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Introduction Esophageal atresia (EA) is often accompanied by tracheobronchial malformations leading to stridor, recurrent bronchitis, and occasionally to life-threatening obstructive apnea after surgical repair. The aim of this study was to identify the presence of tracheomalacia in patients with EA and tracheoesophageal fistula (TEF) pre- and postoperatively and to find endoscopic correlates leading to clinical airway symptoms. Methods In a cohort of 362 patients with EA-TEF who underwent 595 tracheoscopies at the Children's Hospital of Cologne between January 1983 and December 2002, impaired tracheal lumen, localization of TEF, tracheal pulsations, and corresponding clinical symptoms were retrospectively analyzed. Results The incidence of tracheomalacia was higher in patients with EA and TEF (Gross B–D) compared with patients with EA alone (Gross A) and average tracheal collapse does not significantly change before and after surgical repair of the esophagus in all types. Patients with cyanosis while eating and obstructive apnea presented with an average tracheal collapse of 89%. The presence of respiratory symptoms such as cough, stridor, or bronchitis was not associated with a higher grade of tracheal collapse compared with patients without any airway symptoms (average tracheal collapse of 37% in symptomatic patients vs. 33% in nonsymptomatic patients). Conclusion Tracheomalacia tends to be present independently of surgical procedure. Tracheomalacia should be measured by tracheoscopy (in % of tracheal collapse). Patients with a tracheal collapse of >80%, a ventral pulsation, and obstructive apnea or cyanosis in combination, are at risk for life-threatening situations and further surgical treatment should be considered.

Background Some in vivo studies question the traditional "funnel-shaped" infant larynx; further anatomic examinations were warranted. Examination of fixative free fresh autopsy laryngeal and upper tracheal specimens and multiple measurements was needed to determine consistency between current tracheal tube designs and anatomic observations. Methods Larynges from 19 males and 11 females (Caucasian term newborn to 126 months) were examined by the same forensic pathologist. Measurements included anterior/posterior (A/P) and transverse (T) diameters of the cricoid outlet (CO), interarytenoid diameter (IAD), cricothyroid membrane (CTM), distance from the vocal cords (VC) to CO (VC-CO), and calibration of the larynx lumen with uncuffed tracheal tubes as measuring rods. Assessment of "safe tracheal tube placement" was assessed using manufacturer recommended cuffed Microcuff (Kimberly-Clark, Koblenz, Germany) tubes. Results In 77% (95% confidence interval [CI], 58-90) of specimens, the proximal end of the cuff was within the CO and in 23% even with or close to the CO. The VC-CO varied from 9.1 to 13.17 mm in infants, 11.55 to 15.17 mm in toddlers, and 13.19 to 18.34 mm in children. The A-P/T ratio of the CO was nearly 0.99 in most larynges; the IAD was greater than CO in all specimens. The CTM could be minimally distended in all specimens. Conclusions First, despite being marketed as a safer tracheal tube design, the proximal end of the Microcuff cuff rested within or close to the cricoid cartilage theoretically increasing potential cuff-induced injury when using the VC markings for positioning. Our data suggest that the optimal cuff free distance (VC-CO) would be ~13.5 mm for a Microcuff internal diameter (ID) size 3.0, ~15 mm for size 3.5, and ~16 to 19 mm for greater sizes.Second, the CO was virtually circular in all specimens, suggesting that appropriately sized uncuffed tubes should provide an adequate seal in most neonates and toddlers, thus avoiding the potential for cuff-related necrosis injury.Third, the IAD was always greater than CO confirming that the narrowest point of the infant larynx is the nondistensible cricoid cartilage and not the easily distended glottis.Fourth, appropriately sized Microcuff tubes with the cuff deflated completely filled the lumen of the CO and proximal trachea in all specimens. Our data suggest the need for all manufacturers to further evaluate tracheal tube cuff locations and lengths in relation to the VC safe insertion markings, particularly for neonates and toddlers.Fifth, the CTM is minimally distensible, thus having important implications for emergency surgical airway access with most currently available emergency airway devices.

Background There is disagreement regarding the anatomy of the pediatric airway, particularly regarding the shape of the cricoid cartilage and the location of the narrowest portion of the larynx. Aims The aim of this review is to clarify the origin and the science behind these differing views. Methods We undertook a review of published literature, University Libraries, and authoritative textbooks with key search words and phrases. Results In vivo observations suggest that the narrowest portion of the airway is more proximal than the cricoid cartilage. However, in vitro studies of autopsy specimens measured with rods or calipers, confirm that the nondistensible and circular or near circular cricoid outlet is the narrowest level. These anatomic studies confirmed the classic "funnel" shape of the pediatric larynx. In vivo studies are potentially misleading as the aryepiglottic, vestibular, and true vocal folds are in constant motion with respiration. These studies also do not consider the effects of normal sleep, inhalation agents, and comorbidities such as adenoid or tonsil hypertrophy that cause some degree of pharyngeal collapse and alter the normal movement of the laryngeal tissues. Thus, the radiologic studies suggesting that the narrowest portion of the airway is not the cricoid cartilage may be the result of an artifact depending upon which phase of respiration was imaged. Conclusion In vivo studies do not take into account the motion of the highly pliable laryngeal upper airway structures (aryepiglottic, vestibular, and vocal folds). Maximal abduction of these structures with tracheal tubes or bronchoscopes always demonstrates a larger opening of the glottis compared to the outlet of the cricoid ring. Injury to the larynx depends upon ease of tracheal tube or endoscope passage past the cricoid cartilage and not passage through the readily distensible more proximal structures. The infant larynx is funnel shaped with the narrowest portion the circular or near circular cricoid cartilage confirmed by multiple in vitro autopsy specimens carried out over the past century.

The anatomy of the infant larynx has been discussed since 1897. Mainly, anatomists have described the particulars of the paediatric airway and have laid the base for tube selection for safe intubation of infants. The findings were similar to what anaesthesiologists, paediatric ENT-surgeons and airway endoscopists encountered in daily practice. However, since 2003, radiologists challenged the findings of anatomists, paediatric ENT-surgeons and airway endoscopists by using radiologic modalities (such as computed tomographic scans and magnetic resonance imaging) to propose quite different anatomical forms of the infant larynx. They thought that the outlet of the cricoid ring was oval shaped and that the funnel shape of the larynx had its narrowest part at the glottic level. This can be found neither in endoscopic investigations nor in fresh autopsies, the most realistic approach to the anatomy of the infant larynx. These aspects will be thoroughly discussed in this article.

Iatrogenic damage to the pediatric airway occurs rather often. Most injuries will heal without any sequelae because larynx and trachea of children tolerate considerable trauma. However, sometimes the injury is penetrating the mucosa and scar formation can lead to an obstruction of the airway which is followed by a tracheostomy and long term surgery. A great problem is the early detection of trauma since noisy breathing develops often late when scar formation has occluded more than 50% of the airway. A selection of photo documents of airway endoscopy out of more than 5000 photos from the years 1987-2007 were used to explain the development of injuries from minor lesions to large areas of necrosis of the mucosa of larynx and trachea of infants and children. The visualization of airway lesions might help to prevent iatrogenic damage.

This case report discusses the cause of death in a 3-year-old child who survived a high dose (20 mg x kg-1 x h-1) of propofol, infused over a period of 15 h, following which the patient developed a combined respiratory and metabolic acidosis, the oxygenation remaining normal. Bronchospasm was assumed to be the cause of hypercapnia. At this time the doctors in charge did not think of a possible side-effect of propofol. The administration of propofol was interrupted, the patient recovered within 13 h from the acidosis, woke up and required further sedation. A supposedly entirely safe infusion of 4 mg x kg-1 x h-1 propofol, as recommended in the literature for up to 48 h, was administered. After only 8 h intractable bradycardic dysrhythmias occurred. Although pharmacokinetic studies have pointed to a possible accumulation of propofol during continuous infusions, an interruption of an infusion for several hours has been considered sufficient for practically total clearance of the drug from the body. In this case re-exposure with a recommended dose of propofol was accompanied by bradycardia and dysrythmias that proved to be resistant to therapy and led to fatal cardiac insufficiency with a functioning artificial pacemaker in place. This case raises concerns about the safety of long-term infusions of propofol for sedation in children and possibly also in adults. Language: en

Summary Background: Volume replacement with hydroxyethyl starch (HES), a synthetic colloid, is widely accepted in adults, but only few data exist regarding its use in children. The aim of this study was to assess the effect of a low molecular weight HES solution (HES 70/0.5) compared with lactated Ringer's solution (LR) on haemoglobin levels as an indirect measure of plasma expansion in infants and toddlers, and its perioperative safety. Methods: Sixty-four patients, aged 1–38 months, were allocated randomly to receive 20 ml·kg−1 body weight of either HES 70/0.5 or LR during the first hour of urological surgery lasting >2 h. Thereafter, only LR was infused to maintain haemodynamic stability. Intraoperative blood loss and administered fluid volumes were analysed. Haemoglobin levels were determined perioperatively and intraoperatively at completion of volume loading. Changes in body weight and the incidence of postoperative oedema were assessed 24 and 48 h after surgery. For the safety analysis, patients were monitored for 72 h. Results: Intraoperative haemoglobin levels decreased significantly more with HES 70/0.5 (30 ± 10 g·l−1) compared with LR (21 ± 12 g·l−1) (P

Background. Tracheal instability is a hazardous situation after operation for esophageal atresia. In cases with life-threatening apneas, aortopexy is a therapeutic option. To assess efficacy, short-term and long-term outcome was analyzed retrospectively. Methods. Between 1985 and 2000, 29 patients (age, 1.5 months to 5.2 years) were operated on. A flaccid trachea after operation for esophageal atresia was the cause for life-threatening apneas in 27, and there was external vascular compression in 2 patients. The operative procedure consisted of ventropexy of the aortic arch to the sternum and ventral thoracic wall. Results. There was neither early nor late mortality. A reversible lesion of the phrenic nerve was observed in 2 patients, a pneumothorax in 3, and secondary wound healing in 1. In all but 1 patient symptoms improved markedly or disappeared within days or within the first 3 months postoperatively. An increased susceptibility to respiratory infections was observed in long-term follow-up. Conclusions. Aortopexy can be performed with no mortality and low morbidity. Aortopexy is effective to prevent further life-threatening apneas, but does not prevent an increased susceptibility to respiratory infections.

One hundred-and-fifty-five neonates and infants up to the sixth month of postnatal age were investigated to reveal the cause of clinically relevant stridor. In 100 patients congenital stridor was found, in 55 children the stridor was considered to be acquired. A curled, soft epiglottis, almost synonymously used with the diagnosis of congenital stridor, was found in 7% only, indicating different methods of investigation and different selection of patients compared to previous years. In acquired stridor the majority of infants showed laryngeal and tracheal trauma, mostly due to the use of too large tracheal tubes.

Pediatric intubation is an often occurring practice in pediatric anesthesia. However, this does not mean this procedure to be entirely safe. Despite its long history there are still discussions going on whether the epiglottis should be uploaded with the tip of the blade of the laryngoscope or not. Endoscopic evidence has shown that this uploading can injure the mucosa significantly as well as narrow the entrance to the glottis, impeding the advance of tracheal tube which might injure the vocal cords particularly. With more frequent use of simple optical instruments the already high standard of safety in pediatric intubation could be improved.

Summary Bronchoscopy was performed in 161 patients with oesophageal atresia or tracheo-oesophageal fistula without atresia between 1983 and 1991 at The Children's Hospital, Cologne, Germany. Twelve patients had oesophageal atresia without fistula, and seven patients had tracheo-oesophageal fistula without atresia. In the 149 patients with congenital tracheo-oesophageal fistula a total of 154 fistulae were found. In the five patients with two fistulae the second was detected in one patient only during primary anastomosis, and in the other four patients by bronchoscopy up to 18 years after the original operation. The study group comprised 113 newborn infants and 48 patients admitted for evaluation of severe airway problems. A very high proportion (89%) of the newborn infants had an associated abnormality of the respiratory tract. In the other 48 patients, all showed a tracheobronchial abnormality. Fourteen of these patients required tracheal surgery and 12 improved following oesophageal surgery. A comparison between the incidence of the types of oesophageal atresia previously described and this series showed a marked difference, which is probably due to greater precision of the location of the fistula demonstrated by bronchoscopy. Bronchoscopy should be undertaken in all patients with oesophageal atresia with a tracheo-oesophageal fistula.

Since about a decade cuffed intubation is becoming more popular in pediatric anesthesia. Studies supporting cuffed intubation compared cuffed and uncuffed intubation by using stridor as main outcome measure after extubation. No differentiations were made between benign (oedema) and severe (ulceration of mucosa) lesions. Stridor was considered to represent all relevant injuries. Far reaching conclusions for daily practice were drawn from these studies. Pediatric endoscopists and - ENT-surgeons with extensive experience in this field have warned against this opinion because significant injury of the airway is not always accompanied by stridor! The symptom of stridor might develop weeks and months after injury when silent ulcerations of the mucosa retract to significant stenosis. Only endoscopy can evidently detect all airway injuries. Studies describing airway injury by endoscopic control are urgently needed to find the best way of preventing airway injury by intubation.

During a period of 3 years, three infants were admitted to our hospital for unilateral emergency pneumonectomy due to life threatening overinflation of one lung, preventing adequate ventilation of the unaffected contralateral side. All three patients were able to be stabilized by unilateral selective bronchial intubation of the unaffected lung after bronchoscopy, ruling out a flap valve mechanism. No emergency pneumonectomies were required. In one patient, lung function of the overinflated side (three lobes) recovered fully and, in the two remaining patients, one lobe of the overinflated side recovered. The overinflated lobes were removed later by elective surgery, thus not exposing the children to a potentially dangerous emergency operation. These results are in contrast with reports in the literature. Emergency pneumonectomy in neonates and infants due to overinflation of one lung may be avoided by selective unilateral intubation of the main stem bronchus of the compressed lung.

Im Magen und oberen Duodenum des Menschen wurden die „Basal-gekornten Zellen“ (BZ.) auf Form, Verhalten, Lokalisation und Verteilung in Gefrierund Paraffinserienschnitten untersucht (Hamatoxylin-Eosin-Farbung, Diazoreaktion, Argent-affinitat, Argyrophilie, Chromierung, Phasenkontrastmikroskopie).

Zum Thema Kind im Krankenhaus und uber psychologische Aspekte bei arztlichen Masnahmen, Narkose und Operation liegt eine ganze Reihe von Publikationen vor. Trotzdem fallt es schwer, zu diesem Thema zuverlassige Aussagen zu machen, weil in der Literatur die emotional getonten Meinungsauserungen im Vergleich mit den empirischen Arbeiten uberwiegen.