Diagnosis and management of subglottic stenosis after neonatal ventilation

Article Abstract:

Up to eight percent of premature newborns who are intubated to aid respiration subsequently develop subglottic stenosis (SGS), constriction of the airway below the vocal cords. Certain factors predispose the patient to stenosis, including multiple intubations, tight fitting tubes with no air leak, excessive tube movement, and prolonged intubation. Subglottic stenosis is indicated by failed removal of the tubing, stridor (harsh respiratory sounds), decreased exercise tolerance, or croup. Physical examination of patients with SGS reveals difficult breathing and lack of energy for playing or talking. Increased respiration and heart rates are common, while slow heart rate and cyanosis (skin discoloration due to reduced hemoglobin in the blood) are critical indicators of progression of the disorder. Further examinations should include X-ray, including one after the patient swallows barium, visualization of the airway with laryngoscopy and bronchoscopy. These last techniques should be done while the patient is adequately anesthetized with appropriate medications to minimize secretions and spasm of the voice box. The traditional treatment has been to perform a tracheostomy, an opening in the windpipe. This has quick results, but is associated with up to 10 percent mortality. In addition, proper care of tracheostomies by parents may be difficult, and speech development may be affected. A second treatment option is to split the cricoid, the lowermost cartilage of the voice box (larynx). During this procedure, the largest possible endotracheal tube is inserted for 10 days while the patient is mechanically ventilated. Steroids are given to decrease inflammation just before removal of the tubing. This procedure avoids a tracheostomy, but does require prolonged use of intensive care facilities. When the patient reaches two years old, the most desirable procedure, laryngotracheal reconstruction, can be performed, which is successful in over 80 percent of cases. It also has short-term potential complications including difficulty swallowing and food aspiration. Poor voice quality may eventually occur if the grafted tissue is incorrectly placed. Further surgery is occasionally required. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Abnormalities, Pediatric respiratory diseases, editorial, Larynx

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Multicentre randomised controlled trial of high against low frequency positive pressure ventilation

Article Abstract:

Artificial ventilation (mechanical breathing assistance) is frequently used for infants who are born prematurely, and has been shown to improve their rate of survival. However, certain risks are involved in using artificial ventilation. This procedure, called positive pressure ventilation (PPV), uses pressurized air to inflate the lungs. In some cases, PPV can damage the lungs causing pneumothorax (the leakage of air out of the lungs into the pleural space between the lungs and rib cage) and lung disease. There are two different types of positive pressure ventilation: high frequency (HFPPV) and low frequency (LFPPV). HFPPV supplies air to the lungs at a frequency of 60 cycles per minute, while LFPPV provides air at a frequency of 20 to 40 cycles per minute. To determine which method of PPV is safest and has the lowest incidence of pneumothorax, lung disease and neurological complications, 346 infants who required artificial ventilation within 72 hours of birth were assessed. Of these infants, 174 received HFPPV and 172 received LFPPV. Nineteen percent of the infants receiving HFPPV developed pneumothorax, while 26 percent of the LFPPV infants developed pneumothorax. There were no differences in mortality or the incidence (number of new cases) of lung disease between the two groups. In a subgroup of 237 infants with lung disease (hyaline membrane disease), pneumothorax occurred in 18 percent of those receiving HFPPV and 33 percent of the LFPPV infants. These results indicate that HFPPV may be associated with fewer complications and a lower incidence of pneumothorax. However, it should be pointed out that other studies have reported no difference in the development of pneumothorax between LFPPV and HFPPV. (Consumer Summary produced by Reliance Medical Information, Inc.)

Injuries, Causes of, Lungs, Lung, Pneumothorax

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Gastro-oesophageal reflux in mechanically ventilated preterm infants

Article Abstract:

Gastro-oesophageal reflux (GOR) occurs when the acidic contents of the stomach flow backward from the stomach into the esophagus. This can cause a problem if some of the acidic fluid is inhaled (aspirated) into the trachea (windpipe) and lungs. The acid in the fluid can damage the tissues in the trachea and lungs (causing bronchopulmonary dysplasia), and worsen the conditions of patients who already have some form of lung disease. Previous studies have reported that GOR can occur in adults who are mechanically ventilated (receiving mechanical assistance for breathing). Many infants who are born prematurely require mechanical ventilation. To determine if GOR occurs in infants, 42 mechanically ventilated newborns were assessed. The infants were born prematurely, at 32 weeks' gestation (length of pregnancy), and weighed a little over 3 pounds each. The number of episodes of GOR were determined by measuring the amount of acid present in the esophagus. GOR occurred at an average rate of two times per hour. In addition, there was at least one episode of GOR per hour that caused significant amounts of acid to come up from the stomach into the esophagus. The incidence of GOR was not related to birth weight, gestational age, or length of time of mechanical ventilation. These results suggest that GOR can occur in infants who are mechanically ventilated and that the acid that comes up from the stomach may cause tissue damage in the trachea and lungs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Risk factors, Gastroesophageal reflux, Bronchopulmonary dysplasia

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