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Gonzales G, Malka R, Marinelli L, Lee CM, Miar S, Cook S, Dion GR, Guda T. Endotracheal tubes with dexamethasone eluting electrospun coating improve tissue mechanical function after upper airway injury. Sci Rep 2024; 14:2821. [PMID: 38308093 PMCID: PMC10837152 DOI: 10.1038/s41598-024-53328-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 01/31/2024] [Indexed: 02/04/2024] Open
Abstract
Corticosteroid-eluting endotracheal tubes (ETTs) were developed and employed in a swine laryngotracheal injury model to maintain airway patency and provide localized drug delivery to inhibit fibrotic scarring. Polycaprolactone (PCL) fibers with or without dexamethasone were electrospun onto the ETT surface PCL-only coated ETTs and placed in native airways of 18 Yorkshire swine. Regular and dexamethasone-PCL coated ETTs were placed in airways of another 18 swine injured by inner laryngeal mucosal abrasion. All groups were evaluated after 3, 7 and 14 days (n = 3/treatment/time). Larynges were bisected and localized stiffness determined by normal indentation, then sequentially matched with histological assessment. In the native airway, tissue stiffness with PCL-only ETT placement increased significantly from 3 to 7 days (p = 0.0016) and 3 to 14 days (p < 0.0001) while dexamethasone-PCL ETT placement resulted in stiffness decreasing from 7 to 14 days (p = 0.031). In the injured airway, localized stiffness at 14 days was significantly greater after regular ETT placement (23.1 ± 0.725 N/m) versus dexamethasone-PCL ETTs (17.10 ± 0.930 N/m, p < 0.0001). Dexamethasone-loaded ETTs were found to reduce laryngotracheal tissue stiffening after simulated intubation injury compared to regular ETTs, supported by a trend of reduced collagen in the basement membrane in injured swine over time. Findings suggest localized corticosteroid delivery allows for tissue stiffness control and potential use as an approach for prevention and treatment of scarring caused by intubation injury.
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Affiliation(s)
- Gabriela Gonzales
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
| | - Ronit Malka
- Department of Otolaryngology - Head and Neck Surgery, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Lisa Marinelli
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Christine M Lee
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Solaleh Miar
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
- Department of Civil, Environmental, and Biomedical Engineering, University of Hartford, West Hartford, CT, 06117, USA
| | - Stacy Cook
- Department of Otolaryngology - Head and Neck Surgery, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Gregory R Dion
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, University of Cincinnati Medical Center, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| | - Teja Guda
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA.
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Lin H, Ainiwaer M, Jiang Z, Wang Z, Liu J, Chen F. Comparative evaluation of mechanical injury methods for establishing stable tracheal stenosis animal models. Sci Rep 2024; 14:2383. [PMID: 38287058 PMCID: PMC10824766 DOI: 10.1038/s41598-024-52230-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/16/2024] [Indexed: 01/31/2024] Open
Abstract
The study aimed to assess the stability of various mechanical injury techniques in creating tracheal stenosis animal models using endoscopic assistance and investigate the viability of tracheal stoma in this process. Twenty-six healthy adult New Zealand white rabbits were randomly assigned to an experimental and control group. The experimental group underwent tracheal incision followed by steel brush scraping with endoscopic assistance, while the control group received nylon brush scraping. Within the control group, two subgroups were formed: Group A underwent scraping without tracheal stoma, and Group B underwent scraping followed by tracheal stoma. Additionally, a sham operation was performed on a separate group without subsequent scratching, resulting in no stenosis formation. Endoscopic observations were conducted at 7, 14, and 21 days post-scraping, followed by histological examinations of euthanized rabbits on the 21st day. Notably, all rabbits in the non-stoma group survived without complications, whereas Group B rabbits faced mortality post-operation. Histological assessments revealed inflammatory cell infiltration, fibroblast proliferation, and collagen fiber deposition in narrowed tracheal specimens. Steel brush scraping with endoscopic assistance proved more effective in inducing stable tracheal stenosis compared to nylon brush scraping. However, the survival challenges of rabbits with tracheal fistula require further investigation.
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Affiliation(s)
- Hongbin Lin
- Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Head and Neck Surgical CenterWest China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Department of Otolaryngology-Head and Neck Surgery, The Third People's Hospital of Sichuan Province, Chengdu, China
| | - Mailudan Ainiwaer
- Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Head and Neck Surgical CenterWest China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Zheng Jiang
- Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Head and Neck Surgical CenterWest China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Zhenyan Wang
- Department of Otolaryngology-Head and Neck Surgery, The Third People's Hospital of Sichuan Province, Chengdu, China.
| | - Jun Liu
- Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
- Head and Neck Surgical CenterWest China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
| | - Fei Chen
- Department of Otolaryngology-Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
- Head and Neck Surgical CenterWest China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
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Dou Z, Zhou X, Jiang H, Zhao X, Wen C, Zhang GA. Protection of laryngeal mucosa and function in laryngeal burns by heat absorption of perilaryngeal tissue. Eur Arch Otorhinolaryngol 2023; 280:4531-4542. [PMID: 37219683 DOI: 10.1007/s00405-023-08030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The laryngeal tissue carries most of the heat during inhalation injury. This study aims to explore the heat transfer process and the severity of injury inside laryngeal tissue by horizontally studying the temperature rise process at various anatomical layers of the larynx and observing the thermal damage in various parts of the upper respiratory tract. METHODS The 12 healthy adult beagles were randomly divided into four groups, and inhaled room temperature air (control group), dry hot air of 80 °C (group I), 160 °C (group II), and 320 °C (group III) for 20 min, respectively. The temperature changes of the glottic mucosal surface, the inner surface of the thyroid cartilage, the external surface of the thyroid cartilage, and subcutaneous tissue were measured every minute. All animals were immediately sacrificed after injury, and pathological changes in various parts of laryngeal tissue were observed and evaluated under a microscope. RESULTS After inhaling hot air of 80 °C, 160 °C and 320 °C, the increase of laryngeal temperature in each group was ΔT = 3.57 ± 0.25 °C, 7.83 ± 0.15 °C, 11.93 ± 0.21 °C. The tissue temperature was approximately uniformly distributed, and the difference was not statistically significant. The average laryngeal temperature-time curve showed that the laryngeal tissue temperature in group I and group II showed a trend of "first decrease and then increase", except that the temperature of group III directly increased with time. The prominent pathological changes after thermal burns mainly concluded necrosis of epithelial cells, loss of the mucosal layer, atrophy of submucosal glands, vasodilatation, erythrocytes exudation, and degeneration of chondrocytes. Mild degeneration of cartilage and muscle layers was also observed in mild thermal injury. Pathological scores indicated that the pathological severity of laryngeal burns increased significantly with the increase of temperature, and all layers of laryngeal tissue were seriously damaged by 320 °C hot air. CONCLUSIONS The high efficiency of tissue heat conduction enabled the larynx to quickly transfer heat to the laryngeal periphery, and the heat-bearing capacity of perilaryngeal tissue has a certain degree of protective effect on laryngeal mucosa and function in mild to moderate inhalation injury. The laryngeal temperature distribution was in accordance with the pathological severity, and the pathological changes of laryngeal burns provided a theoretical basis for the early clinical manifestations and treatment of inhalation injury.
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Affiliation(s)
- Zhe Dou
- Peking University Fourth School of Clinical Medicine, Beijing, 100035, People's Republic of China
- Department of Burns, Beijing Jishuitan Hospital, Xinjiekoudongjie Street 31, Xicheng District, Beijing, 100035, People's Republic of China
| | - Xiaocheng Zhou
- Department of Dermatology, The First Hospital of Tsinghua University, Beijing, 100016, People's Republic of China
| | - Huihao Jiang
- Department of Burns, Beijing Jishuitan Hospital, Xinjiekoudongjie Street 31, Xicheng District, Beijing, 100035, People's Republic of China
| | - Xiaozhuo Zhao
- Department of Burns, Beijing Jishuitan Hospital, Xinjiekoudongjie Street 31, Xicheng District, Beijing, 100035, People's Republic of China
| | - Chunquan Wen
- Department of Burns, Beijing Jishuitan Hospital, Xinjiekoudongjie Street 31, Xicheng District, Beijing, 100035, People's Republic of China
| | - Guo-An Zhang
- Department of Burns, Beijing Jishuitan Hospital, Xinjiekoudongjie Street 31, Xicheng District, Beijing, 100035, People's Republic of China.
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Malka R, Gonzales G, Detar W, Marinelli L, Lee CM, Isaac A, Miar S, Cook S, Guda T, Dion GR. Effect of continuous local dexamethasone on tissue biomechanics and histology after inhalational burn in a preclinical model. Laryngoscope Investig Otolaryngol 2023; 8:939-945. [PMID: 37621281 PMCID: PMC10446272 DOI: 10.1002/lio2.1093] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 08/26/2023] Open
Abstract
Objective Inhalational burns frequently lead to dysphonia and airway stenosis. We hypothesize local dexamethasone delivery via a novel drug-eluting electrospun polymer-mesh endotracheal tube (ETT) reduces biomechanical and histologic changes in the vocal folds in inhalational burn. Methods Dexamethasone-loaded polymer mesh was electrospun onto ETTs trimmed to transglottic endolaryngeal segments and secured in nine Yorkshire Crossbreed swine with directed 150°C inhalation burns. Uncoated ETTs were implanted in nine additional swine with identical burns. ETT segments were maintained for 3 and 7 days. Vocal fold (VF) structural stiffness was measured using automated-indentation mapping and compared across groups and to four uninjured controls, and matched histologic assessment performed. Statistical analysis was conducted using two-way ANOVA with Tukey's post hoc test and Wilcoxon rank-sum test. Results VF stiffness after burn decreased with longer intubation, from 19.4 (7.6) mN/mm at 3 days to 11.3 (5.2) mN/mm at 7 days (p < .0001). Stiffness similarly decreased with local dexamethasone, from 25.9 (17.2) mN/mm at 3 days to 18.1 (13.0) mN/mm at 7 days (p < .0001). VF stiffness in the dexamethasone group was increased compared to tissues without local dexamethasone (p = .0002), and all groups with ETT placement had higher tissue stiffness at 3 days (p < .001). No significant change in histologic evidence of epithelial ulceration or fibrosis was noted, while an increased degree of inflammation was noted in the dexamethasone group (p = .04). Conclusion Local dexamethasone delivery increases VF stiffness and degree of inflammation compared to uncoated ETTs in an acute laryngeal burn model, reflected in early biomechanical and histologic changes in an inhalational burn model.
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Affiliation(s)
- Ronit Malka
- Department of Biomedical Engineering and Chemical EngineeringUniversity of Texas at San AntonioSan AntonioTexasUSA
| | - Gabriela Gonzales
- Department of Otolaryngology—Head and Neck SurgeryBrooke Army Medical Center, JBSA Fort Sam HoustonHoustonTexasUSA
| | - Will Detar
- Department of Biomedical Engineering and Chemical EngineeringUniversity of Texas at San AntonioSan AntonioTexasUSA
| | - Lisa Marinelli
- Department of Pathology and Area Laboratory ServicesBrooke Army Medical Center, JBSA Fort Sam HoustonHoustonTexasUSA
| | - Christine M. Lee
- Department of Pathology and Area Laboratory ServicesBrooke Army Medical Center, JBSA Fort Sam HoustonHoustonTexasUSA
| | - Alisa Isaac
- Department of Otolaryngology—Head and Neck SurgeryBrooke Army Medical Center, JBSA Fort Sam HoustonHoustonTexasUSA
- Department of Cell Systems and AnatomyUniversity of Texas Health San AntonioSan AntonioTexasUSA
| | - Solaleh Miar
- Department of Otolaryngology—Head and Neck SurgeryBrooke Army Medical Center, JBSA Fort Sam HoustonHoustonTexasUSA
- Department of Civil, Environmental, and Biomedical EngineeringUniversity of HartfordWest HartfordConnecticutUSA
| | - Stacy Cook
- Department of Biomedical Engineering and Chemical EngineeringUniversity of Texas at San AntonioSan AntonioTexasUSA
| | - Teja Guda
- Department of Otolaryngology—Head and Neck SurgeryBrooke Army Medical Center, JBSA Fort Sam HoustonHoustonTexasUSA
- Department of Cell Systems and AnatomyUniversity of Texas Health San AntonioSan AntonioTexasUSA
| | - Gregory R. Dion
- Department of Otolaryngology—Head and Neck SurgeryUniversity of CincinnatiCincinnatiOhioUSA
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Aijaz A, Vinaik R, Jeschke MG. Large animal models of thermal injury. Methods Cell Biol 2022; 168:191-219. [PMID: 35366983 DOI: 10.1016/bs.mcb.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Burn injury results in a triad of inter-related adaptive responses: a systemic inflammatory response, a stress response, and a consequent hypermetabolic state which supports the former two. These pathological responses extend beyond the site of injury to affect distant organs and influence long-term outcomes in the patient. Animal models have proven valuable in advancing our understanding of mechanisms underlying the multifactorial manifestations of burn injury. While rodent models have been unprecedented in providing insights into signaling pathways, metabolic responses, protein turnover, cellular and molecular changes; small animal models do not replicate hypermetabolism, hyperinflammation, and wound healing after a burn injury as seen in humans. Herein, we provide a concise review of preferred large animal models utilized to understand burn pathophysiology based on organ systems and associated dysfunction. Additionally, we present a detailed protocol of contact burn injury in the Yorkshire pig model with a focus on preoperative care, anesthesia, analgesia, wound excision and grafting, dressing application, and frequency of dressing changes.
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Affiliation(s)
- Ayesha Aijaz
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Roohi Vinaik
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, ON, Canada; Department of Surgery, Division of Plastic Surgery, University of Toronto, Toronto, ON, Canada; Department of Immunology, University of Toronto, Toronto, ON, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Abstract
A lack of reliable laryngeal thermal injury models precludes laryngeal burn wound healing studies and investigation of novel therapeutics. We hypothesize that a swine laryngeal burn model can allow for laryngeal burn evaluation over time. Twelve Yorkshire crossbreed swine underwent tracheostomy and endoscopically directed laryngeal burns using heated air (150-160°C). Swine larynges were evaluated and sectioned/stained at 12 hours, 1, 3, 7, 14, and 21 days. A board-certified veterinary pathologist assessed anatomic regions (left and right: epiglottis, true/false vocal folds, and subglottis) using a nine criteria histological injury scoring scale. Six swine were euthanized at scheduled endpoints, three prematurely (airway concerns), and three succumbed to airway complications after 16 to 36 hours. Endoscopic and gross examination from scheduled endpoints revealed massive supraglottic edema and tissue damage, particularly around the arytenoids, extending transglottically. Swine from premature endpoints had comparatively increased edema throughout. Microscopic evaluation documented an inverse relationship between injury severity score and time from injury. Inflammation severity decreased over time, nearly resolving by 14 days. Neutrophils predominated early with histiocytes appearing at 3 days. Granulation tissue appeared at 3 days, and early epiglottic and/or subglottic fibrosis appeared by 7 days and matured by 14 days. Edema, abundant initially, decreased by day 3 and resolved by day 7. This approach is the first to provide longitudinal analysis of laryngeal thermal injuries, reflecting some of the first temporal wound healing characteristic data in laryngeal thermal injuries and providing a platform for future therapeutic studies.
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Affiliation(s)
- Gregory R Dion
- Dental and Craniofacial Trauma Research Department, U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas.,Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Christian S Pingree
- Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Pedro J Rico
- Clinical Investigation and Research Support, 59th Medical Wing, United States Air Force, JBSA-Lackland, Texas
| | - Christine L Christensen
- Clinical Investigation and Research Support, 59th Medical Wing, United States Air Force, JBSA-Lackland, Texas
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Jayawardena A, Lowery AS, Wootten C, Dion GR, Summitt JB, McGrane S, Gelbard A. Early Surgical Management of Thermal Airway Injury: A Case Series. J Burn Care Res 2020; 40:189-195. [PMID: 30445620 DOI: 10.1093/jbcr/iry059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inhalation injury is an independent risk factor in burn mortality, imparting a 20% increased risk of death. Yet there is little information on the natural history, functional outcome, or pathophysiology of thermal injury to the laryngotracheal complex, limiting treatment progress. This paper demonstrates a case series (n = 3) of significant thermal airway injuries. In all cases, the initial injury was far exceeded by the subsequent immune response and aggressive fibroinflammatory healing. Serial examination demonstrated progressive epithelial injury, mucosal inflammation, airway remodeling, and luminal compromise. Histologic findings in the first case demonstrate an early IL-17A response in the human airway following thermal injury. This is the first report implicating IL-17A in the airway mucosal immune response to thermal injury. Their second and third patients received Azithromycin targeting IL-17A and showed clinical responses. The third patient also presented with exposed tracheal cartilage and underwent mucosal reconstitution via split-thickness skin graft over an endoluminal stent in conjunction with tracheostomy. This was associated with rapid abatement of mucosal inflammation, resolution of granulation tissue, and return of laryngeal function. Patients who present with thermal inhalation injury should receive a thorough multidisciplinary airway evaluation, including early otolaryngologic evaluation. New early endoscopic approaches (scar lysis and mucosal reconstitution with autologous grafting over an endoluminal stent), when combined with targeted medical therapy aimed at components of mucosal airway inflammation (local corticosteroids and systemic Azithromycin targeting IL-17A), may have potential to limit chronic cicatricial complications.
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Affiliation(s)
- Asitha Jayawardena
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne S Lowery
- Department of Otolaryngology, Vanderbilt University Medical School, Nashville, Tennessee
| | - Christopher Wootten
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory R Dion
- Department of Otolaryngology, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - J Blair Summitt
- Department of Plastic Surgery, Vanderbilt University Medical Center, Acute Burn Services, Nashville, Tennessee
| | - Stuart McGrane
- Department of Plastic Surgery, Vanderbilt University Medical Center, Acute Burn Services, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
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Reczyńska K, Tharkar P, Kim SY, Wang Y, Pamuła E, Chan HK, Chrzanowski W. Animal models of smoke inhalation injury and related acute and chronic lung diseases. Adv Drug Deliv Rev 2018; 123:107-134. [PMID: 29108862 DOI: 10.1016/j.addr.2017.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
Abstract
Smoke inhalation injury leads to various acute and chronic lung diseases and thus is the dominant cause of fire-related fatalities. In a search for an effective treatment and validation of therapies different classes of animal models have been developed, which include both small and large animals. These models have advanced our understanding of the mechanism of smoke inhalation injury, enabling a better understanding of pathogenesis and pathophysiology and development of new therapies. However, none of the animal models fully mirrors human lungs and their pathologies. All animal models have their limitations in replicating complex clinical conditions associated with smoke inhalation injury in humans. Therefore, for a correct interpretation of the results and to avoid bias, a precise understanding of similarities and differences of lungs between different animal species and humans is critical. We have reviewed and presented comprehensive comparison of different animal models and their clinical relevance. We presented an overview of methods utilized to induce smoke inhalation injuries, airway micro-/macrostructure, advantages and disadvantages of the most commonly used small and large animal models.
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Dion GR, Benedict PA, Amin MR, Branski RC. Morbidity and mortality associated with preclinical tracheostomy models. Laryngoscope 2017; 128:E68-E71. [DOI: 10.1002/lary.26878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Gregory R. Dion
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
- Department of Otolaryngology-Head and Neck Surgery; Brooke Army Medical Center; Fort Sam Houston TX
| | - Peter A. Benedict
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
| | - Milan R. Amin
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
| | - Ryan C. Branski
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
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