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Byline: Maria Elena Ochoa (1), Maria del Carmen Marin (2), Fernando Frutos-Vivar (3,4), Federico Gordo (5), Jaime Latour-Perez (6), Enrique Calvo (5), Andres Esteban (3,4) Keywords: Upper airway obstruction; Reintubation; Cuff-leak test; Meta-analysis; Likelihood ratio Abstract: Purpose To evaluate, in adults, the diagnostic accuracy of the cuff-leak test for the diagnosis of upper airway obstruction secondary to laryngeal edema and for reintubation secondary to upper airway obstruction. Methods Systematic review without language restrictions based on electronic databases and manual review of the literature up to December 2008. When appropriate, a random-effects meta-analysis and meta-regression (Moses' method) were performed. Results Upper airway obstruction was the outcome in nine studies with an overall incidence of 6.9%. There was significant heterogeneity among studies. The pooled sensitivity was 0.56 (95% confidence interval: 0.48--0.63), the specificity was 0.92 (95% CI: 0.90--0.93), the positive likelihood ratio was 5.90 (95% CI: 4.00--8.69), the negative likelihood ratio was 0.48 (95% CI: 0.33--0.72), and the diagnostic odds ratio was 18.78 (95% CI: 7.36--47.92). The area under the curve of the summary receiver-operator characteristic (SROC) was 0.92 (95% CI: 0.89--0.94). Only three studies have evaluated the accuracy of the cuff-leak test for reintubation secondary to upper airway obstruction. Overall incidence was 7%. The pooled sensitivity was 0.63 (95% CI: 0.38--0.84), the specificity was 0.86 (95% CI: 0.81--0.90), the positive likelihood ratio was 4.04 (95% CI: 2.21--7.40), the negative likelihood ratio was 0.46 (95% CI: 0.26--0.82), and the diagnostic odds ratio was 10.37 (95% CI: 3.70--29.13). Conclusions A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction. Author Affiliation: (1) Fundacion Valle del Lili, Cali, Colombia (2) Hospital Regional 1Ao de Octubre, Mexico DF, Mexico (3) Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12,500, Getafe, Madrid, Spain (4) CIBER Enfermedades Respiratorias, Madrid, Spain (5) Hospital del Henares, Coslada, Madrid, Spain (6) Hospital General Universitario de Elche, Alicante, Spain Article History: Registration Date: 16/04/2009 Received Date: 03/03/2009 Accepted Date: 14/04/2009 Online Date: 28/04/2009

OBJECTIVE. The objective of this study was to compare the respiratory physiologic features of healthy term infants placed in either a car bed or a car safety seat. METHODS. Within the first 1 week of life, 67 healthy term infants were recruited and assigned randomly to be monitored in either a car bed (33 infants) or a car safety seat (34 infants). Physiologic data, including oxygen saturation and frequency and type of apnea, were obtained and analyzed in a blinded manner. RESULTS. The groups spent similar amounts of time in the devices (car bed: 71.6 minutes; car seat: 74.2 minutes). The mean oxygen saturation values were not different between the groups (car bed: 97.1%; car seat: 97.3%). The percentages of time with oxygen saturation of CONCLUSIONS. The respiratory physiologic features of infants in the 2 car safety devices were observed to be similar. Of note, substantial periods of time with oxygen saturation of Key Words apnea, car seats, car beds Abbreviation AAP--American Academy of Pediatrics, INFANT CAR SEATS play a critical role in the safe transportation of young infants and have reduced the rates of deaths and injuries during motor vehicle accidents. As with all [...]

Byline: Samir Jaber (1), Gerald Chanques (1), Stefan Matecki (2), Michele Ramonatxo (2), Christine Vergne (3), Bruno Souche (1), Pierre-Francois Perrigault (1), Jean-Jacques Eledjam (1) Keywords: Post-extubation stridor Airway obstruction Laryngeal edema Extubation failure Cuff-leak test Helium-oxygen Unplanned extubation Abstract: Abstract Objective. To evaluate the incidence and identify factors associated with the occurrence of post-extubation stridor and to evaluate the performance of the cuff-leak test in detecting this complication. Design. Prospective, clinical investigation. Setting. Intensive care unit of a university hospital. Patients. Hundred twelve extubations were analyzed in 112 patients during a 14-month period. Intervention. A cuff-leak test before each extubation. Measurements and results.The incidence of stridor was 12%. When we chose the thresholds of 130 ml and 12% to quantify the cuff-leak volume, the sensitivity and the specificity of the test were, respectively, 85% and 95%. The patients who developed stridor had a cuff leak significantly lower than the others, expressed in absolute values (372+-170 vs 59+-92 ml, p Conclusion. A low cuff-leak volume ( Author Affiliation: (1) Department of Anesthesiology. Intensive Care and Transplantation Unit (DAR B), Chu de Montpellier Hopital Saint Eloi, 80, avenue Augustin Fliche, 34295 Montpellier Cedex 5, France (2) Service central de Physiologie Clinique, Chu de Montpellier Hopital Arnaud de Villeneuve, 371, avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France (3) Department of Biostatistics, Faculty of Medicine, Chu de Montpellier Hopital Arnaud de Villeneuve, 371, avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France Article History: Received Date: 25/04/2002 Accepted Date: 08/10/2002 Article note: Electronic Publication

Byline: S. Epstein (1) Keywords: Extubation failure Mechanical ventilation Outcome Non-invasive ventilation Respiratory secretions Upper airway obstruction Predictors Abstract: The need for reintubation within 24--72 h of planned extubation is a common event, occurring in 2--25% of extubated patients. Risk factors for extubation failure include being a medical, multidisciplinary or paediatric patient age >70 years a longer duration of mechanical ventilation use of continuous intravenous sedation and anaemia (haemoglobin Author Affiliation: (1) Medical Intensive Care Unit, Pulmonary and Critical Care Division, Box 369, New England Medical Center, Tufts University School of Medicine, 750 Washington St., Boston, MA 02111, USA Article History: Received Date: 22/11/2001 Accepted Date: 25/01/2002 Article note: Electronic Publication

Byline: Pankaj Kumar (1), Amit Roy (1), Daniel J. Penny (2), George Ladas (1), Peter Goldstraw (1) Keywords: Congenital cardiac defects Vascular compression Airway obstruction Ventilated children Stents Abstract: Objective: Young children with congenital cardiac defect and airway obstruction leading to ventilator dependency present a significant clinical challenge with uncertain outcome. Design: Retrospective review of our experience with self-expanding metal stents in these young children between 1996--2000. Results: Airway stenting has been undertaken in five such children (four boys, one girl) at our institution. Their mean age was 7.4 months (range 2--14 months), and four of the five had undergone congenital cardiac surgery and could not be weaned from the ventilator following surgery. These five children were ventilator dependent for a mean of 112 days (range 40--210 days, median 71). A total of ten self-expanding metal stents were inserted (4--11 mm in diameter and 15--33 mm in length). The sites stented included the trachea (two stents), the left main bronchus (three stents) and the bronchus intermedius (five stents). Four of these five children were successfully weaned from the ventilator and extubated after a mean time interval of 6 days (range 2--11 days, median 5.5) after stenting. One child failed to wean from the ventilator, required tracheostomy and is ventilator dependent after 8 months. There was one death 2 months after extubation but unrelated to the airway. Three children remain well and asymptomatic 24, 36 and 54 months after stenting. Conclusions: Airway stenting in such young children is an infrequent procedure often undertaken in dire circumstances. We have found it valuable in enabling ventilator-dependent children to be extubated with encouraging early results. Their long-term outlook remains uncertain and is dependent on the underlying cardiac status. Author Affiliation: (1) Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK (2) Paediatric Intensive Care, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK Article History: Received Date: 30/05/2001 Accepted Date: 05/11/2001 Article note: Electronic Publication

A physical exam may be all that is needed to rule out adenoid obstruction in children if symptoms such as mouth breathing and nasal voice are absent. Researchers compared physician ratings of the degree of obstruction as well as physician evaluations of X-rays of the head in 1,033 children. There was strong agreement among physicians when symptoms were obvious or completely absent. However, intermediate levels of symptoms were harder to diagnose without X-rays. X-rays may not be necessary if the child has no symptoms., Objective. As part of a comprehensive study of indications for tonsillectomy and adenoidectomy, we investigated the reliability of standardized clinical assessments and standardized roentgenographic assessments of adenoidal obstruction of the nasopharynx, and the degree of correlation between clinical assessments and roentgenographic assessments. Methods. We rated the degree of patients' mouth breathing and patients' speech hyponasality on a 4-point scale (none = 1, mild = 2; moderate = 3; marked = 4), we averaged the ratings for each child to obtain a Nasal Obstruction Index, and we determined levels of interobserver agreement concerning the ratings. We classified lateral soft-tissue roentgenograms of the nasopharynx, based on assessments of adenoid size and of nasopharyngeal airway patency, as showing either no obstruction, borderline obstruction, or obstruction, and we determined levels of inter- and intraobserver agreement concerning the classifications. Finally, we determined correlations in individual patients between clinical ratings and roentgenographic ratings of nasal/nasopharyngeal obstruction, and calculated the predictive values of clinical ratings based on roentgenographic ratings as the gold standard. Results. In sets of paired examinations, weighted [Kappa] values for interobserver agreement concerning mouth breathing (total, 235 children) and speech hyponasality (total, 648 children) ranged from 0.84 to 0.91. The value for interobserver agreement concerning roentgenographic assessment of nasopharyngeal airway status (207 children) was 0.92, and for intraobserver agreement (191 children) 0.88. The Kendall's [Tau] b value for concordance between Nasal Obstruction Index values and roentgenographic ratings (1033 children) was 0.51. Nasal Obstruction Index values at the lower and upper extremes--ie, 1.0 and [is greater than or equal to] 3.5, respectively--were highly predictive of concordant roentgenographic ratings. Conclusions. We conclude that standardized clinical ratings of the degree of children's mouth breathing and speech hyponasality provide reliable and reasonably valid assessments of the presence and degree of adenoidal obstruction of the nasopharyngeal airway. These clinical assessments are particularly valid at the extremes of either marked obstruction or no obstruction. Clinical assessment alone may be insufficient to establish the presence of adenoidal obstruction, but clinical assessment alone when findings are unequivocally negative can suffice to rule out adenoidal obstruction with a high degree of confidence. Pediatrics 1998;101:979-986; adenoidal obstruction, nasal obstruction, nasopharyngeal airway, clinical assessment, roentgenographic assessment, mouth breathing, speech hyponasality, diagnostic reliability, diagnostic validity., ABBREVIATION. AN, adenoidal-nasopharyngeal. Chronic nasal obstruction attributable to large adenoids is a common condition of childhood. However, in our experience few children with nasal obstruction complain about or admit to [...]

A 35-year-old woman was admitted to a hospital after several months of vomiting, nausea, weight loss, and increased sputum production. She was a long-time cigarette smoker. CT imaging of her chest showed a number of small cysts in her lungs, but other physiologic test results were normal. The use of asthma medication to reduce airway constriction did not improve her airflow obstruction. A biopsy of her lung revealed bronchiolar inflammation, scarring, brown pigmentation, and smooth muscle growth consistent with respiratory bronchiolitis from smoking.

A thorough medical examination may detect signs and symptoms of airflow limitation. Airflow limitation is a respiratory disease characterized by narrowed lung passages and increased lung secretions. Researchers reviewed the medical literature that evaluated clinical examination findings indicative of airflow limitation. Patients' exposure to cigarette smoke, particularly the length of smoking history, is positively associated with the risk of airflow limitation. Age is related to airflow limitation, with the highest rates found in children younger than age 10 and adults older than age 30. Physical findings associated with an increased risk of airflow limitation include a rounded, large chest, abnormal breathing sounds including wheezing and rhonchi, abnormal chest sounds heard on percussion, and subxyphoid apical impulse. Patients who cannot blow out a lighted match held 10 centimeters away from their mouth and those with a forced expiratory time greater then nine seconds are likely to have airflow limitation.

Children with obstructive sleep apnea syndrome (OSAS) who exhibit a high-risk profile and who undergo a tonsillectomy or adenoidectomy should be monitored before and after surgery for upper airway obstruction, according to a study of 312 children. Criteria for the high-risk profile included age less than two years, face and head abnormalities, failure to thrive, abnormal muscle tone, morbid obesity, previous upper airway trauma, a respiratory distress index of greater than 40, or a low oxygen concentration. Apnea monitors and oximeters should be used before surgery for these high-risk children with OSAS. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP) can be used to manage patients with upper airway obstruction occurring either before or after surgery., Objective. The aim of this research was to describe the postoperative respiratory complications after tonsillectomy and/or adenoidectomy (T and/or A) in children with obstructive sleep apnea syndrome (OSAS), to define which children are at risk for these complications, and to determine whether continuous positive airway pressure (CPAP) is an effective strategy for dealing with these complications. Methods. The data for this study were gathered through a retrospective chart review of all children 15 years of age or younger with polysomnographically (PSG) proven OSAS who had a T and/or A at Hennepin County Medical Center between January 1985 and September 1992. Particular attention was paid to factors that contributed to the OSAS, postoperative respiratory complications, and intervention strategies for dealing with these complications. Results. The charts of 37 children with OSAS documented by preoperative PSG who later had a T and/or A were reviewed retrospectively. Ten of these children had significant postoperative respiratory compromise secondary to OSAS that prolonged their hospital stay from 1 to 30 days and caused symptoms ranging from [O.sub.2] desaturation 40 and (2) [SaO.sub.2] nadir