Severe Airway Obstruction Research Articles

Clinical characteristics for conservative therapy of pediatric parapharyngeal abscesses

IntroductionThe role of surgical drainage versus conservative therapy in treating patients with parapharyngeal abscesses is still a theme of debate. ObjectivesThis study aimed to investigate the characteristics associated with good outcomes in pediatric patients with parapharyngeal abscesses treated with conservative therapy. MethodsThis retrospective chart review was performed on children aged 0.3–14 years with the diagnosis of parapharyngeal abscesses confirmed by computed tomography from January 2013 to March 2018. Patients with a severe upper airway obstruction required early intervention, while those in a stable condition initially received conservative therapy with antibiotics. If the patients appeared unlikely to recover, additional surgical drainage was provided. Multivariate logistic regression models were constructed to investigate the clinical characteristics associated with a good response to conservative therapy. A receiver operating characteristic curve was used to identify the age and abscess size cutoff for predicting a successful response. ResultsA total of 48 children were included in the study. Patient age, antecedent illness, and abscess size were significantly associated with a response to therapy (Odds Ratio=1.326, 2.314 and 1.235, respectively). The age cutoff associated with the conservative therapy was 4.2 years (76.9% sensitivity, 68.2% specificity), and the abscess size cutoff associated with the conservative therapy was 23mm (84.6% sensitivity, 77.3% specificity). ConclusionThe findings suggested that younger age, smaller abscess size, and less frequent antecedent illnesses, such as upper respiratory tract infection and lymphadenitis, could predict a successful response to conservative therapy in pediatric patients with parapharyngeal abscesses.

Physical Activity in Patients with Chronic Obstructive Pulmonary Disease on Long-Term Oxygen Therapy: A Cross-Sectional Study.

Background and aimThere are few studies evaluating physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT).AimTo assess PA in hypoxemic COPD patients on LTOT.MethodsIn this cross-sectional study, we compared lung function, arterial blood gases, respiratory and peripheral muscle strength, 6-min walking distance (6MWD), daily energy expenditure and steps, and health-related quality of life (HRQL) in COPD patients on LTOT (LTOT group) versus two groups of control patients not needing LTOT: with (HYPOX) and without (COPD) exercise-induced desaturations.ResultsGroups did not differ as regards demographics, anthropometrics, peripheral or respiratory muscle strength. Compared to the other groups, LTOT patients had more severe airway obstruction and lung hyperinflation, greater number and severity of comorbidities, shorter 6MWD, as well as lower mean SpO2 during 6MWD and worse quality of life. LTOT patients had a lower daily energy expenditure, shorter time spent > 3.0 METs and longer sedentary time compared to the COPD group, and less daily steps compared to the other groups. No significant difference in any parameter of PA was found between COPD and HYPOX. In LTOT patients, daily steps showed a strong correlation with 6MWD, and a moderate correlation with airway obstruction, level of oxygenation, comorbidities and quality of life but not with peripheral and respiratory muscle strength. In COPD and HYPOX patients, daily steps were strongly correlated with 6MWD and level of oxygenation as assessed by PaO2/FiO2. There was no significant correlation between mean SpO2 and 6MWD in any group.ConclusionCOPD patients on LTOT perform less physical activity than patients not needing LTOT, both with and without exercise-induced desaturations. Patients with exercise-induced desaturations do not perform less physical activity than those without.

Clinical assessment and related intervention of neonatal upper airway obstruction

Objective:To discuss the diagnosis and evaluation of upper airway obstruction in neonates, classify the possible causes of neonatal upper airway obstruction, establish a standardized diagnosis and treatment procedure to improve the of treatment efficacy. Method:Clinical data of 71 cases with upper airway obstruction history were retrospective analyzed, 38 cases were treated by combined medical and surgical treatment, 17 cases underwent medical treatment, 16 cases abandonment the treatment. The effectiveness of fibrolaryngoscope, CT, neck ultrasound, MRI and other results was evaluated, and to analyze the prognosis of the treatment, the outcomes and risk factors were also analysed, to evaluate risk factors associated with upper airway obstruction. Result:Fifty-five cases were cured or improved. The mortality rate of 16 children who gave up treatment and left hospital automatically was 81.25%（13/16）. The accuracy rate of flexible laryngoscope in detecting the level of upper airway obstruction was 100%, the coincidence rate of B-ultrasound for upper airway cystic occupation was 100%. Etiological order from high to low was congenital space-occupying lesions, congenital upper airway malformation, vocal cord paralysis, Pierre-Robin syndrome. The site of obstruction has a significant influence on the severity of upper airway obstruction（P<0.05）. The cure rate of the non-endotracheal intubation group was higher than that of the endotracheal intubation group（P<0.05）. Conclusion:The obstruction site of upper airway significantly affects the outcome and the severity of the disease. Upper airway space occupying lesions are the primary causes of upper airway obstruction in neonates. Early assessment and timely treatment can improve the cure rate and improve the prognosis. Internal medicine combined with surgical treatment is effective in relieving upper airway obstruction.

Management of neonates with micrognathia and severe upper airway obstruction

Introduction Neonates with micrognathia and upper airway obstruction (UAO) are most commonly managed with positioning or a nasopharyngeal airway, but severe cases may require a temporary tracheostomy. These patients may be considered for distraction osteogenesis (DO). Early referral for DO may improve outcomes while obviating the need for tracheostomy with its associated risks and long-term consequences.

Curvilinearity of a Maximum Expiratory Flow-Volume Curve: A Useful Indicator for Assessing Airway Obstruction in Children With Asthma.

Lung function parameters are used as signs in the diagnosis and evaluation of asthma; however, their sensitivity and specificity are not ideal. We calculated and combined angle β with lung function parameters to identify the ideal indicator. We aimed to identify an ideal indicator for evaluating the severity of airway obstruction in children with asthma. In total, 151 school-age children diagnosed with asthma were selected as the asthma group, and 106 healthy children were selected as the control group. The subjects were divided into the exacerbation group, chronic persistent group, and clinical remission group. Furthermore, the subjects were classified into mild and moderate groups or severe and critical groups. Angle β was calculated in each group. A receiver operating characteristic curve analysis was performed to determine the cutoff values of angle β and lung function parameters that together provided high sensitivity and specificity for airway obstruction evaluation in children with asthma. The mean value of angle β in the asthma group was significantly smaller than that in the control group (178.18° and 196.72°, respectively, P < .001). More exacerbations or greater severity corresponded to smaller angle β values (P < .001). The best cutoff value of angle β was 189.43°, and the area under the receiver operating characteristic curve of angle β was 0.877, which is greater than the area under the receiver operating characteristic curve of FEV1, forced expiratory flow (FEF) at 75% vital capacity (FEF25%), and FEF at 50% vital capacity (FEF50%), but smaller than the area under the receiver operating characteristic curve of FEF75% and FEV1/FVC%. Interestingly, combining these measures can enhance the sensitivity and specificity in assessing airway obstruction. Angle β was a useful indicator for assessing airway obstruction. Furthermore, angle β combined with FEV1, FEV1/FVC%, FEF25%, FEF50%, and FEF75% can enhance the sensitivity and specificity of airway obstruction evaluations.

Relationship between airway obstruction and C-reactive protein levels in a community-based population of Korea.

OBJECTIVE: To examine the relationship between high-sensitivity C-reactive protein (hs-CRP) levels and lung function in a community-based cohort of South Korea.DESIGN: The Ansung-Ansan cohort database (an ongoing prospective study of a community-based population) was used in the analysis. We defined airway obstruction as the ratio between forced expiratory volume in 1 sec:forced vital capacity ratio (FEV1:FVC) of <95% of the predicted value for a healthy person. We also used the serum level of hs-CRP as a marker of inflammation. Multivariate analysis was performed with adjustment for the clinical characteristics of the participants.RESULTS: A total of 5528 individuals were eligible for the study. The average age was 55.1 years, and 47.8% were males. The prevalence of airway obstruction was 9.0%, and the mean hs-CRP level was 1.51 mg/dl. Serum hs-CRP levels increased with the severity of airway obstruction, and the latter worsened with an increase in the hs-CRP level. In multivariate analysis, as the hs-CRP level increased, FEV1 and FVC decreased. A higher FEV1:FVC ratio was associated with lower hs-CRP levels in males.CONCLUSION: Higher hs-CRP levels were associated with decreased FEV1 and FVC in a general population of Korea. The FEV1:FVC ratio decreased with an increase in the hs-CRP level in males.

M203 ACOS THE UNIVERSE: EVOLUTION OF ASTHMA-COPD OVERLAP SYNDROME IN A YOUNG PATIENT WITH SEVERE ASTHMA

Children with persistent asthma have loss of airway function despite chronic corticosteroid therapy. Those with severe disease may experience severe airway obstruction over time. It remains unclear whether treatment with immune-modulating agents, such as biologic agents, attenuates airway remodeling.

THE ASSOCIATION BETWEEN INTRACARDIAC HEMODYNAMICS AND LUNG FUNCTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Study objective. To assess the association between intracardiac hemodynamics and airway obstruction with pulmonary hyperinflation in patients with chronic obstructive pulmonary disease.Materials and methods. Ninety-six patients with chronic obstructive pulmonary disease, aged 40 to 75 years, without concomitant cardiovascular disease, were examined and divided into 4 groups according to the severity of the disease. The patients underwent general clinical examination, spirometry, 24-hour pulse oximetry and echocardiography with assessment of linear and volumetric parameters, as well as diastolic function of left and right ventricles.Results. Linear and volumetric parameters of the left ventricle, LV myocardial mass and geometry in the examined patients with chronic obstructive pulmonary disease matched threshold values. The progression of the severity of chronic obstructive pulmonary disease was accompanied by decrease of the end-diastolic size of the left ventricle, ratio of peak early to late diastolic filling velocity for the left ventricle (E/A) without significant changes in the left ventricle isovolumetric relaxation time (IVRT). Moderate correlations of the inspiratory capacity with the end-diastolic size of the left ventricle (r=0.612; p=0.001) and the left ventricle E/A (r=0.464; p=0.001); forced expiratory volume in 1 second (FEV1) with the left ventricle E/A (r=0.600; p=0.011) were established. As a result of the logistic regression performed, the predictor value of the inspiratory capacity was confirmed (Wald χ2 — 5.795; р=0.024). Impairment of left ventricular diastolic function of grade I was revealed in 12 (31.6 %) patients in group 2, in 7 (24.1 %) patients in group 3, and in 9 (56.2 %) patients in group 4.Conclusion. Airway obstruction severity and pulmonary hyperinflation progression in patients with chronic obstructive pulmonary disease and without concomitant cardiovascular disease is associated with a decrease of left ventricular size and diastolic filling, contributes to the development of the left ventricular diastolic dysfunction, predominantly due to the decrease in filling velocity parameters.

1758 H-type Tracheoesophageal Fistula: A Rare Cause of Cough and Dysphagia in Adults

INTRODUCTION: Tracheoesophageal fistula (TEF) without associated esophageal atresia (H-type) is a rare congenital anomaly, accounting for ∼4% of esophageal malformations. It is defined as a connection between the posterior tracheal and anterior esophageal walls and is typically diagnosed before age 3. However, it can occasionally be seen in adults with chronic cough and respiratory infections. We present a 38-year-old female with a new diagnosis of H-type TEF. CASE DESCRIPTION/METHODS: A 38-year-old female (G16P12-0-3-12) with multiple prior admissions for hypoxia (presumed due to asthma and aspiration in the setting of achalasia) was admitted with HELLP syndrome. Prior pulmonary function tests showed severe airway obstruction and echocardiogram showed normal left and right ventricular systolic function. She reported coughing when supine and with meals, a history of congenital lung abnormality, severe infancy pneumonia, upper lobe resection, diagnosis of achalasia, and yearly admissions for pulmonary issues. After delivery, she was transferred to the pulmonary service for management of her hypoxia. A TEF without inflammation was noted on chest CT and confirmed by EGD and bronchoscopy. EGD showed a 3 mm proximal esophageal fistula. Bronchoscopy demonstrated a normal oropharynx and vocal cords (VC), erythematous larynx, inflamed arytenoids, a 4 mm proximal TEF without mucosal abnormalities, and right upper lobe (RUL) absence. A swallow study showed aspiration on the posterior side of the trachea presumed due to the TEF. Surgical repair rather than endoscopic clip or stent placement was determined to be the best treatment via cervical approach esophagoplasty, muscle flap reconstruction TEF repair, and laparoscopic Heller myotomy with Dor fundoplication. DISCUSSION: H-type TEF is rare and can mimic chronic lung disease due to aspiration, recurrent infection, and bronchiectasis. It must be considered in adults with recurrent respiratory infections, coughing with eating/drinking, and rarely, hemoptysis. A chest CT, bronchoscopy, esophagoscopy, and barium study are crucial to confirm the diagnosis. While endoscopic clip closure of fibrotic TEFs has been successful in 62%, it may obliterate surgical tissue planes. Surgery is the optimal treatment for H-type TEF and reported to be 75-94% successful. As H-type TEF disrupts myenteric plexus development with impaired esophageal peristalsis and lower sphincter dysfunction, a Heller myotomy and Dor fundoplication should be offered.

Relationship between Vitamin D Level and Serum TNF-α Concentration on the Severity of Chronic Obstructive Pulmonary Disease.

BACKGROUND:Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory disease and disturbed bacterial clearance. Vitamin D deficiency is sometimes observed in COPD patients and as significant roles in increasing inflammation of airway obstruction and systemic obstruction, increasing pro-inflammatory cytokine including TNF-α, reduction of bacterial clearance and increase exacerbation risk due to infection. Also, vitamin D plays significant roles in the metabolism of calcium and mineralisation of bones and regulation system of immune. TNF-α also has essential roles in pathogenesis and inflammation of COPD. Several studies that investigate the relationship between vitamin D level and serum TNF-α concentration in COPD patients are relatively uncommon, including in Indonesia.AIM:This study aimed to assess the relationship between vitamin D level and TNF-α concentration in patients on the severity of the chronic obstructive pulmonary disease.METHODS:This study was a hospital-based descriptive cross-sectional study. Total samples were 50 COPD patients with the average age of older than 60 years during their enrollments at the Department of Pulmonology and Respiratory Medicine of the Dr Wahidin Sudirohusodo General Hospital Makassar in September 2018-January 2019. All procedures of the present study were reviewed and approved by the Research Ethics Committee of Medicine Faculty of Hasanuddin University. The severity of COPD was assessed according to the combination of COPD assessment stages that referred to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guideline 2015 that consisted of the combination of scoring COPD Assessment Test (CAT), the modified Medical Research Council (mMRC) questionnaire and results of the spirometry measurement. Assessment of airway obstruction levels referred to the GOLD spirometry criteria. Determination of thoracic photographs was conducted to verify the COPD diagnosis of the severity of COPD. Determination of serum TNF-α concentration and vitamin D3 [1,25(OH)2D3] level used the ELISA method.RESULTS:The majority of COPD patients were observed in the category of older than 60 years old accounted for 34 COPD patients (68%), and the majority of COPD patients were males accounted for 47 males with COPD (94%). The majority of COPD patients were observed in the group of D (38%). All the study subjects observed in this study were smokers, and 82% of them were in the category of heavy smokers. 21 study subjects had higher concentration of serum TNF-α (tertile 3 = 0.21-1.83 pg/dl), 20 study subjects and lower level of vitamin D (tertile 1 = 182.1-364.5 pg/dl). The majority of the study subjects (38%) were in the category of severe COPD (category D of the severity of COPD at the tertile 3) according to the GOLD Combine Assessment. Given the relationship between vitamin D level and serum TNF-α concentration on the airway obstruction, there were significant positive correlations between the increase of vitamin D levels and the increase of serum TNF-α concentrations on airway obstruction. Given the relationship between vitamin D level and serum TNF-α concentration on the severity of COPD, there were significant positive correlations between the increase of vitamin D levels (tertiles 1, 2 and 3) and the increase of serum TNF-α concentrations on the severity of COPD at p-value < 0.05. Overall, there were non-linear relationships between vitamin D level and serum TNF-α concentration on the severity of COPD.CONCLUSIONS:Serum TNF-α concentration was positively associated with airway obstruction level and severity of COPD. Low level of vitamin D was negatively associated with airway obstruction level and severity of COPD. Vitamin D3 level (1,25(OH)2D) was negatively associated with serum TNF-α concentration and airway obstruction level and severity of COPD.

Awake tracheostomy in a patient with acute upper airway obstruction: an emergency application of an elective percutaneous procedure.

Since its introduction in 1985 with Ciaglia, percutaneous tracheostomy (PT) was contraindicated in emergency settings and obesity. However, several case series in the last 20 years have documented the use of PT in life-threatening airway emergencies. We present a case of severe acute airway obstruction in a 66-year-old woman successfully treated with a placement of an awake PT. The woman’s glottic obstruction was caused by a recurrent laryngeal neoplasia and revealed by nasoendoscopy. This acute condition required a serious effort from the patient to oxygenate and therefore prevented orotracheal intubation as well as the use of any supraglottic device and/or sedation. Blood aspiration after a first attempt to make a quick access to the tracheal lumen with an emergency cricothyroidotomy, and difficulties in the exact identification of tumor infiltration, led us to perform an awake tracheostomy. Due to elevated risk of airway bleeding, we started with a surgical approach to better identify anatomical structures. After the correct inter-tracheal ring space identification, sudden worsening of clinical symptoms required that we complete the procedure quickly with the aid of a Ciaglia Blue Rhino™-Cook (CBR) tracheostomy kit. At the tracheostomy tube placement, the patient quickly resolved her dyspnea and physiological breathing was restored.

ASSOCIATION OF BONE MINERAL DENSITY WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN POSTMENOPAUSAL WOMEN.

Osteoporosis (OP) is common in patients with chronic obstructive pulmonary disease (COPD). The relationship between OP and COPD has been primarily studied in male patients, and few reports are available in postmenopausal women. The purpose of this study was to investigate the association between bone mineral density (BMD) and COPD in postmenopausal women. This cross-sectional study included 133 clinically stable female ex-smokers with confirmed COPD, and 31 age-matched "ex-smoker" female controls. We analyzed groups according to their airway obstruction category. BMD was measured on dual-energy X-ray absorptiometry images of the left femoral neck. Patients with COPD had lower T-scores and higher prevalence of osteopenia/OP than the control group. In the COPD group, the airway obstruction category was significantly associated with the T-score after adjustment for confounders. Multivariate logistic regression analysis showed COPD was an independent marker for increased risk of osteopenia/OP in postmenopausal women. COPD and airway obstruction category were strongly related to BMD. Postmenopausal women with COPD, especially those with severe airway obstruction, had a higher prevalence rate and a higher risk of osteopenia and OP than female controls without COPD.

Serious airway-related adverse events with sevoflurane anesthesia via facemask for magnetic resonance imaging in 7129 pediatric patients: A retrospective study.

This retrospective study evaluated the safety and effectiveness of sevoflurane anesthesia by facemask for magnetic resonance imaging (MRI) scanning among pediatric patients in a high-volume MRI department. The medical records of 7129 pediatric patients (median age 12months, range 4.0-36.0months) who were administered anesthesia during MRI scanning were reviewed. Anesthesia via 8% and 1.5%-2% sevoflurane was used for induction and maintenance, respectively. All the patients were monitored by anesthetists in the postanesthesia care unit. Vital signs were recorded every 5minutes. Airway-related adverse events, sevoflurane induction time, MRI scanning time, and recovery time were recorded. Patients were discharged when no complications were found for 10-15 minutes, with Aldrete's score ≥9. After sevoflurane anesthesia, there were 28 severe airway-related adverse events (0.4%, 95% CI: 0.2%-0.5%), and 12 patients had severe respiratory apnea (0.2%, 95% CI: 0.1%-0.2%). The percentage of patients with respiratory apnea was significantly higher in preterm infants compared with term infants (2.4% cf. 0.5%, P=0.012). Sixteen patients had severe airway obstruction (0.2%, 95% CI: 0.1%-0.3%). The major severe airway-related adverse events among pediatric patients associated with sevoflurane anesthesia were respiratory apnea and airway obstruction. The respiratory condition of preterm infants should be monitored carefully when under sevoflurane anesthesia. Overall, sevoflurane is safe and can be used efficiently for pediatric anesthesia in high-volume MRI departments.

Phenotypical diversity of airway morphology in chronic lung graft vs. host disease after stem cell transplantation

Pulmonary graft vs. host disease is a diverse and underestimated complication following allogenic hematopoietic stem cell transplantation. We aimed to compare the airway architecture with chronic lung allograft dysfunction post lung transplantation. Inflated explant lungs from graft vs. host disease patients were compared with lungs with chronic lung allograft dysfunction following lung transplantation, and control lungs using a combination of CT, microCT, and histology (n = 6 per group) and pathology in the (small) airways was further quantified and analyzed. Following allogenic hematopoietic stem cell transplantation, three patients presented as bronchiolitis obliterans syndrome and three patients showed interstitial changes and restriction. The CT analysis demonstrated a strong similarity between bronchiolitis obliterans syndrome after lung transplantation and post allogenic hematopoietic stem cell transplantation, evidenced by severe ( > 50%) airway obstruction from generation 9, with 70.8% of the airways ending in obstruction. Further analysis indicated that the airways either collapsed or accumulated matrix along a segment of the airway. In patients with restriction and interstitial changes following allogenic hematopoietic stem cell transplantation, the degree of airway obstruction was lower compared with bronchiolitis obliterans syndrome post allogenic hematopoietic stem cell transplantation, but similar to restrictive allograft syndrome post lung transplantation, showing a lower proportion of airway obstruction (20–35%), decreased number of terminal bronchioles per lung (p < 0.01), and parenchymal fibrosis. We observed similarities in the airway and parenchymal morphometric changes in lung graft vs. host disease and with chronic lung allograft dysfunction following lung transplantation, suggesting similar pathophysiological mechanisms.

DOZ047.106: Internal stents and external splints for complex airway obstruction

Abstract Background Life-threatening airway obstruction due to severe tracheobronchial stenosis or tracheobronchomalacia not amenable to tracheobronchopexy or resection is still a challenge, and warrants aggressive innovative strategies. In this study, our experience with placement of balloon-expandable stents and/or external bioabsorbable splints in children with severe tracheobronchial obstruction was reviewed. Methods All patients with symptomatic severe airway obstruction who underwent interaluminal stent and/or external splint placement (1997–2019) were retrospectively reviewed. The data collected included age, type of obstruction (stenosis or malacia), associated malformations, technical and clinical success, complications, and outcomes. Airway stents were placed under fluoroscopic guidance. Bioabsorbable splints (RapidSorb, Synthes CMF) were custom molded and then secured externally on the collapsing areas under simultaneous bronchoscopic and direct visualization. Results Seventeen patients underwent 14 airway stents (trachea = 5, bronchi = 9) and/or 11 external bioabsorbable splints (trachea = 5, bronchi = 6) at a median age of 5 months (IQR 3–9 months). Fourteen stents were placed in 8 patients, 10 external splints in 8 patients; one patient had two stents and one splint. Indications for stenting were stenotic airways in 11 patients (postoperative = 7, congenital = 4) and severe distal airway malacia in 3. All the external bioabsorbable splints were placed in patients with severe airway malacia secondary to lack of cartilaginous support and/or extrinsic compression. During follow-up 3/9 stented patients and 3/9 splinted patients did not experience any significant adverse events. Six of nine stented patients experienced serious adverse events: significant in-stent stenosis (n = 3), stent migration, and obstructive granulation tissue (n = 1), erosion through airway wall (n = 1), and death (n = 2). Of the nine splinted patients, one bronchial splint fractured, requiring replacement, and five patients required tracheostomies for continued respiratory failure from unilateral pulmonary hypoplasia and residual distal tracheal stenosis (n = 1), severe tracheomalacia (n = 2), subglottic stenosis (n = 1), and laryngeal cleft (n = 1). One patient died a week after surgery. Conclusion Airway internal stenting and external bioabsorbable splinting are effective therapeutic strategies for selected patients with complex airway abnormalities. Bioabsorbable splints are effective in maintaining airway patency, and being absorbable allow for age-proportional growth of the airways. Airway stents can be associated with significant adverse events and therefore should be reserved for patients who have failed other therapeutical strategies.

Anesthesia for predelivery procedures: ex-utero intrapartum treatment/intrauterine transfusion/surgery of the fetus.

The aim of this study was to review the current literature on anesthesia for predelivery procedures and to summarize recent findings on anesthesiological methods used. Ex-utero intrapartum treatment (EXIT)-procedures are performed to secure the newborn's oxygenation in case of severe airway obstruction due to multiple conditions. A key feature of EXIT is continued intactness of the maternofetal circulation by uterine relaxation achieved by general anesthesia with high doses of anesthetic gases. A dose reduction may be achieved by combining inhaled anesthesia with propofol. After intrauterine transfusion the anesthesia team needs to be prepared for a potential need of emergency cesarean section. Temporary fetal endoluminal tracheal occlusion and laser coagulation for twin-to-twin transfusion syndrome may be either performed in monitored anesthesia care or neuraxial anesthesia. Neuraxial anesthesia also is a method of choice for fetal valvuloplasty and amniotic band release. Fetal myelomenigocele repair requires general anesthesia with tocolysis. Predelivery procedures require a differentiated anesthesia approach depending on the invasiveness of the intervention. Anesthesia ranges from monitored care to neuraxial anesthesia and general anesthesia. Depending on the procedure uterine relaxation and fetal immobilization are crucial for technical success. Interdisciplinary consultation optimizes the anesthesia plan for complex procedures.

Pulmonary outcomes in adults with a history of Bronchopulmonary Dysplasia differ from patients with asthma

BackgroundBronchopulmonary dysplasia (BPD) is a risk factor for respiratory disease in adulthood. Despite the differences in underlying pathology, patients with a history of BPD are often treated as asthmatics. We hypothesized that pulmonary outcomes and health-related quality of life (HRQoL) were different in adults born preterm with and without a history of BPD compared to asthmatics and healthy individuals.MethodsWe evaluated 96 young adults from the LUNAPRE cohort (clinicaltrials.gov/ct2/show/NCT02923648), including 26 individuals born preterm with a history of BPD (BPD), 23 born preterm without BPD (preterm), 23 asthmatics and 24 healthy controls. Extensive lung function testing and HRQoL were assessed.ResultsThe BPD group had more severe airway obstruction compared to the preterm-, (FEV1− 0.94 vs. 0.28 z-scores; p ≤ 0.001); asthmatic- (0.14 z-scores, p ≤ 0.01) and healthy groups (0.78 z-scores, p ≤ 0.001). Further, they had increased ventilation inhomogeneity compared to the preterm- (LCI 6.97 vs. 6.73, p ≤ 0.05), asthmatic- (6.75, p = 0.05) and healthy groups (6.50 p ≤ 0.001). Both preterm groups had lower DLCO compared to healthy controls (p ≤ 0.001 for both). HRQoL showed less physical but more psychological symptoms in the BPD group compared to asthmatics.ConclusionsLung function impairment and HRQoL in adults with a history of BPD differed from that in asthmatics highlighting the need for objective assessment of lung health.

Case report of neonate Pierre Robin sequence with severe upper airway obstruction who was rescued by finger guide intubation

BackgroundPierre Robin Sequence (PRS) patients are known for their triad of micrognathia, glossoptosis, and airway obstruction. Their airway can be a challenge even for the most experienced pediatric anesthesiologist.Case presentationWe report the case of a 9 day old 3.5 kg boy diagnosed with PRS, cleft palate, and a vallecular cyst with severe upper airway obstruction. The combination of PRS, cleft palate and the presence of vallecular cyst made this a cascade reaction of difficult airway. Due to his unique anatomy, we didn’t appreciate how difficult his airway was until multiple attempts with high-tech equipment failed. Ultimately it was the finger guide intubation, this old technique without any equipment, that rescued this patient from lose of airway.ConclusionsThe boy was successfully rescued by finger guided intubation. Finger guide intubation should be added to the anesthesiologist’s newborn rescue intubation training.

Diagnostic accuracy of capnovolumetry for the identification of airway obstruction \u2013 results of a diagnostic study in ambulatory care

BackgroundOne of the known weaknesses of spirometry is its dependence on patients’ cooperation, which can only partially be alleviated by educational efforts. Therefore, procedures less dependent on cooperation might be of value in clinical practice. We investigated the diagnostic accuracy of ultrasound-based capnovolumetry for the identification of airway obstruction.MethodsConsecutive patients from a pulmonary outpatient clinic were included in the diagnostic study. As reference standard, the presence of airway obstruction was evaluated via spirometry and bodyplethysmography. Capnovolumetry was performed as index test with an ultrasound spirometer providing a surrogate measure of exhaled carbon dioxide. Receiver operating characteristic (ROC) analysis was performed using the ratio of slopes of expiratory phases 3 and 2 (s3/s2) ≥ 0.10 as primary capnovolumetric parameter for the recognition of airway obstruction. Logistic regression was performed as secondary analysis to identify further useful capnovolumetric parameters. The diagnostic potential of capnovolumetry to identify more severe degrees of airway obstruction was evaluated additionally.ResultsOf 1400 patients recruited, 1287 patients were included into the analysis. Airway obstruction was present in 29% of patients. The area under the ROC-curve (AUC) of s3/s2 was 0.678 (95% CI 0.645, 0.710); sensitivity of s3/s2 ≥ 0.10 was 47.7 (95% CI 42.7, 52.8)%, specificity 79.0 (95% CI 76.3, 81.6)%. When combining this parameter with three other parameters derived from regression analysis (ratio area/volume phase 3, slope phase 3, volume phase 2), an AUC of 0.772 (95% CI 0.743, 0.801) was obtained. For severe airway obstruction (FEV1 ≤ 50% predicted) sensitivity of s3/s2 ≥ 0.10 was 75.9 (95% CI 67.1, 83.0)%, specificity 75.8 (95% CI 73.3, 78.1)%; for very severe airway obstruction (FEV1 ≤ 30% predicted) sensitivity was 86.7 (95% CI 70.3, 94.7)%, specificity 72.8 (95% CI 70.3, 75.2)%. Sensitivities increased and specificities decreased considerably when the combined capnovolumetric score was used as index test.ConclusionsCapnovolumetry by way of an ultrasound spirometer had a statistically significant albeit moderate potential for the recognition of airway obstruction in a heterogeneous population of patients typically found in clinical practice. Diagnostic accuracy of the capnovolumetric device increased with the severity of airway obstruction.Trial registrationThe study is registered under DRKS00013935 at German Clinical Trials Register (DRKS).

Outcomes of mandibular distraction osteogenesis in omani peadiatric polpulation with severe upper airway obstruction

Outcomes of mandibular distraction osteogenesis in omani peadiatric polpulation with severe upper airway obstruction