Anesthesia for shared airway surgery in children.

Shared airway surgery in children is a complex, high-risk undertaking that requires continuous communication and cooperation between the anesthetic and surgical teams. Airway abnormalities commonly seen in children, the surgical options, and the anesthetic techniques that can be used to care for this vulnerable population are discussed. Many of these procedures were traditionally carried out using jet ventilation, or intermittent tracheal intubation, but increasingly spontaneously breathing "tubeless" techniques are being used. This review has been written from both the surgical and anesthetic perspective, highlighting the concerns that both specialties have in relation to the maintenance of surgical access and operating conditions, and the need for the provision of anesthesia, oxygenation, and ventilation where the airway is the primary site of operation.

Effect of low tidal volume with PEEP on respiratory function in infants undergoing one-lung ventilation.

BACKGROUND: An increasing number of studies have shown that low tidal volume (TV) with positive end-expiratory pressure (PEEP) offers lung protection during one-lung ventilation (OLV). Considering the unique physiological characteristics of infants, we aimed to determine the feasibility and effect of low TV with PEEP in infants undergoing OLV during thoracoscopy. PATIENTS AND METHODS: We randomized 60 infants to a conventional group (group I: TV, 8-10 ml/kg; RR, 23-45 bpm; PEEP, 0 cmH2O) or a low TV with PEEP group (group II: TV, 5-7 ml/kg; RR, 23-45 bpm; PEEP, 4-6 cmH2O). Arterial blood gas analyses were performed at four time points: 5 min of two-lung ventilation (TLV, T0), and 20 min, 40 min, and 60 min of OLV (T1, T2, T3); hemodynamic parameters (heart rate, mean blood pressure), temperature, as well as gas exchange (SpO2 and PETCO2) and ventilation parameters (FiO2, PEEP, Pmax) were recorded simultaneously. Lung compliance and shunt were also calculated. RESULT: No significant difference was found between both groups at T0. Compared with T0, PETCO2, Pmax, PaCO2, lactic acid, and intrapulmonary shunt volume (Qs/Qt) were increased while PaO2 and respiratory system compliance (Cdyx) were decreased noticeably in both groups at T1, T2, and T3. At T1, T2, and T3, Pmax and Qs/Qt were much lower while PETCO2, PaCO2, and Cdyx were higher in group II than in group I. There was no significant difference in lactic acid and PaO2 measurements between the two groups at T1, T2, and T3. CONCLUSION: Low TV with PEEP could be an effective intraoperative ventilation strategy for infants undergoing OLV during video-assisted thoracoscopic surgery and may reduce the risk of lung injury. However, this strategy, as well as the influence of intraoperative hypercapnia on infants, needs further investigation.

Development and validation of a risk prediction model for tracheostomy in acute traumatic cervical spinal cord injury patients.

PURPOSE: Tracheostomy may become indispensable for patients with acute traumatic cervical spinal cord injuries. However, the early prediction of a tracheostomy is often difficult. Previous prediction models using the pulmonary function test (PFT) have limitations because some severely injured patients could not provide acceptable PFT results. We aim to develop an alternative model for predicting tracheostomy using accessible data obtained from the bedside. METHOD: Clinical, neurological and radiological data from 345 consecutive patients with acute tetraplegia were retrospectively reviewed. We applied multiple logistic regression analysis (MLRA) and classification and regression tree (CART) analysis to develop the prediction model for tracheostomy. By train-test cross-validation, we used the sensitivity, specificity, area under the receiver operating characteristics curve (AUC) and correction rate to evaluate the performance of these models. RESULTS: According to the American Spinal Injury Association (ASIA) standards, an admission ASIA motor score (AAMS) ≤ 22, ASIA grade A and presence of respiratory complications were identified as independent predictors of tracheostomy by both models. The model derived by CART suggested that the highest signal change (HSC) in the spinal cord on magnetic resonance imaging (MRI) also affected a patient's requirement for a tracheostomy, while MLRA demonstrated that tracheostomy was also influenced by the presence of an ASIA grade B injury. The CART model had a sensitivity of 73.7%, specificity of 89.7%, AUC of 0.909 and overall correction rate of 87.3%. The sensitivity, specificity, AUC and correction rate of the MLRA model were 81.8, 86.4, 0.889 and 85.7%, respectively. CONCLUSIONS: We suggest using the CART model in clinical applications. Patients with AAMS ≤ 1 exhibit an increased likelihood of requiring a tracheostomy. For patients with an AAMS in the range of 2-22, surgeons should consider giving these patients a tracheostomy once respiratory complications occur. Surgeons should be cautious to give a tracheostomy to patients with an AAMS ≥ 23, if the patient experiences an incomplete spinal cord injury and the HSC in the spinal cord is at C3 level or lower based on MRI. For other patients, close observation is necessary; generally, patients with complete SCI might require a tracheostomy more frequently.

Our experience with respiratory epithelial adenomatoid hamartomas of the olfactory cleft.

Respiratory epithelial adenomatoid hamartoma (REAH) is a relatively recent diagnosis that is gaining more interest in sinus surgery. REAH of the olfactory cleft was often misdiagnosed, and interpreted as nasal polyposis (NP). We present a retrospective case series of 27 patients who were diagnosed and treated for REAH of the olfactory cleft, in the past 7 years, in our department. The aim of this study is to present the diagnostic modalities and the results and follow-up after surgery. The male to female ratio was 2.9:1, with a mean age of 56 years. Almost half of these patients were operated at least once before on their sinuses. The most common presenting symptoms of isolated REAH are olfactory disorders. All cases were treated surgically with endoscopic sinus surgery, without recurrences in the follow-up period. Knowledge and identification of REAH of the olfactory cleft are fundamental. Knowledge, identification, and adequate treatment of these lesions are fundamental, as they limit the number of recurrences.

Standing equine surgery of the upper respiratory tract.

The purpose of this article is to review the literature and personal experiences of equine surgeons so as to describe procedures that can be performed in the standing sedated horse to alleviate conditions that result in upper respiratory tract obstruction. Upper respiratory tract surgery requires attention to detail, meticulous planning, and careful dissection and execution with little room for error. This article describes a selection of standing upper airway procedures, the indications for and possible complications of these surgeries, and advantages and disadvantages of a particular method.

[Advances in pediatric thoracic surgery during the past 50 years].

Surgical strategies and treatment for pediatric airway and lung diseases have advanced significantly, especially in the fields of subglottic stenosis, congenital tracheal stenosis, congenital cystic lung lesions, and endoscopic surgery, during the past 50 years. Pediatricians, pathologists, and pediatric surgeons have engaged in continuous discussions at scientific meetings to establish standard terminology and operative indications and to refine surgical techniques such as laryngoplasty, sliding tracheoplasty, lobectomy under thoracotomy and thoracoscopy. The modified Myer-Cotton grading system for subglottic stenosis was proposed and proved to be useful in selecting reconstructive operative techniques. The addition of aortopexy to sliding tracheoplasty was also confirmed to be effective in maintaining a wide postoperative tracheal lumen. The disease entities of each type of cystic lung lesion were clarified, and the clinical and etiological importance of bronchial/bronchiolar atresia was emphasized. A classification of congenital cystic lung disease was proposed based on anatomic and embryologic considerations. In this classification, congenital pulmonary airway anomaly was introduced to replace congenital cystic adenomatoid malformation of the lung. Intralobar sequestration of the lung must be located in the lower lobe in this definition and classification.

Treatment of persistent postpneumonectomy empyema by vacuum-assisted management: an analysis of nine patients.

BACKGROUND: Conventional treatment methods in postpneumonectomy empyemas (PPE) are associated with long stay in hospital, poor patient comfort, and high rate of postoperative mortality. Vacuum-assisted management (VAM) may be helpful in solving these problems. METHODS: VAM was performed on nine patients with PPE in our clinic between July 2010 and September 2011 to provide continuous drainage of empyema in the pouch and to improve empyema with obliteration of the pouch by accelerating tissue granulation. RESULTS: All nine patients were men (mean age: 54.5 years; range: 18-68 years). Empyema resolution and obliteration of the pouch were achieved with VAM in the cases with empyema without fistula (n = 7) after the pneumonectomy. In the patients with fistula (n = 2), VAM was performed after closure of the fistula. Mean duration of hospital stay was 36.5 (12-57) days. The treatment was successful in eight of nine patients (88.9%). Mean duration of follow-up in the successfully treated patients was 10.9 (3-17) months. CONCLUSION: Intrathoracic VAM was effective and safe in the treatment of PPE.

Isolated juvenile xanthogranuloma in the larynx of a three-year-old child.

Juvenile xanthogranuloma (JXG) is a benign manifestation of non-Langerhans cell histiocytosis characterized by yellowish cutaneous nodules. Its occurrence in the larynx is very rare, but laryngeal JXG may cause severe respiratory distress. We report a patient with isolated laryngeal JXG treated by laryngomicrosurgery, and this is the first report of JXG extending to vocal fold. A 3-year-old girl presented with hoarseness and inspiration stridor. A bulky tumor was found in right glottic to subglottic region. Subtotal resection of the tumor was carried out by laryngomicrosurgery, and airway distress was diminished after the operation. In pathological examination, the resected specimen showed proliferation of histiocytic cells and spindle cells with Touton giant cells that are characterized by polynuclei or wreath nuclei and are known to appear in JXG but not in LCH. Immunohistochemistry of histiocytic cell markers demonstrated positivity for CD68, lysozyme, alpha1-anti-chymotrypsin, factor XIIIa and vimentin, and negativity for CD1a and S-100, leading to diagnosis of JXG, but not LCH. The patient was thus expected with benign prognosis, and additional resection of the tumor including vocal fold was not indicated in the initial treatment. Six weeks later, the JXG recurred and a second procedure using CO2 laser was needed. The tumor did not re-grow thereafter, and there was no residual voice handicap. Because of its favorable prognosis and tendency for spontaneous regression, JXG in the larynx needs to be considered carefully with regard to whether reduction surgery and/or tracheotomy are necessary, and thus precise diagnosis is required.

[Respiratory support in anaesthetic management for thoracic surgery and their comparative characteristics: over 2000 anaesthesia experience].

The article deals with the first comparative study of haemodynamics, gas exchange, and metabolic lung finction in patients with underlying respiratory and cardiovascular diseases. Different anaesthesia and ventilation (conventional AVL, OLV differentiated ALV) techniques were used. Respiratory support methodology with the use of HFV or CPAP during the main phase of thoracic surgery in patients with severe associated cardio-respiratory diseases was developed. Indications for differentiated AL V in thoracic surgery were developed.

Regenerative medicine as applied to general surgery.

The present review illustrates the state of the art of regenerative medicine (RM) as applied to surgical diseases and demonstrates that this field has the potential to address some of the unmet needs in surgery. RM is a multidisciplinary field whose purpose is to regenerate in vivo or ex vivo human cells, tissues, or organs to restore or establish normal function through exploitation of the potential to regenerate, which is intrinsic to human cells, tissues, and organs. RM uses cells and/or specially designed biomaterials to reach its goals and RM-based therapies are already in use in several clinical trials in most fields of surgery. The main challenges for investigators are threefold: Creation of an appropriate microenvironment ex vivo that is able to sustain cell physiology and function in order to generate the desired cells or body parts; identification and appropriate manipulation of cells that have the potential to generate parenchymal, stromal and vascular components on demand, both in vivo and ex vivo; and production of smart materials that are able to drive cell fate.

Mesenchymal stem cells.

Mesenchymal Stem cells (MSCs) are stromal cells that can be readily harvested from adult bone marrow and adipose tissue, but also umbilical cords. With respect to respiratory disease, the therapeutic potential of these cells lies in their paracrine effects which underlie their ability to enhance tissue regeneration and modulate immune responses. MSCs have been shown to be effective in a range of murine models of respiratory disease, and there are currently five clinical trials involving the administration of MSCs for respiratory diseases, including COPD and emphysema. This paper summarises the features of MSCs.

Respiratory epithelial adenomatoid hamartomas of the olfactory clefts.

The objective of this study is to report a 5-year experience with Respiratory Epithelial Adenomatoid Hamartoma (REAH) of the olfactory clefts. The study design is retrospective observational study and the setting is in a Tertiary medical center. The charts of all adult patients operated on bilateral nasal polyps between 2003 and 2008 were retrospectively checked up on the diagnosis of REAH. Three periods have been distinguished according to our experience with REAH. REAH can be observed either as bilateral pseudotumours confined to the olfactory clefts (n = 12 between 2003 and 2008) or associated to nasal polyposis of the ethmoid labyrinths. As the diagnosis of associated REAH became more evident, the number of recognized cases increased from 0% in 2003 and 2004 to 1.6% in 2005 (1/64 patients) and 12.5% in 2006 (10/80 patients) (period 1). Systematic endoscopy of the olfactory clefts during ethmoid labyrinth surgery increased the proportion to 27% (27/100 patients) (period 2). Systematic biopsies of abnormal mucosa in the olfactory clefts during ethmoid surgery increased the proportion to 48% (31/65 patients). The histopathological diagnosis of REAH has been described in 1995 and added to the World Health Organization classification of tumours in 2005. Pseudotumoural REAH confined to the olfactory clefts represent a differential diagnosis for bilateral naso-ethmoidal polyposis. The significance of REAH associated to naso-ethmoidal polyposis is unclear.

[Analysis of 208 flexible bronchoscopies performed in an intensive care unit]. / Análisis de 208 fibrobroncoscopias realizadas en una unidad de cuidados intensivos.

OBJECTIVE: To describe the main indications, clinical results and complications associated with fibrobronchoscopy in the Intensive Care Unit (ICU). DESIGN: A retrospective, single-center observational study was carried out. Setting. Seventeen beds in a medical/surgical ICU. Patients. Consecutive patients undergoing fibrobronchoscopy during their stay in the ICU over a period of 5 years. INTERVENTIONS: Flexible bronchoscopy performed by an intensivist. Main variables of interest. Flexible bronchoscopy indications and complications derived from the procedure. RESULTS: A total of 208 flexible bronchoscopies were carried out in 192 patients admitted to the ICU. Most of the procedures (193 [92.8%]) were performed in mechanically ventilated patients. The average patient age was 58 ± 16 years, with an APACHE II score at admission of 19 ± 7. The most frequent indication for flexible bronchoscopy was diagnostic confirmation of initially suspected pneumonia (148 procedures), with positive bronchoalveolar lavage findings in 46%. The most frequent therapeutic indication was the resolution of atelectasis (28 procedures). Other indications were the diagnosis and treatment of pulmonary hemorrhage, the aspiration of secretions, control of percutaneous tracheotomy, and difficult airway management. The complications described during the procedures were supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%). CONCLUSIONS: A microbiological diagnosis of pneumonia and the resolution of atelectasis are the most frequent indications for flexible bronchoscopy in critically ill patients. Flexible bronchoscopy performed by an intensivist in ICU is a safe procedure.

[Fiberoptic bronchoscopy in a respiratory intensive care unit]. / Fibrobroncoscopia en una unidad de vigilancia intensiva respiratoria.

OBJECTIVE: To describe the indications, diagnostic performance and safety of fiberoptic bronchoscopy (FOB) performed in a respiratory intensive care unit (RICU). DESIGN: A prospective, observational study was carried out. SETTING: A 6-bed RICU in a tertiary university hospital. PATIENTS: Patients admitted to RICU who required FOB. INTERVENTIONS: None. MAIN MEASUREMENTS: FOB indications and complications, endoscopic procedures, time required to perform FOB. RESULTS: Sixty-nine out (23%) of the 297 patients admitted to the RICU underwent a total of 107 FOB. Sixty-eight percent of FOB were performed in patients on mechanical ventilation. FOB was performed for diagnostic and therapeutic purposes in 88 (82%) and 19 cases (18%), respectively. The study of pulmonary infiltrates was the main indication for diagnostic FOB (44 cases; 50%), particularly in immunocompromised patients (24 cases; 27%). In immunocompromised patients the diagnostic performance of FOB was significantly higher than in immunocompetent subjects (48% vs 30%; p<0.01). No major complications were recorded. Only a significant drop in PaO(2)/FiO(2) ratio was observed (182 ± 74 vs 163 ± 79; p<0.005) in patients undergoing bronchoalveolar lavage. Overall mortality in patients in the RICU was 14%. In patients requiring a single FOB procedure, mortality was 25%, versus 45% among those requiring more than one FOB procedure. CONCLUSIONS: These results show that FOB is used commonly in the RICU. It is a safe and fast procedure that contributes significantly to clinical management. Patients requiring additional FOB during admission to the RICU show high mortality.

Paediatric thoracoscopy: state of the art.

Brad Rogers reported the first significant use of thoracoscopy in children in the late 1970s. Over the past two decades there has been an exponential growth and expansion of this technique. Many advanced procedures, including lobectomy, repair of tracheo-esophageal fistula, excision of mediastinal tumours and diaphragmatic hernia repairs, are being done routinely in pediatric surgery centres around the world. This article reviews the state of the art of thoracoscopic surgery in children. The author selected five procedures which in his opinion are most relevant for this discussion. The thoracoscopic technique seems to offer a favourable alternative to open surgery, but more clinical research is necessary to confirm the benefits of minimal access surgery.

[Optimal timing of pediatric surgery to prevent deleterious effects on associated cardiac defects].

Although cardiac defects are thought to have deleterious effects on the outcome of general pediatric surgery due to low cardiac output syndrome and hypoxemia, both pediatric surgery and cardiac surgery can be performed at the optimal timing with good results. However, some conditions requiring pediatric surgery may have deleterious effects on the outcome of cardiac surgery. Airway obstructive diseases sometimes require concomitant repair of the associated cardiac defects. In particular, tracheal stenosis may be repaired in cooperation with not only general pediatric and cardiac surgeons but also with pediatric thoracic surgeons who work in other healthcare institutions. Low birth-weight infants with symptomatic patent ductal artery are at risk of poor outcome. For patients with right isomerism, midgut malrotation or sliding hernia should be diagnosed early and repaired at the optimal timing to prevent urgent surgical intervention. Pediatric surgery should be performed at the optimal timing to prevent any deleterious effects on cardiac defects. Moreover, respiratory infection and neurologic disease should be treated to reduce late deaths.

Office-Based Lower Airway Endoscopy: Feasibility and Safety.

OBJECTIVES: The primary aim of this study was to identify the ease and safety of office-based lower airway endoscopy (OLAE) in patients with and without comorbidities. In addition, we identified the most common indications for OLAE and the associated diagnosis. METHODS: A retrospective review on 567 patients and 706 in-office flexible fiberoptic procedures was performed. Using a previously established grading system, the ease of visualization of the subglottis, trachea, and carina was assessed, in addition to the overall ease of the exam. RESULTS: Four hundred and eighty-eight videos were available for review. Of those, 105 videos included an OLAE, accounting for 21.5% of all procedures. Laryngomalacia was the most common diagnosis in 35 of 105 (36%) OLAE. For all laryngomalacia cases, the overall ease was found to be on average 2.15 (standard error 0.12). Fisher exact testing showed a statistical significance in the ability to visualize the trachea between the types of Laryngomalacia (LM) (P = .035). Fisher exact testing was performed comparing LM types I, II, or III, and combined types of LM; no statistical difference was found between groups. In 4.76% of OLAE procedures, a subglottic pathology was diagnosed. Comorbidities were found in OLAE 26 of 105 patients. There were no complications identified. CONCLUSION: We found OLAE more challenging than previously reported. OLAE of combined types of laryngomalacia was subjectively more difficult, but this difference did not reach statistical significance. OLAE continues to be a safe alternative to operative laryngoscopy in pediatric patients and appears safe in those with comorbidities when precautions are taken. LEVEL OF EVIDENCE: 4. Laryngoscope, 131:E649-E652, 2021.

Surgical interventions and local therapy for Wegener's granulomatosis.

PURPOSE OF REVIEW: This review discusses the use of interventional procedures to treat manifestations of Wegener's granulomatosis caused by tissue damage and scarring. These manifestations include nasal and paranasal sinus disease, middle ear inflammation, nasolacrimal duct obstruction, orbital inflammatory masses, subglottic stenosis, tracheobronchial disease, and end-stage renal disease. RECENT FINDINGS: Tissue damage caused by inflammation or a cicatricial process represents one of the major sources of morbidity for patients with Wegener's granulomatosis. Some of these manifestations require special interventions used alone or in combination with conventional medical treatment. These interventional procedures may include surgical or endoscopic repair of altered tissue, replacement of damaged organs, or the delivery of topical or injectable medications directly to the site of disease. Distinguishing symptoms caused by active disease from symptoms caused by tissue scarring is challenging and may play a critical role regarding the use of systemic immunosuppressive medications in combination with interventional therapy. SUMMARY: Interventional procedures are indicated in certain manifestations of Wegener's granulomatosis. Distinguishing active Wegener's granulomatosis from inactive Wegener's granulomatosis and recognizing disease manifestations that may be amenable to local interventions can greatly improve the quality of life of patients. However, the evidence supporting the use of many of these interventions is based on small case series or individual reports.

Effects of a clinical pathway for video-assisted thoracoscopic surgery (VATS) on quality and cost of care.

PURPOSE: The purpose of this study was to evaluate effects of a clinical pathway (CP) for video-assisted thoracoscopic surgery (VATS) on process quality, outcome quality, and hospital costs. MATERIALS AND METHODS: We implemented a CP for VATS and compared 34 patients treated with CP to 77 patients treated without CP. Indicators for process quality were duration of catheter placement, pain intensity, respiratory exercising, and mobilization. Outcome quality was measured through morbidity, mortality, reoperations, and readmissions. Cost of hospital stay was calculated using an imputed daily rate. RESULTS: Foley catheters were removed significantly earlier after CP implementation. All patients on CP were mobilized and received pulmonary exercising on the operation day. Pain levels were low after CP implementation. Median hospital stay significantly reduced by 5 days. Perioperative outcome quality remained unchanged. Costs significantly diminished by 1,510 Euro per stay. CONCLUSIONS: CP implementation had positive effects on process quality. Specifically, catheter management was improved and a good pain control achieved. Patients benefited from shortened stay and were treated at lower cost. A clear effect on outcome quality was not found. CPs are a promising tool for quality improvement and cost containment in thoracic surgery.