Fetal diagnosis and management of pulmonary artery sling: A case series.

OBJECTIVE: Pulmonary artery sling is a rare congenital anomaly accounting for 2% of all patients with vascular anomalies that cause airway obstruction. In the normal heart, the left (LPA) and right (RPA) pulmonary arteries arise in the intrapericardial space. However, in the pulmonary artery sling, the LPA trunk arises in the extrapericardial space from the posterior aspect of the mid RPA and courses posterior to the trachea causing tracheal compression and, at times, bronchial compression. While a full spectrum of congenital cardiac pathology can be identified before birth, only a few case reports document the prenatal diagnosis of an Left pulmonary artery sling (LPAS). METHOD: We retrospectively identified all cases of prenatal LPAS from three Canadian fetal cardiology centers (2015-2022). RESULTS: Using the 3-vessel-tracheal view via fetal echocardiography (FE), four fetuses from three pregnancies demonstrated abnormal origin of the LPA from RPA and echogenic trachea. In one of two affected monochorionic twins coronal imaging demonstrated a significant narrowing of the large airways consistent with significant airway obstruction. CONCLUSION: Prenatal detection of LPAS by FE is possible and should prompt an evaluation for airway obstruction in the coronal view. Investigating associated lesions and genetic testing are recommended for informed shared decision making.

Successful Postnatal Tracheobronchoplasty for Unilateral Congenital High Airway Obstruction Syndrome due to Mainstem Bronchial Atresia.

INTRODUCTION: Unilateral congenital high airway obstruction syndrome (CHAOS) is caused by a complete obstruction of a mainstem bronchus with resulting hyperinflation and accelerated growth of one lung, severe mediastinal shift, and hydrops. Spontaneous perforation of the atresia has been observed in CHAOS which allows hydrops to resolve but hyperinflation, mediastinal shift and a critical airway obstruction persists as the perforation is usually pinhole-sized. CASE PRESENTATION: We present a case of unilateral CHAOS presenting at 26 2/7 weeks with observed-to-expected total lung volume (O/E TLV) of 203% with spontaneous perforation occurring at 28 weeks with resolution of hydrops but persistence of hyperinflation and mediastinal shift with an O/E TLV of 60.5% on 34 5/7 weeks' magnetic resonance imaging (MRI), successfully managed in a 35 5/7 weeks, 1,670 gm, growth restricted baby, by venoarterial extracorporeal membrane oxygenation (VA ECMO) and resection of the tracheobronchial atresia and tracheobronchoplasty on day of life 5. The baby was separated from ECMO on post-op day 12, required tracheostomy for positive end expiratory pressure for tracheomalacia at 4 months. CONCLUSION: At 2 years of age, she has met all developmental milestones, has been weaned to room air tracheostomy collar, and has been anticipating tracheal decannulation. There is persistent bronchiectasis in the hyperinflated right lung but no malacia. This is the first reported survivor of mainstem bronchial atresia suggesting the importance of preservation of the hyperplastic lung and airway reconstruction to normal long-term outcome.

Non-brachycephalic dogs with stertor have higher nasopharyngeal collapsibility compared with dogs without stertor and foramen lacerum level is ideal for evaluating nasopharyngeal collapse on dynamic CT.

Stertor, a clinical sign associated with obstructive airway syndrome, is often observed in non-brachycephalic dogs. This prospective, case-control study aimed to compare soft palate dimensions, nasopharyngeal cross-sectional area (CSA), and nasopharyngeal collapsibility at various locations in non-brachycephalic dogs with and without stertor. A total of 50 dogs were recruited and stratified into control (n = 34) and stertor (n = 13) groups. Static and dynamic computed tomography was conducted without tracheal intubation, and the following variables were calculated: normalized soft palate length and thickness, normalized maximum and minimum nasopharyngeal CSAs (rCSAmax and rCSAmin), and nasopharyngeal collapsibility at the level of the cranial end of the soft palate, pterygoid hamulus, foramen lacerum, bony labyrinth, and caudal end of the soft palate. The stertor group demonstrated significantly lower rCSAmax and rCSAmin, as well as higher nasopharyngeal collapsibility compared with the control group, while no significant differences were noted in the soft palate dimension. Evaluating nasopharyngeal collapse at the foramen lacerum level was recommended due to the clear presence of identifiable bony landmarks and lower overlap in the nasopharyngeal collapsibility between dogs with and without stertor. Physical dimensions of the soft palate may not be the primary contributing factor to nasopharyngeal collapse and clinical signs in non-brachycephalic dogs.

Long-range optical coherence tomography of pediatric airway during drug induced sleep endoscopy: A preliminary report.

OBJECTIVE: Drug induced sleep endoscopy (DISE) is often performed for pediatric obstructive sleep apnea (OSA) when initial diagnostic studies do not provide adequate information for therapy. However, DISE scoring is subjective and with limitations. This proof-of-concept study demonstrates the use of a novel long-range optical coherence tomography (LR-OCT) system during DISE of two pediatric patients. METHODS: LR-OCT was used to visualize the airway of pediatric patients during DISE. At the conclusion of DISE, the OCT probe was guided in the airway under endoscopic visual guidance, and cross-sectional images were acquired at the four VOTE locations. Data processing involved image resizing and alignment, followed by rendering of three-dimensional (3D) volumetric models of the airways. RESULTS: Two patients were included in this study. Patient one had 18.4%, 20.9%, 72.3%, and 97.3% maximal obstruction at velum, oropharynx, tongue base, and epiglottis, while patient two had 40.2%, 41.4%, 8.0%, and 17.5% maximal obstruction at these regions, respectively. Three-dimensional reconstructions of patients' airways were also constructed from the OCT images. CONCLUSION: This proof-of-concept study demonstrates the successful evaluation of pediatric airway during DISE using LR-OCT, which accurately identified sites and degrees of obstruction with respective 3D airway reconstruction.

Structural and functional features of asthma participants with fixed airway obstruction using CT imaging and 1D computational fluid dynamics: A feasibility study.

Asthma with fixed airway obstruction (FAO) is associated with significant morbidity and rapid decline in lung function, making its treatment challenging. Quantitative computed tomography (QCT) along with data postprocessing is a useful tool to obtain detailed information on airway structure, parenchymal function, and computational flow features. In this study, we aim to identify the structural and functional differences between asthma with and without FAO. The FAO group was defined by a ratio of forced expiratory volume in 1 s (FEV1 ) to forced vital capacity (FVC), FEV1 /FVC <0.7. Accordingly, we obtained two sets of QCT images at inspiration and expiration of asthma subjects without (N = 24) and with FAO (N = 12). Structural and functional QCT-derived airway variables were extracted, including normalized hydraulic diameter, normalized airway wall thickness, functional small airway disease, and emphysema percentage. A one-dimensional (1D) computational fluid dynamics (CFD) model considering airway deformation was used to compare the pressure distribution between the two groups. The computational pressures showed strong correlations with the pulmonary function test (PFT)-based metrics. In conclusion, asthma participants with FAO had worse lung functions and higher-pressure drops than those without FAO.

Imaging studies in evaluating children with stridor. / Los estudios por imágenes en la evaluación del niño con estridor.

Stridor is a symptom of upper airway obstruction and may result from congenital or acquired causes. The diagnosis is usually clinical. If further investigation is necessary for differential diagnosis, endoscopy is the method of choice in most cases. Imaging studies are complementary to endoscopy. They allow evaluation of laryngeal and tracheobronchial pathology and extrinsic airway compressions due to tumors or vascular malformations and define a lesion's location, extent, and characteristics. They are helpful in cases of diagnostic doubt and when endoscopy is unavailable. It is essential to understand the anatomy and pathophysiology of the respiratory tract and to be aware of the indications and limitations of complementary examinations for proper diagnosis. The different imaging modalities available to evaluate stridor in pediatrics are described, and their advantages are discussed.

El estridor es un síntoma de obstrucción de la vía aérea superior y puede ser resultado de causas congénitas o adquiridas. El diagnóstico suele ser clínico. Si es necesaria una investigación adicional para el diagnóstico diferencial, la endoscopia es el método de elección en la mayoría de los casos. Los estudios por imágenes son complementarios a la endoscopia. Permiten evaluar la patología laríngea y traqueobronquial, las compresiones extrínsecas de la vía aérea por tumores o malformaciones vasculares y definir la localización, extensión y características de una lesión. Son útiles en casos de duda diagnóstica y cuando la endoscopia no está disponible. Es fundamental comprender la anatomía y fisiopatología del tracto respiratorio, y ser conscientes de las indicaciones y limitaciones de los exámenes complementarios para el diagnóstico adecuado. Se describen las diferentes modalidades de imágenes disponibles para evaluar el estridor en pediatría y se discuten sus ventajas.

The Assessment of Airway Compression Due to Cervical Fusion in Klippel-Feil Syndrome Patients: A Report of Two Cases.

In general anesthesia for Klippel-Feil syndrome (KFS) patients, there is a potential risk of difficult intubation. However, airway assessment to predict difficult intubation for KFS patients is not known. In Patient 1, cervical spine computed tomography (CT) revealed airway compression due to cervical fusion. For airway assessment, bronchofiberscopy, three-dimensional (3-D) CT, and virtual bronchoscopic image (VBI) construction were performed. Based on these images, fiberoptic nasotracheal awake intubation was performed. In Patient 2, magnetic resonance imaging and bronchofiberscopy showed no airway compression due to cervical fusion; therefore, tracheal intubation was performed using a video laryngoscope after anesthetic administration. Airway compression due to cervical fusion is considered one of the risk factors for difficult intubation in KFS patients.

Association Between Soft Tissue Measures From Computed Tomography and Upper Airway Collapsibility on Drug-Induced Sleep Endoscopy.

OBJECTIVE: Positive airway pressure (PAP) titration during drug-induced sleep endoscopy (DISE) provides objective measures of upper airway collapsibility. While skeletal measurements relate to collapsibility measures on DISE, the influence of soft tissue dimensions on upper airway collapsibility is not known. We analyzed the relationship of measures of upper airway soft tissue volumes, specifically soft palate, pharyngeal lateral walls, and tongue, with metrics of collapsibility. STUDY DESIGN: Cross-sectional analysis from a prospective cohort. SETTING: Academic medical center. METHODS: Patients seeking PAP alternative therapies for obstructive sleep apnea (OSA) underwent standardized supine computed tomography (CT) acquisition and DISE protocols. The CT analysis primarily focused on soft tissue volumes and, secondarily, on airway and skeletal volumetric measures. DISE with PAP administration (DISE-PAP) enabled the determination of the pressure at which inspiratory airflow first commenced (pharyngeal critical pressure, PcritA) and the pressure at which inspiratory flow limitation was abolished (pharyngeal opening pressure, PhOP). Both unadjusted and adjusted correlation analyses were performed to understand the relationship between upper airway anatomy and either PcritA or PhOP. RESULTS: One hundred thirty-nine subjects completed both CT and DISE-PAP. On average, patients were male (70.5%), white (84.2%), middle-aged (56.6 ± 13.5 years), and overweight (29.6 ± 4.7 kg/m2), with moderate-severe apnea-hypopnea index (29.7 ± 21.3 events/h). Adjusted for age, sex, body mass index, and skeletal volumes, soft palate, and lateral pharyngeal wall volumes were not associated with PhOP or PcritA, but a larger tongue was associated with more positive PhOP (⍴ = 0.20, P = .02), and more positive PcritA (⍴ = 0.16, P = .07). Exploratory analyses revealed smaller minimum cross-sectional retropalatal area and intramandibular volume were also associated with increased collapsibility measures. CONCLUSION: After controlling for clinical factors and skeletal volume, greater tongue volume was associated with more severe collapsibility during DISE. These results, in concert with previous work, suggest that greater tongue volume in a smaller skeletal dimensions contribute to the severity of airway collapsibility, a key driver of OSA pathogenesis.

Retrospective evaluation of radiofrequency volumetric tissue reduction for hypertrophic turbinates in dogs with brachycephalic obstructive airway syndrome.

OBJECTIVE: The objective of this study was to retrospectively assess the effect of Radiofrequency Volumetric Tissue Reduction (RFVTR) on hypertrophic turbinates and clinical outcome in brachycephalic dogs when included in multi-level surgery (MLS). STUDY DESIGN: Clinical retrospective multicenter study. ANIMALS: 132 client-owned brachycephalic dogs. METHODS: 132 brachycephalic dogs with high-grade Brachycephalic Obstructive Airway Ayndrome (BOAS) and hypertrophic turbinates were treated with RFVTR as part of MLS of the upper airways. Intranasal obstruction was evaluated by computer tomography (CT) and antero-/retrograde rhinoscopy before and 6 months after RFVTR. The clinical records, the CT images and the rhinoscopy videos were reviewed and clinical evolution was evaluated using a standardized questionnaire. The data was scored semi-quantitatively. RESULTS: In this study, 132 patients were included for a follow-up period of 120 weeks. RFVTR resulted in minor complications, including serous nasal discharge within the first postoperative week in all dogs, and intermittent nasal congestion between 3-8 weeks after treatment in 24.3% of the patients. Rhinoscopy and CT follow-ups were available for 33 patients. Six months after treatment intranasal airspace was increased (p = 0.002) and the presence and overall amount of mucosal contact points was reduced (p = 0.039). CONCLUSION: MLS with RFVTR led to a significant reduction in turbinate volume at the 6-month follow-up examination and significant clinical improvement over a long-term period of 120 weeks. This suggests the viability of RFVTR as a turbinate-preserving treatment for intranasal obstruction in dogs with BOAS. CLINICAL SIGNIFICANCE: RFVTR is a minimally invasive turbinoplasty technique for intranasal obstruction in dogs with BOAS and can be included in MLS without increasing complication rates.

Large congenital cervical mass in a neonate: prenatal diagnosis and postnatal management of teratoma: a case report.

INTRODUCTION: Cervical teratomas are rare congenital neoplasms that can cause neonatal airway obstruction if large. CASE PRESENTATION: The female Persian neonate displayed respiratory distress at birth, with a 7 cm × 8 cm cystic solid mass identified on the left side of the neck. Antenatal ultrasonography revealed polyhydramnios. Despite initial stabilization, the infant required intubation and mechanical ventilation due to persistent respiratory distress. Imaging confirmed a cystic mass compressing the trachea, ruling out cystic hygroma. Surgical resection on postnatal day 17 revealed a 10 cm × 10 cm solid cystic structure, histologically identified as an immature teratoma. CONCLUSION: Despite risks of poor fetal and postnatal outcome from large cervical teratomas, early surgical resection after airway stabilization can result in recovery. Proper multidisciplinary management of respiratory distress from such tumors is paramount.

Carotid Artery Aneurysm-Induced Mediastinal Hematoma Leading to Airway Compression-A Rare Complication of Internal Jugular Vein Puncture.

Carotid artery puncture is a common complication of internal jugular vein (IJV) catheterization. However, there are few reports about an aneurysm from the carotid artery that can develop into an occult mediastinal hematoma, leading to airway compression. In this case study, we present the case of a 71-year-old male who experienced an aneurysm and delayed mediastinal hematoma, ultimately resulting in airway compression after right jugular line insertion. Our findings highlight the importance of not only addressing local hematoma formation at the puncture site promptly, but also recognizing the potential for aneurysm extension into the mediastinum and the formation of an occult hematoma, which can lead to airway compression. Additionally, we provide a summary of landmark technique precautions that can help reduce the occurrence of such severe complications.

Epidemiology and Survival of Malignant Central Airway Obstruction in Lung Cancer Identified on Cross-Sectional Imaging.

BACKGROUND: The prevalence of malignant central airway obstruction at diagnosis and its 5-year incidence are largely unknown, as are basic epidemiological data pertaining to this serious condition. To address these data limitations, we retrospectively collected data from the cohort of patients diagnosed with lung cancer at our institution in 2015 and followed cohort patients 5 years forward, until 2020. METHODS: We reviewed index PET/CT or CT scans at the time of lung cancer diagnosis to identify the presence, subtype, and severity of malignant central airway obstruction as well as progression/development over the next 5 years. RESULTS: The prevalence of malignant central airway obstruction affecting the airway lumen by 25% or greater was 17%, and its 5-year incidence of development was 8.2%. Notable associations from the multivariate analysis included a younger age and a stepwise increase in obstruction with increasing stage of disease. Squamous cell carcinoma and small-cell lung cancer were the 2 histologic subtypes with the strongest association with obstruction. The presence of malignant central airway obstruction either at time of diagnosis or on follow-up imaging was associated with significantly shortened survival (multivariate Cox proportional HR for MCAO=1.702, P<0.001). CONCLUSION: This study provides the first systematic characterization of fundamental epidemiological data on malignant central airway obstructions at a tertiary cancer center in the United States. This data is important to inform research directions and funding efforts of this serious complication. It also serves as a baseline value against which to compare for future studies.

Clinical presentation, radiographic findings, and treatment outcomes in children with adenoid hypertrophy in a paediatric outpatient clinic in Enugu, Nigeria.

Objectives: To determine the clinical presentation, imaging features and outcomes of children with adenoid hypertrophy in our setting. Design: A retrospective study. Setting: The paediatric clinic of a private hospital in Enugu. Participants: 51 children, aged 2 to 108 months, with suggestive clinical features and radiographic report of adenoid hypertrophy who presented over 3 years. Interventions: Clinical information was obtained from the patient's medical records. Data was analysed for the clinical characteristics of the patients, the relationship between the degree of airway narrowing on a postnasal space (PNS) radiograph and treatment outcomes. Main outcome measures: Degree of airway narrowing as measured on a PNS radiograph, the type of and outcomes of treatment. Results: There was an almost equal male (54.7%): female (45.1%) ratio in the occurrence of adenoid hypertrophy, with a mean age of occurrence of 31.50 ± 3.64 months. Noisy breathing was the commonest symptom (94.1%); history of atopic rhinitis in 64.7% of cases and hyperactive airway disease in 45.1% more than 50% of cases with airway narrowing resolved with medical management only. Conclusion: Adenoid hypertrophy should be considered in evaluating the upper airway in children under five. Paediatricians should be conversant with diagnosing and managing this common cause of upper airway obstruction. Funding: None declared.

Diagnóstico tardío de cuerpos extraños en vía aérea en pediatría en el ospital de Especialidades Carlos Andrade Marín / Late diagnosis of foreign bodies in pediatric airway in the Carlos Andrade Marín Specialties Hospital

La aspiración de cuerpos extraños es una de las principales causas de ingreso a urgencias y de morbi-mortalidad en Ecuador en pacientes pediátricos. El diagnóstico suele ser tardío, por falta de interés de los cuidadores, o por errores en la valoración. Es importante detectar el cuadro a tiempo, para evitar complicaciones. OBJETIVO. Demostrar la necesidad de un diagnóstico acertado ante la alta sospecha en un cuadro dudoso de aspiración de cuerpo extraño. SERIE DE CASOS. Evaluación de cuatro pacientes de ambos sexos, de entre 11 meses a 15 años de edad con antecedente de ingesta de cuerpo extraño, atendidos en la Unidad Técnica de Cirugía Pediátrica, del Hospital de Especialidades Carlos Andrade Marín, durante el periodo 2019-2020. Se realizó la extracción exitosa mediante broncoscopia rígida en tres de ellos. DISCUSIÓN. La mayoría de pacientes con aspiración de cuerpo extraño suelen ser menores de 5 años de edad, en contraste con éste estudio, donde sólo un paciente estuvo dentro de este rango, y el resto fueron escolares y adolescentes. El cuerpo extraño más común es de origen orgánico; el 50% de los casos observados fue de origen inorgánico. CONCLUSIÓN. El diagnóstico de aspiración de cuerpo extraño se condiciona a la obtención completa de datos sobre la Historia Clínica; requiere una valoración rápida y manejo adecuado por emergencias.

INTRODUCTION. Foreign body aspiration is one of the main causes of emergency room admissions and morbidity and mortality in pediatric patients in Ecuador. Diagnosis is usually late, due to lack of interest of caregivers, or due to errors in the assessment. It is important to detect the condition in time to avoid complications. OBJECTIVE. To demonstrate the need for an accurate diagnosis in the presence of high suspicion in a doubtful picture of foreign body aspiration. CASE SERIES. Evaluation of four patients of both sexes, between 11 months and 15 years of age with a history of foreign body ingestion, attended at the Pediatric Surgery Technical Unit of the Carlos Andrade Marin Specialties Hospital, during 2019-2020 period. Successful extraction by rigid bronchoscopy was performed in three of them. DISCUSSION. Most patients with foreign body aspiration are usually under 5 years of age, in contrast to this study, where only one patient was within this range, and the rest were schoolchildren and adolescents. The most common foreign body is of organic origin; 50% of the cases observed were of inorganic origin. CONCLUSION. The diagnosis of foreign body aspiration is conditioned to the complete collection of data on the Clinical History; it requires a rapid assessment and appropriate emergency management.

LwPTL: a novel classification for upper airway collapse in sleep endoscopies / LwPTL: uma nova classificação para o colapso das vias aéreas superiores em endoscopias do sono

Abstract Introduction: There is no consensus on a single classification system for the obstructive findings in drug-induced sleep endoscopy. Previous classification systems have neglected to address the upper retropalatal obstruction, the segmental division of the lateral pharyngeal wall and the primary or secondary nature of laryngeal collapse. Objective: To propose, illustrate and evaluate a more comprehensive and yet simple classification for drug-induced sleep endoscopy findings. Methods: Cross sectional study in a tertiary sleep surgery unit. A total of 30 patients with obstructive sleep apnea underwent drug-induced sleep endoscopy according to a new classification system called LwPTL, and its findings were analyzed according to obstructive sleep apnea severity and body mass index. LwPTL incorporates the description of upper retropalatal collapse, distinguishes the lateral pharyngeal wall collapse into three levels and clarify when laryngeal collapses are primary or secondary. Results: 93.3% of the patients presented lateral pharyngeal wall collapse, usually at the level of the velum (73.3%). 80% presented multilevel collapse. Regarding the upper retropalatal region, LwPTL identified 10% of the cases presenting lateral salpingopharyngeal obstruction and 6.6% with high palatal collapse. 3.3% presented epiglottic collapse. Patients presenting lower levels of collapse, either from the lateral wall and/or tongue and/or larynx, represented 30% of the cases and had significantly more severe obstructive sleep apnea, without significant differences in body mass indexes. Conclusion: LwPTL seems a simple and straightforward staging system for classifying drug-induced sleep endoscopy, distinguishing the important upper retopalatal obstruction and the primary and secondary laryngeal collapses, providing more information for appropriate treatment selection.

Resumo Introdução: Não há consenso sobre um sistema único de classificação para os achados obstrutivos da endoscopia do sono induzido por drogas. Os sistemas de classificação anteriores negligenciaram a abordagem da obstrução retropalatal alta, a divisão segmentar da parede lateral da faringe e a natureza primária ou secundária do colapso laríngeo. Objetivo: Propor, ilustrar e avaliar uma classificação mais abrangente e simples para os achados da endoscopia do sono induzido por drogas. Método: Estudo transversal em uma unidade terciária de cirurgia do sono. Foram submetidos à endoscopia do sono induzido por drogas 30 pacientes com apneia obstrutiva do sono, de acordo com um novo sistema de classificação denominado LwPTL, e seus achados foram analisados de acordo com a gravidade da apneia obstrutiva do sono e índice de massa corpórea. O LwPTL incorpora a descrição do colapso retropalatal alto, distingue o colapso da parede faríngea lateral em três níveis e esclarece quando os colapsos laríngeos são primários ou secundários. Resultados: Apresentaram colapso da parede faríngea lateral 93,3% dos pacientes, geralmente no nível do palato mole (73,3%). Em 80% dos pacientes o colapso foi multinível. Em relação à região retropalatal alta, o LwPTL identificou 10% dos casos com obstrução salpingo-faríngea lateral e 6,6% com colapso alto do palato. Em 3,3% ocorreu colapso epiglótico. Pacientes com colapso em regiões baixas, tanto da parede lateral e/ou língua como e/ou laringe, representaram 30% dos casos e apresentaram apneia obstrutiva do sono significativamente mais grave, sem diferenças significantes no índice de massa corpórea. Conclusão: O LwPTL parece um sistema de estadiamento simples e direto para classificar os achados da endoscopia do sono induzido por drogas, distingue a importante obstrução retropalatal alta e os colapsos laríngeos primários e secundários, fornece mais informações para uma seleção adequada do tratamento.