The effect of head position and angle of tracheal bifurcation on bronchus catheterization in the intubated neonate.

The effect of head position and angle of tracheal bifurcation on bronchus catheterization was studied in newborn infants. Frequency of bronchus catheterization following appropriate head positioning was evaluated radiographically after passage of a No. 5 French feeding tube in eight intubated neonates within 30 minutes post mortem. Positioning the infants head to the right in preparation for a suctioning procedure may facilitate but not assure catheterization of the left main stem bronchus (LMSB). Positioning the infant's head straight or rotating to the left appears to be equally effective in catheterization of the right main stem bronchus (RMSB). The predominance of RMSB catheterization in infants with their head in the straight position may be explained by the different angles of mainstem bronchi divergence which we determined using radiographs. The angles of divergence of the LMSB and the RMSB from the trachea averaged 44.4 degrees and 24.1 degrees, respectively.     

儿童气管性支气管20例临床分析

目的分析经支气管镜检查诊断的气管性支气管患儿的临床特征。方法回顾分析20例接受支气管镜检查而确诊的气管性支气管患儿的镜下结果、临床表现、治疗与转归。结果先天性气管性支气管患儿20例,右侧气管性支气管19例,移位型18例,其中6例为2种或2种以上气道异常;左侧气管性支气管1例,为移位型。20例患儿的临床症状包括持续或反复的喘息,持续性局限性肺炎、肺不张,局限性肺气肿。大部分患儿经临床对症治疗后症状缓解。结论气管性支气管异常在临床上并不少见,其临床表现为治疗反应不佳的反复喘息、肺炎、肺不张以及肺气肿等,对可疑患儿应及时进行支气管镜检查以明确诊断。     

Infant sleeping position and inspiratory pressures in the upper airways and oesophagus

Inspiratory pressures were measured at three levels in the upper airways and in the oesophagus in different sleeping positions. Thirty one consecutive healthy infants were examined at the age of 1-3 days, 25 of these at 6 weeks, and 23 at 12 weeks. Oxygen saturation, an electrocardiogram, transthoracic impedance, nasal airflow, and inspiratory pressure in the epipharynx, oropharynx, hypopharynx, and in the intrathoracic part of the oesophagus were measured. There was no significant change in the heart rate, oxygen saturation, or respiratory rate in the four sleeping positions. The peak negative inspiratory pressures obtained from the oesophagus (PES) were significantly lower in the supine head straight compared with the supine head turned and the prone positions. At 6 weeks, the only significant difference was between the supine head straight and the prone positions. The PES is less negative at all ages in the supine head straight than in all other sleeping positions, but this does not reach statistical significance.     

Infant sleeping position and inspiratory pressures in the upper airways and oesophagus.

Inspiratory pressures were measured at three levels in the upper airways and in the oesophagus in different sleeping positions. Thirty one consecutive healthy infants were examined at the age of 1-3 days, 25 of these at 6 weeks, and 23 at 12 weeks. Oxygen saturation, an electrocardiogram, transthoracic impedance, nasal airflow, and inspiratory pressure in the epipharynx, oropharynx, hypopharynx, and in the intrathoracic part of the oesophagus were measured. There was no significant change in the heart rate, oxygen saturation, or respiratory rate in the four sleeping positions. The peak negative inspiratory pressures obtained from the oesophagus (PES) were significantly lower in the supine head straight compared with the supine head turned and the prone positions. At 6 weeks, the only significant difference was between the supine head straight and the prone positions. The PES is less negative at all ages in the supine head straight than in all other sleeping positions, but this does not reach statistical significance.     

Lobar Atelectasis after Nasotracheal Intubation in Newborn Infants

Roper, P. C., Vonwiller, J. B., Fisk, G. C. and Gupta, J. M. (1976). Aust. paediat. J. , 12, 272–275. Lobar atelectasis after nasotracheal intubation in newborn infants. Atelectasis of the right upper lobe is not uncommon after removal of a nasotracheal tube which has been in place for several days. Lobar atelectasis developed in 18 of 188 who were intubated. Six patients had atelectasis of various lobes (predominantly the right upper lobe) while intubated, and 12 after extubation (all of these being the right upper lobe or right lung).
Two patients had recurrent atelectasis, a nasotracheal tube being reinserted for periods of several days. Since then the management of patients after extubation has been changed. Physiotherapy is aimed at clearing the right upper lobe. When tracheal suction is needed, intubation is limited to a few minutes. The average time to expand the affected lobes has been less with this regime. It is suggested that atelectasis of the right upper lobe is associated with (1) damage to the main bronchus by suction catheters and (2) the position of the right upper lobe bronchus.     

临床特征联合多层螺旋 CT 三维重建在儿童气管支气管 异物诊断中的价值

目的探讨临床特征联合多层螺旋CT三维重建在诊断儿童气管支气管异物中的应用价值。方法回顾2012年7月至2015年12月确诊的52例气管支气管异物患儿的资料,从临床特征和多层螺旋CT三维重建技术两方面进行分析总结。结果 52例患儿中男35例、女17例,3岁以下占82.7%。临床表现中以反复咳嗽伴喘憋为主30例,以突发刺激性呛咳为主22例;主要临床体征为双肺呼吸音不对称(43例),闻及哮鸣音(32例)、湿啰音(29例)。多层螺旋CT三维重建阳性率为100%,与手术结果一致,其中5例异物嵌顿于气管内,27例嵌顿于右支气管内,20例嵌顿于左支气管内;主要合并症有肺气肿(38例)、支气管炎和肺炎(32例)、肺不张(5例)。结论临床特征与多层螺旋CT三维重建技术相结合可为诊断儿童气管支气管异物提供确实可靠的依据。     

Head nodding associated with intermittent esotropia

Head nodding (to-and-fro turning about the vertical cervical axis) associated with abnormal eye movements may be seen in spasmus nutans and congenital nystagmus. In the absence of abnormal eye movements, it may be indicative of neurological disease (eg, cerebellar disease, basal ganglia dysfunction). We report a neurologically normal infant without nystagmus but with intermittent head nodding and intermittent esotropia, whose head movements manifested only when his eyes were straight. The head movements ceased with the occlusion of either eye or spontaneous onset of esotropia. When his head was forcibly stabilized, he immediately developed esotropia. The head movement presumably facilitated fusion, although the mechanism of action is unknown.     

Evaluation of tracheal bronchus in Chinese children using multidetector CT

Background Tracheal bronchus is a congenital bronchial anomaly. The diagnosis should be considered early in intubated patients. Multidetector computed tomography (MDCT) is the newest modality for evaluating tracheal bronchus. Objective To evaluate the utility of 16-slice MDCT in children with tracheal bronchus and to characterize the frequency of tracheal bronchus in children with congenital heart disease. Materials and methods From June 2005 to May 2007, 3,187 consecutive children (1,124 with congenital heart disease and 2,063 without congenital heart disease) underwent MDCT examination. Minimum-intensity projection reconstruction was performed to show the tracheobronchial tree in every case. Results Tracheal bronchus was found in 42 children (3.74%) with congenital heart disease but in only 6 children (0.29%) without congenital heart disease. Among the 48 children with tracheal bronchus, 45 had right-side tracheal bronchus and 3 had bilateral tracheal bronchi with heterotaxy syndrome. The diagnostic sensitivity of MDCT was 100% (48/48). Conclusion MDCT is a reliable imaging technique for the diagnosis of tracheal bronchus. Our data showed that right-side tracheal bronchus was more common and bilateral tracheal bronchi usually occurred with heterotaxy syndrome. In addition, tracheal bronchus often occurred with congenital heart disease. The angle between the tracheal bronchus and the trachea is important and should be measured.     

Use of central venous catheters implanted subcutaneously in children with neoplasms

The use of totally implantable right atrial catheters was evaluated in pediatric oncology patients. From September 15, 1987 to March 31, 1989, 26 catheters were inserted in patients (1 year to 20 years of age) with the following diagnosis: acute leukemia (6), osteosarcoma (5), lymphoma (4), central nervous system tumors (6), osteosarcoma (5), lymphoma (4), central nervous system tumors (6) and other solid tumors (5). Total number of catheter days was 5,475. The catheters were maintained for a mean of 210 days (range 10-534). Complications included: documented local infection in 1 patient, successfully treated with antibiotics without removing the catheter and transient obstructions resolved with injection of heparin or urokinase in other children. The use of these right atrial catheters has been widely accepted by patients and families as well as by the health team. Complications have been minimal. Our experience confirms that these catheters contribute to improving quality of life in pediatric patients with neoplasms.     

Bridging bronchus and posterior left pulmonary artery: a unique association

A 6-month-old female with a lifelong history of respiratory distress became increasingly difficult to manage and required right upper and middle pulmonary lobectomies for worsening emphysema and mediastinal shift. The postoperative course was stormy and confusing and the patient died despite emergency tracheostomy. The autopsy disclosed an anomalous bronchus to the right lower lobe, originating from the left mainstem bronchus. In addition, the left main pulmonary artery was positioned posterior to the left mainstem bronchus. Two other cases of bridging bronchus have been reported, but the association with posterior left pulmonary artery has not been described.     

Unilateral or asymmetric congenital ptosis, head posturing, and amblyopia

PURPOSE: To determine the prognostic implication of compensatory head posturing in patients with unilateral or asymmetric congenital ptosis. METHODS: A retrospective review of 80 consecutive patients with unilateral or asymmetric congenital ptosis was performed. The presence of documented compensatory head posturing, age of onset, age of presentation, visual acuity, refraction, and amblyopia were recorded, and binocularity was tested. RESULTS: Five of seven (71%), patients with unilateral or asymmetric congenital ptosis and compensatory head posturing had amblyopia. All of these patients had straight eyes and four of the five amblyopic patients had anisometropia of less than 2 diopters (D). CONCLUSION: The high incidence of amblyopia in this group can occur in the absence of significant anisometropia and strabismus. This unusually high incidence of amblyopia in this subgroup of patients with unilateral or asymmetric congenital ptosis and compensatory head posturing warrants compulsive examination and prophylactic part-time occlusion therapy of the nonptotic eye until reliable vision testing can be performed.     

Non-invasive diagnosis of tracheobronchomalacia using a modified ventilation radioisotope lung scan.

The use of radionuclide ventilation lung scan to characterise the physiological effects of tracheobronchomalacia is a novel application of this non-invasive technique. In the reported case the right upper lobe was found to be not ventilated below a pressure of 20 cm H2O despite evidence from a dynamic tracheobronchogram of the right upper lobe bronchus opening at the lower pressure of 15 cm H2O.     

Non-invasive diagnosis of tracheobronchomalacia using a modified ventilation radioisotope lung scan

The use of radionuclide ventilation lung scan to characterise the physiological effects of tracheobronchomalacia is a novel application of this non-invasive technique. In the reported case the right upper lobe was found to be not ventilated below a pressure of 20 cm H2O despite evidence from a dynamic tracheobronchogram of the right upper lobe bronchus opening at the lower pressure of 15 cm H2O.     

"Porcine bronchus" diagnosed in neonatal period

“Porcine bronchus” is a right upper lobe bronchus arising directly from the trachea. This is an infrequent congenital abnormality and it usually represents the displaced origin of a normal bronchus. We herewith report a case of a child who was diagnosed to have tracheal bronchus in neonatal period and followed subsequently until 13 months of age.     

Pneumothorax and pulmonary intersticial emphysema: treatment with selective bronchial occlusion and high frequency ventilation

OBJECTIVE: Our purpose was to report the use of selective bronchial occlusion with a balloon catheter, associated with high frequency ventilation for a successful treatment of a persistent left hypertensive pneumothorax associated with left bronchopleural fistula and severe bilateral pulmonary intersticial emphysema.METHODS: A newborn infant of 20 hours of age was referred to our ICU for treatment of severe respiratory distress and hemodynamic failure after spontaneous hypertense left pneumothorax. Despite being submitted to conventional mechanical ventilation, volume resuscitation and vasoactive drugs infusion, the patient worsened. Therefore, he underwent selective occlusion of the main left bronchus, a measure that can be effective to interrupt gas flow to the affected lung in situations like lung injury with air leak. In order to avoid worsening intersticial emphysema and air leak, high frequency ventilation was associated. This method is characterized by very low tidal volume, lower than the rest functional capacity, and is indicated in acute respiratory failure associated with air leak syndrome.RESULTS: Selective left main bronchus occlusion and high frequency ventilation were successfully used to treat the patient who, after that, presented a favorable outcome with full hemodynamic and respiratory recovery.CONCLUSION: Selective left main bronchus occlusion permitted mechanical ventilation of the contralateral side and high frequency ventilation allowed adequate oxygenation and ventilation maintenance with decrease of the risk of lung injury and also allowed recovery from the interstitial emphysema.     

Efficacy of thromboresistant umbilical artery catheters in reducing aortic thrombosis and related complications

Previous in vitro and in vivo reports suggest that catheters constructed of polyurethane with heparin bonded to the surface (HB-PU) are less thrombogenic than catheters made of polyvinyl chloride (PVC). A randomized trial sufficiently large (power 80%) to detect a reduction in the incidence of umbilical artery (UA) catheter complications, including aortic thrombus formation, from 45% to 20% was conducted in 125 infants. The infants were monitored for complications possibly related to the use of a UA catheter, such as systemic hypertension and abnormalities of lower extremity perfusion. The presence of aortic thrombi was assessed by ultrasound study 3.5 +/- 1.2 (SD) days and 11.1 +/- 2.3 days after insertion of the catheter. The use of HB-PU umbilical catheters did not lead to a significant reduction in the incidence of complications and aortic thrombi compared with the use of PVC catheters. The lack of reduction may have been related to the prolonged duration of catheter use in both groups. A much larger study would have been required to detect a smaller, but perhaps clinically significant, reduction in catheter-associated complications.     

纤维支气管镜结合多层螺旋CT检查对无脾综合征伴双侧气管性支气管的评估作用

目的使用多层计算机断层扫描(MSCT)和纤维支气管镜对8例双侧气管性支气管病例进行评估。方法在接受纤维支气管镜检查的1 382例患儿中有8例诊断为双侧气管性支气管,对此8例同时进行MSCT检查。结果 7例患儿内镜及MSCT均诊断为双侧气管性支气管,另1例患儿胸部CT加三维气道重建提示右侧气管性支气管,伴右上肺不张,经支气管镜检查并清理阻塞物后提示为双侧气管性支气管。该8例儿童均诊断为无脾综合征。结论纤维支气管镜结合MSCT检查对无脾综合征合并双侧气管性支气管病变的诊断具有较好的价值,并为复杂心血管畸形纠治中的气道管理提供了保障。     

The importance of continuous ambulatory peritoneal dialysis technics in relation to intermittent peritoneal dialysis in acute renal insufficiency in children. Apropos of 7 cases

We report seven cases of acute renal failure (ARF) treated by continuous ambulatory peritoneal dialysis (CAPD). ARF was caused by hemolytic uremic syndrome in six patients and acute fetal distress in one neonate. Mean age was 28 months (range 6 days-6 years). A flexible Tenckhoff catheter was inserted surgically under brief (10 minutes) general anesthesia in all patients. During the first 24 hours, in order to avoid clogging of the catheter, exchanges were done every 45 minutes with 20 ml/kg dialysate initially, gradually increased to 40-50 ml/kg. Thereafter, 5 to 8 exchanges were done every day (mean duration 9 days, range 4-21) until creatinine clearance reached 15 ml/mn/1.73 m2. No case of peritonitis or leakage was recorded. In two patients, migration of the straight catheter caused flow obstruction. None of the crook-shaped catheters migrated. Because dialysis was continuous and fluid balance could be controlled by using a hypertonic dialysate if called for, optimal protein (1-1.5 g/kg/d) and energy intake were possible. This intake was ensured mainly by continuous enteral nutrition. Improved patient comfort (no immobilization, no repeated punctures) and staff comfort (technical simplicity, independence from a cycler) are further non-negligeable advantages of CAPD.     

Malassezia furfur: a cause of occlusion of percutaneous central venous catheters in infants in the intensive care nursery

Growth of Malassezia furfur in the intravascular catheter used for administration of lipid emulsion resulted in occlusion of deep intravascular Silastic catheters in 12 infants in 2 intensive care nurseries. At the time of occlusion visible growth was noted in the clear catheter which was connected to the Silastic intravascular line. Five infants showed clinical signs suggestive of sepsis. The yield of M. furfur from blood cultures and catheter tips was low even when oil enrichment was used. The highest yield of M. furfur was found in the connecting catheter (11 of 11). The source from and the route by which M. furfur entered the catheter remain unclear. The potential portals of entry include the proximal and distal ends of the connecting catheter as well as the colonized skin of the infants and caretakers.