[Functional endoscopic evaluation of swallowing in infants with deglutition disorders]

BACKGROUND

Functional endoscopic evaluation of swallowing (FEES) is a recognized method for Deglutition Disorders (DD) in adults, with anecdotal experience in children, obtaining not conclusive results.

OBJECTIVE

To compare the accuracy of test FEES in infants with high suspicion of altered DD seen in a third level hospital with the gold standard Videofluoroscopic (VF).

PATIENTS, MATERIAL AND METHODS

The results and findings by FEES and VF of 66 children with clinical diagnosis of DD were compared.

STATISTICAL ANALYSIS

An estimate of the sensitivity and specificity of FEES was performed. As well as calculating positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios.

RESULTS

60 patients enrolled, 4 and FEES showed high sensitivity to identify the presence of aspiration and penetration (9 98%) and high specificity for the arrest of spillage and waste (94% and 95%). Gastroesophageal reflux to make the diagnosis of DD with FEES had a sensitivity of 80% and specificity of 84%. Spill and penetration had the highest agreement with respect to the gold standard of 0.81.

CONCLUSIONS

FEES in infants diagnosed with DD had a sensitivity of 80.8% and specificity 85.3%. 0696 concordance regarding to the VFD in the diagnosis of DD, and to identify suction stroke had a kappa of 0815.

Cutoff value of lipid-laden alveolar macrophages for diagnosing aspiration in infants and children

Chronic passage of gastric and/or alimentary material into the airways is a frequent and difficult-to-diagnose condition. Because alveolar macrophages phagocytose aspirated material, it has been suggested that their identification is a useful diagnostic method. To know the usefulness of the lipid-laden alveolar macrophages (LLAM) index as a diagnostic tool for aspiration, children from 1 month to 16 years of age were included in three groups: G-I, children with pulmonary pathology and suspicion of aspiration by clinic or image evaluation; G-II, with pulmonary pathology without suspicion of aspiration; and G-III, without respiratory symptoms nor suspicion of aspiration. Bronchoalveolar lavage was obtained through bronchoscopy in G-I and G-II, and through endotracheal tube in G-III, and the LLAM index (0-400) was determined. A total of 112 patients (41, 30, and 41 in G-I to III, respectively) were studied. LLAM index (mean +/- SEM) was highest in G-I (233.2 +/- 5.5), as compared with G-II (187.8 +/- 11.6, P < 0.05), and G-III (108.5 +/- 13.5, P < 0.001). However, notable overlap of LLAM values was observed between G-I and G-II, and between G-II and G-III. When patients from G-I and G-III were jointly analyzed, the area under the ROC curve for diagnosing aspiration was 0.92, with a best cutoff value of >165 (98.6% sensitivity, 78.0% specificity, 87.8% overall accuracy). LLAM index, with a cutoff value of >165 is a useful diagnostic test for aspiration when there is suspicion of this condition. However, due to its low specificity, it does not discriminate other causes of chronic lung disease.

Foreign body removal by flexible fiberoptic bronchoscopy in infants and children

Rigid bronchoscopy is the preferred method for removal of foreign bodies lodged in the airways, but some studies found that flexible bronchoscopy can also achieve a high success rate. The aim of the present work was to report our experience in using flexible bronchoscopy for foreign body retrieval in infants and children. Reports of all bronchoscopies performed from 1994-2003 at a tertiary-level pediatric hospital in Mexico City were reviewed. Those with a final diagnosis of foreign body aspiration were analyzed. Of 2,376 bronchoscopies performed during the study period, 59 (2.5%) yielded a final diagnosis of foreign body aspiration: 28 lodged in the right bronchi, 15 in the left bronchi, and those remaining, in the larynx or trachea. Foreign bodies were organic in nature in 38 (64.4%), mainly peanuts, pumpkin seeds, and beans, while 21 (35.6%) were inorganic, mainly pen caps and pins. In 23 cases, flexible bronchoscopy was attempted as the initial therapeutic procedure. Among these latter patients, the procedure was successful in 21 (91.3%). Ages of these 21 patients ranged from 9 months to 16 years (median, 5 years). The only two patients in whom foreign bodies could not be removed through flexible bronchoscopy were males, 2 years of age, both with a peanut lodged in right main bronchus. In conclusion, flexible bronchoscopy must be taken into account as initial therapeutic method for foreign body removal in infants and children.

Efficacy of human recombinant DNase in pediatric patients with cystic fibrosis

BACKGROUND

Most respiratory complications in cystic fibrosis (CF) arise from abnormally viscid mucus, and rhDNase has shown to be effective in enhancing mucous clearance. We explored the responses to rhDNase in a Mexican population of CF patients.

METHODS

Patients with CF received aerosolized rhDNase (2.5 mg daily) during 3 months, followed by daily aerosolized placebo during 3 months.

RESULTS

A total of 21 CF patients entered the study (11.1 +/- 0.5 years of age, mean +/- SEM, 10 girls): 15 patients (71%) had basal forced vital capacity (FVC) higher than the 70% predicted value, and the remainder of the patients had an FVC of between 30 and 70%. As a group, rhDNase progressively increased the forced expiratory flow at 1 sec (FEV1) as well as the FVC, reaching statistical significance (p <0.005) at the end of the third month of treatment. Sputum production and difficulty to expectorate or to breathe also improved during the rhDNase treatment period (p <0.05 to p <0.001). All these changes progressively decreased to basal values after 3 months with aerosolized placebo. Adverse reactions were almost null, with a sole patient reporting dysphonia.

CONCLUSIONS

Aerosolized rhDNase was effective in progressively improving respiratory function and symptoms in most CF patients.

[Severe respiratory failure secondary to vascular ring. Report of 2 cases]

Vascular compression of the airways is an infrequent situation that can be masked by inespecific respiratory symptoms. We present two cases with severe respiratory distress, that needed assisted mechanical ventilation in patients with overdistended lungs which improved when the endotracheal cannula was shifted near the carina. The chest radiograph showed hyperinflation of the lungs; an identation was demonstrated in the esophagogram and the endoscopy demostrated extrinsic esophagical compression. The angiogram documented double aortic arch in the first case and aberrant subclavia artery in the second. Vascular section and liberation of trachea and esophagus were performed with good outcome. The decrease of thoracic overdistention when the cannula was placed in the lower part of the trachea gave the clue to the diagnosis of vascular ring. A high index of suspicion is necessary for an early diagnosis.

[Prune belly syndrome associated with cystic adenomatoid malformation of the lung and pulmonary sequestration]

The "prune belly" syndrome classically described in males, has also been described in female patients with a variable incidence. Associations with multiple respiratory tract malformations have been reported which together with urinary tract anomalies and renal failure are often the cause of early mortality. We report the case of a female patient with prune belly in association with cystic adenomatoid malformation of the lung and pulmonary sequestration with a favorable clinical evolution following medical and surgical treatment.