The silent storm: a case report of missed antenatal diagnosis leading to fatal respiratory distress and death in a rare case of congenital high airway obstruction syndrome

Congenital high airway obstruction syndrome in neonates is a rare, life-threatening condition characterized by upper airway obstruction. Typically diagnosed prenatally through advanced imaging, CHAOS results from anomalies such as laryngeal atresia or web or tracheal stenosis. Neonates with CHAOS face respiratory distress at birth, necessitating prompt intervention. Management often involves ex-utero intrapartum treatment procedure or tracheostomy to establish a secure airway. Timely diagnosis and multidisciplinary collaboration are crucial for optimizing outcomes in affected infants. Despite its rarity, CHAOS demands heightened clinical awareness to ensure swift, tailored interventions and improve the chances of neonatal survival. We report here a case of CHAOS which was not diagnosed on antenatal ultrasonography.

Prevalence of obstructive sleep apnea syndrome and predictors of difficult orotracheal intubation

SUMMARY OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is an underdiagnosed condition that causes recurrent episodes of partial or total collapse of the upper airways during sleep. It is associated with perioperative pulmonary complications. The STOP-BANG is a screening tool for assessing patients at risk of OSAS. The aim of this study was to assess the prevalence of patients with OSAS during pre-anesthetic evaluation at a hospital and its correlation with predictors of ventilation and difficult airway. METHODS: This is an observational, cross-sectional study carried out from January 2022 to September 2023. The questionnaire comprised demographic data (age, weight, BMI, type of surgery, and anesthesia), the STOP-BANG, predictors of difficult orotracheal intubation (Mallampati, mouth opening, thyromental distance, cervical mobility, and upper lip bite test), and predictors of difficult ventilation through a facial mask (male sex, absence of teeth, presence of beard, obesity, and >55 years). RESULTS: The study had the participation of 221 patients, of whom 121 presented with a STOP-BANG ≥3, with a prevalence of 54.2%. All patients undergoing bariatric surgeries presented STOP-BANG ≥3. No significant statistical relationships were found between predictors of difficult orotracheal intubation and STOP-BANG ≥3. However, significant statistical relationships were found in relation to predictors of difficult ventilation through the facial mask.

Muerte perinatal por atresia laríngea: reporte de caso

Resumen La atresia laríngea es una malformación congénita de la vía aérea, que se presenta por la falta de recanalización de la luz laríngea durante la embriogénesis. Se requiere de la detección de hallazgos ecográficos característicos durante la gestación para considerar este diagnóstico. En este artículo, se presenta el caso de una gestación de 39,2 semanas con pobres controles prenatales y única ecografía gestacional tardía que no reportaba anomalías. Al nacimiento, el feto estaba no vigoroso e hipotónico, con insuficiente esfuerzo respiratorio, cianosis bucal y puntajes de Apgar 4-4-0, por lo que realizaron maniobras de reanimación con gran dificultad para lograr ventilación y múltiples intentos de intubación endotraqueal fallidos, aunque el personal médico indicó que a pesar de identificar las cuerdas vocales les fue imposible el paso del tubo. Finalmente, el neonato fallece. Ante la sospecha de malformación en la vía respiratoria superior, solicitan al servicio de patología realizar autopsia clínica para confirmar causa de la muerte.

Abstract Laryngeal atresia is a congenital malformation of the airway, which occurs due to the lack of recanalization of the laryngeal lumen during embryogenesis. The detection of characteristic sonographic features during pregnancy is required to consider this diagnosis. In this article we present the case of a 39.2-week gestation with poor prenatal controls and a single late gestational ultrasound that did not report abnormalities. At birth, the fetus was non-vigorous and hypotonic, with poor respiratory effort, oral cyanosis and Apgar scores of 4-4-0, for which it underwent resuscitation maneuvers with great difficulty in achieving ventilation and multiple failed endotracheal intubation attempts, although the medical staff indicates that despite identifying the vocal cords, it was impossible for them to pass the tube. Finally the newborn dies. Suspecting a malformation in the upper respiratory tract, request the pathology service to perform a clinical autopsy to confirm the cause of death.

Ball valving laryngeal masses: a difficult “ball” in the anaesthetists’ court

Dynamic airway obstruction (also called ball-valve effect) is a serious condition often seen in glottic lesions. This is an anesthetic challenge as total airway obstruction can occur after the induction of general anesthesia. We present a case of a middle aged female who had a large laryngeal mass which was showing ball-valve effect. The patient had refused for tracheostomy despite it being the safest procedure in the circumstances. We then performed videolaryngoscopy and managed to intubate the patient with the help of some improvisation. The patient underwent a succesful and uneventful surgery.

Clinical factors associated with extubation failure and post-extubation laryngeal stridor in adult patients on invasive mechanical ventilation / Factores clínicos asociados a extubación fallida y a estridor laríngeo post-extubación en pacientes adultos con ventilación mecánica invasiva

Abstract Introduction: Orotracheal intubation is a procedure that implies risks such as extubation failure and laryngeal stridor, which increase the risk of morbidity. Objective: To identify factors associated with early extubation failure (≤24 hours) and the development of post-extubation laryngeal stridor in adult patients on invasive mechanical ventilation (IMV). Materials and methods: Case-control study conducted in the intensive care unit (ICU) of a quaternary care hospital in Bogotá, Colombia, between April 2019 and February 2020, in which information was collected prospectively. A total of 180 patients with IMV ≥24 hours and at least >1 extubation attempt were included: 30 cases defined as patients with early extubation failure (≤24 hours to extubation), and 150 controls. Differences between cases and controls regarding the variables considered were determined using the Student's t test and the Chi-squared or Fisher's exact tests. In addition, a multivariate analysis (unconditional logistic regression model) was performed to establish the factors associated with extubation failure and post-extubation laryngeal stridor, calculating the odds ratio (OR) and the respective 95% confidence intervals (95%CI). A significance level of p<0.05 was considered. Results: Early extubation failure and laryngeal stridor had a prevalence of 16.66% (n=30) and 3.89% (n=7), respectively. In the multivariate analysis, having a history of intubation (OR=4.27, 95%CI: 1.44-12.66), the presence of active cancer (OR=2.92, 95%CI: 1.08-7.90), and being diagnosed with pneumonia (OR=2.84, 95%CI: 1.15-6.99) were significantly associated with extubation failure, while the duration of IMV (OR=1.53, 95%CI: 1.18-1.99) and history of intubation (OR=37.99, 95%CI: 2.22-650.8) were significantly associated with post-extubation laryngeal stridor. Conclusions: Based on the results reported here, it is suggested to consider factors such as history of intubation, comorbidity with cancer, and diagnosis of pneumonia in the stratification of critically ill patients to increase the likelihood of successful extubation.

Resumen Introducción. La intubación orotraqueal es un procedimiento que conlleva riesgos como la extubación fallida y el estridor laríngeo, los cuales aumentan el riesgo de morbilidad. Objetivo. Identificar los factores asociados a extubación fallida temprana (≤24 horas) y al desarrollo de estridor laríngeo post-extubación en pacientes adultos con ventilación mecánica invasiva (VMI). Materiales y métodos. Estudio de casos y controles con recolección prospectiva de información realizado en la unidad de cuidados intensivos (UCI) de un hospital de IV nivel de Bogotá, Colombia, entre abril de 2019 y febrero de 2020. Se incluyeron 180 pacientes con VMI ≥24 horas y al menos 1 intento de extubación: 30 casos definidos como pacientes con extubación fallida temprana (≤24 horas a la extubación) y 150 controles. Las diferencias en las variables consideradas entre casos y controles se determinaron mediante las pruebas t de Student y Chi-cuadrado o exacta de Fisher. Además, se realizó un análisis multivariado (modelo de regresión logística no condicional) para determinar los factores asociados con extubación fallida y estridor laríngeo post-extubación, calculando los Odds ratio (OR) con sus respectivos intervalos de confianza al 95% (IC95%). Se consideró un nivel de significancia de p<0.05. Resultados. La extubación fallida temprana y el estridor laríngeo tuvieron una prevalencia de 16.66% (n=30) y 3.89% (n=7), respectivamente. En el análisis multivariado, el antecedente de intubación (OR=4.27, IC95%: 1.44-12.66), la presencia de cáncer activo (OR=2.92, IC95%: 1.08-7.90) y ser diagnosticado con neumonía (OR=2.84, IC95%: 1.15-6.99) se asociaron significativamente con extubación fallida, mientras que la duración de la VMI (OR=1.53, IC95%: 1.18-1.99) y el antecedente de intubación (OR=37.99, IC95%: 2.22-650.8), con estridor laríngeo post-extubación. Conclusiones. Con base en los resultados aquí obtenidos, se sugiere considerar factores como antecedente de intubación, comorbilidad con cáncer y diagnóstico de neumonía en la estratificación de los pacientes críticamente enfermos para aumentar la probabilidad de una extubación exitosa.

The Effect of Tonsillectomy and Adenoidectomy on Upper Airway Obstruction Patterns in Children with Obstructive Sleep Apnea

Abstract Introduction Alterations in upper airway flow dynamics and sites of airway obstruction immediately after tonsillectomy and adenoidectomy (TA) have not been assessed. Identification of the changes in airway obstruction patterns after TA potentially improves the surgical management of children with obstructive sleep apnea (OSA). Objectives To evaluate the effect of TA on upper airway obstruction patterns detected with drug-induced sleep endoscopy (DISE). Methods The medical records of patients who underwent pre-TA DISE during the induction of anesthesia and post-TA DISE at the end of TA were reviewed. Data pertaining to polysomnography and DISE findings were analyzed. Results Twenty-seven patients (15 male and 12 females aged between 2 and 18 years old) were identified. All patients had obstruction at multiple sites of the upper airway. Prior to TA, airway obstruction was at the level of the velum in 27 patients, of the oropharynx/lateral walls in 27, of the tongue in 7, and of the epiglottis in 4. After TA, airway obstruction was at the level of the velum in 24 patients, of the oropharynx/lateral walls in 16, of the tongue in 6, and of the epiglottis in 4. The degree of obstruction at the levels of the velum and oropharynx/lateral walls after TA was significantly decreased. Conclusions Drug-induced sleep endoscopy performed prior to TA revealed that most of the sites of airway obstruction persisted after TA in OSA children with multiple sites of airway obstruction. Further studies in larger group of children with OSA are needed to establish the value of DISE findings in predicting residual OSA after TA, surgical planning, determining the need for post TA sleep study, and counseling caregivers.

Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report

Abstract Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

Neurofibromatosis and Debulking Surgery: A Case Report

Introduction: Neurofibromatosis type 1 is an autosomal dominant disorder characterised by propensity to form ectodermal and mesodermal tissue tumours. It exhibits a variety of symptoms, ranging from simple skin neurofibromas to devastating plexiform neurofibromas that cause skin disfiguration, nerve compression and airway obstruction. Case report: A 25 yr old male, diagnosed case of neurofibromatosis type1, presented with complaint of enlarging lower limb with hanging masses for last 9-10 years. Patient was known case of hypertension for past one year and was on treatment with tab. amlodipine 5 mg OD. Patient was posted for debulking surgery of neurofibroma under general anaesthesia. General physical examination showed multiple giant café au lait macule on trunk, gross enlargement of both lower limbs, lisch nodules on iris. Patient was induced with inj. propofol, inj. fentanyl and cisatracurium and intubated with 7.5mm ID endotracheal tube under c-MAC guidance. Patient was extubated uneventfully. Discussion: Anaesthetic considerations include presence of intracranial or spinal neuromas, neurofibromas of tongue, larynx, cervical spine involvement, hypertension, phaeochromocytoma, hypertrophic cardiomyopathy. Thus, a careful systemic assessment is required before selecting the anaesthetic technique. Conclusion: Anaesthesiologist needs to perform a thorough preoperative evaluation of every patient and prepare a comprehensive anaesthetic plan for any complications that may occur. Close cooperation between the surgeon, the anesthesiologist and the cardiologist is required especially for patients with undiagnosed hypertension.

Difficult Ventilation in a Patient with a Giant Aortic Aneurysm: A Challenge for the Anesthesiologist

Patients with Marfan syndrome present anatomic variations that may increase the risk of a difficult airway. Moreover, they can present large aortic aneurysms, which may cause extrinsic airway compression. Therefore, difficult ventilation during general anesthesia poses a challenge in that the anesthesiologist has to promptly make a crucial differential diagnosis. Multidisciplinary preoperative assessment and planning of the airway and ventilation management are of utmost importance in such uncommon and highly complex clinical cases. Fiberoptic bronchoscopy is probably a really useful tool in order to assess the severity and extent of the airway compression, both preoperatively and intraoperatively. We present a clinical case where difficult ventilation occurred immediately after the induction of general anesthesia.

Clinical and bronchoscopy features of tracheobronchial tuberculosis in children / 中国当代儿科杂志

OBJECTIVES@#To study the clinical and bronchoscopic characteristics of tracheobronchial tuberculosis (TBTB) in children and to identify factors influencing residual airway obstruction or stenosis.@*METHODS@#The clinical data of children with TBTB were retrospectively collected. The children were divided into two groups based on the last bronchoscopic result within one year of follow-up: a group with residual airway obstruction or stenosis (n=34) and a group without residual airway obstruction or stenosis (n=58). A multivariate logistic regression analysis was used to identify the factors influencing residual airway obstruction or stenosis in children with TBTB. Receiver operating characteristic (ROC) curves were used to analyze the predictive value of the factors influencing residual airway obstruction or stenosis in children with TBTB.@*RESULTS@#A total of 92 children with TBTB were included, and the main symptoms were cough (90%) and fever (68%). In children under 1 year old, the incidence rates of dyspnea and wheezing were significantly higher than in other age groups (P<0.008). Chest CT findings included mediastinal or hilar lymph node enlargement (90%) and tracheobronchial stenosis or obstruction (61%). The lymphatic fistula type was the main type of TBTB observed bronchoscopically (77%). All children received interventional treatment, and the effective rate was 84%. During one year of follow-up, 34 children had residual airway obstruction or stenosis. The TBTB diagnostic time and the initiation of interventional treatment were significantly delayed in the group with residual airway obstruction or stenosis compared with the group without residual airway obstruction or stenosis (P<0.05). The multivariate logistic regression analysis showed that the TBTB diagnostic time was closely related to residual airway obstruction or stenosis in children (P<0.05). ROC curve analysis showed that at the cut-off value of 92 days of TBTB diagnostic time, the area under the curve for predicting residual airway obstruction or stenosis in children with TBTB was 0.707, with a sensitivity of 58.8% and a specificity of 75.9%.@*CONCLUSIONS@#The clinical manifestations of TBTB are nonspecific, and symptoms are more severe in children under 1 year old. TBTB should be suspected in children with tuberculosis and chest imaging indicating airway involvement. Delayed diagnosis of TBTB is associated with the development of residual airway obstruction or stenosis.

Analysis of 108 flexible bronchoscopies for the removal of foreign bodies from the airways

ABSTRACT Objective To describe the clinical, bronchoscopic, diagnostic, and therapeutic aspects between children and adults. Methods This retrospective study compared the clinical and bronchoscopic characteristics of adults and children who underwent bronchoscopy for suspected foreign body aspiration. Data on sex, outpatient or emergency origin, bronchoscopy results, characteristics of the aspirated foreign body, and complications were analyzed. Results In total, 108 patients were included in the analysis, with foreign body aspiration diagnosed in 69% of patients (30 children and 44 adults). In 91% of patients, there was a clinical history suggestive of aspiration. The mean age of the adults was 65.89 (±19.75) years, and that of the children was 2.28 (±1.78) years. Most of the children were under 3 years of age (80%), while adults were mostly 70 years of age or older (54.5%). Emergency care was more common among children than adults. The most common foreign bodies found in both age groups were organic bodies, primarily seeds. The most frequent locations of foreign bodies were the lobar bronchi in adults and the main bronchi in children. Flexible bronchoscopy is the primary method for diagnosis and treatment. Transient hypoxemia occurred particularly frequently in children (5%). Conclusion Foreign body aspiration, particularly that involving seeds, is more common in the extremes of age. A clinical history suggestive of aspiration is crucial in determining the need for bronchoscopy, which should be performed as early as possible. Flexible bronchoscopy is an effective and safe diagnostic technique.

Obstructive sleep apnea: a review for the orthodontist

ABSTRACT Introduction: Obstructive sleep apnea (OSA) affects an important part of the population and is characterized by recurrent total or partial obstruction of the upper airway (UA) during sleep, negatively affecting the quality of life of patients in the short and long terms, and constituting an important public health problem for the society. The field of expertise of orthodontists is closely related to the UA, placing them in a strategic position to diagnose air passage failures and intervene when necessary. Orthodontists, as health professionals, must know how to recognize respiratory problems and manage them appropriately, when indicated. Objective: Thus, this paper aims to review and critically evaluate the related literature, to provide orthodontists with updated knowledge on the diagnosis and therapy related to OSA. Science and technology are constantly evolving; thus, the literature was also reviewed considering new technologies available in consumer-targeted applications and devices for the diagnosis, monitoring, and treatment of sleep-disordered breathing.

RESUMO Introdução: A apneia obstrutiva do sono (AOS) afeta uma importante parcela da população e caracteriza-se pela obstrução total ou parcial recorrente da via aérea superior (VAS) durante o sono, o que afeta negativamente a qualidade de vida dos pacientes no curto prazo e no longo prazo, e constitui importante problema de saúde pública para a sociedade. A área de atuação do ortodontista está em íntima relação com a VAS, o que o coloca em uma posição estratégica para diagnosticar falhas na passagem de ar e intervir quando necessário. É imperativo que o ortodontista, como profissional da saúde, saiba reconhecer problemas respiratórios e manejá-los de maneira apropriada, quando indicado. Objetivo: O objetivo desse artigo é revisar e avaliar criticamente a literatura pertinente, para proporcionar ao ortodontista conhecimento atualizado sobre o diagnóstico e terapêutica relacionados à AOS. Ciência e tecnologia estão em constante evolução; portanto, a literatura também foi revisada considerando as novas tecnologias disponíveis em aplicativos e dispositivos direcionados aos consumidores para o diagnóstico, monitoramento e tratamento dos distúrbios respiratórios do sono.

Educational intervention about airway obstructions for early childhood teachers: a quasi-experimental study / Intervención educativa sobre la obstrucción de las vías respiratorias para profesores de educación de la primera infancia: estudio casi experimental / Intervenção educativa sobre obstrução das vias respiratórias para professores de educação infantil: estudo quase-experimental

ABSTRACT Objective: To verify the effect of an educational intervention about airway obstructions and an airway clearing technique in teachers from Municipal Child Education Centers in a municipality in western Paraná. Method: A quasi-experimental pre- and post-test study. Data was collectedusing a questionnaire with thirty questions to assess knowledge about the subject. For the analyses, the chi-square and McNemar tests were used, withanα = 5% of significance. Results: After the training sessions, there was a 16.22% increase in the number of correct answers to the questions dealing with the recognition of the obstruction (<0.0001) and the airway clearance technique (<0.0001). Conclusion: The intervention improved the knowledge of early childhood teachers in the municipality regarding the identification of airway obstruction and techniquesairway clearing in school-age children.

RESUMEN Objetivo: Verificar el efecto de una intervención educativa sobre la obstrucción de las vías aéreas y una técnica de desobstrucción en docentes de Centros Municipales de Educación Infantil de un municipio del oeste de Paraná. Método: Estudio cuasiexperimental del tipo pre y postest. Se recolectó a los datos a través de un cuestionario con treinta preguntas para evaluar el conocimiento sobre el tema. Para los análisis se utilizaron las pruebas chi-cuadrado y McNemar, con α = 5% de significación. Resultados: Después del entrenamiento, hubo un aumento del 16,22% en el número de respuestas correctas a las preguntas relacionadas con el reconocimiento de la obstrucción (<0,0001) y la técnica de desobstrucción de la vía aérea (<0,0001). Conclusión: La intervención mejoró el conocimiento de los docentes de los centros municipales de educación infantil en cuanto a la identificación y técnica de desobstrucción de las vías respiratorias en niños en edad escolar.

RESUMO Objetivo: Verificar o efeito de uma intervenção educativa sobre a obstrução de vias aéreas e a técnica de desobstrução, em professores de Centros Municipais de Educação Infantil de um município do Oeste do Paraná. Método: Estudo quase-experimental do tipo pré e pós-teste. Os dados foram coletados por meio de um questionário com trinta questões para avaliar o conhecimento sobre a temática. Para as análises utilizou-se os testes de Qui-quadrado e McNemar, com α = 5% de significância. Resultados: Após o treinamento, houve o aumento de 16,22% no número de acertos das questões que tratavam do reconhecimento da obstrução (<0,0001) e da técnica de desobstrução das vias aéreas (<0,0001). Conclusão: A intervenção melhorou o conhecimento dos professores dos Centros Municipais de Educação Infantil, quanto a identificação e a técnica de desobstrução das vias aéreas em crianças de idade escolar.

Efficacy and predictors of success on laryngomalacia surgery: experience from a tertiary pediatric care center in Brazil

Abstract Objectives: Laryngomalacia is the most common congenital cause of stridor; the natural history of the disease runs through to complete resolution by the age of two. Severe cases are characterized by cyanosis, hypoxia, apnea, furcular and/or subcostal retractions, aspirations, pulmonary hypertension, and failure to thrive and must undergo surgery. This study aimed to evaluate the success rates of supraglottoplasty in our hospital and evaluate the predictive factors for surgical success. Methods: Cohort study, prospectively planned. 75 patients undergoing endoscopic surgery from July 2007 to July 2016 were analyzed at the Santo Antônio Children's Hospital. The primary outcome was percentage of surgical success, defined as the absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative month (late success). The secondary outcomes were the early surgical success (absence of respiratory symptoms or presence of a mild stridor without retractions on the first post-operative day). Results: 39 (58.2%) were male, with an average of 4.9 months. Surgical success on the first day was 80.6% (n = 54). At the end of the 1st month, surgical success was 88.6%, considering only those who completed assessment. Twenty-one (34%) presented comorbidities. Presence of comorbidities, pharyngomalacia and GERD were associated with a worse result on the 1st postoperative day, whereas, at the end of the first month, presence of comorbidities, concomitant injuries (tracheo and bronchomalacia) and pharyngomalacia were the predictive variables of surgery failure. Conclusion: Supraglottoplasty has high rates of efficacy and low morbidity. The presence of comorbidities and pharyngomalacia has shown association with a worse early and late surgical outcome. Synchronous airway lesions predict a worse surgical result at the end of the first month. GERD was associated with obstructive symptomatology only in the 1st post-operative day. Level of evidence: Level 3 of evidence, according to the "The Oxford 2011 Levels of Evidence" from Oxford Centre for Evidence-Based Medicine.

Quiste subglótico adquirido como causa inhabitual de estridor en pediatría. Revisión de la literatura a propósito de un caso / Subglottic cyst as an unusual cause of stridor in pediatric patients. Literature review and case report

El estridor corresponde a un signo altamente frecuente, sin embargo, es heterogéneo e inespecífico. Existen múltiples causas conocidas y manejadas por el otorrinolaringólogo. Los quistes subglóticos constituyen una entidad infrecuente de estridor en pediatría, siendo la población más frecuentemente afectada, niños con antecedentes de prematurez e intubación por períodos prolongados. Su manifestación clínica es variada, desde cuadros asintomáticos a pacientes con riesgo inminente de pérdida de la vía aérea. El diagnóstico suele ser tras largos períodos desde el antecedente de intubación. Su resolución suele ser quirúrgica, teniendo como principal complicación asociada la estenosis subglótica y las recurrencias. Se presenta el caso de una preescolar con un episodio de estridor y distrés respiratorio rápidamente progresivos, cuyo diagnóstico intraoperatorio resultó en quistes subglóticos submucosos bilaterales, que requirieron resolución quirúrgica.

Stridor corresponds to a highly frequent sign; however, it is heterogeneous and nonspecific. There are multiple causes that are widely known and managed by the otorhinolaryngolo-gist. Subglottic cysts are an infrequent entity of stridor in pediatric patients, where the most frequently affected population are childrens with history of prematurity and intubation for long periods. It's clinical manifestations are wide, from asymptomatic cases to patients with imminent risk of airway loss. Their manifestation its often after long periods after the moment of intubation. The management often involves surgery, and the main associated complication is subglottic stenosis and recurrences. We present the case of a preschool girl with an episode of rapidly progressive stridor and respiratory distress; whose intraoperative diagnosis was bilateral subglottic submucosal cysts that required surgical resolution.

Manifestaciones pulmonares de la artritis reumatoide, una revisión en tiempos de pandemia por SARS-CoV-2 / no

La artritis reumatoide (AR) es una de las patologías crónicas de origen autoinmune más frecuentes. Su prevalencia varía del 0,5 al 1%, con un compromiso primario a nivel articular, generando gran discapacidad por las deformidades secundarias derivadas de un estado inflamatorio persistente. Considerando el alto impacto en la calidad de vida de quienes la padecen, sumado al alto costo de las intervenciones terapéuticas, se vuelve imperativo para el personal de salud sumar todos los esfuerzos para promover un diagnóstico temprano y reconocer las potenciales complicaciones con el fin de impactar positivamente en los desenlaces clínicos. Alrededor del 50% de los pacientes con AR pueden tener compromiso extra articular, siendo el pulmón uno de los órganos más afectados. En época de pandemia por el virus SARS-CoV-2 es necesario recordar los tipos de compromiso pulmonar en pacientes con AR y tener en cuenta la susceptibilidad de estos pacientes a cuadros infecciosos que pueden generar una gran morbimortalidad.

Rheumatoid arthritis (RA) is one of the most frequent chronic autoimmune pathologies. It's prevalence varies from 0.5 to 1%, with a primary involvement at the joint, generating disability due to deformities secondary to persistent inflammation. Considering the high impact on the quality of life of those who suffer it, added to the high cost of therapeutic interventions, it becomes imperative for health personnel to join forces to promote early diagnosis and recognize potential complications, in order to impact positively on clinical outcomes. Around 50% of patients with RA may have extra-articular involvement, the lung being one of the most affected organs. In times of SARS-CoV-2 pandemic, it's necessary to remember the types of lung involvement in patients with RA and take into account the susceptibility of these patients to infectious conditions that can generate great morbidity and mortality.

Algoritmo para el manejo de la obstrucción laríngea en pediatría / Algorithm for the management of laryngeal obstruction in pediatrics

La laringe se localiza en la encrucijada aerodigestiva; cualquier patología que la comprometa tendrá repercusión en la respiración, la deglución y/o la voz. Se divide en tres regiones: la supraglotis (comprende la epiglotis, las bandas ventriculares y los ventrículos laríngeos), la glotis (espacio limitado por las cuerdas vocales) y la subglotis (zona más estrecha de la vía aérea pediátrica y único punto rodeado en su totalidad por cartílago: el anillo cricoides). La obstrucción laríngea se puede presentar como una condición aguda potencialmente fatal o como un proceso crónico. El síntoma principal es el estridor inspiratorio o bifásico. La etiología varía mucho según la edad y puede ser de origen congénito, inflamatorio, infeccioso, traumático, neoplásico o iatrogénico. Se describen las patologías que ocasionan obstrucción laríngea con más frecuencia o que revisten importancia por su gravedad, sus síntomas orientadores para el diagnóstico presuntivo, los estudios complementarios y el tratamiento.

The larynx is at the aerodigestive crossroads; any pathology that involves it will have an impact on breathing, swallowing and/or the voice. It`s divided into three regions: supraglottis (includes epiglottis, ventricular bands and laryngeal ventricles), glottis (space limited by the vocal cords) and subglottis (narrowest area of pediatric airway and the only point of larynx completely surrounded by cartilage: the cricoid ring). Laryngeal obstruction can present as a potentially fatal acute condition or as a chronic process. The main symptom is inspiratory or biphasic stridor. The etiology varies widely according to age and it may be of congenital, inflammatory, infectious, traumatic, neoplastic or iatrogenic origin. We describe the pathologies that cause laryngeal obstruction, either those that occur very often or those which are important for their severity, their guiding symptoms to the presumptive diagnosis, additional studies and treatment.

Intubación endotraqueal de emergencia en paciente con estridor inspiratorio y hallazgo de tumor en cuerdas vocales: reporte de un caso / Emergency endotracheal intubation in a patient with inspiratory stridor and a vocal cord tumour finding: a case report

El manejo especializado de la vía aérea (VA) es fundamental en las unidades de urgencia donde la intubación orotraqueal ha sido la técnica de elección para lograrlo. Una VA difícil se define como una situación clínica en la cual un equipo médico entrenado experimenta dificultades en la ventilación y/o en intubación. La obstrucción aguda de la VA constituye una de las emergencias médicas más extremas, requiriendo intervención inmediata. Se presenta el caso de un paciente con estridor inspiratorio con criterios inmediatos de intubación donde se evidencia un tumor en cuerdas vocales con obstrucción de la vía aérea.

Specialized airway management is essential in emergency units where endotracheal intubation has been the technique of choice. The difficult airway is defined as a clinical situation in which a trained medical team experiences difficulties in ventilation and, or intubation. Acute airway obstruction is one of the most extreme medical emergencies, requiring immediate intervention. We present the case of a patient with inspiratory stridor with quick criteria for intubation where a tumour in the vocal cords with airway obstruction is found.

CHAOS: síndrome de obstrucción congénita de las vías aéreas superiores / CHAOS: congenital high airway obstruction syndrome

Resumen El síndrome de obstrucción congénita de vías áreas superiores (CHAOS) es una condición que se caracteriza por la existencia de una obstrucción en las vías áreas altas en el feto, la cual puede ser parcial o completa. Comúnmente es una situación incompatible con la vida, por lo que su diagnóstico prenatal es importante considerando el pronóstico y los diferentes manejos prenatales y posnatales que existen. Presentamos un caso de CHAOS diagnosticado en la semana 21, con una breve revisión de la literatura sobre su diagnóstico, pronóstico y alternativas terapéuticas.

Abstract Congenital high airway obstruction syndrome (CHAOS) is a condition characterized by the existence of an obstruction of the fetal upper airways, which may be partial or complete. It is commonly incompatible with life, so its prenatal diagnosis is important due to the prognosis and the recently described pre and postnatal management options. We present a case of CHAOS in a pregnancy of 21 weeks with a brief review of the current literature about its diagnosis, prognosis and therapeutic alternatives.

Sleep endoscopy as a complementary diagnostic method for snoring and sleep apnea

ABSTRACT Obstructive sleep apnea is a disorder characterized by complete or incomplete and recurrent upper airway collapse induced by sleep. Several diagnostic methods for obstructive sleep apnea are used, but only sleep endoscopy allows an endoscopic assessment of pharyngeal collapse during sedation. It is essential to carry out sleep endoscopy following a systematic institutional protocol, in preestablished stages, to ensure better reproducibility and reliability of the results found. Sleep endoscopy has few limitations and is a safe test, with a low risk of complications.