Evaluation of cuffed tracheal tube size predicted using the Khine formula in children

BACKGROUND: The correct size of cuffed endotracheal tube (CET) limits the risk of postintubation tracheal damage. The aim of this study was to compare the size of the CET used in children with the size predicted by the Khine formula [age (years)/4 + 3]. METHODS: After ethical committee approval, 204 children aged 1 day-15 years were included prospectively in the study. The choice of the size of the CET was made at the discretion of the attending anesthesiologist. The main criterion of judgment was the comparison of the leak before and after inflating the cuff at a pressure of 20 cm.H(2)O. Demographic data, tracheal tube size used and that predicted by Khine's formulae and side-effects were recorded. RESULTS: Overall, 21% of the CET were in accordance with the size predicted by the Khine formula. In the remaining patients, 72% were oversized and 7% undersized. In 12 cases, the size of CET chosen initially was modified: for a larger size in eight children and for a smaller size in four others. Six children (2.9%) presented with minor postoperative complications. CONCLUSIONS: Our data suggest that Khine's formula for predicting the appropriate tracheal tube size underestimates optimal size by 0.5 mm. We therefore recommend the use of the following formula: internal diameter of the CET = [age/4 + 3.5] in children >1 year of age which may be applied without increased risk of complications. The rate of tracheal reintubation as well as the detected leaks supports these recommendations.     

Pediatric anesthetic for tracheobronchial foreign body extraction: A survey of practice in France

Background

Tracheobronchial foreign body aspiration is a classic pediatric emergency, and its associated morbidity particularly depends on the anesthetic management, which differs according to the center and the practitioner.

Aims

The aim of this study was to evaluate the different anesthetic practices for tracheobronchial foreign body extraction.

Methods

A survey was sent via email to the member physicians of the Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF). The survey included 28 questions about the organizational and anesthetic management of an evolving clinical case.

Results

A total of 151 physicians responded to the survey. Only 13.2% of the respondents reported that their institution had a management protocol, and 21.7% required a computerized tomography scan before the procedure was performed for children who were asymptomatic or mildly symptomatic during the night. There were 56.3% of the respondents who reported that extraction with a rigid bronchoscope is the only procedure usually performed in their institution. Regarding rigid bronchoscopy, 47.0% used combined intravenous-inhalation anesthesia. The objective was to maintain the child on spontaneous ventilation for 63.6% of the respondents, but anesthesia management differed according to the physician's experience.

Conclusions

Our study confirms the diversity of practices concerning anesthetic for tracheobronchial foreign body extraction and found reveal differences in practice according to physician experience.     

Developmental anatomy of the airway

The airway develops from the primitive foregut at 4 weeks’ gestation. Congenital anomalies may result when this process is abnormal. The anatomy of the airway at birth is uniquely different from older children and adults, with a large tongue, long floppy epiglottis, large occiput and cephalad larynx. These features affect the technique required for facemask ventilation, supraglottic airway use and endotracheal intubation. A neutral head position and straight-bladed laryngoscope are usually used for intubation. Neonates are also obligate nasal breathers and simultaneously suckle and breath. Minute volume is rate dependent and the highly compliant chest easily displays sternal and intercostal recession during respiratory distress, and early onset of fatigue. From the neonatal period onwards the anatomy gradually begins to resemble that of adults. The cricoid descends caudally, the epiglottis becomes firmer and shorter, and the relatively large occiput recedes. The conventional wisdom of the cricoid ring being the narrowest part of the paediatric airway is not supported by contemporary investigation. The consequence of these findings on endotracheal tube selection and the rationale for increasing use of cuffed endotracheal tubes in children is discussed.     

纤维支气管镜介入在各型气管、支气管结核治疗中的作用探讨

目的探讨纤维支气管镜介入在各型气管、支气管结核治疗中的作用。方法对76例确诊的气管、支气管结核病人，在全身抗结核治疗的同时，根据镜下所见病变类型不同分别实施局部病变多点注射药物（异烟肼、链霉素、激素等）、局部病灶毁损术（微波、激光、高频电刀等）和高压球囊扩张术等治疗方法进行综合治疗。结果显效47例（61．8％），有效25例（32．9％），总有效率为94．7％。无效4例。结论应用纤维支气管介入对各型气管、支气管结核病人进行局部治疗，可迅速缓解症状，加快病灶吸收，避免形成气道狭窄及其相关的外科手术，并发症少见，病人易接收，值得临床推广应用。     

甲状腺癌侵犯喉和气管的外科处理

目的探讨甲状腺癌侵犯喉部和气管时的手术治疗。方法对8例甲状腺乳头状癌和滤泡状癌不同程度侵犯喉部和气管的惠者进行甲状腺切除、颈淋巴结清扫术、术中部分切除气管并用带蒂肌瓣一期修复，侵犯范围大的进行全喉切除。结果8例甲状腺癌均可全部切除，4例康复后发音和呼吸正常，3例呼吸正常但有不同程度的声嘶，1例同时喉全切除后用电子人工喉发音。8例术后均服用甲状腺素片，随访1～2年，没有复发。结论对甲状腺乳头状癌和滤泡状癌累及喉部和气管，手术范围可适当扩大，对于不超过气管直径1／3的气管缺损，可进行带蒂肌瓣一期修复，不会引起气管狭窄，喉部有较大的侵犯，可同时喉全切除术，甲状旁腺的再植可以存活，以提高患者的生活质量。     

低剂量螺旋CT扫描及后处理对小儿气管支气管异物的诊断价值

目的:探讨低剂量螺旋CT扫描及后处理技术对气管支气管异物的诊断价值。方法:对103例气道异物患儿行螺旋CT扫描,CT扫描参数为120kV,40～80mA,层厚7mm,间距7mm,螺距3,扫描后进行层厚3mm,间隔1.5mm内插式重建,对获得的数据进行图像后处理,后处理技术包括多平面重建(MPR)、最小密度投影(MinP)、表面遮盖法重建(SSD)、CT仿真支气管内窥镜(CTVB)。与支气管内窥镜进行比较。结果:103例气管支气管异物均获得满意的后处理图像,螺旋CT及后处理技术的诊断准确性为100%,异物定位与支气管镜检相符97.1%。其中MPR(包括CPR)在显示异物本身和局限性气管、支气管阻塞最好。结论:小儿气管支气管异物可用螺旋CT低剂量扫描,但不能用单一的后处理技术,应该将轴位和多种后处理技术结合起来,综合分析。本病的直接征象是显示异物本身,而局限性支气管阻塞需结合其他征象才能确诊。     

Tissue‐engineered trachea from a 3D‐printed scaffold enhances whole‐segment tracheal repair in a goat model

Traditional treatment therapies for tracheal stenosis often cause severe post‐operative complications. To solve the current difficulties, novel and more suitable long‐term treatments are needed. A whole‐segment tissue‐engineered trachea (TET) representing the native goat trachea was 3D printed using a poly(caprolactone) (PCL) scaffold engineered with autologous auricular cartilage cells. The TET underwent mechanical analysis followed by in vivo implantations in order to evaluate the clinical feasibility and potential. The 3D‐printed scaffolds were successfully cellularized, as observed by scanning electron microscopy. Mechanical force compression studies revealed that both PCL scaffolds and TETs have a more robust compressive strength than does the native trachea. In vivo implantation of TETs in the experimental group resulted in significantly higher mean post‐operative survival times, 65.00 ± 24.01 days (n = 5), when compared with the control group, which received autologous trachea grafts, 17.60 ± 3.51 days (n = 5). Although tracheal narrowing was confirmed by bronchoscopy and computed tomography examination in the experimental group, tissue necrosis was only observed in the control group. Furthermore, an encouraging epithelial‐like tissue formation was observed in the TETs after transplantation. This large animal study provides potential preclinical evidence around the employment of an orthotopic transplantation of a whole 3D‐printed TET.     

Utility of the 3‐Vessel and 3‐Vessel and Trachea Views in Prenatal Diagnosis of a Pulmonary Artery Sling

A pulmonary artery (PA) sling is a very rare congenital cardiovascular anomaly, and only a few studies have reported PA slings in fetuses. The relationship of the PA, aorta, ductus arteriosus, and trachea can be evaluated in the 3‐vessel and 3‐vessel and trachea views during fetal echocardiography. A PA sling can be detected by abnormal positioning of the left PA in relation to the trachea when sweeping from the 3‐vessel view cranially to the 3‐vessel and trachea view. Here we report 3 cases of fetal PA slings and their follow‐ups. Two cases were confirmed by postnatal echocardiography, and the other case was confirmed by a cardiovascular cast after pregnancy termination. We emphasize that the 3‐vessel and 3‐vessel and trachea views are of crucial importance in the prenatal diagnosis of a PA sling.     

喉气管外伤及狭窄的治疗

【目的】探讨喉外伤及狭窄的不同类型的临床治疗方法及效果。【方法】15年来收治各类喉外伤及狭窄患者38例。其中9例闭合性喉腔软组织伤,或合并软骨骨折而无移位,采用药物保守治疗,18例喉外伤颈部有开放性损伤伴有喉气管软骨损伤,或颈部无开放性损伤伴有喉气管软骨损伤,进行清创缝合,开放手术复位骨折,留置硅胶喉扩张管支撑,11例喉气管瘢痕狭窄采用瘢痕切除留置硅胶喉扩张管支撑,喉气管裂开肋软骨移植术,栅栏状喉气管成形术等方法治疗。【结果】37例患者呼吸通畅、发音满意,劳动力恢复,1例患者需终身保留气管造口。【结论】喉气管外伤应尽早明确诊断,早期治疗。喉气管外伤后瘢痕狭窄患者,根据狭窄部位和程度采取瘢痕切除留置硅胶喉扩张管支撑,栅栏状喉气管成形术及喉气管裂开肋软骨移植术,效果比较满意。     

ICU长期经口气管插管固定方法的研究

目的:对ICU长期经口气管插管的固定方法进行研究探讨。方法:采取随机抽样的方法,将160例气管插管病人随机分为两组,A组78例采用无牙垫直接用白寸带固定气管导管,B组82例采用胶布加牙垫外系白寸带固定气管导管。观察和比较两种固定方法的效果。结果:A组导管的牢靠程度明显优于B组,P0.05。结论:长期经口气管插管采用无牙垫直接用白寸带固定的方法,病人舒适、耐受,安全简单,方便有效。