Prolonged endotracheal intubation or tracheostomy in children (author's transl)

Five patients with subglottic tracheal stenosis following prolonged endotracheal intubation are reported. To minimize tracheal stenosis the indications for prolonged intubation should be well defined and tracheostomy considered as an alternative. The incidence of tracheal stenosis following prolonged intubation is stimilar to that following tracheostomy. The risk of stenosis increases with the duration of intubation, the degree of physical trauma to the laryngotracheal mucosa (suction, tube changing, restlessness), infection of the trachea or larynx, and with the age of the child. Prolonged intubation necessitates sedation and intensive care. Tracheostomy has a higher mortality but this and the risk of stenosis depend greatly on the operative technique. Particularly in cases where prolonged intubation increase the risk of tracheal stenosis, the advantages of tracheotomy become evident. Tracheostomised children rarely need sedation, the tracheobronchial tree can be easily and carefully toileted and the changing of the tube is without risk. Neither method is absolutely preferable, but the correct application of both will minimise the complication rate. The indications for each may be summarised as follows: for primary treatment of acute respiratory distress in children prolonged intubation is the treatment of choice. If after 3 days there is no chance of extubation, tracheostomy should be considered but this depends also on the child's age and behaviour, and on the laryngotracheal mucosal reaction. The younger the child the more cautiously should tracheostomy be considered. Children under 2 years of age should only be tracheostomised if there is no alternative.     

High-pressure destruction kinetics of Listeria monocytogenes on pork

OBJECTIVE: To define the incidence of complications of endotracheal intubation and the factors associated with these complications. STUDY DESIGN: During a 22-month period, 227 intubated infants weighing <1,501 g were followed prospectively in a neonatal intensive care unit. Detailed records of events associated with airway management were kept after every intubation, in addition to clinical data. RESULTS: Eleven infants (4.8%) developed respiratory stridor after extubation which was treated with either systemic corticosteroids, racemic epinephrine and/or reintubation for respiratory failure. Four infants were submitted for bronchoscopy, mild subglottic stenosis with tracheal edema was found in 1 patient, granulation tissue and airway edema were noted in 3 infants. Traumatic intubation, prolonged ventilation, multiple intubations and bacterial colonization of the endotracheal tube were the factors associated with postextubation stridor. CONCLUSIONS: Subglottic stenosis is an infrequent complication of endotracheal intubation with current airway management of very-low-birth-weight infants. Less severe complications are still common, but they are usually amenable to clinical treatment. Bronchoscopy should be performed selectively only in infants with clinical evidence of airway obstruction after extubation.     

Tracheostomy: acute and long-term mortality and morbidity in very low birth weight premature infants

Thirty-six very low birth weight premature infants (VLBW-PT) born at 24 to 32 weeks gestation and with birth weights 635 to 1,360 g who had tracheostomies performed for acquired subglottic stenosis or for prolonged mechanical ventilation were followed in relation to acute and long-term mortality and morbidity. Mortality due to the tracheostomy occurred in 4 patients (11%); mortality from all other causes was 25%. Death after hospital discharge was associated with the nonuse of prescribed cardiorespiratory monitors. Complications < 1 week postsurgery occurred in 31% of infants and complications > or = 1 week postsurgery occurred in 64% of infants. Fifty percent of infants required tracheostomy for > 2 years and/or extensive reconstructive surgery of the airway. Parents should be counselled that VLBW-PT infants with a tracheostomy may require extended medical and home care. An effective home care program requires parental training in tracheostomy care, the use of ancillary equipment, and infant cardiopulmonary resuscitation.     

The dietitian''s role in developing and implementing the first federal obesity guidelines

OBJECTIVE: To determine possible indications for tracheotomy in the burned child based on bronchoscopic and laryngoscopic findings. DESIGN AND SETTING: A retrospective case study of all patients admitted to a tertiary children's burn center. PARTICIPANTS: All children admitted with burn inhalation injury between 1990 and 1995 (n = 211). INTERVENTION: All patients underwent laryngoscopy and bronchoscopy and 19 underwent tracheotomy, with 5 tracheotomy tubes placed emergently. MAIN OUTCOME MEASURES: Observations during laryngoscopy and bronchoscopy included erythema, edema, carbonaceous material, ulcerations, and bronchial mucous casts. The supraglottis, glottis, and subglottis were analyzed separately, when possible. Any sepsis resulting from tracheotomy was determined. Complications, such as glottic webs, subglottic stenosis, and tracheomalacia, were noted. RESULTS: Indications for tracheotomy included 6 for airway obstruction, 6 for prolonged intubation, 6 for pulmonary cleansing, and 1 for endotracheal tube complications (subglottic stenosis). When examined by bronchoscopy and laryngoscopy, 17 of 19 children had significant airway edema, 10 had carbonaceous material in the airway, and 3 had ulcerations in the airway. CONCLUSIONS: Tracheotomy is indicated in the burned child when significant airway edema is present. Failure to place a tracheotomy tube in these cases leads to a high incidence of immediate tracheotomies (26%). There was no evidence of clinically significant infection attributable to tracheotomy. The number of airway complications due to tracheotomy was no higher than from endotracheal intubation.     

Definitive localization of isolated tracheoesophageal fistula using bronchoscopy and esophagoscopy for guide wire placement

PURPOSE: To aid in identification of isolated tracheoesophageal fistulas (TEF), many surgeons have recommended the bronchoscopic placement of a ureteric or Fogarty catheter. This method can fail because of intraoperative dislodgment of the catheter. The authors present a new technique that enables us to definitively isolate and treat all H-type fistulas. METHODS: Six cases of isolated TEF are presented consisting of 4 H-type fistulas, a proximal pouch fistula, and a recurrent TEF. Three of the patients had undergone a total of four prior failed operations at outside institutions using attempted bronchoscopic catheter placement. On all six patients, bronchoscopy was first performed where the fistula tract was noted in the trachea and a guide wire was passed through the fistula. After orotracheal intubation, the authors performed rigid esophagoscopy; the guide wire was identified and brought out through the mouth. This created a wire loop through the fistula. With the use of x-ray we were then able to visualize the level of the fistula and determine whether a cervical or thoracic approach should be used. Identification of the fistula intraoperatively was then facilitated by traction on the loop by the anesthesiologist. RESULTS: Five of the six TEFs were repaired with neck exploration; one required right thoracotomy. In all patients, the fistula was identified and divided. There were no recurrences or other complications. CONCLUSION: This new technique is a simple and definitive method in identification and treatment of isolated TEF.     

Lung abscess: an unusual presentation of congenital tracheoesophageal fistula without atresia

Tracheoesophageal fistula (TEF) without atresia is rare and usually presents with symptoms from birth. In this report, a 9-year-old boy presented with productive cough of 4 month's duration and was shown to have a right lung abscess seen on chest radiograph. His parents denied earlier respiratory symptoms or illnesses. Rigid bronchoscopy showed a fistulous opening of about 1 mm in diameter in the posterior wall of the trachea about 16 cm from the upper incisor teeth. Cannulation with a ureteral catheter demonstrated that the fistulous opening communicated with the esophageal lumen. The tracheoesophageal fistula was 1 cm long and was divided through a right supraclavicular incision. The postoperative period was uneventful, and the patient was discharged on the third postoperative day. This case demonstrated that TEF should be considered in any patient presenting with chronic respiratory problems even after a prolonged symptom-free period.     

Technique of management of subglottic stenosis

There have been innumerable approaches to the management of subglottic stenosis, which bear testimony to the difficulty in obtaining predictably satisfactory results. Management includes techniques of endoscopic dilation, laser resection, laryngofissure and stenting, and an ingenious array of plastic reconstructions with or without postoperative stenting. On occasion, permanent intubation with a conventional distal tracheotomy or a silicone rubber T tube may be used.     

Growth factors in subglottic stenosis

We sought to define the role of fibrogenic peptides in subglottic stenosis (SGS). Biopsy specimens were obtained from patients with stenosis following endotracheal intubation (group 1, n = 5, mean age 5), patients without a history of any precedent trauma, ie. idiopathic stenosis (group 2, n = 3, mean age 40), and those without stenosis (group 3, n = 3, mean age 70). Formalin-fixed biopsy specimens were analyzed following immunohistochemical staining to determine if epidermal growth factor (EGF), platelet-derived growth factor-AA and -BB (PDGF-AA/BB), transforming growth factor-beta 1 and -beta 2 (TGF-beta 1, beta 2), or basic fibroblast growth factor (bFGF) was deposited in these tissues. Blinded analysis revealed TGF-beta 2 and PDGF-AA to be present in seven of eight biopsy specimens from SGS and absent in controls. Staining for PDGF-BB was observed in the mucosa and submucosa and occasionally within vessel walls. Staining of individual growth factors appeared to correlate closely with the presence of granulation tissue. Essentially no bFGF or TGF-beta 1 was observed. Differences were found between patients in groups 1 and 2; tissue from group 1 revealed deposition of EGF and PDGF-BB in submucosa, epithelium, and vasculature. In summary, our experimental findings implicate PDGF and TGF-beta 2, perhaps acting in concert, in mediating the pathologic fibrotic process observed in subglottic stenosis. Epidermal growth factor, in conjunction with TGF-beta and PDGF, may also have a role, but further investigation is needed to more precisely define it.     

Neurogenic inflammation in the gastrointestinal tract of the rat

To estimate the risk of repeat low birthweight deliveries among women whose first child was very low birthweight (less than 1500 g), a retrospective cohort of women who had their first and second children in Washington state between 1984 and 1991 was studied. After adjustment for potential confounding factors, a woman whose first infant was very low birthweight experienced an 11.5-fold increased risk of delivering a low birthweight (less than 2500 g) second infant (relative risk 11.5, 95% confidence interval 5.4 to 24.4). Women with a very low birthweight first infant also had a significantly increased risk of repeat very low birthweight infant (p < 0.0001). Women with a previous very low birthweight delivery are at increased risk of repeat low and very low birthweight infants. This high-risk group may benefit from education regarding recurrence risk and modification of factors associated with low birthweight, as well as good prenatal care.     

Coronary disease and tracheal stenosis with tracheo-oesophageal fistula: a combined surgical procedure

A patient with coronary disease class III of the New York Heart Association and tracheal stenosis with a tracheo-oesophageal fistula, which developed after long-term intubation, is described. As both conditions were symptomatic, an aortocoronary double bypass was combined with resection of the trachea and closure of the fistula. Postoperative recovery was uneventful and the patient is symptom-free after 3 years.     

Evaluation of long-term results and donor site defects following transposition of connective tissue flaps

Tracheoesophageal fistula, with or without esophageal atresia (TEF/EA) appears to be a defect of blastogenesis, as is the oculoauriculovertebral (Goldenhar) spectrum (OAVS), with which it has occasionally been associated. We reviewed the records of all OAVS patients evaluated through the University of South Florida Regional Genetics Program between 1985 and 1993. Of 60 OAVS patients, three had TEF/EA. These results suggest that TEF/EA in association with OAVS is underreported. The occurrence of TEF/EA should prompt a thorough search for other known anomalies of OAVS.     

A new variant of esophageal atresia with tracheoesophageal fistula and duodenal atresia: a diagnostic dilemma

A new variant of esophageal atresia (EA) with tracheoesophageal fistula (TEF) associated with duodenal atresia is reported. The TEF was between the lower pouch and the trachea, with a cystic dilatation in the midportion. The tracheal end of the fistula was obstructed by a membranous septum at both ends of a cystic dilatation, leading to a diagnosis of pure EA (gasless abdomen). After the lower pouch was opened beyond the cystic dilatation, 100 ml nonbilious fluid was obtained. A laparotomy revealed a type III atresia of the first part of the duodenum.     

Neither physical exercise nor alpha 1- and beta-adrenergic blockade affect plasma endothelin concentrations

Endothelins (ET) are recently discovered vasoconstrictor agents released from endothelial cells and have been the object of intense investigation by researchers. Many of the factors that seem to influence the release of ET are modified by prolonged exercise. The purpose of this study was to investigate the effect of physical exercise on ET plasma concentrations and the effect of alpha- and beta-blockade on ET concentrations at rest and during exercise. Fifteen young volunteers (age 20-35 years) performed an exercise test on a bicycle ergometer. The starting workload of 50 W was increased by 30 W every 3 min until maximal heart rate was achieved; after a 2 min recovery period at 50 W the test continued for 15 min at 60% maximal work load. Blood samples were taken for ET determination before and after the test. After 1 week, the test was repeated. In the 2 days before either the first or the second test, each volunteer randomly received carvedilol (C) (25 mg), an alpha 1-adrenoceptor and beta-adrenoceptor blocker. There was no significant difference in ET concentrations after exercise with or without C administration (1.24 +/- 0.66, 1.42 +/- 0.83, 1.66 +/- 1.15, 1.61 +/- 0.87 pg/mL), showing that prolonged aerobic exercise does not affect plasma ET levels. Moreover, in our healthy young volunteers, blockade of alpha- and beta-adrenoceptors had no effect on ET levels at rest and after exercise.     

Local low-dose interleukin-2 induces systemic immunity when combined with radiotherapy of cancer. A pre-clinical study

OBJECTIVES: This study examined whether the decline in birth-weight with increasing altitude is due to an independent effect of altitude or an exacerbation of other risk factors. METHODS: Maternal, paternal, and infant characteristics were obtained from 3836 Colorado birth certificates from 1989 through 1991. Average altitude of residence for each county was determined. RESULTS: None of the characteristics related to birthweight (gestational age, maternal weight gain, parity, smoking, prenatal care visits, hypertension, previous small-for-gestational-age infant, female newborn) interacted with the effect of altitude. Birthweight declined an average of 102 g per 3300 ft (1000 m) elevation when the other characteristics were taken into account, increasing the percentage of low birthweight by 54% from the lowest to the highest elevations in Colorado. CONCLUSIONS: High altitude acts independently from other factors to reduce birthweight and accounts for Colorado's high rate of low birthweight.     

Proliferation of human non-small-cell lung cancer cell lines: role of interleukin-6

PURPOSE: The aim of this study was to describe the dysmorphogenetic process leading to esophageal atresia and tracheoesophageal fistula (EA + TEF) in the recently developed Adriamycin model of the malformation. METHODS:Time-mated pregnant rats were given either Adriamycin (1.75 mg/kg intraperitoneally) or saline on days 6 to 9 of gestation, and their embryos recovered on days 12, 12.5, and 13 were serially sectioned in the transversal plane and studied microscopically after H&E and PAS staining. The findings were compared with those of age-matched untreated embryos. RESULTS: All untreated and saline embryos were normal, whereas 49% of Adriamycin embryos had foregut malformations. Tracheoesophageal separation was complete on day 12 in control embryos, whereas 9 of 10 Adriamycin-exposed embryos had a common esophagotrachea with low emergence of the bronchi at that stage. This pattern had evolved into that of a regular EA + TEF in all nine malformed embryos by day 13. On day 12.5, esophagotrachea was found in 6 of 13 and EA + TEF in 5 of 13 embryos. Two had less well-defined malformations. CONCLUSIONS: Esophagotrachea equivalent to complete tracheoesophageal cleft is the first step leading to EA + TEF in this model. The full-blown malformation is finally acquired by partial loss of the posterior wall of the foregut, which tapers-off in the mediastinal mesenchyme and respiratory differentiation of the anterior wall down to the level of bronchial bifurcation, where it constitutes the fistula and the distal esophagus.     

Effects of dexamethasone on laryngeal edema following short-term intubation

Following short-term intubation for general anesthesia, respiratory difficulty may result from laryngeal or subglottic edema after extubation. We have hypothesized that this problem could be pretreated by administering a high-dose of dexamethasone intravenously before extubation. After glottic injuries were made under direct laryngoscopic view, intubation was performed and maintained for 1 hour in 33 rabbits. The rabbits were divided into 3 groups; dexamethasone (1 mg/kg) was administered to group 1(n=12) immediately after intubation and group 2(n=10) just before extubation; group 3(n=11) received normal saline, just before extubation. After extubation, subglottic excursion pressure was measured for 4 hours. 15 injured rabbit larynges and 3 normal ones were extracted for histologic section. 2 of 12 rabbits in group 1; 3 of 10 in group 2; and 5 of 11 in group 3, showed mild stridor after extubation(p>0.05). All rabbits developed maximum increase in subglottic pressure within 2 hours after extubation. Group 1 and 2 showed less increase in pressure compared to group 3(P<0.05), but here was no statistical difference between group 1 and 2(P>0.05). Histologic sections of the larynges showed less submucosal edema, including other changes in group 1 and 2, than in group 3(P<0.05). In conclusion, administering a high-dose of dexamethasone before extubation, is effective in prophylaxis and treatment of laryngeal injuries following short-term intubation in rabbits. This is especially true in edema.     

Percutaneous angioplasty of arterio-venous fistulae with Zijlstra catheters

Brescia-Cimino arteriovenous fistulas are the most common vascular accesses in hemodialysis patients. Arterial blood pressure inside the vein and repeated punctures cause progressive sclerosis of the vessel wall and stenosis or occlusion are the final outcome. Percutaneous dilatation is an effective method to preserve arteriovenous fistulas function. From January 1991 through December 1992, eleven dilatations were performed in 10 patients (7 women and 3 men, mean age: 55 years) using a Zijlstra dedicated catheter provided with multiple infusion holes, which allows long dilatation times and therefore progressive wall distention. A high-pressure balloon yields better results in case of stiff and diffuse stenosis. The immediate results of the maneuver were good in all patients. One acute thrombosis of the fistula was observed a few hours after the procedure, and a second dilatation was performed in a patient 8 months after the first one. Mean arteriovenous fistula patency time was 6 months. Finally, a critical review of the international literature on the subject is made and the value of dilatation in the treatment of fistula stenosis is reported; the necessity to use new dedicated catheters in also stressed.     

Malignant tracheoesophageal fistula in patients with esophageal cancer

BACKGROUND: Patients with esophageal cancer and a malignant tracheoesophageal fistula (TEF) have an extremely poor prognosis. Additionally, these patients often are denied treatment with radiation therapy because there is concern that these treatments may increase the size and associated problems of the TEF. METHODS: To determine the appropriate treatment (use of radiation therapy) for patients with esophageal cancer and malignant TEF, a review was performed of all such cases seen at the Mayo Clinic between 1971 and 1991. RESULTS: Between 1971 and 1991, 41 patients with malignant TEF arising as a result of esophageal cancer were seen at the Mayo Clinic in Rochester. Twenty-eight of these cancers were locally recurrent, and this group of patients had a uniformly poor outcome (median survival time, 1.4 months). Thirteen patients had a malignant TEF and had not received previous treatment for their esophageal cancer. The median survival length was 4 months for this group of patients. Of the 41 patients in this study, 10 received radiation therapy for their malignant TEF (30-66 Gy). The median survival length of this group of patients was 4.8 months. Six of these 10 patients died of metastatic disease (median survival length, 9 months), and there was no evidence of progression of the local tumor. Four of these 10 patients died of local progression of the malignancy (median survival length, 3 months). CONCLUSIONS: Radiation therapy did not increase the severity of the TEF. The authors conclude that radiation therapy can be administered safely in patients with TEF resulting from esophageal cancer. In some patients, radiation treatment may contribute to stabilization of the local tumor process (60% of patients treated with radiation therapy died of metastatic disease without local progression of tumor); however, all patients in this study eventually died of esophageal cancer.     

The effect of the aminoketone nioben in essential circulatory hyperkinesis

Attention is drawn to the case of an oesophagotracheal fistula following prolonged intubation. A combination of physical factors, the use of unsuitable cuffs and a nasogastric feeding tube, are considered to be the cause. Surgical repair of the fistula is advised as soon as possible. While primary closure of the oesophageal defect is always possible, suture of the membraneous trachea may be impossible and a graft may be necessary to cover the defect. For this is recommended oral mucosa, which achieved very good result in this reported case.