A first-aid fast track channel for rescuing critically ill children with airway foreign bodies: our clinical experience

Objective To explore the role of a first-aid fast track channel in rescuing children with airway foreign bodies and to analyse and summarize the experience and lessons of the first-aid fast track channel in rescuing airway foreign bodies from patients in critical condition. Methods We retrospectively reviewed the medical records of children with airway foreign bodies rescued by first-aid fast track channels admitted to our hospital from January 2017 to December 2020. The corresponding clinical features, treatments, and prognoses were summarized. Results Clinical data from 21 cases of first-aid fast track channel patients were retrospectively collected, including 12 males and 9 females aged 9–18 months. Cough was the most frequently exhibited symptom (100.0%), followed by III inspiratory dyspnoea (71.4%). Regarding the location of foreign bodies, 5 cases (23.8%) had glottic foreign bodies, 10 cases (47.6%) had tracheal foreign bodies, and 6 cases (28.6%) had bilateral bronchial foreign bodies. The most common type of FB was organic. FB removal was performed by rigid bronchoscopy in every case, and there were no complications of laryngeal oedema, subcutaneous emphysema, or pneumothorax. No tracheotomy was performed in any of the children. Conclusion The first-aid fast track channel for airway foreign bodies saves a valuable time for rescue, highlights the purpose of rescue, improves the success rate of rescue and the quality of life of children, and is of great value for the treatment of critical tracheal foreign bodies. It is necessary to regularly summarize the experience of the first-aid fast track channel of airway foreign bodies and further optimize the setting of the first-aid fast track channel.

Diverse disease processes of group A Streptococcus infection including severe invasive infections among members of a family

We herein report three cases of group A Streptococcus (GAS) infection in a family. Patient 1, a 50-year-old woman, was transferred to our hospital in shock with acute respiratory distress syndrome, swelling in the right neck and erythemata on both lower extremities. She required intubation because of laryngeal oedema. At the same time, patient 2, a 48-year-old man, was admitted because of septic shock, pneumonia and a pulmonary abscess. Five days later, patient 3, a 91-year-old woman, visited our clinic with bloody stool. All three patients were cured by antibiotics, and GAS was detected by specimen cultures. During these patients’ clinical course, an 84-year-old woman was found dead at home after having been diagnosed with type A influenza. All four patients lived in the same apartment. The GAS genotypes detected in the first three patients were identical. When treating patients with GAS, appropriate management of close contacts is mandatory.

Resolution of Laryngeal Oedema in a Patient with Acquired C1-Inhibitor Deficiency. A Case Report

Introduction Laryngeal oedema caused by acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a life-threatening condition. The swelling is bradykinin mediated and will not respond to the usual treatment with antihistamines, corticosteroids, or epinephrine. Instead, kallikrein-bradykinin-targeted therapies should be used promptly to prevent asphyxiation. Case presentation A 43 years old female presented at the Hereditary Angioedema Centre reporting a one-year history of peripheral, facial, and neck oedema. Treatment with antihistamines and corticosteroids had been ineffective. Laboratory results showed complement level deficiencies and monoclonal gammopathy characterised as immunoglobulin M. An abdominal ultrasound revealed splenomegaly. A bone marrow biopsy was normal. Based on these data, the diagnosis of C1-INH-AAE associated with monoclonal gammopathy of uncertain significance (MGUS) was made. As C1-INH-AAE can present with life-threatening, standard treatment-resistant laryngeal oedema, an emergency care treatment plan was proposed, and the patient was advised to present to the emergency department (ED) with this medical letter. Based on these recommendations, three laryngeal attacks were successfully treated in the ED with recombinant human C1-inhibitor (two attacks) and fresh frozen plasma (one attack). After these episodes, the patient was prescribed prophylactic treatment with antifibrinolytics. No further angioedema attacks were reported by the patient at the 18 months follow-up visit. Conclusions Because angioedema of the upper airways is a life-threatening condition, recognising the specific type of swelling by the emergency physician is critical in providing immediate and effective treatment to reduce the associated risk of asphyxiation. C1-INH-AAE being a rare disorder, patients should have available an emergency care treatment plan with recommendations of acute treatment possibilities.

Use of lignocaine nebulization in post bronchoscopy patients: a study of 150 cases

Background: To see the role of lignocaine nebulisation and to compare its role with use of steroids and bronchodilators alone in post bronchoscopy patients.Methods: In the present study, 150 patients, who underwent rigid bronchoscopy for removal of foreign body, were taken into consideration. Immediately after the rigid bronchoscopy, 100 patients were given nebulization and 50 patients were not nebulized. Out of 100 patients, 50 patients were given nebulization with steroids (budesonide) and bronchodilators (salbutamol) and 50 patients received nebulization with lignocaine 4%, steroids (budesonide) and bronchodilator (salbutamol).Results: In the present study, 38 patients (25.3%) were having complications like laryngobronchial spasm, laryngeal edema, cardiac arrest and respiratory arrest. Out of the 38 patients, 15 patients (39.5%) were having laryngobronchial spasm and 23 patients (60.5%) were having laryngeal edema. Out of 15 patients who had laryngobronchial spasm only 2 (13.3%) patients, who were nebulised developed this complication, while 86.7% cases of laryngobronchial spasm developed in non-nebulised patients. Out of 23 patients who developed laryngeal oedema, only 6 (26%) patients who were nebulised developed this complication, while 74% cases of laryngeal oedema developed in non-nebulised patients.Conclusions: In the present study it is concluded that both morbidity and mortality can be reduced by the use of nebulisation in the postoperative period after rigid bronchoscopy. Addition of lignocaine in nebulisation along with steroids and bronchodilators further reduces the morbidity and mortality in the postoperative period.

Cuff Leak Test and Airway Obstruction in Mechanically Ventilated ICU Patients (COMIC): a pilot randomised controlled trial protocol

IntroductionEndotracheal intubation and invasive mechanical ventilation are lifesaving interventions that are commonly performed in the intensive care unit (ICU). Laryngeal oedema is a known complication of intubation that may cause airway obstruction in a patient on extubation. To date, the only test available to predict this complication is the cuff leak test (CLT); however, its diagnostic accuracy and utility remains uncertain. Herein, we report the protocol for the CuffLeak and AirwayObstruction in MechanicallyVentilated ICU Patients (COMIC) pilottrial.Methods and analysisThis will be a multicentred, pragmatic, pilot randomised controlled trial (RCT). We will enrol 100 mechanically ventilated patients in the ICU who are deemed ready for extubation. We will exclude patients at a high risk of laryngeal oedema. All enrolled patients will have a CLT done before extubation. In the intervention arm, the results of the CLT will be communicated to the bedside physician, and decision to extubate will be left to the treating team. In the control arm, respiratory therapist will not communicate the results of the CLT to the treating physician, and the patient will be extubated regardless of the CLT result. Randomisation will be done in a 1:1 allocation ratio, stratified by size of the endotracheal tube and duration of invasive mechanical ventilation.Although we will examine all clinical outcomes relevant for the future COMIC RCT, the primary outcomes of the COMIC pilottrial will be feasibility outcomes including: consent rate, recruitment rate and protocol adherence. Clinical outcomes include postextubation stridor, reintubation, emergency surgical airway, ICU mortality, in hospital mortality, duration of mechanical ventilation and ICU length of stay in days.Ethics and disseminationThe Hamilton Integrated Research Ethics Board, Imam Abdulrahman Bin Faisal University Institutional Review Board and Bioethical Commission of the Jagiellonian University approved this study. The trial results will be disseminated via publication in peer-reviewed journals.Trial registration numberNCT03372707.

Acute Severe Anaphylaxis in Nepali Patients with Neurotoxic Snakebite Envenoming Treated with the VINS Polyvalent Antivenom

Diagnosing and treating acute severe and recurrent antivenom-related anaphylaxis (ARA) is challenging and reported experience is limited. Herein, we describe our experience of severe ARA in patients with neurotoxic snakebite envenoming in Nepal. Patients were enrolled in a randomised, double-blind trial of high vs. low dose antivenom, given by intravenous (IV) push, followed by infusion. Training in ARA management emphasised stopping antivenom and giving intramuscular (IM) adrenaline, IV hydrocortisone, and IV chlorphenamine at the first sign/s of ARA. Later, IV adrenaline infusion (IVAI) was introduced for patients with antecedent ARA requiring additional antivenom infusions. Preantivenom subcutaneous adrenaline (SCAd) was introduced in the second study year (2012). Of 155 envenomed patients who received ≥ 1 antivenom dose, 13 (8.4%), three children (aged 5−11 years) and 10 adults (18−52 years), developed clinical features consistent with severe ARA, including six with overlapping signs of severe envenoming. Four and nine patients received low and high dose antivenom, respectively, and six had received SCAd. Principal signs of severe ARA were dyspnoea alone (n=5 patients), dyspnoea with wheezing (n=3), hypotension (n=3), shock (n=3), restlessness (n=3), respiratory/cardiorespiratory arrest (n=7), and early (n=1) and late laryngeal oedema (n=1); rash was associated with severe ARA in 10 patients. Four patients were given IVAI. Of the 8 (5.1%) deaths, three occurred in transit to hospital. Severe ARA was common and recurrent and had overlapping signs with severe neurotoxic envenoming. Optimising the management of ARA at different healthy system levels needs more research. This trial is registered withNCT01284855.

Laryngopharyngeal mucosal fold causing upper airway obstruction in a dog

A 2.4-kg, six-year-old, sterilised, male Pomeranian presented with dyspnoea that had begun two years prior and slowly progressed. Pharyngoscopy identified a redundant laryngopharyngeal mucosal fold that was being aspirated cranially into the laryngeal opening causing upper airway obstruction. A diode laser was used to resect the fold. Postoperative laryngeal oedema necessitated the use of a tracheostomy tube for just over two days. Otherwise, the dog made an uneventful recovery. To the authors’ knowledge, this is the first report of a redundant laryngopharyngeal mucosal fold resulting in upper airway obstruction in a dog.

A laryngomalacia endoszkópos ultrapulzációs-lézeres (ultra dream pulse) sebészete. A módszer hazai bevezetése során szerzett tapasztalataink

Introduction: Congenital stridor and dyspnoe are caused by laryngomalacia in most cases. Aim: In this article we present a new, surgical method for treating severe laryngomalacia in patients under the age of 1, where ultrapulsated (UDP) laser beam is used for supraglottoplasty. Ultra dream pulse laser creates lesser thermical side damage in the tissue, therefore the risk of postoperative laryngeal oedema and scarring is lower. Method: We present 10 cases and the endoscopic UDP-laser surgery of patients under the age of 1 with severe laryngomalacia. Results: After the surgery the stridorous symptoms disappeared, and there was no evidence of postoperative laryngeal oedema, there was no need for reoperation or tracheotomy in any of the cases. Conclusion: UDP-laser surgery of laryngomalacia is proven to be a safe and effective surgial modality. During the follow up visits we experienced neither recurrence of stridor nor laryngeal scarring. Orv Hetil. 2017; 158(33): 1288–1292.