Fatal Airway Research Articles

Corona vaccination under immunosuppression

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to play a major role as a severe and potentially fatal airway infection, especially in vulnerable patient groups. In view of the thin data situation on the influence of treatment and response to vaccination, at the beginning of the corona pandemic it was a major challenge to predict the tolerability and effectiveness in patients with inflammatory rheumatic diseases under immunomodulation or immunosuppression. In the meantime, numerous studies have addressed the questions of response and tolerability, at least for the COVID-19 vaccination. Even in the first months of the vaccination campaign, a small study on a single center cohort could show that apart from patients with B‑cell depletion, all included patients showed a seroconversion after the first two vaccinations. This resulted in neither an increased occurrence of exacerbations of the underlying disease nor new autoimmune phenomena. Various studies have since then confirmed these data.

152 Three-Dimensional Printing Bespoke Polycaprolactone Tracheal Splint for Treatment of Tracheomalacia

Abstract Aim Tracheomalacia can be a fatal airway disease with limited treatment options. Three-dimensional (3D) printing has led to various patient-specific tracheal stents and splints. However, these are limited by mismatched stiffness and resulting granulation tissue formation and fibrosis. We aimed to develop a non-toxic and biodegradable polycaprolactone expandable tracheal splint by 3D printing. By fine-tuning mechanical properties, we hypothesised that the splint would match the native trachea and accommodate tracheal growth in tracheomalacia patients. Method We designed splints consisting of concave topological patterns with varying angles and aspect ratios. Fabrication occurred using polycaprolactone filaments in a 3D fuse deposition modelling printer. Uniaxial tensile studies were performed on splints to assess Young’s Modulus, Toughness, Ultimate strain, Strength, and Poisson ratio. Splints displaying optimal mechanical properties were tested for human lung fibroblast cell viability, proliferation, and morphology. Results On a mechanical testing rig, uniaxial tensile studies confirmed that splint designs with smaller angles and negative Poisson ratios of up to strains of 25%, better mimicked mechanical properties of native human trachea, accommodating tracheal growth. In vitro studies using these tracheal splints demonstrated successful human lung cell proliferation with low cell toxicity. Conclusions This study characterised 3D printed bespoke tracheal splints with various 2D structures, showing mechanical properties that match the native trachea. However, in vivo studies investigating cellular interactions on our splint must be performed to further evaluate the ability for endogenous tissue formation.

Nasogastric tube syndrome: A Meta-summary of case reports.

Since its description in 1790 by Hunter, the nasogastric tube (NGT) is commonly used in any healthcare setting for alleviating gastrointestinal symptoms or enteral feeding. However, the risks associated with its placement are often underestimated. Upper airway obstruction with a NGT is an uncommon but potentially life-threatening complication. NGT syndrome is characterized by the presence of an NGT, throat pain and vocal cord (VC) paralysis, usually bilateral. It is potentially life-threatening, and early diagnosis is the key to the prevention of fatal upper airway obstruction. However, fewer cases may have been reported than might have occurred, primarily due to the clinicians' unawareness. The lack of specific signs and symptoms and the inability to prove temporal relation with NGT insertion has made diagnosing the syndrome quite challenging. To review and collate the data from the published case reports and case series to understand the possible risk factors, early warning signs and symptoms for timely detection to prevent the manifestation of the complete syndrome with life-threatening airway obstruction. We conducted a systematic search for this meta-summary from the database of PubMed, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Google scholar, from all the past studies till August 2023. The search terms included major MESH terms "Nasogastric tube", "Intubation, Gastrointestinal", "Vocal Cord Paralysis", and "Syndrome". All the case reports and case series were evaluated, and the data were extracted for patient demographics, clinical symptomatology, diagnostic and therapeutic interventions, clinical course and outcomes. A datasheet for evaluation was further prepared. Twenty-seven cases, from five case series and 13 case reports, of NGT syndrome were retrieved from our search. There was male predominance (17, 62.96%), and age at presentation ranged from 28 to 86 years. Ten patients had diabetes mellitus (37.04%), and nine were hypertensive (33.33%). Only three (11.11%) patients were reported to be immunocompromised. The median time for developing symptoms after NGT insertion was 14.5 d (interquartile range 6.25-33.75 d). The most commonly reported reason for NGT insertion was acute stroke (10, 37.01%) and the most commonly reported symptoms were stridor or wheezing 17 (62.96%). In 77.78% of cases, bilateral VC were affected. The only treatment instituted in most patients (77.78%) was removing the NG tube. Most patients (62.96%) required tracheostomy for airway protection. But 8 of the 23 survivors recovered within five weeks and could be decannulated. Three patients were reported to have died. NGT syndrome is an uncommon clinical complication of a very common clinical procedure. However, an under-reporting is possible because of misdiagnosis or lack of awareness among clinicians. Patients in early stages and with mild symptoms may be missed. Further, high variability in the presentation timing after NGT insertion makes diagnosis challenging. Early diagnosis and prompt removal of NGT may suffice in most patients, but a significant proportion of patients presenting with respiratory compromise may require tracheostomy for airway protection.

Group 2 Innate Lymphoid Cells Are Detrimental to the Control of Infection with Francisella tularensis.

Innate lymphoid cells (ILCs) are capable of rapid response to a wide variety of immune challenges, including various respiratory pathogens. Despite this, their role in the immune response against the lethal intracellular bacterium Francisella tularensis is not yet known. In this study, we demonstrate that infection of the airways with F. tularensis results in a significant reduction in lung type 2 ILCs (ILC2s) in mice. Conversely, the expansion of ILC2s via treatment with the cytokine IL-33, or by adoptive transfer of ILC2s, resulted in significantly enhanced bacterial burdens in the lung, liver, and spleen, suggesting that ILC2s may favor severe infection. Indeed, specific reduction of ILC2s in a transgenic mouse model results in a reduction in lung bacterial burden. Using an in vitro culture system, we show that IFN-γ from the live vaccine strain-infected lung reduces ILC2 numbers, suggesting that this cytokine in the lung environment is mechanistically important in reducing ILC2 numbers during infection. Finally, we show Ab-mediated blockade of IL-5, of which ILC2s are a major innate source, reduces bacterial burden postinfection, suggesting that IL-5 production by ILC2s may play a role in limiting protective immunity. Thus, overall, we highlight a negative role for ILC2s in the control of infection with F. tularensis. Our work therefore highlights the role of ILC2s in determining the severity of potentially fatal airway infections and raises the possibility of interventions targeting innate immunity during infection with F. tularensis to benefit the host.

Total arch and descending thoracic aortic replacement for massive hemoptysis requiring CPR caused by intrapulmonary penetration of chronic dissecting aortic aneurysm: a case report

BackgroundIntrapulmonary penetration of the thoracic aorta is a rare, life-threatening complication of a chronic dissecting aortic aneurysm. It causes massive hemoptysis requiring prompt intervention to prevent fatal airway bleeding. A surgical approach that enables diverse surgical maneuvers and intraoperative organ protection is crucial.Case presentationA 62-year-old man, who underwent graft replacement of the ascending aorta for an acute type A aortic dissection 20 months before, developed massive hemoptysis and cardiac arrest. The hemoptysis was secondary to an aortopulmonary fistula from a rapidly expanding dissecting aortic aneurysm. However, a successful return of spontaneous circulation was achieved with cardiopulmonary resuscitation, including establishment of veno-arterial extracorporeal membrane oxygenation. The patient successfully underwent a total arch and descending thoracic aortic replacement. This was achieved by a median sternotomy combined with a left thoracotomy using a straight incision with a rib-cross (SIRC) approach. The patient was uneventfully discharged and remained well for the following 2 years.ConclusionsWhen performing a surgical graft replacement for an aortopulmonary fistula with a thoracic aortic aneurysm, the surgical approach chosen is critical. A surgical procedure using a median sternotomy combined with a left thoracotomy and a SIRC approach can be an effective therapeutic option.

A Comprehensive Review of Bradykinin-Induced Angioedema Versus Histamine-Induced Angioedema in the Emergency Department.

Angioedema (AE) is a condition that is frequently encountered in the emergency department (ED). It is a rare condition with localized, asymmetrical swelling of the skin and/or mucosa that is frequently nonpruritic and primarily affects locations with loose connective tissue. Physicians must have a thorough understanding of this condition since it can cause fatal airway compromise, which might be the presenting symptom. Histamine-mediated AE is the most common type of AE seen in EDs. However, ED physicians must be on the lookout for the less common bradykinin-mediated types of AEas these do not respond to the same therapy as histamine-mediated AE. Hospitals may lack specialized drugs or protocols, and many ED staff may be unable to identify or treat bradykinin-mediated AE. It is crucial to understand the pathophysiology of the various kinds of AE in order to optimize treatment. The goal of this review paper is to provide an overview of the pathophysiology, clinical manifestations, and treatment options for bradykinin and histamine-induced AE in the ED.

DOUBLE TROUBLE: CENTRAL AIRWAY OBSTRUCTION WITH HEMOPTYSIS FROM A METASTATIC YOLK SAC TUMOR

DOUBLE TROUBLE: CENTRAL AIRWAY OBSTRUCTION WITH HEMOPTYSIS FROM A METASTATIC YOLK SAC TUMOR

妊娠中に併発した縦隔原発B細胞性リンパ腫による気道狭窄症のために緊急帝王切開術を行い，ECMOを導入して救命した1例(A case report of fatal airway obstruction due to primary mediastinal B–cell lymphoma during pregnancy requiring cesarian section and ECMO)

要旨妊娠33週の30歳女性。6週間前から咳嗽が出現し数日前から臥位になれず近医を受診したところ，胸部CTで前縦隔腫瘍が気管と右主気管支とを圧排していたため同日転院となった。搬送時，起坐呼吸で頻脈があった。顔面の浮腫と頸静脈怒張があり，縦隔腫瘍による気道狭窄症と上大静脈症候群と診断した。呼吸苦は急速に進行しており気管挿管と陽圧換気が必要であった。妊娠継続は母体にとってリスクが高いと判断し緊急帝王切開術の方針としたが，術中に換気不全に陥る危険性があったためextra–corporeal membrane oxygenation（ECMO）を待機して手術を開始した。麻酔の導入から児の娩出までは問題なかったが，閉腹の際に換気量を保てず，veno–venous ECMOを導入した。第2病日に生検を行い，迅速病理検査で悪性リンパ腫と診断し化学療法を開始した。第6病日には胸部X線写真で肺野の透過性が改善して従圧式補助調節換気での一回換気量も増加したため，第8病日にECMOを離脱した。その後も化学療法を継続し，第35病日に人工呼吸器を離脱，第85病日に独歩退院となった。初診から3年8か月が経過した現在，再発はない。妊婦が縦隔腫瘍により重篤な呼吸不全を来すことは稀である。救命のためには，緊急帝王切開術の迅速な決断，必要なタイミングでECMOを導入したこと，迅速な病理診断と早期の治療開始が重要であった。

Isolated sublingual hematoma post internal carotid artery stenting for internal carotid artery stenosis in high-risk patients as uncommon and rare misadventure: A case report and review of literature.

Introduction and importanceIsolated sublingual hematoma is a rare complication seen in trauma, severe uncontrolled hypertension, dental operations, bleeding diathesis, and the use of dual antiplatelet and anticoagulant agents. In advanced and neglected cases, a sublingual hematoma may interfere with the patient's airway, causing suffocation and fatal airway obstruction. Our objective was to present a case of iatrogenic isolated sublingual hematoma in a 70-year-old business man, heavy smoker with a history of hypertension. Furthermore, to report the literature review, and to organize treatment strategies to reduce the rate of progression of the hematoma. In addition to recommend or advice a strategic plan to prevent this complication during carotid stenting.Case presentationThis case report has been reported in line with the SCARE Criteria. We represented a case report of an iatrogenic isolated mild/moderate sublingual hematoma in a 70-year-old business man. This hematoma developed as one of the rare complications of endovascular internal carotid artery revascularization because of injury to the sublingual branch of the lingual artery during wire manipulations or its advancement. This hematoma was treated by conservative treatment without any intervention.Clinical discussionImmediately after internal carotid artery stenting procedure, the patient developed a sudden onset of painful swelling in the floor of the mouth. The hematoma showing ecchymotic submucosal swelling underneath the tongue in the floor of the mouth. If it became enlarged, it may push the tongue against the palate and blocking the airway, causing serious airway obstruction. Fortunately, the swelling is isolated (has no extension to any side) and limited to the root and middle third of the tongue but, not extending to its tip. Its development most probably due to injured atherosclerotic sublingual branch of the lingual artery during the procedure.ConclusionsThe first step in management should be prompt airway management. Conservative treatment took place without any further intervention. To date, there is no consensus about the management regarding the hematoma itself. Mostly, clinicians start with observation for spontaneous resolution. When conservative treatment is not appropriate, surgical intervention must be performed. However, electively secure the airway is the main objective for treatment.

COMPARISON OF RECURRENT LARYNGEAL NERVE (RLN) PALSY WITH AND WITHOUT INTRAOPERATIVE NERVE IDENTIFICATION DURING THYROIDECTOMY – A CROSS-SECTIONAL STUDY FROM A TERTIARY LEVEL HOSPITAL IN PESHAWAR

Background:Recurrent laryngeal nerve (RLN) palsy is one of the most common and feared complications of thyroid surgeries. These may be transient or permanent and occur unilaterally or bilaterally, in case of which fatal airway obstruction is possible.
 Objectives:To compare the incidence of RLN palsy with and without intraoperative nerve identification during thyroidectomy.
 Materials and Methods: This is a descriptive cross-sectional study spanning over 9 months during the period July 2020 to March 2021. A pool of 70 patients was included in the study comprising of 18 males and 52 females. Data on demographic, clinical and postoperative variables were compared in relation to RLN palsy.
 Results:The overall incidence of RLN palsy in the study pool was 7.1%. The rate of RLN palsy was 3.51% in the 81.42% cases where intraoperative nerve identification was done and 13.04% incidence was found the remaining 32.86% cases where the nerve was not identified. The incidence of RLN palsy was 14.82% in ages above 45 years, 11.11% in male, 14.29% after total thyroidectomy and 40% with follicular carcinoma.
 Conclusion:Intraoperative nerve identification is an essential step in any thyroid surgery and has proven beneficial in reducing the incidence of RLN palsy.
 
 

A Rare Case Report of Ludwig’s Angina: Early Detection and Prevention of Airway Catastrophe

Background: Ludwig’s angina is infection of the soft tissue or gangrenous cellulitis, starting from the floor of mouth or base of the tongue. It can then directly spread to the soft tissue of neck, result in significant oedema and distortion of the adjacent airway, yielding fatal airway obstruction. Case Report: We report a case of 29 year old female who presented to our emergency department with sore throat for 2 weeks, fever for 12 days, progressively increasing pain in throat for 1 week. She was unable to swallow any solid as well as liquids since last night. In our case we picked up a diagnosis of Ludwig’s Angina quite early as we kept a high threshold of suspicion secondary to subtle signs of an impending airway problem: change in patient’s voice and subtle swelling of her chin described by the patient herself. A CT neck & floor of mouth confirmed our clinical suspicion and diagnosis of Ludwig's Angina. We managed her with aggressive early intravenous (IV) antibiotics, IV steroids and IV hydration and could prevent a fatal airway complication to transpire. Why Should an Emergency Physician Be Aware of This? We, the authors believe that every emergency physicians must be aware of Ludwig’s Angina, though a rare condition but can give rise to fatal airway obstruction and airway management mishaps in emergency departments. We highlighted the importance to recognise early signs of threatened airway, which can be subtle to begin with and easily be missed, if not a very high suspicion, which only comes from being perspicacious about this condition. Early diagnosis and management can reduce mortality and morbidity significantly.

A safe procedure? The unusual case of a fatal airway obstruction by silicone during the production process of a tracheostomal epithesis in a 13-year-old boy

A tracheostomal epithesis is a plastic prosthesis that serves for sealing a tracheostoma and ensuring the position of the tracheostomy tube. The production of a tracheostomal epithesis requires an impression of the tracheostoma. To this end, silicone impression material is applied by an anaplastologist in and around the tracheostomal region, including the trachea. The blocked cuff of the tracheostomy tube serves to prevent aspiration of the material. We report on a 13-year-old boy who died during this procedure because the lower airways were obstructed with cured silicone. Forensic autopsy confirmed asphyctic suffocation as cause of death. Forensic physical investigation of the tracheostomy tube and its cuff revealed no structural or functional defects. Yet, the investigation results prove that the viscous silicone must have passed the cuff. To conclude, this case report demonstrates that the production of an impression of a tracheostoma is a procedure with a potentially lethal outcome. Hence, professional guidelines, including clear safety precautions, are urgently needed.

Dual PD-L1 and TGF-b blockade in patients with recurrent respiratory papillomatosis

BackgroundRecurrent respiratory papillomatosis (RRP) is a human papillomavirus (HPV) driven neoplastic disorder of the upper aerodigestive tract that causes significant morbidity and can lead to fatal airway obstruction. Prior clinical...

Endovascular Management of Internal Carotid Artery Pseudoaneurysm Secondary to Pediatric Deep Neck Space Infection: A Case Report and Review of Literature

AbstractPseudoaneurysms of extracranial internal carotid artery (ICA) are rare in children. Main causes include trauma, iatrogenic causes, and neck space infection. Prompt diagnosis and management is vital, in view of life-threatening complications like fatal airway hemorrhage and stroke. Endovascular management has currently become the preferred treatment strategy due to its minimally invasive nature and lower complication rates. We report a rare case of mycotic pseudoaneurysm of extracranial ICA in a 4-year-old child as a complication of neck space infection, which was successfully managed with endovascular parent artery occlusion.

Fatal Acute Upper Airway Obstruction Due to Cervical Goiter: A Rare Case Report

Fatal Acute Upper Airway Obstruction Due to Cervical Goiter: A Rare Case Report

気管・気管支軟化症に伴う致死的気道虚脱に対する気道管理手法の経験(A case of airway management for fatal airway collapse associated with tracheobronchomalacia)

要旨 気管・気管支軟化症は気管壁の脆弱性のため，呼気時に高度の気道虚脱を来す疾患である。咳嗽，喘鳴，呼吸苦などの呼吸症状を呈し，重篤な場合には気道の完全虚脱により死に至った症例もある。本疾患は臨床症状と気管・気管支の脆弱性の証明により診断を行うが，近年内視鏡検査による気道脆弱性の定量的な評価を行う気道内圧断面積試験が報告されている。今回我々は，肺炎を契機に呼吸不全を呈し，治療中dying spellを来した成人脳性麻痺症例を経験した。本症例は既往歴に気管・気管支軟化症を持ち，当院入院後の内視鏡検査では気管，左主気管支で軟化所見を認め，気道内圧断面積試験を行った結果，予測気道閉塞内圧が気管では −44.9cmH2O，左主気管支では −23.1cmH2Oと気道脆弱性が証明された。人工呼吸器離脱のために気管切開を先行し，気管の軟化部より末梢側までカバーするよう気管切開チューブを適切な位置に留置することで気道閉塞を回避することができた。

Death Due to Obstruction of Airways by a Hyperplastic Polyp: An Unusual Complication of Treated Desmoid Fibromatosis.

Desmoid fibromatosis (DF) is a rare, locally aggressive but benign clonal fibroblastic lesion of deep soft tissue. It can occur at any age. Extra-abdominal lesions are more common in the pediatric population, with equal sex predilection. Desmoid fibromatosis of the head and neck, particularly the anterior neck, is more difficult to manage because of the proximity to vital structures and may eventually require definitive airway management with insertion of a tracheostomy tube. Indwelling tracheostomy tubes carry their own set of complications. This is the case of a 21-month-old boy who died suddenly due to tracheal obstruction by a hyperplastic polyp. He was diagnosed with DF of the neck before he was 1 month old and required an indwelling tracheostomy tube as a result. Chronic tracheostomy intubation can be complicated by granulation tissue polyp or, less commonly, fibroepithelial polyp formation that can become large enough to cause airway obstruction. To the authors' knowledge, this is the first case of hyperplastic polyp causing fatal airway obstruction.

Fatal airway obstruction due to a ball-valve clot with identical signs of tension pneumothorax

Endo-tracheal tube obstruction due to an extensive blood clot is a recognized but very rare complication. A ball-valve obstruction in the airway could function as a check valve for the lung and thorax, resulting in tension pneumothorax-like abnormalities. A 47-year-old female patient had undergone implantation of a left ventricular assist device 3 weeks prior. On post-operative day 17, planned thoracentesis was performed for drainage of a pleural effusion. Despite the drainage, the patient’s oxygenation did not improve, and emergency tracheal intubation was conducted. Subsequent computed tomography revealed bilateral pneumothorax. Two days later, the patient’s trachea was extubated without complication, and a mini-tracheostomy tube was placed. Three hours later, reintubation was conducted due to progressive tachypnea. Although successful intubation was confirmed, ventilation became increasingly difficult and finally impossible. Marked increase in pulmonary artery and central venous pressures suggested progression of the previous tension pneumothorax. After emergency extracorporeal membrane oxygenation was initiated, fiberoptic bronchoscopy revealed the presence of a massive clot and ball-valve obstruction of the endotracheal tube. Two weeks later, the patient died due to severe hypoxic brain damage. Diagnosis of ball valve clot is not simple, but intensivists should consider this rare complication.

Airway emergency during general anesthesia in a child with plastic bronchitis following Fontan surgery: a case report

BackgroundPlastic bronchitis (PB) is a complication of Fontan surgery, results in the formation of mucus plug in the tracheobronchial tree, causing potentially fatal airway obstruction. We report critical airway emergency during general anesthesia in a child with plastic bronchitis.Case presentationA 5-year-old boy was scheduled for intrapulmonary lymphatic embolization through percutaneous catheterization under general anesthesia. He underwent Fontan surgery at the age of 2 and frequently developed respiratory failure due to plastic bronchitis. After induction of general anesthesia and tracheal intubation, mechanical ventilation became difficult even with an inspiratory pressure ≥ 50 mmHg due to airway obstruction. He expectorated a large mucus plug through the tracheal tube after administration of sugammadex, naloxone, and flumazenil, and respiratory condition was stabilized thereafter.ConclusionGeneral anesthesia for a patient with plastic bronchitis should be planned with extracorporeal membrane oxygenation or cardiopulmonary bypass stand by.

Acute supraglottic laryngitis complicated by vocal fold immobility: prognosis and management.

Acute supraglottic laryngitis (ASL) is manifested by supraglottic inflammation that has the potential for rapid and fatal airway obstruction. Complete/incomplete vocal fold immobility (VFIm) in the setting of ASL may contribute to airway obstruction. The rate of VFIm complicating ASL is not known, and it is not clear whether its occurrence alters the course and the management of ASL, particularly the need to secure the airway (by endotracheal intubation/tracheostomy). This study seeks to describe the natural history of VFIm associated with ASL (ASLIm) and to determine the added effect of VFIm on ASL severity, management, and the need for intervention to secure the airway. This is a retrospective cohort study in a tertiary referral center. The medical records of all patients hospitalized due to ASL between January 2007 and December 2016 were reviewed. Of the 214 patients admitted due to ASL, VFIm was identified in 9 (4.2%). The VFIms resolved within 1-90days in all 8 patients with available follow-up of 1-3months. One patient required endotracheal intubation. The 9 ASLIm patients had significantly higher rates of hoarseness and a history of diabetes mellitus. There was no group difference in the need to secure the airway. VFIm is an apparently uncommon finding among patients with ASL. It appears to be usually transient, short-lasting, and full recovery can be expected. VFImdid not alter the ASL course, nor did it put our patients at increased risk for the need for intervention to secure the airway. 4.