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RARE CAUSE OF FAILED RARE CAUSE OF FAILED EXTUBATIONEXTUBATION

DR HIMANSHUDR HIMANSHU

IPCUIPCU

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VINAYVINAY

A 3 ½ month Male child transferred A 3 ½ month Male child transferred from pv t .Hospital with from pv t .Hospital with complains complains of of Cough ,coldCough ,cold , , breathlessness since 1 day breathlessness since 1 day

clinicallyclinically: Tachypnea ,wheezing: Tachypnea ,wheezing bilateral, signs of respiratory distressbilateral, signs of respiratory distress

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HISTORYHISTORY

Second by birth order, FTND .Second by birth order, FTND .

5 days NICU stay for MAS .5 days NICU stay for MAS .

On day 14 of life,pt had a On day 14 of life,pt had a pneumonia ,that time DIAGNOSED pneumonia ,that time DIAGNOSED as ? Laryngomalacia.as ? Laryngomalacia.

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THIS TIME PRESENTED WITH THIS TIME PRESENTED WITH RESPIRATORY COMPLAINTSRESPIRATORY COMPLAINTS

IN PRIVATE HE Rx AS IN PRIVATE HE Rx AS BRONCHIOLITIS WITH RESP. BRONCHIOLITIS WITH RESP. FAILURE & VENTILATED AND FAILURE & VENTILATED AND EXTUBATED IN 24 HR. BUT REQIRE EXTUBATED IN 24 HR. BUT REQIRE REINTUBATION WITHIN 12 HOURS.REINTUBATION WITHIN 12 HOURS.

REFERRED TO WADIA HOS. AS ? REFERRED TO WADIA HOS. AS ? GER CASE. GER CASE.

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CLINICAL COURSECLINICAL COURSE

ON ADMISSION WITH SEVERE ON ADMISSION WITH SEVERE RESPIRATOR DISTRESS .RESPIRATOR DISTRESS .ABG S/O SEVERE RESPIRATORY ABG S/O SEVERE RESPIRATORY ACIDOSIS ( PH 6.98 PCO2 80 PO2 68 ACIDOSIS ( PH 6.98 PCO2 80 PO2 68 SPO2 82 )SPO2 82 )INTUBATED & VENTILATED FOR 48 INTUBATED & VENTILATED FOR 48 HRS & EXTUBATED . THIS TIME CHILD HRS & EXTUBATED . THIS TIME CHILD HAD STRIDOR BUT AGAIN REQUIRE HAD STRIDOR BUT AGAIN REQUIRE REINTUBATION.REINTUBATION.

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Clinical courseClinical course

Extubation tried again Extubation tried again

But failed 3 times !!! Serial ABG But failed 3 times !!! Serial ABG showing co2 retention.showing co2 retention.

And Because of repeated And Because of repeated extubation failure planned for extubation failure planned for tracheostomy with bronchoscopy.tracheostomy with bronchoscopy.

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Clinical courseClinical course

But tracheostomy was not successful & during But tracheostomy was not successful & during bronchoscopy there was no subglottic stenosis , bronchoscopy there was no subglottic stenosis , there was resistance felt during passege of there was resistance felt during passege of scope beyond glottis.scope beyond glottis.

Persistent respiratory distress and stridor with Persistent respiratory distress and stridor with tracheostomy.tracheostomy.

The causes METABOLIC AND SUBGLOTTIC The causes METABOLIC AND SUBGLOTTIC STENOSIS are already ruled out for stridor.STENOSIS are already ruled out for stridor.

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Clinical courseClinical course

Then thought of some Then thought of some extrinsic extrinsic obstructionobstruction we inserted the ET tube we inserted the ET tube through the tracheostomy tube to through the tracheostomy tube to pass that obstructionpass that obstruction

And with that patient was stable on T-And with that patient was stable on T-piece & planned forpiece & planned for CT THORAX. CT THORAX.

WHICH SUGGESTIVE OF !!!!!!!WHICH SUGGESTIVE OF !!!!!!!

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DIAGNOSISDIAGNOSIS

VASCULAR RINGVASCULAR RING ( DOUBBLE AORTIC ARCH ( DOUBBLE AORTIC ARCH ENCIRCLING TRACHEA AT ENCIRCLING TRACHEA AT LEVEL OF BIFURCATION )LEVEL OF BIFURCATION )

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VASCULAR RINGVASCULAR RING

PREVALANCE:PREVALANCE:VASCULAR RING REPORTEDLY REPRESENTS VASCULAR RING REPORTEDLY REPRESENTS

<1 % OF ALL CONGENITAL CV ANOMALIES.<1 % OF ALL CONGENITAL CV ANOMALIES.

PATHOLOGY:PATHOLOGY:VASCULAR RING REFERS TO GROUP OF VASCULAR RING REFERS TO GROUP OF

ANOMALIES OF AORTIC ARCH THAT CAUSE ANOMALIES OF AORTIC ARCH THAT CAUSE RESPIRATORY SYMPTOMS & FEEDING RESPIRATORY SYMPTOMS & FEEDING PROBLEMS .PROBLEMS .

THE VASCULAR RING MAY BE OFTHE VASCULAR RING MAY BE OF 1. COMPLETE TYPE1. COMPLETE TYPE 2.INCOPLETE VASCULAR RING.2.INCOPLETE VASCULAR RING.

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VASCULAR RINGVASCULAR RING

TYPES :TYPES :DOUBLE AORTIC ARCH (40 %)- 3MONTH DOUBLE AORTIC ARCH (40 %)- 3MONTH AGEAGE

RIGHT AORTIC ARCH(20%)-1 YRRIGHT AORTIC ARCH(20%)-1 YR

ANOMALOUS INNOMINATE ARTERY(10)-ANOMALOUS INNOMINATE ARTERY(10)-INFANCYINFANCY

ABBERANT RT. SUBCLAVIAN ARTERY(20%)-ABBERANT RT. SUBCLAVIAN ARTERY(20%)-SWALLOWING DIF.SWALLOWING DIF.

VASCULAR SLING-BIRTH.VASCULAR SLING-BIRTH.

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Embryonic aortic arch with dorsal and ventral Embryonic aortic arch with dorsal and ventral arches and 6 branchial arches on right and left. arches and 6 branchial arches on right and left.

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DOUBLE AORTIC ARCHDOUBLE AORTIC ARCH

Incidence 40% , Onset of Respi . Incidence 40% , Onset of Respi . Symptoms < 3 mo.Symptoms < 3 mo.

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RIGHT AORTIC ARCH WITH Lt. LIG. RIGHT AORTIC ARCH WITH Lt. LIG.

ARTERIOSUMARTERIOSUM

Mild respiratory symptoms at 1 yr.& Mild respiratory symptoms at 1 yr.& swallowing dysfunction.swallowing dysfunction.

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Right aortic arch with mirror-image Right aortic arch with mirror-image branching and retroesophageal ligamentum branching and retroesophageal ligamentum

arteriosumarteriosum

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Left aortic arch with right descending aorta Left aortic arch with right descending aorta and right ligamentum arteriosum. and right ligamentum arteriosum.

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ABERRANT Rt. SUBCLAVIAN ARTERY.ABERRANT Rt. SUBCLAVIAN ARTERY.

Inc. 20%Inc. 20%

OccasionalOccasional

SwallowingSwallowing

dysfunction.dysfunction.

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Aberrant left pulmonary artery or pulmonary Aberrant left pulmonary artery or pulmonary artery sling. artery sling.

Wheezing & Cyanotic episodes Wheezing & Cyanotic episodes since birth. since birth.

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CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

HISTORY:HISTORY:INSPIRATORY STRIDOR &FEEDING INSPIRATORY STRIDOR &FEEDING PROBLEMS : VARYING SEVEARITY PROBLEMS : VARYING SEVEARITY DEPENDING ON TYPEDEPENDING ON TYPE

H/O RECURRENT PNEUMONIAH/O RECURRENT PNEUMONIA

H/O-ATELECTESIS, EMPHYSEMA, PNEUMONIA H/O-ATELECTESIS, EMPHYSEMA, PNEUMONIA OF RT. LUNGOF RT. LUNG

EXAMINATION:EXAMINATION:NOTHING EXCEPT VARYING DEG. OF NOTHING EXCEPT VARYING DEG. OF RHONCHI.RHONCHI.

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DIAGNOSISDIAGNOSIS

VASCULAR RING SUSPECTED BASED ON VASCULAR RING SUSPECTED BASED ON CLINICAL SYMPTOMS.CLINICAL SYMPTOMS.

CXR-SHOWS SHIFTING OF TRACHEA TO CXR-SHOWS SHIFTING OF TRACHEA TO ANTIRIORANTIRIOR

BARIUM SWALLOW- MOST USEFULL BARIUM SWALLOW- MOST USEFULL SHOWS TWO INDENTATION ON PA VIEW & SHOWS TWO INDENTATION ON PA VIEW & POST. INDENTATION ON LATERAL VIEW.POST. INDENTATION ON LATERAL VIEW.

ECHO ,ANGIOGRAPHY.ECHO ,ANGIOGRAPHY.

CT-THORAX,MRI.CT-THORAX,MRI.

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MANAGEMENTMANAGEMENT

MEDICAL :MEDICAL :ASYMPTOMIC PT. NO TREATMENT.ASYMPTOMIC PT. NO TREATMENT.

MILD SYMPTOMS-CAREFULL FEEDING & MILD SYMPTOMS-CAREFULL FEEDING & AGGRESSIVE Rx OF PULMONARY AGGRESSIVE Rx OF PULMONARY INFECTIONS.INFECTIONS.

SURGICAL :SURGICAL : DIVISION OF THE SMALLER OF THE TWO DIVISION OF THE SMALLER OF THE TWO

ARCHES (USALLY LEFT)TROUGH LT.LAT ARCHES (USALLY LEFT)TROUGH LT.LAT THORACOTOMY.THORACOTOMY.

SURGICAL MORTALITY < 5 %.SURGICAL MORTALITY < 5 %.

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KEY MESSAGEKEY MESSAGE

ALL THAT ALL THAT WHEEZE IS NOT ASTHMA WHEEZE IS NOT ASTHMA & ALL ASTHMATIC DOES & ALL ASTHMATIC DOES NOT ALWAYS WHEEZE NOT ALWAYS WHEEZE..

THANK YOUTHANK YOU