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Pediatria d’Urgenza e
Terapia Intensiva Pediatrica
Policlinico Umberto I
Corrado Moretti
Pathophysiology of the Airway and Bronchoscopy
in the Neonate
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When should we suspect a disease of the airway ?
When there is an alteration of its functions
Breathing (air is filtered, humidified and warmed)
Speaking/Crying
Swallowing
Protection from inhalation Upper airways perform many important functions and have no structural rigidity: they are made up of muscles connected to rigid supports
Airway diseases are very dangerous:
can rapidly cause a severe respiratory failure
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Localization of the obstruction
- inspiratory-expiratory symptoms - noise: stridor - barking cough and alterations of the voice (weak, aphonic, husky) - opisthtonus (head arched back forward shift of the hyoid bone)
- difficulties to feed: cough, apnoea, cyanosis, inhalation
- inspiratory symptoms - noise: stertor (low-pitched) or stridor (high pitched) - dyspnoea, retractions, obstructive apnoeas - CXR: pulmonary oedema
- expiratory symptoms - prolonged expiration - noise: weezing - CXR: air trapping
- Upper airway (pressure around airways is 0)
- Larinx
- Lower airway (intrapleurical pressure squeezes the airway)
- All
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Stridor
Obstructive apnoea
Unexplained cyanosis crisis
Recurrent aspiration
Unexplained respiratory distress
Persistent or recurrent atelectasis
Lobar enphisema
Unexplained pulmonary haemorrhage
Pulmonary malformation
Failure to extubate
Position of tracheal tube
Broncho Alveolar Lavage (BAL)
Neonatal symptoms and clinical conditions
which require Bronchoscopy
Upper obstruction: endo-thoracic
negative pressure
Lower obstruction: endo-abdominal
positive pressure
suctioning pushing
Gastro-oesophageal reflux
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Neonatal Flexible Bronchoscopy
Epiglottis
Uvula
Arytenoids
Vocal cords
Monitoring - ECG - SpO2 %
eye piece
insertion tube
flexion-extension lever
suction control
2.8 – 3.5 mm
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Aryepiglottic folds
Arytenoids
Pharyngoepiglottic folds
Epiglottis
Interarytenoid notch
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Valerio
A loud stridor appeared immediately after birth and grew worse when the baby cried
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quiet breathing during cry
Laryngomalacia
Tubular epigottis - whistle shaped
Stridor is produced by the rapid, turbulent flow of air through a narrowed segment of the respiratory tract
Pressure x Flow = K
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Tight tubular epiglottis that curls on itself Redundant, prolapsing arytenoids Short aryepiglottic folds
Mild and/or intermittent stridor
- reassure parents, disease is usually self-limiting
- frequent evaluation of breathing, feeding and growth
- consider reflux precautions
Moderate to severe and persistent stridor and other symptoms as cough, weak cry, etc.
- flexible laryngoscopy
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Giorgia
Noisy breathing and cough from birth
At one month of life progressive abdominal distension followed by a severe apnoea crisis
Transferred intubated to our PICU
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Progressive closure of the glottis
Stronger efforts to breathe
Increasing distension of the bowels
Upward shift of the diaphragm
Cyst at the base of the tongue
APNOEA
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Brian
Coughing during feeding followed by marked wheezing:
Tracheo-Esophageal Fistula?
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Opaque feeding with barium
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Laryngeal Cleft deficiency in the separation of
the larinx from the hypopharinx
in the midline posteriorly;
in severe cases it extends
into the cervical or thoracic trachea
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Tracheo-Esophageal Fistula
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Francesco
Severe RSV bronchiolitis at 20 days of age
Difficult intubation and mechanical ventilation for 3 days
Mild respiratory distress and inspiratory stridor 5 days after discharge from hospital
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Laryngeal Web… the TT broke the membrane, but after a few days the membrane had closed again
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Anna
Admitted to hospital at 3 weeks due to a severe apparent life-threatening event (ALTE)
Transferred intubated to our NICU with diagnosis of pharyngeal mass
Intermittent noisy breathing and cough from birth
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Lateral neck X-ray
A peduncolted mass originating from the pharinx and descending as far as the larynx, obstructing the upper airways
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Pharingeal opening of the auditory tube
Mass
Nasal septum
Palate
Mouth - the baby is supine - left palatine fossa
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The surgeon tries to grasp the mass with forceps to stretch it out
in order to understand where it grows from
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Congenital malformation of the first and second branchial arches growing from
the soft palate and containing hair follicles, and sebaceous and sweat glands
“Hairy Polyp”
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Roberto
- Biphasic wheezing, barking cough, dysphagia
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A barium swallow shows the impression of a double aortic arch on the esophagus
Flow-volume loops
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Tracheal Injury
from Intubation
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Alessio
Admitted to hospital at 2 month due to increasing breathing difficulties
for RSV pneumonia
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progressive hyperinflation
of the right lung
FiO2
0.4 0.8
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...before
…immediatly after lavage
…after few hours
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Bronchiolitis
Bronchial lavage to remove a mucus plug
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If in doubt……it’s always better to give a look!
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Clara
Weight: 4000 gr Severe Pierre-Robin Syndrome waiting for surgery….
…severe apnoea crisis during the night due to a cold
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Difficult Intubation
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… slide the tt on the bronchoscope using it as a guide
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GA: 33 weeks
BW: 1400 gr
Elena
Suspected tracheo-esophageal fistula
Coughing and cyanosis during feeding
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Tracheo-esophogeal fistula
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Marco
Transferred at 15 days due to ……………
GA: 30 weeks
BW: 1450 gr
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Alligator scissors
...inhalation of a defective catheter which broke during suctioning
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Valeria
Stridor, weak cry and opisthotonus
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Laryngeal Emangioma
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Stridor
Obstructive apnoea
Unexplained cyanosis crisis
Recurrent aspiration
Unexplained respiratory distress
Persistent or recurrent atelectasis
Lobar enphisema
Unexplained pulmonary haemorrhage
Pulmonary malformation
Failure to extubate
Position of tracheal tube
Broncho Alveolar Lavage (BAL)
Neonatal symptoms and clinical conditions
which require Fiberoptic Bronchoscopy (FOB)
- Radiology /Echo-scan
- Polisomnography
- Barium swallow
- MRI scan/TC
Investigations to perform beyond FOB
- Oesophageal pH-metry
Upper obstruction: endo-thoracic
negative pressure
Lower obstruction: endo-abdominal
positive pressure GER
suctioning pushing