Herpetic tracheitis and brachial plexus neuropathy in a child with burns

Herpetic tracheobronchitis is a well-recognized clinical entity that most commonly occurs in immunocompromised patients, including patients with burns. Although the diagnosis of herpetic tracheobronchitis is usually not made until postmortem examination, the presence of the condition can be established when histologic specimens of a patient with upper airway obstruction are studied. In this article, a case is described in which a child developed herpetic tracheitis after undergoing elective intubation after the grafting of burns of the face, neck, and upper extremity. The tracheitis resulted in severe upper airway obstruction that required tracheal dilatation and sequential bronchoscopic excisions of granulation tissue. The patient also developed a brachial plexus neuropathy that was most likely related to herpetic infection.

[Interleukin-8 and airway inflammation]

Airway inflammation is a prominent feature of chronic obstructive diseases of the airways, including asthma, bronchiectasis, chronic bronchitis, and diffuse panbronchiolitis. Neutrophils are implicated in the pathogenesis of these diseases. The present review discusses the role of interleukin-8 (IL-8), a neutrophil chemo-attractant, in neutrophil accumulation in the airways, and the mechanisms of inducing IL-8 expression. IL-8 presents in the sputum of patients with inflammatory airway diseases, and accounts in large part for the chemo-attractant activity present. Focusing on Pseudomonas aeruginosa as the stimulus, it was discovered that when a supernatant of bacterial culture is introduced into the airways in vivo, bacterial products induce IL-8 expression in surface airway epithelial cells and the recruitment of neutrophils into the airways. The neutrophil chemotactic activity of the airway fluid was inhibited by an IL-8 antibody. The luminal IL-8 concentration increased in response to instillation of bacteria, and an inhibitor of neutrophil recruitment markedly reduced the IL-8 levels. From these results, it was speculated that bacteria-induced neutrophil accumulation in the airways involves a cascade of events, and that early neutrophil recruitment in response to bacteria is due to epithelium-derived IL-8, while the amplification of the response is due, at least in part, to IL-8 induction in the neutrophils themselves.

Constrictive bronchiolitis and ulcerative colitis

Pulmonary complications occur in an estimated 0.21% of patients with inflammatory bowel disease. The most common presentation of pulmonary manifestations is large airway disease, such as tracheobronchitis, chronic bronchitis or bronchiectasis. Small airway disease, such as constrictive bronchiolitis or bronchiolitis obliterans with organizing pneumonia, is less frequently reported, and is described as occurring in isolation from large airway disease. A case of a postcolectomy ulcerative colitis in a patient who has both large airway involvement, tracheobronchitis and bronchiectasis, and constrictive bronchiolitis is presented.

Tracheal replacement with cryopreserved tracheal allograft: experiment in dogs

BACKGROUND

It has been difficult to perform tracheal allotransplantation without immunosuppression. To determine whether cryopreserved trachea can be used in tracheal replacement, we evaluated the viability of cryopreserved tracheal allografts in a canine model of immunosuppressant-free transplantation.

METHODS

Cryopreserved tracheal allografts, which had been frozen to -80 degrees C in a programmed freezer and then stored in liquid nitrogen (-196 degrees C) (group 1, n = 6), fresh tracheal autografts (group 2, n = 5), and fresh tracheal allografts (group 3, n = 4) were transplanted into the thoracic segment of the trachea using an omental flap without immunosuppressive agents.

RESULTS

All dogs in groups 1 and 2 survived, but in group 3, all 4 died of airway obstruction between 1 month and 2 months after operation. Histologically, the cryopreserved allografts displayed normal epithelium and cartilage, but the fresh allografts showed chronic inflammatory changes, no epithelium, and no cartilage.

CONCLUSIONS

Cryopreserved tracheal allografts maintain their structural integrity after transplantation. The cryopreservation process seems to reduce the allogenic response of the trachea in canine models. Therefore, we believe the cryopreserved tracheal allograft is an excellent choice for tracheal replacement.

Experimental study of the histocompatibility of covered expandable metallic stents in the trachea

STUDY OBJECTIVES

To evaluate the histocompatibility of four different materials used to cover expandable metallic stents.

DESIGN

Prospective, randomized, unblinded study.

SETTING

Animal research laboratory of Kurume University.

PATIENTS OR PARTICIPANTS

Twenty 12- to 18-kg mongrel dogs.

INTERVENTIONS

Handmade Gianturco-type stents with six bends, 20 mm in length, and 15 to 20 mm in diameter were covered using four different materials: polypropylene mesh, silicone-coated mesh, polyester mesh, and ePTFE. Covered stents were inserted into the trachea after i.v. anesthesia. Five animals were used in each group.

MEASUREMENTS AND RESULTS

Postinsertion status was observed using clinical and bronchoscopy measures 7, 14, 28, and 56 days after intervention. Eight weeks after stent insertion, the tracheal specimens were studied pathologically. A scoring system was used to evaluate the histocompatibility of covered stents in each study group. The mean of clinical scores in the polypropylene group was 1.84+/-0.36, which was significantly higher than those in the groups of silicone, polyester, and ePTFE. The means of histopathologic scores in the polypropylene group and the silicone group were 1.60+/-0.55, which were significantly higher than those in groups of polyester and ePTFE.

CONCLUSIONS

Polypropylene mesh cover was more suitable than silicone-coated mesh, polyester mesh, and ePTFE because of its excellent histocompatibility.

Association between inflammation and epithelial damage-restitution processes in allergic airways in vivo

BACKGROUND

Associations between allergen challenge-induced sites of epithelial damage and the distribution of leucocytes and extravasated plasma remain unexplored.

OBJECTIVE

To study neutrophils, eosinophils, and fibrinogen at allergen challenge-induced patchy epithelial damage-restitution sites in guinea-pig trachea.

METHODS

After local challenge tracheal tissue (cryo sections and whole-mounts) and lumen (selective tracheal lavage) were examined at 1, 5, and 24 h. Eosinophils, neutrophils and fibrinogen were identified by histochemistry.

RESULTS

Neutrophils increased markedly in tracheal lavage fluids and in tissue and were strongly associated with the challenge-induced epithelial craters of damage-restitution. At 1 and 24 h eosinophils were increased in the tracheal lumen whereas the surrounding tissue displayed a reversed pattern. Gels rich in fibrinogen, neutrophils, and eosinophils were present in epithelial crater areas, protruding into the lumen. Clusters of free eosinophil granules, Cfegs, released through lysis of eosinophils, and neutrophils with long cytoplasmatic protrusions abounded in these crater areas.

CONCLUSION

The present findings provide important new insights into allergic airways where sites of epithelial damage-restitution processes emerge as the major loci for eosinophil, neutrophil, and plasma protein activities, the latter likely causing leukocyte adhesion and activation in vivo. The distribution of eosinophils in this study suggests roles of these cells both in airway mucosa and in regional lymph nodes. Based on the present study we also propose that lysis of eosinophils and Cfegs generation are a major paradigm for activation of these cells in vivo.

Tracheotomy and the intensive care unit patient

Transportation of the intensive care unit (ICU) patient to the operating room for tracheotomy has been implicated as an unnecessary source of complications and has been cited as a relative indication for percutaneous tracheotomy. However, there is very little evidence in the literature to support this claim. We evaluated 100 consecutive patients who were transported from the ICU to the operating room for tracheotomy. There were no complications related to patient transportation. A total of five complications occurred, all unrelated to patient transportation. Two patients receiving pressure control ventilation developed a pneumothorax on postoperative days 7 and 8, respectively. There were three minor complications directly related to the tracheotomy: peristomal cellulitis, tracheitis, and hemorrhage of less than 25 cc on postoperative day 1. The minor complications were treated appropriately and resolved without any adverse sequelae. We provide a detailed review of 100 consecutive ICU patient tracheotomy cases and compare this with 109 tracheotomies in non-ICU patients. Transportation of the ICU patient does not appear to increase the risk of complications during tracheotomy and should not be cited as a cause of complications in the percutaneous tracheotomy literature. The results with standard surgical tracheotomy in the controlled setting of the operating room should serve as the standard by which other procedures are judged.

Experimental trial of balloon-expandable, metallic Palmaz stent in the trachea

OBJECTIVE

To determine the effect of the Palmaz stent, which has been successfully used to relieve airway obstruction in a small group of children, on the normal and operated on animal trachea.

DESIGN

In this experimental trial, stents were placed bronchoscopically in the thoracic tracheae of 4 groups of 50 anesthetized cats. The cats in group 1 (adults, n = 10) and group 2 (kittens, n = 10) had normal tracheae; the cats in group 3 (adults, n = 15) underwent horizontal tracheal incision and closure; and the cats in group 4 (adults, n = 15) underwent pericardial patch tracheoplasty. In group 3 and 4, the stents were inserted in 10 cats and 5 cats served as controls. Stents were inflated to a 15-mm diameter in group 1 and an 8-mm diameter in the other groups. Half of the animals with stents were killed 5 weeks after the procedure, and the others, 10 weeks after the procedure.

SETTING

The Hospital for Sick Children, Toronto, Ontario.

RESULTS

In group 1, 1 animal died of tracheal perforation. A mild cough was noted in 15 of the 39 cats with stents. In group 4, 3 cats had difficulty eating and lost weight. The results of esophagoscopy excluded esophageal inflammation or obstruction in these 3 animals. The results of bronchoscopy indicated a nonobstructing rim of granulation tissue at the end of the stent in 15 of 20 cats in groups 1 and 2 and 17 of 20 cats in groups 3 and 4 and at the repair site in all animals with stents from groups 3 and 4. The results of autopsy indicated the cross-sectional area at the site of the stent was greater than normal in group 1 (P < .003) and smaller than the normal trachea at the site of the tracheoplasty in group 4 controls without stents (P < .02); however, the cross-sectional area at the tracheoplasty site with the stent was not smaller (P < .13). The results of histologic examination indicated a mild inflammatory reaction, with granulation tissue in all animals with stents, but in group 1, with overexpanded stents, the reaction was more severe, with epithelial ulceration, fibrosis, and sealed-off perforations in most animals. In group 3, the tracheae with stents had significantly more inflammatory reaction, granulation tissue, and epithelial damage than the controls without stents.

CONCLUSIONS

The Palmaz stent provokes an inflammatory reaction in the normal trachea and the trachea recently operated on. With the exception of the group 1 animals with overexpanded stents, this reaction is clinically insignificant. The Palmaz stent is able to maintain a normal lumen size after pericardial tracheoplasty in cats.

Nosocomial pneumonia and tracheitis in a pediatric intensive care unit: a prospective study

We conducted a prospective study in the multidisciplinary pediatric intensive care unit (pediatric ICU) of a tertiary-care university hospital in order to determine the incidence, risk markers, risk factors, and complications related to bacterial nosocomial pneumonia (BNP) and tracheitis (BNT) in children. A cohort of 1,114 consecutive admissions to the pediatric ICU was enrolled over a 56-wk period; 154 cases were excluded mostly (75%) because they already had a respiratory infection at entry. The final sample included 960 admissions (831 patients). Diagnosis of BNP or BNT was based on Centers for Disease Control of Atlanta criteria using a consensus method involving three experts, who also attributed complications to BNP and BNT. A total of 29 BNP and BNT (3.0%; 95% CI: 1.1 to 4.1%) were diagnosed (BNP: 1.2%, 95% CI: 0.7 to 1.9%; BNT: 1.8%, 95% CI: 0.8 to 2.6%). Three factors were retained by multivariate analysis as independent risk factors or markers for BNP (immunodeficiency, immunosuppression, and neuromuscular blockade), and two for BNT (head trauma and respiratory failure). Gram-negative bacteria and Staphylococcus aureus were the microorganisms most frequently found in the tracheal aspirates. Prescription of antibiotics was commonly attributable to BNP (75%) and BNT (59%). Death, as well as multiple organ system failure, resulted from BNP in 8% of cases, but never from BNT. In BNT, the reintubation rate was 24%. Nosocomial bacterial respiratory infections are rare in critically ill children. However, BNP causes significant complications, and more attention should be focused on BNT in the critically ill child.

Respiratory and digestive lesions caused by Salmonella arizonae in two snakes

Cases of diphtheritic necrotizing gastritis in a Rosy Boa (Lichanura trivirgata) and of necrotizing tracheitis in a double-headed Kingsnake (Lampropeltis hondurensis), both associated with Salmonella arizonae, are described. An immunoperoxidase technique indicated that S. arizonae played a role in the causation of the lesions. In addition, the study showed the value of the technique for the detection of S. arizonae in the tissues of infected snakes.

Systemic complications associated with bacterial tracheitis

The toxic shock syndrome, septic shock, pulmonary oedema, and the acute respiratory distress syndrome (ARDS) were recognised in four children with bacterial tracheitis. ARDS has not previously been reported in association with bacterial tracheitis. Prompt recognition of the severe systemic complications of bacterial tracheitis could lead to a decrease in the morbidity and mortality of this condition.

Airway inflammation and asthma

Asthma is currently identified by the presence of characteristic symptoms of wheezing, chest tightness, dyspnea and cough, and by the presence of reversible airway narrowing and/or airway hyperresponsiveness to a variety of inhaled bronchoconstrictor stimuli. Airway inflammation appears to be central to the pathogenesis of all of these clinical manifestations of asthma. There are increased numbers of activated eosinophils and of mast cells in the airways of patients with asthma, even those with mild disease. The presence and survival of these inflammatory cells may be promoted by the presence of increased levels of proinflammatory cytokines, such as GM-CSF, interleukin(IL)-3 or IL-5 in asthmatic airways. These cells have the capacity to release potent bronchoconstrictor mediators such as the cysteinyl leukotrienes, which are responsible, in part at least, for airway narrowing in asthma and for allergen-g exercise- and aspirin-induced asthma. Other cells, such as a subset of T-lymphocytes (TH2), may also be important in maintaining the inflammatory cascade through the formation and release of cytokines. Airway structural changes caused by the persisting inflammation, such as airway epithelial damage, or altered smooth muscle function or volume, are likely to be important in the pathogenesis of stable long-standing airway hyperresponsiveness. Mediators released from the inflammatory cells may be responsible for these changes. Despite the great increase in knowledge about the importance of airway inflammation in the pathogenesis of asthma, the precise sequence of events that leads to the presence of persisting airway inflammatory cells, airway structural changes and airway hyperresponsiveness in asthma remains to be clarified.

Ulcerous tracheitis and mucus ball formation: a nearly fatal complication of a transtracheal oxygen catheter

A transtracheal oxygen catheter may be superior to a nasal cannula. In particular, transtracheal oxygen therapy (TTOT) shows a 50% saving of oxygen consumption, a significant reduction of energy cost of breathing, and an improved patient compliance due to esthetic benefits and avoidance of mucosal injury by a nasal cannula. Most complications so far reported have been of minor clinical importance and could be treated easily. However, using the SCOOP technique, a serious complication has recently occurred in 1 of our patients. Soon after starting TTOT with a SCOOP-1 catheter he developed an ulcerous tracheitis and a severe tracheal obstruction by a mucus ball. To prevent further respiratory emergencies TTOT finally was stopped and the catheter replaced again by a nasal cannula. There is evidence that tracheal injury as well as the formation of mucus balls may be promoted by regular brushing the preliminary SCOOP-1 catheter which usually is left in place during the first weeks. As a result of this harmful experience, we recommend to reconsider carefully the indication for TTOT in patients with copious bronchial secretions and to avoid cleaning of the SCOOP-1 catheter with the rigid wire brush.

[Contact allergy-induced tracheal stenosis caused by vulcanization accelerators in the endotracheal tube?]

Tracheal stenoses occur mainly under iatrogenic conditions: they develop specially after long-term intubation, but also after tracheotomy. Etiological-pathogenic relevant factors include the mechanical irritation of mucosa, perichondrium and cartilage in addition to infected tracheal secretions. An allergic cell-mediated reaction in the respiratory tract has been already described. It is seldom recognized. The possibility of such a hyperergic, allergic, delayed reaction (Type IV Coombs-Gell response) with subsequent tracheal stenosis caused by rubber chemicals (accelerators) found in endotracheal tubes is presented in the following case report.

Airway complications of jet ventilation in neonates

Four cases of airway complications in infants surviving jet ventilation have been observed at the Children's Hospital of New Mexico. Two cases of necrotizing tracheobronchitis in preterm infants are presented: one was treated with bronchoscopy and removal of the necrotizing tissue; the second was placed on extracorporeal membrane oxygenation, prior to dilation of the affected area. A third child developed subglottic stenosis after intubation with an oversized jet endotracheal tube. A fourth child, with a history of prematurity and jet ventilation as a neonate, was found at 3 years of age to have tracheal webs in the lower third of his airway. Management and follow-up of these four cases, as well as a literature review of the known airway complications of jet ventilation, are presented.

Neurogenic inflammation and lowering of interstitial fluid pressure in rat trachea is inhibited by alpha-trinositol

The effect of alpha-trinositol (D-myoinositol-1,2,6-triphosphate) on edema formation and capillary permeability in neurogenically induced inflammatory edema was investigated in rat trachea. Interstitial fluid pressure (Pif) was studied, since increased negativity of Pif contributes to edema formation in this situation. alpha-Trinositol was used because it inhibits edema formation, capillary leakage, and increased negativity of Pif in burn-injured skin. Pif was measured with sharpened glass capillaries (3 to 7 microns) connected to a servocontrolled counterpressure system after circulatory arrest (induced by intracardiac injection of saturated potassium chloride in pentobarbital anesthesia). This was done in order to avoid the edema formation associated with inflammatory reactions, which will raise interstitial fluid volume and Pif, causing the underestimation of an increased negativity of Pif. Neurogenic inflammation induced by electrical-field stimulation of the left vagal nerve (10 V, 20 Hz, 0.5 ms) lowered Pif from -1.4 +/- 0.6 mm Hg to -8.4 +/- 2.1 mm Hg (p < 0.01). Corresponding numbers after the intravenous administration of alpha-trinositol (40 mg/kg) before stimulation were -1.2 +/- 0.4 and -1.4 +/- 0.4 mm Hg, respectively (p > 0.05). Another series of animals with intact circulation was used to study the effect of vagal nerve stimulation and alpha-trinositol on edema formation (total tissue water and extravascular 51Cr-ethylenediamine tetraacetic acid-[EDTA] space) and albumin extravasation. These parameters increased significantly after vagal nerve stimulation, while intravenous alpha-trinositol (40 and 120 mg/kg), as given above, significantly attenuated this increase. Thus, alpha-trinositol prevented a lowering of Pif and the edema formation accompanying neurogenic inflammation in rat trachea.

Ulcerative tracheobronchitis years after colectomy for ulcerative colitis

Two men with severe ulcerative colitis developed ulcerative tracheobronchitis 4 and 8 years after total colectomy. Intense plasma cell infiltration of tracheal mucosa and submucosa and destruction of mucous glands occurred, with partial relief of symptoms with corticosteroids. We compare them with the only other case reported, also years after colectomy.

Problems in postoperative management after anterior cricoid split

OBJECTIVE

Describe complications and postoperative management problems associated with the anterior cricoid split.

DESIGN

Retrospective case series.

SETTING

Urban referral hospital.

PATIENTS

Nine consecutive patients with acquired subglottic stenosis believed amenable to the anterior cricoid split.

INTERVENTION

The anterior cricoid split was performed on 10 occasions between June 1989 and June 1992.

MAIN OUTCOME MEASURE

Extubation or decannulation.

RESULTS

Six of nine patients underwent decannulation, with success. Management problems included those related to surgery or postoperative endotracheal stenting, preexisting medical conditions, and postoperative sedation requirement.

CONCLUSIONS

The number of postoperative complications and management problems was highest in those patients with both bronchopulmonary dysplasia and preexisting tracheotomy.

[Necrotizing tracheobronchitis following radical repair in tetralogy of Fallot with absent pulmonary valve--a case report]

A 3-month-old infant with tetralogy of Fallot and absent pulmonary valve developed necrotizing tracheobronchitis following a radical repair. Right ventricular reconstruction using an equine pericardial valved conduit and plication of the main pulmonary arteries relieved compression of the left main bronchus by the dilated pulmonary artery. However, respiratory distress increased when bronchitis developed. Eventually, both main stem bronchi became stenotic secondary to inflammation, and the patient died 154 days following surgery. Necrotizing tracheobronchitis is a potentially lethal complication in patients with tetralogy of Fallot and absent pulmonary valve.

Necrotizing squamous metaplasia in herpetic tracheitis following prolonged intubation: a lesion similar to necrotizing sialometaplasia

In the last year we have encountered three cases of clinically inapparent herpes simplex virus (HSV) tracheitis in biopsies from patients undergoing tracheostomy following prolonged intubation. The diagnosis was based on finding characteristic inclusion-bodies on haematoxylin and eosin stained sections and was confirmed by immunohistochemical staining of infected cells with antibodies to HSV. A prominent mononuclear infiltrate, originally described in HSV oesophagitis, was recognized in two cases. Diffuse squamous metaplasia of both surface and glandular epithelium adjacent to necrotic ulcerated areas was evident in all three cases. Where extensive, the necrotizing squamous metaplasia of the glandular/ductal component was similar to necrotizing sialometaplasia of salivary glands, and likewise simulated squamous or mucoepidermoid carcinoma.

Gastropharyngeal reflux in infants and children. A pharyngeal pH monitoring study

Gastroesophageal reflux has been shown to play an important role in chronic and acute inflammatory disorders of the airway. In particular, gastroesophageal reflux has been suggested to be the cause of pharyngolaryngeal problems, according to the literature, at any age. However, to our knowledge, the presence of acid in the pharynx in pathological cases has not yet been proved. A series of eight patients (aged 2 months to 7.5 years) with recurrent acute laryngotracheitis underwent a two-channel pH monitoring for 23 to 24 hours. One pH probe was placed in the lower esophagus, the other in the pharynx, at the level of the epiglottis. Acid gastroesophagopharyngeal reflux was demonstrated in every patient. A significant difference with a series of six control subjects was noted in terms of esophageal and pharyngeal pH monitoring. The most significant item is the total time the pH in the pharynx was below 6. Despite the limited number of patients, this study suggests the role of gastroesophageal reflux in recurrent laryngotracheitis in infants and children.

Laryngotracheobronchitis as a complication of measles during an urban epidemic

OBJECTIVE

To evaluate demographic and clinical correlates of laryngotracheobronchitis (LTB) as a complication of measles during a community-wide epidemic.

DESIGN

Retrospective review of medical records.

SETTING

Childrens Hospital Los Angeles, a large urban pediatric facility, during a regional epidemic of measles studied January through June 1990.

PATIENTS

All patients identified at our hospital who met Centers for Disease Control criteria for measles.

MEASUREMENTS AND RESULTS

Of 440 patients with measles, 82 also had LTB (18.6%). Patients in whom LTB developed were significantly younger (mean +/- SD: 14.7 +/- 8.2 months) than the cohort (24.8 +/- 30.1 months) (p less than 0.001) and more likely to require hospitalization (91.5%) than the cohort (44.3%) (p less than 0.001). Thirteen patients (17.3%) required intensive care, including 9 (11%) who required endotracheal intubation for a mean of 8.3 +/- 7.1 days. Pulmonary function testing of five patients with an endotracheal tube in place, including three not clinically assessed as having pneumonia, indicated the presence of concomitant lower respiratory tract disease.

CONCLUSION

Laryngotracheobronchitis was a frequent and often severe complication of measles. The likelihood that LTB would develop was inversely related to age, generally required inpatient care, and necessitated endotracheal intubation in severely affected patients.

Necrotizing tracheobronchitis identified on an indium-111-white blood cell scan

The clinical entity of necrotizing tracheobronchitis (NTB) is well described in the pediatric literature. The incidence of NTB in neonatal autopsies varies from 4% to 44%. More than 3 hr of assisted ventilation may be necessary for the development of NTB in neonates. A similar clinical problem was described as "hemorrhagic tracheitis" in two adults during high frequency jet ventilation and as a complication of conventional mechanical ventilation in an adult. We present here a rather unusual case of NTB in an adult on mechanical ventilation, in whom tracheobronchitis was diagnosed incidentally with an 111In white blood cell scan obtained for other purposes.

Upper airway obstruction in association with perinatally acquired herpes simplex virus infection

Two cases of neonatal upper respiratory tract obstruction caused by herpes simplex virus are described. Infection of the upper respiratory tract with this virus should be included in the differential diagnosis of fever and stridor during the neonatal period.

Ulcerative tracheobronchitis after lung transplantation. A new form of invasive aspergillosis

Invasive aspergillosis is frequently a fatal disease in the setting of immunosuppression, including organ transplant recipients. The fungus usually affects lung parenchyma and may disseminate from there. We have recently noted tracheobronchitis in six patients with heart-lung and lung transplants, three of whom had deep mucosal ulceration and histologic evidence of invasive aspergillosis. This apparently new form of invasive disease is initially limited to the anastomosis site and large airways. Ulceration, necrosis, cartilage invasion, and formation of a pseudomembrane are the pathologic features. In two patients subsequent disseminated aspergillosis occurred with a fatal outcome. In the two single-lung recipients, disease was limited to the transplanted side emphasizing the importance of abnormal local defense mechanisms in the airways of lung transplant recipients. Routine bronchoscopic examination of the airways is important in early detection of this complication. Oral therapy with the new, antifungal agent itraconazole was successful in five of the six patients, with fatal relapse in one. A classification of the various forms of saprophytic, allergic, and invasive forms of aspergillus tracheobronchitis, to include this new entity, is proposed.

Overwhelming necrotizing tracheobronchitis due to inadequate humidification during high-frequency jet ventilation

Necrotizing tracheobronchitis (NT) associated with conventional mechanical ventilation or high-frequency jet ventilation (HFJV) is a lesion reported most often in neonates. In most cases, a specific cause is not identified. We describe a case of NT in an adult that occurred during HFJV and was attributable to inadequate humidification.

Tracheo-bronchitis as a complication of Crohn's disease--a case report

A case of Crohn's enterocolitis associated with diffuse tracheo-bronchitis is presented herein. Although respiratory tract involvement in Crohn's disease is extremely rare, our review of the world literature revealed several common clinical pathologic features. These features include a productive cough with chest X-ray films which are normal except for some peripheral involvement. Bronchoscopy, however, shows diffuse inflammation of the trachea and bronchi with widely scattered whitish lesions while biopsy reveals a granulomatous infiltration of inflammatory cells. This tracheobronchitis typically responds well to treatment with prednisone.

Tracheobronchitis due to Corynebacterium pseudodiphtheriticum

We have presented a case of tracheobronchitis due to C pseudodiphtheriticum in a patient with COPD who was treated with prednisone and apparently was not otherwise immunocompromised. Chronic lung disease seems to predispose to infection with C pseudodiphtheriticum; it can also occur in the immunocompetent host. This organism, when isolated in pure culture, should not be dismissed as a contaminant, but must be considered a possible etiologic agent. Sensitivity of diphtheroids to antibiotics is extremely variable. We believe vancomycin should be used in respiratory tract infections caused by diphtheroids, including C pseudodiphtheriticum, until the results of in vitro antibiotic susceptibility tests are available.

Necrotizing tracheobronchitis (NTB) following high frequency ventilation: role of an angiotensin converting enzyme inhibitor

The purpose of this investigation was to study the effect of an angiotensin converting enzyme inhibitor (enalaprilat) on the morphologic manifestations of experimentally induced necrotizing tracheobronchitis (NTB). Twenty piglets were anesthetized before saline lung lavage. High frequency flow interrupter (HFFI) ventilation was used with a strategy known to produce NTB. Animals were randomly assigned to receive IV enalaprilat 0.1 mg/kg (ENP-Hi), enalaprilat 0.01 mg/kg (ENP-Lo), or saline (C). After 8 hours of ventilation, the piglets were sacrificed. Total airway injury scores (mean +/- S.D.) were 1.2 +/- 0.7 for ENP-Hi, 0.2 +/- 0.2 for ENP-Lo, and 21.3 +/- 16 for group C. Enalaprilat minimizes NTB lesions in neonatal piglets exposed to high frequency oscillatory ventilation. Although the origin of NTB is multifactorial, airway mucosa ischemia may play an important role. Enalaprilat may compensate for the reduction of mucosal blood flow by limiting formation of angiotensin II and/or preventing degradation of bradykinin.

[The effect of air pollution factors on the frequency of acute laryngotracheitis in children]

The authors investigated 325 children with acute laryngotracheitis. The frequency of the disease in 1986 was correlated with the three most frequent factors of atmospheric contamination, dust, sulphur dioxide and nitrogen oxides. The author found a significant increase of the morbidity from laryngotracheitis in conjunction with a greater contamination of the atmosphere.

Bacterial tracheitis: report of eight new cases and review

Bacterial tracheitis, previously referred to as nondiphtheritic laryngitis with marked exudate, was commonly discussed in pediatric textbooks before 1940. It seemed to disappear as a clinical entity after that time, but it has been recorded with increasing frequency in the pediatric literature since 1979. We describe eight new cases and review 110 previously described cases. The clinical course consists of a prodromal upper respiratory illness with stridor, fever, and a variable degree of respiratory distress. Unlike patients with croup, patients with bacterial tracheitis do not respond to aerosolized racemic epinephrine. Most patients require endotracheal intubation; some require tracheostomy. Reported complications include pneumonia, pneumothorax, formation of pseudomembranes, toxic shock syndrome, and cardiopulmonary arrest. Bacterial tracheitis is a secondary bacterial infection following a primary viral respiratory infection. The most common preceding viral infection is parainfluenza. Staphylococcus aureus and Haemophilus influenzae are the predominant causes of bacterial tracheitis. Secondary bacterial infection may occur as a result of tracheal mucosal injury or impairment of normal phagocytic function due to viral infection.

[Experiences with long-term transtracheal oxygen therapy]

A transtracheal catheter (TTC) (Scoop) was implanted in 24 patients (19 men, 5 women) with a mean age of 64 +/- 9 (47 to 78) years. The pO2 was 6.78 +/- 1.65 kPa. Two patients suffered from pulmonary restriction, 22 from severe COPD with a FEV1 of 880 +/- 165 ml. Purulent tracheitis developed in six patients. The pre-Scoop catheter had to be removed in three. In four patients, bronchoscopic aspiration of mucus plugs adhering to the tip of the TTC was necessary. In one patient, the TTC was removed after an uneventful course due to patient's discomfort; another patient no longer qualified for LOT. 19 patients were using the TTC without major problems. Of those, five have died due to severe lung disease. By using TTC, oxygen consumption is halved for the same degree of oxygenation. 12 are using a demand valve device (Oxymatic), which allows a further conservation of oxygen. Patients prefer LOT by a TCC for cosmetic reasons and lack of nasal discomfort.

Ligneous conjunctivitis: an ophthalmic disease with potentially fatal tracheobronchial obstruction. Laryngeal and tracheobronchial features

Ligneous conjunctivitis is a rare disease of unknown cause characterized by pseudomembranous, fibrous, woody, plaquelike deposits on the conjunctiva. The disease appears to be hereditary and/or familial. Deposits similar to those found in the eye occur in the larynx, tracheobronchial tree, nose and nasopharynx, and vagina. When these lesions occur in the larynx and tracheobronchial tree, voice change and potentially life-threatening obstruction and pulmonary disease may occur. This paper reports the findings in a child with ligneous conjunctivitis who was followed for 1 1/2 years and who had laryngeal and tracheobronchial involvement with voice change and airway obstruction. The literature is reviewed and the histopathologic findings and endoscopic findings and management of the patient are documented. Because the patient had multiple papillomata of both hands, a possible association with human papillomavirus was suspected but never confirmed.

Tracheobronchial and pulmonary histopathology following conventional and high-frequency jet ventilation

The advent of high-frequency jet ventilation (HFJV) as an alternative method of respiratory support for newborns has been implicated as a causative agent of necrotizing tracheobronchitis (NTB). We conducted a controlled trial of prolonged HFJV and conventional mechanical ventilation (CMV) in adult cats to determine effects on airway injury related to mode of ventilation and placement of the jet injector (proximal vs distal trachea). Fifteen cats were randomly assigned to either high-frequency positive pressure ventilation, proximal injection jet ventilation, or distal injection jet ventilation. The animals were ventilated for more than 33 hours. Post mortem, the trachea and respiratory tree were removed en bloc and fixed in formalin. A pathologist, unaware of the mode of ventilation, examined tracheobronchial histology and assigned scores using a technique previously described. Lung parenchymal tissue was also assessed using a similar grading system. Statistical analysis (Kruskal-Wallis analysis of variance) demonstrated no significant differences between tracheobronchial or lung parenchymal histopathology regardless of the mode of ventilation. We conclude that (1) the adult cat serves as a useful model for evaluating histopathologic effects of prolonged ventilation, (2) the etiology and pathogenesis of airway injury appears to be multifactorial, and the mode of ventilation is only one of many contributing variables, and (3) previously demonstrated differences between CMV and HFJV may be related to a much shorter duration of ventilation.

[Four cases of airway infections caused by MRSA (methicillin resistant Staphylococcus aureus)]

Currently, infections caused by MRSA (methicillin-resistant Staphylococcus aureus) pose a great problem clinically. We present 4 patients with MRSA infections experienced by us. In these patients the infection was localized in the trachea and main bronchus. The first patient was a 62-year-old man. After undergoing operation for early gastric cancer, he had septic shock and was admitted to our center. The second was a 60-year-old man. After he underwent operation for advanced gastric carcinoma at another hospital septicemia developed due to suture failure and he was admitted to our center. The third was a 38-year-old woman who was admitted to our center because of grades II degrees-III degrees burns on 75 to 80% of her body surface area. The fourth was a 60-year-old man who was admitted to our center because of rupture of an aneurysm of the abdominal aorta. It is assumed that MRSA has quite different characteristics from the usual MSSA (methicillin-sensitive Staphylococcus aureus) in that it produces a new penicillin-bound protein (PBP-2') within cells. Thus, from the fiberoptic bronchoscopy findings of our own cases it is considered that there may be cases in which the observed lesion is localized in the central airway alone, without involvement of the segmental bronchi. We believe it necessary to take some prompt measures under a suspicion of airway infection caused by MRSA in the following cases: (1) compromised hosts under tracheal intubation, (2) patients who are under treatment with second or third generation cephalosporins, and (3) patients with production of bloody sputum, and (4) endotoxin-positive patients.

Studies of wall shear and mass transfer in a large scale model of neonatal high-frequency jet ventilation

The problem of endotracheal erosion associated with neonatal high-frequency jet ventilation (HFJV) is investigated through measurement of air velocity profiles in a scaled up model of the system. Fluid mechanical scaling principles are applied in order to construct a model within which velocity profiles are measured by hot-wire anemometry. The effects of two different jet geometries are investigated. Velocity gradients measured near the tracheal wall are used to measure the shear stresses caused by the jet flow on the wall. The Chilton-Colburn analogy between the transport of momentum and mass is applied to investigate tracheal drying caused by the high shear flow. Shear forces are seen to be more than two times higher for jets located near the endotracheal tube wall than for those located axisymmetrically in the center of the tube. Since water vapor fluxes are dependent on these shears, they are also higher for the asymmetric case. Fluxes are shown to be greatly dependent on the temperature and relative humidity of the inspired gas. Water from the tracheal surface may be depleted within one second if inspired gases are inadequately heated and humidified. It is recommended that the design of neonatal HFJV devices include delivery of heated (near body temperature), humidified (as close to 100% humidity as possible) gases through an axisymmetric jet to best avoid the problem of endotracheal erosion.

Necrotizing tracheobronchitis following high frequency ventilation: effect of hydrocortisone

A piglet model of acute respiratory failure was used to determine whether necrotizing tracheobronchitis (NTB) produced during high-frequency pneumatic flow interrupter (HFFI) ventilation could be attenuated by prior administration of 2 mg/kg hydrocortisone IV. Fourteen piglets (means age 3.6 days, means wt 1.4 kg) were anesthetized and paralyzed before saline lung lavage. The animals were randomly assigned to either placebo (P) or hydrocortisone (H) group. Continuous HFFI (10 Hz) was interrupted five times per minute by a 1-second deflationary pause. All animals were kept on 1.0 FI02 with ventilators adjusted to maintain adequate arterial blood gases. Airway pressures were similar for both groups. After 8 hours of ventilation the animals were sacrificed and their lungs inflated with formalin to 40 cm H2O. Sections were obtained from trachea, carina, main stem, and peripheral bronchi. A total airway injury (TAIS) was calculated by a pathologist unaware of treatment assignment. There was a significant difference (p less than 0.01, Wilcoxon rank sum) in TAIS scores between P (means 21.3) and H (means 7.8). In five out of seven P animals and in one out of seven H animals, NTB was severe and extended to the hilar bronchi. Although NTB is multifactorial in origin, the prior use of hydrocortisone may decrease the severity and extent of lesions by modifying the inflammatory response to this specific airway injury.

Swollen head syndrome in chickens: a preliminary report on the isolation of a possible aetiological agent

An extremely pleomorphic virus was isolated from broilers with swollen head syndrome. This virus seems to be related to the virus causing turkey rhinotracheitis.

Bacterial tracheitis

Bacterial tracheitis is the term used to describe a severe infraglottic infection characterized by toxicity, brassy cough, inspiratory stridor, subglottic oedema and the presence of copious mucopurulent secretions in the trachea. It is an uncommon condition that requires prompt diagnosis and intensive medical therapy if significant morbidity and mortality are to be avoided. Since the condition was first described in 1979 approximately one hundred cases have been reported. In this paper we present four children with bacterial tracheitis to add to the current literature. Interestingly, one child was admitted on two separate occasions with the disease, an event not previously recorded. All patients underwent endoscopy which revealed findings typical of bacterial tracheitis in each case. None required tracheostomy though three required nasotracheal intubation. Post-endoscopy all were managed in the Intensive Care Unit. There were no fatalities or significant morbidity. The average duration of hospitalization was seven days.