Study on Tracheal Collapsibility, Compliance, and Stress by Considering Nonlinear Mechanical Property of Cartilage

Impact of palatopharyngeal sizes changing on pharyngeal airflow fluctuation and airway vibration in a pediatric airway

Snoring is common in children and is associated with many adverse consequences. One must study the relationships between pharyngeal morphology and snoring physics to understand snoring progression. Although some model studies have provided fluid-structure interaction dynamic descriptions for the correlation between airway size and snoring physics, the descriptions still need to be further investigated in patient-specific airway models. Fluid-structure interaction studies using patient-specific airway structures complement the above model studies. Based on reported cephalometric measurement methods, this study quantified and preset the size of the palatopharynx airway in a patient-specific airway and investigated how the palatopharynx size affects the pharyngeal airflow fluctuation, soft palate vibration, and glossopharynx vibration with the help of a verified FSI method. The results showed that the stenosis anterior airway of the soft palate increased airway resistance and airway resistance fluctuations, which can lead to increased sleep effort and frequent snoring. Widening of the anterior airway can reduce airflow resistance and avoid obstructing the anterior airway by the soft palate vibration. The pharyngeal airflow resistance, mouth inflow proportion, and soft palate apex displacement have components at the same frequencies in all airway models, and the glossopharynx vibration and instantaneous inflow rate have components at the same frequencies, too. The mechanism of this same frequency fluctuation phenomenon can be explained by the fluid-structure interaction dynamics of an ideal coupled model consisting of a flexible plate model and a collapsible tube model. The results of this study demonstrate the potential of FSI in studying snoring physics and clarify to some degree the mechanism of airway morphology affecting airway vibration physics.

Molecular Mechanisms and Physiological Changes behind Benign Tracheal and Subglottic Stenosis in Adults

Laryngotracheal stenosis (LTS) is a complex and heterogeneous disease whose pathogenesis remains unclear. LTS is considered to be the result of aberrant wound-healing process that leads to fibrotic scarring, originating from different aetiology. Although iatrogenic aetiology is the main cause of subglottic or tracheal stenosis, also autoimmune and infectious diseases may be involved in causing LTS. Furthermore, fibrotic obstruction in the anatomic region under the glottis can also be diagnosed without apparent aetiology after a comprehensive workup; in this case, the pathological process is called idiopathic subglottic stenosis (iSGS). So far, the laryngotracheal scar resulting from airway injury due to different diseases was considered as inert tissue requiring surgical removal to restore airway patency. However, this assumption has recently been revised by regarding the tracheal scarring process as a fibroinflammatory event due to immunological alteration, similar to other fibrotic diseases. Recent acquisitions suggest that different factors, such as growth factors, cytokines, altered fibroblast function and genetic susceptibility, can all interact in a complex way leading to aberrant and fibrotic wound healing after an insult that acts as a trigger. However, also physiological derangement due to LTS could play a role in promoting dysregulated response to laryngo-tracheal mucosal injury, through biomechanical stress and mechanotransduction activation. The aim of this narrative review is to present the state-of-the-art knowledge regarding molecular mechanisms, as well as mechanical and physio-pathological features behind LTS.

Morphometric characterisation of human tracheas: focus on cartilaginous ring variation

PURPOSE

Details regarding tracheal anatomy are currently lacking, with existing literature focussing mainly on the cricoid-tracheal region or the carina. External gross anatomy and internal morphology throughout the entire trachea is important for normal physiological functioning and various clinical applications such as designs for tracheal implants or endotracheal devices.

OBJECTIVE

To determine quantitative and qualitative characteristics of gross tracheal and individual tracheal ring anatomy.

METHOD

10 tracheas were harvested from formaldehyde-fixed cadavers. Tracheal length, height and inter-ring distance were measured from complete tracheas. Individual rings were excised and the following measurements were taken at three points on the ring: thickness, width, and antero-posterior (A-P) length.

RESULTS

The average tracheal length was 10.38 ± 0.85 cm with a mean of 19 ± 3 rings per trachea. The average width and A-P diameter of tracheal lumens were 17.31 ± 2.57 and 17.27 ± 2.56 mm, with a width-AP ratio of 1.00 ('C' shaped ring). The A-P diameter shows a trend of narrowing slightly from the upper 1/3 to the lower 1/3 of the trachea. While majority of tracheal rings consisted of the expected 'C' shape, more than 41% of the 147 counted rings consisted of abnormally shaped rings which were further analysed.

CONCLUSION

This study provides further details regarding tracheal anatomy which will be useful for implant design. Of interest for anatomists, is the marked variability in tracheal ring morphology which could be further characterised in larger studies.

Viscoelastic Properties of Human Tracheal Tissues

The physiological performance of trachea is highly dependent on its mechanical behavior, and therefore, the mechanical properties of its components. Mechanical characterization of trachea is key to succeed in new treatments such as tissue engineering, which requires the utilization of scaffolds which are mechanically compatible with the native human trachea. In this study, after isolating human trachea samples from brain-dead cases and proper storage, we assessed the viscoelastic properties of tracheal cartilage, smooth muscle, and connective tissue based on stress relaxation tests (at 5% and 10% strains for cartilage and 20%, 30%, and 40% for smooth muscle and connective tissue). After investigation of viscoelastic linearity, constitutive models including Prony series for linear viscoelasticity and quasi-linear viscoelastic, modified superposition, and Schapery models for nonlinear viscoelasticity were fitted to the experimental data to find the best model for each tissue. We also investigated the effect of age on the viscoelastic behavior of tracheal tissues. Based on the results, all three tissues exhibited a (nonsignificant) decrease in relaxation rate with increasing the strain, indicating viscoelastic nonlinearity which was most evident for cartilage and with the least effect for connective tissue. The three-term Prony model was selected for describing the linear viscoelasticity. Among different models, the modified superposition model was best able to capture the relaxation behavior of the three tracheal components. We observed a general (but not significant) stiffening of tracheal cartilage and connective tissue with aging. No change in the stress relaxation percentage with aging was observed. The results of this study may be useful in the design and fabrication of tracheal tissue engineering scaffolds.

Mechanical Characterization and Constitutive Modeling of Human Trachea: Age and Gender Dependency

Tracheal disorders can usually reduce the free lumen diameter or wall stiffness, and hence limit airflow. Trachea tissue engineering seems a promising treatment for such disorders. The required mechanical compatibility of the prepared scaffold with native trachea necessitates investigation of the mechanical behavior of the human trachea. This study aimed at mechanical characterization of human tracheas and comparing the results based on age and gender. After isolating 30 human tracheas, samples of tracheal cartilage, smooth muscle, and connective tissue were subjected to uniaxial tension to obtain force-displacement curves and calculate stress-stretch data. Among several models, the Yeoh and Mooney-Rivlin hyperelastic functions were best able to describe hyperelastic behavior of all three tracheal components. The mean value of the elastic modulus of human tracheal cartilage was calculated to be 16.92 ± 8.76 MPa. An overall tracheal stiffening with age was observed, with the most considerable difference in the case of cartilage. Consistently, we noticed some histological alterations in cartilage and connective tissue with aging, which may play a role in age-related tracheal stiffening. No considerable effect of gender on the mechanical behavior of tracheal components was observed. The results of this study can be applied in the design and fabrication of trachea tissue engineering scaffolds.

Upper Airway Elasticity Estimation in Pediatric Down Syndrome Sleep Apnea Patients Using Collapsible Tube Theory

Elasticity of the soft tissues surrounding the upper airway lumen is one of the important factors contributing to upper airway disorders such as snoring and obstructive sleep apnea. The objective of this study is to calculate patient specific elasticity of the pharynx from magnetic resonance (MR) images using a 'tube law', i.e., the relationship between airway cross-sectional area and transmural pressure difference. MR imaging was performed under anesthesia in children with Down syndrome (DS) and obstructive sleep apnea (OSA). An airway segmentation algorithm was employed to evaluate changes in airway cross-sectional area dilated by continuous positive airway pressure (CPAP). A pressure-area relation was used to make localized estimates of airway wall stiffness for each patient. Optimized values of patient specific Young's modulus for tissue in the velopharynx and oropharynx, were estimated from finite element simulations of airway collapse. Patient specific deformation of the airway wall under CPAP was found to exhibit either a non-linear 'hardening' or 'softening' behavior. The localized airway and tissue elasticity were found to increase with increasing severity of OSA. Elasticity based patient phenotyping can potentially assist clinicians in decision making on CPAP and airway or tissue elasticity can supplement well-known clinical measures of OSA severity.

Pilot study of a novel vacuum-assisted method for decellularization of tracheae for clinical tissue engineering applications

Tissue engineered tracheae have been successfully implanted to treat a small number of patients on compassionate grounds. The treatment has not become mainstream due to the time taken to produce the scaffold and the resultant financial costs. We have developed a method for decellularization (DC) based on vacuum technology, which when combined with an enzyme/detergent protocol significantly reduces the time required to create clinically suitable scaffolds. We have applied this technology to prepare porcine tracheal scaffolds and compared the results to scaffolds produced under normal atmospheric pressures. The principal outcome measures were the reduction in time (9 days to prepare the scaffold) followed by a reduction in residual DNA levels (DC no-vac: 137.8±48.82 ng/mg vs. DC vac 36.83±18.45 ng/mg, p<0.05.). Our approach did not impact on the collagen or glycosaminoglycan content or on the biomechanical properties of the scaffolds. We applied the vacuum technology to human tracheae, which, when implanted in vivo showed no significant adverse immunological response. The addition of a vacuum to a conventional decellularization protocol significantly reduces production time, whilst providing a suitable scaffold. This increases clinical utility and lowers production costs. To our knowledge this is the first time that vacuum assisted decellularization has been explored. Copyright © 2015 John Wiley & Sons, Ltd.

Creation of an in vitro biomechanical model of the trachea using rapid prototyping

Previous in vitro models of the airways are either rigid or, if flexible, have not matched in vivo compliance characteristics. Rapid prototyping provides a quickly evolving approach that can be used to directly produce in vitro airway models using either rigid or flexible polymers. The objective of this study was to use rapid prototyping to directly produce a flexible hollow model that matches the biomechanical compliance of the trachea. The airway model consisted of a previously developed characteristic mouth-throat region, the trachea, and a portion of the main bronchi. Compliance of the tracheal region was known from a previous in vivo imaging study that reported cross-sectional areas over a range of internal pressures. The compliance of the tracheal region was matched to the in vivo data for a specific flexible resin by iteratively selecting the thicknesses and other dimensions of tracheal wall components. Seven iterative models were produced and illustrated highly non-linear expansion consisting of initial rapid size increase, a transition region, and continued slower size increase as pressure was increased. Thickness of the esophageal interface membrane and initial trachea indention were identified as key parameters with the final model correctly predicting all phases of expansion within a value of 5% of the in vivo data. Applications of the current biomechanical model are related to endotracheal intubation and include determination of effective mucus suctioning and evaluation of cuff sealing with respect to gases and secretions.

Anisotropic material behaviours of soft tissues in human trachea: an experimental study

BACKGROUND

Human trachea is a multi-component structure composed of cartilage, trachealis muscle, mucosa and submucosa membrane and adventitial membrane. Its mechanical properties are essential for an accurate prediction of tracheal deformation, which has a significant clinic relevance. Efforts have been made in quantifying the material behaviour of tracheal cartilage and trachealis muscle. However, the material behaviours of other components have been least investigated.

METHODS

Three human cadaveric trachea specimens were used in this study. Trachealis muscle, mucosa and submucosa membrane and adventitia membrane were excised to perform the uniaxial test in axial and circumferential directions. In total, 72 tissue strips were prepared and tested. Tangent modulus was used to quantified the stiffness of each tissue strip at various stretch levels.

RESULTS

The obtained results indicated that all types of tracheal soft tissues were highly non-linear and anisotropic. Trachealis muscle in the circumferential direction had the most excellent extensibility; and the adventitial collagen membrane in the circumferential direction was the stiffest.

CONCLUSION

This study is helpful in understanding the material behaviour of trachea. Obtained results can be used for computational and analytic modelling to quantify the tracheal deformation.

Evaluation of the structural integrity and extracellular matrix components of tracheal allografts following cyclical decellularization techniques: comparison of three protocols

Tracheal reconstruction is indicated in cases of malignancy, traumatic injury, and subglottic or tracheal stenosis. Recent progress in airway transplantation has provided renewed optimism for potential solutions for defects involving more than half of the tracheal length in adults or one-third of the tracheal length in children. Biologic scaffolds derived from decellularized tissues and organs have shown great promise in tracheal allotransplantation, and cyclical decellularization techniques have been hypothesized as abrogating the need for immunosuppressive therapy. In this study, we performed a direct comparison of three decellularization protocols (Protocols A, B, and C) previously described in the literature, two of which were described in tracheal tissue (Protocols A and B). We concentrated on the immunogenicity within the epithelium and mucosa, quantified and qualified the extracellular matrix (ECM) components, and performed compliance measurements on large circumferential decellularized tracheal scaffolds following cyclical decellularization techniques using all three protocols. Quantitative measurements of glycosaminoglycans (GAGs) showed a significant decrease in the mucosal component following 17 cycles of all 3 protocols as well as a significant decrease of GAGs in the cartilaginous component following cycles 1, 9, and 17 of Protocol A and cycle 17 of Protocol C. Compliance measurements were also shown to be different between the protocols, with grafts becoming more compliant at physiologic pressures after cyclical decellularization with Protocols A and B and slightly less compliant but remaining similar to native trachea using Protocol C. Positive staining for anti-major histocompatibility complex Class I (anti-MHCI) and anti-MHCII remained within the submucosal glandular components despite multiple cycles of decellularization using all three protocols. This study illustrated that there are significant differences in ECM composition and resultant structural integrity of decellularized tracheal scaffolds depending on the decellularization protocol. Protocol B was shown to maintain the GAGs components despite an increase in tracheal compliance, while Protocol C decreases GAGs components following multiple cycles, despite showing a tracheal compliance resembling that of the native trachea at physiologic airway pressures.

Shape and material characteristics of the trachea in the leatherback sea turtle promote progressive collapse and reinflation during dives

The leatherback turtle regularly undertakes deep dives and has been recorded attaining depths in excess of 1,200 m. Its trachea is an almost solid, elliptical-section tube of uncalcified hyaline cartilage with minimal connective tissue between successive rings. The structure appears to be advantageous for diving and perfectly designed for withstanding repeated collapse and reinflation. This study applies Boyle's law to the respiratory system (lungs, trachea and larynx) and estimates the changes in tracheal volume during a dive. These changes are subsequently compared with the results predicted by a corresponding finite element (FE) structural model, itself based on laboratory studies of the trachea of an adult turtle. Boyle's law predicts that the trachea will collapse progressively with greater volume change occurring in the early stages. The FE model reproduces the changes extremely well (agreeing closely with Boyle's law estimations) and provides visual representation of the deformed tracheal luminal area. Initially, the trachea compresses both ventrally and dorsally before levelling ventrally. Bulges are subsequently formed laterally and become more pronounced at deeper depths. The geometric configuration of the tracheal structure confers both homogeneity and strength upon it, which makes it extremely suited for enduring repeated collapse and re-expansion. The structure actually promotes collapse and is an adaptation to the turtle's natural environment in which large numbers of deep dives are performed annually.