Guía de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) para el manejo de la vía aérea difícil. Parte I / Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

La sección de Vía Aérea de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) presentan la Guía para el manejo integral de la vía aérea difícil en el paciente adulto. Sus principios están focalizados en el factor humano, los procesos cognitivos para la toma de decisiones en situaciones críticas y la optimización en la progresión de la aplicación de estrategias para preservar una adecuada oxigenación alveolar con el objeto de mejorar la seguridad y la calidad asistencial. El documento proporciona recomendaciones basadas en la evidencia científica actual, herramientas teórico/educativas y herramientas de implementación, fundamentalmente ayudas cognitivas, aplicables al tratamiento de la vía aérea en el campo de la anestesiología, cuidados críticos, urgencias y medicina prehospitalaria. Para ello se realizó una amplia búsqueda bibliográfica según las directrices PRISMA-R y se analizó utilizando la metodología GRADE. Las recomendaciones se formularon de acuerdo con esta metodología. Las recomendaciones de aquellas secciones con evidencia de baja calidad se basaron en la opinión de expertos mediante consenso alcanzado a través de un cuestionario Delphi.(AU)

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.(AU)

Guía de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) para el manejo de la vía aérea difícil. Parte II / Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

La sección de Vía Aérea de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) presentan la Guía para el manejo integral de la vía aérea difícil en el paciente adulto. Sus principios están focalizados en el factor humano, los procesos cognitivos para la toma de decisiones en situaciones críticas y la optimización en la progresión de la aplicación de estrategias para preservar una adecuada oxigenación alveolar con el objeto de mejorar la seguridad y la calidad asistencial. El documento proporciona recomendaciones basadas en la evidencia científica actual, herramientas teórico/educativas y herramientas de implementación, fundamentalmente ayudas cognitivas, aplicables al tratamiento de la vía aérea en el campo de la anestesiología, cuidados críticos, urgencias y medicina prehospitalaria. Para ello se realizó una amplia búsqueda bibliográfica según las directrices PRISMA-R y se analizó utilizando la metodología GRADE. Las recomendaciones se formularon de acuerdo con esta metodología. Las recomendaciones de aquellas secciones con evidencia de baja calidad se basaron en la opinión de expertos mediante consenso alcanzado a través de un cuestionario Delphi.(AU)

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.(AU)

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management.

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II.

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Extubation failure: Upper airway obstruction by chewing gum. A case report.

Extubation failure can result from different complications, mostly well described in the literature such as laryngeal edema. Airway obstruction by foreign bodies is a less frequent and unexpected complication and its detection remains a challenge to healthcare professionals. In this case-report, we describe a patient admitted in an intensive care unit following a motor vehicle accident and who underwent an extubation failure and tracheostomy placement due to a misdiagnosed obstruction of a foreign body in the upper airway. Thus, screening of foreign bodies should be considered with a careful interpretation of medical imagery and clinical evaluation in these patients. Finally, cuff leak test, ultrasonography and videolaryngoscopy can be important adjuvants to the identification of suspected foreign bodies.

Parálisis bilateral de las cuerdas vocales con obstrucción aguda de la vía aérea y traqueotomía urgente en una paciente con ictus vertebrobasilar agudo / Bilateral vocal cord paralysis with acute airway obstruction and urgent tracheotomy in a patient with an acute vertebrobasilar stroke

Introducción El ictus vertebrobasilar puede suponer un reto diagnóstico. La parálisis bilateral de las cuerdas vocales como manifestación de ictus agudo es muy rara, pero potencialmente mortal, por la posibilidad de obstrucción aguda de la vía aérea. No hay casos descritos de parálisis bilateral de las cuerdas vocales como presentación de ictus agudo de etiología neurológica mixta central y periférica. Caso clínico Mujer de 88 años con disfonía secuelar a parálisis de la cuerda vocal derecha postiroidectomía que presentó un cuadro brusco de vértigo, dismetría y disartria leve (National Institutes of Health Stroke Scale: 2) asociado a hipertensión arterial. La tomografía computarizada cerebral urgente demostró trombosis distal oclusiva de la arteria vertebral izquierda sin isquemia establecida. Por mejoría sintomática con control tensional, no se realizó terapia de revascularización. Cuatro horas después, la paciente desarrolló de forma brusca estridor inspiratorio e insuficiencia respiratoria grave por parálisis bilateral de las cuerdas vocales con obstrucción completa de la vía aérea. Se realizó una traqueotomía urgente con mejoría respiratoria. Una tomografía computarizada cerebral de control a las 24 horas mostró un infarto establecido en el hemicerebelo izquierdo y la región bulbar lateral, congruente con territorio de la arteria cerebelosa posterior inferior izquierda. Conclusión Nuestro caso ilustra la posibilidad de la rara aparición de una parálisis bilateral aguda de las cuerdas vocales en el contexto de un ictus agudo junto con una afectación periférica crónica del nervio recurrente laríngeo. Aunque es excepcional, ejemplifica el potencial riesgo asociado a los ictus vertebrobasilares. Un tratamiento más agresivo de reperfusión podría ser adecuado en estos casos, pese a un déficit inicialmente leve, por la posibilidad de progresar a complicaciones vitales. (AU)

INTRODUCTION Vertebrobasilar stroke can be a diagnostic challenge. Bilateral vocal cord paralysis is very rare as a manifestation of acute stroke, yet it is potentially life-threatening because of the possibility of acute airway obstruction. No cases of bilateral vocal cord paralysis have been reported as a presenting symptom of acute stroke of mixed central and peripheral neurological aetiology. CASE REPORT An 88-year-old woman with dysphonia resulting from paralysis of the right vocal cord following a thyroidectomy presented with sudden onset of vertigo, dysmetria and mild dysarthria (National Institutes of Health Stroke Scale: 2) associated with arterial hypertension. An urgent brain computed tomography (CT) scan evidenced distal occlusive thrombosis of the left vertebral artery without established ischaemia. Due to the improvement of symptoms achieved with control of her blood pressure, revascularisation therapy was not performed. Four hours later, the patient suddenly developed inspiratory stridor and severe respiratory failure due to bilateral vocal cord paralysis with complete airway obstruction. An urgent tracheotomy was performed, which resulted in an improvement in her breathing. A control brain CT scan performed at 24 hours showed established infarction in the left hemicerebellum and lateral medullary region, consistent with the territory of the left posterior inferior cerebellar artery. CONCLUSION. Our case illustrates the possibility of the rare occurrence of acute bilateral vocal cord paralysis in the context of acute stroke in conjunction with chronic peripheral involvement of the recurrent laryngeal nerve. Although exceptional, it exemplifies the potential risk associated with vertebrobasilar strokes. A more aggressive reperfusion therapy may be appropriate in these cases, despite an initially mild deficit, because of the possibility of progression to life-threatening complications. (AU)

TC torácica en espiración. Cuándo la hago y cómo la interpreto / Expiratory CT scan: When to do it and how to interpret it

La TC torácica en espiración es una técnica complementaria de la inspiración que aporta valiosa información fisiológica y puede ser más sensible que las pruebas de función respiratoria para detectar atrapamiento aéreo. Tiene múltiples indicaciones, entre las más frecuentes están la enfermedad obstructiva de la vía aérea producida por bronquiolitis obliterante, asma, síndrome de Swyer-James, traqueomalacia, neumonitis por hipersensibilidad o sarcoidosis. En alguna de ellas, como la bronquiolitis obliterante, la TC espiratoria puede ser la única técnica de imagen que detecta alteraciones en las fases iniciales. Si queremos que sea de utilidad diagnóstica, hay que asegurarse de que el estudio tenga calidad suficiente. Para ello se recomienda explicar al paciente en qué consiste la prueba, emplear instrucciones precisas y realizar un breve entrenamiento antes de iniciar la adquisición. En este trabajo sugerimos estrategias para optimizar la técnica y proponemos un algoritmo para interpretar los hallazgos radiológicos en el contexto de la patología obstructiva pulmonar.(AU)

Expiratory CT scan is a complementary technique of inspiratory CT that provide valuable physiological information and may be more sensitive to detect air trapping than pulmonary function tests. It is useful in many obstructive airway diseases, including obliterative bronchiolitis, asthma, Swyer-James syndrome, tracheomalacia, hypersensitivity pneumonitis and sarcoidosis. In obliterative bronchiolitis, expiratory CT scan may be the only imaging technique that shows abnormalities in the early phase of disease. In order to obtain a good quality study, we should explain the procedure to the patient, use precise instructions and do some practice before image acquisition. Here we describe strategies to optimize the technique and propose an algorithm that help in interpretation of imaging findings in patients with obstructive airway disease.(AU)

Expiratory CT scan: When to do it and how to interpret it.

Expiratory CT scan is a complementary technique of inspiratory CT that provide valuable physiological information and may be more sensitive to detect air trapping than pul-monary function tests. It is useful in many obstructive airway diseases, including obliterative bronchiolitis, asthma, Swyer-James syndrome, tracheomalacia, hypersensitivity pneumonitis and sarcoidosis. In obliterative bronchiolitis, expiratory CT scan may be the only imaging technique that shows abnormalities in the early phase of disease. In order to obtain a good quality study, we should explain the procedure to the patient, use precise instructions and do some practice before image acquisition. Here we describe strategies to optimize the techni-que and propose an algorithm that help in interpretation of imaging findings in patients with obstructive airway disease.

Difficult airway in a patient with lymphoma. A case report.

A 86-year-old male patient, diagnosed with lymphoma, was scheduled for a submaxillectomy to choose his best chemotherapy treatment. He referred recent voice changes and laterocervical adenopathies without respiratory symptoms. There were no additional risk predictors in preoperative airway assessment. Following anaesthesic induction, an upper airway obstruction occurred. After that, an unexpected difficult airway was encountered. Both clinical situations resulted in unpredicted difficult airway management. Image tests seen after the procedure revealed a severe narrowing of parapharyngeal space due to Waldeyer's ring hypertrophy. This medical condition had remained unnoticed in preoperative assessment. Advanced lymphoproliferative syndromes cause disseminated adenopathies whose parapharyngeal involvement can lead to a difficult airway even in the absence of preoperative risk predictors.

Vía aérea difícil en paciente con linfoma. Descripción de un caso clínico / Difficult airway in a patient with lymphoma. A case report

Paciente varón de 86 años, diagnosticado de linfoma, programado para una submaxilectomía con objeto de elegir el régimen quimioterápico óptimo. En la valoración preanestésica destacaba la presencia de cambios recientes en la voz acompañados de adenopatías laterocervicales, sin síntomas respiratorios asociados. No se hallaron predictores de riesgo adicionales en la valoración preoperatoria de la vía aérea. Tras la inducción anestésica, se produjo una obstrucción completa de la vía aérea superior. Se realizó una primera laringoscopia en la que se objetivó una vía aérea difícil imprevista. Las pruebas de imagen consultadas tras la cirugía revelaron la existencia de un estrechamiento severo del espacio parafaríngeo secundario a la hipertrofia del anillo de Waldeyer. Esta condición clínica había pasado desapercibida en la valoración perioperatoria. Los síndromes linfoproliferativos en estadio avanzado cursan con adenopatías diseminadas cuya afectación parafaríngea puede ocasionar una vía aérea difícil, incluso en ausencia de factores de riesgo preoperatorios.(AU)

A 86-year-old male patient, diagnosed with lymphoma, was scheduled for a submaxillectomy to choose his best chemotherapy treatment. He referred recent voice changes and laterocervical adenopathies without respiratory symptoms. There were no additional risk predictors in preoperative airway assessment. Following anaesthesic induction, an upper airway obstruction occurred. After that, an unexpected difficult airway was encountered. Both clinical situations resulted in unpredicted difficult airway management. Image tests seen after the procedure revealed a severe narrowing of parapharyngeal space due to Waldeyer's ring hypertrophy. This medical condition had remained unnoticed in preoperative assessment. Advanced lymphoproliferative syndromes cause disseminated adenopathies whose parapharyngeal involvement can lead to a difficult airway even in the absence of preoperative risk predictors.(AU)

Manejo de vía aérea difícil en secuencia de Pierre Robin. Reporte de un caso / Difficult airway management in Pierre Robin Sequence. A case report

La secuencia de Pierre Robin (SPR) es una enfermedad rara, caracterizada por una tríada de malformaciones orofaciales como retrognatia, glosoptosis y fisura velopalatina media (paladar hendido); las cuales, generalmente provocan obstrucción de la vía aérea (OVA). La corrección de los defectos palatinos requiere en ocasiones varias intervenciones quirúrgicas, por esta razón el cuidado anestésico y abordaje de la vía aérea en forma adecuada, evita complica-ciones asociadas a esta enfermedad. Se presenta el caso de un paciente de 1 año y 20 días de edad, con antecedentes de vía aérea difícil, intentos fallidos de intubaciones preliminares e intervenido quirúrgicamente para corrección de paladar hendido, luego de una técnica combinada de intubación nasal con fibrobroncoscopio, desplazamiento de glosoptosis con ayuda de pala número 2 de videolaringoscopio (Glidescope®); manejo transoperatorio anestésico y proceso de extubación con excelentes resultados. Destacamos la importancia de realizar una adecuada planificación multidisciplinaria prequirúrgica con valoración exhaustiva de la vía aérea (VA) por laringoscopía directa o fibrobroncospia flexible para conocer el sitio exacto de la obstrucción y evitar desen-laces adversos.

Pierre Robin Sequence (PRS) is a rare disease characterized by a triad of orofacial malformations such as retrognathia, glossoptosis and velopalatine fissure (cleft palate). The malformations in PRS can lead into airway obstruction. The correction of the palatal defects sometimes requires several surgical interven-tions. Proper anesthetic care and a carefully planned approach to the airway can avoid complications associated with this disease. We present the case of a 1 year and 20 days old patient, with history of difficult airway, unsuccessful prior attempts of intubation, who underwent surgery to correct a cleft palate. We used a combined approach that included nasal intubation technique with a fiberoptic bronchoscope aided with a number 2 video laryngoscope blade (Gli-descope®) for displacement of the glossoptosys. Details of the intraoperative anesthetic management and subsequent successful extubation are provided. We highlight the importance of developing an adequate preoperative multidisciplinary plan of action, after a careful and detailed evaluation of the airway with direct laryngoscopy or fiberoptic bronchoscopy in order to identify the exact location of the obstruction and avoid adverse outcomes.

Difficult airway in a patient with lymphoma. A case report. / Vía aérea difícil en paciente con linfoma. Descripción de un caso clínico.

A 86-year-old male patient, diagnosed with lymphoma, was scheduled for a submaxillectomy to choose his best chemotherapy treatment. He referred recent voice changes and laterocervical adenopathies without respiratory symptoms. There were no additional risk predictors in preoperative airway assessment. Following anaesthesic induction, an upper airway obstruction occurred. After that, an unexpected difficult airway was encountered. Both clinical situations resulted in unpredicted difficult airway management. Image tests seen after the procedure revealed a severe narrowing of parapharyngeal space due to Waldeyer's ring hypertrophy. This medical condition had remained unnoticed in preoperative assessment. Advanced lymphoproliferative syndromes cause disseminated adenopathies whose parapharyngeal involvement can lead to a difficult airway even in the absence of preoperative risk predictors.

Edema agudo pulmonar Postextubación / Edema agudo pulmonar Postextubación

El edema pulmonar agudo posextubación constituye un evento poco frecuente en la práctica anestésica. Cuando ocurre es necesario administrar tratamiento adecuado, ya que las complicaciones del mismo pueden traducirse en mayor estancia hospitalaria y lesiones serias del aparato respiratorio, como edema pulmonar intersticial, elevación de la presión hidrostática capilar y aumento de la presión transmural de las cámaras cardiacas, lo que puede conducir a fallo del aparato cardiovascular y a la muerte subsecuente del paciente. Se presenta el caso de un paciente con clasificación del estado físico ASA (American Society of Anesthesiologist) II, sin patología pulmonar previa, quien al momento de la emersión anestésica presenta un episodio agudo de dificultad respiratoria, con evidencia de edema pulmonar posextubación confirmado por clínica e imágenes con ulterior resolución satisfactoria.

Post-extubation acute pulmonary edema is a rare event in anesthetic practice. When it occurs, it requires adequate treatment, since its complications may result in longer hospital stay and serious respiratory system lesions, such as interstitial pulmonary edema, increased capillary hydrostatic pressure and increased transmural pressure of the cardiac chambers, which may progress to cardiopulmonary arrest and death of the patient. We present the case of a patient who was classified with the (American Society of Anesthesiologist (ASA) II physical status, without a history of pulmonary disease, who upon emergence of general anesthesia developed an acute episode of respiratory distress, with evidence of post-extubation pulmonary edema confirmed by clinical and imaging findings with subsequent satisfactory resolution.

Insuficiencia respiratoria aguda como forma de debut de una anomalía congénita (doble arco aórtico) / Acute respiratory failure as a form of debut of a congenital anomaly (double aortic arch)

El doble arco aórtico es una anomalía vascular poco frecuente que provoca compresión traqueal y esofágica, habitualmente en losprimeros meses de vida. La estenosis traqueal asociada con el doble arco aórtico conlleva un alto riesgo de morbilidad, mortalidady reestenosis. Presentamos el caso de un paciente en que su anomalía no fue diagnosticada, y permaneció en silencio hasta la edad adulta cuando comenzó a padecer clínica compresiva. (AU)

The double aortic arch is a rare vascular anomaly that usually causes tracheal and esophageal compression in the first months oflife. Tracheal stenosis associated with double aortic arch carries a high risk of morbidity, mortality, and restenosis. We present thecase of a patient in whom his anomaly was not diagnosed, and he remained silent until adulthood when he began to suffer from compression symptoms. (AU)

Pólipo piloso nasofaríngeo en un recién nacido con obstrucción intermitente de la vía aérea. Presentación de un caso / Nasopharyngeal hairy polyp in a newborn with intermittent airway obstruction. Case report

Los pólipos pilosos nasofaríngeos son tumores benignos poco frecuentes. Se presenta el caso de esta patología en una paciente recién nacida, quien presentó cianosis y dificultad respiratoria por obstrucción de la vía aérea superior, durante las primeras 24 horas de vida. La paciente requirió maniobras de reanimación e intubación endotraqueal. Estudios diagnósticos confirmaron la presencia de una masa en la pared lateral de la faringe. Se realizó la extirpación quirúrgica exitosa con evolución satisfactoria de la paciente

Nasopharyngeal hairy polyps are rare benign tumors. We present a newborn case with a hairy polyp mass causing cyanosis and respiratory distress due to obstruction of the upper airway during the first 24 hours of life. The patient required resuscitation and endotracheal intubation. Diagnostic studies confirmed the presence of a mass in the lateral pharyngeal wall. Surgical treatment and removal of the mass was performed with satisfactory evolution of the patient

Reactivity Study of a Biodegradable Polydioxanone Tracheal Stent in a Rabbit Model. / Stent traqueal biodegradable de polidioxanona. Estudio de la reactividad en conejo.

INTRODUCTION: The objective of this study was to evaluate tracheal reactivity induced by a biodegradable polydioxanone tracheal stent. MATERIALS AND METHODS: Twenty-two rabbits were divided into 3 groups assigned to different survival times (30, 60 and 90days post-implantation). A biodegradable stent was implanted in each animal, except for 1 of each group (negative control). Implantation was performed through a small tracheotomy under fluoroscopic control. CT and histopathological studies were scheduled at the end of survival times. RESULTS: No animal died during the procedure or follow-up. The stent had disappeared in 100% of the cases at 90days, in 50% at 60days, and in none at 30days. CT studies revealed a greater tracheal wall thickness at 30days than at 60 and 90days (1.60±0.41mm in the central part of the stent versus 1.11±0.18 and 0.94±0.11; P=.007, respectively). No granulomas were observed on histopathology. Some degree of histological changes were noted at 30days, which had reduced at 60 and 90days. Differences were also found in both CT and histology between animals in which the stent was present and animals in which it had degraded. CONCLUSIONS: Polydioxanone stents produce a mild reaction that reverts with tracheal degradation. The use of these biodegradable stents in benign tracheal disease is promising.

A rare case of kinked reinforced endotracheal tube in an intensive care unit: a case report / Un caso infrecuente de acodamiento de un tubo endotraqueal reforzado en una unidad de cuidados intensivos: reporte de un caso

Abstract Reinforced endotracheal tubes (ETTs) are regularly applied in anesthetic practices to prevent compression or kinking. Although these tubes are designed to bend easily and prevent obstruction, they still carry a potential hazard of being obstructed following external forces. In this article, we reported an unusual case in which a reinforced ETT was collapsed due to the patient bite. The patient's bite force on the tube resulted in obstruction, hypoxia, and desaturation. To overcome this near-fatally condition, we removed the blocked reinforced ETT.

Resumen Los tubos endotraqueales reforzados (TET) se usan generalmente en la práctica anestésica para evitar la compresión o el acodamiento. Aun cuando dichos tubos están diseñados para flexionarse fácilmente y prevenir obstrucciones, de todos modos, existe la posibilidad de que se obstruyan, como consecuencia de fuerzas externas. En el presente trabajo reportamos un caso inusual en el cual se colapsó el TET a causa de la mordida del paciente. La fuerza de mordida sobre el tubo produjo obstrucción, hipoxia y desaturación. Con el fin de superar esta condición casi fatal, retiramos el TET reforzado bloqueado.

Tratamiento de la estenosis traqueobronquial con prótesis: factores de buena respuesta / Treatment of tracheobronchial stenosis with stents: good response factors

OBJETIVO: Determinar predictores de buena respuesta con el uso de prótesis en la estenosis traqueobronquial. MATERIALES Y MÉTODO: Estudio retrospectivo descriptivo de una serie de casos entre junio de 2014 y junio de 2016. Se revisaron registros clínicos, protocolos operatorios, estudios histopatológicos y de imagen. Se consignaron antecedentes demográficos y clínicos al ingreso y luego del procedimiento, etiología de la estenosis traqueal, necesidad de oxígeno en litros, estadía hospitalaria, morbilidad asociada al procedimiento, indicación de terapia complementaria posterior y sobrevida. Se analizaron los datos con estadística descriptiva y analítica. RESULTADOS: Se realizaron 68 procedimientos, en 44 pacientes, 24 mujeres, el diagnóstico principal fue estenosis traqueal con 40 casos. La etiología neoplásica fue el 88% de los casos. El Performance status (PS) de ingreso fue mayor o igual a 2 en el 68% y posterior al procedimiento disminuyó a 22% p < 0,05. En 36 casos los pacientes requerían al menos 1 L de oxígeno lo que disminuyó en 13 casos posterior a la intervención p < 0,05. El tiempo de hospitalización promedio fue 6,2 días (1-60). En 13 pacientes con patología neoplásica se indicó terapia paliativa complementaria. La morbilidad asociada al procedimiento fue de 2,9% dado por prótesis desplazada y lesión iatrogénica. La sobrevida fue de 27% a un año. CONCLUSIONES: La etiología benigna, el PS previo a la intervención menor o igual a 3, requerimiento de oxígeno de 1 litro y obstrucción tumoral menor al 70% del lumen fueron elementos de buena respuesta.

AIM: Determine good response predictors in use of stent in benign and malignant tracheobronchial stenosis. MATERIAL AND METHODS: We retrospectively reviewed medical records of patients submitted to the procedure in the period 2014 to 2016. Clinical records, operative protocols, and histopathological and imaging studies were reviewed. Demographic and clinical data, performance status (PS) at admission and after the procedure, etiology of tracheal stenosis, need for oxygen in liters (L) Post-intervention, hospital stay, procedure-related morbidity, indication of therapy (Chemotherapy and/or Radiotherapy) and survival. Data were analyzed with descriptive and analytics statistics. RESULTS: A total of 68 procedures were performed in 44 patients, 24 women. Tracheal stenosis 40 cases were diagnosed. The malignant etiology was 88%. The admission PS was greater than or equal to 2 in 68% and 22% after the procedure. The oxygen requirements prior to the procedure were at least 1 L in 36 cases and decreased in 13 cases after the procedure. The average hospitalization period was 6.2 days (1-60). Complementary therapy was indicated in 13 patients; the morbidity associated with the procedure was 2.9%, displaced installation and iatrogenic injury. The one year survival was 27%. CONCLUSIONS: Benign etiology, el PS minor than or equal to 3, oxygen requirements prior to the procedure of 1 L and tumoral obstruction less than 75% were good response predictors in our study.

Prevalencia y factores de riesgo del fracaso de extubación en una Unidad de Cuidados Intensivos Pediátricos de alta complejidad / Prevalence of extubation and associated risk factors at a tertiary care pediatric intensive care unit

Introducción. El fracaso de la extubación (FE) está asociado a mayor riesgo de neumonía, estadía hospitalaria y mortalidad. Objetivo. Determinar la prevalencia del FE e identificar factores asociados en nuestra población. Materiales y métodos. Diseño observacional y retrospectivo. Ingresaron todos los pacientes mayores de 1 mes hasta 18 años que, en el período 2012-2016, requirieron asistencia respiratoria mecánica más de 12 h, y al menos tuvieron una extubación programada durante su internación. Se registraron los aspectos relacionados con la ventilación y las causas de fracaso. Resultados. Se extubaron 731 pacientes y la prevalencia de FE fue del 19,3 %. Las causas de fracaso fueron la obstrucción alta de la vía aérea (51,4 %), fatiga muscular (20,1 %), depresión del centro respiratorio (14,6 %) e incapacidad de proteger la vía aérea (9,7 %). Los factores independientes para explicar el FE según el análisis multivariado fueron afección crónica compleja neurológica (odds ratio -#91;OR-#93;= 2,27; intervalo de confianza del 95 % -#91;IC-#93;= 1,21-4,26); infección respiratoria aguda baja en el paciente con una secuela previa (OR= 1,87; IC 95 %= 1,113,15); lesión neurológica aguda (OR= 1,92; IC 95 %= 1,03-3,57); extubación no planeada (OR= 2,52; IC 95 %= 1,02-6,21) y la presencia de estridor (OR= 5,84; IC 95%= 3,66-9,31). Conclusión. La principal causa de FE fue la obstrucción alta de la vía aérea. La secuela neurológica y la afección neurológica aguda, la extubación no planeada y la presencia de estridor posextubación fueron identificadas como factores de riesgo asociados al FE.

Introduction. Extubation failure (EF) is associated with a higher risk for pneumonia, hospital stay, and mortality. Objective. To determine the prevalence of EF and identify the associated factors in our population.Materials and methods. Observational and retrospective design. All patients aged 1 month old to 18 years old who required mechanical ventilation for more than 12 hours and underwent at least one scheduled extubation during their stay in the 2012-2016 period were included. The aspects related to ventilation and the causes of failure were recorded. Results. Seven hundred and thirty-one patients were extubated and the prevalence of EF was 19.3 %. The causes of failure included upper airway obstruction (51.4 %), muscle fatigue (20.1 %), respiratory center depression (14.6 %), and inability to protect the airways (9.7%). As per the multivariate analysis, the independent factors that accounted for EF were neurological complex chronic condition (odds ratio [OR] = 2.27; 95 % confidence interval [CI] = 1.21-4.26); acute lower respiratory tract infection in a patient with prior sequelae (OR = 1.87, 95 % CI = 1.11- 3.15); acute neurological injury (OR = 1.92, 95 % CI=1.03-3.57); unplanned extubation (OR =2.52, 95 % CI = 1.02-6.21), and presence of stridor (OR = 5.84, 95 % CI = 3.66-9.31). Conclusion. The main cause of EF was upper airway obstruction. Neurological sequelae, acute neurological injury, unplanned extubation, and the presence of postextubation stridor were identified as risk factors associated with EF

Enfermedad de Rosai-Dorfman con compromiso laríngeo: a propósito de un caso / Rosai-Dorfman disease with laryngeal involvement: about a case

RESUMEN La enfermedad de Rosai-Dorfman (ERD) o histiocitosis sinusal con linfadenopatía masiva es una enfermedad infrecuente, de etiología desconocida caracterizada por linfadenopatías cervicales masivas bilaterales. El compromiso extraganglionar puede ocurrir en diferentes sitios, incluida la vía aérea, en la cual la localización nasosinusal es la más frecuente, pero puede comprometer también otros sitios de la vía aérea superior. Dentro de éstos, el compromiso laríngeo es muy poco frecuente. Se presenta el caso de una paciente de 82 años con antecedentes de ERD localizada en los ganglios linfáticos cervicales en remisión espontánea, que desarrolló posteriormente una obstrucción subaguda de las vías respiratorias. La tomografía computarizada y la nasofaringolaringoscopía mostraron lesiones subglóticas que obstruían severamente las vías respiratorias. Se realizó una traqueostomía de emergencia y biopsia de las lesiones, confirmando el diagnóstico de ERD extranodal.

ABSTRACT Rosai-Dorfman disease or sinus histiocytosis with massive lymphadenopathy is a rare disease of unknown etiology characterized by bilateral massive cervical lymphadenopathy. Extranodal involvement can occur in different sites including airway where nasosinusal involvement is common but this disease may occur in other sites of the upper airway. Laryngeal involvement is rare. We present the case of an 82-year-old female patient with a history of Rosai-Dorfman disease located in cervical lymph nodes in spontaneous remission that subsequently develops airway obstruction. Computed tomographic scan and nasopharyngolaryngoscopy showed subglottic lessons that severely obstructed the airway. Emergency tracheotomy and biopsy were performed, confirming the diagnosis of extranodal RDD. Patient was observed and tracheostomy was maintained with good tolerance.