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Background: Congenital epulis is a rare benign, smooth, sessile, or pedunculated, solitary mass of varying sizes commonly occurring at the anterior alveolar ridge of the maxilla. It can occur as a solitary as well as a multifocal lesion. Case Presentation: Case 1: A two-day-old female newborn presented with a single round, smooth, pedunculated mass measuring 3x2x2cm on the anterior alveolar ridge of the maxilla. Complete excision of the mass was done under general anesthesia. Histopathology confirms congenital epulis. No recurrence was found till one year of follow-up. Case 2: A one-day-old female newborn presented with a 3x4x3cm soft to firm mass arising from the right upper alveolar margin attached with a stalk and extending into the mouth without any respiratory difficulty. Complete excision of the mass was done under general anesthesia. Follow-up for one year showed no recurrence.

In the background of a sudden surge of coronavirus disease 2019 (COVID-19) cases, reports of themultisystem inflammatory syndrome in children from different parts of the globe are a matter ofconcern for physicians. We report a similar case presenting with persisting fever, rashes, bulbarconjunctivitis, abdominal pain, respiratory difficulty, and shock. Initial reports suggestive of highinflammatory markers, neutrophilic leucocytosis, high d-dimer, transaminitis, and found to haveCOVID 19 IgG antibodies positive in high titer. The echo at the bedside is suggestive of poor LVfunction with normal coronaries. Managed successfully in PICU with non-invasive ventilation support,ionotropy, aspirin, IVIG, and steroids and discharged. Early referral, a high index of suspicion,prompt recognition of shock, and early management by steroids and intravenous immunoglobulin(IVIG) may bring success.

Background The optimal timing of repair for inguinal hernia in premature infants remains a controversial topic. Our objective was to assess the clinical effects of inguinal hernia repair done before or after neonatal intensive care unit (NICU) discharge. Methods MEDLINE, Embase, CINAHL, and CENTRAL were searched in July 2018. Publications comparing clinical outcomes of the premature infants with inguinal hernia repair before (early) and after (delayed) NICU discharge were identified. Two reviewers independently screened studies, extracted data, and assessed for quality. Results were pooled using random effects meta-analysis. Results Of 640 publications identified, six comparative studies assessing a total of 1761 premature infants were included. Meta-analysis indicated no statistically significant difference in incarceration rate (odds ratio (OR) 2.15, 95% confidence interval (CI) 0.83–5.58, I2 = 0%), surgical complications (OR 2.36, 95% CI 0.66–8.41, I2 = 0%) and other secondary complications. However, the odds of recurrence and respiratory difficulty was significantly increase in the early group compared to delayed (OR 4.12, 95% CI 1.17–14.45, I2 = 0%; OR 3.59, 95% CI 1.10–11.75, I2 = 42%). Conclusions Repair of inguinal hernia in premature infants before NICU discharge may increase the odds of recurrence, but not incarceration or surgical complications. Level of evidence Level III

La respiración comprende una serie mecanismos complejos, que van desde el intercambio de gases con el exterior hasta la utilización de oxígeno (O2) por la célula y la eliminación de dióxido de carbono (CO2). Estos mecanismos requieren de la coordinación de diferentes órganos y sistemas, no únicamente del sistema respiratorio, el cual se encuentra estrechamente relacionado con la succión y la deglución en el neonato, convirtiéndose en un determinante a la hora de alimentar o no a un neonato por vía oral, sobre todo si este es nacido pretérmino o presenta alguna dificultad respiratoria. El objetivo de esta revisión es determinar los criterios más importantes para el inicio de la succión nutritiva en los neonatos con dificultades respiratorias, para ello se realiza la búsqueda de evidencia científica al respecto en diferentes bases de datos como PubMed, Scopus y Cochrane desde el año 2000 en adelante, en donde se eligen 70 artículos, de los cuales después de aplicar los criterios de selección se trabaja con 16 de ellos, considerados los más apropiados para el desarrollo de la temática. Se concluyó que, dentro de los criterios más importantes para iniciar la succión nutritiva en pacientes con dificultades respiratorias, se encuentran la medición de la saturación periférica de oxígeno (SpO2), una coordinación de la triada SRD adecuada, la inexistencia de signos de alarma como la tos, la regurgitación nasal y el tiraje intercostal y definitivamente una succión nutritiva a través de la lactancia materna, gracias a sus múltiples beneficios incluida la disminución del riesgo de desaturación.

Introducción: El Síndrome de Dificultad Respiratoria (SDR), es la causa más frecuente de morbilidad y mortalidad en el recién nacido. Se debe conocer la patología y sus factores asociados a la misma para un manejo oportuno y eficaz. El objetivo del presente estudio fue determinar los factores asociados al Síndrome de Dificultad Respiratoria de los recién nacidos en el Hospital “José Carrasco Arteaga” en el año 2018. Métodos: Estudio de casos y controles con una relación de 1:2; se parearon respecto al sexo y al mes de nacimiento. Se comparó en relación al peso, edad materna, Apgar, controles prenatales, edad gestacional, tipo de parto, patología materna, presencia de líquido meconial y el uso antenatal de corticoides. Se evaluó la asociación mediante OR (IC 95%) y la significancia con la prueba X2; considerando una significancia estadística a una P

Schaaf-Yang syndrome (SYS) is a recently identified disorder caused by a loss-of-function mutation in a maternally imprinted gene, MAGEL2, at 15q11.2q13. Due to its extreme rarity and wide range of clinical severity, clinical suspicion is difficult for a physician. In the current study, its frequency among the Korean pediatric patients with developmental delay (DD) or intellectual disability (ID) was assessed. As the first report of Korean patients with SYS, our study aims to increase the awareness of this condition among the physicians taking care of the pediatric patients with DD/ID and hypotonia. The patients diagnosed with SYS by whole-exome sequencing (WES) among the 460 Korean pediatric patients with DD/ID were included, and their clinical and molecular features were reviewed. Four patients (0.9%) were diagnosed with SYS. Profound DD (4 patients), multiple anomalies including joint contractures and facial dysmorphism (4 patients), generalized hypotonia (3 patients), and severe respiratory difficulty requiring mechanical ventilation (3 patients) were noted in most cases, similar to those in previous reports. Sleep apnea (2 patients), autistic features (2 patients), a high grade of gastroesophageal reflux (1 patient), and seizures (1 patient) were found as well. A total of 3 different truncating MAGEL2 mutations were identified. A previously-reported mutation, to be the most common one, c.1996dupC, was found in 2 patients. The other 2 mutations, c.2217delC and c.3449_3450delTT were novel mutations. As MAGEL2 is maternally imprinted, 2 patients had inherited the MAGEL2 mutation from their respective healthy fathers. SYS is an extremely rare cause of DD/ID. However, hypotonia, joint contractures, profound DD/ID and facial dysmorphism are the suggestive clinical features for SYS. As a maternally imprinted disorder, it should be reminded that SYS may be inherited in form of a mutation from a healthy father.

Background Lungultarsound(LUS) is widely used to diagnose neonatal lung diseases, yet image patterns on intrauterine to extrauterine stage(right after birth), of which impairment is well related to lung disease, remains unclear. Objectives To identify these image patterns that can distinguish healthy infants from infants with lung disease.Methods This is a nested case-control study in a top-ranking obstetrics hospital in China, between 1 January 2020 to 1 April 2020. Infants transferred to the NICU after birth who had LUS obtained at 0.5, 1, 2, 4, 6 hours time intervals were enrolled. Confirmed by 3-day follow-up, case and control groups contains 22 patients and 473 healthy infants. Their GA ranges from 33.5 to 41.0 weeks. A newly designed protocol was used to capture the LUS image. The image patterns and their variations were shown and categorized as high and low-risk groups. The predictive value for healthy infants and patients were calculated. Results Low-risk patterns, accompanied with no high-risk ones, typically appeared in healthy infants (specificity=86.4%, PPV=99.0%), whereas four high-risk patterns could be seen in both healthy infants and patients (specificity=62.4%, PPV=9.6%). High-risk patterns were more likely to be pathological signs when appearing at the oxter and lower back and to be physiological signs when appearing at the prothorax. Conclusions LUS is valid to differentiate healthy infants from potential patients shortly after birth. Infants with low-risk patterns only are highly likely to be healthy, whereas infants with high-risk patterns have a risk for respiratory issues but need prolonged monitoring to confirm.

Purpose To distinguish healthy infants from potential patients right after birth using lungultrasound(LUS). Design, Setting and Patients This is a nested case-control study containing 22 lung diseases patients and 473 healthy infants from a total of 504 successive infants. They were admitted to Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China, from 1st January 2020 to 1st April 2020. A newly designed scanning protocol was used to capture LUS images. Sensitivity, specificity, PPV and NPV for predicting healthy infants and patients were calculated individually. The transition process image patterns and thier variation were shown. The relationship between clinic signs and the high-risk image patterns was calculated by Kendall’s tau-b test. Measurements and main results LUS images were captured and its preditive value has been caculated. Four low-risk patterns almost only can be seen in healthy infants(specificity=86.4%, PPV=99.0%) whereas four high-risk patterns can be seen both in healthy infants and patients(specificity=62.4%, PPV=9.6%). High-risk patterns are more likely to be pathological when appearing at oxter and lower back but to be a physiological sign when appearing at Lower and upper of the prothorax. These high-risk patterns are significantly related to clinic sign. All these patterns are alsmost consistent during 6 hours after birth. Conclusions LUS is valid to differentiate healthy infants from potential patients who with mild respiratory difficulty. Four low-risk patterns have high value to predict healthy infants, but four high-risk patterns are not specific enough to discover patients. This criterion is valid for this 6 hours stage.

Laryngotracheoesophageal cleft is a rare congenital malformation where a communication exists between the aero-digestive tracts that is associated with high morbidity and mortality. In this case series, we describe our experience with two neonates evaluated in our institution with two diverse initial presentations and symptomatology of type IV laryngotracheoesophageal clefts. One patient presented with acute distress and respiratory failure due to bowel contents obstructing the trachea and the other presented with mild subcostal retractions and inspiratory stridor without overt respiratory failure. Most importantly, not every patient with type IV laryngotracheoesophageal clefts will present with fulminant respiratory difficulty. This prompted a literature review.

Inhalation of a foreign body into the airway is a common accident among children and can have severe and even fatal consequences. Obstruction of the airway can occur at all levels of the respiratory system, depending on the age of the child and the size and type of the object. The clinical situation ranges from acute respiratory difficulty to chronic and/or recurring manifestations secondary to unnoticed inspiration of a foreign body at the bronchial level. Up to 80% of inhaled foreign body events occur in males aged 9 months to 3 years. When inhalation of a foreign body is suspected, a complete clinical picture is vital to ascertain whether or not bronchoscopy should be performed.

Primary tumours of the trachea are rare. Adenoid cystic carcinoma (ACC) constitutes less than 1% of these tumours. They occasionally masquerade as asthma. We are presenting a case of a young female, who had been treated for 3 years as asthma. She presented in emergency with severe respiratory difficulty, stridor and decreasing saturation of 85% on room air. Two weeks back, she had a CT scan in a local hospital, but they did not notify the tracheal mass. Her clinical picture and CT scan helped us diagnose the case. She was treated in emergency with primary resection of tracheal mass and anastomosis. The tumor was diagnosed as ACC. Postoperative recovery was uneventful. Continuity of the trachea was restored and adjuvant radiotherapy was given.

Paradoxical vocal fold motion (PVFM) is a laryngeal disorder where episodic, inappropriate adduction of the true vocal cords during inspiration causes sudden respiratory difficulty or distress. This chapter discusses approaches to diagnosis, assessment, and management of the disorder in a pediatric population from both speech-language pathologist and otolaryngologist perspectives.

A term male newborn develops a painful bilateral swelling over both lacrimal sacs with purulent ocular discharge. A 5-day-old male newborn presents to the emergency department with bilateral mucopurulent ocular discharge and is given a topical antibiotic. On the following day, he develops a painful bilateral swelling over both lacrimal sacs. No fever, nasal obstruction, or respiratory difficulty are present. According to the mother, he had a blueish coloration of both medial canthal regions since birth. ### Physical Examination

Background: Diseases of the pharynx and upper esophageal sphincter can result in debilitating respiratory difficulty, dysphagia or a combination of both. An exact diagnosis is essential to properly prognosticate and guide therapy. Videofluoroscopic assessment of the pharynx and upper esophageal sphincter with or without orally administered contrast material is the diagnostic of choice for many diseases as both anatomic and functional information is gleaned. The purpose of this review is to assess for continuity in imaging protocols across institutions and to record quantitative and qualitative parameters used for analysis of videofluoroscopy of the pharynx and upper esophageal sphincter in dogs. Methods: A systematic literature search was performed including articles published in peer-reviewed veterinary journals involving the topic of videofluoroscopy of the pharynx and upper esophageal sphincter through August 1, 2018. Specifics of study acquisition technique were recorded. Quantitative and qualitative videofluoroscopic parameters were recorded and compared across institutions where appropriate using one-way ANOVA with p ≤ 0.05 being considered significant. Results: Videofluoroscopy of the pharynx and upper esophageal sphincter is performed either in right lateral or standing postures depending on the institution. Bolus size and consistency used during contrast videofluoroscopy of swallowing differs between institutions. Some institutions evaluate videofluoroscopic studies using qualitative criteria while others apply quantitative measures. Reported quantitative measures include inter-swallow interval, swallow rate, jaw cycles per swallow ratio, time to upper esophageal opening, maximal pharyngeal contraction, maximum laryngeal excursion, upper esophageal closure, epiglottic re-opening, and pharyngeal constriction ratio. Measurement outcomes are significantly different between institutions and when bolus size/consistency is variable when assessing healthy dogs. Conclusions: The current peer-reviewed literature on fluoroscopic evaluation of the pharynx and UES in dogs shows a lack of standardization regarding imaging protocol. There is not a standard set of quantitative criteria applied amongst the institutions and there are significant differences in the outcomes obtained from videofluoroscopic assessment of swallowing suggesting significant inter-observer or inter-institutional variability. A consensus statement regarding imaging protocol and what parameters should be used to interpret airway and swallowing videofluoroscopic studies of the pharynx and UES in dogs is needed along with targeted analysis of observer variability.

Unusual laryngeal and tracheobronchial obstructing lesions are seen on occasion [1-3]. A patient was evaluated by his primary physician and pulmonologist due to symptoms referable to his chest including a cough and shortness of breath. Evaluation, including lexible bronchoscopy, revealed a primary carcinoma of the left upper lobe of the long.

Objective: To explore prevalence, validity of associated factors and their outcome of pneumonia in neonates.Methods: We retrospectively enrolled neonates admitted to a rural hospital in Bangladesh from January 2012-December 2014. Those with pneumonia constituted cases (n=142) and randomly selected three folds of cases from those without pneumonia formed the controls (n=426). Pneumonia was diagnosed by hospital physicians based on respiratory difficulty and/or abnormal auscultatory findings in lungs.Result: The deaths were significantly higher among the cases than the controls (p=0.025). In logistic regression analysis, fast breathing, lower chest wall in-drawing, adventitious sound and cough were independently associated with neonatal pneumonia (for all, p

To investigate the feasibility and effectiveness of integrated self-expanding Y-shaped airway stent placement for patients with carinal stenosis. From May 2010 to March 2015, 12 consecutive patients with carinal stenosis, treated by placement of integrated self-expanding Y-shaped airway stent, were included this retrospective study. Data on technical success, clinical success, and follow-up were analyzed. Technical success was 100 %. Eleven uncovered stents and one covered stent placed in 12 patients. Eleven patients underwent stent insertion under local pharyngeal anesthesia, and one patient underwent stent insertion under general anesthesia. Clinical success was 100 %. The respiratory difficulty improved instantly after treatment. The average Hugh–Jones classification grade and arterial oxygen saturation improved from 4.3 ± 0.6 and 83.0 ± 2.6 % before treatment to 1.4 ± 0.5 (p

Congenital pulmonary airway malformation (CPAM) is a congenital lung disease that is usually diagnosed in the prenatal or neonatal period but is rarely seen in adults as well. In this report, we present a 26-year-old male patient who presented to our clinic with respiratory difficulty due to a CPAM that affected the entire right lung, caused mediastinal and diaphragmatic compression, and led to extensive diffuse hemorrhage from the adjacent structures that required massive transfusion.

Background: Dyspnoea (shortness of breath) is a common excruciating symptom. Shortness of breath is a feeling associated with impaired respiratory function. As difficulty breathing, I can not breathe. It occurs in 64 % in Covid 19 patients. Objective: Our goal is to evaluate dyspnoea using Borg scale that assesses the functional state of respiratory function. Material–methods: We assessed (92) Covid 19 patients with a categorical ten-point rating, a corresponding verbal description (Table 1). Patients were aged between 44–78 years old. Fifty of them (50) were obese, body weight >greater than 90 kg with comorbidities (hypertension and diabetes mellitus). The assessment was performed by a specialist anaesthesiologist (pain clinic) on the Borg scale. Results: (12) Covid 19 patients with moderate dyspnoea. (30) Covid 19 patients with severe dyspnoea (hard). (46) Covid 19 patients very severe dyspnoea (really hard). (4) Covid 19 patients maximum intolerable dyspnoea (maximum). We immediately intubated them. There’s not internationally accepted way to assess shortness of breath. Scales are commonly used to assess respiratory difficulty (for example: respiratory distress observation scale). Conclusions: The Borg scale has been used successfully in Covid 19 patients. Every patient experiences dyspnoea differently, depending on the severity of the disease. However, it seems that the assessment of dyspnoea on the Borg scale, taking into account co-factors leads to safer monitoring of severely ill Covid 19 patients. © 2021, Pharmamed Mado Ltd. All rights reserved.

Introduction: Purulent pleurisy refers to the presence in the large pleural cavity of a purulent, cloudy or lemon-yellow liquid, but containing altered polynuclear cells. It is a frequent pathology, the epidemiology of which is constantly changing in Africa and throughout the world. This is why we conducted this study with the aim of updating epidemiological, clinical, bacteriological and therapeutic data. Methods: This is a retrospective, mono-centric, descriptive study including the records of children aged 0 to 15 years old hospitalized during the period from 20 May 2014 to 26 March 2019 at the Children's Hospital of Diamniadio for purulent pleurisy. The data were entered and analyzed using sphinx, Excel under Windows 8 and SPSS software. Results: We counted 42 cases of purulent pleurisy, i.e. a hospital frequency of 0.7%. Most of the patients were aged between 2 and 12 years (48%). The average age at diagnosis was 46 months. The sex ratio was 2.5. Most of the children came from parents with a low socio-economic status (64%); fever was the most frequent reason for consultation (50%), followed by cough (33%) and respiratory difficulty (29%). In all cases, a liquid effusion syndrome was objectively diagnosed (100%), tachycardia in 36% of cases and a pulmonary condensation syndrome in 33% of patients. X-rays showed a predominantly right-sided effusion (62%) which was very abundant in 71% of cases. In bacteriology, staphylococcus aureus was the most frequently isolated germ (75%), followed by streptococcus pneumoniae (20%) and group D streptococcus (5%). Biology showed an average hemoglobin level of 9.2 and there was a predominantly neutrophilic hyperleukocytosis in 98% of cases. All patients had received antibiotic therapy and pleural drainage in 76% of cases. Mortality was 10%. Conclusion: In the light of this work, we insist on the importance of early diagnosis and adequate management of purulent pleurisy in order to avoid complications and after-effects. Thus, antibiotic therapy should be more closely monitored, and its administration better codified to reduce bacterial resistance and germ selection.

Objectives Our objective was to compare the prevalence and outcomes of pediatric ARDS using the Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria and Berlin definitions. Methods We screened case records of all children aged 1 month to 17 years of age admitted to the Pediatric Intensive Care Unit (PICU) over a 3 year period (2015- 2017) for presence of any respiratory difficulty at admission or during PICU stay. We applied both PALICC and Berlin criteria to these patients. Data collection included definition and outcome related variables. Data were compared between the 'PALICC only group' and the 'Berlin with or without PALICC' group using Stata 11. Results Of a total of 615 admissions, 246 were identified as having respiratory difficulty at admission or during PICU stay. A total of 61 children (prevalence 9.9%; 95% CI: 7.8 to 12.4) fulfilled the definition of ARDS with either of the two criteria. While 60 children (98%) fulfilled PARDS criteria, only 26 children (43%) fulfilled Berlin definition. There was moderate agreement between the two definitions (Kappa: 0.51; 95% CI: 0.40 to 0.62; observed agreement 85%). Greater proportion of patients had severe ARDS as per Oxygenation Index criteria in the 'Berlin with or without PALICC group' as compared to the 'PALICC only' group (36.3% vs. 17.2%). There was no difference between the groups with regard to key clinical outcomes such as duration of ventilation (7 vs. 8 days) or mortality [57.1% vs. 57.7%: RR (95% CI): 0.99 (0.64 to 1.5)]. Conclusion In comparison to Berlin definition, the PALICC criteria identified more number of patients with ARDS. Proportion with severe ARDS and complications was greater in the 'Berlin with or without PALICC' group as compared to the 'PALICC only' group. There were no differences in clinical outcomes between the groups. Key words: PARDS; Berlin definition; pediatric ARDS; Acute respiratory distress syndrome; Oxygenation index; oxygen saturation index

We report a rare case of sinonasal mucosal malignant melanoma in the nasal cavity. The patient had respiratory difficulty, continuous epistaxis and nasal pain. We identified a malignant tumour which is a rare pathology with detailed physical examination, anterior rhinoscopy, computed tomography (CT) scan, magnetic resonance imaging (MRI) and histopathologic examination. The patient did not accept surgical procedures and was referred for chemotherapy orimmunotherapy. Continued follow-up of this is necessary.

Esophageal foreign body retrieval is typically performed by rigid or flexible esophagoscopy. Despite evidence supporting the efficacy and safety of balloon extraction, it is rarely performed. We sought to establish the financial benefits of this minimally invasive approach.A retrospective review of 241 children with esophageal coins between 2011 and 2013 was performed. Coins were removed via endoscopy or fluoroscopic-guided balloon retrieval. Timing, symptoms, facility cost, and patient charges were compared.Two hundred patients had attempted balloon retrieval with 80% success. Forty-one patients went directly for operative removal. Patients with respiratory difficulty (p=0.05), wheezing (p0.01), or fever (p=0.03) were more often taken directly for endoscopic retrieval. The median cost and charges for attempted balloon extraction were $484 and $1647. The median cost and charges for primary endoscopy were $1834 and $6746. The median total cost and charges of attempted balloon extraction including ED, OR, transport, admission, and balloon retrieval were $1231 and $3539 versus $3615 and $12,204 in the primary endoscopy group (p0.001, p0.001). Seventeen percent of patients who underwent attempted balloon retrieval were admitted prior to removal compared to 76% who underwent primary endoscopy (p0.001).Fluoroscopic guided balloon extraction of esophageal coins is a financially prudent choice which shortens hospital stay.III.Retrospective treatment and economic study.

Congenital cystic adenomatoid malformation is a rare entity presenting with respiratory difficulty in newborns and even later in infancy. Various cases have been reported but recurrent spontaneous pneumothorax in an infant with failure to thrive and pectus carinatum since birth(with uneventful antenatal history and asymptomatic course in the first seven months of life) is an extremely rare presentation of this congenital lung condition.J Nepal Paediatr Soc 2016;36(1):91-93.

Retropharyngeal and parapharyngeal abscesses are rare but associated with significant morbidity and potential mortality. In recent years, there has been an increase in the incidence of these infections, mainly due to a greater availability of computed tomography scan and a greater virulence of the germs (Group A b-hemolytic Streptococcus and methicillin-resistant Staphylococcus aureus). They predominate in children younger than 5 years. Treatment of retropharyngeal and parapharyngeal abscesses consists of an intravenous antibiotic and eventually surgical drainage. Surgical treatment is indicated in patients with abscesses greater than 2 cm 3, with respiratory difficulty or poor response to initial antibiotic treatment. The aim of this study is to describe clinical features and treatment of three cases of deep neck abscesses presented at Hospital de Ninos Pedro de Elizalde, Otorhinolaryngology Department in the period of one year.

Many children frequently fail extubation or require a prolonged period of positive pressure ventilation support after cardiac surgery. Pediatric cardiac Intensive Care Unit (PCICU) ultrasound (US) stands as a simple, basic bedside tool that can be performed by trained intensivists for the diagnosis with immediate implication on therapeutic decisions in multiple scenarios that physicians may face in PCICU. Bedside US is widely available, convenient, and inexpensive. This educational article based mainly on our own experience is highlighting the role of US in detecting the most common causes of respiratory weaning difficulties and extubation failure in postoperative cardiac children through proposed illustration and algorithm.

Heart Failure Respiratory difficulty and diaphragm weakness are known symptoms of heart failure, but they are usually attributed to pulmonary edema damaging the diaphragm through physical stress. Foster et al. found that this is not the only contributing factor. In mouse models, diaphragm weakness developed even in heart failure without pulmonary edema. The authors linked this observation to changes in angiotensin II and β-adrenergic signaling, which result in centrally controlled ventilatory overdrive. Drugs targeting β-adrenergic signaling were effective in preventing ventilatory overdrive and subsequent diaphragmatic injury, but only if they penetrated the blood-brain barrier. Sci. Transl. Med. 9 , eaag1303 (2017).

Negative pressure pulmonary oedema (NPPO) is a life-threatening complication occurring due to large negative intrathoracic pressures created by inspiration against a closed glottis. Timely diagnosis and management is important to prevent any fatal outcome. Although it presents acutely most of the time, its presentation may rarely be delayed. We present a case of a 21-year-old female weighing 40 kg who developed NPPO 1.5 h after warding in the post-anaesthesia care unit. Despite the delayed presentation, she was diagnosed in a timely manner and managed successfully. This case emphasises the need for extended monitoring of all patients with any respiratory difficulty in the perioperative period for delayed development of NPPO.

We report a case of an iatrogenic congenital diaphragmatic hernia (CDH) following left pleuroamniotic shunting at 20 weeks gestation for severe left pleural effusion. The infant developed respiratory difficulty after birth and was diagnosed with left CDH on imaging with the intraoperative findings confirming the hernia to be at an unusual site and likely secondary to the shunting.

Impacted foreign body of the larynx in the middle-aged man is a rare occurrence. Occupational and habitual surroundings make them prone to foreign body aspiration and impaction in the larynx. Proper history helps in establishing the diagnosis. We report 2 cases of unusual laryngeal foreign body in middle-aged adults who presented with complaints of sudden onset of change in their voice without any respiratory difficulty with accurate history of aspiration. Foreign bodies were successfully removed by direct laryngoscopy under general anesthesia.