RESUMO
Bronchopulmonary dysplasia (BPD) is occasionally associated with tracheobronchomalacia, and it is this combination that can lead to serious outcomes. The most severe cases require tracheostomies, ventilatory support and eventually even tracheal stents or surgery. Ventilation in patients with tracheomalacia is complicated without a good patient-ventilator synchrony; the neurally adjusted ventilatory assist (NAVA) mode is potentially beneficial in these cases. This case report presents a patient affected by BPD and severe tracheobronchomalacia who was tracheostomised and ventilated 24 hours a day and who suffered from episodes of airway collapse despite using the NAVA mode. It was necessary to increase the positive end-expiratory pressure to 20 cmH2O (the PEEP-20 manoeuvre) for several minutes during an episode; this allowed the trachea to remain open and allowed us to optimise the patient's ventilation. This strategy has previously been described in a patient with tracheomalacia, reducing the frequency and need for sedation in the following episodes.
Assuntos
Displasia Broncopulmonar/terapia , Respiração com Pressão Positiva , Traqueobroncomalácia/terapia , Traqueostomia , Desmame do Respirador , Humanos , LactenteRESUMO
CONTEXT: Tracheobronchomalacia (TBM) results from structural and functional abnormalities of the respiratory system. It is characterized by excessive collapse: at least 50% of the cross-sectional area of the trachea and main bronchi. In this paper, we present a rare case of a patient with TBM who first presented with stridor and respiratory failure due to exacerbation of chronic bronchitis. CASE REPORT: An 81-year-old Caucasian man was admitted presenting coughing, purulent sputum, stridor and respiratory failure. He had a medical history of chronic obstructive pulmonary disease (COPD) and silicosis and was a former smoker. Axial computed tomography on the chest revealed marked collapse of the trachea in its middle third. Bronchoscopy showed characteristics compatible with TBM. He was treated with noninvasive ventilation, without any good response. Subsequently, a Dumon Y stent was placed by means of rigid bronchoscopy. After the procedure, he was discharged with a clinical improvement. CONCLUSION: TBM is fatal and often underdiagnosed. In COPD patients, stridor and respiratory failure may be helpful signs that should alert physicians to consider TBM as an early diagnosis. Thus, these signs may be important for optimizing the treatment and evolution of such patients.
Assuntos
Doença Pulmonar Obstrutiva Crônica/complicações , Doenças Raras/complicações , Insuficiência Respiratória/etiologia , Sons Respiratórios/etiologia , Traqueobroncomalácia/complicações , Idoso de 80 Anos ou mais , Broncoscopia , Humanos , Masculino , Stents , Traqueobroncomalácia/terapiaRESUMO
CONTEXT: Tracheobronchomalacia (TBM) results from structural and functional abnormalities of the respiratory system. It is characterized by excessive collapse: at least 50 percent of the cross-sectional area of the trachea and main bronchi. In this paper, we present a rare case of a patient with TBM who first presented with stridor and respiratory failure due to exacerbation of chronic bronchitis. CASE REPORT: An 81-year-old Caucasian man was admitted presenting coughing, purulent sputum, stridor and respiratory failure. He had a medical history of chronic obstructive pulmonary disease (COPD) and silicosis and was a former smoker. Axial computed tomography on the chest revealed marked collapse of the trachea in its middle third. Bronchoscopy showed characteristics compatible with TBM. He was treated with noninvasive ventilation, without any good response. Subsequently, a Dumon Y stent was placed by means of rigid bronchoscopy. After the procedure, he was discharged with a clinical improvement. CONCLUSION: TBM is fatal and often underdiagnosed. In COPD patients, stridor and respiratory failure may be helpful signs that should alert physicians to consider TBM as an early diagnosis. Thus, these signs may be important for optimizing the treatment and evolution of such patients.
CONTEXTO: Traqueobroncomalácia (TBM) é resultado de alterações funcionais e estruturais do aparelho respiratório. É caracterizada pelo colapso excessivo de pelo menos 50 por cento da área de secção transversal da traqueia e dos brônquios principais. Neste trabalho, descrevemos um raro caso de paciente com TBM que primeiro apresentou estridor e insuficiência respiratória devido à exacerbação da bronquite crônica. RELATO DE CASO: Homem de 81 anos de idade, caucasiano, foi admitido apresentando tosse, expectoração purulenta, estridor e falência respiratória. Ele apresentava história médica prévia de doença pulmonar obstrutiva crônica (DPOC), silicose e era ex-tabagista. A tomografia axial computadorizada de tórax revelou marcado colapso da traqueia em seu terço médio. A broncoscopia mostrou aspectos compatíveis com TBM. Foi submetido a ventilação não invasiva, sem boa resposta. Na sequência, foi colocado stent Dumon em Y por broncoscopia rígida. Após o procedimento, o paciente teve alta com melhora clínica. CONCLUSÃO: TBM é uma entidade fatal e muitas vezes subdiagnosticada. Em pacientes com DPOC, o estridor e a insuficiência respiratória podem ser sinais úteis que devem alertar os médicos a considerar TBM como diagnóstico precoce. Assim, pode ser importante para otimizar o tratamento e a evolução dos pacientes.
Assuntos
Idoso de 80 Anos ou mais , Humanos , Masculino , Doença Pulmonar Obstrutiva Crônica/complicações , Doenças Raras/complicações , Insuficiência Respiratória/etiologia , Sons Respiratórios/etiologia , Traqueobroncomalácia/complicações , Broncoscopia , Stents , Traqueobroncomalácia/terapiaRESUMO
Tracheobronchomalacia refers to the presence of trachea and bronchi with soft, collapsible walls. Its incidence has been reported from 1:1500 to 1:2500. It can be congenital or acquired. This disease ranges from mild to life threatening. A high clinical suspicion is required for diagnosis, which needs to be confirmed endoscopically. Depending on severity, treatment can include from physical therapy and antibiotics to mechanical ventilation, surgery and tracheostomy, and is based on expert opinion and case series. Prognosis is usually good, with tendency to spontaneous resolution near the 2d year of life.
Traquebroncomalacia se refiere a la presencia de tráquea y/o bronquios cuya pared es blanda y tiene tendencia al colapso. Se ha reportado una incidencia entre 1:1.500 a 1:2.500. Puede ser congénita o adquirida. La severidad de los síntomas varía desde leve a incluso riesgo vital y muerte. El diagnóstico requiere una alta sospecha clínica y confirmación endoscópica. El tratamiento está basado en opiniones de expertos y series clínicas y varía según la severidad de los síntomas desde kinesioterapia y antibióticos en los casos más leves hasta ventilación mecánica, traqueostomía y cirugía en los más severos. El pronóstico en general es bueno con tendencia a la resolución espontánea aproximadamente a los 2 años de vida.