Transdiaphragmatic intercostal hernia: imaging aspects in three cases.

Transdiaphragmatic intercostal hernia is uncommon and mostly related to blunt or penetrating trauma. We report three similar cases of cough-induced transdiaphragmatic intercostal hernia, highlighting the anatomic findings obtained with different imaging modalities (radiography, ultrasonography, CT, and magnetic resonance) in each of the cases.

Transdiaphragmatic intercostal hernia: imaging aspects in three cases / Hernia intercostal transdiafragmatica: aspectos de imagem em tres casos

Transdiaphragmatic intercostal hernia is uncommon and mostly related to blunt or penetrating trauma. We report three similar cases of cough-induced transdiaphragmatic intercostal hernia, highlighting the anatomic findings obtained with different imaging modalities (radiography, ultrasonography, CT, and magnetic resonance) in each of the cases.

Hérnias intercostais transdiafragmáticas são eventos raros e são geralmente relacionadas a traumas abertos ou fechados, com risco de complicações. Relatamos três casos semelhantes, decorrentes de crises de tosse, destacando o aspecto das alterações anatômicas nos exames de imagem obtidos em cada situação (radiografia, ultrassonografia, TC e ressonância magnética).

Estudo das pressões no interior dos balonetes de tubos traqueais / Study of tracheal tube intra-cuff pressure

JUSTIFICATIVA E OBJETIVOS: Como não é rotineiro o controle da pressão no interior dos balonetes de tubos traqueais, e não há descrição detalhada na literatura de como mantê-la abaixo dos 30 cmH2O sem utilização de manômetro, decidiu-se verificar as pressões no interior de balonetes de tubos traqueais em pacientes sob intubação traqueal na unidade de terapia intensiva e no cento cirúrgico, testando manobra para manter a pressão no balonete abaixo de 30 cmH2O, mas em níveis mínimos necessários para ciclagem do ventilador sem perda do volume corrente. MÉTODO: Foram estudadas as pressões no interior de balonetes de tubos traqueais de 50 pacientes sob intubação traqueal na unidade de terapia intensiva (Grupo I) e 72 pacientes sob intubação traqueal no centro cirúrgico (Grupo II). Testou-se uma manobra para obter a pressão mínima no interior do balonete do tubo traqueal, necessária para adequada ventilação, sem vazamento de ar. Registrou-se a pressão inicial (P1) no interior dos balonetes dos tubos traqueais utilizando-se manômetro digital graduado em centímetros de água, acoplado a seringa de 15 ml. Aspirou-se secreção da orofaringe. Com o meato acústico externo do examinador próximo da boca do paciente entre 10 e 20 cm, conectou-se o manômetro ao balonete, que foi esvaziado lentamente, até se ouvir ruído em sopro, pelo vazamento do volume corrente no período inspiratório da ventilação artificial. Neste momento, encheu-se lentamente o balonete até o desaparecimento do ruído. Anotou-se a pressão final (P2) do balonete e o volume de ar que restou na seringa do manômetro (V). RESULTADOS: As médias das pressões P1 nos grupos I e II foram 85,3 e 56,2 cmH2O, respectivamente. As médias de pressões P2 nos grupos I e II foram 26,7 e 15,5 cmH2O respectivamente...

BACKGROUND AND OBJECTIVES: Since controlling tracheal tube cuffs internal pressure is unusual and there is no detailed description in the literature on how to maintain it below 30 cmH2O without manometer, this study aimed at checking tracheal tube intra-cuff pressures in intensive care unit and operating room patients. A maneuver was tested to keep intra-cuff pressure below 30 cmH2O, but at minimum levels needed for ventilator cycling with no tidal volume leakage. METHODS: Tracheal tube intra-cuff pressures were evaluated in 50 intensive care unit intubated patients (Group I) and 72 intubated patients in the operating room (Group II). A maneuver was tested to obtain the minimum tracheal tube intra-cuff pressure to maintain adequate ventilation with no air leakage. Initial tracheal tube intra-cuff pressure (P1) was recorded using a gaged digital manometer (cmH2O) coupled to a 15-ml syringe. Oropharynx secretion was aspirated. With the investigator’s external acoustic meatus positioned 10-20 cm apart from patient’s mouth and cuff connected to the manometer, cuff was slowly deflated until a murmur sound was heard, determined by tidal volume leakage during the inspiratory period of artificial ventilation. At this moment, cuff was slowly inflated until murmur disappearance. Final intra-cuff pressure (P2) and the remaining air volume in the manometer syringe (V) were recorded. RESULTS: Mean P1 values in groups I and II were 85.3 and 56.2 cmH2O, respectively. Mean P2 values in groups I and II were 26.7 and 15.5 cmH2O, respectively...

JUSTIFICATIVA Y OBJETIVOS: Como no es de rutina el control de la presión en el interior de los balones de tubos traquéales, y como también no hay descripción detallada en la literatura de como mantenerla abajo de los 30 cmH2O sin utilización de manómetro, se decidió confirmar las presiones en el interior de los balones de tubos traquéales en pacientes bajo intubación traqueal en la unidad de terapia intensiva y en el centro quirúrgico, ensayando maniobras para mantener la presión en el balón abajo de 30 cmH2O, más en niveles mínimos necesarios para el ciclo del ventilador sin pérdida del volumen corriente. MÉTODO: Se estudiaron las presiones en el interior de balones de tubos traquéales de 50 pacientes bajo intubación traqueal en la unidad de terapia intensiva (Grupo I) y 72 pacientes bajo intubación traqueal en el centro quirúrgico (Grupo II). Se experimentó una maniobra para obtener la presión mínima en el interior del balón del tubo traqueal, necesaria para una adecuada ventilación, sin vaciamiento de aire. Se registró la presión inicial (P1) en el interior de los balones de los tubos traquéales utilizándose un manómetro digital graduado en centímetros de agua, acoplado a una jeringa de 15 ml. Fue aspirada secreción de la orofaringe. Con el meato acústico externo del examinador próximo de la boca del paciente entre 10 y 20 cm, se conectó el manómetro al balón, que fue vaciado lentamente, hasta escucharse ruido en soplo, por el vaciamiento del volumen corriente en el período inspiratorio de la ventilación artificial. En este momento, se llenó lentamente el balón hasta el desaparecimiento del ruido. Se anotó la presión final (P2) del balón y el volumen de aire que quedó en la jeringa del manómetro (V). RESULTADOS: Las medias de las presiones P1 en los grupos I y II fueron 85,3 y 56,2 cmH2O, respectivamente...

[Study of tracheal tube intra-cuff pressure.]. / Estudo das pressões no interior dos balonetes de tubos traqueais.

BACKGROUND AND OBJECTIVES: Since controlling tracheal tube cuffs internal pressure is unusual and there is no detailed description in the literature on how to maintain it below 30 cmH2O without manometer, this study aimed at checking tracheal tube intra-cuff pressures in intensive care unit and operating room patients. A maneuver was tested to keep intra-cuff pressure below 30 cmH2O, but at minimum levels needed for ventilator cycling with no tidal volume leakage. METHODS: Tracheal tube intra-cuff pressures were evaluated in 50 intensive care unit intubated patients (Group I) and 72 intubated patients in the operating room (Group II). A maneuver was tested to obtain the minimum tracheal tube intra-cuff pressure to maintain adequate ventilation with no air leakage. Initial tracheal tube intra-cuff pressure (P1) was recorded using a gaged digital manometer (cmH2O) coupled to a 15-ml syringe. Oropharynx secretion was aspirated. With the investigators external acoustic meatus positioned 10-20 cm apart from patients mouth and cuff connected to the manometer, cuff was slowly deflated until a murmur sound was heard, determined by tidal volume leakage during the inspiratory period of artificial ventilation. At this moment, cuff was slowly inflated until murmur disappearance. Final intra-cuff pressure (P2) and the remaining air volume in the manometer syringe (V) were recorded. RESULTS: Mean P1 values in groups I and II were 85.3 and 56.2 cmH2O, respectively. Mean P2 values in groups I and II were 26.7 and 15.5 cmH2O, respectively. After the maneuver, standard deviation decreased from 56.3 to 8.2 in group I, and from 48 to 6.7 in group II. Maneuver has decreased cuff volume and pressure in 100% of group I patients, and in 97.3% of group II patients. CONCLUSIONS: Both groups had intra-cuff pressures higher than necessary to keep ventilator cycling with no tidal volume leakage. Maneuver to keep intra-cuff pressure below 30 cmH2O was simple and cheap.