there are many case yet to discuss & note of many other CV anomalies

1. RARE CAUSE OF FAILED
EXTUBATION
DR HIMANSHU
IPCU
1

2. VINAY
A 3 ½ month Male child transferred
from pv t .Hospital with complains of
Cough ,cold , breathlessness since 1 day
clinically: Tachypnea ,wheezing
bilateral, signs of respiratory distress
2

3. HISTORY
Second by birth order, FTND .
5 days NICU stay for MAS .
On day 14 of life,pt had a
pneumonia ,that time DIAGNOSED
as ? Laryngomalacia.
3

4. THIS TIME PRESENTED WITH
RESPIRATORY COMPLAINTS
IN PRIVATE HE Rx AS
BRONCHIOLITIS WITH RESP.
FAILURE & VENTILATED AND
EXTUBATED IN 24 HR. BUT REQIRE
REINTUBATION WITHIN 12 HOURS.
REFERRED TO WADIA HOS. AS ?
GER CASE.
4

5. CLINICAL COURSE
ON ADMISSION WITH SEVERE
RESPIRATOR DISTRESS .
ABG S/O SEVERE RESPIRATORY
ACIDOSIS ( PH 6.98 PCO2 80 PO2 68
SPO2 82 )
INTUBATED & VENTILATED FOR 48
HRS & EXTUBATED . THIS TIME CHILD
HAD STRIDOR BUT AGAIN REQUIRE
REINTUBATION.
5

6. Clinical course
Extubation tried again
But failed 3 times !!! Serial ABG
showing co2 retention.
And Because of repeated
extubation failure planned for
tracheostomy with bronchoscopy.
6

7. Clinical course
But tracheostomy was not successful & during
bronchoscopy there was no subglottic stenosis ,
there was resistance felt during passege of
scope beyond glottis.
Persistent respiratory distress and stridor with
tracheostomy.
The causes METABOLIC AND SUBGLOTTIC
STENOSIS are already ruled out for stridor.
7

8. Clinical course
Then thought of some extrinsic
obstruction we inserted the ET tube
through the tracheostomy tube to
pass that obstruction
And with that patient was stable on T-
piece & planned for CT THORAX.
WHICH SUGGESTIVE OF !!!!!!!
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9. DIAGNOSIS
VASCULAR RING
( DOUBBLE AORTIC ARCH
ENCIRCLING TRACHEA AT
LEVEL OF BIFURCATION )
9

10. VASCULAR RING
PREVALANCE:
VASCULAR RING REPORTEDLY REPRESENTS
<1 % OF ALL CONGENITAL CV ANOMALIES.
PATHOLOGY:
VASCULAR RING REFERS TO GROUP OF
ANOMALIES OF AORTIC ARCH THAT CAUSE
RESPIRATORY SYMPTOMS & FEEDING
PROBLEMS .
THE VASCULAR RING MAY BE OF
1. COMPLETE TYPE
2.INCOPLETE VASCULAR RING.
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11. VASCULAR RING
TYPES :
DOUBLE AORTIC ARCH (40 %)- 3MONTH
AGE
RIGHT AORTIC ARCH(20%)-1 YR
ANOMALOUS INNOMINATE ARTERY(10)-
INFANCY
ABBERANT RT. SUBCLAVIAN ARTERY(20%)-
SWALLOWING DIF.
VASCULAR SLING-BIRTH.
11

12. Embryonic aortic arch with dorsal and ventral
arches and 6 branchial arches on right and left.
12

13. DOUBLE AORTIC ARCH
Incidence 40% , Onset of Respi .
Symptoms < 3 mo. 13

14. RIGHT AORTIC ARCH WITH Lt. LIG.
ARTERIOSUM
Mild respiratory symptoms at 1 yr.&
swallowing dysfunction. 14

15. Right aortic arch with mirror-image
branching and retroesophageal ligamentum
arteriosum
15

16. Left aortic arch with right descending aorta
and right ligamentum arteriosum.
16

17. ABERRANT Rt. SUBCLAVIAN ARTERY.
Inc. 20%
Occasional
Swallowing
dysfunction.
17

18. Aberrant left pulmonary artery or pulmonary
artery sling.
Wheezing & Cyanotic episodes
since birth. 18

19. CLINICAL MANIFESTATIONS
HISTORY:
INSPIRATORY STRIDOR &FEEDING
PROBLEMS : VARYING SEVEARITY
DEPENDING ON TYPE
H/O RECURRENT PNEUMONIA
H/O-ATELECTESIS, EMPHYSEMA, PNEUMONIA
OF RT. LUNG
EXAMINATION:
NOTHING EXCEPT VARYING DEG. OF
RHONCHI.
19

20. DIAGNOSIS
VASCULAR RING SUSPECTED BASED ON
CLINICAL SYMPTOMS.
CXR-SHOWS SHIFTING OF TRACHEA TO
ANTIRIOR
BARIUM SWALLOW- MOST USEFULL
SHOWS TWO INDENTATION ON PA VIEW &
POST. INDENTATION ON LATERAL VIEW.
ECHO ,ANGIOGRAPHY.
CT-THORAX,MRI.
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21. 21

22. 22

23. MANAGEMENT
MEDICAL :
ASYMPTOMIC PT. NO TREATMENT.
MILD SYMPTOMS-CAREFULL FEEDING &
AGGRESSIVE Rx OF PULMONARY
INFECTIONS.
SURGICAL :
DIVISION OF THE SMALLER OF THE TWO
ARCHES (USALLY LEFT)TROUGH LT.LAT
THORACOTOMY.
SURGICAL MORTALITY < 5 %.
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24. KEY MESSAGE
ALL THAT
WHEEZE IS NOT ASTHMA
& ALL ASTHMATIC DOES
NOT ALWAYS WHEEZE.
THANK YOU
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