Congenital pulmonary malformations in children in a pediatric hospital in Peru, 2010-2020

BACKGROUND

Congenital pulmonary malformations (CPMs) are rare in children. This study aimed to describe the clinical, imaging characteristics, and treatment of patients with this pathology.

METHODS

We conducted a descriptive and retrospective study with data from patients with CPMs diagnosed at Instituto Nacional de Salud del Niño-Breña (Lima-Peru), from January 2010 to December 2020. We described CPM clinical and imaging characteristics, type and treatment.

RESULTS

The sample was formed of 70 patients. The median age was 29 months (range 15 days-14 years) and the male/female ratio was 1.4. The chest tomography found parenchymal involvement in 50 (71.4%) cases and mixed involvement (parenchymal and vascular) in 18 (25.7%) cases. Congenital malformation of the pulmonary airway was present in 39 (55.7%) cases, followed by bronchogenic cyst in 10 (14.3%), intralobar pulmonary sequestration in 9 (12.9%), and extralobar pulmonary sequestration in 7 (10%). Lobectomy was performed in 61 (87.1%) cases, cystectomy in 5 (7.1%), segmentectomy in 2 (2.9%), and embolization in 2 (2.9%). The most frequent post-operative complication was pneumonia, found in 9 (12.9%) cases. The median hospital stay was 26 days. No patient died during hospitalization.

CONCLUSIONS

In our institution, the most frequent CPM was congenital malformation of the pulmonary airway, and lobectomy was the most frequently performed surgical procedure. CPMs represent a diverse group of disorders of lung development with varied imaging patterns and clinical manifestations.

Management of Congenital Lung Malformations

Congenital lung malformations represent a spectrum of lesions, each with a distinct cause and tailored clinical approach. This article will focus on the following malformations: congenital pulmonary airway malformations, formally known as congenital cystic adenomatoid malformations, bronchopulmonary sequestration, congenital lobar emphysema, and bronchogenic cyst. Each of these malformations will be defined and examined from an embryologic, pathophysiologic, and clinical management perspective unique to that specific lesion. A review of current recommendations in both medical and surgical management of these lesions will be discussed as well as widely accepted treatment algorithms.

Large congenital pulmonary airway malformation with mucinous cell clusters - a case report

We report the clinical case of a 38 weeks gestational age neonate, antenatally diagnosed with a left large macrocystic pulmonary malformation conditioning dextrocardia. At birth, he presented with respiratory distress requiring non-invasive ventilation with high-flow nasal cannula (HFNC). A left inferior lobectomy was performed via thoracotomy on day 21 of life. Histological features of the lesion were compatible with congenital pulmonary airway malformation (CPAM) type I with muci- nous cell clusters. No surgical complications were reported and the neonate was discharged six days after surgery. Follow-up two months after surgery was unremarkable.

Impact of Additional Anomalies on Postnatal Outcomes in Congenital Lung Malformations

BACKGROUND

Approximately 20% of fetuses diagnosed with congenital lung malformations (CLMs) are found to have additional anomalies. We aim to determine if additional anomalies have an impact on postnatal outcomes for patients with CLMs.

METHODS

After institutional review board approval, we performed a retrospective review of live-born patients with CLMs from 2008 to 2018. All patients were prenatally diagnosed with CLMs. Clinical information pertaining to additional congenital anomalies and outcomes was collected from the electronic health record and analyzed.

RESULTS

Of the 88 patients who had a prenatal diagnosis of CLMs, 20.5% had additional anomalies. Ten of the 18 patients (56%) were considered to have a major anomaly in addition to CLMs. Outcomes for patients electing nonoperative management of CLMs were similar between those with and without an additional anomaly. Although patients with an additional anomaly were more likely to have perinatal respiratory complications (44% versus 17%, P = 0.03), the number of preoperative clinic and emergency department visits, age at surgery, minimally invasive approach to surgical resection of CLM, estimated blood loss, length of hospital stay, intubation, duration of intubation, 30-day postoperative complications, and long term sequelae were not statistically different. This held true when stratified for major versus minor anomalies.

CONCLUSIONS

Twenty percent of fetuses diagnosed with CLM in our population have additional anomalies. Newborns with additional anomalies have a higher risk of pre-excision pulmonary complications. However, the overall outcomes of all patients with CLMs are similar.

Recurrent Peumonia in an Infant With an Esophageal Lung

Esophageal lung is a rare variety of communicating bronchopulmonary foregut malformation with anomaolous communication between an isolated portion of respiratory tissue and esophagus. Children present in early life with recurrent cough and pneumonia. Majority of the reported cases are associated with other anomalies like tracheoesophageal fistula. We report a case of a 7-month-old girl with right sided esophageal lung who was misdiagnosed as dextrocardia with right sided pneumonitis.

Complete Tracheal Ring Deformity. A Translational Genomics Approach to Pathogenesis

Rationale: Complete tracheal ring deformity (CTRD) is a rare congenital abnormality of unknown etiology characterized by circumferentially continuous or nearly continuous cartilaginous tracheal rings, variable degrees of tracheal stenosis and/or shortening, and/or pulmonary arterial sling anomaly.Objectives: To test the hypothesis that CTRD is caused by inherited or de novo mutations in genes required for normal tracheal development.Methods: CTRD and normal tracheal tissues were examined microscopically to define the tracheal abnormalities present in CTRD. Whole-exome sequencing was performed in children with CTRD and their biological parents ("trio analysis") to identify gene variants in patients with CTRD. Mutations were confirmed by Sanger sequencing, and their potential impact on structure and/or function of encoded proteins was examined using human gene mutation databases. Relevance was further examined by comparison with the effects of targeted deletion of murine homologs important to tracheal development in mice.Measurements and Main Results: The trachealis muscle was absent in all of five patients with CTRD. Exome analysis identified six de novo, three recessive, and multiple compound-heterozygous or rare hemizygous variants in children with CTRD. De novo variants were identified in SHH (Sonic Hedgehog), and inherited variants were identified in HSPG2 (perlecan), ROR2 (receptor tyrosine kinase-like orphan receptor 2), and WLS (Wntless), genes involved in morphogenetic pathways known to mediate tracheoesophageal development in mice.Conclusions: The results of the present study demonstrate that absence of the trachealis muscle is associated with CTRD. Variants predicted to cause disease were identified in genes encoding Hedgehog and Wnt signaling pathway molecules, which are critical to cartilage formation and normal upper airway development in mice.

Variability of presentation and surgical approach in Congenital Cystic Lesions of Lung: A retrospective study in children presenting in Mayo Hospital

The objective was to study the clinical presentation and surgical outcome in children with congenital cystic lesions of the lung. The medical records of 11 patients operated in the department of paediatric surgery, from January 2014 to December 2017, were evaluated retrospectively. Median age was 18 months (1-108).Respiratory distress was seen in 5 (45.4%) patients, recurrent chest infections in 4 (36.4%) patients and only 2 (18.2%) presented after birth. One patient of congenital lobar emphysema was misdiagnosed as pneumothorax and four patients of recurrent chest infection had been misdiagnosed as pulmonary tuberculosis. All patients underwent lateral thoracotomy. There was no mortality, median length of hospital stay was 4 days (4-5) and only one patient needed postoperative ventilation. On follow up, 10 (90.9%) patients had attained normal level of physical activities. We conclude that increasing awareness of these lesions can prevent misdiagnosis and unnecessary tube thoracostomy and anti-tubercular therapy in children.

Congenital pulmonary airway malformation mimicking lung cancer: A case report

RATIONALE

Congenital pulmonary airway malformation (CPAM) is a rare developmental deformity of the lower respiratory tract. The disease occurs more in newborns. However, on rare occasions, CPAM can be found in adults. Radiologic features of CPAM include cystic or solid mass pattern. In an elderly patient, CPAM can be easily misdiagnosed as lung cancer.

PATIENT CONCERNS

A 66-year old woman was admitted with complaints of chronic cough, expectoration. Her past history was unremarkable with no history of tuberculosis or smoking. Physical examination was normal. Computerized tomography of the chest showed an irregular cystic lesion in right lower lobe.

DIAGNOSIS

Histopathological results confirmed the diagnosis of CPAM.

INTERVENTION

The right pulmonary wedge resection was performed via thoracoscopic surgery.

OUTCOMES

On follow up 1 year later, the patient is asymptomatic.

LESSONS

CPAM is rare in adults, and imaging cannot accurately distinguish CPAM from thin-walled cystic lung cancer. Hence, histopathology is mandatory to confirm the diagnosis.

Pathophysiology, evaluation, and management of sleep disorders in the mucopolysaccharidoses

The mucopolysaccharidoses (MPS) represent a heterogeneous group of lysosomal storage disorders, each one associated with a deficiency in one of the enzymes involved in glycosaminoglycan degradation. Sleep disorders are a frequent manifestation of all types of MPS. Underlying causes are diverse and comprised of both respiratory and central nervous system (CNS) abnormalities. Sleep disordered breathing such as obstructive sleep apnea and nocturnal hypoventilation can arise in patients with upper airway obstruction and/or with alterations in respiratory mechanics, causing restrictive pulmonary disease. MPS patients with CNS disease can also develop sleep disturbances unrelated to ventilatory impairments, often associated with severe behavioral problems or night-time epileptic seizures. The present review discusses the pathophysiology, evaluation, and management of sleep disorders in MPS based on information from a meeting on the brain in MPS, attended by an international group of experts (April 28-30, 2016, Stockholm, Sweden), and additional literature searches.

Accessory-lobed accessory cardiac bronchus: Presentation and treatment in a pediatric patient

Accessory cardiac bronchus (ACB) is a supernumerary bronchus usually arising from right main or intermediate bronchus. We report the case of a 9-year-old male who presented a 6-month history characterized by two right pneumonia episodes followed by persistent productive cough, recurrent bloody sputum, and chest x-ray persistence of a segmental thickening of right inferior lobe. Bronchoscopy revealed no abnormalities. Computed tomography documented an accessory-lobed ACB originating from right lower brochus. Surgical removal of ACB and related parenchyma was approached thoracoscopically and converted to thoracotomy for evidence of a bronchial injury. Two-year follow-up showed no recurrent infections or respiratory symptoms.

Classification of congenital nasal deformities: a proposal to amend the existing classification

Congenital nasal anomalies are rare malformations with a broad spectrum of defects. The only existing classification strictly relating to nasal anomalies was presented by Losee et al. (Plast Reconstr Surg 113(2):676-689, 2004). The aim of this paper is to propose some suggestions, based on our current knowledge and experience gained by treating our patients in the clinic, in creating a specification of patients with congenital nasal anomalies. All patients with congenital nose defects treated in our health center were selected for this study. The research was retrospective and included years from 1995 to 2015. Nasal anomaly associated with cleft lip and palate was excluded. Patients were classified into four categories of congenital nasal anomalies, according to Losee et al.

CLASSIFICATION

In the period of 20 years, 191 patients with congenital nasal anomalies were treated in our health center. Type 1 defects were found in 124 patients, type 2 in 15, type 3 in 32 and type 4 in 20 patients. The nasal defect accompanying craniofacial syndrome is the most common type of nose malformation. The nose cleft is not always a part of craniofacial clefts; isolated forms of such malformations can occur. Vascular anomalies, due to different etiology, categorization and treatment, should not be recognized as nasal malformation.

Type IV congenital laryngeal web: Case report and 15 year follow up

A five day old patient with mild VACTERL syndrome had repair of a type IV congenital laryngeal web with successful decannulation 76 days later. Voice and respiratory outcome is good with follow up 15 years later. This case presents a rare clinical finding of a type IV laryngeal web successfully repaired with a keel and subsequent long term follow up during an era when it was suggested that repair be delayed until 18 months of age at the earliest.

Flexible bronchoscopy contribution in the approach of diagnosis and treatment of children's respiratory diseases: the experience of a unique pediatric unit in Tunisia

OBJECTIVE

Our study aimed at assessing the role of flexible bronchoscopy (FB) in improving diagnosis and management of children's respiratory conditions in the pediatric unit of FB, newly created and unique in Tunisia.

METHODS

Retrospective study including all the FB achieved in our pediatric unit from 2009 to 2014.

RESULTS

We performed 365 FB in 333 patients aged 46 months on average (1 month - 15 years), often under conscious anesthesia (81.6%). FB was performed for diagnostic purposes in 341 cases and for therapeutic purposes in 24 cases. Eight anatomical abnormalities were revealed in 22 patients. An intraluminal bronchial obstruction was found in 71 FB, mainly due to a foreign body (n=36). A vascular anomaly was responsible for nine cases out of 17 extraluminal obstructions. Airways malacia was observed in 60 FB. Bronchoalveolar lavage was performed in 196 cases. It was determinant in 43.9% of the cases. FB was of great diagnostic value in 74.8% of the cases. It influenced the management of the patients in 58% of the cases. The FB for therapeutic purposes was beneficial in all cases. Few complications occurred (5.5%).

CONCLUSION

FB is a safe tool providing precious diagnostic and/or therapeutic help for the clinician.

Management of perinatal lung malformations

This review uses the most up-to-date literature to help guide obstetrical providers through the diagnosis and management of perinatal lung malformations. These lesions, which include congenital pulmonary airway malformation [CPAM, formerly congenital cystic adenomatoid malformation (CCAM)] and bronchopulmonary sequestration (BPS), are relatively rare but are becoming increasingly common because of the improved resolution and enhanced sensitivity of fetal ultrasound. Serial assessment throughout pregnancy remains the norm rather than the exception. Perinatal management strategies can differ based on the sonographic characteristics and dynamic growth patterns of lung masses. Fetal magnetic resonance imaging and other diagnostic testing can sometimes be helpful in providing additional prognostic information. Over the last decade, the importance of echocardiography and utility of maternal steroids have been recognized in cases of non-immune hydrops. Fetal surgery is now rarely performed. Decisions regarding whether delivery of these fetuses should occur in a tertiary care center with pediatric surgery coverage versus delivery at a local community hospital are now highly relevant in most prenatal counseling discussions with families. Large lung malformations may require urgent surgical removal in the early postnatal period because of respiratory distress. Other complications, such as recurrent pneumonia, pneumothorax, and cancer, are indications for lung resection on an elective basis. In the vast majority of cases, the overall prognosis remains excellent.

[Respiratory manifestations of Marfan's syndrome]

Marfan's syndrome is a rare genetic disorder caused by a mutation of the gene FBN1, coding for the protein fibrillin-1. Cardiovascular, musculoskeletal and ophthalmic manifestations are the most commonly observed, but minor diagnostic criteria also include pulmonary manifestations. Pneumothorax, frequently relapsing, affects 5 to 11% of patients. Rib cage abnormalities (pectus excavatum or pectus carinatum) and apical blebs may contribute to their occurrence. Treatment does not require any specific procedure but there is an increased risk of recurrence. Pectus excavatum affects up to 60% of the patients, without any functional impairment in most cases. Surgery may be required (using the Nuss procedure) in case of cardiovascular or psychological symptoms. Marfan's syndrome is frequently associated with obstructive sleep apnoea, which may itself contribute to aortic dilatation. Some studies suggest a potential role of craniofacial abnormalities in the pathogenesis of sleep apnea in these patients. Pulmonologists should consider Marfan's syndrome when treating patients for recurrent spontaneous pneumothorax or rib cage abnormalities, since early detection of cardiac abnormalities improves the prognosis significantly.

Office-based lower airway endoscopy (OLAE) in pediatric patients: a high-value procedure

OBJECTIVES

Office-based lower airway endoscopy (OLAE) is not a widespread practice in children due to concerns about its safety and efficacy. In 2003, we reported on OLAE in 105 children presenting with airway symptoms and found it both safe and effective as a diagnostic tool. The current study is a follow-up to the 2003 study that reports on an additional 122 pediatric patients who received OLAE with special attention to the safety and efficacy of the procedure.

METHODS

A retrospective review at a tertiary-quaternary pediatric institution of 122 consecutive pediatric patients in which an airway lesion, by history and initial physical exam, was determined to be present at the level of the supraglottic larynx to the carina. In all patients, airway endoscopy was performed in the office using flexible fiberoptic laryngoscopy (FFL) and the endoscope was passed beyond the glottis to assess the lower airway, including the subglottis, trachea, and carina. The diagnoses were recorded and the number of times each diagnosis was encountered as well as the percent of patients who had each diagnosis was calculated. All cases requiring operating room procedures for further diagnosis or therapy were assessed for office-based and operating room diagnostic agreement. The ease of performing the lower airway assessment and the ease with which the subglottis, trachea, and carina were visualized were graded. An assessment for complications was also performed.

RESULTS

There were no complications with OLAE in any of the 122 patients. The percent of patients rated as having good visualization of anatomic structures were: 97% for visualization of the subglottis, 98% for visualization of the trachea, and 92% for visualization of the carina. In 93% of the cases the procedure was easily performed. There was excellent correlation between OLAE and operative endoscopy.

CONCLUSION

OLAE continues to be a safe, efficacious, and cost-effective tool for the diagnosis of lower airway pathology in pediatric patients.

Detection of airway anomalies in pediatric patients with cardiovascular anomalies with low dose prospective ECG-gated dual-source CT

Objectives

To assess the feasibility of low-dose prospective ECG-gated dual-source CT (DSCT) in detecting airway anomalies in pediatric patients with cardiovascular anomalies compared with flexible tracheobronchoscopy (FTB).

Methods

33 pediatrics with respiratory symptoms who had been revealed cardiovascular anomalies by transthoracic echocardiography underwent FTB and contrast material–enhanced prospective ECG-triggering CT were enrolled. The study was approved by our institution review board and written informed consent was obtained from all patients’ guardian. DSCT examinations were performed to detect cardiovascular abnormalities using weight-adjusted low–dose protocol. Two radiologists independently performed CT image analysis. The FTB reports were reviewed by an experienced pulmonologist. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of DSCT in the detection of airway anomalies were assessed. The tracheobronchial stenoses revealed on FTB were graded. Effective radiation dose was calculated.

Results

Thirty cases were diagnosed with tracheobronchial narrowing and/or abnormality in 33 patients by FTB, while 3 patients had normal FTB findings. Twenty-eight cases were diagnosed with airway anomalies by CT, of which 27 were correct positive. 3 patients with normal findings at CT had findings of tracheobronchial narrowing due to tracheobronchomalacia at inspiration at FTB. Sensitivity and specificity of CT were 90.0% (95% CI: 72.3%, 97.4%) and 66.7% (95% CI: 12.5 %, 98.2 %), respectively. PPV and NPV were 96.4% (95% CI: 79.8 %, 99.8%) and 40.0% (95% CI: 7.3%, 83.0%), respectively. Overall accuracy of DSCT in detecting airway anomalies in pediatrics with cardiovascular anomalies was 87.9% (95% CI: 74.5%, 97.6%). In grading of tracheobronchial stenosis, images from CT correlated closely (r = 0.89) with those of FTB. Mean effective dose was 0.60±0.20 mSv.

Conclusion

In pediatric patients, ECG-triggered CT to evaluate congenital cardiovascular anomalies can also be used to diagnose and characterize fixed airway involvement in relation to the vascular structures.

[Diagnostic values of bronchoscopy and multi-slice spiral CT for congenital dysplasia of the respiratory system in infants: a comparative study]

OBJECTIVE

To investigate and compare the diagnostic values of bronchoscopy and multi-slice spiral computed tomography (CT) for congenital dysplasia of the respiratory system in infants.

METHODS

Analysis was performed on the clinical data, bronchoscopic findings and multi-slice spiral CT findings of 319 infants (≤1 years old) who underwent bronchoscopy and/or multi-slice spiral CT and were diagnosed with congenital dysplasia of the respiratory system.

RESULTS

A total of 476 cases of congenital dysplasia of the respiratory system were found in the 319 infants, including primary dysplasia of the respiratory system (392 cases) and compressive dysplasia of the respiratory system (84 cases). Of the 392 cases of primary dysplasia of the respiratory system, 225 (57.4%) were diagnosed by bronchoscopy versus 167 (42.6%) by multi-slice spiral CT. There were significant differences in etiological diagnosis between bronchoscopy and multi-slice spiral CT in infants with congenital dysplasia of the respiratory system (P<0.05). All 76 cases of primary dysplasia of the respiratory system caused by tracheobronchomalacia were diagnosed by bronchoscopy and all 17 cases of primary dysplasia of the respiratory system caused by lung tissue dysplasia were diagnosed by multi-slice spiral CT. Of the 84 cases of compressive dysplasia of the respiratory system, 74 cases were diagnosed by multi-slice spiral CT and only 10 cases were diagnosed by bronchoscopy.

CONCLUSIONS

Compared with multi-slice spiral CT, bronchoscopy can detect primary dysplasia of the respiratory system more directly. Bronchoscopy is valuable in the confirmed diagnosis of tracheobronchomalacia. Multi-slice spiral CT has a higher diagnostic value for lung tissue dysplasia than bronchoscopy.

[Non-tumoral vascular disorders of the lung in the adulthood]

Non-tumoral vascular disorders of the lung are multiple, even if cases diagnosed in the adulthood are rare. They include congenital or acquired conditions, which related symptoms, if present, are non specific. This explains why their diagnosis is challenging and usually delayed. Surgery is the cornerstone of their treatment, although interventional radiology represents currently a less invasive alternative option for some of them.

[When congenital lung malformations have to be operated?]

Both technical and anatomical features and the need for a long follow-up, usually over several years, explain the specificity of lung surgery in children. Apart from the oncological resections, the main indications for this surgery are congenital lung anomalies (cystic adenomatoid malformation, bronchopulmonary sequestration, lobar emphysema), symptomatic postinfectious lesions (bronchiectasis, atelectasis, abscess) and pneumothorax. Advances in miniaturization of the surgical equipment are used to carry the majority of these interventions by thoracoscopy, except when performed at the neonatal period. In the newborn, for which the indications for lung surgical resections are exceptional, ventilatory conditions and the tightness of the chest lead to still prefer open surgery. Pulmonary malformations can also be managed prenatally when they affect lung development or cause heart failure because of compressive complications. These interventions, performed after the 30th week of gestation, are not intended to remove the lesions, but to release the compression. But these procedures are still under evaluation and, in light of possible fetal and maternal complications, they should only be performed in tertiary centers and in the context of specific protocols.

Prenatal diagnosis of congenital lung malformations

Prenatal diagnosis of congenital lung anomalies has increased in recent years as imaging methods have benefitted from technical improvements. The purpose of this pictorial essay is to illustrate typical imaging findings of a wide spectrum of congenital lung anomalies on prenatal US and MRI. Moreover, we propose an algorithm based on imaging findings to facilitate the differential diagnosis, and suggest a follow-up algorithm during pregnancy and in the immediate postnatal period.

Management of supraglottic dysgenesis presenting as laryngomalacia

Laryngomalacia is a common source of stridor and can lead to significant upper airway obstruction and feeding disturbances in infants. We describe a unique case of supraglottic dysgenesis presenting as laryngomalacia featuring a prominent "s-shaped" epiglottis with both posterior edges fused to the right aryepiglottic fold/arytenoid complex. Although this anomaly is not accounted for in any of the current laryngomalacia classification schemes, modified laser supraglottoplasty was a satisfactory approach leading to successful decannulation. Laryngeal embryology and possible timing of the pathogenesis of this rare occurrence are reviewed as well.

Congenital unilateral pulmonary malformation misdiagnosed as bronchial foreign body: a review of 14 cases

CONCLUSION

Congenital unilateral pulmonary malformation can easily be misdiagnosed as a bronchial foreign body. Although rigid bronchoscopy helps the proper diagnosis, high risks associated with anesthesia and operative complications may limit its application. However, high-resolution computed tomography (CT) and three-dimensional lung reconstruction provide a non-invasive tool to improve the diagnosis of congenital unilateral pulmonary malformation.

OBJECTIVES

To compare clinical manifestations, physical signs, and radiological examinations of congenital unilateral pulmonary malformation and bronchial foreign body, and summarize the characteristics and methods for diagnosis of congenital unilateral pulmonary malformation.

METHODS

Fourteen patients (five males and nine females, aged from 3 months to 14 years) with congenital unilateral pulmonary malformation, who were misdiagnosed or suspected as having bronchial foreign body or bronchial foreign body with pulmonary atelectasis, were analyzed retrospectively. Three typical cases are presented in detail.

RESULTS

All patients were previously misdiagnosed and treated as having pneumonia. From onset to final diagnosis, the longest misdiagnosis time was 10 years, and the shortest was 2 days. Only three patients presented with a history of foreign body inhalation. Six cases were finally diagnosed as having unilateral pulmonary malformation by rigid bronchoscope, five cases by X-ray and high-resolution CT scan, two cases by CT and three-dimensional lung reconstruction, and one case by autopsy. The malformation of left and right lungs was present in five and nine cases, respectively. Among these patients, four patients also had congenital cardiovascular diseases and other malformations, two patients underwent tracheotomy, and one patient died during salvage surgery.

Thoracoscopy in the management of congenital lung diseases in infancy

BACKGROUND

This study aimed to compare the results of thoracoscopic surgery for congenital lung diseases between infants younger than 6 months and those older than 6 months at the time of surgery in terms of operation duration, surgical complications, chest tube duration, and hospital stay.

METHODS

The charts of 30 thoracoscopic resections for congenital lung diseases were retrospectively reviewed. This study compared 17 children younger than 6 months (mean, 3.94 months; range, 0.37-5.7 months; group 1) with 13 children older than 6 months (mean, 12.05 months; range, 6.2-24.63 months; group 2) at the time of surgery. The median follow-up period was 9 months (range, 1-41 months).

RESULTS

Lobectomy was performed in 27 cases, bilobectomy in 1 case, and nonanatomic excision in 2 cases. The mean operating time for group 1 (176±54 min) was similar to that for group 2 (160±46 min). The difference is not significant. The mean duration of chest tube drainage was similar in the two groups (4.4 days; range, 1-9 days for group 1 vs. 4.1 days; range, 3-8 days for group 2). The complications included 1 major and 10 minor complications, with no statistically significant difference between the two groups. Three surgical procedures in each group were converted. The hospital stay was not statistically different between the two groups (8 days; range, 3-20 days for group 1 vs. 6 days; range, 4-10 days for group 2).

CONCLUSIONS

The study findings showed no statistically significant difference between the two groups in terms of operation time, complication rate, conversion rate, or hospital stay. Lobectomy can be safely and successfully performed by thoracoscopy even for children younger than 6 months.

Correlations between exercising arterial blood gas values, tracheal wash findings and upper respiratory tract abnormalities in horses presented for poor performance

REASONS FOR PERFORMING STUDY

There are limited data on the correlations between arterial blood gas (ABG) values, tracheal wash (TW) cytology and upper respiratory tract (URT) abnormalities.

OBJECTIVES

To identify horses with abnormal exercising ABG, and compare the proportions of horses with abnormal ABG and TW cytology, mucus or URT dysfunction with those with normal ABG results and abnormal TW cytology, mucus or URT dysfunction.

METHODS

Medical records of 813 horses presenting to the treadmill facility that had a complete treadmill examination, including ABG analysis, TW and URT endoscopy were selected. Diagnoses, ABG results, TW cytology and URT endoscopy were compared.

RESULTS

Two hundred and eleven horses met the study criteria of a complete treadmill examination and could have ABG evaluated. There were no significant differences in the age distribution of horses having normal and abnormal ABG or upper respiratory tract (URT) examinations. There was a significantly higher percentage of geldings with abnormal ABG analysis. In the horses with abnormal URT examinations, there were no differences in the proportion of horses having mucus vs. no mucus. However, in the horses with normal URT, there were a higher percentage of horses with visible mucus in the group with abnormal ABG analysis. The majority of horses had abnormal TW cytology and evidence of prior EIPH, with no differences in proportions between the groups.

CONCLUSIONS

Because such a large percentage of horses had evidence of inflammation and/or evidence of prior EIPH on TW cytology, it was not possible to determine the effect of these findings on gas exchange. Mucus was present in a larger percentage of cases with abnormal ABG analysis and normal URT examinations, suggesting that the presence of mucus may affect gas exchange. Standardbreds may be more likely to have abnormal gas exchange than Thoroughbreds. A larger number of horses is needed to determine the significance of these findings.

POTENTIAL RELEVANCE

Abnormal TW cytology and endoscopic visualised mucus may contribute to impairment of gas exchange, but they do not specifically predict abnormal ABG analysis.

Dynamic obstructions of the equine upper respiratory tract. Part 2: Comparison of endoscopic findings at rest and during high-speed treadmill exercise of 600 Thoroughbred racehorses

REASONS FOR PERFORMING STUDY

The reliability of diagnoses of obstructive conditions of the upper respiratory tract (URT) based on examinations performed at rest vs. at exercise is controversial.

OBJECTIVE

To compare diagnosis of URT by endoscopy at rest with that achieved during high-speed treadmill exercise (HSTE).

HYPOTHESIS

Endoscopy of URT at rest, when performed in isolation from other simpler techniques is unreliable in the prediction of dynamic respiratory obstructions.

METHODS

Endoscopic findings of 600 Thoroughbred racehorses during quiet breathing were compared with findings during high-speed treadmill exercise. Other parameters were also assessed for their specificity in diagnosis.

RESULTS

Endoscopy of the resting horse showed low sensitivity (0.15) in the diagnosis of dorsal displacement of the soft palate (DDSP) and palatal instability (PI). When endoscopy and reported noises were taken together there was still a 35% misdiagnosis rate. Although there was significant association between resting laryngeal function score (LFS) and dynamic vocal cord and/or arytenoid cartilage collapse at exercise, 19% of horses with a grade 4/5 LFS were able to attain and maintain full abduction during exercise and 7% of those with 'normal' grades 1 or 2 LFS at rest showed dynamic laryngeal collapse when exerted. Sensitivity of the diagnostic model was greatly increased (80%) when a history of inspiratory noise and palpable intrinsic muscle atrophy were included.

CONCLUSIONS AND POTENTIAL RELEVANCE

Endoscopy of the upper respiratory tract of static horses is unreliable in the diagnosis of dynamic obstructions of the URT and should not be used in isolation in surgical decision-making or in the assessment of horses at the time of sale.

The displaced equine soft palate as a source of abnormal respiratory noise during expiration

REASONS FOR PERFORMING STUDY

To develop the technique of respiratory sound analysis for the diagnosis of dorsal displacement of the equine soft palate.

OBJECTIVES

To show that 1) the displaced soft palate can spontaneously vibrate in the presence of expiratory airflow; 2) the observed frequency of vibration can be detected in respiratory sound recordings; and 3) the frequency of vibrations measured in cadaveric specimens are similar to those obtained from audio spectra in exercising horses with DDSP.

METHODS

Palatal movements and respiratory sounds were recorded from artificially ventilated cadaveric heads. The fundamental mode of palate vibrations calculated from high-speed videoendoscopic recordings was compared with frequencies detected in the audio spectra and with data collected from exercising horses with DDSP.

RESULTS

Palate vibrations occurred when air was blown through the trachea. The fundamental mode of vibrations was present in the audio spectra and was not significantly different from those recorded in vivo.

CONCLUSIONS

Vibrations of the soft palate are the probable source of expiratory sounds recorded in horses with DDSP.

POTENTIAL RELEVANCE

This study strengthens the case for the application of respiratory sound analysis in the diagnosis of DDSP in exercising horses.

[Clinical analysis of 234 cases with congenital malformations of respiratory system]

OBJECTIVE

To explore clinical characteristics, radiographic findings and diagnostic methods of patients with congenital malformations of respiratory system for enhancing the diagnosis of congenital malformations of respiratory system in children.

METHOD

Totally 234 patients with congenital malformations of respiratory system were chosen from the inpatient department of Yuying Children's Hospital Affiliated to Wenzhou Medical College from July 2003 to June 2008. The clinical presentations and radiographic findings of these children were analyzed.

RESULT

Of the 234 patients with congenital malformations of respiratory system, the age at diagnosis was between the first day and 14 years of age, mean age was 1.12 years. The main symptoms were persistent laryngeal stridor, recurrent wheezing, recurrent respiratory tract infections and dyspnea. Through the use of chest X-ray, spiral CT 3D reconstructions, fiberoptic bronchoscopy and other laboratory techniques, 213 cases were diagnosed as having single malformation and 21 cases were found to have multiple malformations. Of the 213 cases with single malformation, 97 cases had laryngeal malformation (congenital laryngeal stridor in 90 cases, congenital laryngeal webs in 5 cases and congenital laryngeal cyst in 2 cases), 35 cases had tracheal-bronchial malformation (congenital tracheobronchial stenosis in 17 cases, congenital abnormal bronchial origin in 7 cases, tracheobronchomalacia in 10 cases and tracheoesophageal fistula in 1 case), 43 cases had lung malformation (pulmonary sequestration in 5 cases, congenital lung cysts in 22 cases, congenital lobar emphysema in 1 case, agenesis of lung and hypoplasia of lung in 8 cases and congenital cystic adenomatoid malformation in 7 cases), 38 cases had diaphragm malformation, 28 cases had congenital tracheal-bronchial stenosis as confirmed by spiral CT 3D reconstructions and fiberoptic bronchoscopy. Ten cases with congenital abnormal bronchial origin were diagnosed with spiral CT 3D reconstructions. Laryngeal stridor and tracheobronchomalacia were diagnosed by fiberoptic laryngoscope and fiberoptic bronchoscopy. The accuracy rates of preoperative diagnosis through clinical and radiographic examinations of 37 cases with lung malformation and 36 cases with diaphragm malformation were 83.78% and 91.67%.

CONCLUSION

Congenital malformations of respiratory system are a group of diseases that are important for pediatric respiratory clinicians. Congenital malformations of respiratory system should be considered in children with persistent laryngeal stridor, recurrent wheezing, recurrent respiratory tract infections and dyspnea. The radiographic examination and respiratory endoscope play important roles in the diagnosis of congenital malformations of respiratory system.

Clinical trials using a telemetric endoscope for use during over-ground exercise: a preliminary study

Dynamic collapse of the upper respiratory tract (URT) is a common cause of poor performance in horses. These conditions occur predominantly during strenuous exercise when the URT is unable to maintain dilation in the face of high inspiratory pressures. In most cases, these disorders cannot be accurately diagnosed during a resting endoscopic examination. To date, a definitive diagnosis of dynamic URT obstructions has been possible only by performing an endoscopic examination during high-speed treadmill exercise. However, recent technological advances now enable URT endoscopy to be performed while the horse is exercising in its normal environment.

[Diagnosis and treatment of partial anomalous pulmonary venous connection]

OBJECTIVE

To explore the diagnosis and treatment of partial anomalous pulmonary venous connection (PAPVC).

METHODS

The clinical data of 38 pediatric patients with PAPVC were retrospectively reviewed. All received ultrasonography and part of them received angiography or 64-detector spiral computed tomography. Then the enlarged atrial septal was repaired with patch to separate the pulmonary vein dystopia to left atrium or the vertical vein was anastomosed to left atrium directly or by homograft vessel. The complicating abnormalities were corrected. Follow-up was conducted for 3 months to 7 years.

RESULTS

One case died from severe low cardiac output after operation. Two cases were complicated postoperatively with II degree atrial ventricular block and one with pulmonary hypertensive crisis, and all were cured after treatment. And the other patients recovered after surgery. Follow-up showed that the quality of their postoperative life was good and no relapse to obstruction of pulmonary venous was reported.

CONCLUSION

Missed diagnosis always occur in PAPVC, the debauche and blood flow of pulmonary vein should be overviewed carefully during ultrasonographic examination. Transesophageal echocardiography and contrast examination may help. CT and MRI elevate the final diagnosis rate of PAPVC. The result of operation on PAPVC is good.

Antenatal Diagnosis of Congenital Thoracic Malformations: Early Surgery, Late Surgery, or No Surgery?

Today, congenital thoracic malformations (CTMs), which comprise a spectrum of anomalies rather than separate entities, are frequently detected on routine antenatal ultrasound. However, with similar appearances of different congenital lung and nonpulmonary lesions, a definitive diagnosis cannot usually be established antenatally with absolute certainty. The natural history of CTMs is extremely variable. Large lesions may cause serious complications in the fetus, necessitating treatment in utero. Such prenatal therapy, however, is only required in a small minority of fetuses. Many lesions decrease in size before birth, and some are no longer detectable by ultrasound or chest radiography in the newborn period. All patients with prenatally detected CTMs require thorough postnatal evaluation, including a chest computed tomographic scan. Postnatally, the clinical appearance of CTMs can vary from immediate respiratory distress at birth to an incidental finding on a chest radiograph at any age. A few patients with large lesions require emergency or urgent surgery in the neonatal period. Furthermore, surgery is the accepted standard of care for all symptomatic lesions. Many children, however, will be asymptomatic at birth and in the neonatal period, and there is controversy as to the management of these newborns. Some authors recommend expectant long-term management of asymptomatic lesions, in particular congenital lobar emphysema and extrapulmonary sequestration. Most authors advocate elective resection of all cystic adenomatoid malformations, bronchogenic cysts, and intrapulmonary sequestrations because of the risk of complications, such as infection, hemorrhage, pneumothorax, sudden respiratory compromise, and malignant transformation. Elective lobectomy appears to be very well tolerated and is the most prevalent surgical method. Video-assisted thoracoscopic surgery was reported to be safe and effective. The timing of surgery in asymptomatic patients is not well delineated, with recommendations ranging from 1 month to 2 years of age. Some authors advocate surgery between 6 and 12 months of age because anesthetic and surgical risks decrease within the first months of life. Long-term prospective studies of CTMs are urgently needed to document their natural history.

Pneumosinus dilatans

Pneumosinus dilatans refers to an abnormally large aerated sinus; two other characteristic features of this disease are that the bony walls of the sinus are of normal thickness and there is no evidence of erosion. Most cases occur in the frontal sinuses. We describe a new case of pneumosinus dilatans in a 21-year-old woman. She required no treatment.

Congenital malformations of the lung

Congenital malformations of the lung are rare and vary widely in their presentation and severity. The most common manifestation of the congenital cystic disease of the lung at newborn and early infancy is respiratory distress. Later on in life, cysts usually lose this compressive character and may remain asymptomatic until infection occurs, while producing cough, dyspnea and thoracic pain. The purpose of this study is to review authors institutional experience of congenital cystic lung disease, with specific reference to diagnosis, treatment, as well as outcome, furthermore, to present some cases with unusual clinical manifestations.

The lung and the gut: common origins, close links

Because of the common embryologic origin, alteration of the many factors modulating the development of the alimentary and the respiratory tract often results in structural abnormalities involving the two systems. Indeed, some of the most common embryologic disorders of the airways are frequently associated with anomalies of the gastrointestinal tract. Lung growth occurs as a series of tightly regulated events, depending on a number of factors, including developmental, genetic and environment ones. Abnormalities of any of these factors may causes developmental alterations of the lung leading to a group of disorders termed "bronchopulmonary-foregut malformations". These are usually sporadic, solitary cystic hamartomas, involving conducting airways, arteries, venous drainage, and lung parenchyma, which are now often discovered on routine prenatal sonography. While some lesions may be large and cause serious complications in the foetus or newborn, many will be asymptomatic at birth, raising controversy about management: simple observation or surgery and, if so, at what age? Over the past two decades molecular studies have started to shed light on the complex series of events that control proper formation of the lung, with the hope that a better understanding of the molecular basis of pulmonary maturation will allow the design of new therapeutic strategies.

Dynamic obstructions of the equine upper respiratory tract. Part 1: observations during high-speed treadmill endoscopy of 600 Thoroughbred racehorses

REASONS FOR PERFORMING STUDY AND OBJECTIVE

To review the prevalence of single and complex forms of dynamic airway obstructions within a large group of Thoroughbred horses in training referred for investigation of poor performance.

METHODS

Video-endoscopic recordings of the upper respiratory tract made during a standardised treadmill exercise test of 600 Thoroughbred racehorses were reviewed and analysed in real time and slow motion to identify dynamic collapse by the tissues bordering onto the pharyngeal and laryngeal airways.

RESULTS

Dynamic collapse within the nasopharynx or larynx was confirmed in 471 of the 600 horses. Dorsal displacement of the soft palate (DDSP; 50%) and palatal instability (33%) were the disorders most frequently identified. It was concluded that deglutition is not a significant event in the triggering of DDSP. Complex forms of dynamic collapse were present in 30% of the horses with upper respiratory tract obstructions. A significant influence of age on the prevalence of DDSP and dynamic laryngeal collapse was identified. There was an increased risk of DDSP in younger horses, and of laryngeal collapse in older horses. No association with gender or format of racing was identified.

CONCLUSIONS AND POTENTIAL RELEVANCE

Palatal instability and DDSP comprised the most frequently encountered forms of dynamic collapse within the upper respiratory tract of the Thoroughbred racehorses in this study and are probably expressions of the same nasopharyngeal malfunction. Complex obstructions, i.e. where more than one structure collapses into the airway, occur frequently and therefore treatments that address solitary disorders may often be unsuccessful. Younger horses were found to be at greater risk of sustaining DDSP while older horses seemed more at risk to vocal cord collapse but not to collapse of the arytenoid cartilage itself.

Congenital Bronchial Atresia Associated With Spontaneous Pneumothorax

A 36-year-old woman presented with left chest pain and frequent symptoms of upper respiratory infection. Chest roentgenograms revealed a left pneumothorax and apical bulla, and hyperlucency in the left pulmonary field. She was diagnosed with congenital bronchial atresia associated with a left spontaneous pneumothorax. A thoracoscopy-assisted left superior segmentectomy was performed. There was no recurrence of the pneumothorax or symptoms of recurrent upper respiratory infection at the 1-year follow-up examination. Bulla formation was believed to have resulted from emphysematous changes in the peripheral lung due to congenital bronchial atresia. The pneumothorax may have occurred due to rupture of the bulla.

Measurement of abnormal respiratory sounds during over-ground exercise

REASONS FOR PERFORMING STUDY

The presence of abnormal respiratory sounds is commonly associated with obstructions of the upper respiratory tract. In order to establish their clinical significance measurements are required of both normal and abnormal respiratory sounds produced by horses exercising over-ground.

OBJECTIVES

To determine whether high quality recordings of respiratory sound can be made during over-ground exercise, and to develop a convenient measurement system that can be used to obtain respiratory sounds from horses exercising in field conditions.

METHODS

A range of prototypes was evaluated against the requirements that the system must be easy to use under field conditions and produce high-quality recordings of respiratory sound. The chosen design incorporated a miniature microphone and an air-flow direction sensor mounted on a lightweight plastic face mask. The mask was attached to the horse's head using nylon straps secured by velcro fastenings. Sound and flow signals were recorded on a portable minidisc player carried by the jockey.

RESULTS

The system fulfilled the design criteria. High quality recordings of respiratory sounds were obtained from Thoroughbred horse exercising on a training gallop under a variety of weather conditions. Intermittently occurring abnormal sounds were readily identified from the data.

CONCLUSIONS

High quality measurements of respiratory sounds during over-ground exercise can be made relatively easily.

POTENTIAL RELEVANCE

The system enables measurement of respiratory sounds outside a laboratory environment creating new opportunities for scientific research and clinical assessment. The study demonstrated that diagnostic systems based on respiratory sound analysis could potentially be manufactured at relatively low cost and be convenient and simple to use.

Adult outcome of congenital lower respiratory tract malformations

In this article, the most important lower respiratory tract malformations are briefly reviewed, with special focus on those factors that may have some impact on the long-term respiratory outcome of specific lesions, like the amount of lung tissue resected, compensatory lung growth, lung hypoplasia, intensive care and mechanical ventilation.

[Diagnosis and treatment of laryngeal web in infants]

OBJECTIVE

To summarize the clinical manifestation, operative method and therapeutic effect of various type of laryngeal web in infants.

METHODS

The clinical data of 12 cases were analyzed, 5 cases of which were congenital laryngeal web (4 cases, glottic type; 1 case, subglottic type), 7 cases of which were secondary laryngeal web (1 case, tuberculous laryngeal web; 6 cases, traumatic laryngeal web). Diagnosis was mainly depended on history and clinical manifestation. Final diagnosis was depended on fibrolaryngoscope and pathological report. Microlaryngoscopic surgery was the main operative method. However, specific infection should be cured before operation.

RESULTS

During 3-18 months follow-up, 4 glottic laryngeal webs were cured. One subglottic laryngeal web case well recovered and secondary surgery is not needed at least recently. One tuberculous laryngeal web was followed up for 6 months, no vocal adhesion was observed. During 3-6 months follow-up, 1 traumatic laryngeal web was cred, while the other 6 cases need secondary surgery.

CONCLUSIONS

Final diagnosis of congenital laryngeal web is mainly depended on fibrolaryngoscope. And prognosis of it is well. Laryngeal web induced by specific infection should be cured specific infection before operation. The prevention is the key for traumatic laryngeal web because the surgery outcome is not satisfactory.

Adult case of accessory cardiac bronchus presenting with bloody sputum

We report an adult case of accessory cardiac bronchus (ACB) which extended from the carina to the diaphragm. A 32-year-old woman, with a history of frequent respiratory infections since childhood, recently presented with bloody sputum, and was admitted to our hospital. The ACB was detected as a supernumerary bronchus diverging from tracheal bifurcation. Complete resection of the ACB was performed by video-assisted thoracic surgery via minithoracotomy, approaching from the 5th intercostal space. The bloody sputum was caused by chronic inflammation of the ACB. She has been asymptomatic since surgery.