Significant Airway Obstruction Research Articles

The Differential Diagnosis of Asthma: Endobronchial Pulmonary Mesenchymoma

A variety of airway tumours are reported to manifest with symptoms similar to those of asthma and may cause delays in exact diagnosis because of the increase in size at a slow rate. Pulmonary endobronchial mesenchymoma is one of the slow growing tumours which is associated with symptoms or signs of airway obstruction mimicking asthma. So, patients with chronic symptoms suggestive of asthma, poor response to asthma medications, and frequent exacerbations should be evaluated for endobronchial mesenchymoma.

Physiologic findings in children previously ventilator dependent at home due to bronchopulmonary dysplasia.

Bronchopulmonary dysplasia (BPD) is the primary respiratory complication of premature birth. Some preterm newborns develop chronic respiratory failure, requiring home ventilator support. While physiologic measures have been described for prematurely born children, little is known about spirometric indices in patients with severe BPD who were previously ventilator dependent at home. We retrospectively reviewed medical charts of patients with severe BPD who were ventilator dependent at home. We excluded patients with other comorbidities that could contribute to the severity of BPD. Spirometry was performed when the patient was able to follow commands. Between 1984 and 2012, within our severe BPD cohort who previously required home ventilator support, 19 patients were able to perform reproducible spirometry meeting ATS/ERS acceptability criteria. Ten (52.6%) were females, 13 (68.4%) were Caucasians. Mean age at liberation from ventilation was 2.4 years (C.I. 2.0, 2.9) and at decannulation was 3.5 years (C.I. 2.9, 4.0); median age at first reproducible spirometry measurement was 6.6 years (IQR: 4.9, 8.3). Spirometry results revealed significant airway obstruction, as demonstrated by Z-scores values of -1.5 (C.I. -2.5, -0.4) for FVC, -2.7 (C.I. -3.3, -1.9) for FEV1 , and -3.6 (C.I. -4.3, -2.9) for FEF25-75 . More so, serial spirometric measurements' slopes revealed that the airway obstruction remained static over time (FEV1 slope: -0.07, P-value: 0.2624; FVC slope: -0.01, P-value: 0.9064; and FEF25-75 : 0.0, P-value: 0.8532). Extreme prematurity associated with severe BPD requiring home ventilator support carries significant risks of morbidity. These patients had substantially diminished respiratory function reflecting airflow abnormalities that remained static over time.

Diagnosis of children with occult bronchial foreign body

To investigate the clinical manifestation of children with occult bronchial foreign body, to analyze the reasons of misdiagnosis, to summarize the way of diagnosis and to emphasize the value of bronchoscopy in diagnosis and treatment of children with such disease. A retrospective analysis of 22 cases of occult bronchial foreign body diagnosed and treated with bronchoscopy in Children's Hospital of Chongqing Medical University during the period from March 1, 2009 to February 28, 2014. Of the 22 cases, 15 were male and 7 female. Their age ranged from nine months and eight days to fourteen years and six months. The course of disease ranged in length from six days to one year. It took us one to thirty-three days in diagnosing the problem. They or their parents all denied aspirating foreign body and the patients did not have irritating chokes. They did not have tracheal displacement or flapping sound. There were no direct signs of bronchial foreign body in their imaging examination. Twenty-one patients were diagnosed as pneumonia before bronchoscopy, and the remaining one was diagnosed as tuberculosis. All of the patients were complicated with infection; atelectasis was found in 15 cases/times, lung consolidation in 10 cases/times, emphysema in 4, pleural effusion in 5, bronchiectasis in 4, one case had respiratory failure, one case had septicemia. The clinical symptoms were relieved in the patients after bronchoscopy, 3 cases were cured, 19 cases were improved. Occult bronchial foreign body with certain complications and great harm is hard to diagnose. We should pay more attention to the important clues, such as a child with repeated pulmonary infection, indirect signs of airway obstruction and difficult to treat. Early bronchoscopy will be useful to improve diagnostics once the vital clue is found.

PO-0641 Paediatric Subglottic Cysts : Risk Factors And Prevention – Case Control Study

Background Subglottic cysts (SGCs) are a rare, but important cause of stridor in children. They can cause significant upper airway obstruction, with potentially lethal consequences, particularly when exacerbated by upper respiratory tract infection. Although seen typically in pre-term infants, there is a paucity of literature regarding their aetiology. Aim To examine the background characteristics and to determine any risk factors in paediatric patients with SGCs. Methods A retrospective case control study was conducted, reviewing reports of all laryngotracheobronchoscopies (LTB) conducted in a tertiary paediatric hospital, between January 2009 and 2014. SGCs were identified in 15 patients from the 1095 LTBs performed. Cases were matched to controls based on gestational age at birth, birth weight and age. Medical records of cases and controls were reviewed to identify possible risk factors. Results Of the 15 patients with SGCs, 14 were born prematurely. All of the patients with SGCs had been ventilated, and 13 of the 15 controls were ventilated. Overall time of ventilation and frequency of re-intubations were similar between the two groups, however SGCs patients had significantly higher frequency of ETT suctioning conducted during period of ventilation. Conclusion This study demonstrated an association of SGCs in the pre-term infants with previous intubation. SGCs were more prevalent in infants that required more frequent suctioning. Consequently it is likely that infants with repeated or multiple manipulations of the airway may be at higher risk for developing SGCs and should be followed up closely to avoid potential life threatening complications.

Subglottic diffuse large B-cell lymphoma presenting as biphasic stridor

Abstract The management of airway obstruction in children is often challenging with acute presentation and uncertainty in the diagnosis. We report a case of a young child with acute onset biphasic stridor who was found to have a large subglottic lesion causing significant airway obstruction. We were able to successfully resect it to achieve a pathologic diagnosis and address the subglottic stenosis with an anterior laryngofissure followed by laryngotracheal reconstruction (LTR) using a rib graft. The final pathology was diffuse large B-cell lymphoma, anaplastic variant, and patient had complete response to chemotherapy and is currently free of disease.

The efficacy of the symptomatic therapy of the non-atopic bronchial asthma attack in schoolchildren

The effectiveness of symptomatic treatment of bronchial asthma in children has been studied. It has been found that patients with non-atopic asthma phenotype were characterized by more severe bronchial obstruction during exacerbations compared with atopic patients. Children afflicted with nonatopic phenotype of the disease were characterized by more pronounced signs of airway obstruction during the whole hospitalization period despite the identical standard regimens in the comparison groups.

Angioedema of the upper aerodigestive tract: risk factors associated with airway intervention and management algorithm

Angioedema of the upper aerodigestive tract can lead to significant airway obstruction. To date no articles have delineated risk factors for progression after initial evaluation. This article presents the results of a retrospective study of patients with angioedema at a single institution. Patients included were consecutive otolaryngology consultations for angioedema in the emergency department (ED) from 1999 to 2003. All patients were evaluated by an otolaryngologist and underwent fiber-optic laryngoscopy, which was repeated serially depending on findings. Data was collected on demographics, comorbidities, intubation, disposition, and progression of angioedema. A total of 177 patients were included in the study: 32 (18%) patients required intubation; 25 (14%) on initial presentation and 7 (4%) who progressed from an initially stable airway to requiring intervention after reevaluation. Analysis of variance (ANOVA) demonstrated a statistically significant variance between location of edema and rate of intubation, with higher rates in the pharynx and larynx vs the lip and face. Patients who required intubation after progression between serial evaluations were statistically more likely to have edema that involved deeper portions of the aerodigestive tract. Patients who required intubation were statistically more likely to be older (average age 61.8 vs 55.1 years, p = 0.03). In this large series of patients managed for aerodigestive angioedema we demonstrate risk factors associated with airway intervention, and risk factors associated with clinical progression on serial examination to airway intervention. In addition, we demonstrate a successful management algorithm for patients with aerodigestive angioedema.

Invited Commentary

Invited Commentary

Post-mortem CT findings in a case of necrotizing cellulitis of the floor of the mouth (Ludwig angina)

Ludwig angina is a rare but potentially lethal infection of the submandibular space that can cause significant upper airway obstruction. We report a case of undiagnosed Ludwig angina that progressed rapidly to death. Ludwig angina was suspected after post-mortem computed tomography (PMCT) found swollen mylohyoid muscle with stranding in subcutaneous fat, thickening of deep fascia, and local lymphadenopathy. Subsequently, an autopsy revealed woody induration of the submental region and liquefactive necrosis of the mylohyoid muscle, confirming the diagnosis. It is likely that the dental abscess identified on PMCT was the source of infection. Multiple invasive medical procedures were performed on the subject by the ambulance crew prior to his death. PMCT assisted further in determining procedural success.

Dysanaptic growth of lung and airway in children with post‐infectious bronchiolitis obliterans

Post-infectious bronchiolitis obliterans (PBO) is a rare form of chronic obstructive lung disease associated with small airway fibrosis following a severe insult to the lower respiratory tract. It has been suggested that PBO is a non-progressive disease. However, evidence supporting this statement is limited. In this case series, we sought to determine the changes of pulmonary function tests (PFT) over time in children with PBO. Seven children with PBO, ages 6-15 years old, were retrospectively studied between 1994 and 2012. Spirometry and lung volumes tests were performed in accordance with American Thoracic Society (ATS) guidelines and were monitored over time. The average rate of change was calculated using generalized linear mixed models. The median baseline values for forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), the FEV1/FVC ratio and forced expiratory flow 25%-75% (FEF25%-75%) were 57%, 50%, 87% and 29%, respectively. FVC increased at a rate of 1.8% per year (P = 0.008). There was no significant change in FEV1 over time (P = 0.112). However, the FEV1/FVC ratio decreased by 2.6% per year (P < 0.001). PFT in childhood PBO was characterized by significant airway obstruction. Over time, FVC (lung parenchyma) increased and FEV1 (airway) remained stable, but FEV1/FVC ratio declined more than expected, suggesting a mismatch in the growth of the airway and lung parenchyma (dysanaptic growth). Further studies in larger populations are needed to validate these observations.

Outcome Assessment of 603 Cases of Concomitant Inferior Turbinectomy and Le Fort I Osteotomy

This retrospective study assessed the outcome of 603 patients undergoing partial inferior turbinectomies (PIT) in association with Lefort I osteotomy. The study included 1234 patients from a single private practice; these patients had dentofacial deformities and underwent Lefort I osteotomy procedures. For the full patient group, 888 patients (72%) were women; in the turbinectomy group, 403 (67%) were women. The anteroposterior, transverse, and vertical dimensions of the mandible, maxilla, and occlusal plane of each subject were assessed, in addition to cephalometric analysis and determination of the presence or absence of temporomandibular joint disorders. PIT, when indicated, was performed after downfracture of the maxilla, providing access to the turbinates where approximately two thirds of the total turbinate volume was removed and septoplasty was completed if indicated. Hypertrophied turbinates causing significant nasal airway obstruction were present in 603 (49%) of the 1234 patients undergoing Le Fort I osteotomy. The results of this study showed that PIT performed simultaneously with Le Fort I osteotomy is a safe method of managing nasal airway obstruction related to hypertrophied turbinates with minimal complications.

Small airway impairment in moderate to severe asthmatics without significant proximal airway obstruction

Asthma is a disease characterized by inflammation which affects both proximal and distal airways. We evaluated the prevalence of small airway obstruction (SAO) in a group of clinically stable asthmatics with both normal forced expiratory volume in the first second (FEV1) and normal FEV1/forced vital capacity (FVC) and treated with an association of inhaled corticosteroids (ICSs) and long acting β2-agonists (LABAs). Clinical evaluation included the measurement of dyspnea, asthma control test and drug compliance. The prevalence of SAO was estimated by spirometry and plethysmography and defined by thepresence of one or more of the following criteria: functional residual capacity (FRC)>120% predicted (pred), residual volume (RV)>pred+1.64 residual standard deviation (RSD), RV/total lung capacity (TLC)>pred+1.64 RSD, forced expiratory flow (FEF)25-75% <pred-1.64 RSD, FEF50%<pred-1.64 RSD, slow vital capacity (SVC)-FVC>10%. Among the 441 patients who were included, 222 had normal FEV1 and FEV1/FVC. At least one criteria of SAO was found in 115 (52%) mainly lung hyperinflation (39% based on high FRC, RV or RV/TLC) and more rarely distal airflow limitation (15% based on FEF25-75% or FEF50%) or expiratory trapping (10% based on increased SVC-FVC). In the patients with only SAO (no PAO), there was no relationship between SAO, asthma history and the scores of dyspnea, asthma control or drug compliance. These results suggest that in asthmatics with normal FEV1 and FEV1/FVC, treated with ICSs and LABAs, SAO is found in more than half of the patients indicating that the routinely used lung function tests can underestimate dysfunctions occurring in the small airways.

Propranolol in the Treatment of Upper Airway Hemangiomas

Airway hemangiomas (AHs), which are common in infant airways, often cause significant upper airway obstruction. The various therapies used for AH have limitations and complications. Propranolol may have a potential role in its treatment, since it leads to regression or stabilization of cutaneous infantile hemangiomas. To date, only 4 previous case reports (7 patients) in which propranolol was used for AH have been published. Based on encouraging preliminary data on propranolol use for AH treatment, our goal was to further investigate propranolol as an effective initial treatment of upper AHs that cause significant obstruction symptoms. In this retrospective case series, we reviewed the medical records of 5 consecutive pediatric patients with AH (glottic and subglottic) treated with propranolol at a tertiary care children's hospital. All 5 patients were 2 months of age at the time of hemangioma diagnosis and had stridor and physical signs of severe upper airway obstruction. Hemangioma was diagnosed by flexible laryngoscopy or flexible bronchoscopy. All patients received propranolol 2 mg/kg/day and showed significant relief of obstruction symptoms within 24 hours of treatment initiation. All patients tolerated propranolol without significant cardiovascular complications. Outcomes from this case series, in conjunction with available case reports in the literature, suggest that propranolol is a safe initial treatment for symptomatic upper AH.

Propranolol in the Treatment of Upper Airway Hemangiomas

Airway hemangiomas (AHs), which are common in infant airways, often cause significant upper airway obstruction. The various therapies used for AH have limitations and complications. Propranolol may have a potential role in its treatment, since it leads to regression or stabilization of cutaneous infantile hemangiomas. To date, only 4 previous case reports (7 patients) in which propranolol was used for AH have been published. Based on encouraging preliminary data on propranolol use for AH treatment, our goal was to further investigate propranolol as an effective initial treatment of upper AHs that cause significant obstruction symptoms. In this retrospective case series, we reviewed the medical records of 5 consecutive pediatric patients with AH (glottic and subglottic) treated with propranolol at a tertiary care children's hospital. All 5 patients were 2 months of age at the time of hemangioma diagnosis and had stridor and physical signs of severe upper airway obstruction. Hemangioma was diagnosed by flexible laryngoscopy or flexible bronchoscopy. All patients received propranolol 2 mg/kg/day and showed significant relief of obstruction symptoms within 24 hours of treatment initiation. All patients tolerated propranolol without significant cardiovascular complications. Outcomes from this case series, in conjunction with available case reports in the literature, suggest that propranolol is a safe initial treatment for symptomatic upper AH.

Pediatric Neck Masses

Pediatric Neck Masses

Negative pressure pulmonary oedema following use of ProSeal LMA

Negative pressure pulmonary oedema (NPPO) is a life threatening condition, manifested due to upper airway obstruction in a spontaneously breathing patient. Upper airway obstruction caused by classic laryngeal mask airway (cLMA) and ProSeal laryngeal mask airway (PLMA) has been reported, and NPPO has also been reported following the use of cLMA. Search of literature did not confirm NPPO following the use of PLMA. We encountered a female patient of NPPO scheduled for incision and drainage of an abscess who had signs of airway obstruction following PLMA insertion. Multiple attempts were made to get patent airway without success. PLMA was replaced with endotracheal tube following which pink frothy secretion appeared in breathing circuit. Patient was managed successfully with ICU care.

Bilateral vocal cord paralysis detected incidentally during direct laryngoscopy on general anesthesia

Bilateral vocal cord paralysis detected incidentally during direct laryngoscopy on general anesthesia

Lingual Haematoma due to Tenecteplase in a Patient with Acute Myocardial Infarction

The use of intravenous thrombolytic agents has revolutionised the treatment of acute myocardial infarction. However, the improvement in mortality rate achieved with these drugs is tempered by the risk of serious bleeding complications, including intracranial haemorrhage. Tenecteplase is a genetically engineered mutant tissue plasminogen activator. Haemorrhagic complications of tissue plasminogen activator (tPA) are well known. Compared to other tPAs, tenecteplase use leads to lower rates of bleeding complications. Here, we report a case of unusual site of spontaneous bleeding, intralingual haematoma during tenecteplase therapy following acute myocardial infarction, which caused significant upper airway obstruction and required tracheotomy to maintain the patient's airway. Clinical dilemmas related to securing the airway or reversing the effects of tissue plasminogen activator are discussed.

Bronchoscopic assessment of airway involvement in children presenting with clinically significant airway obstruction due to tuberculosis

The incidence of complicated lymph node disease in tuberculosis (TB) in children less than 15 years of age varies from 8% to 38%. There are few published studies on the bronchoscopic appearance and severity of airway obstruction caused by lymph node involvement of the airways resulting from Mycobacterium tuberculosis (MTB). The primary aim of the study was to describe the flexible bronchoscopic findings of lymph node involvement of the airways caused by MTB in children with severe airway obstruction. The secondary aim was to compare the degree of airway involvement in HIV negative to HIV positive children as well the airway involvement caused by drug susceptible and drug resistant MTB. All children between 1 month and 13 years of age presenting with clinical and radiological signs of significant airway obstruction suspected of being the result of MTB infection were studied. In addition to routine examination for MTB disease a flexible bronchoscope and bronchoalveolar lavage (BAL) for MTB culture were performed on all the children. Two hundred fifty children (16% HIV positive) were studied. Median age was 14 months and the median weight 8.5 kg. MTB was cultured from 78% (n = 194) of children with the BAL positive in 44%. The BAL culture yield was significantly higher in children with radiological evidence of pneumonia when compared to children with airway involvement alone (P = 0.004). The bronchial tree was obstructed on the right in 85% (n = 212), the left in 66% (n = 164), and both sides in 53% (n = 132) of cases. The commonest sites of obstruction were bronchus intermedius (72%) and left main bronchus (62%). Drug resistance was present in 16% (n = 28). There was no difference in the site or severity of obstruction when comparing drug susceptible to drug resistant cases or HIV positive to HIV negative children. Bronchus intermedius and left main bronchus were the commonest sites of airway obstruction. The MTB culture yield from BAL was higher in children with pneumonia when compared to those with airway involvement alone. HIV positive or children with drug resistant TB did not have more severe airway obstruction.

Exercise-induced bronchoconstriction in school-age children born extremely preterm

School children born preterm often show airway hyperresponsiveness to methacholine or histamine. Less attention has been paid to their airway response to exercise, an important point because of the role of exercise in the child's daily life. The aim of this study was to describe the characteristics of, and potential determinants to, the airway response to exercise in children born extremely preterm. Forty-two nonasthmatic nonatopic children born before 32 wk gestation were compared with 27 healthy nonasthmatic nonatopic term children at age 7. Spirometry and respiratory impedance were measured at baseline and repeated after a single-step 6-min treadmill exercise in a climate-controlled room. The preterm group showed significant broncho-constriction induced by exercise. Prematurity, but not low baseline lung function, neonatal oxygen supplementation, mechanical ventilation, chronic lung disease, or maternal smoking, was a determinant of exercise-induced bronchoconstriction. Children born extremely preterm present significant exercise-induced airway obstruction at age 7. The response has different characteristics from that occurring in asthmatics and is likely to express airway noneosinophilic inflammation.