Airway Injury Research Articles

Posterior membranous tracheal injury during mckeown oesophagectomy. A case report with literature review

Minimally invasive techniques such as thoracoscopic or robotic surgical approaches for oesophageal pathologies have been gaining traction as the preferred method of surgical technique. McKeown’s minimally invasive oesophagectomy has been shown to reduce hospitalisation, with reduced cardiopulmonary morbidities. However, it is not without complications, and an iatrogenic tracheobronchial injury (TBI) could occur intraoperatively during anatomical plane dissection. We report a case of iatrogenic posterior membranous tracheal injury during the thoracic dissection of a McKeown’s oesophagectomy, detected intraoperatively and patient recovered without any complications. The diagnosis of TBI involves a multicentric approach. Confirmation of the diagnosis and classification of TBI based on clinical signs, radiological studies, and endoscopy procedures such as bronchoscopy are necessary to tailor the best possible management for the patient. In cases where a full-thickness airway defect exceeds 2 cm and is detected intraoperatively, immediate primary repair is advised to optimize outcomes. TBI pose significant clinical challenges, particularly in cases of iatrogenic injury during procedures such as minimally invasive oesophagectomy. While the overall incidence of TBI remains low, awareness of risk factors and vigilant monitoring during procedures is paramount. While TBI remains rare, its management shares principles with oncological oesophageal surgery, making this case pertinent to surgical oncology practice. The evolving landscape of diagnostic techniques, including bronchoscopy and advanced imaging modalities, facilitates prompt and accurate identification of injuries, enabling timely intervention.

Inhibition of the MRTF-A/SRF signaling axis alleviates vocal fold scarring.

Inhibition of the MRTF-A/SRF signaling axis alleviates vocal fold scarring.

Comparison of Haemodynamic Changes and Intubation Conditions during Awake Fiberoptic Oral Intubation using Conscious Sedation with Either Dexmedetomidine or Fentanyl: A Prospective Interventional Study

Introduction: Awake Fiberoptic Intubation (AFOI) is the preferred intubation technique in cases of anticipated difficult airway or unstable cervical spine injury. The patient will not be comfortable if it is performed without the appropriate sedative. AFOI achieves a better safety profile and a higher success rate due to preserved muscle tone and minimal risk of desaturation. Aim: To compare the effects of fentanyl and dexmedetomidine on haemodynamic changes and intubating conditions during AFOI in patients scheduled for elective cervical spine surgery. Materials and Methods: In this prospective interventional study conducted at Fortis Hospitals, Bengaluru, Karnataka, India, 84 patients aged 18 to 60 years with American Society of Anaesthesiologists (ASA) grade I or II, scheduled for elective cervical spine surgery requiring AFOI, were randomly assigned to two groups. Group A received dexmedetomidine at a dose of 1 µg/kg intravenously over 10 minutes, while Group B received fentanyl at a dose of 2 µg/kg intravenously over 10 minutes. Sedation levels were assessed using the Ramsay Sedation Score (RSS), and intubation was performed when the score reached 2 or higher. Intubation conditions were evaluated based on the cough score during bronchoscopy and the postintubation score. Statistical analysis, including appropriate tests such as t-tests or Chi-square tests, was conducted to assess differences in changes in pulse rate, Mean Arterial Pressure (MAP), and oxygen saturation during AFOI between the two groups and to evaluate the occurrence and significance of any adverse effects. Results: The mean age of the patients was 41.12±3.73 years in Group A and 40.21±3.03 years in Group B. Group A showed superior RSSs compared to Group B. Additionally, Group A demonstrated more favourable cough and postintubation scores in comparison to Group B. During the intubation and postintubation phases, Group B experienced a notable increase in pulse rate and MAP, whereas these haemodynamic parameters remained stable in Group A. Furthermore, Group A exhibited no significant desaturation events in contrast to Group B. Conclusion: Dexmedetomidine proved to be more effective than fentanyl for AFOI, providing superior intubating conditions by ensuring better patient comfort, which was assessed and confirmed through favourable scores on RSS (score of 2), cough score (score of 1), and postintubation score (score of 1). These advantages make dexmedetomidine the preferred choice for AFOI, offering a more favourable balance of sedation, haemodynamic stability and oxygenation.

Navigating Bloodless ECMO: A Case of Tracheal Injury Repair in a Jehovah's Witness Patient

Navigating Bloodless ECMO: A Case of Tracheal Injury Repair in a Jehovah's Witness Patient

Silicone Y Tracheal Stent Used to Treat Iatrogenic Tracheal Injury With Veno Venous Extracorporeal Membrane Oxygenation (ECMO) Support

Silicone Y Tracheal Stent Used to Treat Iatrogenic Tracheal Injury With Veno Venous Extracorporeal Membrane Oxygenation (ECMO) Support

Early Detection and Ventilator Adjustment in Managing Post-intubation Tracheal Injury in an ARDS Patient: A Case Report

Early Detection and Ventilator Adjustment in Managing Post-intubation Tracheal Injury in an ARDS Patient: A Case Report

Claudin-18 Restricts Goblet Differentiation During Airway Injury Response

Claudin-18 Restricts Goblet Differentiation During Airway Injury Response

PROSEAL LARYNGEAL MASK AIRWAY VERSUS CLASSIC LARYNGEAL MASK AIRWAY FOR AIRWAY MANAGEMENT IN BURN NECROSIS AND SKIN GRAFTING SURGERY

Objectives: To compare the efficiency of the classic laryngeal mask airway (c-LMA) and the proseal laryngeal mask airway (p-LMA) in patients with indications for burn necrosis and skin grafting surgery. Methods: A clinical descriptive, randomized comparison study was conducted on 60 patients divided into two groups: p-LMA (30 patients) and c-LMA (30 patients) were anesthetized with p-LMA and c-LMA, respectively. Accessing and comparing the ease of placement, respiratory function, and hemodynamic response, and the degree of airway injury after surgery between two groups. Results: 100% patients were successfully inserted laryngeal mask airway (LMA) with insertion time of 22.14 seconds and 20.56 seconds, respectively (p > 0.05); oropharyngeal leak pressure (OLP) was 28.56 cmH2O (p-LMA) and 19.66 cmH2O (c-LMA) (p < 0.05); hemodynamic and respiratory function during surgery were maintained in normal range and there was no difference between the two groups (p > 0.05), and no airway complications related to insertion technique (sore throat, hoarseness, or blood staining) were found in either group. Conclusion: Both LMAs are useful for managing airways in burn necrosis and skin grafting procedures. Both kinds of masks are simple to put on, do not significantly alter hemodynamic response or respiratory function, and patients recover safely from LMA placement without any problems.

Comparison of the incidence and severity of postoperative sore throat and subglottic airway injury with cylindrical versus tapered cuff endotracheal tubes in women undergoing surgery for breast cancer: a randomized controlled trial

BackgroundPostoperative sore throat (POST) is a minor complication of general anesthesia with tracheal intubation but may negatively affect patient satisfaction and postoperative recovery. The shape of the endotracheal tube (ETT) cuff may influence the incidence and severity of POST.MethodsThis prospective, randomized, double-blinded study was conducted on 174 female patients with breast cancer. They were randomized into the cylindrical (CYL) (group C) and tapered (TAP) (group T) cuff ETT groups. Data on patient demographics, surgical characteristics, and factors related to tracheal intubation were collected. Furthermore, the incidence and severity of POST at the selected time points were duly recorded for analysis. Other adverse events and anesthesia satisfaction were also documented.ResultsDuring the 48-h evaluation period, group T exhibited reduced overall incidence of POST compared with group C. The incidence and severity of POST at 1, 6, 12, 24, and 48 h postoperatively were also significantly lower in group T than in group C. No significant difference in subglottic airway injury was observed between the two groups. Postoperative anesthesia satisfaction was higher in group T.ConclusionsThe present study demonstrates that the utilization of a TAP cuff ETT rather than a CYL cuff ETT in patients undergoing breast cancer surgery reduced the incidence and severity of POST. The selection of an appropriate ETT for surgical patients could play a pivotal role in alleviating airway complications, enhancing postoperative recovery, and improving anesthesia satisfaction.Trial registrationThe study was registered at ClinicalTrials.gov (NCT06505850) on 2024-07-17.

Effects of the head-elevated position on cervical spine motion during videolaryngoscopic intubation with manual in-line stabilization: a randomized controlled trial.

The head-elevated position during videolaryngoscopic intubation enables better visualization of the glottis than the head-flat position. We hypothesized that the head-elevated position would result in less cervical spine motion during videolaryngoscopic intubation under manual in-line stabilization. We conducted a randomized controlled trial in which we assigned patients undergoing coil embolization for unruptured cerebral aneurysms into the head-elevated (N = 55) or head-flat (N = 54) groups. Manual in-line stabilization was applied to simulate cervical spine immobilization during Macintosh-type videolaryngoscopic intubation. To measure the cervical spine angle, two lateral cervical spine radiographs using the capture method were taken, one before and one during intubation, respectively. The primary outcome was cervical spine motion during intubation (cervical spine angle during intubation - cervical spine angle before intubation) at the occiput-C1 segment. We investigated cervical spine motion at the C1-C2 and C2-C5 segments; intubation performance, such as the success rate at the first attempt, intubation time, and frequency of external laryngeal maneuver; and intubation-associated airway complications (airway bleeding, injury, sore throat, and hoarseness). There was significantly less cervical spine motion at the occiput-C1 segment in the head-elevated group than the head-flat group (mean [standard deviation], 8.6° [5.6°] vs 11.4° [5.7°]; mean difference [95% confidence interval], -2.9° [-5.0 to -0.7]; P = 0.009). Cervical spine motion at the C1-C2 and C2-C5 segments, intubation performance, and intubation-associated airway complications did not significantly differ between the groups. The head-elevated position during Macintosh-type videolaryngoscopic intubation with manual in-line stabilization resulted in less upper cervical spine motion than the head-flat position. CRIS.nih.go.kr ( KCT0008669 ); date of registration (approved), 1 August 2023.

Current state of causes, pathophysiology, and treatment methods of laryngeal and tracheal trauma in Japan.

Current state of causes, pathophysiology, and treatment methods of laryngeal and tracheal trauma in Japan.

Visual-Guided Transillumination Method for Accurate Percutaneous Tracheal Tube Placement.

Percutaneous tracheostomy (PT) is generally considered a safe procedure, but complications such as malpositioning, bleeding, and tracheal ring rupture remain concerns, particularly during initial needle insertion. This study investigates the feasibility, ease of use, and safety of a novel device and technique for bedside PT, named the Illuminated Tracheal Alignment Guide (iTAG). An interventional pilot study evaluated the feasibility and safety of the iTAG device and method. The study was approved by our local institutional review board and a Food and Drug Administration waiver was granted for use of our device. Patients in a neurocritical care unit requiring tracheostomy were screened and consented for inclusion. Exclusion criteria included significant vascular overlap and specific ventilator settings. The iTAG method involves a laser light source and a needle guide with a hard stop, used in conjunction with standard PT equipment. Data on demographics, procedure details, and early complications were collected and compared with historical control data from patients who underwent standard tracheostomy (ST). From January 2023 to July 2024, 30 patients underwent PT using the iTAG device. The mean time from intubation to tracheostomy was 15.53 days, with a mean ICU length of stay of 31.14 days. The iTAG group experienced significantly fewer early complications compared with the historical ST control group, including reduced hemorrhage, and there were no instances of tracheal ring fracture, posterior wall injury, or pneumothorax. The iTAG method allowed for safe PT in all patients. The iTAG device enhances the safety and efficacy of PT by providing precise visualization and limiting needle penetration, reducing early complications. Its use expands patient candidacy for PT and offers a valuable tool for training less-experienced practitioners. Further research with larger cohorts and randomized controlled trials is needed to confirm these findings and establish the iTAG method as a standard of care for PT.

Contribution of post-infectious bronchiolitis obliterans to non-cystic fibrosis bronchiectasis in children.

<sec><title>BACKGROUND</title>Post-infectious bronchiolitis obliterans (PIBO) is a complication of severe childhood respiratory infection resulting in small airway injury, bronchiectasis, and prolonged respiratory consequences. Risk factors for PIBO and PIBO-associated bronchiectasis are unclear.</sec><sec><title>METHODS</title>This retrospective study identified all children with PIBO at a South African tertiary hospital between 1 January 2016 and 31 December 2022. The clinical characteristics, chest CT findings, and details of prior hospitalisation for respiratory infection were collected, and the characteristics of those with and without bronchiectasis were compared.</sec><sec><title>RESULTS</title>A total of 59 children were included (median age at primary lung insult: 10 months, IQR 6-17; median age at PIBO diagnosis: 16 months, IQR 11-28). Twenty-three had comorbidities, most frequently premature birth (30.5%) and HIV infection (6.8%). The most common pathogen was adenovirus (n = 41; 69.5%). At initial lung insult, 19 (32.2%) required mechanical ventilation. Mosaic attenuation on the chest CT was present in all. Thirty-three (55.9%) had bronchiectasis. The clinical characteristics, ventilation, causative pathogen, and comorbidity were similar in those with and without bronchiectasis.</sec><sec><title>CONCLUSION</title>Bronchiectasis occurs frequently in paediatric PIBO and is present within months of initial respiratory insult with no identified risk factors. Premature birth is common and may contribute to PIBO development.</sec>.

Imaging of tracheobronchial and laryngeal injuries.

Tracheobronchial and laryngeal injuries are relatively rare and may be life-threatening. Rapid diagnosis of these injuries is critical for the survival of patients. Findings of tracheobronchial and laryngeal injuries can be subtle. This pictorial essay reviews the imaging findings of tracheobronchial and laryngeal injuries.

A Case of Tracheal Injury during Emergency Tracheal Intubation

A Case of Tracheal Injury during Emergency Tracheal Intubation

Ferrostatin-1 inhibits tracheal basal cell ferroptosis to facilitate the rapid epithelization of 3D-printed tissue-engineered tracheas

BackgroundTracheal replacement is a promising approach for treating tracheal defects that are caused by conditions such as stenosis, trauma, or tumors. However, slow postoperative epithelial regeneration often leads to complications, such as infection and granulation tissue formation. Ferroptosis, which is an iron-dependent form of regulated cell death, limits the proliferation of tracheal basal cells (TBCs), which are essential for the epithelialization of tissue-engineered tracheas (TETs). This study explored the potential of ferrostatin-1 (FER-1), which is a ferroptosis inhibitor, to increase TBC proliferation and accelerate the epithelialization of 3D-printed TETs.MethodsTBCs were isolated from rabbit bronchial mucosal tissues and cultured in vitro. Ferroptosis was induced in TBCs at passage 2, as shown by increased reactive oxygen species (ROS) levels, Fe2⁺ accumulation, decreased ATP contents, and mitochondrial damage. TBCs were treated with FER-1 (1 μM) for 48 h to inhibit ferroptosis. The effects on ROS levels, Fe2⁺ levels, ATP contents, and mitochondrial morphology were measured. For in vivo experiments, FER-1-treated TBCs were seeded onto 3D-printed polycaprolactone (PCL) scaffolds, which were implanted into rabbits with tracheal injury. Epithelial regeneration and granulation tissue formation were evaluated 6 months after surgery.ResultsFER-1 treatment significantly reduced ferroptosis marker levels in vitro; that is, FER-1 treatment decreased ROS and Fe2⁺ accumulation, ameliorated mitochondrial structures, and increased ATP levels. TBC proliferation and viability were increased after ferroptosis inhibition. In vivo, the group that received 3D-printed scaffolds seeded with TBCs exhibited accelerated TET epithelialization and reduced granulation tissue formation compared with the control groups. These results suggest that inhibiting ferroptosis with FER-1 improves TBC function, leading to more efficient tracheal repair.ConclusionsFerrostatin-1 effectively inhibits ferroptosis in tracheal basal cells, promoting their viability and proliferation. This results in faster epithelialization of tissue-engineered tracheas, offering a promising strategy for improving tracheal reconstruction outcomes and reducing complications such as infection and granulation tissue formation. Future studies are needed to further investigate the molecular mechanisms underlying ferroptosis in TBCs and its potential clinical applications.

Tracheal rupture resulting from superinfected aortic intramural hematoma in ascending aortic prosthesis.

Tracheal rupture resulting from superinfected aortic intramural hematoma in ascending aortic prosthesis.

Modulation of the Epithelial–mesenchymal transition process by Forkhead Box C2 in the repair of airway epithelium after injury

BackgroundEpithelial–mesenchymal transition (EMT) is regarded as a key process in repair of airway epithelium after injury. Forkhead Box C2 (FOXC2) is a transcription factor involved in EMT process, whether it is involved in repair of bronchial epithelium remains unknown.MethodsC57BL/6 mice were subjected to intraperitoneal injection with naphthalene (NAPH; 200 mg/kg) to induce airway injury model. qPCR, immunoblot and FOXC2 immunohistochemistry assays were conducted to detect the expression of FOXC2 in bronchial epithelium. To explore the function of FOXC2 in NAPH-induced airway injury, the mice were given intratracheal administration of shFOXC2- or shNC-lentivirus particles, followed by NAPH treatment. Hematoxylin-and-eosin staining was used to assess the histopathology of the bronchial epithelium. Immunofluorescence analysis of CCSP, a club cell marker confirmed the CCSP expression in bronchial epithelium. Immunoblot and immunofluorescence assays determined the expression of E-cadherin, vimentin, and N-cadherin. In mouse primary bronchial epithelial cells (PBECs), we overexpressed and silenced FOXC2 by lentivirus particles, respectively. Cell migration was analyzed using wound healing assay. Immunoblot assays determined the E-cadherin, vimentin, FN-EDA expression in TGF-β1-induced PBECs. mRNA sequencing (mRNA-seq) and FOXC2 ChIP sequencing (ChIP-seq) to reveal the downstream genes of FOXC2 in TGF-β1-induced PBECs. Luciferase assay, ChIP-PCR and functional rescue experiments were performed to confirm the interaction of FOXC2/formin binding protein 1 (FNBP1) in TGF-β1-induced PBECs.ResultsFOXC2 expression was up-regulated in the lung tissues of mice at 2, 3 and 6 days post-NAPH. FOXC2 knockdown in bronchial epithelium of mice delayed CCSP+ club cell regeneration and normal repair of the airway epithelium within 14 days after injury. Knockdown of FOXC2 increased E-cadherin but decreased vimentin and N-cadherin, EMT markers during early phase after injury. In vitro, knockdown of endogenous FOXC2 repressed the migration of cells and increased TGF-β1-induced E-cadherin but decreased vimentin, N-cadherin and FN-EDA. Exogenous FOXC2 addition exerted opposite effects. Furthermore, mRNA-seq and FOXC2 ChIP-seq revealed that FNBP1 might be a downstream target of FOXC2. Overexpression of FNBP1 reversed the inhibitory role of FOXC2 knockdown in EMT.ConclusionsThese data highlight the important function of FOXC2 as a regulator in repair of bronchial epithelium after injury.Graphical

Middle-Lobe Bronchus Transection in Blunt Thoracic Trauma From a High-Speed Motor Vehicle Collision: A Case Report.

BACKGROUND Bronchial rupture following blunt thoracic trauma is an uncommon but potentially fatal injury that requires early recognition and appropriate intervention. Timely diagnosis and multidisciplinary trauma care are essential for improving outcomes and preventing complications. CASE REPORT A 52-year-old man with no prior medical history was admitted to the Emergency Department after a high-speed motor vehicle collision. He presented with multiple injuries, dyspnea, and thoracic and pelvic pain. His initial Glasgow Coma Scale (GCS) score was 15/15. Physical examination revealed subcutaneous emphysema in the cervical region, a distended right hemiabdomen, and absent breath sounds in the right lung. Multiple right-sided chest wall lacerations were noted. An extended focused assessment with sonography in trauma (eFAST) was suggestive of intra-abdominal free fluid, prompting further imaging. A chest CT confirmed the right pneumothorax. An exploratory laparotomy revealed 200 cc of hemoperitoneum, grade 1 liver trauma (segments II and IV), and a non-bleeding hepatic hilum hematoma. Additional procedures included cystostomy, left iliac vein clamping, and pelvic bone stabilization with external fixators. Due to worsening respiratory status on postoperative day 2, the patient underwent an emergency thoracotomy, which revealed a 200-mL clot hemothorax in the costodiaphragmatic recess, middle-lobe contusions, ischemia, and a complete transection of the middle-lobe bronchus extending to the intermediate bronchus. Rib fractures (5th and 6th) necessitated a middle lobectomy and rib fixation. CONCLUSIONS This case underscores the importance of a high index of suspicion for tracheobronchial injuries in blunt thoracic trauma. While eFAST aids in initial assessment, definitive diagnosis requires advanced imaging modalities such as CT and bronchoscopy. Timely surgical interventions and a coordinated multidisciplinary approach are essential for optimal patient outcomes. By sharing this case, we aim to contribute to the understanding and management of rare bronchial injuries.

Tenascin-X Deficiency Causing Classical-Like Ehlers-Danlos Syndrome Type 1 in Humans is a Significant Risk Factor of Gastrointestinal and Tracheal Ruptures.

Classical-like Ehlers-Danlos syndrome type 1 (clEDS1) is a very rare form of Ehlers-Danlos syndrome caused by tenascin-X deficiency, with only 56 individuals reported in medical literature. Tenascin-X is an extracellular matrix protein needed for collagen stability. Previous publications propose that individuals with clEDS1 might be at risk of gastrointestinal (GI) tract perforations and/or tracheal ruptures. The aim of this study was to characterize complications resulting from perforations of the GI tract and/or tracheal rupture in an international case series of individuals with clEDS1 due to disease-related tissue fragility. This case series includes individuals with confirmed clEDS1 and GI perforations and/or tracheal ruptures from participating centers. Researchers who previously reported such individuals were contacted for additional information. A retrospective assessment of clinical features was performed. Fifteen individuals were included. Ten had spontaneous GI perforations, 7 of whom had multiple GI perforations. Almost all had severe diverticulosis. Three individuals experienced iatrogenic tracheal ruptures. Severe GI complications, such as perforation, and tracheal rupture were observed in a substantial number of individuals with clEDS1. As these features seem significantly more common in clEDS1 than in the average population, we advise vigilance during intubation and GI endoscopic interventions of individuals with clEDS1. Routine referrals to clinical geneticists are recommended for patients with symptoms indicative of clEDS1, especially with unexplained GI perforations and connective tissue symptoms. Our findings offer valuable insights for the clinical management of clEDS1 and underscore the importance of specialized care, providing a foundation for improved clinical guidelines and preventive strategies.