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Revue Des Maladies Respiratoires May 2022In the overwhelming majority of cases, Airway stents offer relief of malignant or benign central airway obstruction. In some non-tumoral situations, they can be... (Review)
Review
In the overwhelming majority of cases, Airway stents offer relief of malignant or benign central airway obstruction. In some non-tumoral situations, they can be curative, providing a bridge to local or systemic treatments in the context of malignant obstruction. The efficacy and tolerance of these medical devices have dramatically improved over the past three decades with the development of silicone airway stents and, more recently, of third-generation, covered, self-expandable metallic stents with an increasingly widened panel of shapes. We review herein the main categories of airway stents with their specific indications, pitfalls, and advantages, not only in neoplastic situations, but also in the treatment of benign stenoses of the respiratory tract. The recent advances and perspectives in the field are also taken into consideration, particularly the development of biodegradable, drug-eluting, and patient-specific customized AS.
Topics: Airway Obstruction; Bronchoscopy; Humans; Respiratory System; Silicones; Stents; Treatment Outcome
PubMed: 35305856
DOI: 10.1016/j.rmr.2022.02.059 -
Pediatric Pulmonology Feb 2022Plastic bronchitis (PB) is a condition characterized by the formation of thick airway casts leading to acute and often life-threatening airway obstruction. PB occurs...
BACKGROUND AND OBJECTIVES
Plastic bronchitis (PB) is a condition characterized by the formation of thick airway casts leading to acute and often life-threatening airway obstruction. PB occurs mainly in pediatric patients with congenital heart disease (CHO) who have undergone staged surgical palliation (Glenn, Fontan), but can also occur after chemical inhalation, H1N1, severe COVID-19, sickle cell disease, severe asthma, and other diseases. Mortality risk from PB can be up to 40%-60%, and no treatment guideline exist. The objectives herein are to develop a standardized evaluation, classification, and treatment guideline for PB patients presenting with tracheobronchial casts, based on our experience with PB at the Children's Hospital of Colorado in Denver.
METHODS
We describe 11 patients with CHO-associated PB (post-Fontan [n = 9], pre-Fontan [n = 2]) who presented with their initial episodes. We utilized histopathological analysis of tracheobronchial casts to guide treatment in these patients, utilizing our hospital-wide guideline document and classification system.
RESULTS
We found that 100% of post-Fontan PB patients had fibrinous airway casts, while pre-Fontan PB casts were fibrinous only in one of two patients (50%). Utilizing histopathology as a guide to therapy, PB patients with fibrin airway casts were treated with airway-delivered fibrinolytics and anticoagulants, as well as aggressive airway clearance and other supportive care measures. These therapies resulted in successful cast resolution and improved survival in post-Fontan PB patients.
CONCLUSION
We have shown an improved outcome in PB patients whose treatment plan was based on Denver's PB classification schema and standardized treatment guideline based on tracheobronchial cast histopathology.
Topics: Airway Obstruction; Bronchitis; COVID-19; Child; Fibrin; Fontan Procedure; Humans; Influenza A Virus, H1N1 Subtype; SARS-CoV-2
PubMed: 34713989
DOI: 10.1002/ppul.25746 -
Pediatric Pulmonology Sep 2021To characterize the upper and lower airway findings in children with Down syndrome and chronic respiratory symptoms, based on evaluation by flexible bronchoscopy (FB)...
OBJECTIVE
To characterize the upper and lower airway findings in children with Down syndrome and chronic respiratory symptoms, based on evaluation by flexible bronchoscopy (FB) with bronchoalveolar lavage and microlaryngoscopy with bronchoscopy (MLB).
STUDY DESIGN
A retrospective review was conducted of children with Down syndrome aged 1 month to 17 years, who underwent both FB and MLB within a 1-year timeframe between 2010 and 2019 at Children's Hospital Colorado. Anatomic airway findings are reported as frequencies within the cohort. Bronchoalveolar lavage fluid (BALF) culture results, cell differential, and cytopathology are reported as frequencies or mean ± standard deviation. BALF results were compared between children with and without dysphagia documented on a recent swallow evaluation.
RESULTS
Overall, 168 children with Down syndrome were included, with median age of 2.1 years (interquartile range: 0.9-5.1 years). At least one abnormal airway finding was recorded in 96% of patients and 46% had at least three abnormal findings. The most common findings included tracheomalacia (39% FB; 37% MLB), subglottic stenosis (35% MLB), pharyngomalacia (32% FB), and laryngomalacia (16% FB; 30% MLB). Comparison of BALF based on dysphagia status showed that children with dysphagia had more frequent cultures positive for mixed upper respiratory flora (76% vs. 47%, p = 0.004) and a higher percentage of neutrophils (20% vs. 7%, p = 0.006).
CONCLUSION
Abnormal findings for FB and MLB are common in children with Down syndrome and chronic respiratory symptoms, and performing the procedures together may increase the diagnostic yield.
Topics: Airway Obstruction; Bronchoscopy; Child; Child, Preschool; Down Syndrome; Humans; Infant; Inflammation; Retrospective Studies
PubMed: 34245494
DOI: 10.1002/ppul.25573 -
Seminars in Respiratory and Critical... Aug 2022Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced...
Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.
Topics: Airway Obstruction; Bronchoscopy; Humans; Lung Neoplasms; Pulmonary Medicine; Pulmonologists
PubMed: 35654419
DOI: 10.1055/s-0042-1748187 -
Anesthesiology Clinics Sep 2020Children have unique characteristics that make them particularly vulnerable to perioperative adverse events. Skilled airway management is a cornerstone of high-quality... (Review)
Review
Children have unique characteristics that make them particularly vulnerable to perioperative adverse events. Skilled airway management is a cornerstone of high-quality anesthetic management. The use of hybrid airway techniques is a critical tool for the pediatric anesthesiologist. Point-of-care ultrasonography has an expanding role in airway management, from preoperative assessment of airway pathology and gastric contents to confirmation of tracheal intubation and identification of the cricothyroid membrane. The exciting fields of 3-dimensional printing, artificial intelligence, and machine learning are areas of innovation that will transform pediatric difficult airway management in years to come.
Topics: Airway Management; Airway Obstruction; Artificial Intelligence; Child; Humans; Image Interpretation, Computer-Assisted; Point-of-Care Systems; Respiratory System; Ultrasonography
PubMed: 32792177
DOI: 10.1016/j.anclin.2020.05.001 -
European Respiratory Review : An... Mar 2023Endobronchial stenting is an important aspect of the practice of interventional pulmonology. The most common indication for stenting is the management of clinically... (Review)
Review
Endobronchial stenting is an important aspect of the practice of interventional pulmonology. The most common indication for stenting is the management of clinically significant airway stenosis. The list of endobronchial stents available on the market continues to grow. More recently, patient-specific 3D-printed airway stents have been approved for use. Airway stenting should be considered only when all other options have been exhausted. Due to the environment of the airways and the stent-airway wall interactions, stent-related complications are common. Although stents can be placed in various clinical scenarios, they should only be placed in scenarios with proven clinical benefit. The unwarranted placement of a stent can expose the patient to complications with little or no clinical benefit. This article reviews and outlines the key principles of endobronchial stenting and important clinical scenarios in which stenting should be avoided.
Topics: Humans; Bronchoscopy; Stents; Airway Obstruction
PubMed: 36889785
DOI: 10.1183/16000617.0189-2022 -
Paediatric Anaesthesia Mar 2020Interventional procedures in the airway can be performed in interventional radiology suites or the operating room, by radiologists or other specialists. The most common... (Review)
Review
Interventional procedures in the airway can be performed in interventional radiology suites or the operating room, by radiologists or other specialists. The most common therapeutic interventions carried out by radiologists are balloon dilatation, stenting, and the treatment of certain airway fistulas. These operations can be very challenging for anesthetists in terms of planning, airway management, the identification and treatment of procedural complications and postoperative care. In particular, a multidisciplinary approach to decision-making and planning is important to obtain the best results.
Topics: Airway Obstruction; Child; Humans; Radiology, Interventional; Respiratory System
PubMed: 31903683
DOI: 10.1111/pan.13821 -
Otolaryngologic Clinics of North America Oct 2019Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary... (Review)
Review
Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA.
Topics: Adenoidectomy; Airway Obstruction; Child; Endoscopy; Humans; Magnetic Resonance Imaging; Polysomnography; Sleep Apnea, Obstructive; Tonsillectomy
PubMed: 31301824
DOI: 10.1016/j.otc.2019.06.004 -
European Journal of Pediatrics Jan 2022Major congenital anomalies are known to play a role in the management and prognosis of airway obstruction. Most studies assess acquired forms of airway obstruction. Data...
Major congenital anomalies are known to play a role in the management and prognosis of airway obstruction. Most studies assess acquired forms of airway obstruction. Data on congenital or otherwise non-acquired forms of airway obstruction is sparse. In this retrospective, single-institution cohort study, we sought to evaluate and compare the patterns of airway obstruction in children with and without major congenital anomalies, and to assess the impact of management and outcome, irrespective of aetiology. Fifty-five patients were included, 23 with and 32 without underlying major congenital anomalies. Multilevel airway obstruction (usually affecting the nasopharynx, oropharynx, and the trachea) was more common in children with congenital anomalies (91% vs. 41%, p < .001). Consequently, these children required more frequent and earlier surgical management, especially tracheostomy and adenotonsillar surgery.Conclusions: Major congenital anomalies are associated with multilevel airway obstruction and poor functional prognosis. A simple clinical definition considering impact of major congenital anomalies on development and growth may help guide management plans following endoscopic evaluation of the entire airway and flanked by multidisciplinary discussions. What is Known: • Children with major comorbidities display increased disease severity and more prevalent multilevel airway obstruction • Previous studies include both children with acquired and non-acquired forms of airway obstruction; therefore, the actual impact major comorbidities in children with non-acquired causes of airway obstruction remain unclear. What is New: • A total of 42% children in this study population had major comorbidities with and impact on growth and/or psychomotor development, with a higher prevalence of multilevel airway obstruction and worse rates of functional improvement/recovery. • Children with major comorbidities require tracheostomy more often and earlier than those without major comorbidities, and remain tracheostomy-dependent for a longer time.
Topics: Airway Obstruction; Child; Cohort Studies; Humans; Infant; Retrospective Studies; Trachea; Tracheostomy
PubMed: 34291330
DOI: 10.1007/s00431-021-04198-6 -
Seminars in Pediatric Surgery Aug 2019Ex Utero Intrapartum Treatment (EXIT) is a technique developed to safely and efficiently establish cardiopulmonary support at delivery while maintaining placental... (Review)
Review
Ex Utero Intrapartum Treatment (EXIT) is a technique developed to safely and efficiently establish cardiopulmonary support at delivery while maintaining placental bypass. Indications for the EXIT approach are expanding and currently include EXIT-to-airway, EXIT-to-resection, EXIT-to-extracorporeal membrane oxygenation (ECMO), and EXIT-to-separation of conjoined twins. The EXIT technique involves planned partial delivery of the fetus via hysterotomy while maintaining uterine relaxation and placental support, allowing for the establishment of neonatal cardiopulmonary stability in a controlled manner. Fetal interventions performed during EXIT can include endotracheal intubation, tracheostomy, mass excision, removal of a temporary tracheal occlusive device, ECMO cannulation, and others. The most important aspect of an EXIT procedure is the formation of a multi-disciplinary team with broad expertise in fetal intervention to collaborate throughout the pre, intra, and post-partum periods. This chapter reviews the prenatal workup, decision making, surgical indications, and operative considerations associated with EXIT procedures.
Topics: Airway Obstruction; Anesthesia, General; Extracorporeal Membrane Oxygenation; Female; Fetal Diseases; Humans; Hysterotomy; Infant, Newborn; Patient Care Team; Pregnancy; Prenatal Diagnosis
PubMed: 31451172
DOI: 10.1053/j.sempedsurg.2019.07.003