Early detection of laryngeal cleft in infants by novel technique of flexible endoscopy with sustained pharyngeal inflation.

OBJECTIVE: We report a novel technique of flexible endoscopy with noninvasive ventilation (NIV) and sustained pharyngeal inflation (FE-NIV-SPI) in assessing aeroesophageal tracts (AET) to facilitate early detection of laryngeal clefts in infants. METHODS: Medical charts and flexible endoscopy videos of the children who were diagnosed with laryngeal cleft in a tertiary care hospital between January 2000 and December 2020 were retrospectively reviewed and analyzed. The FE-NIV-SPI technique had been applied to all these children. RESULTS: Totally, 12 infants with laryngeal cleft were identified. This equates to a prevalence of 0.28% in all the children who underwent flexible endoscopy at our institution. Their mean age was 5.0 ± 4.9 months and mean body weight was 4.7 ± 2.3 kg. Nine (75%) infants were referred in without laryngeal cleft diagnosis, which was missed by 11 prior bronchoscopy and 5 computer tomography examinations. With the FE-NIV-SPI technique, the pharyngolaryngeal space could be pneumatically dilated permitting a detailed assessment. All laryngeal cleft types and coexisting AET lesions were visualized at the first FE-NIV-SPI examination with a mean time of 4.2 ± 0.9 min; they were eight Type I, two Type II, and one Type III. Ten (83.3%) infants had coexisting airway malacia. CONCLUSION: Routine use of FE-NIV-SPI technique can help in early detection of laryngeal clefts and other associated AET lesions. Further multicenter collaborative investigations are essential to verify the early detection of this rare and occult lesion of the laryngeal cleft with this technique.

A novel technique of non-invasive ventilation: Pharyngeal oxygen with nose-closure and abdominal-compression--Aid for pediatric flexible bronchoscopy.

OBJECTIVE: To evaluate the safety, feasibility and efficacy of a novel non-invasive ventilation (NIV) technique--pharyngeal oxygen with nose-closure and abdominal-compression (PhO2 -NC-AC)--to aid pediatric flexible bronchoscopy (FB). DESIGN: A prospective 1 year study of patients who received FB. A basic PhO2 flow (0.5-1.0 L/kg/min, maximal 5.0 L/min) was routinely applied. Active NIV was initiated when the heart rate dropped <80 beats/min or desaturation was <80% for >10 sec. It was performed as follows: NC 1 sec for inspiration then released, followed by AC 1 sec for active expiration at a rate of 20-30 cycles/min until vital signs returned to acceptable levels for >10 sec. When the patients were stable, supplementary NIV was optionally given. Cardiopulmonary parameters were collected and analyzed. MEASUREMENTS AND MAIN RESULTS: Three hundred thirty-seven FBs, including 188 therapeutic, were conducted in 286 patients with a mean age of 18.3 months (± 14.4, 10 min to 12 years) and a mean body weight of 13.5 kg (± 6.7, 0.5-35 kg). Three hundred thirty-three active NIVs were executed with a mean duration of 87.8 sec (± 40.4, 28-190 sec). A significantly longer FB duration (33.2 ± 16.7 min vs. 7.2 ± 2.8 min, P < 0.001) and a higher application rate of active NIV (1.44/FB vs. 0.42/FB) were noted in the therapeutic compared to the diagnostic group. Vital signs and blood gases (35 cases) improved rapidly and returned to baseline within 3 min. All FBs were safely and successfully completed without significant complications. CONCLUSIONS: PhO2 -NC-AC is a simple, safe and effective NIV technique for respiratory support and rescue during various pediatric FB procedures.

Nasopharyngeal oxygen with intermittent nose-close and abdomen-compression: a novel resuscitation technique in a piglet model.

OBJECTIVE: To evaluate the efficacy of a simple and novel cardiopulmonary resuscitation (CPR) technique, nasopharyngeal oxygen with intermittent nose-close and abdomen-compression (NPO(2) -NC-AC) in an animal model. DESIGN: Prospective piglet study. SETTING: In an animal physiology laboratory of a medical university. PIGLETS: Six healthy piglets <14 days old. INTERVENTIONS: Spontaneous breathing of the anesthetized piglets (n = 6) was medically ceased until severe bradycardia (<20 beat/min). NPO(2) -NC-AC CPR trial was then initiated by delivering NPO(2) at 1.0-1.5 L/kg/min and intermittently performing the NC-AC maneuver: (1) NC for inspiration, occluded nostrils for 1 sec; and (2) AC for expiration, released nostrils, and compressed the abdomen for 1 sec. NC-AC was repeated at a rate of 30/min for 5 min. This CPR trial was repeated three times in each piglet. Cardiopulmonary variables were monitored, recorded, and compared. MEASUREMENTS AND MAIN RESULTS: A total of 18 CPR trials were performed. All of these acute life-threatening asphyxia events rapidly improved within 1 min of CPR. Cardiopulmonary variables recovered to the baseline levels and oxygenation continually increased. The intratracheal pressure (P(tr) ) values of positive end expiratory pressure and peak inspiratory pressure values were 4.3 ± 0.8 cmH(2) O and 26.2 ± 4.1 cmH(2) O, respectively. Chest wall movement was observed when the P(tr) reached 17.5 ± 3.1 cmH(2) O. All six piglets fully recovered after 63.8 ± 7.2 min of experiment without additional support. CONCLUSIONS: NPO(2) -NC-AC is a simple and effective CPR technique for severe acute cardiopulmonary asphyxia in piglets. It may be clinically applicable for supportive or rescue use.

Pediatric obstructive fibrinous tracheal pseudomembrane--characteristics and management with flexible bronchoscopy.

OBJECTIVE: To evaluate the incidence, characteristics, flexible bronchoscopy (FB) findings, interventions and outcome of pediatric obstructive fibrinous tracheal pseudomembrane (OFTP) in our pediatric and neonatal intensive care units (ICUs). PATIENTS AND METHODS: This is a retrospective study of medical and FB video records in a single tertiary university-affiliated teaching hospital over a ten-year period. Data was collected from patients who were admitted and extubated of endotracheal tube in the ICUs with a FB diagnosis of an OFTP-like lesion. The associated medical information, FB interventions and video records were reviewed and analyzed. RESULTS: Eight patients with OFTP were enrolled, with an incidence rate of 1.48% in the postextubation respiratory distress patients. Mean age was 32 ± 32 months (range, 2 months to 13 years); mean body weight was 13.7 ± 8.1 kg (range, 4.3-45 kg); mean intubation period was 37.6 ± 12.3h; mean time for symptoms to develop after extubation was 3.6 ± 1.4h. Symptoms lasted for 20.8 ± 20.3h before FB examination. All patients were accurately diagnosed with OFTP at the first postextubation FB examination and revealed various morphologies. The estimated cross-sectional tracheal lumen was reduced by 70-90% and the mean length of lesion was 18.1 ± 5.2mm (range, 10-30 mm). All OFTP were successfully ablated immediately after the diagnosis in one FB session by using various techniques and without any complication. Total duration for both diagnostic and interventional FB was 19.4 ± 2.5 min. No recurrence was noted thereafter. CONCLUSIONS: OFTP should always be considered in the event of postextubation respiratory distress, especially in the pediatric and neonatal ICUs. Early diagnosis and effective ablation can be achieved with aid of FB.

Comparison between rigid and flexible laser supraglottoplasty in the treatment of severe laryngomalacia in infants.

OBJECTIVE: Traditionally, laser supraglottoplasty for the treatment of severe laryngomalacia (SLM) is via rigid endoscopy (RE). Potassium-titanyl-phosphate (KTP) laser fiber can pass through a flexible endoscopy (FE) and cauterize tissue. This study is designed to evaluate and compare clinical variables between these two techniques in the treatment of SLM in infants. METHODS: A retrospective study includes four-year period of consecutive infants who received laser supraglottoplasty. In the first two years (2006-2007), conventional RE CO(2)-laser with general anesthesia and endotracheal intubation were used. In the latter two years (2008-2009), a novel technique of FE KTP-laser with intravenous sedation, nasopharyngeal oxygen and a noninvasive respiratory support (if indicated), without any artificial airway was used immediately after the diagnostic FE. After laser surgery, infants were followed for three months. Clinical variables were analyzed and compared. RESULTS: A total of 57 infants (27 in RE group, 30 in FE group) were enrolled. Basic variables were similar between both groups. Clinical improvement was comparable with 88.9% and 93.3% in the RE and FE groups, respectively. There are no significant differences in mean number of laser surgery, major complications, duration of post-laser respiratory support and hospitalization days, body weight percentile between the two groups. However, the durations of waiting time, operation, ET intubation and total hospital days were significantly less in the FE group. CONCLUSIONS: FE technique has similar success rate but more convenient and cost-effective than the RE technique. It may to be a practical alternative therapy for infants with SLM.

Life-threatening anaphylactic reaction after the administration of airway topical lidocaine.

A 9-year-old boy who developed a life-threatening anaphylaxis reaction of the airway and subsequent dyspnea and circulation collapse because of instilled the topical lidocaine into the airway within 2 min before performing flexible bronchoscopy (FB). FB revealed swollen airway mucosa and extensive foamy secretion that severely compromised the ventilation lumen. Rapid detection with FB and immediate resuscitation, including prompt administration of epinephrine, volume expander, and positive pressure ventilation with pure oxygen via an endotracheal tube, were successfully save the patient's life.

Tracheal foreign body after laser supraglottoplasty: a hidden but risky complication of an aluminum foil tape-wrapped endotracheal tube.

Wrapping of the endotracheal tube with aluminum foil tape can prevent laser-beam-induced ignition of the tube during laryngoplasty. However, this modified endotracheal tube may pose complications. Two newborn infants had a portion of the foil tape trapped in their trachea after extubation from laser supraglottoplasty. One infant was totally asymptomatic. The other infant's symptoms were masked by the concurrent tracheomalacia. Both residual tapes were radiolucent on chest radiographs. Flexible endoscopy was the suitable and safe modality for an accurate diagnosis and immediate retrieval of the residual tapes in one session.