Bronchoskopie bei Kindern

Pediatric bronchoscopy is a valuable diagnostic and therapeutic tool in the hands of experienced physicians, in particular pediatric pulmonologist and in anesthesia and pediatric intensive care. A large body of publications exists with regard to the indications, results, safety, side effects and sedation or anesthesia for this procedure; however, as for many other long-established diagnostic and therapeutic techniques, no prospective controlled studies in the sense of evidence-based medicine are available for many practical aspects of the technical details of this procedure. This is unlikely to change in the future as such studies for well-established techniques are difficult to envision for many reasons (e.g. ethical, parental acceptance and financing). It is therefore the aim of this paper to summarize the current knowledge and report a consensus by experts in the field regarding rational indications and safe technical performance of pediatric bronchoscopy.     

The laryngeal mask airway in fibreoptic bronchoscopy

A large series of patients is reported in whom the laryngeal mask airway was used to perform fibreoptic bronchoscopy. It allows direct visualisation of the airways during spontaneous respiration. It has enabled bronchoalveolar lavage and bronchography to be performed in children as young as 6 months and transbronchial biopsies in children as young as 4 years.     

The laryngeal mask airway in fibreoptic bronchoscopy.

A large series of patients is reported in whom the laryngeal mask airway was used to perform fibreoptic bronchoscopy. It allows direct visualisation of the airways during spontaneous respiration. It has enabled bronchoalveolar lavage and bronchography to be performed in children as young as 6 months and transbronchial biopsies in children as young as 4 years.     

支气管镜检查在儿科临床中的应用

支气管镜检查在儿科肺疾病的评估和治疗中发挥了很重要的作用.支气管肺泡灌洗、支气管刷检及活检为诊断提供了很多帮助,甚至在很小的患儿中也能安全施行.文章描述了纤维支气管镜检查的经典过程及其在临床中适应证.     

Management of Plastic Bronchitis With Topical Tissue-type Plasminogen Activator

Plastic bronchitis or cast bronchitis is a rare disease of unclear etiology characterized by formation of airway casts that can lead to life-threatening airway obstruction. There is currently limited data regarding optimal treatment of plastic bronchitis. Several therapies have been suggested, but recurrences are common and mortality remains high. We report the case of a 6-year-old boy with refractory eosinophilic bronchial casts, unresponsive to low-dose systemic corticosteroids, inhaled corticosteroids, azithromycin, and dornase alfa, who was treated successfully and safely with direct instillation of tissue-type plasminogen activator (tPA) to the obstructing casts during flexible bronchoscopy and inhaled tPA. Our case illustrates that the current therapy for plastic bronchitis remains inadequate. To our knowledge, this case is the first to show that direct instillation of tPA can be used safely for treatment of this disease. The use of tPA via direct administration into the airways during bronchoscopy and via a nebulizer appeared to be a safe and effective therapy for plastic bronchitis and should be considered early in the course of the disease to prevent complications of severe airway obstruction.     

Fiberoptic flexible bronchoscopy via the laryngeal mask airway in children

The laryngeal mask airway (LMA) is a new device for controlling the airway during many procedures. Aside from its use in different kinds of surgical procedures, fiberoptic flexible bronchoscopy can also be performed easily with this mask in children under sedation. This procedure was performed via LMA in 36 children (aged 2-16 years) who suffered from different kinds of respiratory diseases and were seen at Hacettepe University Ihsan Do?ramaci Children's Hospital, Pediatric Chest Disease Unit, during a seven-month period. The procedure was performed with success and no complications occurred. To the best of our knowledge, this is the first report from Turkey on flexible bronchoscopic evaluation via LMA in children with different kinds of respiratory diseases. We suggest that this technique can be used safely.     

Anterograde endotracheal intubation with a laryngeal mask airway and guidewire in an infant with micrognathia

Tracheal intubation through a laryngeal mask airway is an alternative to secure the ventilation in patients with difficult airway. Different techniques have been described to intubate these patients. A case of micrognathia in remote location anesthesia is reported. Endotracheal intubation was unsuccessful with the conventional methods. A soft tip angiography guidewire was advanced through a laryngeal mask airway. The position of the catheter was confirmed by fluoroscopy. Laryngeal mask airway was removed after endotracheal tube was inserted over the guidewire. This technique is recommended as an alternative where fiberoptic bronchoscopy is unavailable and in emergency situations.     

现代儿科呼吸介入技术在喘息性疾病中的应用进展

喘息是小儿常见的临床症状,可因气道腔内阻塞、管壁疾患、腔外压迫等原因引起。儿童喘息病因众多,临床医生诊治较为困难,常规治疗效果不佳。支气管镜是明确婴幼儿反复或持续性喘息病因的重要辅助检查,可直接观察到气管支气管局部病变,明确气道异常的类型、解剖位置以及病变严重程度,为儿童喘息性疾病病因诊断提供直观的诊断依据和有效呼吸介入治疗手段,值得在临床推广。     

电子支气管镜在儿童重症监护室脱机困难患儿中的应用

目的 探讨电子支气管镜术在儿童重症监护室 （PICU） 脱机困难患儿病因诊断及治疗中的价值。方法 对入住PICU的脱机困难患儿行电子支气管镜检查和/或治疗的92例患儿的临床资料进行回顾性分析。结果 92例脱机困难患儿中,基础疾病以呼吸系统疾病为主 （39例）。电子支气管镜检查发现87例异常 （95%）,以大量气管内分泌物和气道结构异常多见。电子支气管镜检查显示脱机困难的先天性心脏病 （CHD） 患儿 （n=19） 和无脱机困难的CHD患儿 （n=9） 气管支气管狭窄或软化的程度差异无统计学意义;气管支气管狭窄或软化对预测CHD患儿脱机困难的灵敏度为68.4%、特异度为66.7%。36例因大量分泌物或痰栓堵塞气道的肺不张患儿,经支气管灌洗和/或单肺通气治疗后,23例完全或部分复张。结论 电子支气管镜检查有助于PICU脱机困难的患儿尽早明确脱机困难的原因,并针对病因进行支气管镜下干预治疗。对于CHD患儿,通过电子支气管镜发现气管支气管狭窄或软化不应纳入作为患儿预测脱机的指标。     

Submucosal Hemangioma of the Trachea in an Infant: Diagnosis and Follow-Up with 3D-CT/Bronchoscopy

Introduction:

Infantile hemangiomas of the airway are diagnosed at bronchoscopy as part of the investigation of stridor or other respiratory symptoms. Here, we present three-dimensional computed tomography (3D-CT)/bronchoscopy findings of submucosal subglottic hemangioma missed at bronchoscopy.

Case Presentation:

We report on the clinical usefulness of 3D-CT/bronchoscopy as the primary diagnostic tool and follow-up method in the evaluation of suspected airway infantile hemangiomas, especially when the hemangioma is the submucosal type.

Conclusions:

3D-CT/bronchoscopy will reduce the need for invasive laryngoscopic studies and help to diagnose submucosal hemangiomas undetected on laryngoscope. Additionally, 3D-CT/bronchoscopy will help evaluating the extent of the lesion, degree of airway narrowing, and treatment response.     

纤维支气管镜术在小儿慢性咳嗽诊断及治疗中的价值

目的 探讨纤维支气管镜(纤支镜)术在小儿慢性咳嗽诊断及治疗中的价值.方法 对2006年8月-2011年3月在本院应用纤支镜进行检查和(或)治疗的61例慢性咳嗽患儿的临床资料进行回顾性分析.病例均采用局部麻醉的方法,而且患儿均经临床程序排除咳嗽变异性哮喘和胃食管反流.通过镜下直视、支气管刷检及肺泡灌洗液,明确病因诊断;应用支气管肺泡灌洗、局部注药和钳取异物进行治疗,并对疗效做出评价.结果 61例患儿中男36例,女25例;年龄8个月～13岁.61例患儿镜下炎性改变21例(34.5％),先天性心肺发育畸形12例(19.7％),支气管异物10例(16.4％),上呼吸道咳嗽综合征8例(13.1％),支气管内膜结核7例(11.5％),未见异常3例(4.9％).气管黏膜刷检涂片找到革兰阳性细菌和(或)革兰阴性细菌12例(12/31例,38.7％),肺泡灌洗液细菌培养阳性5例(5/40例,12.5％),未找到抗酸杆菌和癌细胞.对镜下炎性改变重、有痰栓阻塞者经纤支镜行支气管灌洗治疗,取得较好疗效.10例支气管异物经纤支镜成功取出8例.结论 小儿慢性咳嗽经纤支镜检查发现以炎症及支呼吸管异物多见,婴幼儿期慢性咳嗽应警惕心肺发育异常及呼吸道异物.纤支镜检查对儿童慢性咳嗽的病因诊断与治疗具有重要价值,尤其对先天性心肺发育畸形及支气管细小异物的诊断有独特价值.     

CT findings of plastic bronchitis in children after a Fontan operation

BACKGROUND: Plastic bronchitis is a rare cause of acute obstructive respiratory failure in children. Life-threatening events are much more frequent in patients with repaired cyanotic congenital heart disease, and most frequent following a Fontan operation. Commonly, the diagnosis is not made until bronchial casts are expectorated. Detailed CT findings in plastic bronchitis have not been described. OBJECTIVE: To describe the CT findings in plastic bronchitis in children after a Fontan operation. MATERIALS AND METHODS: Three children with plastic bronchitis after a Fontan operation were evaluated by chest CT. Bronchial casts were spontaneously expectorated and/or extracted by bronchoscopy. Airway and lung abnormalities seen on CT were analyzed in the three children. RESULTS: CT demonstrated bronchial casts in the central airways with associated atelectasis and consolidation in all children. The affected airways were completely or partially obstructed by the bronchial casts without associated bronchiectasis. The airway and lung abnormalities rapidly improved after removal of the bronchial casts. CONCLUSION: CT can identify airway and lung abnormalities in children with plastic bronchitis after a Fontan operation. In addition, CT can be used to guide bronchoscopy and to monitor treatment responses, and thereby may improve clinical outcomes.     

Effect of jaw-thrust and continuous positive airway pressure on tidal breathing in deeply sedated infants

OBJECTIVES: To examine the physiologic impact of the jaw-thrust maneuver or the administration of continuous positive airway pressure (CPAP) on tidal breathing in deeply sedated infants.Study design: Prospective, non-randomized study of infants undergoing elective fiberoptic bronchoscopy while sedated with intermittent doses of propofol. METHODS: Spontaneous tidal breathing was measured in the supine position by means of a spirometer attached to a bronchoscopy face mask. Tidal breaths were recorded under the following conditions: (1) neutral sniffing position, (2) jaw-thrust, (3) neutral sniffing position, and (4) CPAP of 5 cm H(2)O. Improvement was defined as a change of more than twice the coefficient of variation of repeated measurements of tidal volume and flows from baseline. RESULTS: Jaw-thrust increased tidal volume, minute ventilation, and peak tidal inspiratory and expiratory flows significantly in all 13 infants studied (mean +/- SEM age = 8 +/- 2 months). CPAP increased peak tidal inspiratory and expiratory flows by more than twice the coefficient of variation of baseline measurements in 6 patients and tidal volume and minute ventilation in 5 of 10 patients studied. CONCLUSION: Jaw-thrust and CPAP are effective techniques to improve ventilation of sedated infants undergoing interventions that compromise upper airway patency.     

经支气管镜介入治疗在气道发育异常中的应用

支气管镜是诊治儿童呼吸系统疾病不可缺少的方法之一,是儿童肺介入治疗技术不断发展的基础。随着临床经验的不断积累及支气管镜在儿科的广泛应用,其价值得到了一致肯定。该文将对经支气管镜介入治疗在气道发育异常中的应用概况作一综述。     

Fiberoptic bronchoscopy in children using the laryngeal mask airway

 We describe our experience using the laryngeal mask airway (LMA) in children to facilitate diagnostic procedures in fiberoptic bronchoscopy (FOB). Two cases of stridor, two cases of protracted pneumonia, and one case of laryngotracheomalacia were studied. Intravenous atropine (0.02 mg/kg) was given, and induction was carried out by either inhalation of a mixture of halothane-nitrous oxide-oxygen (n = 3) or IV injection of propofol (n = 2). After an adequate depth of anesthesia was obtained, a LMA was introduced. A 2.7-mm-OD flexible fiberoptic bronchoscope was introduced through the LMA and the diagnostic procedure was performed. Ventilation and oxygenation were maintained, and no serious morbidity was associated with the procedure. We found the use of the LMA to facilitate FOB to be useful, easy to perform, and safe, avoiding nasal trauma and providing a patent airway. Accepted: 7 April 1999     

Das bewusstseinsgestörte Kind

Background

Disturbances of consciousness are frequent pediatric emergencies.

Aims

This article describes the principles of emergency care of consciousness disturbance in children. The article is based on clinical guidelines with broad implementation.

Results and discussion

If a child loses consciousness, the initial treatment consists of ensuring a reliable airway and maintaining adequate ventilation, oxygenation and blood pressure (ABC rule: airway, breathing, circulation). The severity of unconsciousness must be quantified by scoring systems, e.g. the Glasgow coma scale or the AVPU scale (alert, voice, pain or unresponsive). The patient’s history and further clinical abnormalities (e.g. fever, meningism and focal signs) are crucial for the next diagnostic step including urgent neuroimaging and lumbar puncture. If a central nervous system (CNS) infection is suspected, anti-infective treatment must not be delayed. In unconscious patients with ventriculoperitoneal shunt systems a pediatric neurosurgeon has to be contacted in order to rule out shunt insufficiency.     

中国儿科可弯曲支气管镜术在严重急性呼吸综合征冠状病毒2(SARS-CoV-2)感染疫情期间诊疗建议(试行)

严重急性呼吸综合征冠状病毒2(SARS-CoV-2)感染所致肺炎(COVID-19)的疫情已经蔓延到儿童。其传染性强,人群普遍易感,包括儿童。传染源主要是SARS-CoV-2感染的患者,无症状感染者也可能成为传染源。支气管镜诊疗中患儿咳嗽、开放气道等将产生大量的飞沫和分泌物,污染诊室、设备和空气等,甚至感染与患儿近距离接触的医务人员、其他患儿及陪护人员,属于传染高危操作。为此特组织专家撰写儿科可弯曲支气管镜术在SARS-CoV-2感染疫情期间诊疗建议(试行),确立儿科在疫情特殊时期支气管镜诊疗适应证及防控方案,为从事儿科可弯曲支气管镜工作的医务人员提供依据。     

Laryngeal mask airway used as a delivery conduit for the administration of surfactant to preterm infants with respiratory distress syndrome

BACKGROUND: The laryngeal mask airway (LMA(TM), Laryngeal Mask Co. Ltd, Jersey, UK) is a supraglottic device used to administer positive pressure ventilation (PPV) in adults, pediatric and neonatal patients. OBJECTIVES: To avoid endotracheal intubation, we evaluated the feasibility and practicality of administering surfactant via the LMA(TM) in preterm infants with respiratory distress syndrome (RDS). METHODS: Infants less than 72 h old with a gestational age of < or =35 weeks and a birth weight of >800 g, treated with nasal continuous positive airway pressure (CPAP, 5 cm H2O) for RDS were eligible for inclusion in the study if the arterial-to-alveolar oxygen tension ratio (a/APO2) was <0.20 over a period of >60 min. RESULTS: Eight preterm infants, median gestational age 31 (range 28-35) weeks; birth weight 1,700 (880-2,520) g, treated with nasal CPAP for RDS were enrolled. Three hours after surfactant instillation, the mean a/APO2 was significantly increased (0.13 +/- 0.04 to 0.34 +/- 0.11; p < 0.01) without complications. CONCLUSIONS: The LMA may be a useful and noninvasive conduit for the administration of surfactant therapy. A large randomized comparative clinical trial will be required to confirm the efficacy of this technique.     

Laryngeal mask airway for the interhospital transport of neonates

Airway control during interhospital transport may present enormous management difficulties, even for experienced personnel. The laryngeal mask airway is an airway management device that has been established as a safe reliable tool in adult and pediatric practice. We describe 2 cases of successful interhospital transfer of infants with congenital airway malformations with the use of the laryngeal mask airway, and we review the literature.     

Noninvasive positive-pressure ventilation in children with lower airway obstruction.

STUDY OBJECTIVES: Mechanical ventilation of patients with severe lower airway obstruction presents significant risks; therefore, avoiding the intubation in these patients has been a principal goal of clinical management. Noninvasive positive-pressure ventilation has been shown to be effective in treating adults with chronic obstructive pulmonary disease, but its use has not been studied prospectively in children with acute obstructive lower airways disease. The objective of this study was to determine whether noninvasive mask ventilation improved respiratory function in children with asthma and other obstructive lower airways diseases. STUDY DESIGN: A prospective, randomized, crossover study. PATIENTS: A total of 20 children admitted to the pediatric intensive care unit with acute lower airway obstruction. METHODS: Children were randomized to receive either 2 hrs of noninvasive ventilation followed by crossover to 2 hrs of standard therapy or 2 hrs of standard therapy followed by 2 hrs of noninvasive ventilation. RESULTS: Using a Clinical Asthma Score, we found that noninvasive ventilation decreased signs of work of breathing such as respiratory rate, accessory muscle use, and dyspnea as compared with standard therapy. There was no serious morbidity associated with noninvasive ventilation. CONCLUSIONS: We conclude that noninvasive ventilation can be an effective treatment for children with acute lower airway obstruction.