged between 19 and 87 years, with tracheal stent for a mean of 46 ± 28 days and with clinical criteria for decannulation. They were submitted to tracheostomy tube occlusion tolerance testfor 24 hours, and then to flexible bronchoscopy. We described and classified the diagnosed laryngotracheal changes. We compared the clinical criteria for decannulation indication with the bronchoscopy-diagnosed laryngotracheal injuries that contraindicated decannulation. We identified the factors that could interfere in decannulation and evaluated the importance of bronchoscopy as part of the process. RESULTS: Forty (80.4%) patients had laryngotracheal alterations. Of the 40 patients considered clinically fit to decannulation, eight (20%) (p = 0.0007) presented with laryngotracheal injuries at bronchoscopy that contraindicated the procedure. The most frequent laryngeal alteration was vocal cords lesion, in 15 (29%) individuals, and granuloma, the most prevalent tracheal lesion, in 14 (27.5%) patients. CONCLUSION: flexible bronchoscopy showed a large number of laryngotracheal injuries, the most frequent being the vocal cords injury in the larynx and the granuloma in the trachea, which contributed to increase the decannulation procedure safety.

OBJETIVO: Avaliar a importância do emprego, da broncoscopia flexível nos pacientes traqueostomizados em vias de decanulação para conhecer a incidência e os tipos de lesões laringotraqueais e comparar a presença destas lesões com os critérios clínicos utilizados para a decanulação. MÉTODOS: foram estudados 51 pacientes, com idade entre 19 e 87 anos, traquestomizados, com critérios clínicos de decanulação e com tempo médio de órtese traqueal de 46 ± 28 dias. Foram submetidos ao teste de tolerância à oclusão da cânula de traqueostomia por 24 horas, seguida da realização da broncoscopia flexível. As alterações laringotraqueais diagnosticadas foram descritas e classificadas. Comparou-se a indicação de decanulação por critérios clínicos com o diagnóstico de lesões laringotraqueais à broncoscopia que contraindicavam a decanulação. Identificaram-se os fatores que poderiam interferir na decanulação e avaliou-se a importância da broncoscopia como parte do processo. RESULTADOS: Apresentaram alterações laringotraqueais, 40 pacientes (80,4%). Dos 40 pacientes considerados clinicamente aptos à decanulação, oito (20%) (p=0,0007) apresentaram lesões laringotraqueais à broncoscopia que contraindicaram o procedimento. A alteração laríngea mais frequente foi lesão de pregas vocais em 15 (29%) e o granuloma, a lesão traqueal mais prevalente em 14 (27,5%) pacientes. CONCLUSÃO: a broncoscopia flexível evidenciou um número elevado de lesões laringotraqueais, sendo mais prevalentes a lesão de pregas vocais na laringe e o granuloma na traqueia, que contribuiu para aumentar a segurança do procedimento de decanulação.

Complicações após a implantação de stent intraluminal de nitinol em cães com colapso da traqueia relato de três casos / Complications after the implantation of intraluminal nitinol stent in dogs with tracheal collapse a three-case report / Complicaciones posteriores a la colocación del stent intraluminal de nitinol en perros con colapso traqueal reporte de tres casos

O colapso da traqueia é uma doença caracterizada pela degeneração progressiva dos anéis cartilaginosos e pela frouxidão do músculo liso dorsaltraqueal, que acomete predominantemente cães de raças pequenas e toys. Os animais afetados podem apresentar tosse seca, ronqueira, dispneia, intolerância a exercícios físicos, cianose, síncopes e insuficiência respiratória. O tratamento é paliativo e tem 71% de eficácia com o uso de medicamentos, e não há cura definitiva. A implantação de stent intraluminal de nitinol é um procedimento minimamente invasivo, que tem mostrado resultado com eficácia de até 85% em cães que não responderam à terapia medicamentosa. É um procedimento considerado seguro, contudo não isento de complicações. Este trabalho objetivou relatar algumas das possíveis complicações em pacientes que foram submetidos à implantação do stent intraluminal de nitinol.(AU)

Tracheal collapse affects predominantly small and toy-breed dogs and is characterized by a progressive degenerative disease of the cartilage rings and laxity of the trachealis dorsalis muscle. Affected animals may present dry cough, honking, dyspnea, exercise intolerance, cyanosis, syncope episodes and respiratory insufficiency. There is no cure for this disease; the medical treatment is palliative and has shown 71% of success rate. Nitinol intraluminal tracheal stenting is a minimally invasive procedure that has yielded good results and a success rate up to 85% in dogs unresponsive to pharmacological therapy. Although it is not complication-free, the procedure is considered safe. This article reports some of the possible complications in patients who underwent the surgical procedure for implantation of a nitinol intraluminal stent.(AU)

El colapso de la tráquea es una enfermedad caracterizada por la degeneración progresiva del cartílago de los anillos, y por la laxitud del músculo liso dorsal de la tráquea. Los animales afectados, principalmente perros de razas pequeñas y toys, suelen presentar tos seca, ronquidos, disnea, intolerancia al ejercicio, cianosis, síncopes e insuficiencia respiratoria. El tratamiento es paliativo y tiene un 71% de eficiencia a través del uso de medicamentos; no hay cura definitiva de esta enfermedad. La implantación de un stent intraluminal de nitinol es un procedimiento de mínima invasión, que ha mostrado resultados con una eficiencia de hasta un 85% en los perros que no respondieron a la terapia con medicamentos. Es un procedimiento considerado como seguro, a pesar de que pueden presentarse complicaciones. Este trabajo tuvo como objetivo relatar algunas de las posibles complicaciones en pacientes que fueron sometidos a la implantación de stent intraluminal de nitinol.(AU)

Complicações após a implantação de stent intraluminal de nitinol em cães com colapso da traqueia – relato de três casos / Complications after the implantation of intraluminal nitinol stent in dogs with tracheal collapse – a three-case report / Complicaciones posteriores a la colocación del stent intraluminal de nitinol en perros con colapso traqueal – reporte de tres casos

O colapso da traqueia é uma doença caracterizada pela degeneração progressiva dos anéis cartilaginosos e pela frouxidão do músculo liso dorsaltraqueal, que acomete predominantemente cães de raças pequenas e toys. Os animais afetados podem apresentar tosse seca, ronqueira, dispneia, intolerância a exercícios físicos, cianose, síncopes e insuficiência respiratória. O tratamento é paliativo e tem 71% de eficácia com o uso de medicamentos, e não há cura definitiva. A implantação de stent intraluminal de nitinol é um procedimento minimamente invasivo, que tem mostrado resultado com eficácia de até 85% em cães que não responderam à terapia medicamentosa. É um procedimento considerado seguro, contudo não isento de complicações. Este trabalho objetivou relatar algumas das possíveis complicações em pacientes que foram submetidos à implantação do stent intraluminal de nitinol.

Tracheal collapse affects predominantly small and toy-breed dogs and is characterized by a progressive degenerative disease of the cartilage rings and laxity of the trachealis dorsalis muscle. Affected animals may present dry cough, honking, dyspnea, exercise intolerance, cyanosis, syncope episodes and respiratory insufficiency. There is no cure for this disease; the medical treatment is palliative and has shown 71% of success rate. Nitinol intraluminal tracheal stenting is a minimally invasive procedure that has yielded good results and a success rate up to 85% in dogs unresponsive to pharmacological therapy. Although it is not complication-free, the procedure is considered safe. This article reports some of the possible complications in patients who underwent the surgical procedure for implantation of a nitinol intraluminal stent.

El colapso de la tráquea es una enfermedad caracterizada por la degeneración progresiva del cartílago de los anillos, y por la laxitud del músculo liso dorsal de la tráquea. Los animales afectados, principalmente perros de razas pequeñas y toys, suelen presentar tos seca, ronquidos, disnea, intolerancia al ejercicio, cianosis, síncopes e insuficiencia respiratoria. El tratamiento es paliativo y tiene un 71% de eficiencia a través del uso de medicamentos; no hay cura definitiva de esta enfermedad. La implantación de un stent intraluminal de nitinol es un procedimiento de mínima invasión, que ha mostrado resultados con una eficiencia de hasta un 85% en los perros que no respondieron a la terapia con medicamentos. Es un procedimiento considerado como seguro, a pesar de que pueden presentarse complicaciones. Este trabajo tuvo como objetivo relatar algunas de las posibles complicaciones en pacientes que fueron sometidos a la implantación de stent intraluminal de nitinol.

Frecuencia de lesión de la vía aérea identificada por broncoscopia en recién nacidos con intubación endotraqueal prolongada en una unidad de cuidados intensivos neonatales de tercer nivel / Frequency and type of airway injury identified by bronchoscopic examination in newborns with prolonged endotracheal intubation in a neonatal intensive care unit

Introducción. La intubación endotraqueal y la ventilación mecánica son recursos que se utilizan frecuentemente en la Unidad de Cuidados Intensivos Neonatales. Sin embargo, se ha observado que elevan significativamente la mortalidad, dado que se presentan complicaciones. Por tanto, el objetivo de este trabajo fue reportar la frecuencia y el tipo de lesiones de la vía aérea en recién nacidos con intubación endotraqueal prolongada a quienes se les realizó broncoscopia. Métodos. Se incluyeron 150 recién nacidos con tiempo de intubación endotraqueal ≥ 5 días a quienes se les realizó broncoscopia. Se registraron las siguientes variables: edad gestacional, peso al nacer, indicación de la intubación, tamaño del tubo endotraqueal, número de reintubaciones, tiempo de intubación, indicación de la broncoscopia, hallazgos de la broncoscopia, tipo de tratamiento y número de broncoscopias. Resultados. La principal indicación de la broncoscopia fue la atelectasia persistente o recidivante. Del total de los pacientes, 96% presentaron alguna alteración de la vía aérea. Predominaron las lesiones inflamatorias (67.3%), seguidas de malacia (39.3%) y estenosis (28.7%). Las estructuras anatómicas más afectadas fueron los bronquios (31.6%), la laringe (24%) y la tráquea (22%). En 126 pacientes se indicó tratamiento médico; los esteroides se utilizaron con mayor frecuencia. Además del tratamiento médico, a 21 pacientes (14%) se les realizó dilatación bajo broncoscopia y a 7 (4.6%), traqueostomía. Conclusiones. Las lesiones más frecuentes fueron de tipo inflamatorio. La atelectasia persistente fue la principal manifestación clínica, por lo que se sugiere considerarla para que, durante la exploración broncoscópica, se descarte lesión de la vía aérea en recién nacidos con intubación endotraqueal prolongada.

Background. Endotracheal intubation and mechanical ventilation are frequently use resources in the Neonatal Intensive Care Unit. Higher mortality has been observed as a result of complications. We undertook this study to report the frequency and type of airway injury in newborns with prolonged endotracheal intubation who underwent bronchoscopy examination. methods. Newborns (n = 150) who were intubated endotracheally for ≥ 5 consecutive days and who underwent bronchoscopy were included. We recorded the following variables: gestational age, birth weight, indications for intubation, size of endotracheal tube, number of reintubations, intubation length, indication for bronchoscopy, bronchoscopic findings, type of treatment for airway injury, and number of bronchoscopies. Results. The main indication for bronchoscopy was atelectasis (persistent and/or recurrent); 96% of newborns had at least one injury. The most frequent were inflammatory type (67.3%), malacia (39.3%), and stenosis (28.7%). The most injured anatomic structures were the bronchi (31.6%), larynx (24%), and trachea (22%). For 126 patients, primary medical treatment was steroids. For 21 patients (14%), dilatation was performed under bronchoscopy; and for 7 (4.6%) patients, tracheostomy was performed. Conclusions. The most frequent injuries were inflammatory-type. Persistent atelectasis was the principal clinical manifestation; therefore, it should be considered as an indication of bronchoscopic exploration to identify airway injury in newborns with prolonged endotracheal intubation.

Modelo experimental de estenose traqueal mediante ressecção cirúrgica submucosa de anéis traqueais combinada com instilações de hidróxido de sódio / Experimental model of tracheal stenosis with submucosal resection of cartilaginous rings combined with sodium hydroxide instillations

OBJETIVO: Desenvolver, experimentalmente, malácia e estenose traqueal para testar novos modelos de órteses traqueais. MÉTODOS: Ressecamos três anéis cartilaginosos da traqueia cervical de cães no grupo A (n=5) e seis anéis no grupo B (n=4) para produzir malácia. Logo após, a mucosa da região com malácia recebeu aplicações de uma solução de hidróxido de sódio (NaOH) a 23 por cento, e os animais eram acompanhados com exames broncoscópicos para observar o desenvolvimento de estreitamento da luz da via aérea. Quando a estenose era de mais de 50 por cento da luz, ou havia sinais mínimos de insuficiência ventilatória, os animais eram sacrificados. O segmento de via aérea estreitada foi então coletado para análise histológica e era calculada a área de luz residual do segmento traqueal com estenose e malácia. RESULTADOS: Na análise histológica, foi constatada fibrose na submucosa e adventícia, associada a granulomas na mucosa. A luz residual média dos segmentos com estenose foi de 9 por cento e 12 por cento nos grupos A e B, respectivamente, (p>0,05). CONCLUSÃO: A combinação da ressecção de anéis cartilaginosos e da aplicação de NaOH 23 por cento na mucosa respiratória promoveu uma estenose traqueal intensa, porém esteve associada à perda de animais. Novos estudos são necessários para verificar se o emprego isolado de uma das técnicas seria mais seguro e eficaz para desenvolver estenose traqueal.

OBJECTIVE: To experimentally develop tracheal stenosis and malacia to test new models of tracheal stents. METHODS: We resected three cartilaginous rings from the cervical trachea of dogs in group A (n = 5) and six rings in group B (n = 4) to produce malacia. The mucosa of the region with malacia then received applications of a solution of sodium hydroxide (NaOH) at 23 percent, and the animals were accompanied with bronchoscopic examinations to observe the development of luminal narrowing of the airway. When the stenosis was of more than 50 percent or there were minimal signs of ventilatory failure, the animals were sacrificed. The segment of narrowed airway was then collected for histological analysis and calculation of the area of residual lumen in the tracheal segment with stenosis and malacia. RESULTS: In histological analysis, fibrosis was found in the submucosa and adventitia, associated with granulomas in the mucosa. The average residual lumen of the segments with stenosis was 9 percent and 12 percent in groups A and B, respectively (p> 0.05). CONCLUSION: The combination of resection of the cartilaginous rings and the application of 23 percent NaOH in the respiratory mucosa promoted severe tracheal stenosis, but was associated with loss of animals. Further studies are needed to verify that the isolated use of one of the techniques would be safer and more effective to develop tracheal stenosis.

Laringotraqueomalacia: diagnóstico fibroendoscópico videoasistido: Presentación de un caso / Laryngotracheomalacia: Video-assisted fybroendoscopic diagnosis: Presentation of a case

Fundamento: La laringomalacia es la más común de las anomalías congénitas de la laringe y muchos niños que la presentan tienen anomalías sincrónicas de la vía aérea, entre ellas la traqueomalacia. La evaluación de la dinámica de la vía aérea mediante la endoscopia flexible es el método que permite el diagnóstico de confirmación de estas entidades. Presentación de caso: un niño de 4 meses de edad con estridor laríngeo congénito y empeoramiento progresivo asociado a deformidad torácica y distress respiratorio, en el que la fibroendoscopia videoasistida demostró que se trataba de una laringotraqueomalacia(AU)

Background: Laryngomalacia is the most common congenital anomaly of the larynx, and many children who suffer from it have synchronous anomalies of the airway, including tracheomalacia. The evaluation of the airways dynamics by means of flexible endoscopy is the diagnostic method for confirmation of these entities. Case presentation: a 4-month-old with congenital stridor and progressive worsening associated with respiratory distress and chest deformity, in which video-assisted fybroendoscopy showed that it was a laryngotracheomalacia(AU)

Tratamento endoscopico das estenoses funcionais das vias aereas / Bronchoscopic management of functional airway obstruction

O objetivo do presente estudo foi caracterizar a traqueobroncomalacia (TBM) e excessive dynamic airway collapse (EDAC, colapso dinâmico excessivo das vias aereas). Embora a TBM e o EDAC, caracterizados por uma redução de 50% ou mais da luz, sejam descritos com frequencia crescente na forma de relatos de casos clinicos, faltam dados sistematizados que permitam o pronto diagnostico e a distinção entre TBM e EDAC. As tecnicas endoscopicas tem papel fundamental no diagnostico e podem ser uma alternativa para o tratamento de TBM e EDAC. É evidente a necessidade de estudos mais aprofundados acerca de TBM e EDAC que permitam o pronto reconhecimento e o tratamento adequado dessas entidades e das doenças subjacentes, contribuindo para uma melhora na qualidade de vida dos pacientes.

The objective of this review was to characterize tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC). There have been clinical case reports of TBM and EDAC, both of which are characterized by a ¡Ý 50% reduction in the crosssectional area of the tracheobronchial lumen, and the number of such reports is increasing. However, there are no systematicdata that would facilitate prompt diagnosis and allow distinctions to be drawn between TBM and EDAC. Endoscopic techniques play a key role in the diagnosis of both conditions and might represent an alternative means of treating patients with TBM or EDAC.There is a clear need for further studies of TBM and EDAC in order to develop strategies for the prompt recognition andproper treatment of these entities, as well as of the underlying diseases. The use of such strategies could lead to an improvement in the quality of life of patients within this population.