Mediastinal bronchogenic cyst with respiratory distress from airway and vascular compression

A 45-year-old female, who had undergone emergency drainage of a cyst, complained of severe dyspnea. Chest computed tomography scans showed a large mass, compressing the right pulmonary artery, superior vena cava, and tracheal bifurcation. Subtotal resection of the cyst wall was carried out due to dense adhesion to adjacent structures. Immediately after surgery, her symptoms resolved completely. Mediastinal bronchogenic cysts in the subcarinal space can cause severe respiratory distress from airway and vascular compression.     

Vocal cord closure. A cause of upper airway obstruction during controlled ventilation.

Studies of vocal cord function were undertaken in a quadriplegic patient requiring ventilatory assistance, and in 2 normal subjects during controlled ventilation in a tank-type respirator. When the patient and the normal subjects relaxed and made no conscious effort to assist the respirator, the vocal cords were observed to close during inspiration and a large pressure gradient (12 to 19 cm H2O) developed across the cords. When the subjects made a slight inspiratory effort ("assist" mode), the cords opened widely during inspiration. There were large increases in flow and tidal volume in the "assist" mode compared with passive ventilation. Measurements of transdiaphragmatic pressure and esophageal pressure showed that these variables did not increase with the slight assist. Thus, increase in ventilation during the "assist" mode appeared to be due to alleviation of inspiratory obstruction at the level of the vocal cords. The same phenomenon was observed in the patient during phrenic nerve pacing. A pacemaker was designed to be triggered by the electromyographic impulse from an accessory muscle of respiration. In this manner, vocal cord opening could be coordinated with the mechanical assist given by the phrenic nerve pacer.     

Tracheitis: the 'other' cause of upper airway obstruction

A 22-year-old woman presented to an ear, nose, and throat clinic with an upper respiratory infection and sudden stridorous respirations. Aerosolized isoethrane therapy was beneficial and fiber-optic nasolaryngoscopy revealed a normal supraglottis and purulent intratracheal secretions. Secretions were cultured and grew Staphylococcus aureus and alpha hemolytic Streptococcus. IV cefazolin was initiated and the patient recovered without sequelae. This case illustrates a rare cause of upper airway obstruction, tracheitis. Tracheitis has been found in the pediatric literature. This is the first adult case reported in the literature.     

Hysterical stridor: a benign cause of upper airway obstruction

We present the cases of three patients with stridor that resolved spontaneously. Paradoxical vocal cord motion was documented in one patient. Normal vocal cord motion was present in the other two patients, but stridor had resolved in both cases. Many different terms have been used to describe this entity in the literature. Emergency physicians must recognize the subtle signs of hysterical stridor. Once more serious etiologies are ruled out, sedation and reassurance instead of aggressive airway intervention are required for this benign condition.     

Tracheal sounds in upper airway obstruction.

A boy with subglottic narrowing secondary to laryngotracheitis presented with noisy breathing. Acoustic measurements of tracheal sounds at standardized air flows correlated well with the clinical course and with spirometric assessments. This indicates the potential value of respiratory sound characterization in patients with upper airway obstruction.     

Functional upper airway obstruction. Psychogenic pharyngeal constriction.

A 15-year-old boy, known to have asthma, developed acute inspiratory airway obstruction with marked stridor. Spirometry indicated extrathoracic airway obstruction and a bronchofiberoptic examination disclosed narrowing in the hypopharynx. After administration of sedatives, the stridor suddenly disappeared. Psychotherapy decreased the frequency of subsequent stridor attacks. It is suggested that psychogenic pharyngeal constriction may have caused the upper airway obstruction with respiratory distress.     

Retropharyngeal hematoma as a new cause of acute upper airway obstruction in rheumatoid arthritis

A patient with severe rheumatoid arthritis (RA) receiving chronic anticoagulation therapy developed acute life threatening airway obstruction. The source of obstruction was a retropharyngeal hematoma compressing the upper airway rather than acute laryngeal dysfunction from the patient's RA. Our case illustrates a new cause of acute stridor and airway obstruction in RA. Publications on upper airway obstruction in RA and airway obstruction secondary to retropharyngeal hematoma are discussed.     

Diagnosis of upper airway obstruction by pulmonary function testing.

We compared 11 patients with upper airway obstruction (obstruction at or proximal to the carina) to 22 patients with chronic obstructive pulmonary disease and to 15 normal subjects utilizing spirometry, lung volumes, airway resistance, maximal voluntary ventilation, single-breath diffusion capacity, and maximal inspiratory and expiratory flow-volume loops. Four values usually distinguished patients with upper airway obstruction: (1) forced inspiratory flow at 50 percent of the vital capacity (FIF50%) less than or equal to 100 L/min; (2) ratio of forced expiratory flow at 50 percent of the vital capacity of the FIR50% (FEF50%/FIF50%) larger than or equal to 1; (3) ratio of the forced expiratory volume in one second measured in milliliters to the peak expiratory flow rate in liters per minute (FEV1/PEFR) larger than or equal to 10 ml/L/min; and (4) ratio of the forced expired volume in one second to the forced expired volume in 0.5 second (FEV1/FEV0.5) larger than or equal to 1.5. The last ratio can be determined with a simple spirometer.     

Bronchiolitis in adults. A reversible cause of airway obstruction associated with airway neutrophils and neutrophil products

In the past 4 yr, 16 adult patients were identified who had accelerated onset of a severe respiratory disorder (usually obstructive in nature) that was clinically distinct from the more commonly encountered chronic obstructive disorders (e.g., chronic bronchitis, emphysema, asthma, bronchiectasis, cystic fibrosis, and alpha 1-antitrypsin deficiency). These patients, termed patients with "bronchiolitis," underwent pulmonary function testing, bronchoscopy with bronchoalveolar lavage (BAL), and open lung biopsy. Although lung biopsy findings varied somewhat among the patients, each biopsy contained a prominent component of bronchiolitis. Pulmonary function testing and BAL were also repeated after 3 months of treatment with oral prednisone (1 mg/kg/day). Initial BAL neutrophil percentages were significantly higher in the bronchiolitis group (54 +/- 10%) than in smokers with chronic bronchitis (3.9 +/- 1.0%) or in normal nonsmoking volunteers (0.8 +/- 0.5%) (p less than 0.01, both comparisons). Eleven of 15 patients with bronchiolitis had significant improvement (greater than or equal to 15% increase in FEV1) in their lung function after prednisone treatment. Furthermore, this "responder" subgroup had a significant reduction in BAL neutrophil percentages after treatment with prednisone (46 +/- 15% to 6 +/- 3%, p less than 0.05). Finally, the neutrophil products collagenase and myeloperoxidase were detected in the BAL fluid of patients with bronchiolitis. These findings suggest a central role for the neutrophil in the pathogenesis of bronchiolitis and emphasize the utility of BAL in the identification of these patients.     

A modified nasopharyngeal tube to relieve high upper airway obstruction

Infants with high upper airway obstruction (UAO) are managed with a variety of techniques to relieve their UAO. Among these techniques, the least invasive and safest is the nasopharyngeal tube (NPT). However, the traditional NPT is not always satisfactory, and tracheostomies need to be done. We recently described a modified NPT technique that, in contrast to the traditional tube, does not add airway dead space and resistance, is easy to use, is well-tolerated, has proven highly successful, and allows the simultaneous use of oxygen nasal prongs. This modified NPT has many advantages over the traditional NPT as a temporary management of high UAO that resolves with growth of the infant. This report highlights the respiratory care of 10 infants with high UAO (Pierre Robin syndrome, Down syndrome, Goldenhar syndrome, isolated microngathia, and idiopathic hypotonia) who were managed with a modified NPT. The modified NPT described potentially reduces the need for surgical intervention to relieve high UAO in infants.     

腹膜后支气管源性囊肿1例报告

支气管囊肿（bronchogenic cysts,BC）是源于胚胎早期发育过程中原始前肠异常发育所致的一种少见的先天性囊性疾病^（[1]）。具体的发病机制尚不明确。任何由原始胚胎前肠发育而成的器官（食管、胃、十二指肠上部、肝脏、胰腺和胆囊）或附近均可发生此类疾病,通常好发于胸腔（特别是后纵隔）和肺实质^（[2]）,也可发生于胸腔外。而腹膜后支气管源性囊肿（retroperitoneal bronchogenic cyst,RBC）是极其罕见的,     

Infectious mononucleosis presenting as upper airway obstruction

Upper airway obstruction though a common complication of infectious mononucleosis is rarely considered in differential diagnosis of stridor. We report a three-year-old child who had upper airway obstruction due to infectious mononucleosis, managed conservatively with oxygen, intravenous fluids and steroids.