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Un nuevo reto anestésico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 584 "Ancho" => 755 "Tamanyo" => 44604 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Aorta arteriography showing aortic ulcer (arrow). (B) Pre-operative 3D digital subtraction angiography.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Alegre Cortés, A. Bilbao Ares, A. Pola Jiménez, Y. Abaurrea Díaz, S. Fernández Alonso, M. 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A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "619" "paginaFinal" => "622" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Gonzalez-Anton, T. Gallice, A. Borges Da Silva, C. Carrié" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Gonzalez-Anton" "email" => array:1 [ 0 => "thomas.gallice@chu-bordeaux.fr" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "T." "apellidos" => "Gallice" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Borges Da Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Carrié" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Trauma and Surgical Intensive Care Unit, Emergency Unit, Bordeaux Universitary Hospital, Bordeaux, France" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Neurologic Intensive Care Unit and Neurosurgery Unit, Bordeaux Universitary Hospital, Bordeaux, France" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fracaso de la extubación: obstrucción de la vía aérea superior por chicle. Informe de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1066 "Ancho" => 755 "Tamanyo" => 81665 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chewing gum.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Aspiration of foreign bodies in adults is an uncommon but life-threatening complication in critically ill trauma patients. Difficulties in diagnosis of foreign body airway obstruction under mechanical ventilation may lead to a delayed treatment with potential consequences in morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Herein we describe the case of an upper airways obstruction as a consequence of an unidentified chewing gum, responsible for an extubation failure and a preventable tracheostomy in a young adolescent. This report highlights the challenge in diagnosis of foreign body’s aspiration in critically ill trauma patients under mechanical ventilation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 17-year-old woman admitted in our surgical and traumatic intensive care unit after a motor vehicle road accident responsible for a multiple trauma, associating mainly a cervical spine trauma (atlanto-occipital dislocation) without cervical cord injury and a moderate traumatic brain injury with bulbar contusion. These lesions leaded to a Glasgow Coma Scale Score 4 with incomplete neurological deficit. The patient was intubated in the field by the emergency service and transferred to hospital. The patient was treated by an External Ventricular Drain and a Philadelphia cervical collar while expecting a C0–C2 arthrodesis, performed ten days later.</p><p id="par0015" class="elsevierStylePara elsevierViewall">During the intensive care unit stay, a right hemiplegia was observed. A stable hemodynamical and respiratory status permitted a successful spontaneous breathing trial followed by extubation. As soon as the endotracheal tube was removed the patient choked immediately (absence of breathing response, deep desaturation and rapid acute respiratory distress signs). Consequently, the patient was rescued by a rapid oro-tracheal sequence intubation and mechanically ventilated performed by the attending physician allowing a prompt resolution of the respiratory distress. This extubation failure was hypothesized to result from a bulbar damage and hence, a tracheostomy was performed. Tracheostomy weaning was started the following day as described: the cuff was deflated and tracheostomy tube was capped with a speaking valve. At this moment the patient showed respiratory difficulties newly with signs of mechanical obstruction. A bedside fibroscopic assessment was performed by an otorinholaryngologist who found a pink colored chewing gum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) just above the vocal cords; which was extracted with laryngoscope and Magill clamp. Tracheostomy weaning was resumed the following day with a successful decannulation seventeen days after tracheostomizing. Both phonation and swallowing disorders improved with physiotherapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">When patients are involved in motor vehicle collisions with shattered glass, plastic, or other debris, the oropharynx should ideally be examined before intubation; however this is not always feasible, especially when patients require urgent intubation in the field due to the priority of hemodynamical and respiratory stabilisation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In our specific case, foreign body obstruction might have been diagnosed at four times i) during the initial and the second orotracheal intubations; ii) at the initial body-scan (<a class="elsevierStyleCrossRefs" href="#fig0010">Fig. 2 and 3</a>) and iii) while cuff leak test (CLT).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">During both orotracheal intubation procedures, the upper airways larygoscopic examination did not reveal the foreign body, which colour was closely to the laryngo-pharyngeal mucosa. In association with the emergency situation it may have been the most important factor contributing to its undetection.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Second, foreign bodies located in the superior aerodigestive pathways can easily be missed in initial imaging exams of poly-trauma patients due to two main reasons. Firstly, the presence of life-threatening injuries can distract the attention of the radiologist from the analysis of the oropharyngeal cavity, as in the case of our patient who presented amongst other lesions a cervico-occipital dislocation. Secondly, the radiological aspect of foreign bodies of the superior aerodigestive pathways may be misleading, especially edible ones which can present as hyperdense (up to 475 UH) ovoid images matching with the contours of the mucosa and in consequence, be mistaken for either hemorrhage, abscess, tumors, malformations or calcifications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In our case the chewing gum was initially considered as a declivous hyperdensity of the oropharynx and assumed to be a small hemorrhage due to intubation maneuvers and hence, neglected.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During the weaning process, a qualitative CLT was performed. The cuff was deflated and a spontaneous cough without any audible sign of obstruction was noticed. Based on this observation and on the absence of evident risk factors<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> the patient was not considered to be at high risk of post-extubation airway complications. In retrospect, probably performing a quantitative CLT would have been more effective to reveal a foreign body obstruction.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However, the quantitative CLT would probably not have allowed us to discriminate between a laryngeal edema or a foreign body; even more it would may led to an unsuccessful corticosteroid therapy and a delayed extubation.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Additionally, the CLT cannot be considered as totally safe.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It is plausible that CLT may increase the risk of deeper respiratory tract aspiration with the consequent rise of ventilator acquired pneumonia (VAP). Further studies are needed to evaluate this possibility.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Alternatively, two devices can be used to assess upper airway patency more eficiently. Firstly the recently developed laryngeal ultrasonography is a cheap, readily available and a non-invasive procedure with a valuable role in the evaluation of the upper airway.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Secondly, videolaryngoscopy can be also useful to easily provide a clear real-time magnified visualisation of the upper respiratory tract.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In combination with CLT, they could be used either to predict postextubation stridor related to a laryngeal edema or to detect foreign bodies.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The presence of a foreign body obstructing the respiratory airway is a life-threatening and often underdiagnosed complication in patients with polytrauma, that should be brought to the attention of physicians, respiratory therapists, and other healthcare professionals taking care of intubated and mechanically ventilated patients. Patients involved in motor vehicle crash and the inherent risk of projections should require a careful inspection and clearance of the larynx before intubation, whenever possible. A prompt recognition of obstruction and appropriate actions<span class="elsevierStyleSup">7</span> might prevent patients comorbidity and mortality related to an extended weaning process, reintubation or even execution of a rescue tracheostomy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This case point out the importance of carefully reviewing medical imagery in severe motor vehicle accidents searching for glass, metal, food or any small object that could be accidentally inhaled. Discussion about cuff leak test, videolaryngoscopy or a laryngeal ultrasound in patients other than high risk airway complications may be over the table.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Declarations about ethic approval and consent to participate and publication</span><p id="par0050" class="elsevierStylePara elsevierViewall">A signed informed consent was obtained from the patient for the use of medical data, medical imagery and photography in order to be exploited for scientific publication (available on request from the corresponding author DGA).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Declaration about availability of data and material</span><p id="par0055" class="elsevierStylePara elsevierViewall">The data that supports the findings of this article are available on request from the corresponding author (DGA). The data are not publicly available due to ethical restrictions.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres2260309" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1885938" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2260310" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1885939" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Declarations about ethic approval and consent to participate and publication" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Declaration about availability of data and material" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack778684" "titulo" => "Acknowledgement" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-11" "fechaAceptado" => "2023-11-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1885938" "palabras" => array:5 [ 0 => "Airway foreign body obstruction" 1 => "Aspiration" 2 => "Extubation failure" 3 => "Chewing gum" 4 => "Intensive care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1885939" "palabras" => array:5 [ 0 => "Obstrucción de la vía aérea por cuerpo extraño" 1 => "Aspiración" 2 => "Fallo de la extubación" 3 => "Chicle" 4 => "Cuidados intensivos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Extubation failure can result from different complications, mostly well described in the literature such as laryngeal edema. Airway obstruction by foreign bodies is a less frequent and unexpected complication and its detection remains a challenge to healthcare professionals. In this case-report, we describe a patient admitted in an intensive care unit following a motor vehicle accident and who underwent an extubation failure and tracheostomy placement due to a misdiagnosed obstruction of a foreign body in the upper airway. Thus, screening of foreign bodies should be considered with a careful interpretation of medical imagery and clinical evaluation in these patients. Finally, cuff leak test, ultrasonography and videolaryngoscopy can be important adjuvants to the identification of suspected foreign bodies.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El fracaso de la extubación puede deberse a diversos factores, tales como edema laríngeo, habiéndose descrito ampliamente la mayoría de ellos en la literatura. La obstrucción de la vía aérea por un cuerpo extraño es una complicación poco frecuente por lo que su detección exige una especial atención por parte del personal sanitario. En este informe, describimos el caso de una paciente ingresada en la unidad de cuidados intensivos tras un accidente de tráfico cuya extubación fallida y posterior traqueostomía fue debida a la detección tardía de un cuerpo extraño que obstruía la vía aérea superior. Por ello, es especialmente importante la interpretación detenida de las pruebas de imagen y la evaluación de los hallazgos clínicos en pacientes politraumatizados. Por último, la prueba de fuga, la ecografía laríngea y el videolaringoscopio pueden ayudar a confirmar la sospecha de obstrucción por cuerpo extraño.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1066 "Ancho" => 755 "Tamanyo" => 81665 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chewing gum.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 795 "Ancho" => 755 "Tamanyo" => 68250 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Initial body scan. Sagittal view.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 933 "Ancho" => 755 "Tamanyo" => 52737 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Initial body scan. 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