Posted by James
Spirometry (pre- and postbronchodilator) was assessed using a flow-sensitive spirometer (Renaissance II; Puritann-Bennett, Carlsbad, CA). A respiratory therapist who was experienced in performing spirometry in children conducted all tests, and all tests conformed to the criteria of the American Thoracic Society. All tests were performed between 10 a.m. and 2 p.m. The following parameters were measured: forced vital capacity (FVC), forced expiratory volume in 1 second (FEVi) and forced expiratory flow at midlung volume (FEF25-75). The ratio of FEVi to FVC (FEVi/FVC) was calculated. All values were adjusted for body temperature and barometric pressure. Percent predicted values for FVC,
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Posted by James
LIMITATIONS
This study is limited in part by the small number of inner-city children studied at one secondary school in the midwestern part of the United States. Participation was voluntary and based on the willingness of children and their parents to consent for enrollment into the study. This may introduce selection bias into the results of the study. Another critical issue is the definition of overweight in children and adolescents. A child who is physically active may have a high BMI but an acceptable level of body fat. Some studies have suggested that BMI may be a poor indicator of adiposity in an individual child. The sum of triceps and subscapular skinfold thickness (sum of skinfolds) is another measure of obesity that has been used to evaluate the association between asthma and obesity in children. However, Figueroa-Munoz et al. found that BMI was more consistently associated with asthma than the sum of skinfolds in children 4-11 years of age. We selected BMI instead of sum of skinfolds because caliper measurements are somewhat less reproducible than weight and height measurements and because Pietrobelli et al. validated the use of BMI as a measure of adiposity in children.
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Posted by James
INTRODUCTION
Asthma is the principal cause of chronic illness and school absenteeism in children. Asthma imposes a disproportionate burden on ethnic and racial minorities and poor inner-city children. Obesity in children is another major public health concern. The rise in obesity has been attributed to lifestyle changes that have resulted in decreased energy expenditure, whereas the increase in asthma prevalence remains unexplained. Because the increases in asthma and obesity appear to have coincided, it has been suggested that they may be causally related. Results of studies on the association between overweight/obesity and asthma in children have been inconsistent, and the exact nature of the relationship remains unclear.
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Posted by James
The patient was brought to the operating room and placed in a semirecumbent position. A Nellcor Puritan Bernett multiparameter patient monitor was applied. The pulse was 120 beats/min, blood pressure was 100/70 mmHg and peripheral arterial oxygen saturation was 92%, with the patient breathing oxygen-enriched air. A peripheral intravenous access was established and 0.9% saline commenced. This was followed by bilateral superficial plexus block performed by a consultant anesthetist (first author) as follows: the midpoint of the posterior border of the sternomastoid muscle was identified. From this point, 15 ml of 0.375% bupivacaine with 1:400,000 epinephrine was infiltrated along the posterior border of the muscle, 3 cm cephalad and caudad, to block the superficial branches of the cervical plexus. A further 3 ml of the solution was also infiltrated superficially above the muscle to block the transverse cervical nerves. The block was performed on both sides of the neck using a size 21-gauge hypodermic needle. This procedure was well tolerated by the patient. Surgical anesthesia was demonstrated in 15 minutes. The patient was positioned supine with the head supported on a head ring and elevated by about 25°. The classical thyroidectomy positioning, with the head fully extended with the aid of a shoulder pad, could not be effected because this position worsened the patient’s respiratory distress.
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Posted by James
The occurrence of goiters causing airway obstruction is not new. As far back as 1821, Hedenus reported successful thyroidectomies in six patients for goiters, which he described as “suffocating.” Goiter still remains an uncommon cause of upper airway obstruction even today. This is particularly so in developing countries, where goiters are often neglected for long due to ignorance and lack of ready access to affordable medical services. However, when respiratory obstructive symptom does occur, it is usually insidious, intermittent and postural in manifestation, especially in bed at night, initially. Severe/life-threatening airway obstruction, as seen in our patient, is extremely rare. It is not clear why the airway obstruction in this patient suddenly worsened on admission. There was no histological evidence of hemorrhage into the thyroid gland. It could, however, be due to upper airway infection, resulting in edema and retention of secretions.
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Posted by James
A 65-year-old woman presented at the emergency unit of the University of llorin Teaching Hospital, llorin, Nigeria, with one-week history of progressively increasing degree of breathlessness. She had a 10-year history of a progressively increasing anterior neck swelling. She had noticed a rapid increase in the size of the swelling with associated nodularity within the proceeding eight months. About two weeks prior to presentation, the patient developed a productive (purulent) cough with hemoptysis. She had no previous history of any other significant illness or anesthesia. She had no allergies. Family and social history was not contributory. Physical examination revealed a chronically ill-looking patient with dyspnea, tachypnea (respiratory rate of 32 cycles/min and stridor. She was mildly pale, afebrile, acyanosed, anicteric and not dehydrated. Her pulse was nObeats/min and regular, and blood pressure was 120/90 mmHg. She had a huge firm, nontender multinodular goiter, measuring 20×14 cm, extending from the submandibular region to the suprasternal notch (Figure 1). The goiter was more pronounced on the left. The trachea was deviated to the right with the thyroid notch located about 12 cm from the midline. She had positive Berry’s sign (left) and positive Kocher’s sign. There were cervical, supraclavicular and bilateral axillary lym-phadenopathies. The chest was clinically clear with moderate air entry bilaterally. Examinations of the other systems revealed no abnormalities. A provisional diagnosis of giant malignant goiter causing upper airway obstruction was made. The patient was admitted for investigations and scheduled for early thyroidectomy on the surgeon’s next elective list, which was to be two days later. She was commenced on oxygen therapy by nasal cannula.
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Posted by James
INTRODUCTION
Most patients with goiter are asymptomatic. Consequently, thyroidectomy is usually a planned elective procedure. However, there are few reports of patients with goiter presenting with varying degrees of airway compromise necessitating emergency thyroidectomy. This situation presents considerable challenges to anesthetists. We present the case of an elderly woman who presented with a giant malignant goiter causing severe upper airway obstruction. There was associated pulmonary metastasis. Several anesthetic options were considered. Regional anesthesia (bilateral superficial cervical plexus block) was eventually chosen. The procedure was well tolerated and the intraoperative course was uneventful.
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