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Panpruang P, Eksombatchai D, Boonsarngsuk V. Tracheobronchomalacia following allogeneic haematopoietic stem cell transplantation. Respirol Case Rep 2024; 12:e01348. [PMID: 38690063 PMCID: PMC11059568 DOI: 10.1002/rcr2.1348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
Tracheobronchomalacia (TBM) occurs due to the weakening of cartilaginous part of the trachea, resulting in compromised airway function and leading to symptoms such as dyspnea, cough, and inability to clear secretions. Bronchiolitis obliterans syndrome (BOS) is the most prevalent late noninfectious pulmonary complication in patients who underwent allogeneic haematopoietic stem cell transplantation (HSCT). Therefore, patients experiencing progressive dyspnea and chronic cough after allogenic HSCT, with new obstructive pattern on pulmonary function test, are typically diagnosed with post-transplant BOS. However, it is important to note that TBM can also manifest as an obstructive defect pattern on pulmonary function test. Tracheomalacia has been reported as a rare complication of allogenic stem cell transplantation. We present two patients who developed TBM following allogeneic HSCT and were initially treated for post-transplant BOS but did not experience symptom improvement. However, after treatment with continuous positive airway pressure, their symptom subsided.
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Affiliation(s)
- Pitirat Panpruang
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi HospitalMahidol UniversityBangkokThailand
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of MedicineSrinakharinwirot UniversityOngkharakThailand
| | - Dararat Eksombatchai
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Viboon Boonsarngsuk
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi HospitalMahidol UniversityBangkokThailand
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2
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Kuo FH, Elliott RA, Watkins SC, Shieh HF, Smithers CJ, Jennings RW, Munoz-San Julian C. Negative pressure suction test: An intraoperative airway maneuver to assess effectiveness of surgical correction of tracheobronchomalacia. Paediatr Anaesth 2024; 34:289-292. [PMID: 38130114 DOI: 10.1111/pan.14822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/15/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Surgical correction of tracheobronchomalacia (TBM) has evolved greatly over the past decade, with select pediatric institutions establishing dedicated surgery and anesthesia teams to navigate the complexities and challenges of surgical airway repairs. Although anesthetic techniques have evolved internally over many years to improve patient safety and outcomes, many of these methods remain undescribed in literature. TECHNIQUE In this article, we describe the intraoperative negative pressure suction test. This simulates the negative pressure seen in awake and spontaneously breathing patients, including the higher pressures seen during coughing which induce airway collapse in patients with TBM. Also known as the Munoz maneuver in surgical literature, this test has been performed on over 300 patients since 2015. DISCUSSION The negative pressure suction test allows for controlled intraoperative assessment of surgical airway repairs, replaces the need for risky intraoperative wake-up tests, increases the chances of a successful surgical repair, and improves anesthetic management for emergence and extubation. We provide a guide on how to perform the test and videos demonstrating its efficacy in intraoperative airway evaluation. CONCLUSIONS As surgeries to repair TBM become more prevalent in other pediatric institutions, we believe that pediatric patients and anesthesia providers will benefit from the insights and methods described here.
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Affiliation(s)
- Frederick H Kuo
- Department of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Richard A Elliott
- Department of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Scott C Watkins
- Department of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Charles J Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Russell W Jennings
- Department of Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Carlos Munoz-San Julian
- Department of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
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3
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Yadav S, Rawal G. Unifying Endotracheal Intracuff-Pressure Monitoring in the Intensive Care Unit: Bridging the Gap Between Standardization and Neglect. Cureus 2024; 16:e56875. [PMID: 38659555 PMCID: PMC11041519 DOI: 10.7759/cureus.56875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Endotracheal cuff-pressure monitoring is a critical component of patient care in the intensive care unit, ensuring the safety and efficacy of mechanical ventilation. Despite its importance, there remains a lack of standardized protocols regarding optimal pressure targets and documentation practices. This editorial examines the significance of endotracheal intracuff-pressure monitoring in enhancing patient outcomes, highlighting the challenges and potential solutions in clinical practice.
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Affiliation(s)
- Sankalp Yadav
- Medicine, Shri Madan Lal Khurana Chest Clinic, New Delhi, IND
| | - Gautam Rawal
- Respiratory Medical Critical Care, Max Super Speciality Hospital, New Delhi, IND
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Ghezzi M, Garancini N, De Santis R, Gianolio L, Zirpoli S, Mandelli A, Farolfi A, D’Auria E, Zuccotti GV. Recurrent Respiratory Infections in Children with Down Syndrome: A Review. Children (Basel) 2024; 11:246. [PMID: 38397357 PMCID: PMC10888118 DOI: 10.3390/children11020246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024]
Abstract
Down Syndrome (DS) is the most common chromosomal abnormality compatible with life. The life of patients suffering from DS can be strongly impacted by Recurrent Respiratory tract Infections (RRIs), leading to an increased rate of hospitalisation, a higher need for intensive care and fatality. With a literature review, we summarise here the main etiological factors for RRI in this category of patients, particularly focusing on airway malformations such as tracheomalacia, tracheal bronchus and bronchomalacia, comorbidities associated with the syndrome, like congenital heart diseases, dysphagia, gastroesophageal reflux, musculoskeletal involvement and obesity, and immunologic impairments, involving both innate and adaptive immunity. For these patients, a multidisciplinary approach is imperative as well as some preventive strategies, in particular vaccinations in accordance with their national schedule for immunization.
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Affiliation(s)
- Michele Ghezzi
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (N.G.); (R.D.S.); (L.G.); (A.F.); (E.D.); (G.V.Z.)
| | - Nicolò Garancini
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (N.G.); (R.D.S.); (L.G.); (A.F.); (E.D.); (G.V.Z.)
| | - Raffaella De Santis
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (N.G.); (R.D.S.); (L.G.); (A.F.); (E.D.); (G.V.Z.)
| | - Laura Gianolio
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (N.G.); (R.D.S.); (L.G.); (A.F.); (E.D.); (G.V.Z.)
| | - Salvatore Zirpoli
- Pediatric Radiology Unit, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy;
| | - Anna Mandelli
- Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy;
| | - Andrea Farolfi
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (N.G.); (R.D.S.); (L.G.); (A.F.); (E.D.); (G.V.Z.)
| | - Enza D’Auria
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (N.G.); (R.D.S.); (L.G.); (A.F.); (E.D.); (G.V.Z.)
| | - Gian Vincenzo Zuccotti
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (N.G.); (R.D.S.); (L.G.); (A.F.); (E.D.); (G.V.Z.)
- Department of Biomedical and Clinical Science, Università Degli Studi di Milano, 20157 Milan, Italy
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Gunatilaka CC, McKenzie C, Hysinger EB, Xiao Q, Higano NS, Woods JC, Bates AJ. Tracheomalacia Reduces Aerosolized Drug Delivery to the Lung. J Aerosol Med Pulm Drug Deliv 2024; 37:19-29. [PMID: 38064481 PMCID: PMC10877398 DOI: 10.1089/jamp.2023.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/23/2023] [Indexed: 02/12/2024] Open
Abstract
Rationale: Neonates with respiratory issues are frequently treated with aerosolized medications to manage lung disease or facilitate airway clearance. Dynamic tracheal collapse (tracheomalacia [TM]) is a common comorbidity in these patients, but it is unknown whether the presence of TM alters the delivery of aerosolized drugs. Objectives: To quantify the effect of neonatal TM on the delivery of aerosolized drugs. Methods: Fourteen infant subjects with respiratory abnormalities were recruited; seven with TM and seven without TM. Respiratory-gated 3D ultrashort echo time magnetic resonance imaging (MRI) was acquired covering the central airway and lungs. For each subject, a computational fluid dynamics simulation modeled the airflow and particle transport in the central airway based on patient-specific airway anatomy, motion, and airflow rates derived from MRI. Results: Less aerosolized drug reached the distal airways in subjects with TM than in subjects without TM: of the total drug delivered, less particle mass passed through the main bronchi in subjects with TM compared with subjects without TM (33% vs. 47%, p = 0.013). In subjects with TM, more inhaled particles were deposited on the surface of the airway (48% vs. 25%, p = 0.003). This effect becomes greater with larger particle sizes and is significant for particles with a diameter >2 μm (2-5 μm, p ≤ 0.025 and 5-15 μm, p = 0.004). Conclusions: Neonatal patients with TM receive less aerosolized drug delivered to the lungs than subjects without TM. Currently, infants with lung disease and TM may not be receiving adequate and/or expected medication. Particles >2 μm in diameter are likely to deposit on the surface of the airway due to anatomical constrictions such as reduced tracheal and glottal cross-sectional area in neonates with TM. This problem could be alleviated by delivering smaller aerosolized particles.
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Affiliation(s)
- Chamindu C. Gunatilaka
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Erik B. Hysinger
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Qiwei Xiao
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nara S. Higano
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jason C. Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alister J. Bates
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio, USA
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Dress C, Silva CT, von Allmen DC, Zak S. Airway findings in trisomy 13 and trisomy 18: A 10-year retrospective review. Pediatr Pulmonol 2024; 59:342-347. [PMID: 37937891 DOI: 10.1002/ppul.26750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/12/2023] [Accepted: 10/28/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Trisomy 18 and trisomy 13 are the most common autosomal trisomies following trisomy 21, with overall incidence rising. Both diagnoses are characterized by multisystem involvement and were previously thought to be incompatible with life. New data suggest that prolonged survival is possible, and thus many families are opting for more aggressive medical interventions. This study aims to describe airway findings in trisomy 18 and trisomy 13, as these have not been comprehensively studied and can impact medical decision-making. We hypothesize that most children with trisomy 18 and trisomy 13 will have abnormal findings on airway endoscopy. METHODS This a 10-year retrospective analysis of children with trisomy 13 or trisomy 18 who underwent endoscopic airway evaluation at a single center between 2011 and 2021. A total of 31 patients were evaluated. RESULTS Thirty-one patients were included and underwent flexible bronchoscopy by a pediatric pulmonologist, often in conjunction with rigid bronchoscopy performed by pediatric otolaryngology. Findings were typically complimentary. All patients had at least one clinically significant finding on evaluation, and most patients had both upper and lower airway, as well as static and dynamic airway findings. The most common airway findings in children with trisomy 13 and 18 include tracheomalacia, bronchomalacia, laryngomalacia, hypopharyngeal collapse, glossoptosis, and bronchial compression. CONCLUSION These findings can have significant implications for clinical care, and thus knowledge of trends has the potential to improve counseling on expected clinical course, presurgical planning, and informed consent before interventions.
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Affiliation(s)
- Carolyn Dress
- Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cherie T Silva
- Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Douglas C von Allmen
- Department of Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sara Zak
- Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Corcoran A, Foran A, Phinizy P, Biko DM, Piccione JC, Rapp JB. Dynamic airway computed tomography and flexible bronchoscopy for diagnosis of tracheomalacia in children: A comparison study. Pediatr Pulmonol 2024. [PMID: 38197524 DOI: 10.1002/ppul.26844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/28/2023] [Accepted: 12/19/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Tracheomalacia (TM) is an important cause of respiratory morbidity. Dynamic flexible bronchoscopy is considered the gold standard for diagnosis. Dynamic airway computed tomography (DACT) is a low radiation, noninvasive diagnostic tool utilizing images obtained continuously over several respiratory cycles. We aimed to assess the accuracy of DACT in TM diagnosis. METHODS Retrospective analysis of all patients who underwent both DACT and flexible bronchoscopy within 6 months. Airway anterior-posterior (AP) diameter was measured on multiplanar reconstructions CT in both the inspiratory and expiratory phases. Using still images from the bronchoscopy videos, the AP diameter of the trachea was measured at points of maximal and minimal diameter during tidal breathing. Degree of TM on both DACT and flexible bronchoscopy were graded using a scaling system of 50%-74%, 75%-89%, and 90%-100% as described by the European Respiratory Society. RESULTS Twenty-four patients met inclusion criteria with an average time of 19.5 days between CT and bronchoscopy. The specificity and sensitivity of DACT for the overall diagnosis of TM was 100% and 68%, respectively, with a positive predictive value of 100% and a negative predictive value of 62%. There was a strong positive correlation between DACT and flexible bronchoscopy in the measurement of tracheal AP diameter changes (ρ = 0.773, R2 0.597, p = 0.00001). Mean effective radiation dose for DACT was 0.1 mSv. CONCLUSION Ultralow dose DACT has excellent specificity and positive predictive value for both detection of TM and categorizing severity of tracheal collapse but is not sufficiently sensitive to rule it out.
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Affiliation(s)
- Aoife Corcoran
- Department of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ann Foran
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pelton Phinizy
- Department of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph C Piccione
- Department of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Hirotani T, Tamura R, Ando M, Okajima H. External Esophageal Stenting Technique in Palliation for Tracheal Agenesis in a Case of Esophageal Lung: A Lesson Learned from the Experience for Tracheomalacia. Children (Basel) 2023; 10:1907. [PMID: 38136109 PMCID: PMC10741666 DOI: 10.3390/children10121907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023]
Abstract
Tracheal agenesis (TA) is a rare congenital anomaly with an incidence of 1 per 50,000 newborns. It appears at birth with severe respiratory distress, cyanosis, and inaudible crying. Prompt esophageal intubation and long-term management of the esophageal airway are essential to overcome this catastrophic condition. In the long-term management, external stenting of the esophageal airway has been reported as promising to support the fragile esophageal wall; this technique was taken from the surgery for tracheomalacia. We experienced a case of an infant with tracheal agenesis whose respiratory status was stabilized after external esophageal stenting. The stenting was performed based on a lesson learned in the extensive experience in the surgical treatment for tracheomalacia, and the surgical techniques for successful stenting are herein described.
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Affiliation(s)
- Taichi Hirotani
- Department of Pediatric Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku 920-0293, Ishikawa, Japan
- Advanced Pediatric Surgical Center, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku 920-0293, Ishikawa, Japan;
| | - Ryo Tamura
- Department of Pediatric Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku 920-0293, Ishikawa, Japan
- Advanced Pediatric Surgical Center, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku 920-0293, Ishikawa, Japan;
| | - Makoto Ando
- Advanced Pediatric Surgical Center, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku 920-0293, Ishikawa, Japan;
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku 920-0293, Ishikawa, Japan
- Advanced Pediatric Surgical Center, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku 920-0293, Ishikawa, Japan;
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Alsalihi Y, Yousef NM, Grewal S, Teitelbaum B. Tracheomalacia in Adults: An Uncommon Cause of Dyspnea. Cureus 2023; 15:e49190. [PMID: 38130571 PMCID: PMC10735051 DOI: 10.7759/cureus.49190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Tracheomalacia (TM), the most common congenital tracheal defect, is due to compromised cartilage integrity, manifesting in the narrowing of expiratory airways and various respiratory symptoms. While TM is common in infants and toddlers, it is rarely found in adults, often due to acquired injuries or chronic lung diseases. We present a unique case of a 67-year-old man with persistent dyspnea and hoarseness for two years. Despite a history of smoking, he had no signs of pulmonary disease and had a consistently high oxygen saturation during episodes of dyspnea. His dyspnea was of unknown etiology until a diagnostic bronchoscopy revealed tracheal stenosis and flaccidity of cartilaginous structures, with pronounced collapse during expiration. This atypical presentation highlights the complexity of TM in adults. It underscores the importance of considering it as a differential diagnosis, particularly in male smokers with gradual, persistent dyspnea and a minimal history of pulmonary disease.
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Affiliation(s)
- Yusur Alsalihi
- Clinical Education Department, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Natalie M Yousef
- Clinical Education Department, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Sundeep Grewal
- Clinical Education Department, Internal Medicine, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
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10
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Pugh CP, Ali S, Agarwal A, Matlock DN, Sharma M. Dynamic computed tomography for evaluation of tracheobronchomalacia in premature infants with bronchopulmonary dysplasia. Pediatr Pulmonol 2023; 58:3255-3263. [PMID: 37646125 PMCID: PMC10993911 DOI: 10.1002/ppul.26652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/26/2023] [Accepted: 08/19/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Dynamic computed tomography (dCT) gives real-time physiological information and objective descriptions of airway narrowing in tracheobronchomalacia (TBM). There is a paucity of literature in the evaluation of TBM by dCT in premature infants with bronchopulmonary dysplasia (BPD). The aim of this study is to describe the findings of dCT and resultant changes in management in premature infants with TBM. METHODS A retrospective study of 70 infants was performed. Infants included were <32 weeks gestation without major anomalies. TBM was defined as ≥50% expiratory reduction in cross-sectional area with severity defined as mild (50%-75%), moderate (≥75%-90%), or severe (≥90%). RESULTS Dynamic CT diagnosed malacia in 53% of infants. Tracheomalacia was identified in 49% of infants with severity as 76% mild, 18% moderate, and 6% severe. Bronchomalacia was identified in 43% of infants with varying severity (53% mild, 40% moderate, 7% severe). Resultant management changes included PEEP titration (44%), initiation of bethanechol (23%), planned tracheostomy (20%), extubation trial (13%), and inhaled ipratropium bromide (7%). CONCLUSION Dynamic CT is a useful noninvasive diagnostic tool for airway evaluation of premature infants. Presence and severity of TBM can provide actionable information to guide more precise clinical decision making.
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Affiliation(s)
- C. Preston Pugh
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Sumera Ali
- Department of Radiology, Emory University, Children’s Hospital of Atlanta, GA
| | - Amit Agarwal
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - David N. Matlock
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Megha Sharma
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
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Andrew O, Folorunsho O, Faustina B, Alufohai EJ, Andrew D. A case report of tracheal tenting to the skin: An option to tracheostomy for post-thyroidectomy tracheomalacia. Niger J Clin Pract 2023; 26:1579-1583. [PMID: 37929539 DOI: 10.4103/njcp.njcp_472_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Operating on a huge and long-standing goiter is challenging to the surgeon and anesthetist because of the possibility of tracheomalacia and collapse of the tracheal rings after extubation. We report our innovation of tenting the trachea to the skin using sutures (passed through the strap and sternocleidomastoid muscles) to prevent post-thyroidectomy tracheomalacia.
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Affiliation(s)
- O Andrew
- Department of Surgery, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - O Folorunsho
- Department of Anaesthesia, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - B Faustina
- Department of ENT, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - E J Alufohai
- Joe Alufohai Medical Centre, Sabongida-Ora, Edo State, Nigeria
| | - D Andrew
- Department of Surgery, Ambrose Alli University, Ekpoma, Edo State, Nigeria
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12
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Mondal A, Visner GA, Kaza AK, Dupont PE. A novel ex vivo tracheobronchomalacia model for airway stent testing and in vivo model refinement. J Thorac Cardiovasc Surg 2023; 166:679-687.e1. [PMID: 37156367 PMCID: PMC10524727 DOI: 10.1016/j.jtcvs.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/14/2023] [Accepted: 04/10/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We sought to develop an ex vivo trachea model capable of producing mild, moderate, and severe tracheobronchomalacia for optimizing airway stent design. We also aimed to determine the amount of cartilage resection required for achieving different tracheobronchomalacia grades that can be used in animal models. METHODS We developed an ex vivo trachea test system that enabled video-based measurement of internal cross-sectional area as intratracheal pressure was cyclically varied for peak negative pressures of 20 to 80 cm H2O. Fresh ovine tracheas were induced with tracheobronchomalacia by single mid-anterior incision (n = 4), mid-anterior circumferential cartilage resection of 25% (n = 4), and 50% per cartilage ring (n = 4) along an approximately 3-cm length. Intact tracheas (n = 4) were used as control. All experimental tracheas were mounted and experimentally evaluated. In addition, helical stents of 2 different pitches (6 mm and 12 mm) and wire diameters (0.52 mm and 0.6 mm) were tested in tracheas with 25% (n = 3) and 50% (n = 3) circumferentially resected cartilage rings. The percentage collapse in tracheal cross-sectional area was calculated from the recorded video contours for each experiment. RESULTS Ex vivo tracheas compromised by single incision and 25% and 50% circumferential cartilage resection produce tracheal collapse corresponding to clinical grades of mild, moderate, and severe tracheobronchomalacia, respectively. A single anterior cartilage incision produces saber-sheath type tracheobronchomalacia, whereas 25% and 50% circumferential cartilage resection produce circumferential tracheobronchomalacia. Stent testing enabled the selection of stent design parameters such that airway collapse associated with moderate and severe tracheobronchomalacia could be reduced to conform to, but not exceed, that of intact tracheas (12-mm pitch, 0.6-mm wire diameter). CONCLUSIONS The ex vivo trachea model is a robust platform that enables systematic study and treatment of different grades and morphologies of airway collapse and tracheobronchomalacia. It is a novel tool for optimization of stent design before advancing to in vivo animal models.
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Affiliation(s)
- Abhijit Mondal
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
| | - Gary A Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pierre E Dupont
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
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13
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Cao A, Swami P, Kaye R, Goldstein T, Grande DA, Smith LP. An Ex Vivo Model of Posterior Tracheomalacia With Evaluation of Potential Treatment Modalities. Laryngoscope 2023; 133:2000-2006. [PMID: 36073673 DOI: 10.1002/lary.30383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/27/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Posterior tracheomalacia (TM) is characterized by excessive intraluminal displacement of the tracheal membranous wall. Recently, novel surgical strategies for repair of posterior TM have been introduced. To our knowledge, these strategies have not been evaluated in a model of posterior TM. Thus, we sought to design an ex vivo mechanical model of posterior TM to evaluate potential repair interventions. METHODS A model for posterior TM was created with partial thickness longitudinal incisions to the posterior aspect of ex vivo porcine trachea. Three groups of tracheas were tested: (1) control (unmanipulated), (2) posterior TM (injury), and (3) intervention (repair). Interventions included external splinting with 0.3 and 0.5 mm bioresorbable plates, posterior tracheopexy, and injection tracheoplasty with calcium hydroxylapatite. An airtight tracheal system was created to measure tracheal wall collapse with changes in negative pressure. A bronchoscope and pressure transducer were connected to either end. Cross-sectional area of the tracheal lumen was analyzed using ImageJ software (National Institutes of Health, Bethesda, MD). RESULTS Average percent reduction in cross-sectional area of the tracheal lumen was compared using a two-tailed paired t-test. Significant differences were found between control and TM groups (p < 0.019). There was no significant difference between control and external splinting and posterior tracheopexy groups (p > 0.14). CONCLUSION We describe an ex vivo model for posterior TM that replicates airway collapse. External splinting and tracheopexy interventions showed recovery of the injured tracheal segment. Injection tracheoplasty did not improve the TM. LEVEL OF EVIDENCE N/A Laryngoscope, 133:2000-2006, 2023.
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Affiliation(s)
- Angela Cao
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein School of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Pooja Swami
- Department of Otolaryngology, The Feinstein Institute for Medical Research, Manhasset, New York, U.S.A
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
| | - Rachel Kaye
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Todd Goldstein
- Department of Otolaryngology, The Feinstein Institute for Medical Research, Manhasset, New York, U.S.A
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
| | - Daniel A Grande
- Department of Otolaryngology, The Feinstein Institute for Medical Research, Manhasset, New York, U.S.A
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
| | - Lee P Smith
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Long Island Jewish Medical Center, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York, U.S.A
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14
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Petreschi F, Coretti A, Porcaro F, Toscano A, Campanale CM, Trozzi M, Secinaro A, Allegorico A, Cutrera R, Carotti A. Pediatric airway compression in aortic arch malformations: a multidisciplinary approach. Front Pediatr 2023; 11:1227819. [PMID: 37547103 PMCID: PMC10401269 DOI: 10.3389/fped.2023.1227819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Background Aortic arch malformations (AAMs) should be suspected in the presence of persistent respiratory symptoms despite medical treatment or feeding problems at the pediatric age. Aim We report a descriptive cohort of patients with AAMs and the local management protocol applied. Methods A total of 59 patients with AAM were retrospectively reviewed. Three groups were identified: double aortic arch (DAA), group 1; complete vascular ring (non-DAA), group 2; and anomalous origin of the innominate artery (IA), group 3. Results Prenatal diagnosis was available for 62.7% of the patients. In all, 49.2% of children were symptomatic. There was a significantly different prevalence of respiratory symptoms within the three groups: 73.7% in group 1, 24.2% in group 2, and 100% in group 3 (p-value: <0.001). Surgery was considered in the presence of symptoms in patients with DAA and in those with reduction of the tracheal section area greater than 50%. A total of 52.5% of the patients underwent surgical repair (median age 6 months). The median follow-up interval was 21.9 months. Respiratory symptoms improved in most symptomatic patients. Conclusions No specific protocols are available for the management of patients with AAMs. Conservative treatment seems to be reasonable for asymptomatic patients or those with airway stenosis less than 50%. A close follow-up is necessary to identify early patients who become symptomatic.
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Affiliation(s)
- Francesca Petreschi
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Coretti
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Federica Porcaro
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Alessandra Toscano
- Perinatal Cardiology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Marilena Trozzi
- Airway Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Annalisa Allegorico
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Adriano Carotti
- Unit of Complex Cardiac Surgery with Innovative Techniques, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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15
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Martín‐Serrano P, Sarrió‐Badenes E, Durá‐Aranda M, Molero‐Sala L. Management of preeclampsia with severe features in a patient with relapsing polychondritis affecting the tracheobronchial tree. Anaesth Rep 2023; 11:e12249. [PMID: 37736065 PMCID: PMC10511154 DOI: 10.1002/anr3.12249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 09/23/2023] Open
Abstract
Relapsing polychondritis is a rare disease that affects cartilaginous structures throughout the body. Progressive destruction of the laryngeal structures and the tracheobronchial tree occurs in 50% of patients, potentially leading to loss of patency and collapse of the airway. Respiratory involvement in relapsing polychondritis includes airway stenosis, tracheomalacia and recurrent lung infections due to chronic inflammation caused by the destruction of upper and lower airway cartilage. Pregnancy and preeclampsia can worsen pharyngolaryngeal oedema, while treatment with magnesium sulphate can affect neuromuscular function, exacerbating the degree of airway collapse in the most serious cases of relapsing polychondritis, possibly altering obstetric outcomes. Here, we present the management of a pregnant woman with relapsing polychondritis who presented with features of severe preeclampsia at 29 weeks and 6 days gestation. We believe that this is the first published case of the combination of the two disorders, complicated by acute respiratory failure after treatment with magnesium sulphate.
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Affiliation(s)
- P. Martín‐Serrano
- Department of Anaesthesiology and ResuscitationComplejo Hospitalario Universitario Insular Materno InfantilLas PalmasSpain
| | - E. Sarrió‐Badenes
- Department of Anaesthesiology and ResuscitationComplejo Hospitalario Universitario Insular Materno InfantilLas PalmasSpain
| | - M. Durá‐Aranda
- Department of Anaesthesiology and ResuscitationComplejo Hospitalario Universitario Insular Materno InfantilLas PalmasSpain
| | - L. Molero‐Sala
- Department of Obstetrics and Gynaecology, Complejo Hospitalario Universitario Insular Materno InfantilLas PalmasSpain
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16
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Afzal M, Mohamed A, Volkin Y. It's a Bird, It's a Plane, It's a Vein: Jugular Vein Phlebectasia in a Pediatric Patient With Tracheomalacia. Cureus 2023; 15:e42746. [PMID: 37654952 PMCID: PMC10467607 DOI: 10.7759/cureus.42746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/02/2023] Open
Abstract
Jugular vein phlebectasia is seen in the first decade of life and carries a high chance of misdiagnosis as it can often be mistaken for other conditions observed in pediatric populations. High clinical suspicion along with radiological studies can help to confirm the diagnosis. Treatment is usually conservative, with surgery reserved for unique circumstances. This is the first case to be reported with concomitant tracheomalacia and a history of tracheoesophageal fistula repair in a pediatric patient with external jugular vein phlebectasia.
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Affiliation(s)
- Muhammad Afzal
- Medical School, St. George's University School of Medicine, St. George's, GRD
| | - Alaa Mohamed
- Pediatrics, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, Elmhurst, USA
| | - Yakov Volkin
- Pediatrics, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, Elmhurst, USA
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17
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Yavuz S, Sherif A, Saif S, Alzamar A, Alawad D, Abdelwahab A, Nabawi MN, Amirrad M, Francis N. Indications, Efficacy, and Complications of Pediatric Bronchoscopy: A Retrospective Study at a Tertiary Center. Cureus 2023; 15:e40888. [PMID: 37492847 PMCID: PMC10364458 DOI: 10.7759/cureus.40888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2023] [Indexed: 07/27/2023] Open
Abstract
Background Bronchoscopy is an essential procedure for evaluating, diagnosing, and treating pediatric respiratory diseases. In this study, we demonstrate the indications and contraindications of bronchoscopy done in a tertiary referral hospital, Al Qassimi Woman's and Children's Hospital (AQWCH) in Sharjah, United Arab Emirates (UAE), in order to achieve better service. This study aims to evaluate patients' characteristics, diagnostic and therapeutic indications, and complications of bronchoscopy. Material and method This retrospective chart review included children aged between one day and 13 years, admitted to AQWCH, who underwent bronchoscopy (rigid or flexible) procedures between January 2018 and December 2019. All patients were identified by using a computerized search of hospital discharge diagnosis, which was codified as "pediatric bronchoscopy, flexible, rigid, bronchoalveolar lavage". The main study outcome measure was to evaluate patients' characteristics, diagnostic or therapeutic indications, bronchoalveolar lavage (BAL) analysis, as well as complications of bronchoscopy at AQWCH. Results There were 72 pediatric bronchoscopies (rigid and flexible) performed in patients aged less than 13 years old; the reason for bronchoscopy procedure was diagnostic in 51% and both diagnostic and therapeutic in 49%. Cough was the most common symptom (n=53; 74%), and chest recession was the most common clinical finding (n=46; 64%). Foreign body aspiration was the main indication (n=23; 32%), followed by stridor (26%). Consolidation was the most common radiological finding. Foreign body was the common finding, seen in 25% of bronchoscopies, followed by tracheomalacia in 17%. The suspected diagnosis was confirmed in 89%, and management change was needed in 54% of patients. The main complication during the procedure was desaturation (26%), and cough was the main post-bronchoscopy complication (14%). BAL was done for 28 (39%) patients, in which BAL culture was positive in 75%. Rigid bronchoscopy was done when foreign body aspiration was suspected based on positive history in 70%, abnormal physical examination in 60%, and chest X-ray abnormalities in 39% of patients. Sensitivity and specificity for patient history, physical examination, and chest X-ray were 80% and 83%, 66% and 60%, and 40% and 66 %, respectively. Conclusion Bronchoscopy is an important tool for evaluating, diagnosing, and treating pediatric respiratory diseases. While it is a safe procedure, it still needs a careful selection of patients as it is invasive.
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Affiliation(s)
- Sinan Yavuz
- Pediatrics/Pediatric Pulmonology, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Amal Sherif
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Safiya Saif
- Pediatrics/Pediatric Pulmonology, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Asma Alzamar
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Doaa Alawad
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Ahmed Abdelwahab
- Pediatrics, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Maged N Nabawi
- Pediatrics/Pediatric Intensive Care, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
| | - Maryam Amirrad
- Education, Uinversity of Ottawa, Ottawa, CAN
- Pediatrics, Royal College of Pediatrics & Child Health, London, GBR
- Pediatrics, Ajman University, Ajman, ARE
| | - Nader Francis
- Pediatrics/Pediatric Pulmonology, Al Qassimi Woman's and Children's Hospital, Sharjah, ARE
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18
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Sriboonyong T, Preutthipan A, Nugboon M. Long-term sleep apnea CPAP via tracheostomy in children with tracheomalacia: 20-year experience. Front Pediatr 2023; 11:1169613. [PMID: 37325360 PMCID: PMC10266409 DOI: 10.3389/fped.2023.1169613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Children with severe tracheobronchomalacia may need placements of tracheostomies and long-term mechanical ventilation. Due to financial constraints, continuous positive airway pressure (CPAP) machines commonly used to treat obstructive sleep apnea in adults have been utilized to deliver positive distending pressure to such children at our institution for more than 20 years with favorable outcomes. We, therefore, reported our experience with 15 children using this machine. Methods This is a retrospective study during 2001-2021. Results Fifteen children, 9 boys, aged ranged 3 months-5.6 years, were discharged home with CPAP via tracheostomies. All had co-morbidities including gastroesophageal reflux (n = 9, 60%), neuromuscular disorders (n = 6, 40%), genetic abnormalities (n = 6, 40%), cardiac diseases (n = 4, 27%) and chronic lungs (n = 3, 20%). Eight (53%) children were aged less than 1 year old. The smallest child was aged 3 months old, weighing 4.9 kg. All caregivers were relatives and non-medical health professionals. The 1-month and 1-year readmission rates were 13% and 66% respectively. No factor-associated unfavorable outcomes were statistically identified. No complications related to CPAP malfunction were found. Five (33%) were weaned off CPAP, and 3 died (2 from sepsis and 1 from a sudden unknown cause). Conclusion We first reported the use of sleep apnea CPAP via tracheostomy in children with severe tracheomalacia. In limited-resource countries, this simple device may be another option for long-term invasive ventilatory support. The CPAP use in children with tracheobronchomalacia requires adequately trained caregivers.
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Affiliation(s)
- Tidarat Sriboonyong
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Aroonwan Preutthipan
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Malinee Nugboon
- Nursing Affairs, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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19
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Serpen JY, Presley W, Beil A, Armenti ST, Johnson K, Mian SI, Innis JW, Prasov L. A Novel 13q12 Microdeletion Associated with Familial Syndromic Corneal Opacification. Genes (Basel) 2023; 14:1034. [PMID: 37239394 PMCID: PMC10218699 DOI: 10.3390/genes14051034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Progressive corneal opacification can result from multiple etiologies, including corneal dystrophies or systemic and genetic diseases. We describe a novel syndrome featuring progressive epithelial and anterior stromal opacification in a brother and sister and their mildly affected father, with all three family members having sensorineural hearing loss and two also with tracheomalacia/laryngomalacia. All carried a 1.2 Mb deletion at chromosome 13q12.11, with no other noteworthy co-segregating variants identified on clinical exome or chromosomal microarray. RNAseq analysis from an affected corneal epithelial sample from the proband's brother revealed downregulation of XPO4, IFT88, ZDHHC20, LATS2, SAP18, and EEF1AKMT1 within the microdeletion interval, with no notable effect on the expression of nearby genes. Pathway analysis showed upregulation of collagen metabolism and extracellular matrix (ECM) formation/maintenance, with no significantly down-regulated pathways. Analysis of overlapping deletions/variants demonstrated that deleterious variants in XPO4 were found in patients with laryngomalacia and sensorineural hearing loss, with the latter phenotype also being a feature of variants in the partially overlapping DFNB1 locus, yet none of these had reported corneal phenotypes. Together, these data define a novel microdeletion-associated syndromic progressive corneal opacification and suggest that a combination of genes within the microdeletion may contribute to ECM dysregulation leading to pathogenesis.
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Affiliation(s)
- Jasmine Y. Serpen
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - William Presley
- Department of Human Genetics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Adelyn Beil
- Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephen T. Armenti
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kayla Johnson
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Shahzad I. Mian
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
| | - Jeffrey W. Innis
- Department of Human Genetics, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lev Prasov
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105, USA
- Department of Human Genetics, University of Michigan, Ann Arbor, MI 48109, USA
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20
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Stafler P, Landau E, Blau H. Of catarrh and catharsis. Pediatr Pulmonol 2023; 58:1812-1814. [PMID: 37042575 DOI: 10.1002/ppul.26390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Patrick Stafler
- Kathy and Lee Graub Cystic Fibrosis Center and Pulmonary Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edwina Landau
- Kathy and Lee Graub Cystic Fibrosis Center and Pulmonary Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Hannah Blau
- Kathy and Lee Graub Cystic Fibrosis Center and Pulmonary Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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Almogarry L, Alradhi A, Alshamrani AS. Isolated Tracheabronchomalacia Misdiagnosed for Years as Bronchial Asthma. Cureus 2023; 15:e35641. [PMID: 36875250 PMCID: PMC9976646 DOI: 10.7759/cureus.35641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
Tracheomalacia (TM) is an abnormal collapse of the tracheal lumen, which often occurs when the cartilaginous part of the trachea has not developed. It is a rare condition but is seen often in infancy and childhood period. The incidence of primary airway malacia in children was estimated to be at least one in 2,100. It has a wide range of etiologies, and it is often localized but rarely generalized as in our case. It could be severe enough to indicate frequent admission and might expose the patient to multiple unnecessary medications. We are reporting a case with unusual primary tracheobronchomalacia (TBM) that was missed for several years with a huge burden on both families and healthcare providers. A five-year-old Saudi girl had multiple admissions to the intensive care unit with similar presentation each time, and she was misdiagnosed as having asthma exacerbation with an occasional chest infection. Bronchoscopy revealed the underlying condition, and the patient was kept on the minimal intervention of nasal continuous positive airway pressure (CPAP) and aggressive airway hydration therapy, all with the goal of improving the patient's outcome and reducing hospital admissions. We emphasize the importance of alerting physicians about malacia as an important cause of recurrent wheezy chest, which is one of the common asthma mimickers; in such cases, flexible bronchoscopy remains the gold standard diagnostic test, while the treatment remained supportive.
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Affiliation(s)
- Lubna Almogarry
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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22
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Koenigs M, Young C, Lillis A, Morrison J, Kelly N, Elmaraghy C, Krishnamurthy R, Chiang T. Dynamic Volumetric Computed Tomography Angiography is an Effective Method to Evaluate Tracheomalacia in Children. Laryngoscope 2023; 133:410-416. [PMID: 35411953 PMCID: PMC10792495 DOI: 10.1002/lary.30125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV-CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference-standard of rigid bronchoscopy. METHODS Children who had undergone DV-CTA and bronchoscopy in one-year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as >50% collapse of the tracheal cross-sectional area in exhalation. Pearson correlation was used for comparison. RESULTS Over a 19-month period, we identified 32 children (median age 8 months, range 3-14 months) who had undergone DV-CTA and bronchoscopy within a 90-day period of each other. All studies were unsedated and free-breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV-CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p < 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p < 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia. CONCLUSION For most children, DV-CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia. LEVEL OF EVIDENCE 3 Laryngoscope, 133:410-416, 2023.
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Affiliation(s)
- Maria Koenigs
- The Warren Alpert Medical School of Brown University, Providence, U.S.A
- Department of Otolaryngology - Head and Neck Surgery, Hasbro Children's Hospital, Providence, U.S.A
| | - Cody Young
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Anna Lillis
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Jessica Morrison
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Natalie Kelly
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Charles Elmaraghy
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Rajesh Krishnamurthy
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Tendy Chiang
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
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23
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Wang S, Li Z, Guan W, Zhang J. Unsuspected severe tracheal stenosis and tracheomalacia after correction surgery for congenital scoliosis: A case report. Paediatr Anaesth 2023; 33:167-169. [PMID: 36217730 DOI: 10.1111/pan.14573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 08/19/2022] [Accepted: 09/24/2022] [Indexed: 01/21/2023]
Abstract
Tracheal stenosis and tracheomalacia in patients with congenital scoliosis are serious and rare conditions caused by congenital dysplasia, postintubation injury, trauma, and tracheal tumor. Anesthesia of a child with tracheal stenosis is challenging for anesthesiologists. We describe an 8-year-old female patient developed severe tracheal stenosis and tracheomalacia after growing rod implantation for congenital scoliosis. Comprehensive assessment of preoperative pulmonary function and airway morphology, which can be neglected clinically, should be performed in congenital scoliosis patients.
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Affiliation(s)
- Shengru Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Ziquan Li
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Wenmin Guan
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
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24
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Aljawad M, Albaqshi A, Qazi S, Madkhali R. Tracheal Stent Migration in a Patient With Tracheomalacia and Tracheoesophageal Fistula: A Rare Case. Cureus 2023; 15:e34560. [PMID: 36879694 PMCID: PMC9985470 DOI: 10.7759/cureus.34560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
Tracheomalacia refers to diffuse or segmental tracheal weakness. Most commonly, tracheomalacia develops after prolonged endotracheal intubation or tracheostomy. Surgical management is warranted in symptomatic patients with severe tracheomalacia. Relief of airway obstruction via stenting often provides immediate improvement in both airflow and symptoms. However, stent placement is associated with significant complications. Here, we present the case of a 71-year-old man who was brought to the emergency department with acute respiratory distress. The patient was known to have tracheomalacia with tracheoesophageal fistula. He had multiple medical comorbidities, including longstanding hypertension, diabetes mellitus, and asthma. The patient had a progressive decline in his level of consciousness and was admitted to the intensive care unit for further management. Despite the maximum ventilatory support, the patient did not achieve an adequate oxygenation level. The patient underwent tracheal stent placement by the interventional radiology team. The insertion was unsuccessful despite three attempts. The tracheal stent had migrated into the upper esophagus on the first and second insertion attempts. Because the patient was unstable to tolerate further attempts, the multidisciplinary team recommended the insertion of an esophageal stent to cover the tracheoesophageal fistula. Despite this, the patient continued to have air leakage with progressive worsening of his respiratory condition as he developed multiorgan failure and died. The management of tracheomalacia in the setting of the tracheoesophageal fistula may pose several challenges. The present case highlights an essential complication of stent placement with the stent migrating into the tracheoesophageal fistula, which is an unusual site of migration. A multidisciplinary approach is crucial in the management of difficult cases of tracheomalacia.
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Affiliation(s)
- Mahdi Aljawad
- Radiology, National Guard Health Affairs, Riyadh, SAU
| | | | - Shahbaz Qazi
- Radiology, National Guard Health Affairs, Riyadh, SAU
| | - Raad Madkhali
- Radiology, National Guard Health Affairs, Riyadh, SAU
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25
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Morita K, Higuma T, Kuroda Y, Miyauchi H, Hatakeyama T. Aortopexy with pericardiopexy for tracheomalacia in right pulmonary agenesis. Pediatr Int 2023; 65:e15474. [PMID: 36645402 DOI: 10.1111/ped.15474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/24/2022] [Accepted: 01/10/2023] [Indexed: 01/17/2023]
Affiliation(s)
- Keiichi Morita
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Tomonori Higuma
- Department of Cardiovascular Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Yasuhiro Kuroda
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Harunori Miyauchi
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
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26
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Martens T, Schaballie H, Willekens J, Schelstraete P, Willems J, Muthialu N, Desender L. Anterior and posterior tracheopexy for severe tracheomalacia. JTCVS Tech 2023; 17:159-63. [PMID: 36820339 DOI: 10.1016/j.xjtc.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/17/2022] [Accepted: 11/02/2022] [Indexed: 12/15/2022] Open
Abstract
Objectives Congenital tracheomalacia can be the cause of respiratory failure in young children. Although the indication for surgical treatment has already been discussed vigorously, no clear guidelines about the modality are available. Methods Through a sternotomy approach, a combination of posterior pexy and anterior tracheopexy using a tailored ringed polytetrafluoroethylene prosthesis is performed. Patient demographic characteristics, as well as operative details and postoperative outcomes, are included in the analysis. Results Between 2018 and 2022, 9 children underwent the operation under review. All patients showed severe clinical symptoms of tracheomalacia, which was confirmed on bronchoscopy. The median age was 9 months. There was no operative mortality. Eight patients could be weaned from the ventilator. One patient died because of interstitial lung disease with bronchomalacia and concomitant severe cardiac disease. The longest follow-up now is 4 years, and shows overall excellent clinical results, without any reintervention. Conclusions Surgical treatment of tracheomalacia through a combination of posterior and anterior pexy is feasible, with acceptable short- and midterm results.
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27
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Lopez-Minguez S, Rodriguez-Zapater S, Bonastre C, Rodriguez J, De Gregorio MA, Guirola JA, Serrano-Casorran C. A New Removable Helical Metallic Stent for the Treatment of Tracheomalacia in Children: Study in Pathological Animal Model. J Clin Med 2022; 11. [PMID: 36431234 DOI: 10.3390/jcm11226757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Congenital tracheomalacia is a pathology with no consensus of medical or surgical approach. The permanent nature and the major complications associated with metallic stents have limited their use over the years. The purpose of this study was to evaluate the feasibility of a helical stent design removal. METHODS Ten dogs diagnosed with tracheal collapse and treated with the helical stent were involved in the study. Animals were classified into three groups depending on stent indwelling time. Prior to the removal, endoscopic evaluation was performed to assess endothelization grade, mucous accumulation, and the presence of stenosis. During the removal, bleeding, fracture, or impossibility of removal were noted. After the removal, all macroscopic mucosal changes were recorded. RESULTS Technical success was 100%, without any complications. Complete epithelization of the stent was visualized in 7/10 animals. The removal procedure duration ranged from 2-12 min. At post-removal endoscopy, bleeding or epithelial damage, was visualized in any case. Stent fracture during removal occurred in one animal. CONCLUSIONS The removal of a metallic stent with spiral geometry is feasible, simple, and without complications, regardless of the degree of neo-epithelialization.
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28
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Boonjindasup W, Marchant JM, McElrea MS, Yerkovich ST, Thomas RJ, Masters IB, Chang AB. Pulmonary function of children with tracheomalacia and associated clinical factors. Pediatr Pulmonol 2022; 57:2437-2444. [PMID: 35785487 PMCID: PMC9796637 DOI: 10.1002/ppul.26054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/01/2022] [Accepted: 06/25/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Spirometry is easily accessible yet there is limited data in children with tracheomalacia. Availability of such data may inform clinical practice. We aimed to describe spirometry indices of children with tracheomalacia, including Empey index and flow-volume curve pattern, and determine whether these indices relate with bronchoscopic features. METHODS From the database of children with tracheomalacia diagnosed during 2016-2019, we reviewed their flexible bronchoscopy and spirometry data in a blinded manner. We specially evaluated several spirometry indices and tracheomalacia features (cross-sectional lumen reduction, malacic length, and presence of bronchomalacia) and determined their association using multivariable regression. RESULTS Of 53 children with tracheomalacia, the mean (SD) peak expiratory flow (PEF) was below the normal range [68.9 percent of predicted value (23.08)]. However, all other spirometry parameters were within normal range [Z-score forced expired volume in 1 s (FEV1 ) = -1.18 (1.39), forced vital capacity (FVC) = -0.61 (1.46), forced expiratory flow between 25% and 75% of vital capacity (FEF25%-75% ) = -1.43 (1.10), FEV1 /FVC = -1.04 (1.08)], Empey Index = 8.21 (1.59). The most common flow-volume curve pattern was the "knee" pattern (n = 39, 73.6%). Multivariable linear regression identified the presence of bronchomalacia was significantly associated with lower flows: FEV1 [coefficient (95% CI) -0.78 (-1.54, -0.02)], FEF25%-75% [-0.61 (-1.22, 0)], and PEF [-12.69 (-21.13, -4.25)], all p ≤ 0.05. Other bronchoscopic-defined tracheomalacia features examined (cross-sectional lumen reduction, malacic length) were not significantly associated with spirometry indices. CONCLUSION The "knee" pattern in spirometry flow-volume curve is common in children with tracheomalacia but other indices, including Empey index, cannot be used to characterize tracheomalacia. Spirometry indices were not significantly associated with bronchoscopic tracheomalacia features but children with tracheobronchomalacia have significantly lower flow than those with tracheomalacia alone.
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Affiliation(s)
- Wicharn Boonjindasup
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julie M Marchant
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Margaret S McElrea
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Stephanie T Yerkovich
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Rahul J Thomas
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ian B Masters
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Anne B Chang
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
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29
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Gunatilaka CC, Hysinger EB, Schuh A, Xiao Q, Gandhi DB, Higano NS, Ignatiuk D, Hossain MM, Fleck RJ, Woods JC, Bates AJ. Predicting tracheal work of breathing in neonates based on radiological and pulmonary measurements. J Appl Physiol (1985) 2022; 133:893-901. [PMID: 36049059 PMCID: PMC9529254 DOI: 10.1152/japplphysiol.00399.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022] Open
Abstract
Tracheomalacia is an airway condition in which the trachea excessively collapses during breathing. Neonates diagnosed with tracheomalacia require more energy to breathe, and the effect of tracheomalacia can be quantified by assessing flow-resistive work of breathing (WOB) in the trachea using computational fluid dynamics (CFD) modeling of the airway. However, CFD simulations are computationally expensive; the ability to instead predict WOB based on more straightforward measures would provide a clinically useful estimate of tracheal disease severity. The objective of this study is to quantify the WOB in the trachea using CFD and identify simple airway and/or clinical parameters that directly relate to WOB. This study included 30 neonatal intensive care unit subjects (15 with tracheomalacia and 15 without tracheomalacia). All subjects were imaged using ultrashort echo time (UTE) MRI. CFD simulations were performed using patient-specific data obtained from MRI (airway anatomy, dynamic motion, and airflow rates) to calculate the WOB in the trachea. Several airway and clinical measurements were obtained and compared with the tracheal resistive WOB. The maximum percent change in the tracheal cross-sectional area (ρ = 0.560, P = 0.001), average glottis cross-sectional area (ρ = -0.488, P = 0.006), minute ventilation (ρ = 0.613, P < 0.001), and lung tidal volume (ρ = 0.599, P < 0.001) had significant correlations with WOB. A multivariable regression model with three independent variables (minute ventilation, average glottis cross-sectional area, and minimum of the eccentricity index of the trachea) can be used to estimate WOB more accurately (R2 = 0.726). This statistical model may allow clinicians to estimate tracheal resistive WOB based on airway images and clinical data.NEW & NOTEWORTHY The work of breathing due to resistance in the trachea is an important metric for quantifying the effect of tracheal abnormalities such as tracheomalacia, but currently requires complex dynamic imaging and computational fluid dynamics simulation to calculate it. This study produces a method to predict the tracheal work of breathing based on readily available imaging and clinical metrics.
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Affiliation(s)
- Chamindu C Gunatilaka
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erik B Hysinger
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Andreas Schuh
- Department of Computing, Imperial College London, London, United Kingdom
| | - Qiwei Xiao
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Deep B Gandhi
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nara S Higano
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Daniel Ignatiuk
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Md M Hossain
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert J Fleck
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jason C Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alister J Bates
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio
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30
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Park YJ, Kim E, Jung HS. Successful management of a tracheomalacia patient with active endotracheal bleeding due to intraoperative innominate artery injury: A case report. Medicine (Baltimore) 2022; 101:e30797. [PMID: 36181007 PMCID: PMC9524874 DOI: 10.1097/md.0000000000030797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Intraoperative innominate artery injury is life-threatening in tracheomalacia patients with prolonged tracheostomy. Anesthetic management is challenging in cases with massive hemorrhage into the endotracheal tube. We report a case in which we successfully managed a tracheomalacia patient with acute endotracheal bleeding due to innominate artery injury. PATIENT CONCERNS A 24-year-old patient with tracheomalacia was scheduled to undergo exploratory thoracotomy for the treatment of intermittent bleeding at the tracheostomy site. During exploration, sudden active bleeding due to innominate artery injury was observed in the endotracheal lumen. DIAGNOSES The patient was diagnosed with tracheomalacia. INTERVENTIONS We immediately used the bronchoscope to place the tip of the endotracheal tube at the bleeding site and hyperinflated the cuff. OUTCOMES The ballooned cuff compressed the active bleeding site, so no additional bleeding was detected by bronchoscopy, and no additional massive bleeding was observed in the operative field. LESSONS Immediate and appropriate overinflation of the endotracheal tube cuff by an anesthesiologist may provide improved surgical field visibility and time for critical surgical procedures in cases of massive hemorrhaging.
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Affiliation(s)
- Yoo Jung Park
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eunji Kim
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hong Soo Jung
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- *Correspondence: Hong Soo Jung, Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea (e-mail: )
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31
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Enzer KG, Wine TM, Gien J, Somme S, Prager JD, Baker CD. Posterior tracheopexy for preterm infants with severe bronchopulmonary dysplasia and severe tracheobronchomalacia: A case series. Pediatr Pulmonol 2022; 57:2279-2281. [PMID: 35666077 DOI: 10.1002/ppul.26029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022]
Abstract
We report a series of four patients with severe bronchopulmonary dysplasia (BPD) who underwent posterior tracheopexy for severe tracheomalacia (TM). While posterior tracheopexy is an established surgical treatment for TM associated with tracheoesophageal fistula, it has not been previously described in TM associated with BPD. There were no significant intraoperative or postoperative complications from the surgeries. Three of the four patients required tracheostomy and mechanical ventilation, which may reflect the degree of lung disease and other multisystem comorbidities in these patients. More investigation is needed to determine whether posterior tracheopexy is an effective surgical option for TM related to BPD.
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Affiliation(s)
- Katelyn G Enzer
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Todd M Wine
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jason Gien
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Stig Somme
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeremy D Prager
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christopher D Baker
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
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32
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Morante-Valverde R, Usategui A, López M, Grau M, Luna-Paredes MC, Albi S, Alonso-Riaño M, Pablos JL, Antón-Pacheco JL. Histological and structural effects of biodegradable polydioxanone stents in the rabbit trachea. Eur J Cardiothorac Surg 2022; 62:6628586. [PMID: 35781568 DOI: 10.1093/ejcts/ezac380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/03/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the potential biologic effects caused by successive placement of biodegradable polydioxanone (PDO) stents in the rabbit trachea. PDO stents could eventually induce a fibroproliferative reaction in the submucosa that could be beneficial in the treatment of malacia due to an increase in its consistency without impairing the tracheal lumen. METHODS Sixteen adult NZ rabbits were distributed into 3 groups with different survival times according to the number of stents placed: One stent (14 weeks), 2 stents (28 w.), and 3 stents (42 w.). Stent insertion was performed endoscopically in the cervical trachea of the animal. Histopathological studies included Masson's trichrome staining for submucosal fibrosis and Safranin O to assess structural integrity of cartilage. Potential inflammatory changes were analysed by means of immunohistochemistry determining the number of CD45 positive cells. RESULTS Stent placement was successful in every case. Histological studies did not show a statistically significant increase in tracheal wall collagen area and cartilage structure was not modified in those rabbits with one or more PDO stents inserted compared to non-stented tracheal sections. Furthermore, no statistically significant changes in the number of CD45+ cells were observed in stented tracheal segments compared to normal tracheal tissues. CONCLUSIONS According to our data, successive PDO stenting caused mild inflammatory changes in the tracheal wall, no increase in the collagen matrix, and the cartilaginous support was not modified during a long follow-up period (up to 42 weeks). These findings suggest that they may be safe and show good biocompatibility in the long-term.
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Affiliation(s)
- Rocío Morante-Valverde
- Pediatric Surgery Division & Pediatric Airway Unit. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Universidad Complutense de Madrid. Spain
| | - Alicia Usategui
- Inflammatory and Autoimmune Diseases Research Group. Instituto de Investigación Hospital U. 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid 28041. Spain
| | - María López
- Pediatric Surgery Division & Pediatric Airway Unit. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Universidad Complutense de Madrid. Spain
| | - Montserrat Grau
- Research Center, Veterinary Unit. Instituto de Investigación Hospital U. 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Ma Carmen Luna-Paredes
- Pulmonary Unit, Division of Pediatrics. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Salomé Albi
- Pulmonary Unit, Division of Pediatrics. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Marina Alonso-Riaño
- Division of Pathology. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Spain
| | - José L Pablos
- Inflammatory and Autoimmune Diseases Research Group. Instituto de Investigación Hospital U. 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Juan L Antón-Pacheco
- Pediatric Surgery Division & Pediatric Airway Unit. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Universidad Complutense de Madrid. Spain.,Inflammatory and Autoimmune Diseases Research Group. Instituto de Investigación Hospital U . 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid, 28041, . Spain
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33
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Yu D, Peng W, Mo X, Zhang Y, Zhang X, He J. Personalized 3D-Printed Bioresorbable Airway External Splint for Tracheomalacia Combined With Congenital Heart Disease. Front Bioeng Biotechnol 2022; 10:859777. [PMID: 35620475 PMCID: PMC9127074 DOI: 10.3389/fbioe.2022.859777] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
Severe tracheomalacia (TM) patients with respiratory symptoms need surgical intervention, including aortopexy, internal stents or external splint. While some patients continue to have respiratory symptoms after tracheal relief, and there is no evidence to support any one surgery therapy over another. Here we introduce a clinical safety and efficacy of the three-dimensional (3D)-printed bioresorbable airway external splints in treating congenital heart disease (CHD) patients with severe TM. From May 2019 to September 2020, nine patients with severe TM were enrolled. The median age was 5 months (range, 3–25 months), and the median weight was 7.5 kg (range, 3–15 kg). All patients had wheezing, and two patients were assisted by machine ventilation (MV) preoperatively. The median length of TM was 1.5 cm (range, 1.0–3.0 cm). All patients underwent suspension of a “C”-shaped lumen airway external splint, which were designed in SOLIDWORKS and made of polycaprolactone (PCL). The airway external splint could provided effective support for at least 6 months and was completely degraded into carbon dioxide and water within 2–3 years. The median time of postoperative machine assisted ventilation was 23.7 h (range, 3.3–223.4 h), and the median time of ICU stay was 9 days (range, 4–25 days). The median follow-up time was 18 months (range, 12–24 months). Respiratory symptoms were all relieved, and no external splint-associated complications occurred. The 3D computed tomography reconstruction showed no airway stenosis. Personalized 3D-printed bioresorbable airway external splint can not only limit external compression and prevent airway collapse but also ensure the growth potential of the airway, which is a safe, reliable and effective treatment for CHD with TM.
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Affiliation(s)
- Di Yu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Peng
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yuxi Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xing Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jiankang He
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
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Topolnitskiy EB, Shefer NA, Kapitanova DV, Podgornov VF. [Treatment of post-intensive care tracheal stenosis after previous covid-19 pneumonia]. Khirurgiia (Mosk) 2022:5-10. [PMID: 35477194 DOI: 10.17116/hirurgia20220415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze postoperative outcomes and perioperative management of patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia. MATERIAL AND METHODS There were 8 patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia aged 34-61 years between January 2021 and April 2021. Lung damage CT-3 was observed in 2 (25%) patients, CT-4 - in 5 (62.5%) patients. In one case, COVID-19 pneumonia with lung damage CT-2 joined to acute cerebrovascular accident. Post-tracheostomy stenosis was detected in 7 (87.5%) cases, post-intubation stenosis - in 1 patient. Duration of invasive mechanical ventilation ranged from 5 to 130 days. In 75% of cases, tracheal stenosis was localized in the larynx and cervical trachea. Two patients admitted with tracheostomy. In one case, an extended tracheal stenosis was combined with atresia of infraglottic part of the larynx. One patient had tracheal stenosis combined with tracheoesophageal fistula (TEF). Length of tracheal stenosis was 15-45 mm. Tracheomalacia was observed in 4 (50%) patients. All patients had severe concomitant diseases. RESULTS To restore airway patency, we used circular tracheal resection with anastomosis, laryngotracheoplasty and endoscopic methods. Tracheal resection combined with TEF required circular tracheal resection with disconnection of fistula. Adequate breathing through the natural airways was restored in all patients. There was no postoperative mortality. Three patients with baseline tracheal stenosis had favorable postoperative outcomes after circular tracheal resection. Four patients are at the final stage of treatment after laryngotracheoplasty and tracheal stenting. CONCLUSION Patients after invasive mechanical ventilation for COVID-19 pneumonia are at high risk of cicatricial tracheal stenosis and require follow-up. Circular tracheal resection ensures early rehabilitation and favorable functional results. Laryngotracheoplasty is preferred if circular tracheal resection is impossible. This procedure ensures adequate debridement of tracheobronchial tree and respiratory support. Endoscopic measures are an alternative for open surgery, especially for intrathoracic tracheal stenosis and intractable tracheobronchitis.
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Affiliation(s)
- E B Topolnitskiy
- Siberian State Medical University, Tomsk, Russia.,Tomsk Regional Clinical Hospital, Tomsk, Russia
| | - N A Shefer
- Tomsk Regional Clinical Hospital, Tomsk, Russia
| | - D V Kapitanova
- Siberian State Medical University, Tomsk, Russia.,Alperovich Tomsk City Clinical Hospital No. 3, Tomsk, Russia
| | - V F Podgornov
- Alperovich Tomsk City Clinical Hospital No. 3, Tomsk, Russia
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Okuno T, Igarashi A, Sugihara Y, Imoto Y, Ohshima Y. Retinal folds and tracheomalacia in a boy with otopalatodigital syndrome type 2. Pediatr Int 2022; 64:e15127. [PMID: 35396784 DOI: 10.1111/ped.15127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/25/2021] [Accepted: 01/11/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Takashi Okuno
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Aiko Igarashi
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yuka Sugihara
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yoshimasa Imoto
- Division of Otorhinolaryngology Head & Neck Surgery, Department of Sensory and Locomotor Medicine, Faculty of Medical Science, University of Fukui, Fukui, Japan
| | - Yusei Ohshima
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Gunatilaka CC, Hysinger EB, Schuh A, Gandhi DB, Higano NS, Xiao Q, Hahn AD, Fain SB, Fleck RJ, Woods JC, Bates AJ. Neonates With Tracheomalacia Generate Auto-Positive End-Expiratory Pressure via Glottis Closure. Chest 2021; 160:2168-2177. [PMID: 34157310 PMCID: PMC8692107 DOI: 10.1016/j.chest.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND In pediatrics, tracheomalacia is an airway condition that causes tracheal lumen collapse during breathing and may lead to the patient requiring respiratory support. Adult patients can narrow their glottis to self-generate positive end-expiratory pressure (PEEP) to raise the pressure in the trachea and prevent collapse. However, auto-PEEP has not been studied in newborns with tracheomalacia. The objective of this study was to measure the glottis cross-sectional area throughout the breathing cycle and to quantify total pressure difference through the glottis in patients with and without tracheomalacia. RESEARCH QUESTION Do neonates with tracheomalacia narrow their glottises? How does the glottis narrowing affect the total pressure along the airway? STUDY DESIGN AND METHODS Ultrashort echo time MRI was performed in 21 neonatal ICU patients (11 with tracheomalacia, 10 without tracheomalacia). MRI scans were reconstructed at four different phases of breathing. All patients were breathing room air or using noninvasive respiratory support at the time of MRI. Computational fluid dynamics simulations were performed on patient-specific virtual airway models with airway anatomic features and motion derived via MRI to quantify the total pressure difference through the glottis and trachea. RESULTS The mean glottis cross-sectional area at peak expiration in the patients with tracheomalacia was less than half that in patients without tracheomalacia (4.0 ± 1.1 mm2 vs 10.3 ± 4.4 mm2; P = .002). The mean total pressure difference through the glottis at peak expiration was more than 10 times higher in patients with tracheomalacia compared with patients without tracheomalacia (2.88 ± 2.29 cm H2O vs 0.26 ± 0.16 cm H2O; P = .005). INTERPRETATION Neonates with tracheomalacia narrow their glottises, which raises pressure in the trachea during expiration, thereby acting as auto-PEEP.
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Affiliation(s)
- Chamindu C Gunatilaka
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Physics, University of Cincinnati, Cincinnati, OH
| | - Erik B Hysinger
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Andreas Schuh
- Department of Computing, Imperial College London, London, UK
| | - Deep B Gandhi
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nara S Higano
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Qiwei Xiao
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew D Hahn
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI
| | - Sean B Fain
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI
| | - Robert J Fleck
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jason C Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Physics, University of Cincinnati, Cincinnati, OH; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Alister J Bates
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH.
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Guarnieri M, Andreoni P, Gay H, Giudici R, Bottiroli M, Mondino M, Casella G, Chiara O, Morelli O, Conforti S, Langer T, Fumagalli R. Tracheostomy in Mechanically Ventilated Patients With SARS-CoV-2-ARDS: Focus on Tracheomalacia. Respir Care 2021; 66:1797-1804. [PMID: 34548406 PMCID: PMC9993780 DOI: 10.4187/respcare.09063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. The aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence. METHODS This retrospective, single-center study was performed in an Italian teaching hospital. All adult subjects admitted to the ICU between February 24, 2020, and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, whereas information regarding airway management was collected daily. RESULTS A total of 151 subjects were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 40%. A tracheostomy was performed in 73 (48%), open surgical technique in 54 (74%), and percutaneous Ciaglia technique in 19 (26%). Subjects who had a tracheostomy performed had, compared to the other subjects, a longer duration of mechanical ventilation and longer ICU and hospital stay. Tracheomalacia was diagnosed in 8 (5%). The factors associated with tracheomalacia were female sex, obesity, and tracheostomy. CONCLUSIONS In our population, approximately 50% of subjects with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized subjects had a longer ICU and hospital stay. In our population, 5% were diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature, and the underlying mechanisms are not fully understood.
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Affiliation(s)
- Marcello Guarnieri
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Patrizia Andreoni
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Hedwige Gay
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Riccardo Giudici
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Maurizio Bottiroli
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Michele Mondino
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Gianpaolo Casella
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Osvaldo Chiara
- Department of Emergency and Trauma Surgery, Niguarda Hospital, University of Milan, Milan, Italy
| | - Oscar Morelli
- Department of Otolaryngology, Niguarda Hospital, Milan, Italy
| | - Serena Conforti
- Department of Thoracic Surgery, Niguarda Hospital, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
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Sonoda S, Sato K, Takagi Y, Sato Y, Murao F, Koide Y, Oda T. Undiagnosed tracheomalacia accompanied with accidental expiratory central airway collapse after tracheal intubation. Acute Med Surg 2021; 8:e665. [PMID: 34094584 PMCID: PMC8157476 DOI: 10.1002/ams2.665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 12/19/2022] Open
Abstract
Background A patient with undiagnosed tracheomalacia undergoing surgery experienced accidental expiratory central airway collapse after tracheal intubation. Here, we aimed to diagnose tracheomalacia from the preoperative data. Case Presentation A 73‐year‐old man, scheduled for abdominal surgery, had a clinical history of chronic obstructive pulmonary disease. Preoperative chest computed tomography revealed a lateral narrowing of the tracheal shape. After tracheal intubation, we could not manually ventilate the inflated lung. Emergent bronchoscopy findings, including severe expiratory tracheal collapse, indicated a diagnosis of tracheomalacia. We could fully ventilate the patient by moving the endotracheal tube near the tracheal carina and finally changing it to a double‐lumen tube. Airway collapse did not occur under spontaneous breathing. Conclusion Accidental expiratory central airway collapse could occur in patients with undiagnosed tracheomalacia during surgery. A diagnosis of tracheomalacia should be presumed from a deformed trachea on preoperative imaging and history of chronic obstructive pulmonary disease.
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Affiliation(s)
- Seijiro Sonoda
- Department of Anesthesiology Shonan Kamakura General Hospital Kamakura Japan
| | - Kozo Sato
- Department of Anesthesiology Shonan Kamakura General Hospital Kamakura Japan
| | - Yoshito Takagi
- Department of Anesthesiology Shonan Kamakura General Hospital Kamakura Japan
| | - Yumiko Sato
- Department of Anesthesiology Shonan Kamakura General Hospital Kamakura Japan
| | - Fumi Murao
- Department of Anesthesiology Shonan Fujisawa Tokusyukai Hospital Fujisawa Japan
| | - Yasuhiro Koide
- Department of Anesthesiology Tokyo Nishi Tokusyukai Hospital Tokyo Japan
| | - Toshiyuki Oda
- Department of Anesthesiology Shonan Kamakura General Hospital Kamakura Japan
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Fockens MM, Hölscher M, Limpens J, Dikkers FG. Tracheal anomalies associated with Down syndrome: A systematic review. Pediatr Pulmonol 2021; 56:814-822. [PMID: 33434377 PMCID: PMC8247859 DOI: 10.1002/ppul.25203] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Airway anomalies are accountable for a substantial part of morbidity and mortality in children with Down syndrome (DS). Although tracheal anomalies occur more often in DS children, a structured overview on the topic is lacking. We systematically reviewed the characteristics of tracheal anomalies in DS children. METHODS A MEDLINE and EMBASE search for DS and tracheal anomalies was performed. Tracheal anomalies included tracheal stenosis, complete tracheal ring deformity (CTRD), tracheal bronchus, tracheomalacia, tracheal web, tracheal agenesis or atresia, laryngotracheoesophageal cleft type 3 or 4, trachea sleeve, and absent tracheal rings. RESULTS Fifty-nine articles were included. The trachea of DS children is significantly smaller than non-DS children. Tracheomalacia and tracheal bronchus are seen significantly more often in DS children. Furthermore, tracheal stenosis, CTRD, and tracheal compression by vascular structures are seen regularly in children with DS. These findings are reflected by the significantly higher frequency of tracheostomy and tracheoplasty performed in DS children. CONCLUSION In children with DS, tracheal anomalies occur more frequently and tracheal surgery is performed more frequently than in non-DS children. When complaints indicative of tracheal airway obstruction like biphasic stridor, dyspnea, or wheezing are present in children with DS, diagnostic rigid laryngotracheobronchoscopy with special attention to the trachea is indicated. Furthermore, imaging studies (computed tomography, magnetic resonance imaging, and ultrasound) play an important role in the workup of DS children with airway symptoms. Management depends on the type, number, and extent of tracheal anomalies. Surgical treatment seems to be the mainstay in severe cases.
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Affiliation(s)
- M. Matthijs Fockens
- Department of Otorhinolaryngology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Michiel Hölscher
- Faculty of Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jacqueline Limpens
- Medical Library, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Frederik G. Dikkers
- Department of Otorhinolaryngology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Tsuboi N, Tsuboi K, Nosaka N, Nishimura N, Nakagawa S. The Ventilatory Strategy to Minimize Expiratory Flow Rate in Ventilated Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2021; 16:301-304. [PMID: 33603356 PMCID: PMC7886110 DOI: 10.2147/copd.s296343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/25/2021] [Indexed: 01/15/2023] Open
Abstract
Although the pathophysiology of chronic obstructive pulmonary disease (COPD) is multifactorial, central airway collapse is reported to have a great impact on symptom severity. In COPD patients, positive pressure formed by hyperinflated lungs compressing the tracheal wall and negative changes in intratracheal static pressure due to rapid expiratory flow velocity at the beginning of expiration collapse the trachea. This phenomenon can be explained by fluid dynamics theory. Our hypothesis is that ventilatory strategy focusing on minimization of expiratory flow rate may be advantageous for patients receiving mechanical ventilation for COPD. If appropriate counter pressure could be applied on exhalation, patients may be able to exhale slowly with reduced expiratory flow rates which may prevent negative changes of the intratracheal static pressure. We devised a new conceptual ventilation mode “minimized expiratory flow rate ventilation (MExV)” which applies regulated counter pressure on exhalation. The conceptual waveforms of “minimized expiratory flow rate ventilation” including flow rate, volume, and airway pressure are shown, compared with typical waveforms of the conventional ventilation modes.
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Affiliation(s)
- Norihiko Tsuboi
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kaoru Tsuboi
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuyuki Nosaka
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan.,Department of Intensive Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nao Nishimura
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
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Vehapoğlu A, Çakır E, Uzuner S, Çalım ÖF, Yazan H. A Rare Presentation of Acquired Laryngomalacia and Tracheomalacia in a Child Associated with Apricot Sulfurization. Turk Arch Otorhinolaryngol 2021; 58:286-288. [PMID: 33554206 DOI: 10.5152/tao.2020.5398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022] Open
Abstract
Sulfur fumigation has come to replace traditional sun drying methods for drying fruits over the years around the world as it is a cheaper and faster method because of its pesticidal and anti-bacterial properties. We report the case of an 11-year-old boy with acquired severe biphasic stridor who was exposed to extremely high concentrations of sulfur dioxide (SO2) during apricot sulfurization processes with his mother. The patient's bronchoscopy revealed severe glottic and subglottic damage. Exposure to SO2 is a health risk, particularly for individuals who are sulfide-sensitive, especially in childhood. The pulmonary epithelium may be directly injured by inhaled toxic substances at various levels of the respiratory system. To the best of our knowledge, this is the first case reported of acquired airway damage associated with sulfurization in a pediatric patient without a known history of any respiratory disease or symptoms.
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Affiliation(s)
- Aysel Vehapoğlu
- Department of Pediatrics, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Erkan Çakır
- Department of Pediatric Pulmonology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Selçuk Uzuner
- Department of Pediatrics, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Ömer Faruk Çalım
- Department of Otorhinolaryngology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Hakan Yazan
- Department of Pediatric Pulmonology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
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Poore TS, Weinman JP, Handley E, Wine T, Helland S, Corbett B, Antoniolli N, Somme S, Friedlander J, Prager JD, DeBoer EM. Vascular and pulmonary comorbidities in children with congenital EA/TEF. Pediatr Pulmonol 2021; 56:571-577. [PMID: 33300304 DOI: 10.1002/ppul.25219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/18/2020] [Accepted: 12/02/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Esophageal atresia with tracheoesophageal fistula (EA/TEF) is associated with many congenital and vascular malformations; however, reports utilizing computed tomography (CT) and computed tomography angiography (CTA) are limited. The objective of this study is to review CT scans of the chest from patients with EA/TEF and report their pulmonary and vascular findings. METHODS We completed a retrospective chart review of children with congenital EA/TEF evaluated in the aerodigestive clinic at Children's Hospital Colorado. Results of the most recent CTA or CT of the chest were investigated. Demographics, medical conditions, and bronchoscopy findings were also recorded. The ratio of tracheal lumen area between inspiratory and expiratory CTA images was measured. RESULTS Of the patients with congenital EA/TEF seen in the program, 47 patients had a chest CT available for review. Eight patients (17%) had bronchiectasis. Of the contrast CT scans, 15 (58%) had a vascular abnormality and 16 (62%) demonstrated tracheal compression (38% at the level of the innominate artery, 35% from other structures). Nineteen of the CTAs had volumetric expiratory images of the trachea to evaluate tracheomalacia. The mean expiratory:inspiratory area was 0.57 (SD ± 0.23) at the level of the innominate. CONCLUSION Patients with EA/TEF frequently have vascular abnormalities that may alter airway mechanics as well as pulmonary comorbidities that may affect long-term management. For patients experiencing persistent respiratory symptoms, CTA of the chest should be considered adjunct to bronchoscopy to help with medical and surgical management of these children.
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Affiliation(s)
- Thomas S Poore
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jason P Weinman
- Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elyse Handley
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Todd Wine
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sparrow Helland
- Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Benjamin Corbett
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Natalie Antoniolli
- Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Stig Somme
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joel Friedlander
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Gastroenterology, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jeremy D Prager
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Emily M DeBoer
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
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van Tuyll van Serooskerken ES, Tytgat SHAJ, Verweij JW, Bittermann AJN, Coenraad S, Arets HGM, van der Zee DC, Lindeboom MYA. Primary Posterior Tracheopexy in Esophageal Atresia Decreases Respiratory Tract Infections. Front Pediatr 2021; 9:720618. [PMID: 34568240 PMCID: PMC8459008 DOI: 10.3389/fped.2021.720618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Esophageal atresia (EA) is often accompanied by tracheomalacia (TM). TM can lead to severe respiratory complaints requiring invasive treatment. This study aims to evaluate if thoracoscopic primary posterior tracheopexy (PPT) can prevent the potential sequelae of TM in patients with EA. Methods: A cohort study including all consecutive EA patients treated between 2014 and July 2019 at the Wilhelmina Children's Hospital was conducted. Two groups were distinguished: (group 1) all EA patients born between January 2014 and December 2016 and (group 2) all EA patients born between January 2017 and July 2019, after introduction of PPT. In the latter group, PPT was performed in EA patients with moderate (33-66%) or severe (67-100%) tracheomalacia, seen during preoperative bronchoscopy. Group differences were assessed using the Fisher's exact test for bivariate variables and the Mann-Whitney U-test for continuous variables. Results: A total of 64 patients were included in this study (28 patients in group 1; 36 patients in group 2). In group 2, PPT was performed in 14 patients. Respiratory tract infections (RTIs) requiring antibiotics within the first year of life occurred significantly less in group 2 (61 vs. 25%, p = 0.004). Brief resolved unexplained events (BRUEs) seemed to diminish in group 2 compared to group 1 (39 vs. 19%, p = 0.09). Conclusion: Thoracoscopic primary posterior tracheopexy decreases the number of respiratory tract infections in EA patients. The clinical impact of reducing RTIs combined with the minimal additional operating time and safety of PPT outweighs the risk of overtreatment.
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Affiliation(s)
| | - Stefaan H A J Tytgat
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Johannes W Verweij
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Arnold J N Bittermann
- Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Pediatric Otorhinolaryngology, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Saskia Coenraad
- Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Pediatric Otorhinolaryngology, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hubertus G M Arets
- Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Pediatric Pulmonology, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Maud Y A Lindeboom
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
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Saynhalath R, Battles R, Mehta SD, Alex G. Aortopexy Complicated by ST Segment Elevations in a Four-Month-Old Infant. Cureus 2020; 12:e11436. [PMID: 33324519 PMCID: PMC7732736 DOI: 10.7759/cureus.11436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A four-month-old female infant presented for a thoracoscopic aortopexy for severe tracheomalacia. The case proceeded uneventfully until a specimen bag was introduced into the chest to remove the thymus. The child developed significant ST segment elevations in all 12 leads on electrocardiogram. An emergent intraoperative echocardiogram was performed but did not reveal any findings to account for the diffuse ST segment elevations. The ST segment elevations remained elevated for 48 hours following the procedure with no apparent hemodynamic instability or structural damage to the heart. Troponin levels returned to normal a few days later, and the child was discharged home without sequelae. The incidence of ST segment elevations in children without congenital heart disease is rare but can potentially lead to significant morbidity and mortality. This case report seeks to highlight the importance of swift recognition of ST changes in the pediatric population, discuss possible causes, and describe appropriate workup.
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Affiliation(s)
- Rita Saynhalath
- Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, USA.,Outcomes Research Consortium, Cleveland, USA
| | - Rhae Battles
- Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, USA
| | - Sonia D Mehta
- Anesthesiology, University of Florida, Gainesville, USA
| | - Gijo Alex
- Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, USA
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45
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Harper S, Robinson M, Manning G, Jones A, Hobson J, Shelton CL. Management of tracheostomy-related tracheomegaly in a patient with COVID-19 pneumonitis. Anaesth Rep 2020; 8:e12076. [PMID: 33210094 DOI: 10.1002/anr3.12076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 11/06/2022] Open
Abstract
Acquired tracheomegaly is a rare condition associated with pulmonary fibrosis, connective tissue disease and the use of cuffed tracheal tubes. We describe the urgent tracheal re-intubation and subsequent tracheal repair of a previously well 58-year-old man who developed tracheostomy-related tracheomegaly during prolonged mechanical ventilation for coronavirus disease 2019 pneumonitis. Urgent tracheal re-intubation was required due to a persistent cuff leak, pneumomediastinum and malposition of the tracheostomy tube. We describe the additional challenges and risks associated with airway management in patients with tracheomegaly, and discuss how even in urgent cases these can be mitigated through planning and teamwork. We present a stepwise approach to tracheal re-intubation past a large tracheal dilatation, including the use of an Aintree catheter inserted via the existing tracheal stoma for oxygenation or tracheal re-intubation if required. Computed tomography imaging was valuable in characterising the defect and developing a safe airway management strategy before starting the procedure. This report emphasises the role of planning, teamwork and the development of an appropriate airway strategy in the safe management of complex cases.
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Affiliation(s)
- S Harper
- North West School of Anaesthetics Health Education England North West Manchester UK
| | - M Robinson
- North West School of Anaesthetics Health Education England North West Manchester UK
| | - G Manning
- Department of Anaesthesia Wythenshawe Hospital Manchester University NHS Foundation Trust Manchester UK
| | - A Jones
- Department of Anaesthesia Wythenshawe Hospital Manchester University NHS Foundation Trust Manchester UK
| | - J Hobson
- Division of Surgery Wythenshawe Hospital Manchester University NHS Foundation Trust Manchester UK
| | - C L Shelton
- Department of Anaesthesia Wythenshawe Hospital Manchester University NHS Foundation Trust Manchester UK.,Lancaster Medical School Faculty of Health and Medicine Lancaster University Lancaster UK
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Abstract
Tracheobronchomalacia (TBM) is an obstructive airway disease characterized by laxity and redundancy of the posterior membrane of the main airways leading to dynamic airway collapse during exhalation. The gold standard for diagnosis is dynamic computed tomography (DCT) scan and dynamic flexible bronchoscopy (DFB). Patients with complete or near-complete collapse (>90% reduction in cross-sectional area) of the airway are possible candidates for surgical management. Central airway stabilization by tracheobronchoplasty (TBP) effectively corrects malacic airways and has demonstrated significant improvement in objective functional measures, which is often but not uniformly accompanied by equal improvement in health-related quality of life (HRQOL) metrics. This article reviews HRQOL instruments used to report outcomes after TBM surgery.
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Affiliation(s)
- Joseph McGinn
- Department of Surgery, General Surgery Residency, North Shore-LIJ, Northwell Health System, Manhasset, NY, USA
| | - Benoit Herbert
- Department of Thoracic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, USA
| | - Andrew Maloney
- Department of Thoracic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, USA
| | - Byron Patton
- Department of Thoracic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, USA
| | - Richard Lazzaro
- Department of Thoracic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, USA
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Koumbourlis AC, Belessis Y, Cataletto M, Cutrera R, DeBoer E, Kazachkov M, Laberge S, Popler J, Porcaro F, Kovesi T. Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula. Pediatr Pulmonol 2020; 55:2713-2729. [PMID: 32716120 DOI: 10.1002/ppul.24982] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/18/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
Abstract
Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.
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Affiliation(s)
- Anastassios C Koumbourlis
- Division of Pulmonary & Sleep Medicine, Children's National Hospital, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Yvonne Belessis
- Department of Respiratory Medicine, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Mary Cataletto
- Division of Pediatric Pulmonary Medicine, New York University, Winthrop University Hospital, Mineola, New York
| | - Renato Cutrera
- Academic Department of Pediatrics (DPUO), Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Pediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Emily DeBoer
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver, Children's Hospital Colorado Breathing Institute, Aurora, Colorado
| | - Mikhail Kazachkov
- Department of Pediatric Pulmonology, Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, New York
| | - Sophie Laberge
- Department of Pediatrics, Division of Respiratory Medicine, Sainte-Justine University Hospital Center, Université de Montréal, Montreal, Quebec, Canada
| | - Jonathan Popler
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Federica Porcaro
- Department of Pediatrics, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Thomas Kovesi
- Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
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Gunatilaka CC, Higano NS, Hysinger EB, Gandhi DB, Fleck RJ, Hahn AD, Fain SB, Woods JC, Bates AJ. Increased Work of Breathing due to Tracheomalacia in Neonates. Ann Am Thorac Soc 2020; 17:1247-1256. [PMID: 32579852 PMCID: PMC7640633 DOI: 10.1513/annalsats.202002-162oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/24/2020] [Indexed: 11/20/2022] Open
Abstract
Rationale: Dynamic collapse of the tracheal lumen (tracheomalacia) occurs frequently in premature neonates, particularly in those with common comorbidities such as bronchopulmonary dysplasia. The tracheal collapse increases the effort necessary to breathe (work of breathing [WOB]). However, quantifying the increased WOB related to tracheomalacia has previously not been possible. Therefore, it is also not currently possible to separate the impact of tracheomalacia on patient symptoms from parenchymal abnormalities.Objectives: To measure the increase in WOB due to airway motion in individual subjects with and without tracheomalacia and with different types of respiratory support.Methods: Fourteen neonatal intensive care unit subjects not using invasive mechanical ventilation were recruited. In eight, tracheomalacia was diagnosed via clinical bronchoscopy, and six did not have tracheomalacia. Self-gated three-dimensional ultrashort-echo-time magnetic resonance imaging (MRI) was performed on each subject with clinically indicated respiratory support to obtain cine images of tracheal anatomy and motion during the respiratory cycle. The component of WOB due to resistance within the trachea was then calculated via computational fluid dynamics (CFD) simulations of airflow on the basis of the subject's anatomy, motion, and respiratory airflow rates. A second CFD simulation was performed for each subject with the airway held static at its largest (i.e., most open) position to determine the increase in WOB due to airway motion and collapse.Results: The tracheal-resistive component of WOB was increased because of airway motion by an average of 337% ± 295% in subjects with tracheomalacia and 24% ± 14% in subjects without tracheomalacia (P < 0.02). In the tracheomalacia group, subjects who were treated with continuous positive airway pressure (CPAP) using a RAM cannula expended less energy for breathing compared with the subjects who were breathing room air or on a high-flow nasal cannula.Conclusions: Neonatal subjects with tracheomalacia have increased energy expenditure compared with neonates with normal airways, and CPAP may be able to attenuate the increase in respiratory work. Subjects with tracheomalacia expend more energy on the tracheal-resistive component of WOB alone than nontracheomalacia patients expend on the resistive WOB for the entire respiratory system, according to previously reported values. CFD may be able to provide an objective measure of treatment response for children with tracheomalacia.
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Affiliation(s)
| | - Nara S. Higano
- Center for Pulmonary Imaging Research
- Division of Pulmonary Medicine, and
| | - Erik B. Hysinger
- Division of Pulmonary Medicine, and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Deep B. Gandhi
- Center for Pulmonary Imaging Research
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robert J. Fleck
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | | | - Sean B. Fain
- Department of Medical Physics
- Department of Radiology, and
- Department of Biomedical Engineering, University of Wisconsin–Madison, Madison, Wisconsin
| | - Jason C. Woods
- Center for Pulmonary Imaging Research
- Division of Pulmonary Medicine, and
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Alister J. Bates
- Center for Pulmonary Imaging Research
- Division of Pulmonary Medicine, and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
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49
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Fockens MM, de Bakker BS, Oostra RJ, Dikkers FG. Development pattern of tracheal cartilage in human embryos. Clin Anat 2020; 34:668-672. [PMID: 32986245 PMCID: PMC8247355 DOI: 10.1002/ca.23688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/07/2020] [Accepted: 09/19/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Congenital tracheal anomalies are associated with high morbidity and mortality. The etiology of congenital tracheal anomalies is not well understood, but often attributed to malformed tracheal cartilage. The development of tracheal cartilage has not been described in detail. In this study, we aimed to investigate the development pattern and timing of normal tracheal cartilage to better understand the etiology of tracheal anomalies. MATERIALS AND METHODS The development of tracheal cartilage was examined by studying the trachea in histological sections of 14 healthy human embryos from the Carnegie collection. Two specimens for Carnegie Stages 17-23 (42-60 days of embryological development) were studied. RESULTS At Carnegie Stages 17-19 (42-51 days), a continuous mesenchymal condensation was observed ventral to the tracheal lumen. At Stages 20 and 21 (51-54 days), this pre-tracheal mesenchyme showed sites of increased condensation indicative of future tracheal rings. Furthermore, growth centers were identified both proximally and distally in the trachea. Characteristic horseshoe shaped tracheal rings were apparent at Carnegie Stages 22 and 23 (54-60 days). CONCLUSIONS In human embryos, tracheal rings arise from growth centers in the ventral mesenchyme at approximately 51-54 days of embryological development. The observation of proximal and distal growth centers suggests a centripetal growth gradient, potentially contributing to occurrence of complete tracheal ring deformity (CTRD). Although this study shows new insights on tracheal cartilage development, the exact origin of congenital tracheal defects has yet to be elucidated.
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Affiliation(s)
- M Matthijs Fockens
- Department of Otorhinolaryngology, Amsterdam University Medical Center location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bernadette S de Bakker
- Department of Medical Biology, Section Clinical Anatomy & Embryology, Amsterdam University Medical Center location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roelof-Jan Oostra
- Department of Medical Biology, Section Clinical Anatomy & Embryology, Amsterdam University Medical Center location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederik G Dikkers
- Department of Otorhinolaryngology, Amsterdam University Medical Center location AMC, University of Amsterdam, Amsterdam, The Netherlands
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50
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Yan C, Hu Y, Qiu G, Gong X, Elda D. The clinical safety and efficacy of flexible bronchoscopy in a neonatal intensive care unit. Exp Ther Med 2020; 20:95. [PMID: 32973944 DOI: 10.3892/etm.2020.9223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/22/2020] [Indexed: 12/22/2022] Open
Abstract
Flexible bronchoscopy (FB), developed in the 1960s, is widely used in the clinical practice of pediatrics and has demonstrated fundamental value in clinical diagnoses and treatment. However, as an invasive procedure, the use of FB is limited due to concerns regarding the tolerance of the procedure and the possible complications in neonatal units. Thus, the present study aimed to investigate the clinical safety and efficacy of flexible bronchoscopy (FB) in a neonatal intensive care unit (NICU). Neonates (n=54) who received FB in the NICU of Shanghai Children's Hospital between January 2012 and December 2016 were enrolled as the experimental group and another 54 neonates who required nebulization and tracheal secretion suction treatments were the control group. Indicators including blood gas, complete blood count, C-reactive protein (CRP), X-ray, patient breathing rate, temperature and blood pressure were monitored prior to and following the procedure. No significant differences in sex, gestational age, birth weight or postnatal age were observed between the experimental group and the control group (P>0.05). Among the 54 FB patients, several cases with side effect were identified, including 18 (33.3%) with respiratory tract stenosis, nine (16.7%) with malacia and stenosis and six (11.1%) with esophagotracheal fistula. Among the 54 members of the control group, 44 neonates (81.4%) were discharged with improved condition, five (9.3%) succumbed and five patients (9.3%) abandoned the treatment and left the hospital. Bronchoalveolar lavage demonstrated consistent results with respiratory secretion culture or tracheal tube culture. In comparison between the experimental and the control groups, no significant difference in pH, partial pressure of carbon dioxide (PCO2), partial pressure of oxygen (PO2) and HCO3 - was observed, while there were no statistical differences in the values of pH, PCO2 and HCO3 - (P>0.05). However, PO2 was significantly increased, and CRP was significantly reduced, following FB procedure compared with prior to FB (P<0.05). No pneumothorax, shock, other severe complications, fever or diffused pneumonia were observed during or after FB. The data from the present study demonstrated that FB is a safe and effective strategy for the diagnosis and differentiation of neonatal respiratory diseases in NICU.
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Affiliation(s)
- Chongbing Yan
- Department of Neonatology, Shanghai Children's Hospital, Shanghai 200062, P.R. China
| | - Yong Hu
- Department of Neonatology, Shanghai Children's Hospital, Shanghai 200062, P.R. China
| | - Gang Qiu
- Department of Neonatology, Shanghai Children's Hospital, Shanghai 200062, P.R. China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, Shanghai 200062, P.R. China
| | - Dermyshi Elda
- Department of Neonatology, Shanghai Children's Hospital, Shanghai 200062, P.R. China
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