成人のstridorへの アプローチ - JHospitalist Network

1 Stridor 2017 3 9 78 100 20 24 Vital sign:BP 145/90mmHg, HR 130/min, RR36/min,SpO2 86%, BT 38 C Stridor BVM 7mm - BGA(Vein) pH , PaO2 63 Torr, PCO2 Torr coarse crackles A CO2 10 SpO2 Stridor Stridor Stridor Clinical Ques3on Stridor 400H Stridor Stridor wheezing Am Rev Respir ;143:890-892 8 Crit Care Med 2004; 169: 1278-1297.

2 5mm ;216:1984-1985 Central airway obstrucYon(CAO) : upper airway obstrucYon(UAO) : CAO Lower airway obstrucYon(LAO) : COPD CAO UAO Up to date: Clinical presentaYon , diagnosYc evaluaYon,and management of central airway obstrucYon in adults CAO Crit Care Med 2004; 169: 1278-1297. common History and examina3on sub acute CAO COPD COPD 4 6 CAO Up to date: Clinical presentaYon , diagnosYc evaluaYon ,and management of central airway obstrucYon in adults History and examina3on stridor wheezes Upper airway obstruc3on Stridor UAO Stridor 10 J Laryngol.

3 122(8):818 10 2006 Annual EsYmates of the PopulaYon by Five-Year Age Groups and Sex for the United States: April 1, 2000 to July 1, 2006 (NC-EST2006-01) (Hib ) 90 100 C (26 90 ) 50 80 stridor ( 33 ) (20 40 ) 6 Emerg Med J. 2008;25(5):253. Life-threatening central airway obstrucYon no dedicated airway team is available, paYent transfer to a specialized center should be considered the paYent s airway has been secured and their condiYon has been stabilized. Up to date: Clinical presentaYon , diagnosYc evaluaYon,and management of central airway obstrucYon in adults CT , CT 50 Golden S Sign Crit Care Med 2004; 169: 1278-1297.

4 1280 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 169 2004 Figure with tracheal obstruction/deviation due to non smallcell lung carcinoma in the right upper as tracheal deviation (Figure 1), can be identified; however,the chest X-ray is unable to determine airway invasion or aidin procedure planning. Standard computed tomography (CT)scans provide much more information, including the ability todocument dynamic airway collapse, and help predict responseto treatment such as photodynamic therapy (16, 17). Advancesin airway imaging, however, now allow multiplanar and three-dimensional reconstruction with internal (virtual bronchoscopy)and external rendering, and excellent image quality is achievableby low-dose techniques (18 23). These new imaging protocolsgive better characterization as to whether the lesion is intralumi-nal, extrinsic to the airway, or has features of both types of lesions(Figure 2) and whether the airway distal to the obstruction ispatent.

5 In addition, the length and diameter of the lesions, andthe relationship to other structures such as vessels, are assessedto a much higher degree of accuracy. All these features areinvaluable in helping the physician determine the (either rigid or flexible) is always necessary inassessing airway obstructions. There is debate, however, as towhether the treating physician should routinely perform (andeven reperform if initially done by the referring physician) flexi-ble bronchoscopy, or to defer endoscopy to the time of definitivetreatment (24, 25). Direct visualization allows the nature andextent of the obstruction to be determined, and provides usefultreatment planning information such as the relative amount ofintraluminal and extraluminal disease. Most importantly, bron-choscopy allows a tissue diagnosis to be made. The additionof endobronchial ultrasound (EBUS) has been shown to beextremely sensitive for determining the degree of tracheal inva-sion as well as aiding in planning therapeutic interventions (26 28).

6 In a study by Miyazu and coworkers, EBUS demonstratedextracartilaginous disease in patients initially thought to be ap-propriate candidates for photodynamic therapy, and thereforeother therapies were selected (28). EBUS has also been used tohelp identify the distal end of an obstructing lesion that wouldhave otherwise been inaccessible with a bronchoscope to facili-tate stent placement and plan brachytherapy (29). The largestseries describing the use of EBUS in therapeutic bronchoscopyFigure of computed tomography airway rendering showing external compression from adenopathy (A);external rendering revealing tracheal stenosis (B); external renderingillustrating a left mainstem anastomatic stricture (C). (Courtesy PhillipBoiselle, , Beth Israel Deaconess Medical Center, Boston, MA).was published by Herth and colleagues (30). EBUS was utilizedin 1,174 of 2,446 cases over a 3-year period, including mechanicaltumor debridement, stent placement, neodymium:yttrium aluminum garnet (Nd:YAG) laser, argon plasma coagulation(APC), brachytherapy, foreign body removal, and the endo-scopic drainage of abscesses.

7 EBUS was found to guide or changemanagement in 43%, and changes included selecting properUp to date: Clinical presentaYon , diagnosYc evaluaYon,and management of central airway obstrucYon in adults 12 24 Crit Care Med 2004; 169: 1278-1297. Stridor COPD COPD UAO CAO 1/2100 dynamic expiratory collapse and percent ,59 Flow limitation theories explain maximal forced expiration, with development ofhighly negative transmural pressure in the airway segmentdownstream (ie, mouthward) from the site offlowlimitation (choke point) (Fig 5), even healthy individualscan demonstrate substantial intrathoracictracheobronchial narrowing.

8 This process is exaggeratedin COPD, asthma, and morbid obesity (Fig 3).60,61 COPDand morbid obesity influence several aspects of airwayflow leading to EDAC (Fig 5). Expiratory collapse isassociated significantly with BMI, with worse trachealcollapse among patients who are morbidly ,60 Studies also suggest that the prevalence of both TBM andEDAC is related directly to age, sex (female), and asthmaseverity, with EDAC being much more frequent thanTBM in all patients with EDAC, defined as>70% reduction in CSAduring expiration because of bulging of the posteriormembrane, was found in 17% of patients in another study,there was no correlation between the degree of obstructionand the results from pulmonary function tests, supportingthe current understanding that EDAC is a CT orbronchoscopy imagingfinding localized downstreamfrom the choke points and, thus, not responsible ,62 Healthy people may have EDAC withoutany effects on expiratoryflow.

9 EDAC was seen in 78% ofhealthy subjects with normal pulmonary function testresults, with some healthy individuals having 80% to90% CSA likely preferred method forclarifyingflow limitation in EDAC requires intraluminalairway pressure measurements across the physiologic studies using airway pressuremeasurements show no pressure drop along thecollapsible airway in systematic evaluation ofpatients with severe EDAC (71%-100% collapse),however, has not yet been performed. Such a studypotentially could clarify the true physiologic impact ofEDAC and assist in patient selection for membranoustracheoplasty or stent Insertion for ECACP ublished studies on stent insertion for TBM and EDACare case series, and some included stents that may not beFigure 3 Morphological types of expiratory central airway collapse. A, Normal, physiologic dynamic airway compression (DAC). B, Excessive dynamicairway collapse (EDAC; the airway cross-sectional area [CSA] is reduced by>50% during forced expiration).

10 C, Severe EDAC; the airway CSA isreduced by 100% during coughing (the posterior membrane contacts the anterior cartilaginous wall). In DAC and EDAC, the cartilaginous wall isintact. D, Crescent type of tracheomalacia in which the anterior wall isflattened. E, Circumferential type of tracheomalacia in relapsing polychondritis,characterized by collapse of the entire cartilaginous ring and airway wall edema. F, Severe (100% closure) saber sheath type of tracheomalacia due tocollapse of the lateral walls during expiration in a patient with posttracheostomy 2016; 150: 426-441. 2014 20 25 97 17 8 5 3 5 1 4 9 Woo PC, Young K, Tsang KW, et al. : Adult croup: a rare but more severe condiYon.