Chronic sclerosing tracheobronchitis

We report a child with wheezing and respiratory distress of 53 months duration which was undiagnosed and unresponsive to treatment. Necropsy examination of trachea and bronchi showed narrowing by chronic inflammation and fibrosis of mucosa and submucosa. Despite intensive investigations, the aetiology and pathogenesis remained undetermined.

Clinical experience with the silicone tracheal cannula in obstructive sleep apnea

The surgical and postoperative course was evaluated in 20 patients with severe obstructive sleep apnea who underwent tracheostomy in which a silicone tracheal cannula was used. The cannula has been introduced recently by Dr. William Montgomery for use in a variety of clinical settings. Our findings indicate that the silicone tracheal cannula is a simple and reliable method of maintaining the tracheal airway in patients with severe sleep apnea. There were infrequent complications and a high degree of patient acceptance with this surgical procedure. Advantages of the silicone tracheal cannula include ease of insertion (especially in the often obese neck of the patient with sleep apnea), the inconspicuous nature of the cannula itself, the ease of care, and the maintenance of speech. Thus our clinical experience with this new tracheal cannula in the treatment of certain types of sleep-related breathing disorders indicates that it has a number of advantages as well as infrequent complications.

Role of mitogenicity in pathogenicity of mycoplasmas for murine hosts

The mitogenicity and pathogenicity of Mycoplasma pulmonis were compared in two rat strains. Both the mitogenic and the pathologic effects induced by M. pulmonis membranes were more severe in Lewis rats than in Hooded rats, and were dependent on the mitogen doses used. It was concluded that the severity of lung lesions induced by M. pulmonis membranes correlated with the degree of mitogenic responses of the different rat strains to this organism. The roles of T- and B-cell mitogens in induction of pneumonia were studied in Hooded rats treated intranasally with either the T-cell mitogen concanavalin A or with M. neurolyticum membranes which stimulate the B-cell populations, or with both concanavalin A and M. neurolyticum. Results clearly showed that the individual B- and T-cell mitogens affected the lungs of treated animals. Nevertheless, the mitogenic co-stimulation of both B and T lymphocytes in rat lungs was necessary to obtain maximal development of interstitial lymphocytic pneumonia.

[Infectious complications in patients with thoracic injuries under long-term artificial ventilation of the lungs]

Infectious complications developing in patients with chest traumas under prolonged artificial ventilation of lungs are described in the article, such as infection of respiration pathways, pneumonia, empyema of the pleura and sepsis. New methods for the treatment and prevention of such complications are presented.

[Membranous laryngotracheobronchitis]

Four cases of membranous laryngotracheobronchitis (MLTB) are presented. This entity is defined as an inflammation of larynx, trachea and bronchi, with mucopurulent membranes adhered to subglottic space wall. Radiological study shows irregularity of the proximal tracheal mucosa as well as adhered membranes resembling foreign bodies. Two out of the four children suffered from measles and one had staphylococcal pleuropneumonia. Tracheal aspirate obtained by laryngoscopy yielded S. aureus in two cases, and beta-lactamase positive H. influenzae in another. All patients required nasotracheal intubation and antibiotherapy. Characteristics of MLTB are discussed, pointing out its difference from viral laryngotracheobronchitis. Possibility of MLTB being initially a viral process undergoing bacterial superinfection later on is analyzed.

Respiratory infection complicating long-term tracheostomy. The implication of persistent gram-negative tracheobronchial colonization

Colonization of the lower respiratory tract by enteric Gram-negative bacilli (EGNB) has been a frequent finding in patients with long-term tracheostomies; however, the association of hospitalization and certain features of serious illness with this phenomenon has not been clearly established. Because such factors can render the oropharynx more susceptible to EGNB colonization, we sought to discover whether they can also have this effect on the tracheobronchial tree and its microflora. Thus, we collected serial paired culture samples from these two mucosal sites in 15 subjects with long-term tracheostomies and examined patterns and rates of colonization and related these findings to clinical parameters. In 49 sets of cultures, we found that EGNB (especially Pseudomonas species) were present in significantly fewer upper-airway cultures (36.7 percent) than lower-airway cultures (75.5 percent) (p = 0.009). At the tracheobronchial site, seven subjects had persistent EGNB colonization, all with Pseudomonas species, while only one subject had this finding at the oropharyngeal site (p = 0.015). Patients with persistent tracheobronchial colonization were more ill than those without this finding. They were treated with higher doses of prednisone (p = 0.06), received antibiotics more often, and developed purulent tracheobronchitis more often (100 percent vs 25 percent) than patients without persistent colonization. In addition, in the month following the culture survey, four subjects developed pneumonia, and three of these had previous persistent tracheobronchial colonization.(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumonia and acute febrile tracheobronchitis due to haemophilus influenzae

Of 30 patients with pneumonia due to Haemophilus influenzae, 26 had infection due to nontypable and 4 due to typable organisms. Biotype I isolates were implicated with surprising frequency. Blood cultures were positive in six patients. An additional 14 patients, all with nontypable H. influenzae infection, had febrile purulent tracheobronchitis that was clinically indistinguishable from pneumonia except for the absence of a radiographic infiltrate; none were bacteremic. Penicillin susceptibility was shown for 95% of isolates, and response to ampicillin was prompt. Patients had high serum levels of bactericidal antibody on admission but had lower levels of serum opsonizing activity against their own organism than did uninfected carriers with chronic bronchitis; 2 to 3 weeks later, levels of opsonizing antibody had risen to equal those of carriers. Deficient opsonizing activity may have contributed to susceptibility to infection. These findings identify both host and bacterial factors that may cause susceptibility to pulmonary infection from H. influenzae.

Respiratory tract lesions from infectious laryngotracheitis virus of low virulence

The pathogenicity of the A4557-5 strain of infectious laryngotracheitis virus for eight-week-old chickens was investigated by aerosol route of infection; chickens were necropsied five days after infection. The virus caused mild catarrhal tracheitis, peribronchial lymphoid infiltration, and focal lymphocytic infiltration in the lung and focal lymphocytic infiltration in the air sacs of some chickens. Chickens infected with this virus developed low levels of humoral antibody and were resistant to intratracheal challenge with the virulent V154 strain. By comparison, aerosol infection with a similar dose of virulent V154 strain caused severe necrotizing laryngotracheitis with marked suppurative bronchopneumonia and airsacculitis.

Mycoplasma pneumoniae respiratory disease symposium: summation and significance

The symposium on M. pneumoniae respiratory disease has examined the clinical expression of infection in adults and children, the pathophysiologic disturbances which occur, and the laboratory diagnosis by isolation and serology. That these infections are very common has been well documented; however, a variable incidence over periods of several years tends to minimize importance of the disease for many clinicians. While good laboratory diagnostic methods exist, they provide retrospective insight predominantly and are not useful for early diagnosis or therapeutic decision making. Development of rapid diagnostic methods which are sensitive and specific is an important goal for future research. Success would facilitate our understanding and control of M. pneumoniae disease.

[Air-conditioner disease. Results of an industrial medicine survey (author's transl)]

The results of a survey conducted in a company employing 1850 persons working in air-conditioned premises are reported. One hundred and five persons were examined, including 790 who mostly complained of respiratory disorders and 20 controls. Regular check-ups during the last two years have failed to reveal any serious disease. The most frequent complaints were rhinitis and tracheitis, especially among female employees. No alveolitis was observed. The finding of Bacillus subtilis in samples of ambient air and air-conditioner filters in conjunction with the presence of precipitating antibodies against crude extracts from these samples, suggested that the respiratory disorders might have been due to this microorganism. A multifactorial analysis demonstrated a statistically significant correlation between clinical symptoms and immunological disorders. The air-conditioner disease, therefore, may present as a benign condition.

Reconstructive techniques for extensive post-intubation tracheal stenosis

Extensive destruction of the trachea by post-intubation stenosis is usually the result of ill-advised treatment, either conservative or excisional, of an already existing stenosis. Under these circumstances, reconstruction may be done by use of adjunctive techniques, the chief of which is laryngeal release. The rarity of the need for adjunctive procedures is indicated by the fact that only 28 patients out of 208 required such procedures in an extensive series of reconstructions for these lesions. This series included 33 patients who had undergone prior attempts at surgical reconstruction and many extensive lesions which were referred to us because of their difficulty. It is emphasized that these stenoses can generally be managed safely by intubation if they are non-resectable and non-reparable, with long-term life expectancy.

Inflammatory stenosis of the trachea

The authors report their experience of 30 cases of inflammatory tracheal stenosis. Of the patients, 53.4% showed postoperative improvement, while in 10% mediocre results were observed (50% reduction of the tracheal lumen). After a second operation, however, the rate of failure was reduced from 26.6% to 13.3%. Postoperative mortality was 10%. An examination of these results demonstrates that tracheal surgery is not always successful at the first attempt and that the complications involved (granulations, recurrent stenosis) require further definition.

Cytologic features of nonfatal herpesvirus tracheobronchitis

Herpesvirus infections of the lower respiratory tract have most commonly been reported in patients with severe burns, immunosuppression or malignancies. Two patients without any of these underlying conditions developed severe herpetic tracheobronchitis, diagnosed by cytologic examination and confirmed by serologic studies. Serial examination of sputum, bronchial brushings and bronchial washings permitted observation of the evolution and progression of cellular changes found in herpesvirus infection of the lower respiratory tract. both patients recovered without specific antiviral therapy, but both developed superinfection with gram-negative organisms, requiring intensive antibiotic therapy. The distinctive features of herpesvirus infection in the tracheobronchial tree are similar to those recognized elsewhere in the body. Early findings include a variety of nonspecific changes in nuclear chromatin configurations; multinucleated cells may be common but do not often contain the central intranuclear inclusion bodies seen in later stages. These distinctive central intranuclear inclusions disappear in a few days, leaving only reparative changes in the surface epithelium. Herpesviruses are increasingly being reported in the literature as an etiologic agent of acute tracheobronchitis in otherwise healthy individuals.

A comparison of synthetic absorbable suture with synthetic nonabsorbable suture for construction of tracheal anastomoses

This study compares the use of synthetic absorbable suture (SAS, Vicryl) with that of synthetic nonabsorbable suture (SNS, Ticron) for construction of cervical tracheal anastomoses in the dog. Fourteen mongrel dogs underwent resection of one to four tracheal rings. Paired tracheal anastomoses were constructed, using 10 SAS or 10 SNS. After two months each anastomosis was removed and analyzed. All animals survived with intact anastomoses. There were no visible reactions to the SAS. Twenty-six of 70 SNS developed gross suture granulations. Significant stenosis developed in one of seven SAS and in four of seven SNS anastomoses. Histologic examination revealed no residual inflammatory reaction in the SAS specimens, while the SNS demonstrated a spectrum of inflammatory response that directly correlated in intensity with the gross appearance. These findings support the continued evaluation for the use of SAS in clinical tracheobronchoplastic procedures.

Mitogenicity and pathogenicity of Mycoplasma pulmonis in rats. I. Atypical interstitial pneumonia induced by mitogenic myeoplasmal membranes

Mitogenic preparations of nonviable lysed cells and purified membranes of Mycoplasma pulmonis induced interstitial pneumonia and tracheitis after intranasal administration to pathogen-free rats. The pneumonia, characterized by peribronchial, perivascular, and alveolar wall infiltration by lymphocytes, was indistinguishable from that produced by viable M. pulmonis. Both pathologic and mitogenic effects were significanlty reduced by prior treatment of membranes with heat or proteolytic enzyme. Intranasal administration of the thymus-derived-cell mitogen, concanavalin A, produced interstitial pneumonia but not tracheitis. These results indicate a correlation of mitogenicity and pathogenicity and suggest that activation of thymus-derived lymphocytes is the major cause of the pneumonia resulting from infections with M. pulmonis.

Seasonal pattern in childhood viral lower respiratory tract infections in Melbourne

Respiratory syncytial virus and parainfluenza viruses are the major pathogens in acute lower respiratory infection in infants and younger children. They show distinct seasonal patterns. An annual epidemic of respiratory syncytial virus infection is seen in Melbourne and this coincides with the coldest months of the year. Parainfluenza virus Type 1, the most frequent cause of laryngotracheobronchitis, occurs as an autumn epidemic every second year. Parainfluenza virus Types 2 and 3 are present most years and do not show a clear seasonal pattern.

Bacterial colonization, tracheobronchitis, and pneumonia following tracheostomy and long-term intubation in pediatric patients

Serial tracheal cultures for aerobic and anaerobic bacteria were obtained from 27 pediatric patients during one year of follow-up. The patients had required tracheostomy and prolonged intubation for periods ranging from 3 to 12 months (average, 7 1/2 months). Cultures of tracheal aspirates yielded 1,508 isolates of pathogenic aerobic (969 isolates) and anaerobic (539 isolates) bacteria. The most frequent aerobic isolates were Streptococcus pneumoniae and Staphylococcus aureus. The predominant anaerobes were anaerobic gram-positive cocci, Fusobacterium nucleatum, and Bacteroides fragilis. Replacement of one pathogen by another occurred frequently. Tracheobronchitis occurred in 24 patients, all of whom had episodes of pneumonia. The data suggest that anaerobic bacteria are a part of the bacterial flora in colonization, tracheobronchitis, and pneumonia in patients with tracheostomy and prolonged intubation.

Membranous laryngotracheobronchitis (membranous croup)

Membranous laryngotracheobronchitis (membranous croup), not previously described as a distinct entity, is characterized by diffuse inflammation of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes in the subglottic trachea (conus elasticus) and in the upper trachea distal to the conus elasticus. We reviewed 28 cases of membranous croup diagnosed by endoscopy and/or radiographic examination. The importance of the recognition of membranous croup as a distinct entity is discussed. The characteristic radiologic findings consist of subglottic tracheal narrowing, irregularity of contour of the proximal tracheal mucosa, and sometimes detached or partially detached proximal tracheal membranes, which can be mistaken for tracheal foreign bodies.

Membranous tracheitis following endotracheal intubation

In this study, four patients with membranous tracheitis following endotracheal intubation are presented. Possible causes for the development of the condition were mostly related to subglottic epithelial trauma caused by the pressure of the cuff of the tube for a long time on the mucosa and the drying effect of atropine. The literature concerning the development of membranous tracheitis in previous studies is also presented.

[Anaesthesia for the relief of dyspnoea caused by fibrin membranes in the larynx and trachea (author's transl)]

Three cases of life-endangering airway obstruction by fibrin membranes are reviewed which developed in a 17-year-old girl with virus pneumonia, in a 21-year-old girl with a history of thrombopathy after general anaesthesia with naso-tracheal intubation and in a 23-year-old woman after short anaesthesia with orotracheal intubation. Possible causal factors, the clinical symptoms and the therapeutic measures taken by the anaesthetist are discussed. Since these cases are generally in a state of severe respiratory collapse by the time treatment is initiated general anaesthesia with muscle relaxation should be attempted only if the anaesthesist is certain that he can effectively ventilate the patient before and during the operation. Otherwise it is better to apply assisted ventilation with oxygen and halothane via a mask until a clear air passage has been restored. Administration of anticholine drugs and control of shock are essential.

[Serum IgE in patients suffering from IgA deficiency with or without atopy]

Numerous studies, based upon the frequency of allergic and auto-immune disorders in association with selective deficiency in IgA, as well as the abnormally high proportion of IgA deficiency in atopic patients, have led to the hypothesis that allergy results from a deficiency in IgA during the first months of life. Thus subjects with an initial transient deficiency in IgA (followed by normal or greater than average production) produce an excess of IgE. The aim of this study, carried out by multifactorial data analysis, was to determine whether serum IgE levels were related to those of IgA. Comparison of the serum Ig levels of 4 groups of individuals, with or without IgA deficiency, showed that the production of IgE was more closely related to the respiratory condition responsible than to IgA levels. According to IgA and E levels, the 4 groups differ distinctly, atopic patients without asthma constituting a "bridge" between the control group and those with asthma. In the presence of an apparently identical situation, i.e. an IgA deficiency, individuals may react in two different ways: some produce an abundance of IgE whilst others fail to do so and are more susceptible to recurrent infective episodes. The role of the genetic control of IgE as well as environmental factors in the pathogenesis of allergic manifestations is discussed.

[Some respiratory viruses in the etiology of acute upper respiratory infections]

The viral etiology of acute respiratory diseases, determined in 107 children admitted to hospital during the 1966-1969 period, was confirmed in 36% of the cases by isolation of the viral agent and in 59% by serologic reactions. Parainfluenza viruses, especially of type 1 and 3, were encountered more often in the etiology of acute or obstructive laryngitis, and the syncytial respiratory virus in tracheobronchitis.

[Occupational allergy due to inhalation of pollen from Euphorbia fulgens Karw (author's transl)]

The increased cultivation and sales of Euphorbia fulgens Karw., originating in Mexico, has in the last few years led to occupational allergy, type I, in three growers manifesting itself as nasal disease, tracheobronchitis or bronchial asthma. Intracutaneous tests with pollen extracts were positive in all cases, even at high dilution. A specific hyposensitisation regimen, conducted over five months, gave highly promising results in one patient who had no symptoms in the following season, despite similar exposure. Such sensitisation by pollens of Euphorbia fulgens Karw. is probably widespread among growers and florists. The allergen is found only in the pollen, not in other parts of the plant. There is no relation to the toxic substances in the milk-sap of this plant family (Euphorbiaceae).

Innominate artery compression syndrome. Presentation of 16 cases

A series of 16 patients with tracheal compression by the innominate artery is presented. In more than half of the patients the symptoms began during the first few days of life with stridor varying severity, recurrent tracheobronchitis and apneic spells. In six cases requiring surgical treatment the immediate result was good. In ten mild cases treatment consisted of medical management and follow-up. The present study confirms that the great arteries can exert compression on the trachea, which can always be relieved by means of an operation which moves the arteries forward. Bronchoscopy is considered to be the only reliable means of diagnosis. This entity should be considered more often in the differential diagnosis in children less than 3 years of age with stridor, breathing difficulties, recurrent infections, apneic spells, and asthma.

[Acute obstructive laryngitis in children (author's transl)]

Three types of acute obstructive laryngitis in children are distinguished: 1. Acute supraglottic laryngitis (Epiglottitis acuta): The usual causative organism is Hemophilus influenzae, type B. Characteristic findings include a swollen red epiglottis. Treatment is based on Ampicillin, Solucortef (hydrocortisone-sodium succinate) i.m., air humidification, intravenous infusions and airway protection (tracheotomy or intubation). From 1958-1967, 68 children were treated, of whom boys were twice as commonly affected as girls. In about 80% of cases, tracheotomy was still found necessary. 2. Acute subglottic laryngitis: Mucosal swelling in the subglottic space causes a clinical picture which initially is common to several groups of deseases. In allergic subglottic edema, a pale "pillow-shaped" swelling occurs which responds favorably to antiallergenics and cortisone. In contrast, infectious swelling is partially caused by the infiltration of inflammatory cells. Parainfluenzae virus was isolated in 60% of these cases at our hospital. During the period studied, 2,741 cases were treated, of whom boys were 3.3 times more frequently affected than girls. The use of Solu-cortef i.m. has decreased the tracheotomy rate from 12% to 0. 3. Acute laryngotracheobronchitis: In this disease process, the initial infection is attributed to a virus, with the infected mucosa secondarily invaded by bacteria. The clinical course is prolonged when compared to subglottic laryngitis, and the general condition seriously affected. Both expiratory and inspiratory stridors occur. Tracheotomy is usually required, with viscous crusts removed by bronchoscopy. Respirator treatment is also often required. Fourteen children have been treated, of whom two have died.

[Serological studies of the role of the respiratory syncytial virus in acute respiratory diseases in children]

The presence of the syncytial respiratory virus was determined by CF in 281 children admitted with acute respiratory diseases between 15 Sept. 1971 and 30 Dec. 1973, using the Long antigen prepared in the "St. Nicolau" Institute of Virology, Bucharest. In 38 children (13.5%) a serologic diagnosis of infection with the syncytial virus was established; in the other cases of respiratory infection of different etiology, antibodies to the syncytial virus were found in low but constant titers in both serum samples. The presence of these antibodies in a high proportion of the children points to the wide circulation of the syncytial virus in the infantile population, with all its clinico-epidemiologic implications.

The influence of dose fractionation on acute and late reactions in patients with postoperative rasiotherapy for carcinoma of the breast

The clinical courses of 418 patients with breast carcinoma who received postradical-mastectomy radiation therapy to the internal mammary and supraclavicular are were revied in order to determine the normal tissue tolerance with various time-dose fractionation radiation regimens. Four different dose fractionation schedules wereemplyed during the period 1958-1968 at Memorial Hospital: 4900 rads/10f/32d; 4410 rads/9f/30d; 5000 rads/13f/18d; and 4600 rads/20f/28d. There was no difference in the acute reaction or local recurrence rate of the tumor in the irradiated area among the four fractionation schemes, but the late effects were quite different. Patients who received 4900 rads in 10 fractions in 32 days had a 33% incidence of subcutaneous fibrosis.A similiar dose in 13 fractions in 21/2-3 weeks resulted in about 17% subcutaneous fibrosis. No significance of these clinical findings is discussed in relation to the various formulae currently being used to express time-dose equivalence.

[Complications arising from the use of controlled respiration in patients with neurological diseases]

The authors applied controlled respiration in 112 cases of central nervous system diseases, polyneuropathies and myasthenia. During clinical observation or on autopsy in 30 cases complications were found in the form of subcutaneous and mediastinal emphysema or pneumothorax, narrowing or chondromalacis of the trachea, granuloma formation, decubitus ulcers in the trachea with or without bleeding, and haemorrhagic-ulcerative tracheitis. In 7 cases (6.25%) these complications caused death. Factors leading to complications and their prevention are discussed.

A prospective study of complications after tracheostomy for assisted ventilation

A prospective study of 40 patients having elective tracheostomy for ventilatory assistance used fiberoptic bronchoscopy and radiologic examination to assess tracheal healing after extubation. Ten percent of patients had bleeding complications of tracheostomy and 17.5 percent had tracheostomy management problems. Sixteen percent of survivors had asymptomatic stomal site tracheal narrowing and 8 percent required tracheal resection for symptomatic stomal site tracheal stenosis, 16 percent had asymptomatic tracheal defects at the cuff site. Stomal healing was seen to consist of gradual stomal shrinkage, resolution of tracheitis, and approximation of divided tracheal rings. No statistically significant correlation was demonstrated between various factors operative during ventilatory assistance and subsequent tracheal healing. All patients should have routine endoscopic or radiologic tracheal assessment after-tracheostomy.