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Sul B, Altes T, Ruppert K, Qing K, Hariprasad DS, Morris M, Reifman J, Wallqvist A. In vivo dynamics of the tracheal airway and its influences on respiratory airflows. J Biomech Eng 2019; 141:2733770. [PMID: 31074759 DOI: 10.1115/1.4043723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Indexed: 11/08/2022]
Abstract
Respiration is a dynamic process accompanied by morphological changes in the airways. Although deformation of large airways is expected to exacerbate pulmonary disease symptoms by obstructing airflow during increased minute ventilation, its quantitative effects on airflow characteristics remain unclear. Here, we used an exemplar case derived from in vivo dynamic imaging and examined the effects of tracheal deformation on airflow characteristics under different conditions. First, we measured tracheal deformation profiles of a healthy lung using magnetic resonance imaging during forced exhalation, which we simulated to characterize subject-specific airflow patterns. Subsequently, for both inhalation and exhalation, we compared the airflows when the maximal deformation in tracheal cross-sectional area was 0% (rigid), 33% (mild), 50% (moderate), or 75% (severe). We quantified differences in airflow patterns between deformable and rigid airways by computing the correlation coefficients (R) and the root-mean-square of differences (Drms) between their velocity contours. For both inhalation and exhalation, airflow patterns were similar in all branches between the rigid and mild conditions (R > 0.9; Drms < 32%). However, airflow characteristics in the moderate and severe conditions differed markedly from those in the rigid and mild conditions in all lung branches, particularly for inhalation (moderate: R > 0.1, Drms < 76%; severe: R > 0.2, Drms < 96%). Our exemplar case supports the use of a rigid airway assumption to compute flows for mild deformation. For moderate or severe deformation, however, dynamic contraction should be considered, especially during inhalation, to accurately predict airflow and elucidate the underlying pulmonary pathology.
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Affiliation(s)
- Bora Sul
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland; Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Talissa Altes
- Department of Radiology, University of Missouri, Columbia, Missouri
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kun Qing
- Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Daniel S Hariprasad
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland; Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Michael Morris
- Graduate Medical Education, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Jaques Reifman
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Anders Wallqvist
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
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Schweiger T, Hoetzenecker K. Getting in shape: Current hurdles in 3-dimensionally printed airway stents. J Thorac Cardiovasc Surg 2019; 157:e301-e302. [DOI: 10.1016/j.jtcvs.2019.01.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
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Ultralow Dose Dynamic Expiratory Computed Tomography for Evaluation of Tracheomalacia. J Comput Assist Tomogr 2019; 43:307-311. [PMID: 30531547 DOI: 10.1097/rct.0000000000000806] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the average effective radiation dose and feasibility of ultralow dose dynamic expiratory computed tomography (CT) for evaluation of tracheomalacia (ULD) and to evaluate factors that impact image quality. METHODS This is a retrospective study of 64 consecutive patients from September to October 2016 for the evaluation of tracheomalacia. All studies were performed with routine inspiration chest CT followed by ULD z(kilovoltage peak (kVp) 80, 100, or 120 and fixed milliamperage 10) or typical dose CT (TD) (kVp 100 or 120 with automated milliamperage) dynamic expiration CT. Image quality was considered diagnostic if the trachea area could be accurately measured for tracheomalacia assessment, and diagnostic studies were graded fair, good, or excellent. Scan length, image quality, and effective radiation dose were compared for ULD versus TD and ULD at 100 kVp versus ULD at 80 kVp. For ULD studies, patient factors were compared across image quality. RESULTS The ULD had a mean effective radiation dose of 0.08 mSv, with all studies of diagnostic image quality. The ULD showed 95% reduction in effective radiation dose (P < 0.001), 14% significant reduction in scan length (P = 0.029), and qualitatively decreased image quality compared w2 ith TD (P < 0.001). The ULD at 100 kVp had significantly better image quality compared with ULD at 80 kVp (P = 0.041) with higher effective radiation dose (0.09 vs 0.05 mSv) (P < 0.001). Body mass index significantly impacted image quality for all ULD studies but not for ULD at 80 or 100 kVp. CONCLUSION For evaluation of tracheomalacia, ULD showed low effective radiation dose less than 0.1 mSv and maintained diagnostic image quality.
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Rendo M, Sjulin TJ, Morris MJ, Burguete S. Upper airway wheezing: Inducible laryngeal obstruction vs. excessive dynamic airway collapse. Respir Med Case Rep 2019; 27:100827. [PMID: 30989047 PMCID: PMC6446124 DOI: 10.1016/j.rmcr.2019.100827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 12/02/2022] Open
Abstract
There are multiple causes of dyspnea upon exertion in young, healthy patients to primarily include asthma and exercise-induced bronchospasm. Excessive dynamic airway collapse (EDAC) describes focal collapse of the trachea or main bronchi with maintained structural integrity of the cartilaginous rings. It is commonly associated with pulmonary disorders like bronchiectasis, chronic obstructive pulmonary disease and asthma. It is believed to result secondary to airway obstruction in these conditions. While uncommon in young, healthy adults, it has recently been found as a cause of dyspnea in this population. Inducible laryngeal obstruction (ILO) is an umbrella term that describes an induced, intermittent upper airway impediment. While ILO is found in 10% of young patients with exertional dyspnea, it is primarily inspiratory in nature due to paradoxical closure of the glottis or supraglottis. This report highlights the presentation of a United States Army soldier who after a deployment was given a diagnosis of asthma, later found to have ILO and was subsequently diagnosed with concurrent EDAC. We follow up with a literature review and discussion of symptomatology, diagnosis, exercise bronchoscopy, and treatment modalities for both EDAC and ILO.
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Affiliation(s)
- Matthew Rendo
- San Antonio Military Medical Center, Internal Medicine, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6160, USA
| | - Tyson J Sjulin
- San Antonio Military Medical Center, Pulmonary/Critical Care, USA
| | - Michael J Morris
- San Antonio Military Medical Center, Pulmonary/Critical Care, USA
| | - Sergio Burguete
- University of Texas Health Science Center at San Antonio, Pulmonary/Critical Care, USA
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Abstract
Tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) are more frequently being recognized as the etiology of multiple types of respiratory complaints from chronic cough to exertional syncope to recurrent infections. Identification of these conditions requires a high suspicion, as well as a thorough history and physical examination. Dynamic computed tomography imaging and bronchoscopic evaluation are integral in achieving an accurate diagnosis. Once recognized, treatment ranges from addressing underlying contributing conditions to surgical stabilization of the airway. Referral to an institution familiar with the evaluation and treatment of TBM/EDAC is essential for the appropriate management of these conditions.
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Affiliation(s)
- Kendra Hammond
- Division of Pulmonary and Critical Care Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
| | - Uzair K Ghori
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Suite 5200, Milwaukee, WI 53226, USA
| | - Ali I Musani
- Division of Pulmonary Sciences and Critical Care, University of Colorado Medical Center, 12605 E 16th Avenue, Aurora, CO 80045, USA; Interventional Pulmonology, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, Academic Office 1, 12631 East 17th Avenue, M/S C323, Office # 8102, Aurora, CO 80045, USA.
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Diagnostic flexible versus rigid bronchoscopy for the assessment of tracheomalacia in children. The Journal of Laryngology & Otology 2018; 132:1083-1087. [PMID: 30565533 DOI: 10.1017/s0022215118002050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This project compares the degree of tracheal collapse determined by rigid and flexible bronchoscopy in paediatric patients with tracheomalacia. METHODS A total of nine patients with tracheomalacia underwent both rigid and flexible video bronchoscopy. All patients were breathing spontaneously. Cross-sectional images of the airway were processed using the ImageJ program and analysed via colour histogram mode technique in order to delineate the luminal area. Paired t-tests (conducted using Stata software version 13.0) quantified differences between rigid and flexible bronchoscopes regarding the ratios of luminal pixels at maximum airway collapse to expansion. Correlation between both techniques in terms of airway collapse to expansion ratios was determined by calculating the Pearson correlation coefficient (R). RESULTS The difference in ratios of maximum collapse to expansion between rigid and flexible bronchoscopy was not statistically significant (p = 0.4656) and was positively correlated (R = 0.523). CONCLUSION The ratios suggest that rigid and flexible bronchoscopy are equally efficacious in assessing tracheomalacia severity, and may be used interchangeably in a clinical setting.
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Tracheal collapsibility in adults is dynamic over time. Respir Med 2018; 146:124-128. [PMID: 30665510 DOI: 10.1016/j.rmed.2018.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/15/2018] [Accepted: 11/28/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tracheal collapse is a weakness of the tracheal wall leading to expiratory central airway collapse of more than 50% compared to inspiration. It has previously been discussed whether the collapsibility of the greater airways is a stable or a dynamic condition. Indeed, other well-known lung diseases such as asthma are characterized by dynamic changes with respect to pulmonary function indices. There are several different morphologies of the trachea related to collapsibility such as the crescent type and the saber-sheath type both involving the tracheal cartilage and excess dynamic airway collapse only involving the posterior membranous part of the trachea. Is the morphology of the trachea important for the course of the disease? The effect or adverse effects of inhaled corticosteroids are thought to play a role in the increasing incidence of the excess tracheal collapse. In this pilot study, we hypothesized that the excess collapsibility of the tracheal wall is dynamic. METHODS We prospectively examined 20 patients with excessive tracheal collapse on previous CT scans performed primarily due to bronchiectasis. A repeat CT scan was performed in order to evaluate the collapsibility. Before the repeat scan, patients were trained in maximal inspiration, expiration and breathholding. CT was performed in full inspiration and at end-expiration. Image assessment was performed on a dedicated CT workstation using standard lung window display settings. The percentage expiratory collapse based on cross sectional areas from carina to the thoracic inlet was calculated. Pulmonary function tests were performed and analysed in accordance with the American Thoracic Society and the European Respiratory Society guidelines. RESULTS Repeat CT scan were performed after 24 month +/- 7.2. Six of the 20 participants (30%) were males. Mean age was 67 +/- 11.3 years. Mean FEV1 was 83% of predicted, FVC 96.6 % of predicted and FEV1/FVC-ratio 71%. In 45% of the patients tracheal expiratory collapse improved (by more than 10%) based on percentage change in cross sectional areas in expiration compared to inspiration. 35% of patients showed disease progression with increased collapse and in 20% the collapsibility remained unchanged. CONCLUSION We demonstrate that the collapsibility in a large fraction of the patients had actually improved at the follow up examination. We do not find any dependency of the change in collapsibility on the morphology of the trachea after end expiration, use of corticosteroid, or recurrent infections. In addition, no correlation between the changes in collapse and changes in the pulmonary function tests and the symptoms is observed.
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Morrison RJ, Sengupta S, Flanangan CL, Ohye RG, Hollister SJ, Green GE. Treatment of Severe Acquired Tracheomalacia With a Patient-Specific, 3D-Printed, Permanent Tracheal Splint. JAMA Otolaryngol Head Neck Surg 2018; 143:523-525. [PMID: 28125750 DOI: 10.1001/jamaoto.2016.3932] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Robert J Morrison
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Shayan Sengupta
- University of Michigan Medical School, University of Michigan, Ann Arbor
| | | | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan, Ann Arbor
| | - Scott J Hollister
- Department of Biomedical Engineering, University of Michigan, Ann Arbor
| | - Glenn E Green
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
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Oh D, Lee S, Kim S, Choen S, Choi M, Yoon J. Computed tomographic bronchial collapsibility values over 50% may be detected in healthy dogs. Vet Radiol Ultrasound 2018; 60:28-37. [DOI: 10.1111/vru.12692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/15/2018] [Accepted: 07/17/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Dayoung Oh
- College of Veterinary Medicine and the Research Institute for Veterinary Science; Seoul National University; Seoul 08826 Republic of Korea
| | - Siheon Lee
- College of Veterinary Medicine and the Research Institute for Veterinary Science; Seoul National University; Seoul 08826 Republic of Korea
| | - Seungji Kim
- College of Veterinary Medicine and the Research Institute for Veterinary Science; Seoul National University; Seoul 08826 Republic of Korea
| | - Sangkyung Choen
- College of Veterinary Medicine and the Research Institute for Veterinary Science; Seoul National University; Seoul 08826 Republic of Korea
| | - Mincheol Choi
- College of Veterinary Medicine and the Research Institute for Veterinary Science; Seoul National University; Seoul 08826 Republic of Korea
| | - Junghee Yoon
- College of Veterinary Medicine and the Research Institute for Veterinary Science; Seoul National University; Seoul 08826 Republic of Korea
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Abstract
PURPOSE OF REVIEW Breathlessness is a common symptom in many chronic diseases and may be refractory to pharmacotherapy. In this review, we discuss the pathophysiology of breathlessness and the role of positive airway pressure (PAP) devices to ameliorate it. RECENT FINDINGS Breathlessness is directly related to neural respiratory drive, which can be modified by addressing the imbalance between respiratory muscle load and capacity. Noninvasive PAP devices have been applied to patients limited by exertional breathless and, as the disease progresses, breathlessness at rest. The application of PAP is focussed on addressing the imbalance in load and capacity, aiming to reduce neural respiratory drive and breathlessness. Indeed, noninvasive bi-level PAP devices have been employed to enhance exercise capacity by enhancing pulmonary mechanics and reduce neural drive in chronic obstructive pulmonary disease (COPD) patients, and reduce breathlessness for patients with progressive neuromuscular disease (NMD) by enhancing respiratory muscle capacity. Novel continuous PAP devices have been used to maintain central airways patency in patients with excessive dynamic airway collapse (EDAC) and target expiratory flow limitation in severe COPD. SUMMARY PAP devices can reduce exertional and resting breathlessness by reducing the load on the system and enhancing capacity to reduce neural respiratory drive.
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Li N, Zhu L, Sun J, Pan Y, Gao M. Difficulty in tracheal extubation followed by tracheal collapse after balloon dilatation for tracheal stenosis therapy: A case report. Medicine (Baltimore) 2018; 97:e10907. [PMID: 29851818 PMCID: PMC6393024 DOI: 10.1097/md.0000000000010907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Tracheobronchomalacia (TBM) refers to the weakening trachea or the trachea loss of structural integrity of airway cartilaginous structures. It causes tracheal stenosis, resulting in significantly high rates of mortality. Bronchoplasty by high-pressure balloon dilation under general anesthesia is a simple but effective and safe method to treat tracheobronchial stenosis. However, recurrent postoperative dyspnea after extubation due to tracheal collapse is still a challenge for anesthetists. PATIENT CONCERNS A 52-year-old man weighing 72 kg was scheduled for balloon dilatation surgery under general anesthesia because of breathing difficulties caused by tracheal stenosis. His previous medical history included rheumatoid arthritis, obstructive sleep apnea syndrome (OSAS), chronic bronchitis and a history of tracheal intubation. Laryngeal computerized tomography confirmed the stenosis at the level of thyroid gland. DIAGNOSIS The tracheal collapse after balloon dilatation for tracheal stenosis therapy. INTERVENTIONS Postoperatively, the patient presented with more serious and repetitive symptoms of dyspnea after extubation when compared to that before treatment. So, we had to re-insert the laryngeal mask airway (LMA), and exclude some anesthesia-associated factors, such as laryngospasm, bronchospasm and so on. After a series of treatments, we ultimately found the cause in time (the airway collapsed), and succeeded in tracheal extubation after the stent was inserted. OUTCOMES The patient recovered well and reported high satisfaction with anesthesia management. LESSONS In such an emergency even, the anesthesiologist should take valuable treatments to ensure the patient's effective ventilation. If the anesthesia-related factors can be eliminated, tracheomalacia or airway collapse should be considered whenever dyspnea occurs in the patients who unexpectedly fail to be extubated.
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Banka R, Terrington D, Kamath AV. A 31-year-old female with
a rare cause of recurrent lower lobar collapses. Breathe (Sheff) 2018; 14:e72-e77. [PMID: 30131839 PMCID: PMC6095233 DOI: 10.1183/20734735.017318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Can you diagnose this patient presenting to the emergency department with a short history of productive cough and breathlessness and a history of recurrent admission for chest infections? http://ow.ly/PoHQ30kmGPi.
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Affiliation(s)
- Radhika Banka
- Dept of Respiratory Medicine, Norfolk and Norwich University Hospital, Norwich, UK
| | - Dayle Terrington
- Dept of Respiratory Medicine, Norfolk and Norwich University Hospital, Norwich, UK
| | - Ajay V Kamath
- Dept of Respiratory Medicine, Norfolk and Norwich University Hospital, Norwich, UK
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Abstract
Tracheobronchomalacia is an uncommon acquired disorder of the central airways. Common symptoms include dyspnea, constant coughing, inability to raise secretions and recurrent respiratory infections. Evaluation includes an inspiratory-expiratory chest computed tomography (dynamic CT), an awake functional bronchoscopy and pulmonary function studies. Patients with significant associated symptoms and severe collapse on CT and bronchoscopy are offered membraneous wall plication. Tracheobronchoplasty is performed through a right thoracotomy. The posterior airway is exposed after the azygous vein is ligated. The posterior wall of the trachea (and usually both main bronchi) is plicated to a sheet of thick acellular dermis (or polypropylene mesh) with a series of 4 mattress sutures of 4-0 sutures from the thoracic inlet to the bottom of the trachea to re-shape the trachea and restore the normal D shape. Patients report generally good results with improvement of their symptoms. Quality of life is usually improved while pulmonary function tests usually are not improved.
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Affiliation(s)
- Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Abstract
Excessive dynamic airway collapse is a relatively new diagnosis separate from tracheobronchomalacia that is manifested by functional collapse of the large airways. Most commonly described in patients with underlying obstructive lung disease such as chronic obstructive pulmonary disease and asthma, it may contribute to increased dyspnea, cough, or exacerbations. There are few data published on the role of excessive dynamic airway collapse as related specifically to exercise. It was recently described as the cause for exertional dyspnea in individuals without underlying lung disease.
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Shim SS, Schiebler ML, Evans MD, Jarjour N, Sorkness RL, Denlinger LC, Rodriguez A, Wenzel S, Hoffman EA, Lin CL, Gierada DS, Castro M, Fain SB. Lumen area change (Delta Lumen) between inspiratory and expiratory multidetector computed tomography as a measure of severe outcomes in asthmatic patients. J Allergy Clin Immunol 2018; 142:1773-1780.e9. [PMID: 29438772 DOI: 10.1016/j.jaci.2017.12.1004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Quantitative computed tomographic (QCT) biomarkers of airway morphology hold potential for understanding and monitoring regional airway remodeling in asthmatic patients. OBJECTIVE We sought to determine whether the change in airway lumen area between total lung capacity (TLC) and functional residual capacity (FRC) lung volumes measured from CT imaging data was correlated with severe outcomes in asthmatic patients. METHODS We studied 152 asthmatic patients (90 female and 62 male patients) and 33 healthy subjects (12 female and 21 male subjects) using QCT. Postprocessing of airways at generations 1 to 5 (1 = trachea) was performed for wall area percentage, wall thickness percentage (WT%), lumen area at baseline total lung capacity (LATLC), lumen area at baseline functional residual capacity (LAFRC), and low attenuation area at FRC. A new metric (reflecting remodeling, distal air trapping, or both), Delta Lumen, was determined as follows: Percentage difference in lumen area (LATLC - LAFRC)/LATLC × 100. RESULTS Postprocessing of 4501 airway segments was performed (3681 segments in the 152 patients with asthma and 820 segments in the 33 healthy subjects; range, 17-28 segments per subject). Delta Lumen values were negatively correlated with WT% and low attenuation area (P < .01) in asthmatic patients. Delta Lumen values were significantly lower for airway generations 3 to 5 (segmental airways) in subjects undergoing hospitalization because of exacerbation and in patients with refractory asthma requiring treatment with systemic corticosteroids. WT% and low attenuation area were positively and Delta Lumen values were negatively associated with systemic corticosteroid treatment (P < .05), suggesting that a reduced Delta Lumen value is a potential outcome biomarker in patients with severe asthma. CONCLUSION Reduced Delta Lumen value in the central airways measured by using QCT is a promising exploratory biomarker of unstable refractory asthma that warrants further study.
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Affiliation(s)
- Sung Shine Shim
- Department of Radiology, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | | | - Michael D Evans
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wis
| | - Nizar Jarjour
- Department of Medicine, University of Wisconsin, Madison, Wis
| | - Ron L Sorkness
- School of Pharmacy, University of Wisconsin, Madison, Wis
| | | | - Alfonso Rodriguez
- Department of Medical Physics, University of Wisconsin, Madison, Wis
| | - Sally Wenzel
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Eric A Hoffman
- Departments of Radiology, Biomedical Engineering, Mechanical and Industrial Engineering, and Medicine, University of Iowa, Iowa City, Iowa
| | - Ching-Long Lin
- Departments of Radiology, Biomedical Engineering, Mechanical and Industrial Engineering, and Medicine, University of Iowa, Iowa City, Iowa
| | - David S Gierada
- Department of Radiology, Washington University, St Louis, Mo
| | - Mario Castro
- Department of Medicine, Washington University, St Louis, Mo; Department of Radiology, Washington University, St Louis, Mo
| | - Sean B Fain
- Department of Radiology, University of Wisconsin, Madison, Wis; Department of Medical Physics, University of Wisconsin, Madison, Wis; Department of Biomedical Engineering, University of Wisconsin, Madison, Wis.
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Ryu C, Boffa D, Bramley K, Pisani M, Puchalski J. A novel endobronchial approach to massive hemoptysis complicating silicone Y-stent placement for tracheobronchomalacia: A case report. Medicine (Baltimore) 2018; 97:e9980. [PMID: 29465600 PMCID: PMC5842006 DOI: 10.1097/md.0000000000009980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Airway stabilization for severe, symptomatic tracheobronchomalacia (TBM) may be accomplished by silicone Y-stent placement. Common complications of the Y-stent include mucus plugging and granulation tissue formation. PATIENT CONCERNS We describe a rare case of massive hemoptysis originating from a silicone Y-stent placed for TBM. DIAGNOSES An emergent bronchoscopy showed an actively bleeding, pulsatile vessel at the distal end of the left bronchial limb of the Y-stent. It was felt that the bleeding was caused by, or at least impacted by, the distal left bronchial limb of the Y-stent eroding into the airway wall. INTERVENTIONS We hypothesized that placement of oxidized regenerated cellulose (ORC) would provide initial hemostasis, and the subsequent placement of a biocompatible surgical sealant would lead to definitive resolution. OUTCOMES ORC provided sufficient hemostasis and the subsequent synthetic polymer reinforced the tissue for complete cessation of the bleed. LESSONS The combined use of ORC and a biocompatible surgical sealant provided long-term management for life-threatening hemoptysis, and potentially morbid procedures such as embolization or surgery were avoided by advanced endobronchial therapy.
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Affiliation(s)
- Changwan Ryu
- Yale School of Medicine, Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine
| | - Daniel Boffa
- Yale School of Medicine, Department of Thoracic Surgery, New Haven, CT, USA
| | - Kyle Bramley
- Yale School of Medicine, Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine
| | - Margaret Pisani
- Yale School of Medicine, Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine
| | - Jonathan Puchalski
- Yale School of Medicine, Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine
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Exercise-associated Excessive Dynamic Airway Collapse in Military Personnel. Ann Am Thorac Soc 2018; 13:1476-82. [PMID: 27332956 DOI: 10.1513/annalsats.201512-790oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Evaluation of military personnel for exertional dyspnea can present a diagnostic challenge, given multiple unique factors that include wide variation in military deployment. Initial consideration is given to common disorders such as asthma, exercise-induced bronchospasm, and inducible laryngeal obstruction. Excessive dynamic airway collapse has not been reported previously as a cause of dyspnea in these individuals. OBJECTIVES To describe the clinical and imaging characteristics of military personnel with exertional dyspnea who were found to have excessive dynamic collapse of large airways during exercise. METHODS After deployment to Afghanistan or Iraq, 240 active U.S. military personnel underwent a standardized evaluation to determine the etiology of persistent dyspnea on exertion. Study procedures included full pulmonary function testing, impulse oscillometry, exhaled nitric oxide measurement, methacholine challenge testing, exercise laryngoscopy, cardiopulmonary exercise testing, and fiberoptic bronchoscopy. Imaging included high-resolution computed tomography with inspiratory and expiratory views. Selected individuals underwent further imaging with dynamic computed tomography. MEASUREMENTS AND MAIN RESULTS A total of five men and one woman were identified as having exercise-associated excessive dynamic airway collapse on the basis of the following criteria: (1) exertional dyspnea without resting symptoms, (2) focal expiratory wheezing during exercise, (3) functional collapse of the large airways during bronchoscopy, (4) expiratory computed tomographic imaging showing narrowing of a large airway, and (5) absence of underlying apparent pathology in small airways or pulmonary parenchyma. Identification of focal expiratory wheezing correlated with bronchoscopic and imaging findings. CONCLUSIONS Among 240 military personnel evaluated after presenting with postdeployment exertional dyspnea, a combination of symptoms, auscultatory findings, imaging, and visualization of the airways by bronchoscopy identified six individuals with excessive dynamic central airway collapse as the sole apparent cause of dyspnea. Exercise-associated excessive dynamic airway collapse should be considered in the differential diagnosis of exertional dyspnea.
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Taherian S, Rahai H, Gomez B, Waddington T, Mazdisnian F. Computational fluid dynamics evaluation of excessive dynamic airway collapse. Clin Biomech (Bristol, Avon) 2017; 50:145-153. [PMID: 29101894 DOI: 10.1016/j.clinbiomech.2017.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/21/2017] [Accepted: 10/25/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Excessive dynamic airway collapse, which is often caused by the collapse of the posterior membrane wall during exhalation, is often misdiagnosed with other diseases; stents can provide support for the collapsing airways. The standard pulmonary function tests do not necessarily show change in functional breathing condition for evaluation of these type of diseases. METHODS Flow characteristics through a patient's airways with excessive dynamic airway collapse have been numerically investigated. A stent was placed to support the collapsing airway and to improve breathing conditions. Computed tomography images of the patient's pre- and post-stenting were used for generating 3-Dimensional models of the airways, and were imported into a computational fluid dynamics software for simulation of realistic air flow behavior. Unsteady simulations of the inspiratory phase and expiratory phase were performed with patient-specific boundary conditions for pre- and post-intervention cases to investigate the effect of stent placement on flow characteristic and possible improvements. FINDINGS Results of post-stent condition show reduced pressure, velocity magnitude and wall shear stress during expiration. The variation in wall shear stress, velocity magnitude and pressure drop is negligible during inspiration. INTERPRETATION Although Spirometry tests do not show significant improvements, computational fluid dynamics results show significant improvements in pre- and post-treatment results, suggesting improvement in breathing condition.
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Affiliation(s)
- Shahab Taherian
- Center for Energy and Environmental Research and Services, California State University Long Beach, 1250 Bellflower Boulevard Long Beach, California 90840, USA.
| | - Hamid Rahai
- Center for Energy and Environmental Research and Services, California State University Long Beach, 1250 Bellflower Boulevard Long Beach, California 90840, USA.
| | - Bernardo Gomez
- Center for Energy and Environmental Research and Services, California State University Long Beach, 1250 Bellflower Boulevard Long Beach, California 90840, USA.
| | - Thomas Waddington
- Mount Nittany Medical Center, Pulmonary Division, 3901 South Atherton St. Suite 2, State College, PA 16801, USA.
| | - Farhad Mazdisnian
- Pulmonary Division, Long Beach Veterans Administration (LBVA) Hospital, 5901 E 7th St, Long Beach, CA 90822, USA.
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Husta BC, Raoof S, Erzurum S, Mehta AC. Tracheobronchopathy From Inhaled Corticosteroids. Chest 2017; 152:1296-1305. [PMID: 28864055 DOI: 10.1016/j.chest.2017.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/06/2017] [Accepted: 08/01/2017] [Indexed: 12/17/2022] Open
Abstract
Inhaled corticosteroids (ICSs) have become the mainstay of asthma control. They are also recommended as an add-on therapy to long-acting beta agonists and anticholinergics in moderate to severe COPD with recurrent exacerbations. Ultimately this clinical practice has led to the widespread use of ICSs, which are supported by a more favorable side effect profile than that of systemic steroids.
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Affiliation(s)
- Bryan C Husta
- Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, NY
| | - Suhail Raoof
- Lenox Hill Hospital, Hofstra Northwell School of Medicine, New York, NY
| | - Serpil Erzurum
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Atul C Mehta
- Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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71
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Leong P, Tran A, Rangaswamy J, Ruane LE, Fernando MW, MacDonald MI, Lau KK, Bardin PG. Expiratory central airway collapse in stable COPD and during exacerbations. Respir Res 2017; 18:163. [PMID: 28841915 PMCID: PMC5574204 DOI: 10.1186/s12931-017-0646-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 08/21/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Tracheal obstruction resulting from expiratory tracheal deformation has been associated with respiratory symptoms and severe airway exacerbations. In chronic obstructive pulmonary disease (COPD), acute exacerbations (AECOPD) create large intrathoracic pressure swings which may increase tracheal deformation. Excessive central airway collapse (ECAC) may be diagnosed when the tracheal area on expiration is less than 50% of that on inspiration. The prevalence of ECAC in AECOPD and its temporal course have not been systematically studied. METHODS We prospectively recruited healthy volunteers (n = 53), stable outpatients with COPD (n = 40) and patients with hospitalised acute exacerbations of COPD (AECOPD, n = 64). 17 of the AECOPD group returned for repeat evaluation when clinically well at 6-12 weeks. All subjects underwent dynamic 320-slice computed tomography of the larynx and trachea during tidal breathing, enabling quantitation of tracheal area and dimensions (mean ± SD). RESULTS No healthy individuals had ECAC. The prevalence of ECAC in stable COPD and AECOPD was 35% and 39% respectively. Mean tracheal collapse did not differ between stable COPD (57.5 ± 19.8%), AECOPD (53.8 ± 19.3%) and in the subset who returned when convalescent (54.9 ± 17.2%). AECOPD patients with and without ECAC had similar clinical characteristics. CONCLUSIONS Tracheal collapse in both stable and AECOPD is considerably more prevalent than in healthy individuals. ECAC warrants assessment as part of comprehensive COPD evaluation and management. Further studies should evaluate the aetiology of ECAC and whether it predisposes to exacerbations.
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Affiliation(s)
- Paul Leong
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
- Monash University, Clayton, VIC Australia
| | - Anne Tran
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Jhanavi Rangaswamy
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Laurence E. Ruane
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Michael W. Fernando
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Martin I. MacDonald
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Kenneth K. Lau
- Monash University, Clayton, VIC Australia
- Diagnostic Imaging, Monash Medical Centre, Clayton, Australia
| | - Philip G. Bardin
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
- Monash University, Clayton, VIC Australia
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Our Experience on Silicone Y-Stent for Severe COPD Complicated With Expiratory Central Airway Collapse. J Bronchology Interv Pulmonol 2017; 24:104-109. [PMID: 28005835 DOI: 10.1097/lbr.0000000000000346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Expiratory central airway collapse (ECAC) is abnormal central airway narrowing during expiration. ECAC involves 2 different pathophysiological entities as tracheobronchomalacia and excessive dynamic airway collapse (EDAC). Although the exact cause is unknown, chronic obstructive pulmonary disease (COPD) is frequently accompanied by ECAC. Although there are various publications on the relationship between COPD and ECAC, there are very few data for stent placement in patients with tracheobronchomalacia accompanied severe COPD. We share our results for stenting in ECAC among patients with severe COPD. METHODS The data in this case series were collected retrospectively. The ECAC diagnosis was made during flexible bronchoscopy with severe COPD. Silicone Y-stents were placed via rigid bronchoscopy under general anesthesia. RESULTS A total of 9 patients' (7 men) data were evaluated with an average age of 67±10.73 years. One patient experienced stent migration on the second day of stenting prompting stent removal. Another patient died 1 month after stenting. Consequently, we evaluated the follow-up data of remaining 7 patients. The changes in forced expiratory volume 1 was not significant for these 7 cases (P=0.51). The modified Medical Research Council (mMRC) score improvement was statistically significant (P=0.03). Functional status improvement was observed in 4 of 7 patients. Of the 7 patients, mean additional follow-up bronchoscopic interventions requirement was 2.2 times. CONCLUSIONS Our study showed significant decrease in mMRC score with stenting for ECAC in severe COPD. For 2 patients, we experienced severe complications during short-term follow-up period after stenting. Additional follow-up bronchoscopic interventions were required.
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Abstract
The term tracheobronchomalacia refers to excessively compliant and collapsible central airways leading to symptoms. Although seen as a coexisting condition with various other pulmonary condition, it may cause symptoms by itself. The condition is often misdiagnosed as asthma, bronchitis or just chronic cough due to a lack of specific pathognomonic history and clinical findings. The investigation revolves around different modes of imaging, lung function testing and usually confirmed by flexible bronchoscopy. The treatment widely varies based on the cause, with most cases treated conservatively with non-invasive ventilation. Some may require surgery or stent placement. In this article, we aim to discuss the pathophysiology behind this condition and recognize the common symptoms and causes of tracheobronchomalacia. The article will highlight the diagnostic steps as well as therapeutic interventions based on the specific cause.
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Affiliation(s)
- Abhishek Biswas
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States.
| | - Michael A Jantz
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - P S Sriram
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - Hiren J Mehta
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
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Abstract
Chronic cough in children is increasingly defined as a cough that lasts more than four weeks. It is recognized as a different entity than cough in adults. As a result, the diagnostic approach and management of chronic cough in children are no longer extrapolated from adult guidelines. These differences are attributed to the various characteristics of the respiratory tract, immunological system and nervous system in children. Specific paediatric guidelines and algorithms for chronic cough are now widely applied. Post-infectious cough, asthma, bronchiectasis, malacia and protracted bacterial bronchitis (PBB) appear to be the major causes of cough in young children. By adolescence, the causes of cough are more likely to be similar to those in adults, namely, gastroesophageal reflux, asthma, and upper airway syndrome. In a primary setting, it is essential to investigate the underlying disease entity that initiates and sustains chronic cough. The use of cough management protocols or algorithms improves clinical outcomes and should differ depending on the associated characteristics of the cough and the child's clinical history. Performing a thorough history and physical examination is crucial to starting an individualised approach. A correct interpretation of the phenotypic presentation can be translated into guidance for workup. This approach will be helpful for adequate management without the risk of inappropriate investigations or inadequate treatment.
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Affiliation(s)
- Ahmad Kantar
- Paediatric Asthma and Cough Centre, University and Research Hospitals, Gruppo Ospedaliero San Donato, Bergamo, Italy
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75
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Bu R, Balakrishnan S, Iftimia N, Price H, Zdanski C, Oldenburg AL. Airway compliance measured by anatomic optical coherence tomography. BIOMEDICAL OPTICS EXPRESS 2017; 8:2195-2209. [PMID: 28736665 PMCID: PMC5516819 DOI: 10.1364/boe.8.002195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/16/2017] [Accepted: 03/10/2017] [Indexed: 05/25/2023]
Abstract
Quantification of airway compliance can aid in the diagnosis and treatment of obstructive airway disorders by detecting regions vulnerable to collapse. Here we evaluate the ability of a swept-source anatomic optical coherence tomography (SSaOCT) system to quantify airway cross-sectional compliance (CC) by measuring changes in the luminal cross-sectional area (CSA) under physiologically relevant pressures of 10-40 cmH2O. The accuracy and precision of CC measurements are determined using simulations of non-uniform rotation distortion (NURD) endemic to endoscopic scanning, and experiments performed in a simplified tube phantom and ex vivo porcine tracheas. NURD simulations show that CC measurements are typically more accurate than that of the CSAs from which they are derived. Phantom measurements of CSA versus pressure exhibit high linearity (R2>0.99), validating the dynamic range of the SSaOCT system. Tracheas also exhibited high linearity (R2 = 0.98) suggestive of linear elasticity, while CC measurements were obtained with typically ± 12% standard error.
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Affiliation(s)
- Ruofei Bu
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3216, USA
| | - Santosh Balakrishnan
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3216, USA
| | - Nicusor Iftimia
- Physical Sciences Inc., New England Business Center, Andover, MA 01810, USA
| | - Hillel Price
- Department of Physics and Astronomy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3255, USA
| | - Carlton Zdanski
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7070, USA
| | - Amy L. Oldenburg
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3216, USA
- Department of Physics and Astronomy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3255, USA
- Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
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76
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Bryant R. External tracheal stenting for pediatric airway obstruction: A word of caution. J Thorac Cardiovasc Surg 2017; 153:1178-1179. [PMID: 28237064 DOI: 10.1016/j.jtcvs.2017.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Roosevelt Bryant
- Division of Cardiovascular Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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77
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Matus I, Richter W, Mani SB. Awareness, Competencies, and Practice Patterns in Tracheobronchomalacia: A Survey of Pulmonologists. J Bronchology Interv Pulmonol 2017; 23:131-7. [PMID: 27058715 DOI: 10.1097/lbr.0000000000000281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tracheobronchomalacia (TBM) is a disorder of expiratory central airway collapse. TBM is separate from excessive dynamic airway collapse. Historically TBM has lacked a universally accepted definition. No consensus recommendations on evaluation and management exist. We suspect these unresolved issues contribute to deficits in pulmonologists' awareness and management of TBM. METHODS We created a 20-question survey obtaining information about overall awareness, knowledge base, competencies, and practice patterns in managing TBM. The survey was disseminated via email by American College of Chest Physicians to members of their Interventional Chest Diagnostic Procedures Network. RESULTS One hundred sixty-five clinicians participated in the survey. Seventy-seven percent of respondents chose the correct definition for TBM. Twenty-two percent of respondents never considered TBM in patients with cough, sputum production, dyspnea, and recurrent infections. Thirty-eight percent did not proceed with further evaluation of TBM if pulmonary function tests were normal. Eighteen percent use a classification system to describe the severity of TBM. Only 29% could identify TBM on bronchoscopy and only 39% identified TBM on computed tomography. Respondents that practice interventional pulmonology demonstrated a better knowledge base of TBM. CONCLUSION This survey exposes deficits among pulmonologists in their ability to confidently and correctly diagnose and manage TBM. These deficits are not surprising as our understanding of this clinical entity is evolving. There exists a need for further education of pulmonologists about TBM and a need to promote collaborative efforts through research and expert consensus committees to progress our knowledge and management of this disease.
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Affiliation(s)
- Ismael Matus
- *Interventional Pulmonlogy Program, Division of Pulmonary, Critical Care Medicine †Department of Internal Medicine, Georgetown University Hospital, Washington, DC
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Buitrago DH, Wilson JL, Parikh M, Majid A, Gangadharan SP. Current concepts in severe adult tracheobronchomalacia: evaluation and treatment. J Thorac Dis 2017; 9:E57-E66. [PMID: 28203438 DOI: 10.21037/jtd.2017.01.13] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There is increasing recognition of tracheobronchomalacia (TBM) in patients with respiratory complaints, though its true incidence in the adult population remains unknown. Most of these patients have an acquired form of severe diffuse TBM of unclear etiology. The mainstays of diagnosis are dynamic (inspiratory and expiratory) airway computed tomography (CT) scan and dynamic flexible bronchoscopy with forced expiratory maneuvers. While the prevailing definition of TBM is 50% reduction in cross-sectional area, a high proportion of healthy volunteers meet this threshold, thus this threshold fails to identify patients that might benefit from intervention. Therefore, we consider complete or near-complete collapse (>90% reduction in cross-sectional area) of the airway to be severe enough to warrant potential intervention. Surgical central airway stabilization by posterior mesh splinting (tracheobronchoplasty) effectively corrects malacic airways and has been shown to lead to significant improvement in symptoms, health-related quality of life, as well as functional and exercise capacity in carefully selected adults with severe diffuse TBM. A short-term stent trial clarifies a patient's candidacy for surgical intervention. Coordination of care between experienced interventional pulmonologists, radiologists, and thoracic surgeons is essential for optimal outcomes.
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Affiliation(s)
- Daniel H Buitrago
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
| | - Mihir Parikh
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
| | - Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
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80
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Uyar M, Sanli M, Kervancioglu S, Taskin-Dogan B, Bakir K, Dikensoy O. Tracheobronchomalacia as a Rare Cause of Chronic Dyspnea in Adults. Med Princ Pract 2017; 26:179-181. [PMID: 28068652 PMCID: PMC5588378 DOI: 10.1159/000455858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 01/09/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To emphasize the importance of a careful clinical evaluation to prevent unnecessary interventions and treatments. CLINICAL PRESENTATION AND INTERVENTION A 76-year-old female patient had been diagnosed with asthma during previous admissions to different hospitals. She had also undergone fiberoptic bronchoscopy (FOB) on 2 occasions for evaluation of right middle lobe atelectasis observed on computed tomography. A repeated FOB revealed tracheobronchomalacia and nodular bronchial amyloidosis. A silicone Y stent was inserted, but the dyspnea increased. Excessive granulation tissue developed, and the patient died despite ventilatory support. CONCLUSION The stenting technique used did not prevent the development of respiratory failure and death in this patient. Hence, a surgical procedure could be considered as an alternative to stenting in such cases.
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Affiliation(s)
- Meral Uyar
- Department of Pulmonary Medicine, Gaziantep, Turkey
- *Assoc. Prof. Meral Uyar, Department of Pulmonary Medicine, School of Medicine, Gaziantep University, University Boulevard, TR-27310 Gaziantep (Turkey), E-Mail
| | - Maruf Sanli
- Department of Thoracic Surgery, Gaziantep, Turkey
| | | | | | - Kemal Bakir
- Department of Pathology, Gaziantep University, Gaziantep, Turkey
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Cook DP, Adam RJ, Abou Alaiwa MH, Eberlein M, Klesney-Tait JA, Parekh KR, Meyerholz DK, Stoltz DA. Mounier-Kuhn syndrome: a case of tracheal smooth muscle remodeling. Clin Case Rep 2016; 5:93-96. [PMID: 28174630 PMCID: PMC5290513 DOI: 10.1002/ccr3.794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/23/2016] [Accepted: 11/28/2016] [Indexed: 11/29/2022] Open
Abstract
Mounier–Kuhn syndrome is a rare clinical disorder characterized by tracheobronchial dilation and recurrent lower respiratory tract infections. While the etiology of the disease remains unknown, histopathological analysis of Mounier–Kuhn airways demonstrates that the disease is, in part, characterized by cellular changes in airway smooth muscle.
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Affiliation(s)
- Daniel P Cook
- Department of Internal Medicine University of Iowa Iowa City Iowa USA; Department of Molecular Physiology and Biophysics University of Iowa Iowa City Iowa USA
| | - Ryan J Adam
- Department of Internal Medicine University of Iowa Iowa City Iowa USA; Department of Biomedical Engineering University of Iowa Iowa City Iowa USA
| | | | - Michael Eberlein
- Department of Internal Medicine University of Iowa Iowa City Iowa USA
| | | | - Kalpaj R Parekh
- Department of Cardiothoracic Surgery University of Iowa Iowa City Iowa USA
| | | | - David A Stoltz
- Department of Internal Medicine University of Iowa Iowa City Iowa USA; Department of Molecular Physiology and Biophysics University of Iowa Iowa City Iowa USA; Department of Biomedical Engineering University of Iowa Iowa City Iowa USA; Pappajohn Biomedical Institute University of Iowa Iowa City Iowa USA
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82
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Kloth C, Thaiss WM, Ditt H, Hetzel J, Schülen E, Nikolaou K, Horger M. Segmental bronchi collapsibility: computed tomography-based quantification in patients with chronic obstructive pulmonary disease and correlation with emphysema phenotype, corresponding lung volume changes and clinical parameters. J Thorac Dis 2016; 8:3521-3529. [PMID: 28149545 DOI: 10.21037/jtd.2016.12.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Global pulmonary function tests lack region specific differentiation that might influence therapy in severe chronic obstructive pulmonary disease (COPD) patients. Therefore, the aim of this work was to assess the degree of expiratory 3rd generation bronchial lumen collapsibility in patients with severe COPD using chest-computed tomography (CT), to evaluate emphysema-phenotype, lobar volumes and correlate results with pulmonary function tests. METHODS Thin-slice chest-CTs acquired at end-inspiration & end-expiration in 42 COPD GOLD IV patients (19 females, median-age: 65.9 y) from November 2011 to July 2014 were re-evaluated. The cross-sectional area of all segmental bronchi was measured 5 mm below the bronchial origin in both examinations. Lung lobes were semi-automatically segmented, volumes calculated at end-inspiratory and end-expiratory phase and visually defined emphysema-phenotypes defined. Results of CT densitometry were compared with lung functional tests including forced expiratory volume at 1 s (FEV1), total lung capacity (TLC), vital capacity (VC), residual volume (RV), diffusion capacity parameters and the maximal expiratory flow rates (MEFs). RESULTS Mean expiratory bronchial collapse was 31%, stronger in lobes with homogenous (38.5%) vs. heterogeneous emphysema-phenotype (27.8%, P=0.014). The mean lobar expiratory volume reduction was comparable in both emphysema-phenotypes (volume reduction 18.6%±8.3% in homogenous vs. 17.6%±16.5% in heterogeneous phenotype). The degree of bronchial lumen collapsibility, did not correlate with expiratory volume reduction. MEF25 correlated weakly with 3rd generation airway collapsibility (r=0.339, P=0.03). All patients showed a concentric expiratory reduction of bronchial cross-sectional area. CONCLUSIONS Changes in collapsibility of 3rd generation bronchi in COPD grade IV patients is significantly lower than that in the trachea and the main bronchi. Collapsibility did not correlate with the reduction in lung volume but was significantly higher in lobes with homogeneous vs. heterogeneous emphysema phenotype. Changes in the 3rd generation bronchial calibres between inspiration and expiration are not predictive for the degree of small airway collapsibility and related airflow limitation.
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Affiliation(s)
- Christopher Kloth
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, 72076 Tübingen, Germany
| | - Wolfgang Maximilian Thaiss
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, 72076 Tübingen, Germany
| | - Hendrik Ditt
- Siemens AG Healthcare, Imaging & Therapy Systems Computed Tomography & Radiation Oncology, HC IM CR R&D PA CA DC, 91301 Forchheim, Germany
| | - Jürgen Hetzel
- Department of Internal Medicine II, Eberhard-Karls-University, 72076 Tübingen, German
| | - Eva Schülen
- Department of Internal Medicine II, Eberhard-Karls-University, 72076 Tübingen, German
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, 72076 Tübingen, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, 72076 Tübingen, Germany
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83
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Manimtim WM, Rivard DC, Sherman AK, Cully BE, Reading BD, Lachica CI, Gratny LL. Tracheobronchomalacia diagnosed by tracheobronchography in ventilator-dependent infants. Pediatr Radiol 2016; 46:1813-1821. [PMID: 27541367 DOI: 10.1007/s00247-016-3685-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/14/2016] [Accepted: 08/02/2016] [Indexed: 10/25/2022]
Abstract
BACKGROUND Tracheobronchomalacia prevalence in premature infants on prolonged mechanical ventilation is high. OBJECTIVE To examine the prevalence of tracheobronchomalacia diagnosed by tracheobronchography in ventilator-dependent infants, and describe the demographic, clinical and dynamic airway characteristics of those infants with tracheobronchomalacia. MATERIALS AND METHODS This retrospective review studies 198 tracheobronchograms performed from 1998 to 2011 in a cohort of 158 ventilator-dependent infants <2 years of age. Dynamic airway assessment during tracheobronchography determined the optimal positive end-expiratory pressure to maintain airway patency at expiration in those infants with tracheobronchomalacia. RESULTS Tracheobronchograms were performed at a median age of 52 weeks post menstrual age. The primary diagnoses in these infants were bronchopulmonary dysplasia (53%), other causes of chronic lung disease of infancy (28%) and upper airway anomaly (13%). Of those with bronchopulmonary dysplasia, 48% had tracheobronchomalacia. Prematurity (P=0.01) and higher baseline - pre-tracheobronchogram positive end-expiratory pressure (P=0.04) were significantly associated with tracheobronchomalacia. Dynamic airway collapse during tracheobronchography showed statistically significant airway opening at optimal positive end-expiratory pressure (P < 0.001). There were no significant complications noted during and immediately following tracheobronchography. CONCLUSION The overall prevalence of tracheobronchomalacia in this cohort of ventilator-dependent infants is 40% and in those with bronchopulmonary dysplasia is 48%. Infants born prematurely and requiring high pre-tracheobronchogram positive end-expiratory pressure were likely to have tracheobronchomalacia. Tracheobronchography can be used to safely assess the dynamic function of the airway and can provide the clinician the optimal positive end-expiratory pressure to maintain airway patency.
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Affiliation(s)
- Winston M Manimtim
- Division of Neonatology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA. .,University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.
| | - Douglas C Rivard
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Radiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Ashley K Sherman
- Department of Research, Children's Mercy Hospital, Kansas City, MO, USA
| | - Brent E Cully
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Radiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Brenton D Reading
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Radiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Charisse I Lachica
- Division of Neonatology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.,University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Linda L Gratny
- Division of Neonatology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.,University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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Huang L, Wang L, He J, Zhao J, Zhong D, Yang G, Guo T, Yan X, Zhang L, Li D, Cao T, Li X. Tracheal suspension by using 3-dimensional printed personalized scaffold in a patient with tracheomalacia. J Thorac Dis 2016; 8:3323-3328. [PMID: 28066613 DOI: 10.21037/jtd.2016.10.53] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The major methods are used to fix or stabilize the central airways and major bronchi with either anterior suspension and/or posterior fixation for severe tracheomalacia (TM). Many support biomaterials, like mesh and sternal plate, can be used in the surgery. But there are no specialized biomaterials for TM which must be casually fabricated by the doctors in operation. Three dimensional printing (3DP) has currently untapped potential to provide custom, protean devices for challenging and life-threatening disease processes. After meticulous design, we created a polycaprolactone (PCL) scaffold for a female patient with TM, which would support for at least 24 months, to maintain the native lumen size of collapsed airways. Using 4-0 Polyglactin sutures, we grasped and suspended the malacic trachea into the scaffold. A remarkable improvement can be observed in the view of bronchoscope and chest CT after surgery. In the narrowest cavity of malacic trachea, the inner diameter increased from 0.3 to 1.0 cm, and the cross sectional area increased 4-5 times. The patient felt an obvious relief of dyspnea after surgery. In a word, the 3DP PCL scaffold can supply a personalized tool for suspending the malacic trachea in the future.
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Affiliation(s)
- Lijun Huang
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Lei Wang
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Jiankang He
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an 710049, China
| | - Jinbo Zhao
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Daixing Zhong
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Guanying Yang
- Department of Diagnostic Ultrasound, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Ting Guo
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Xiaolong Yan
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Lixiang Zhang
- School of Software and Microelectronics, Northwestern Polytechnical University, Xi'an 710072, China
| | - Dichen Li
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an 710049, China
| | - Tiesheng Cao
- Department of Diagnostic Ultrasound, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
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85
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Bertella E, Simonelli C, Bianchi L. Non-invasive method for airway clearance in a patient with excessive dynamic airway collapse: A case study. REVISTA PORTUGUESA DE PNEUMOLOGIA 2016; 23:45-47. [PMID: 27769817 DOI: 10.1016/j.rppnen.2016.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 07/28/2016] [Accepted: 08/27/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- E Bertella
- Respiratory Rehabilitation Division, Salvatore Maugeri Foundation, IRCCS - Institute of Lumezzane (Brescia), Italy.
| | - C Simonelli
- Respiratory Rehabilitation Division, Salvatore Maugeri Foundation, IRCCS - Institute of Lumezzane (Brescia), Italy
| | - L Bianchi
- Respiratory Rehabilitation Division, Salvatore Maugeri Foundation, IRCCS - Institute of Lumezzane (Brescia), Italy
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86
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Billet D, Bernu É. [CPAP interest in help of mucus clearance in tracheo-bronchomalacia outpatients]. REVUE DE PNEUMOLOGIE CLINIQUE 2016; 72:305-309. [PMID: 27567981 DOI: 10.1016/j.pneumo.2016.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 05/18/2016] [Accepted: 05/23/2016] [Indexed: 06/06/2023]
Abstract
The patients suffering of trachea bronchial dyskinesia in a context of trachea bronchomalacia present an important decrease of the expiratory flow during the Forced Expiration Techniques, and during the cough, returning difficult mucus clearance. The use of CPAP for these patients as a pneumatic prothesis can bring a considerable help during the chest physiotherapy techniques, avoiding the tracheobronchial collapse. The objectivation of the efficiency of this technique through a clinical case, its ease of application and control, allows us to propose the attempt of this additive help when the indication and the contraindications are clearly defined.
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Affiliation(s)
- D Billet
- IKARE (inhalotherapie, kinésithérapie respiratoire, association pour la recherche et l'enseignement), CoRAL (coordination respiratoire de l'agglomération lyonnaise), 42, chemin du Belvédère, 69340 Francheville, France.
| | - É Bernu
- IKARE (inhalotherapie, kinésithérapie respiratoire, association pour la recherche et l'enseignement), cabinet de kinésithérapie, innoparc, avenue Marc-Séguin, 07000 Privas, France.
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87
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Sindhwani G, Sodhi R, Saini M, Jethani V, Khanduri S, Singh B. Tracheobronchomalacia/excessive dynamic airway collapse in patients with chronic obstructive pulmonary disease with persistent expiratory wheeze: A pilot study. Lung India 2016; 33:381-4. [PMID: 27578929 PMCID: PMC4948224 DOI: 10.4103/0970-2113.184870] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Tracheobronchomalacia (TBM) refers to a condition in which structural integrity of cartilaginous wall of trachea is lost. Excessive dynamic airway collapse (EDAC) is characterized by excessive invagination of posterior wall of trachea. In both these conditions, airway lumen gets compromised, especially during expiration, which can lead to symptoms such as breathlessness, cough, and wheezing. Both these conditions can be present in obstructive lung diseases; TBM due to chronic airway inflammation and EDAC due to dynamic compressive forces during expiration. The present study was planned with the hypothesis that TBM/EDAC could also produce expiratory wheeze in patients with obstructive airway disorders. Hence, prevalence and factors affecting presence of this entity in patients with obstructive airway diseases were the aims and objectives of this study. MATERIALS AND METHODS Twenty-five patients with obstructive airway disorders (chronic obstructive pulmonary disease [COPD] or bronchial asthma), who were stable on medical management, but having persistent expiratory wheezing, were included in the study. They were evaluated for TBM/EDAC by bronchoscopy and computed tomographic scan of chest. The presence of TBM/EDAC was correlated with variables including age, sex, body mass index (BMI), smoking index, level of dyspnea, and severity of disease. RESULTS Mean age of the patients was 62.7 ± 7.81 years. Out of 25 patients, 14 were males. TBM/EDAC was found in 40% of study subjects. Age, sex, BMI, severity of disease, frequency of exacerbations and radiological findings etc., were not found to have any association with presence of TBM/EDAC. CONCLUSION TBM/EDAC is common in patients with obstructive airway disorders and should be evaluated in these patients, especially with persistent expiratory wheezing as diagnosis of this entity could provide another treatment option in these patients with persistent symptoms despite medical management.
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Affiliation(s)
- Girish Sindhwani
- Department of Pulmonary Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | - Rakhee Sodhi
- Department of Pulmonary Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | - Manju Saini
- Department of Radiodiagnosis, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | - Varuna Jethani
- Department of Pulmonary Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | - Sushant Khanduri
- Department of Pulmonary Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | - Baltej Singh
- Lecturer Biostatistics, Guru Gobind Singh Medical College, Baba Faridkot University, Faridkot, Punjab, India
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88
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Bairdain S, Zurakowski D, Baird CW, Jennings RW. Surgical Treatment of Tracheobronchomalacia: A novel approach. Paediatr Respir Rev 2016; 19:16-20. [PMID: 27237407 DOI: 10.1016/j.prrv.2016.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 04/13/2016] [Indexed: 11/19/2022]
Abstract
Tracheobronchomalacia, as a whole, is likely misdiagnosed and underestimated as a cause of respiratory compromise in pediatric patients. Currently, there is no standardized approach for the overall evaluation of pediatric tracheobronchomalacia (TBM) and the concept of excessive dynamic airway collapse (EDAC); no grading score for the evaluation of severity; nor a standardized means to successfully approach TBM and EDAC. This paper describes our experience standardizing the approach to these complex patients whose backgrounds include different disease etiologies, as well as a variety of comorbid conditions. Preoperative and postoperative evaluation of patients with severe TBM and EDAC, as well as concurrent development of a prospective grading scale, has allowed us to ascertain correlation between surgery, symptoms, and effectiveness on particular tracheal-bronchial segments. Long-term, continued collection of patient characteristics, surgical technique, complications, and outcomes must be collected given the overall heterogeneity of this particular population.
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Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115; Department of Anesthesia, Boston Children's Hospital, Boston MA 02115
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston MA 02115
| | - Russell W Jennings
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115.
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89
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Biphasic flow-volume loop in granulomatosis with polyangiitis related unilateral bronchus obstruction. Respir Investig 2016; 54:280-3. [PMID: 27424828 DOI: 10.1016/j.resinv.2016.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/21/2016] [Accepted: 01/24/2016] [Indexed: 11/20/2022]
Abstract
Spirometry flow-volume measurement is used routinely in the outpatient setting to rule out obstructive lung diseases. Biphasic flow-volume loop is a classic presentation of unilateral bronchial stenosis due to multiple etiologies and it should raise clinical suspicion. Granulomatosis with polyangiitis (GPA) is a systemic inflammatory condition with pulmonary manifestations that may be infiltrative (e.g., pneumonia), hemorrhagic, and may rarely cause bronchial stenosis. Herein, we present a case of GPA-related, bronchial obstruction that caused biphasic flow-volume loop along with a literature review.
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90
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Dalar L, Tural Önür S, Özdemir C, Sökücü SN, Karasulu AL, Altin S. Is silicone stent insertion a clinically useful option for tracheobronchomalacia? Turk J Med Sci 2016; 46:437-42. [PMID: 27511508 DOI: 10.3906/sag-1412-104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 05/11/2015] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND/AIM Tracheobronchomalacia (TBM) leads to the obstruction of expiratory airflow and interference with secretion clearance. Stabilization of the airway wall using a silicon stent or laser coagulation of the posterior wall may be treatment options. This study aimed to retrospectively analyze which interventional bronchoscopic method could be used to provide airway stabilization and gain control of symptoms and for whom this method could be used. MATERIALS AND METHODS Fifteen patients who had received treatment in our interventional pulmonology unit were analyzed. We analyzed the techniques used, stent duration, complications, and long-term treatment success retrospectively. RESULTS Stents were used in 10 patients: 4 patients had silicon Y-stents and 4 patients had silicon tracheal stents. Stents were removed due to early migration in 3 patients. In 5 of the 7 cases, the stent was removed due to frequent obstructions of the stent due to recurrent severe mucostasis. A suitable stent was not found for one patient who had an extremely enlarged trachea. Good clinical results were achieved in just two cases. The frequency of admissions to the emergency room and hospitalizations were diminished during the follow-up time in these two patients. CONCLUSION Silicon stents may be a good treatment option in selected patients with TBM and dynamic collapse. However, our patients were high-risk; thus, the criteria for candidates for bronchoscopic treatment should be carefully defined.
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Affiliation(s)
- Levent Dalar
- Department of Pulmonary Medicine, Faculty of Medicine, İstanbul Bilim University, İstanbul, Turkey
| | - Seda Tural Önür
- Department of Chest Disease, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Cengiz Özdemir
- Department of Chest Disease, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Sinem Nedime Sökücü
- Department of Chest Disease, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Levent Karasulu
- Department of Chest Disease, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Sedat Altin
- Department of Chest Disease, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
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91
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Morrison RJ, Hollister SJ, Niedner MF, Mahani MG, Park AH, Mehta DK, Ohye RG, Green GE. Mitigation of tracheobronchomalacia with 3D-printed personalized medical devices in pediatric patients. Sci Transl Med 2016; 7:285ra64. [PMID: 25925683 DOI: 10.1126/scitranslmed.3010825] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Three-dimensional (3D) printing offers the potential for rapid customization of medical devices. The advent of 3D-printable biomaterials has created the potential for device control in the fourth dimension: 3D-printed objects that exhibit a designed shape change under tissue growth and resorption conditions over time. Tracheobronchomalacia (TBM) is a condition of excessive collapse of the airways during respiration that can lead to life-threatening cardiopulmonary arrests. We demonstrate the successful application of 3D printing technology to produce a personalized medical device for treatment of TBM, designed to accommodate airway growth while preventing external compression over a predetermined time period before bioresorption. We implanted patient-specific 3D-printed external airway splints in three infants with severe TBM. At the time of publication, these infants no longer exhibited life-threatening airway disease and had demonstrated resolution of both pulmonary and extrapulmonary complications of their TBM. Long-term data show continued growth of the primary airways. This process has broad application for medical manufacturing of patient-specific 3D-printed devices that adjust to tissue growth through designed mechanical and degradation behaviors over time.
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Affiliation(s)
- Robert J Morrison
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Scott J Hollister
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Matthew F Niedner
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Albert H Park
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, UT 84132, USA
| | - Deepak K Mehta
- Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA 15224, USA
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Glenn E Green
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Michigan, Ann Arbor, MI 48109, USA.
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92
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Tracheal CT morphology: correlation with distribution and extent of thoracic adipose tissue. Eur Radiol 2016; 26:3669-76. [DOI: 10.1007/s00330-016-4205-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 10/10/2015] [Accepted: 01/08/2016] [Indexed: 12/26/2022]
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93
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Abstract
Excessive dynamic airway collapse (EDAC) has been diagnosed using dynamic CT during inspiration and expiration. We herein report an asthma patient with EDAC that was detected incidentally using nondynamic CT. The patient presented with wheezing, cough and mild fever. Treatment for the asthma did not improve her wheeze. CT revealed tracheal narrowing and bulging of the posterior bronchial wall. The patient was diagnosed with EDAC by bronchoscopy. Her wheeze improved with continuous positive airway pressure therapy. Clinicians should be aware of the airway shape when performing nondynamic CT in refractory asthma patients because recognizing the existence of EDAC may help when deciding on the treatment strategy.
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94
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Suwatanapongched T, Thongprasert C, Lertpongpiroon S, Muntham D, Kiatboonsri S. Expiratory air trapping during asthma exacerbation: Relationships with clinical indices and proximal airway morphology. Eur J Radiol 2015; 84:2671-8. [DOI: 10.1016/j.ejrad.2015.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/21/2015] [Accepted: 09/08/2015] [Indexed: 12/22/2022]
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95
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Dedhia RC, Kapur VK, Weaver EM. Excessive Dynamic Airway Collapse of the Lower Airway: A Cause for Persistent Sleep Disordered Breathing after Tracheostomy. J Clin Sleep Med 2015; 11:1337-9. [PMID: 26235162 DOI: 10.5664/jcsm.5202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 07/09/2015] [Indexed: 11/13/2022]
Abstract
ABSTRACT Tracheostomy has demonstrated effectiveness in the control of obstructive sleep apnea (OSA) in most patients; however, current evidence suggests significant sleep disordered breathing may persist, particularly in morbidly obese individuals. While several mechanisms have been proposed to explain this phenomenon, we demonstrate evidence of a previously unidentified pathophysiology: excessive dynamic airway collapse (EDAC) of the lower airway. We present the case of a 62-year-old woman status post tracheostomy with persistent dyspnea in the supine position. Both radiographic and bronchoscopic images demonstrate prolapse of the posterior membranous trachea at the level of the trachea and mainstem bronchi with partial or complete obstruction. The prolapse was completely relieved with upright positioning or positive airway pressure. This case illustrates a novel mechanism of post-tracheostomy sleep disordered breathing in obese individuals and emphasizes the need to consider follow-up polysomnography after tracheostomy in this patient population, especially those with persistent symptoms related to sleep or the supine position.
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Affiliation(s)
- Raj C Dedhia
- Division of Pulmonary & Critical Care Medicine, University of Washington School of Medicine, Seattle, WA.,Department of Otolaryngology, University of Washington School of Medicine, Seattle, WA
| | - Vishesh K Kapur
- Division of Pulmonary & Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Edward M Weaver
- Department of Otolaryngology, University of Washington School of Medicine, Seattle, WA.,Surgery Service, Department of Veterans Affairs Medical Center, Seattle, WA
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96
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Park J, Lee YJ, Kim SJ, Park JS, Yoon HI, Lee JH, Lee CT, Cho YJ. Successful High Flow Nasal Oxygen Therapy for Excessive Dynamic Airway Collapse: A Case Report. Tuberc Respir Dis (Seoul) 2015; 78:455-8. [PMID: 26508945 PMCID: PMC4620351 DOI: 10.4046/trd.2015.78.4.455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 06/19/2015] [Accepted: 06/19/2015] [Indexed: 11/24/2022] Open
Abstract
Excessive dynamic airway collapse (EDAC) is a disease entity of excessive reduction of the central airway diameter during exhalation, without cartilage collapse. An 80-year-old female presented with generalized edema and dyspnea at our hospital. The patient was in a state of acute decompensated heart failure due to pneumonia with respiratory failure. We accordingly managed the patient with renal replacement therapy, mechanical ventilation and antibiotics. Bronchoscopy confirmed the diagnosis of EDAC. We scheduled extubation after the improvement of pneumonia and heart condition. However, extubation failure occurred due to hypercapnic respiratory failure with poor expectoration. Her EDAC was improved in response to high flow nasal oxygen therapy (HFNOT). Subsequently, the patient was stabilized and transferred to the general ward. HFNOT, which generates physiologic positive end expiratory pressure (PEEP) effects, could be an alternative and effective management of EDAC. Further research and clinical trials are needed to demonstrate the therapeutic effect of HFNOT on EDAC.
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Affiliation(s)
- Jisoo Park
- Division of Pulmonology, Department of Internal Medicine, CHA University, CHA Bundang Medical Center, Seongnam, Korea. ; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Se Joong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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97
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Johnson LR, Singh MK, Pollard RE. Agreement Among Radiographs, Fluoroscopy and Bronchoscopy in Documentation of Airway Collapse in Dogs. J Vet Intern Med 2015; 29:1619-26. [PMID: 26365563 PMCID: PMC4895679 DOI: 10.1111/jvim.13612] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 06/04/2015] [Accepted: 08/03/2015] [Indexed: 12/01/2022] Open
Abstract
Background Airway collapse is a common finding in dogs with chronic cough, yet the diagnosis can be difficult to confirm without specialty equipment. Hypothesis Bronchoscopic documentation of tracheobronchial collapse will show better agreement with fluoroscopic imaging than with standard radiography. Animals Forty‐two dogs prospectively evaluated for chronic cough. Methods In this prospective study, three‐view thoracic radiographs were obtained followed by fluoroscopy during tidal respiration and fluoroscopy during induction of cough. Digital images were assessed for the presence or absence of collapse at the trachea and each lobar bronchus. Bronchoscopy was performed under general anesthesia for identification of tracheobronchial collapse at each lung segment. Agreement of imaging tests with bronchoscopy was evaluated along with sensitivity and specificity of imaging modalities as compared to bronchoscopy. Results Airway collapse was identified in 41/42 dogs via 1 or more testing modalities. Percent agreement between pairs of tests varied between 49 and 87% with poor–moderate agreement at most bronchial sites. Sensitivity for the detection of bronchoscopically identified collapse was highest for radiography at the trachea, left lobar bronchi, and the right middle bronchus, although specificity was relatively low. Detection of airway collapse was increased when fluoroscopy was performed after induction of cough compared to during tidal respiration. Conclusions Radiography and fluoroscopy are complementary imaging techniques useful in the documentation of bronchial collapse in dogs. Confirming the presence or absence of tracheal or bronchial collapse can require multiple imaging modalities as well as bronchoscopy.
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Affiliation(s)
- L R Johnson
- Department of Medicine & Epidemiology, School of Veterinary Medicine, University of California, Davis, CA
| | - M K Singh
- Small Animal Specialist Hospital, North Ryde, NSW, Australia
| | - R E Pollard
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA
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98
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Lindl Bylicki BJ, Johnson LR, Pollard RE. COMPARISON OF THE RADIOGRAPHIC AND TRACHEOSCOPIC APPEARANCE OF THE DORSAL TRACHEAL MEMBRANE IN LARGE AND SMALL BREED DOGS. Vet Radiol Ultrasound 2015; 56:602-8. [DOI: 10.1111/vru.12276] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 05/01/2015] [Accepted: 05/10/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Britany J. Lindl Bylicki
- Veterinary Medical Teaching Hospital, Davis School of Veterinary Medicine; University of California; Davis CA 95616
| | - Lynelle R. Johnson
- Department of Medicine and Epidemiology, Davis School of Veterinary Medicine; University of California; Davis CA 95616
| | - Rachel E. Pollard
- Department of Surgical and Radiological Sciences, Davis School of Veterinary Medicine; University of California; Davis CA 95616
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99
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Lyaker MR, Davila VR, Papadimos TJ. Excessive Dynamic Airway Collapse: An Unexpected Contributor to Respiratory Failure in a Surgical Patient. Case Rep Anesthesiol 2015; 2015:596857. [PMID: 26167306 PMCID: PMC4475727 DOI: 10.1155/2015/596857] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/27/2015] [Indexed: 11/20/2022] Open
Abstract
Central airway collapse plays a significant, underrecognized role in respiratory failure after extubation of critically ill patients. Historically, airway collapse has been attributed to tracheomalacia (TM), softening of the cartilage in the trachea and other large airways. More recently, excessive dynamic airway collapse (EDAC) has been described as a distinct process unrelated to a loss of cartilaginous airway support. EDAC is caused by the posterior wall of the trachea bulging forward and causing airway obstruction during exhalation. This process is exaggerated when intrathoracic pressure is increased and results in a clinical picture of coughing, difficulty clearing secretions, dyspnea, and stridor. The increased use of computerized tomography and fiberoptic bronchoscopy has identified varying degrees of EDAC and TM in both symptomatic and asymptomatic individuals. This has led to renewed consideration of airway collapse and the different processes that contribute to it. Here we describe a 43-year-old morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. We will discuss the processes of EDAC and TM, describe how this condition contributed to this patient's respiratory failure, and review diagnosis and management options.
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Affiliation(s)
- Michael R. Lyaker
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
| | - Victor R. Davila
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
| | - Thomas J. Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
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Hohenforst-Schmidt W, Linsmeier B, Zarogoulidis P, Freitag L, Darwiche K, Browning R, Turner JF, Huang H, Li Q, Vogl T, Zarogoulidis K, Brachmann J, Rittger H. Transtracheal single-point stent fixation in posttracheotomy tracheomalacia under cone-beam computer tomography guidance by transmural suturing with the Berci needle - a perspective on a new tool to avoid stent migration of Dumon stents. Ther Clin Risk Manag 2015; 11:837-50. [PMID: 26045666 PMCID: PMC4448926 DOI: 10.2147/tcrm.s83230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Tracheomalacia or tracheobronchomalacia (TM or TBM) is a common problem especially for elderly patients often unfit for surgical techniques. Several surgical or minimally invasive techniques have already been described. Stenting is one option but in general long-time stenting is accompanied by a high complication rate. Stent removal is more difficult in case of self-expandable nitinol stents or metallic stents in general in comparison to silicone stents. The main disadvantage of silicone stents in comparison to uncovered metallic stents is migration and plugging. We compared the operation time and in particular the duration of a sufficient Dumon stent fixation with different techniques in a patient with severe posttracheotomy TM and strongly reduced mobility of the vocal cords due to Parkinson’s disease. The combined approach with simultaneous Dumon stenting and endoluminal transtracheal externalized suture under cone-beam computer tomography guidance with the Berci needle was by far the fastest approach compared to a (not performed) surgical intervention, or even purely endoluminal suturing through the rigid bronchoscope. The duration of the endoluminal transtracheal externalized suture was between 5 minutes and 9 minutes with the Berci needle; the pure endoluminal approach needed 51 minutes. The alternative of tracheobronchoplasty was refused by the patient. In general, 180 minutes for this surgical approach is calculated. The costs of the different approaches are supposed to vary widely due to the fact that in Germany 1 minute in an operation room costs on average approximately 50–60€ inclusive of taxes. In our own hospital (tertiary level), it is nearly 30€ per minute in an operation room for a surgical approach. Calculating an additional 15 minutes for patient preparation and transfer to wake-up room, therefore a total duration inside the investigation room of 30 minutes, the cost per flexible bronchoscopy is per minute on average less than 6€. Although the Dumon stenting requires a set-up with more expensive anesthesiology accompaniment, which takes longer than a flexible investigation estimated at 1 hour in an operation room, still without calculation of the costs of the materials and specialized staff that the surgical approach would consume at least 3,000€ more than a minimally invasive approach performed with the Berci needle. This difference is due to the longer time of the surgical intervention which is calculated at approximately 180 minutes in comparison to the achieved non-surgical approach of 60 minutes in the operation suite.
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Affiliation(s)
- Wolfgang Hohenforst-Schmidt
- Medical Clinic I, "Fuerth" Hospital, University of Erlangen, Fuerth, Germany ; II Medical Clinic, "Coburg" Hospital, University of Wuerzburg, Coburg, Germany
| | - Bernd Linsmeier
- Department of Thoracic Surgery, Medinos Clinic Sonneberg, Sonnerberg, Germany
| | - Paul Zarogoulidis
- Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lutz Freitag
- Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Essen-Duisburg, Tueschener Weg, Essen, Germany
| | - Kaid Darwiche
- Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Essen-Duisburg, Tueschener Weg, Essen, Germany
| | - Robert Browning
- Pulmonary and Critical Care Medicine, Interventional Pulmonology, National Naval Medical Center, Walter Reed Army Medical Center, Bethesda, MD, USA
| | - J Francis Turner
- Division of Interventional Pulmonology and Medical Oncology, Cancer Treatment Centers of America, Western Regional Medical Center, Goodyear, AZ, USA
| | - Haidong Huang
- Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai, People's Republic of China
| | - Qiang Li
- Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai, People's Republic of China
| | - Thomas Vogl
- Department of Diagnostic and Interventional Radiology, Goethe University of Frankfurt, Frankfurt, Germany
| | - Konstantinos Zarogoulidis
- Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Johannes Brachmann
- II Medical Clinic, "Coburg" Hospital, University of Wuerzburg, Coburg, Germany
| | - Harald Rittger
- Medical Clinic I, "Fuerth" Hospital, University of Erlangen, Fuerth, Germany
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