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Patel N, Madi P, Monteiro I, Shah SP. The anesthetic management of a child with ohtahara syndrome and severe stridor: a case report. BMC Pediatr 2024; 24:434. [PMID: 38969971 PMCID: PMC11225127 DOI: 10.1186/s12887-024-04907-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/23/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Ohtahara syndrome is a progressive developmental and epileptic encephalopathy that manifests in the early infantile period. This rare condition is characterized by intractable seizures, psychomotor retardation, and poor prognosis. To date, there are a handful of case reports regarding the anesthetic management of children with Ohtahara syndrome. However, limited reports exist of patients with Ohtahara syndrome who present with difficult airways. This report describes our airway findings and general anesthetic management of a pediatric patient with Ohtahara syndrome undergoing diagnostic bronchoscopy for severe inspiratory stridor. CASE PRESENTATION A 14-month-old, 9 kg, male patient with Ohtahara syndrome presented with a year-long history of severe inspiratory stridor and was scheduled for bronchoscopy with lavage. On exam, the patient had noisy breathing, was non-verbal with developmental delay, and had poor head control with significant central hypotonia. The patient was induced with ketamine and general anesthesia was maintained with propofol. Bronchoscopic evaluation was completed uneventfully and revealed a diagnosis of laryngotracheomalacia. The patient's breathing was maintained spontaneously throughout the procedure and no seizures were noted. In the post anesthesia care unit, the patient's respiratory and cardiovascular function were stable. CONCLUSIONS This report documents the unusual finding of severe inspiratory stridor in a 14-month-old child diagnosed with Ohtahara syndrome and our anesthetic management during their diagnostic bronchoscopy. Currently, documentation of complex airway pathology present in patients with Ohtahara syndrome is limited and should be further evaluated. This will assist pediatric anesthesiologists as these patients may require careful preoperative assessment, thoughtful airway management, and surgical alternatives on standby.
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Affiliation(s)
- Nidhi Patel
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, 538 E-MSB, 185 South Orange Ave, Newark, NJ, 07103, USA
| | - Peymon Madi
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, 538 E-MSB, 185 South Orange Ave, Newark, NJ, 07103, USA
| | - Iona Monteiro
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, 538 E-MSB, 185 South Orange Ave, Newark, NJ, 07103, USA
| | - Shridevi Pandya Shah
- Department of Anesthesia and Perioperative Care, Rutgers New Jersey Medical School, 538 E-MSB, 185 South Orange Ave, Newark, NJ, 07103, USA.
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Endotypes of Prematurity and Phenotypes of Bronchopulmonary Dysplasia: Toward Personalized Neonatology. J Pers Med 2022; 12:jpm12050687. [PMID: 35629108 PMCID: PMC9143617 DOI: 10.3390/jpm12050687] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD), the chronic lung disease of prematurity, is increasingly recognized as the consequence of a pathological reparative response of the developing lung to both antenatal and postnatal injury. According to this view, the pathogenesis of BPD is multifactorial and heterogeneous with different patterns of antenatal stress (endotypes) that combine with varying postnatal insults and might distinctively damage the development of airways, lung parenchyma, interstitium, lymphatic system, and pulmonary vasculature. This results in different clinical phenotypes of BPD. There is no clear consensus on which are the endotypes of prematurity but the combination of clinical information with placental and bacteriological data enables the identification of two main pathways leading to birth before 32 weeks of gestation: (1) infection/inflammation and (2) dysfunctional placentation. Regarding BPD phenotypes, the following have been proposed: parenchymal, peripheral airway, central airway, interstitial, congestive, vascular, and mixed phenotype. In line with the approach of personalized medicine, endotyping prematurity and phenotyping BPD will facilitate the design of more targeted therapeutic and prognostic approaches.
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3
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Montoya C, Steinhorn R, Berger J, Haroyan H, Said M, Perez GF. Dynamic PEEP Study: A Non-invasive Diagnostic Exam to Assess for Effective PEEP in Children with Severe BPD. Lung 2022; 200:59-65. [PMID: 35013755 DOI: 10.1007/s00408-021-00497-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tracheobronchomalacia (TBM) is common in neonates with bronchopulmonary dysplasia (BPD) and is associated with higher morbidity. This study evaluates the value of a CT protocol to assess the degree of TBM and gauge the adequacy of prescribed PEEP. STUDY DESIGN Four infants with severe BPD on invasive mechanical ventilation underwent a chest CT protocol, including limited reduced-dose expiratory scans with varying PEEP levels. RESULTS Baseline PEEP was adjusted in all subjects after performing the Dynamic PEEP CT. In two infants, the PEEP was increased due to significant TBM and in the other two without signs of TBM PEEP was decreased. The clinical course improved in all patients after adjusting PEEP. CONCLUSION A "Dynamic PEEP" study may be reliable and non-invasive imaging modality for the evaluation of adequate ventilator settings in infants with severe BPD who are not optimal candidates for bronchoscopy.
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Affiliation(s)
- Cassie Montoya
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University Chicago, Evanston, IL, USA
| | - Robin Steinhorn
- Division of Neonatology, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - John Berger
- Division of Cardiology, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Harutyun Haroyan
- Division of Radiology, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Mariam Said
- Division of Neonatology, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Geovanny F Perez
- Division of Pulmonary and Sleep Medicine, Oishei Children's Hospital, Jacobs School of Medicine and Biomedical Sciences, 1001 Main Street, Buffalo, NY, 14203, USA.
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Patterson K, Beyene TJ, Asti L, Althubaiti A, Lind M, Pattisapu P. Quantifying Upper Aerodigestive Sequelae in Esophageal Atresia/Tracheoesophageal Fistula Neonates. Laryngoscope 2021; 132:695-700. [PMID: 34369591 DOI: 10.1002/lary.29798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/08/2021] [Accepted: 07/24/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES We examined rates of upper aerodigestive tract (UADT) procedures in a multi-institutional cohort of neonates with esophageal atresia/tracheoesophageal fistula (EA/TEF) to estimate secondary UADT pathology. METHODS A retrospective cohort study was performed using a previously-validated population of patients with EA/TEF within the Pediatric Health Information System (PHIS) between 2007 and 2015. ICD-9/10-CM codes for aerodigestive procedures were examined from 2007 to 2020: 1) diagnostic direct laryngoscopy and/or bronchoscopy (DLB), 2) DLB with intervention, 3) tracheostomy, 4) gastrostomy, 5) fundoplication, 6) aortopexy, 7) laryngotracheoplasty, and 8) esophageal dilation. Associations between procedures and demographics, length of gestation, and weight were estimated using generalized linear mixed models. RESULTS We identified 2,509 patients with EA/TEF from 47 hospitals, 56.7% male and 43.3% female. Median length of stay for the first admission was 24 days (interquartile range: 12-55). Of these patients, 1,943 (77.4%) had at least one aerodigestive procedure within 14 admissions. Specifically, 1,635 (65.2%) underwent diagnostic DLB, 85 (3.4%) DLB with intervention, 167 (6.7%) tracheostomy, 1,043 (41.2%) gastrostomy, 211 (11.0%) fundoplication, 52 (2.1%) aortopexy, 161 (6.4%) laryngotracheoplasty, and 207 (8.3%) esophageal dilation. Preterm gestation increased odds of tracheostomy (adjusted odds ratio (OR) 2.4, 95% confidence interval (CI) 1.5-3.7), gastrostomy (OR 2.1, CI 1.7-2.7), fundoplication (OR 1.7, CI 1.1-2.4), aortopexy (OR 5.8, CI 2.1-16.1), and esophageal dilation (OR 2.0, CI 1.4-3.0). Very low birth weight (<1,500 g) increased odds of gastrostomy (OR 2.5, CI 1.6-3.8). CONCLUSION Patients with EA/TEF frequently have aerodigestive sequelae. This work helps quantify aerodigestive needs in neonates with EA/TEF, suggesting early otolaryngology evaluation in their care. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Kelli Patterson
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, U.S.A
| | - Tariku J Beyene
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, U.S.A
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, U.S.A
| | - Abdulrahman Althubaiti
- Department of Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, U.S.A
| | - Meredith Lind
- Department of Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, U.S.A
| | - Prasanth Pattisapu
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, U.S.A
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5
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Chiu CC, Lai SH, Lin JJ, Chan OW, Chiu CY, Tseng PL, Hsia SH, Lee EP. Clinical survey and predictors for the development of tracheobronchomalacia in preterm infants. Pediatr Pulmonol 2021; 56:2553-2560. [PMID: 34048639 DOI: 10.1002/ppul.25445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/25/2021] [Accepted: 04/17/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Tracheobronchomalacia (TBM) contributes to the increased morbidity and mortality observed in preterm infants. Effective strategies for the prevention of TBM are necessary to achieve better outcomes. We sought to identify risk factors associated with the development of TBM in preterm infants. Optimal cut-off values for each risk factor were also determined. METHODS A total of 80 infants who were born at 36 week's gestation or earlier and underwent flexible bronchoscopy were included in our study sample. A comparison of demographic and clinical risk factors between those with TBM (n = 35, 44%) and those without TBM (n = 45, 56%) was conducted using multivariate logistic regression analysis. Receiver operating characteristic curve analysis was performed to determine the appropriate cut-off values for predicting the development of TBM. RESULTS In the multivariate analysis, only peak inspiratory pressure (PIP) and the number of intubation days remained significantly different between infants with and without TBM. Preterm infants with TBM received higher PIP (odds ratio: [OR], 1.067; 95% confidence interval [CI], 1.010-1.128; p = .020) and were intubated for longer (odds ratio [OR], 1.019; 95% CI, 1.003-1.035; p = .016) than those without TBM. Infants who received PIP > 19.5 cmH2 O or were intubated for >79.5 days were associated with a significantly higher risk of presence of TBM. CONCLUSION High PIP and prolonged intubation were major risk factors for the development of TBM in premature infants. Those who require PIP > 19.5 cmH2 O or intubation >79.5 days warrant bronchoscopy examination for early diagnosis and management of TBM.
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Affiliation(s)
- Chun-Che Chiu
- Department of Pediatrics, Tucheng Composite Municipal Hospital, New Taipei City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shen-Hao Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Oi-Wa Chan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chih-Yung Chiu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Pei-Ling Tseng
- College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Shao-Hsuan Hsia
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - En-Pei Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
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Dubey S, Gelder C, Pink G, Ali A, Taylor C, Shakespeare J, Townsend S, Murphy P, Hart N, D'Cruz D. Respiratory subtype of relapsing polychondritis frequently presents as difficult asthma: a descriptive study of respiratory involvement in relapsing polychondritis with 13 patients from a single UK centre. ERJ Open Res 2021; 7:00170-2020. [PMID: 33614776 PMCID: PMC7882783 DOI: 10.1183/23120541.00170-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 11/30/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction Relapsing polychondritis is a rare multisystem vasculitis characterised by recurrent cartilage inflammation. Respiratory involvement, of which tracheobronchomalacia (TBM) is the commonest form, is difficult to treat and is linked to increased mortality. We describe 13 patients with respiratory involvement. Methods This is a retrospective study of all the patients with relapsing polychondritis at University Hospitals Coventry and Warwickshire NHS Trust (UHCW), a secondary care provider for ∼500 000. Only patients with respiratory involvement were included in this study. Results We identified 13 patients who fulfilled the inclusion criteria. Most patients were identified from the “difficult asthma” clinic. TBM was seen in 11 patients, whilst two patients had pleural effusions which resolved with immunosuppression and one patient had small airways disease. Computed tomography scans (inspiratory and expiratory) and bronchoscopy findings were useful in diagnosing TBM. Pulmonary function testing revealed significant expiratory flow abnormalities. All patients were treated with corticosteroids/disease-modifying anti-rheumatic drugs (DMARDs) and some were given cyclophosphamide or biological agents, although the response to cyclophosphamide (1 out of 4) or biologicals (2 out of 4) was modest in this cohort. Ambulatory continuous positive airway pressure ventilation was successful in four patients. Conclusions Relapsing polychondritis may be overlooked in “difficult asthma” clinics with patients having TBM (not asthma) and other features of relapsing polychondritis. Awareness of this condition is crucial to enable early diagnosis and interventions to reduce the risk of life-threatening airway collapse. A number of patients respond well to DMARDs and are able to minimise corticosteroid use. Tracheobronchomalacia can present as “difficult asthma” and can be associated with relapsing polychondritis. Optimal management of relapsing polychondritis is through medical treatments and support for the damaged airway through positive airway pressure.https://bit.ly/2JGoq23
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Affiliation(s)
- Shirish Dubey
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Colin Gelder
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Grace Pink
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Asad Ali
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Joanna Shakespeare
- Dept of Respiratory and Sleep Sciences, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Susan Townsend
- Dept of Respiratory and Sleep Sciences, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Nicholas Hart
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David D'Cruz
- Louise Coote Lupus Unit, Guy's Hospital, London, UK
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7
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Su YT, Chiu CC, Lai SH, Hsia SH, Lin JJ, Chan OW, Chiu CY, Tseng PL, Lee EP. Risk Factors for Tracheobronchomalacia in Preterm Infants With Bronchopulmonary Dysplasia. Front Pediatr 2021; 9:697470. [PMID: 34249821 PMCID: PMC8270074 DOI: 10.3389/fped.2021.697470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/04/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: To identify the risk factors associated with the development of tracheobronchomalacia (TBM) in preterm infants with bronchopulmonary dysplasia (BPD). Methods: This was a retrospective cohort study using chart reviews of preterm infants born at ≤ 36 week's gestation who underwent flexible fiberoptic bronchoscopy in a tertiary pediatric referral center between January 2015 and January 2020. Indications for the bronchoscopy examination included lobar atelectasis on plain chest film, persistent CO2 retention, recurrent extubation failure, or abnormal breathing sounds such as wheeze or stridor. Optimal cutoff values for each risk factor were also determined. Results: Fifty-eight preterm infants with BPD were enrolled, of whom 29 (50%) had TBM. There were no significant differences in gestational age and birth weight between those with and without TBM. Significantly more of the patients with TBM had severe BPD compared to those without TBM (68.9 vs. 20.6%, p < 0.001). Clinical parameters that were significantly different between the two groups were included in multivariate analysis. Among these factors, severe BPD was the most powerful risk factor for the development of TBM (odds ratio 5.57, 95% confidence interval 1.32-23.5, p = 0.019). The areas under the receiver operating characteristic curves for peak inspiratory pressure (PIP) and the duration of intubation were 0.788 and 0.75, respectively. The best predictive cutoff values of PIP and duration of intubation for TBM were 18.5 mmHg and 82 days, respectively. Conclusion: Preterm infants with severe BPD are at high risk for the development of TBM, and the risk is even higher in those who receive a higher PIP or are intubated for longer. Bronchoscopy examinations should be considered for the early diagnosis and management of TBM in infants with these risk factors.
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Affiliation(s)
- Ya-Ting Su
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Che Chiu
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Department of Pediatrics, Tucheng Composite Municipal Hospital, New Taipei City, Taiwan
| | - Shen-Hao Lai
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chih-Yung Chiu
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Pei-Ling Tseng
- College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - En-Pei Lee
- Chang Gung University College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
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8
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Koumbourlis AC, Belessis Y, Cataletto M, Cutrera R, DeBoer E, Kazachkov M, Laberge S, Popler J, Porcaro F, Kovesi T. Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula. Pediatr Pulmonol 2020; 55:2713-2729. [PMID: 32716120 DOI: 10.1002/ppul.24982] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/18/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
Abstract
Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.
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Affiliation(s)
- Anastassios C Koumbourlis
- Division of Pulmonary & Sleep Medicine, Children's National Hospital, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Yvonne Belessis
- Department of Respiratory Medicine, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Mary Cataletto
- Division of Pediatric Pulmonary Medicine, New York University, Winthrop University Hospital, Mineola, New York
| | - Renato Cutrera
- Academic Department of Pediatrics (DPUO), Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Pediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Emily DeBoer
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver, Children's Hospital Colorado Breathing Institute, Aurora, Colorado
| | - Mikhail Kazachkov
- Department of Pediatric Pulmonology, Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, New York
| | - Sophie Laberge
- Department of Pediatrics, Division of Respiratory Medicine, Sainte-Justine University Hospital Center, Université de Montréal, Montreal, Quebec, Canada
| | - Jonathan Popler
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Federica Porcaro
- Department of Pediatrics, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Thomas Kovesi
- Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
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9
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Liu R, Rui L, Li S, Zhang B, Zhang H, Lin Y, Li H. Absorbable Microplate Externally Suspending Bronchomalacia in Congenital Heart Disease Infant. Pediatr Cardiol 2020; 41:1092-1098. [PMID: 32382764 DOI: 10.1007/s00246-020-02358-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/23/2020] [Indexed: 11/28/2022]
Abstract
To evaluate the feasibility and efficacy of external suspension with absorbable poly-l-lactic acid material shaping microplates for infants with severe bronchomalacia and congenital heart disease. From November 2017 to January 2019, 11 continual patients with severe bronchomalacia and congenital heart disease underwent bronchial membrane external suspension together with cardiovascular surgery. An absorbable plate made with poly-l-lactic acid material was used as the shaping fixation material in all patients. Data included the details of the operation, and clinical results were collected. The mean age was 1.2 ± 1.0 years, and the mean weight was 7.7 ± 2.9 kg. The patients with cardiac malformations were operated on under low-temperature cardiopulmonary bypass (CPB) through median sternotomy. There were no in-hospital deaths. The CPB time, mechanical ventilation time, and length of intensive care unit stay were 123.9 ± 36.9 min, 20.7 ± 19.4 h, and 71.6 ± 54.9 h, respectively. Two patients underwent surgery through a left posterolateral incision without CPB. One was a double aortic arch repair, and the other was only bronchial membrane external suspension with prior IAA repair. No patients needed ECMO support. The mean follow-up time was 12.1 ± 5.6 months, and no patients were lost to follow-up. No cases of late death were noted, and no patients needed reoperation. According to the CT scans, no patients had bronchial restenosis. External bronchial membrane suspension with an absorbable poly-l-lactic acid material shaping plate, which had better histocompatibility, for infants with severe bronchomalacia and congenital heart disease was a safe and feasible procedure.
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Affiliation(s)
- Rui Liu
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Lu Rui
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Shoujun Li
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Benqing Zhang
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Heng Zhang
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Ye Lin
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Hanmei Li
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
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10
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Abstract
Airway and other head and neck disorders affect hundreds of thousands of patients each year and most require surgical intervention. Among these, congenital deformity that affects newborns is particularly serious and can be life-threatening. In these cases, reconstructive surgery is resolutive but bears significant limitations, including the donor site morbidity and limited available tissue. In this context, tissue engineering represents a promising alternative approach for the surgical treatment of otolaryngologic disorders. In particular, 3D printing coupled with advanced imaging technologies offers the unique opportunity to reproduce the complex anatomy of native ear, nose, and throat, with its import in terms of functionality as well as aesthetics and the associated patient well-being. In this review, we provide a general overview of the main ear, nose and throat disorders and focus on the most recent scientific literature on 3D printing and bioprinting for their treatment.
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Affiliation(s)
- Roberto Di Gesù
- Fondazione Ri.MED, Palermo, Italy.,Department of Pediatrics, Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abhinav P Acharya
- Department of Chemical Engineering, Arizona State University, Tempe, AZ, USA
| | - Ian Jacobs
- Department of Surgery, Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Riccardo Gottardi
- Fondazione Ri.MED, Palermo, Italy.,Department of Pediatrics, Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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11
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Nacoti M, Consonni F, Bonanomi E, Vedovati S. Severe Perinatal Bronchomalacia in a Newborn with Patent Ductus Arteriosus. Am J Respir Crit Care Med 2020; 201:e3-e4. [PMID: 31425656 DOI: 10.1164/rccm.201902-0410im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Mirco Nacoti
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Consonni
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ezio Bonanomi
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Sergio Vedovati
- Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
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12
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Babus LW, Gainsburg DM. Dynamic Tracheobronchial Compression in Steep Trendelenburg Position With Pneumoperitoneum for Robotic-Assisted Cystectomy: A Case Report. A A Pract 2020; 14:18-20. [PMID: 31789827 DOI: 10.1213/xaa.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tracheobronchomalacia is a weakness of the trachea and bronchi due to abnormal cartilage and muscular support leading to airway obstruction. We report a case of an adult former smoker without pulmonary symptoms who underwent robotic-assisted laparoscopic cystectomy in the steep Trendelenburg position. After repeated episodes of hypoxemia, bronchoscopic examination revealed collapse of the distal trachea and bronchi, supporting a diagnosis of tracheobronchomalacia. Tracheomalacia is an underdiagnosed condition in patients with a smoking history and may mimic other obstructive diseases. The anesthesiologist should remain vigilant to the possibility of airway collapse in former smokers, specifically in cases of increased intrathoracic pressure.
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Affiliation(s)
- Lenard W Babus
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
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13
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Wallis C, Alexopoulou E, Antón-Pacheco JL, Bhatt JM, Bush A, Chang AB, Charatsi AM, Coleman C, Depiazzi J, Douros K, Eber E, Everard M, Kantar A, Masters IB, Midulla F, Nenna R, Roebuck D, Snijders D, Priftis K. ERS statement on tracheomalacia and bronchomalacia in children. Eur Respir J 2019; 54:13993003.00382-2019. [PMID: 31320455 DOI: 10.1183/13993003.00382-2019] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/16/2019] [Indexed: 01/20/2023]
Abstract
Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study.
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Affiliation(s)
- Colin Wallis
- Respiratory Medicine Unit, Great Ormond Street Hospital for Children, London, UK
| | - Efthymia Alexopoulou
- 2nd Radiology Dept, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Juan L Antón-Pacheco
- Pediatric Airway Unit and Pediatric Surgery Division, Universidad Complutense de Madrid, Madrid, Spain
| | - Jayesh M Bhatt
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Andrew Bush
- Imperial College London and Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anne B Chang
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | | | | | - Julie Depiazzi
- Physiotherapy Dept, Perth Children's Hospital, Perth, Australia
| | - Konstantinos Douros
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Dept of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Mark Everard
- Division of Paediatrics, University of Western Australia, Perth Children's Hospital, Perth, Australia
| | - Ahmed Kantar
- Pediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
| | - Ian B Masters
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Fabio Midulla
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy
| | - Raffaella Nenna
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy.,Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Derek Roebuck
- Interventional Radiology Dept, Great Ormond Street Hospital, London, UK
| | - Deborah Snijders
- Dipartimento Salute della Donna e del Bambino, Università degli Studi di Padova, Padova, Italy
| | - Kostas Priftis
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
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14
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Altun D, Demir G, Ayhan A, Türköz A. Successful anesthetic and airway management in Coffin-Siris syndrome with congenital heart disease: Case report. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Dilek Altun
- Baskent University, Istanbul Training and Research Center, Anesthesiology and Reanimation (Cardiovascular Intensive Care Unit), Turkey
| | - Güray Demir
- Bakirkoy Dr. Sadi Konuk Training & Research Hospital, Anesthesiology and Reanimation, Turkey
| | - Asude Ayhan
- Baskent University, Ankara Training and Reasearch Center, Anesthesiology and Reanimation, Turkey
| | - Ayda Türköz
- Baskent University, Istanbul Training and Reasearch Center, Anesthesiology and Reanimation, Turkey
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15
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Clinical Characteristics and Associated Congenital Lesions with Tracheomalacia in Infants. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1401-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Masaracchia MM, Polaner DM, Prager JD, DeBoer EM, Dewberry LC, Somme S, Wine T, Janosy NR. Pediatric tracheomalacia and the perioperative anesthetic management of thoracoscopic posterior tracheopexy. Paediatr Anaesth 2018; 28:768-773. [PMID: 29962064 DOI: 10.1111/pan.13420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2018] [Indexed: 12/25/2022]
Abstract
Tracheomalacia is a broad term used to describe an abnormally compliant trachea that can lead to exaggerated collapse and obstruction with expiration. We describe the perioperative management of a complex pediatric patient undergoing a posterior tracheopexy which is a relatively new surgical treatment, with a novel surgical approach-thoracoscopy. This procedure has competing surgical and anesthetic needs and presents unique challenges to the physicians involved in caring for these patients. We also review the current literature on pediatric tracheomalacia and examine the newest treatment options to highlight the potential anesthetic challenges and pitfalls associated with management.
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Affiliation(s)
- Melissa M Masaracchia
- Department of Anesthesiology, Section of Pediatric Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - David M Polaner
- Department of Anesthesiology, Section of Pediatric Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jeremy D Prager
- Department of Otolaryngology, Pediatric Otolaryngology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Emily M DeBoer
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Lindel C Dewberry
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stig Somme
- Department of Surgery, Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Todd Wine
- Department of Otolaryngology, Pediatric Otolaryngology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Norah R Janosy
- Department of Anesthesiology, Section of Pediatric Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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17
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Ravi P, Wright J, Shiakolas PS, Welch TR. Three-dimensional printing of poly(glycerol sebacate fumarate) gadodiamide-poly(ethylene glycol) diacrylate structures and characterization of mechanical properties for soft tissue applications. J Biomed Mater Res B Appl Biomater 2018; 107:664-671. [DOI: 10.1002/jbm.b.34159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 04/12/2018] [Accepted: 04/29/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Prashanth Ravi
- Department of Mechanical and Aerospace Engineering; The University of Texas at Arlington; Arlington Texas 76019
| | - Jamie Wright
- Division of Pediatric Cardiovascular and Thoracic Surgery; The University of Texas Southwestern Medical Center; Dallas Texas 75390
| | - Panos S. Shiakolas
- Department of Mechanical and Aerospace Engineering; The University of Texas at Arlington; Arlington Texas 76019
| | - Tré R. Welch
- Division of Pediatric Cardiovascular and Thoracic Surgery; The University of Texas Southwestern Medical Center; Dallas Texas 75390
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18
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Lee J, Yun S, Lee I, Choi M, Yoon J. Fluoroscopic characteristics of tracheal collapse and cervical lung herniation in dogs: 222 cases (2012-2015). J Vet Sci 2018; 18:499-505. [PMID: 28057909 PMCID: PMC5746443 DOI: 10.4142/jvs.2017.18.4.499] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 10/04/2016] [Accepted: 11/23/2016] [Indexed: 11/24/2022] Open
Abstract
This retrospective study included 222 dogs suspected to have tracheal collapse (TC) and examined between 1 January 2012 and 31 December 2015. Fluoroscopic and radiographic images and medical records were evaluated to investigate the fluoroscopic characteristics of TC and cervical lung herniation (CLH), and to determine their relationships to various influencing. Grade of TC, existence of tracheal kinking, location of CLH (right or left side), and grade of CLH were evaluated fluoroscopically. One hundred ninety-nine dogs (89.6%) were diagnosed with TC. Presence of TC was not associated with the patients' cough history; however, CLH was positively correlated with cough history (odds ratio [OR], 2.896; 95% confidence interval [CI], 1.556 to 5.390) and was affected by tracheal kinking (OR, 3.841; 95% CI, 1.884 to 7.831). Chronic cough was not related with CLH. Since TC can be observed in patients without a history of cough, presence of TC should be ruled out by using physical examination and diagnostic imaging. Although CLH is associated with a history of cough, it is a common appearance in dogs, and transient coughing can elicit CLH in patients without a history of cough.
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Affiliation(s)
- Jeosoon Lee
- College of Veterinary Medicine and the Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Sookyung Yun
- College of Veterinary Medicine and the Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Inhyung Lee
- College of Veterinary Medicine and the Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Mincheol Choi
- College of Veterinary Medicine and the Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Junghee Yoon
- College of Veterinary Medicine and the Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
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19
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Wallis C, McLaren CA. Tracheobronchial stenting for airway malacia. Paediatr Respir Rev 2018; 27:48-59. [PMID: 29174374 DOI: 10.1016/j.prrv.2017.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 11/28/2022]
Abstract
Tracheobronchomalacia is a rare but clinically troublesome condition in paediatrics. The softening of the major airways - which can include some or all of the tracheobronchial tree can lead to symptoms ranging from the minor (harsh barking cough, recurrent chest infections) to severe respiratory difficulties including prolonged ventilator support and 'near death attacks'. The causes are broadly divided into intrinsic softening of the airway wall which is considered a primary defect (e.g. syndromes; post tracheo-oesophageal fistula repair; extreme prematurity) or secondary malacia due to external compression from vascular structures or cardiac components. These secondary changes can persist even when the external compression is relieved, for example, following the repair of a pulmonary artery sling or double aortic arch. For children with severe clinical symptoms attributed to malacia, consideration is given to possible surgical remedies such as an aortopexy for short limited areas of malacia, or long term positive pressure support with CPAP either by non invasive or tracheostomy interface. More recently the role of stenting in children is receiving attention, especially with the development of newer techniques such as bioabsorbable stents which buy time for a natural history of improvement in the malacia to occur. This paper reviews the stents available and discusses the pros and cons of stenting in paediatric airway malacia.
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Affiliation(s)
- Colin Wallis
- Department of Respiratory Paediatrics, Great Ormond Street Hospital for Children, London, UK.
| | - Clare A McLaren
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
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20
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Abstract
Airway malacia can occur in the larynx (larygomalacia), trachea (tracheomalacia), or bronchi (bronchomalacia). As a group these are the most common congenital abnormalities of the pediatric airway and are characterized by increased airway compliance, resulting in excessive dynamic collapse during the respiratory cycle. While a diagnosis can be suspected based on clinical history and physical examination, definitive evaluation is based of nasopharyngolaryngoscopy and/or bronchoscopy. Observation and conservative management are typically all that are required. However, surgical intervention can be necessary in the most severe cases, and can result in significant improvement in symptoms.
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Affiliation(s)
- Erik B Hysinger
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH.
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21
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Maddali MM, Kandachar PS, Al-Hanshi S, Al Ghafri M, Valliattu J. Mechanical cause for acute left lung atelectasis after neonatal aortic arch repair with arterial switch operation: Conservative management. Ann Card Anaesth 2017; 20:252-255. [PMID: 28393792 PMCID: PMC5408537 DOI: 10.4103/aca.aca_197_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Respiratory complications due to mechanical obstruction of the airways can occur following pediatric cardiac surgery. Clinically significant intrathoracic vascular compression of the airway can occur when extensive dissection and mobilization of arch and neck vessels is involved as in repair of interrupted aortic arch. This case report describes a neonate who underwent interrupted aortic arch repair along with an arterial switch operation and developed a left lung collapse immediately after tracheal extubation. Fiber-optic bronchoscopy revealed vascular compression as the real culprit. The child was successfully managed conservatively.
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Affiliation(s)
- Madan Mohan Maddali
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Sultanate of Oman
| | | | - Said Al-Hanshi
- Department of Pediatric Intensive Care, National Heart Center, Royal Hospital, Muscat, Sultanate of Oman
| | - Mohammed Al Ghafri
- Department of Pediatric Intensive Care, National Heart Center, Royal Hospital, Muscat, Sultanate of Oman
| | - John Valliattu
- Department of Cardiothoracic Surgery, National Heart Center, Royal Hospital, Muscat, Sultanate of Oman
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22
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Use of a biodegradable, oversized stent in a child with tracheomalacia secondary to vascular external compression. Cardiol Young 2017; 27:196-198. [PMID: 28281415 DOI: 10.1017/s104795111600113x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe the implantation of an absorbable, custom-made stent of polydioxanone to treat tracheomalacia in a 5-month-old patient with extrinsic compression by a double aortic arch. The use of an absorbable, oversized stent treated the tracheal collapse caused by vascular compression, avoided removal procedures, and allowed the infant's growth. The use of an oversized stent prevented stent migration and gave minimal problems of granulation.
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23
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Abstract
Neonates and infants may need a tracheostomy for many different reasons, ranging from airway obstruction to a requirement for long term mechanical ventilator support. Here, we present the pathophysiology of the many congenital and acquired conditions that might be managed with a tracheostomy. Decisions about tracheostomy demand consideration of not only the benefits, but also the potential side-effects, which may differ in the short and long term and may be attributable to underlying conditions as well as the tracheostomy. Evaluation of potential advantages of tracheostomy will influence decisions about optimal timing. In many cases, an infant may 'graduate' from dependence on a tracheostomy and resume a natural airway, although some will require reconstructive airway surgery.
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Affiliation(s)
- Sara B DeMauro
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Julie L Wei
- Nemours Children's Hospital, Orlando, FL, USA; University of Central Florida College of Medicine, Orlando, FL, USA
| | - Richard J Lin
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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24
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Goodfriend AC, Welch TR, Thomas CE, Nguyen KT, Johnson RF, Forbess JM. Bacterial sensitivity assessment of multifunctional polymeric coatings for airway stents. J Biomed Mater Res B Appl Biomater 2016; 105:2153-2161. [PMID: 27424845 DOI: 10.1002/jbm.b.33754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 05/27/2016] [Accepted: 06/26/2016] [Indexed: 11/08/2022]
Abstract
Current interventional technology for pediatric airway obstruction consists of cardiovascular stents and silicon tubes. These devices are composed of permanent materials that have limitations in biocompatibility and mechanical properties that make them controversial for used in pediatrics. Bioresorbable stents offer a temporary intervention that dissolves in the body over time and can serve as a platform for local drug delivery. Here we investigate a novel approach to use an antibiotic, ciprofloxacin, as a polymerization initiator to synthesize poly(ciprofloxacin fumaric acid) (PCFA) and then a second polymer using gadodiamide as an initiator to synthesize poly(gadodiamide ciprofloxacin fumaric acid) (PGCFA). Polymer structure, degradation, thermal properties, and rheological behavior were analyzed. Ciprofloxacin released was determined and polymer degradation extracts were used in bacterial sensitivity assessments with four common airway pathogens. PCFA and PGCFA polymers and drug release properties were compared to our previously published polymer poly(fumaric acid) (PFA). These novel polymers enable new possibilities as coatings for bioresorbable biomedical applications that require antibiotic resistance and imaging capabilities. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2153-2161, 2017.
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Affiliation(s)
- Amy C Goodfriend
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390-9130
| | - Tré R Welch
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390-9130
| | - Collin E Thomas
- Office of Research, Technology Translation Laboratory, University of Texas at Dallas, Richardson, Texas, 75080-3021
| | - Kytai T Nguyen
- Department of Bioengineering, University of Texas Arlington, Arlington, Texas, 76019
| | - Romaine F Johnson
- Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, 75390-9130
| | - Joseph M Forbess
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390-9130
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25
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Clark ES, Best C, Onwuka E, Sugiura T, Mahler N, Bolon B, Niehaus A, James I, Hibino N, Shinoka T, Johnson J, Breuer CK. Effect of cell seeding on neotissue formation in a tissue engineered trachea. J Pediatr Surg 2016; 51:49-55. [PMID: 26552897 PMCID: PMC4824302 DOI: 10.1016/j.jpedsurg.2015.10.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 10/06/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Surgical management of long segment tracheal disease is limited by a paucity of donor tissue and poor performance of synthetic materials. A potential solution is the development of a tissue-engineered tracheal graft (TETG) which promises an autologous airway conduit with growth capacity. METHODS We created a TETG by vacuum seeding bone marrow-derived mononuclear cells (BM-MNCs) on a polymeric nanofiber scaffold. First, we evaluated the role of scaffold porosity on cell seeding efficiency in vitro. We then determined the effect of cell seeding on graft performance in vivo using an ovine model. RESULTS Seeding efficiency of normal porosity (NP) grafts was significantly increased when compared to high porosity (HP) grafts (NP: 360.3 ± 69.19 × 10(3) cells/mm(2); HP: 133.7 ± 22.73 × 10(3) cells/mm(2); p<0.004). Lambs received unseeded (n=2) or seeded (n=3) NP scaffolds as tracheal interposition grafts for 6 weeks. Three animals were terminated early owing to respiratory complications (n=2 unseeded, n=1 seeded). Seeded TETG explants demonstrated wound healing, epithelial migration, and delayed stenosis when compared to their unseeded counterparts. CONCLUSION Vacuum seeding BM-MNCs on nanofiber scaffolds for immediate implantation as tracheal interposition grafts is a viable approach to generate TETGs, but further preclinical research is warranted before advocating this technology for clinical application.
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Affiliation(s)
- Elizabeth S. Clark
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205,Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, 1900 Coffey Road, Columbus, OH, 43210
| | - Cameron Best
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205
| | - Ekene Onwuka
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205,Department of Surgery, The Ohio State University, 395 W. 12th Avenue – Suite 670, Columbus, OH, 43210
| | - Tadahisa Sugiura
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205
| | - Nathan Mahler
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205
| | - Brad Bolon
- Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, 1900 Coffey Road, Columbus, OH, 43210,Comparative Pathology and Mouse Phenotyping Shared Resource, College of Veterinary Medicine, The Ohio State University, 1900 Coffey Road, Columbus, OH, 43210
| | - Andrew Niehaus
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, 601 Vernon Tharp Street, Columbus, OH, 43210
| | - Iyore James
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205
| | - Narutoshi Hibino
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205,Department of Cardiothoracic Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Toshiharu Shinoka
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205,Department of Cardiothoracic Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Jed Johnson
- Nanofiber Solutions, Inc., 1275 Kinnear Road, Columbus, OH, 43212
| | - Christopher K. Breuer
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive – Suite WB4154, Columbus, OH, 43205,Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
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26
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Rai A, Trikha A, Kumar A, Chandran R. Supraglottic airway and caudal epidural for anesthetic management of a child with Larsen syndrome. J Anaesthesiol Clin Pharmacol 2016; 32:266-7. [PMID: 27275063 PMCID: PMC4874088 DOI: 10.4103/0970-9185.173369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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27
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28
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Sigler M, Klötzer J, Quentin T, Paul T, Möller O. Stent implantation into the tracheo-bronchial system in rabbits: histopathologic sequelae in bare metal vs. drug-eluting stents. Mol Cell Pediatr 2015; 2:10. [PMID: 26542300 PMCID: PMC4635111 DOI: 10.1186/s40348-015-0021-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/16/2015] [Indexed: 11/12/2022] Open
Abstract
Background Stent implantation into the tracheo-bronchial system may be life-saving in selected pediatric patients with otherwise intractable stenosis of the upper airways. Following implantation, significant tissue proliferation may occur, requiring re-interventions. We sought to evaluate the effect of immunosuppressive coating of the stents on the extent of tissue proliferation in an animal model. Methods Bare metal and sirolimus-coated stents (Bx Sonic and Cypher Select, Johnson & Johnson, Cordis) were implanted into non-stenotic lower airways of New Zealand white rabbits (weight 3.1 to 4.8 kg). Three stents with sirolimus coating and six bare metal stents could be analyzed by means of histology and immunohistochemistry 12 months after implantation. Results On a macroscopic evaluation, all stents were partially covered with a considerable amount of whitish tissue. Histologically, these proliferations contained fiber-rich connective tissue and some fibromuscular cells without significant differences between both stent types. The superficial tissue layer was formed by typical respiratory epithelium and polygonal cells. Abundant lymphocyte infiltrations and moderate granulocyte infiltrations were found in both groups correspondingly, whereas foreign-body reaction was more pronounced around sirolimus-eluting stents. Conclusions After stent implantation in the tracheo-bronchial system of rabbits, we found tissue reactions comparable to those seen after stent implantation into the vascular system. There was no difference between coated and uncoated stents with regard to quality and quantity of tissue proliferation. We found, however, a significantly different inflammatory reaction with a more pronounced foreign-body reaction in sirolimus-coated stents. In our small series, drug-eluting stents did not exhibit any benefit over bare metal stents in an experimental setting.
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Affiliation(s)
- Matthias Sigler
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg August University Göttingen, Robert Koch Strasse 40, D 37075, Göttingen, Germany.
| | - Julia Klötzer
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg August University Göttingen, Robert Koch Strasse 40, D 37075, Göttingen, Germany.
| | - Thomas Quentin
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg August University Göttingen, Robert Koch Strasse 40, D 37075, Göttingen, Germany.
| | - Thomas Paul
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg August University Göttingen, Robert Koch Strasse 40, D 37075, Göttingen, Germany.
| | - Oliver Möller
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg August University Göttingen, Robert Koch Strasse 40, D 37075, Göttingen, Germany.
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Carter CL, Jones JW, Barrow K, Kieta K, Taylor-Howell C, Kearney S, Smith CP, Gibbs A, Farese AM, MacVittie TJ, Kane MA. A MALDI-MSI Approach to the Characterization of Radiation-Induced Lung Injury and Medical Countermeasure Development. HEALTH PHYSICS 2015; 109:466-78. [PMID: 26425906 PMCID: PMC4745118 DOI: 10.1097/hp.0000000000000353] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Radiation-induced lung injury is highly complex and characterized by multiple pathologies, which occur over time and sporadically throughout the lung. This complexity makes biomarker investigations and medical countermeasure screenings challenging. Matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) has the ability to resolve differences spatially in molecular profiles within the lung following radiation exposure and can aid in biomarker identification and pharmaceutical efficacy investigations. MALDI-MSI was applied to the investigation of a whole-thorax lung irradiation model in non-human primates (NHP) for lipidomic analysis and medical countermeasure distribution.
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Affiliation(s)
- Claire L. Carter
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences
| | - Jace W. Jones
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences
| | - Kory Barrow
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Kaitlyn Kieta
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Cheryl Taylor-Howell
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Sean Kearney
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Cassandra P. Smith
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Allison Gibbs
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Ann M. Farese
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Thomas J. MacVittie
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD 21201
| | - Maureen A. Kane
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences
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Anterior Tracheal Suspension for Tracheobronchomalacia in Infants and Children. Ann Thorac Surg 2014; 98:1246-53. [DOI: 10.1016/j.athoracsur.2014.05.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/27/2014] [Accepted: 05/05/2014] [Indexed: 12/20/2022]
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Dessoffy KE, Modaff P, Pauli RM. Airway malacia in children with achondroplasia. Am J Med Genet A 2013; 164A:407-14. [PMID: 24311312 DOI: 10.1002/ajmg.a.36303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 09/26/2013] [Indexed: 11/07/2022]
Abstract
This study was undertaken to assess the frequency of airway malacia in infants and young children with achondroplasia, a population well known to be at risk for a variety of respiratory problems. We also wished to evaluate what, if any, contribution airway malacia makes to the complex respiratory issues that may be present in those with achondroplasia. Retrospective chart review of all infants and young children with achondroplasia who were assessed through the Midwest Regional Bone Dysplasia Clinics from 1985 through 2012 (n = 236) was completed. Records of comprehensive clinical examinations, polysomnographic assessments, and airway visualization were reviewed and abstracted using a data collection form. Analyses were completed comparing the group with and those without evidence for airway malacia. Thirteen of 236 patients (5.5%) were found to have airway malacia. Most of those affected had lower airway involvement (9/13). The presence of airway malacia was correlated with an increased occurrence of obstructive sleep apnea as well as need for oxygen supplementation, airway surgeries and tracheostomy placement. Although estimates of the frequency of airway malacia in the general population are limited, its frequency in children with achondroplasia appears to be much higher than any published general population estimate. The presence of airway malacia appears to confound other breathing abnormalities in this population and results in the need for more invasive airway treatments.
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Affiliation(s)
- Kimberly E Dessoffy
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin
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Establishment of smooth muscle and cartilage juxtaposition in the developing mouse upper airways. Proc Natl Acad Sci U S A 2013; 110:19444-9. [PMID: 24218621 DOI: 10.1073/pnas.1313223110] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In the trachea and bronchi of the mouse, airway smooth muscle (SM) and cartilage are localized to complementary domains surrounding the airway epithelium. Proper juxtaposition of these tissues ensures a balance of elasticity and rigidity that is critical for effective air passage. It is unknown how this tissue complementation is established during development. Here we dissect the developmental relationship between these tissues by genetically disrupting SM formation (through Srf inactivation) or cartilage formation (through Sox9 inactivation) and assessing the impact on the remaining lineage. We found that, in the trachea and main bronchi, loss of SM or cartilage resulted in an increase in cell number of the remaining lineage, namely the cartilage or SM, respectively. However, only in the main bronchi, but not in the trachea, did the loss of SM or cartilage lead to a circumferential expansion of the remaining cartilage or SM domain, respectively. In addition to SM defects, cartilage-deficient tracheas displayed epithelial phenotypes, including decreased basal cell number, precocious club cell differentiation, and increased secretoglobin expression. These findings together delineate the mechanisms through which a cell-autonomous disruption of one structural tissue can have widespread consequences on upper airway function.
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Abstract
BACKGROUND Tracheomalacia, a disorder of the large airways where the trachea is deformed or malformed during respiration, is commonly seen in tertiary paediatric practice. It is associated with a wide spectrum of respiratory symptoms from life-threatening recurrent apnoea to common respiratory symptoms such as chronic cough and wheeze. Current practice following diagnosis of tracheomalacia includes medical approaches aimed at reducing associated symptoms of tracheomalacia, ventilation modalities of continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), and surgical approaches aimed at improving the calibre of the airway (airway stenting, aortopexy, tracheopexy). OBJECTIVES To evaluate the efficacy of medical and surgical therapies for children with intrinsic (primary) tracheomalacia. SEARCH METHODS The Cochrane Airways Group searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group's Specialised Register, MEDLINE and EMBASE databases. The Cochrane Airways Group performed the latest searches in March 2012. SELECTION CRITERIA All randomised controlled trials (RCTs) of therapies related to symptoms associated with primary or intrinsic tracheomalacia. DATA COLLECTION AND ANALYSIS Two reviewers extracted data from the included study independently and resolved disagreements by consensus. MAIN RESULTS We included one RCT that compared nebulised recombinant human deoxyribonuclease (rhDNase) with placebo in 40 children with airway malacia and a respiratory tract infection. We assessed it to be a RCT with overall low risk of bias. Data analysed in this review showed that there was no significant difference between groups for the primary outcome of proportion cough-free at two weeks (odds ratio (OR) 1.38; 95% confidence interval (CI) 0.37 to 5.14). However, the mean change in night time cough diary scores significantly favoured the placebo group (mean difference (MD) 1.00; 95% CI 0.17 to 1.83, P = 0.02). The mean change in daytime cough diary scores from baseline was also better in the placebo group compared to those on nebulised rhDNase, but the difference between groups was not statistically significant (MD 0.70; 95% CI -0.19 to 1.59). Other outcomes (dyspnoea, and difficulty in expectorating sputum scores, and lung function tests at two weeks also favoured placebo over nebulised rhDNase but did not reach levels of significance. AUTHORS' CONCLUSIONS There is currently an absence of evidence to support any of the therapies currently utilised for management of intrinsic tracheomalacia. It remains inconclusive whether the use of nebulised rhDNase in children with airway malacia and a respiratory tract infection worsens recovery. It is unlikely that any RCT on surgically based management will ever be available for children with severe life-threatening illness associated with tracheomalacia. For those with less severe disease, RCTs on interventions such as antibiotics and chest physiotherapy are clearly needed. Outcomes of these RCTs should include measurements of the trachea and physiological outcomes in addition to clinical outcomes.
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Affiliation(s)
- Vikas Goyal
- Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane,
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Torre M, Speggiorin S, Roebuck DJ, McLaren CA, Elliott MJ. Congenital absence of cartilaginous tracheal rings associated with esophageal atresia and trifurcated carina: a novel anomaly? J Pediatr Surg 2012; 47:1008-11. [PMID: 22595591 DOI: 10.1016/j.jpedsurg.2012.01.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 11/29/2022]
Abstract
Tracheomalacia associated with esophageal atresia (EA) is a well-known condition. However, complete absence of tracheal rings (TRs) is extremely rare. Our aim is to describe a novel triad of conditions and to discuss the best treatment. An expremature male operated for EA presented with severe respiratory distress. The diagnosis of absent cartilage rings, suspected on bronchoscopy, was confirmed by optical coherence tomography. The absence of TRs was localized to a short tracheal segment, and the carina trifurcated into right upper lobe, right intermediate, and left main bronchus. The patient was treated with resection and anastomosis with a completely satisfactory course. Absence of TRs was previously reported by us in 2 other cases, both with associated EA and trifurcation of the carina. One child was treated with tracheostomy and the other with a stent, but the outcome was far from optimal. The patient with tracheostomy eventually underwent resection and anastomosis with tracheostomy closure. Congenital absence of TRs is extremely rare. Although localized, it is responsible for severe symptoms owing to complete tracheal collapse and may be misdiagnosed as tracheomalacia. In our experience, it has been associated with EA and trifurcated carina. Our limited experience suggests resection of the abnormal segment and tracheal anastomosis as the best treatment.
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Affiliation(s)
- Michele Torre
- Paediatric Surgery Department, Istituto G. Gaslini, 16148 Genova, Italy.
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Adamama-Moraitou KK, Pardali D, Day MJ, Prassinos NN, Kritsepi-Konstantinou M, Patsikas MN, Rallis TS. Canine bronchomalacia: A clinicopathological study of 18 cases diagnosed by endoscopy. Vet J 2012; 191:261-6. [DOI: 10.1016/j.tvjl.2010.11.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 11/15/2010] [Accepted: 11/18/2010] [Indexed: 10/18/2022]
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Sanchez MO, Greer MC, Masters IB, Chang AB. A comparison of fluoroscopic airway screening with flexible bronchoscopy for diagnosing tracheomalacia. Pediatr Pulmonol 2012; 47:63-7. [PMID: 21830315 DOI: 10.1002/ppul.21517] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 06/16/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Flexible bronchoscopy (FB) is the gold standard method of diagnosing tracheomalacia but it is not always feasible in settings with limited resources. Fluoroscopy is sometimes performed as an alternative diagnostic tool but there are no prospective studies that have evaluated the diagnostic accuracy of airway fluoroscopy for tracheomalacia using a-priori definitions. We determined the sensitivity, specificity, and likelihood predictive ratio of airway fluoroscopy compared with FB in children suspected of having an airway abnormality. METHODS Airway fluoroscopic examination was undertaken within 2-weeks of a FB in children aged <18-years and reported by a pediatric radiologist blinded to FB data. Fluoroscopic and FB methods and diagnostic criteria were standardized and defined a-priori. Tracheomalacia diagnosed by FB were independently scored (mild, moderate, severe) by 2 pulmonologists in a blinded manner. RESULTS In 22 children (median age 33 months, range 1-187) evaluated for airway abnormality, tracheomalacia was found in 21 children at bronchoscopy. Of these, fluoroscopy detected tracheomalacia in five children. Airway fluoroscopy was poorly sensitive (23.8%) but highly specific (100%), positive likelihood ratio was 8.6. However, in moderate-severe tracheomalacia, the sensitivity improved to 57.1% but the specificity reduced (93.3%). The agreement between bronchoscopists for tracheomalacia severity was excellent, weighted kappa 0.74 (95% CI 0.77, 0.98). CONCLUSION Airway fluoroscopy cannot replace FB which remains the tool for definitively diagnosing airway malacia. However, in absence of other modalities for diagnosis fluoroscopy should be considered in the setting of persistent respiratory symptoms compatible with the clinical picture of tracheomalacia.
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Affiliation(s)
- M O Sanchez
- Queensland Children's Respiratory Centre and Queensland Children's Medical Research Institute, Brisbane, Queensland, Australia.
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Kwon YS, Lim YH, Park HL, Yoo BH, Woo SH, Yon JH. Reversible airway obstruction caused by changing the size and length of an endotracheal tube in a premature neonate with suspected tracheomalacia -A case report-. Korean J Anesthesiol 2011; 59 Suppl:S30-2. [PMID: 21286454 PMCID: PMC3030050 DOI: 10.4097/kjae.2010.59.s.s30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 07/27/2010] [Accepted: 08/18/2010] [Indexed: 11/10/2022] Open
Abstract
Tracheomalacia is a malformation of the tracheal membranosa. It is maintained during spontaneous breathing but can be altered by bronchoscopy or positive airway pressure. Tracheomalacia is associated with a high mortality and may cause prolonged intubation and ventilation. Here, the case of a 13-day-old infant with jejunoileal stenosis that had surgery is reported. During induction of general anesthesia, endotracheal intubation was attempted several times with different sized endotracheal tubes. Airway obstruction occurred after the endotracheal intubation. After the airway was maintained, the operation was completed. Tracheomalacia was diagnosed after otolaryngology evaluation postoperatively.
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Affiliation(s)
- Young Suk Kwon
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
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Sala FG, Del Moral PM, Tiozzo C, Alam DA, Warburton D, Grikscheit T, Veltmaat JM, Bellusci S. FGF10 controls the patterning of the tracheal cartilage rings via Shh. Development 2011; 138:273-82. [PMID: 21148187 PMCID: PMC3005603 DOI: 10.1242/dev.051680] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2010] [Indexed: 12/19/2022]
Abstract
During embryonic development, appropriate dorsoventral patterning of the trachea leads to the formation of periodic cartilage rings from the ventral mesenchyme and continuous smooth muscle from the dorsal mesenchyme. In this work, we have investigated the role of two crucial morphogens, fibroblast growth factor 10 and sonic hedgehog, in the formation of periodically alternating cartilaginous and non-cartilaginous domains in the ventral mesenchyme. Using a combination of gain- and loss-of-function approaches for FGF10 and SHH, we demonstrate that precise spatio-temporal patterns and appropriate levels of expression of these two signaling molecules in the ventral area are crucial between embryonic day 11.5 and 13.5 for the proper patterning of the cartilage rings. We conclude that the expression level of FGF10 in the mesenchyme has to be within a critical range to allow for periodic expression of Shh in the ventral epithelium, and consequently for the correct patterning of the cartilage rings. We propose that disturbed balances of Fgf10 and Shh may explain a subset of human tracheomalacia without tracheo-esophageal fistula or tracheal atresia.
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Affiliation(s)
- Frédéric G. Sala
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Pierre-Marie Del Moral
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Caterina Tiozzo
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Denise Al Alam
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - David Warburton
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Tracy Grikscheit
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Jacqueline M. Veltmaat
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Saverio Bellusci
- Developmental Biology and Regenerative Medicine Program, Saban Research Institute of Childrens Hospital Los Angeles, Los Angeles, CA 90027, USA
- University of Giessen Lung Center, Excellence Cluster in Cardio-Pulmonary Systems, Department of Internal Medicine II, Klinikstrasse 36, 35392 Giessen, Germany
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Warburton D, El-Hashash A, Carraro G, Tiozzo C, Sala F, Rogers O, De Langhe S, Kemp PJ, Riccardi D, Torday J, Bellusci S, Shi W, Lubkin SR, Jesudason E. Lung organogenesis. Curr Top Dev Biol 2010; 90:73-158. [PMID: 20691848 DOI: 10.1016/s0070-2153(10)90003-3] [Citation(s) in RCA: 297] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Developmental lung biology is a field that has the potential for significant human impact: lung disease at the extremes of age continues to cause major morbidity and mortality worldwide. Understanding how the lung develops holds the promise that investigators can use this knowledge to aid lung repair and regeneration. In the decade since the "molecular embryology" of the lung was first comprehensively reviewed, new challenges have emerged-and it is on these that we focus the current review. Firstly, there is a critical need to understand the progenitor cell biology of the lung in order to exploit the potential of stem cells for the treatment of lung disease. Secondly, the current familiar descriptions of lung morphogenesis governed by growth and transcription factors need to be elaborated upon with the reinclusion and reconsideration of other factors, such as mechanics, in lung growth. Thirdly, efforts to parse the finer detail of lung bud signaling may need to be combined with broader consideration of overarching mechanisms that may be therapeutically easier to target: in this arena, we advance the proposal that looking at the lung in general (and branching in particular) in terms of clocks may yield unexpected benefits.
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Affiliation(s)
- David Warburton
- The Saban Research Institute, Childrens Hospital Los Angeles, Los Angeles, California, USA
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Boogaard R, de Jongste JC, Vaessen-Verberne AAPH, Hop WCJ, Merkus PJFM. Recombinant human DNase in children with airway malacia and lower respiratory tract infection. Pediatr Pulmonol 2009; 44:962-9. [PMID: 19768804 DOI: 10.1002/ppul.21073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children with airway malacia often have protracted courses of airway infections, because dynamic airway collapse during coughing results in impaired mucociliary clearance. The aim of this study was to determine the effect of the mucolytic drug recombinant human deoxyribonuclease (rhDNase) on the recovery of respiratory symptoms in children with airway malacia and lower respiratory tract infection (LRTI). METHODS In a randomized double-blind controlled clinical trial, 40 children with airway malacia and LRTI were randomly assigned to receive either 2.5 mg nebulized rhDNase or placebo twice daily for 2 weeks. The primary endpoint was the change in the cough diary score (CDS) (scale 0-5) from baseline to the second week of treatment. Secondary endpoints were VAS symptom scores for cough, dyspnea, and difficulty in expectorating sputum, need for an antibiotic course, and lung function data (FVC, FEV(1), FEF(75), R(int(e))). RESULTS There was no significant difference in the mean change in CDSs from baseline between the rhDNase group and the placebo group (mean difference for daytime 0.19 (95% CI -0.53 to 0.90); for nighttime 0.38 (95% CI -0.30 to 1.05). Proportions of patients requiring antibiotics, and the mean changes in symptom scores and lung function from baseline did not significantly differ between both groups. CONCLUSION Treatment with 2 weeks of nebulized rhDNase does not enhance recovery or reduce the need for antibiotics in children with airway malacia and LRTI. (Controlled-trials.com number, ISRCTN85366144).
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Affiliation(s)
- Ruben Boogaard
- Division of Pulmonology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Abstract
UNLABELLED We report left main-stem bronchomalacia occurring in monozygotic twins that became symptomatic during infancy. This phenomenon has not previously been reported to occur in twins. Little is known about the aetiology of primary bronchomalacia, but this occurrence suggests that there may be a significant genetic component in some cases. CONCLUSION Left main-stem bronchomalacia occurring in monozygotic twins suggests that there may be a significant genetic component in some cases and provides further information about the inheritance of this condition.
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Affiliation(s)
- Malcolm Brodlie
- Department of Respiratory Paediatrics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK.
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Jović RM, Komazec Z, Mitrović S, Dragicević D, Janjević D. Surgical treatment of primary tracheal dyskinesia in a 14-month-old child--case report. Auris Nasus Larynx 2009; 37:263-7. [PMID: 19709830 DOI: 10.1016/j.anl.2009.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 05/28/2009] [Accepted: 06/17/2009] [Indexed: 10/20/2022]
Abstract
The primary form of tracheal dyskinesia in early childhood is a rare congenital malformation of unknown origin. The degree of the posterior membranous tracheal wall involvement determines the intensity of obstruction and the severity of the clinical picture. The aim of this paper is to present a case of a 14-month-old child with severe tracheal dyskinesia that required surgical treatment. Fascia lata graft fixated with fibrin glue was used in strengthening the posterior tracheal wall. Three years following the surgery, the child is without breathing difficulties. In severe cases of primary dyskinesia, surgical treatment using fascia lata graft, fixated with fibrin glue is recommended in strengthening the posterior tracheal wall.
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Affiliation(s)
- Rajko M Jović
- University ENT Clinic, Clinical Center of Vojvodina Novi Sad, Hajduk Veljkova 1, Novi Sad, Serbia.
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Affiliation(s)
- Iain A Bruce
- Department of Paediatric ENT, Royal Manchester Children's Hospital, Manchester, UK.
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Vilozni D, Efrati O, Barak A, Yahav Y, Augarten A, Bentur L. Forced inspiratory flow volume curve in healthy young children. Pediatr Pulmonol 2009; 44:105-11. [PMID: 19142889 DOI: 10.1002/ppul.20835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Spirometry testing should include both expiratory and inspiratory measurements. Inspiratory forced maneuvers can demonstrate extrathoracic airway abnormalities, of which various symptoms may suggest asthma. However, the inspiratory portion of the forced flow/volume maneuver in young healthy children has not yet been described. OBJECTIVES To document and analyze the forced inspiratory flow volume curve indices in healthy young children. SETTINGS AND PARTICIPANTS Healthy preschool children (age 2.5-6.5 years) from community kindergartens around Israel. METHODS The teaching method included multi-target, interactive spirometry games and accessory games for inspiration (e.g., inspiratory whistle). RESULTS One hundred and fourteen out of a total of 157 children performed duplicate full adequate inspiratory maneuvers. Repeatability between two maneuvers was 5.6%, 4.0%, 5.1%, 7.3% for inspiratory capacity (IC), forced inspiratory vital capacity (FIVC), peak inspiratory flow (PIF), and mid inspiratory flow (FIF50). Inspiratory flow indices were significantly lower than the expiratory flow indices. The time to reach PIF was significantly longer (mean +/- SD; 229 +/- 21 msec) than the time to reach peak expiratory flow (92 +/- 8 msec; P < 0.0001). The shape of the inspiratory curve was parabolic and did not vary with age. The formed predicted equations were in agreement with the extrapolated values for older healthy children. CONCLUSIONS The majority of healthy young children can perform reliable maximum inspiratory flow volume curves. Our results provide a framework of reference equations for maximum inspiratory flow volume curve in the young children. The clinical applications of these equations have to be explored.
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Affiliation(s)
- Daphna Vilozni
- The Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center Tel-HaShomer, Affiliated with the Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.
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MDCT Evaluation of the Prevalence of Tracheomalacia in Children With Mediastinal Aortic Vascular Anomalies. J Thorac Imaging 2008; 23:258-65. [DOI: 10.1097/rti.0b013e31817fbdf7] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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49
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Bilan N, Behbahan AG, Miabi Z. Diagnosis of airway malacia by virtual bronchoscopy. Pak J Biol Sci 2008; 11:1881-3. [PMID: 18817238 DOI: 10.3923/pjbs.2008.1881.1883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The study was aimed to identify the role of virtual bronchoscopy in detection of airway malacia in children. In a pre-experimental study over 3 years (from Nov. 2003 to Oct. 2006), 35 consecutive patients were presented to Tabriz Children's Hospital with clinical manifestations of airway malacia, examined by the technique of virtual bronchoscopy. Thirty five patients including 23 males and 12 females with the mean age of 3.7 +/- 1.6 months were studied. The presence of airway malacia and its location and severity were determined by virtual bronchoscopy in all studied cases; that revealed: laryngomalacia, bronchomalacia, tracheomalacia, laryngotracheomalacia and laryngobronchomalacia in 42.8, 25.7, 20, 8.6 and 2.9% of patients, respectively. Virtual bronchoscopy is a non-invasive, accurate and rapid imaging technique with an excellent validity for diagnosis of airway malacia and stenosis, therefore it can replace conventional bronchoscopy.
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Affiliation(s)
- Nemat Bilan
- Department of Pediatrics, Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran
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50
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Doshi J, Krawiec ME. Clinical manifestations of airway malacia in young children. J Allergy Clin Immunol 2008; 120:1276-8. [PMID: 18073123 DOI: 10.1016/j.jaci.2007.09.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 09/27/2007] [Indexed: 11/25/2022]
Abstract
A case of recurrent respiratory distress, wheezing, and "noisy" breathing in a 6-month-old infant with a normal birth history and chest radiographic evaluation is presented. The distinction between primary and secondary tracheomalacia is outlined. This report emphasizes the importance of clinical history in the evaluation of primary tracheomalacia.
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Affiliation(s)
- Jayna Doshi
- Department of Pediatrics, Division of Allergy and Immunology, National Jewish Medical and Research Center, Denver, CO 80206, USA
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