Airway Injury Research Articles

Endoscopic treatment of intermediate bronchus rupture in a 4-year-old child with polytrauma

In the structure of children's injuries, thoracic trauma occurs in less than 10% of cases, but it is the second most likely cause of death of a child. The culprit of the fatal outcome may be a rupture of the bronchus, which disrupts adequate ventilation of the lungs. The purpose of our publication is to demonstrate a rare clinical case of successful endoscopic treatment of intermediate bronchus rupture in a 4-year-old child with polytrauma. Description of the observation. A 4-year-old boy was injured in an accident as a pedestrian. For the first 3 days, he was treated for polytrauma (ISS=41) in the hospital at the place of residence, where, according to emergency indications, drainage of the right pleural cavity with two drains for tension pneumothorax and laparotomy for intra-abdominal bleeding due to liver rupture were performed. The relative stabilization of the child's condition by the 3rd day of the post-traumatic period made it possible to transport him to our clinic (level 1 trauma center). Against the background of the therapy, stable stabilization of hemodynamics was achieved, but air blowing through the drains was preserved, complete expansion of the right lung parenchyma could not be achieved, and the gas composition of the blood remained subcompensated. On the 5th day of the posttraumatic period, LTBS was performed, which made it possible to diagnose a rupture of the intermediate bronchus measuring 3x9 mm and perform its occlusion with a positive effect. After 7 days, LTBS was performed with the removal of blockers. After the removal of the blockers, complete expansion of the right lung was noted, recurrence of the bronchopulmonary fistula was not noted. The duration of mechanical ventilation and hospitalization of the child was due to TBI. In the follow-up after 1 year, clinical laboratory, X-ray and endoscopic examination did not reveal respiratory pathology. Conclusion. The cause that disrupts adequate ventilation of the lungs and aggravates the course of the post-traumatic period in polytrauma may be bronchus rupture. In the presented case, intraluminal endoscopy made it possible to timely detect a rupture of a large bronchus and perform minimally invasive surgical treatment, which ensured further positive dynamics in the child's condition and a favorable outcome of polytrauma as a whole.

A Case of Posterior Tracheal Wall Rupture During Tracheostomy Treated With Sternocleidomastoid Muscle Reinforcement

A posterior tracheal wall rupture is a rare but life-threatening complication of tracheostomy. Several flaps based on the sternocleidomastoid (SCM) muscle, which has sufficient length and abundant blood supply, are utilized for the reconstruction of tracheal defects. We discuss here a case of a 71-year-old male with multiple organ failure and mental retardation, with posterior tracheal wall damage that had occurred during tracheostomy tube insertion. When planning the repair of the wound, additional reinforcement was necessary due to saliva leakage secondary to decreased consciousness. Direct suturing was followed by the reinforcement of SCM muscle transposition, which was conducted through cervical and endoscopic approach.

Identification of Nicotinic Acetylcholine Receptor for N-Acetylcysteine to Rescue Nicotine-induced Injury Using BeatingCilia in Primary Tissue Derived Airway Organoids.

Smoking is one of the major contributors to airway injuries. N-acetylcysteine (NAC) has been proposed as a treatment or preventive measure for such injuries. However, the exact nature of the smoking-induced injury and the protective mechanism of NAC are not yet fully understood. Here, patient tissue-derived airway organoids for modeling smoking-induced injury, therapeutic investigation, and mechanism studies are developed. Airway organoids consist mainly of ciliated cells, together with basal cells, goblet cells, and myofibroblast-like cells. The organoids display apical-out and basal-in polarity and are enriched in beating cilia, which are sensitive to smoking challenge and NAC treatment. An algorithm is developed to measure ciliary beating activity by analyzing the altered beating pattern of cilia in response to nicotine challenge and NAC treatment. Nicotinic acetylcholine receptors (nAChRs) expressed by airway organoids are involved in the mechanisms of nicotine-induced injury through the nicotine-nAChR pathway. In contrast to the common understanding that NAC has an antioxidative effect that mitigates airway damage, it is elucidated that NAC binding to nicotine can abolish the binding capacity of nicotine to nAChRs and thus prevent nicotine-induced injury. This study focuses on the advances and potential of humanized organoids in understanding biological processes, mechanisms, and identifying therapeutic targets.

Tips and tricks in the operative management of esophageal, trachea, and bronchial injuries: What you need to know.

Tracheal injuries can be immediately life-threatening. Fiberoptic bronchoscopy in the operating room can make the diagnosis and satisfy the principle of achieving an airway distal to the injury. Repair is performed with a single layer of absorbable suture. Esophageal injuries are diagnosed with imaging, endoscopy, or intraoperatively. In the chest, esophageal injuries are best repaired through posterolateral incisions. Repairs are performed in one or two layers, and drains are routinely used. For a damage-control approach to esophageal injuries, wide drainage can be considered. For both tracheal and esophageal injuries, the operative approach is based on the anatomic location of the injury and muscle flap buttressing of the repairs is routinely employed.

Streptococcus salivarius pneumonia-associated pneumomediastinum: a case report and literature review

BackgroundStreptococcus salivarius is an opportunistic pathogen, and there have been no reported cases of Streptococcus salivarius pneumonia to date. Pneumomediastinum is usually secondary to tracheal or esophageal injury and is very rare as a complication of pneumonia. We report a case of Streptococcus salivarius pneumonia complicated by pneumomediastinum, aiming to enhance clinicians’ awareness of rare pathogens and uncommon complications in pneumonia.Case presentationThe patient, a 36-year-old male, presented with a persistent cough and sputum production for one week, accompanied by a sore throat that had developed just one day prior. Chest computed tomography (CT) disclosed pneumomediastinum alongside obstructive atelectasis in the left lower lobe. Streptococcus salivarius infection was conclusively identified through bronchoalveolar lavage metagenomic next-generation sequencing (mNGS), as well as smear and culture analyses. The patient was administered intravenous amoxicillin-clavulanate potassium for a duration of seven days as part of the anti-infection regimen. Given the stability of the patient’s respiratory and circulatory systems, a tube drainage procedure was deemed unnecessary. Post-treatment, the patient’s clinical symptoms notably improved. A subsequent chest CT scan revealed the re-expansion of the left lower lung and near-complete resolution of pneumomediastinum.ConclusionThere are numerous pathogens that can cause pneumonia. While focusing on common pathogens, it is important not to overlook rare ones. When considering infections from rare pathogens, it is recommended to promptly perform a bronchoscopy and submit bronchoalveolar lavage fluid for mNGS to improve pathogen detection rates. During the diagnosis and treatment of pneumonia, it is crucial to be vigilant for rare complications. When a patient presents with symptoms such as dyspnea or subcutaneous emphysema, it is advisable to immediately perform a chest CT scan to rule out pneumomediastinum.

A novel approach to calculate the required volume of air for bronchial blockers in young children.

Bronchial blocker balloons inflated with small volumes of air increase balloon pressure, involving a risk of airway injury especially in young children. However, there are no established guidelines regarding the appropriate volumes of air required to provide safe bronchial occlusion. This study aimed to introduce a novel method for calculating the amount of air required for safe bronchial blocker balloon occlusion for one lung anesthesia in young children. We included 79 pediatric patients who underwent video-assisted thoracoscopic surgery at our hospital. Preoperatively, the balloon pressure and corresponding diameter of 5F bronchial blockers inflated with different volumes of air were measured. Intraoperatively, bronchial diameters measured by computerized tomographic scans were matched to the exvivo measured balloon diameters. The quality of lung isolation, incidence of balloon repositioning, and airway injury were documented. Postoperatively, airway injury was evaluated through fiberoptic bronchoscopy. Balloon pressure and balloon diameter showed linear and nonlinear correlations with volume, respectively. The median lengths of the right and left mainstem bronchi were median (interquartile range) range: 5.3 mm (4.5-6.3) 2.7-8.15 and 21.8 (19.6-23.4) 14-29, respectively. Occluding the left mainstem bronchus required <1 mL of air, with a balloon pressure of 27 cm H2O. The isolation quality was high with no case of mucosal injury or displacement. Occluding the right mainstem bronchus required a median air volume of 1.3 mL, with a median balloon pressure of 44 cm H2O. One patient had poor lung isolation due to a tracheal bronchus and another developed mild and transient airway injury. The bronchial blocker cuff should be regarded as a high-pressure balloon. We introduced a new concept for safe bronchial blocker balloon occlusion for one-lung ventilation in small children.

Subglottic airway injury during fiberscope-monitored intubation with a supraglottic airway device: A randomized controlled comparison of three tracheal tubes.

Subglottic airway injury during fiberscope-monitored intubation with a supraglottic airway device: A randomized controlled comparison of three tracheal tubes.

Copper hydrogen phosphate nanosheets functionalized hydrogel with tissue adhesive, antibacterial, and angiogenic capabilities for tracheal mucosal regeneration

Timely and effective interventions after tracheal mucosal injury are lack in clinical practices, which elevate the risks of airway infection, tracheal cartilage deterioration, and even asphyxiated death. Herein, we proposed a biomaterial-based strategy for the repair of injured tracheal mucosal based on a copper hydrogen phosphate nanosheets (CuHP NSs) functionalized commercial hydrogel (polyethylene glycol disuccinimidyl succinate-human serum albumin, PH). Such CuHP/PH hydrogel achieved favorable injectability, stable gelation, and excellent adhesiveness within the tracheal lumen. Moreover, CuHP NSs within the CuHP/PH hydrogel effectively stimulate the proliferation and migration of endothelial/epithelial cells, enhancing angiogenesis and demonstrating excellent tissue regenerative potential. Additionally, it exhibited significant inhibitory effects on both bacteria and bacterial biofilms. More importantly, when injected injured site of tracheal mucosa under fiberoptic bronchoscopy guidance, our results demonstrated CuHP/PH hydrogel adhered tightly to the tracheal mucosa. The therapeutic effects of the CuHP/PH hydrogel were further confirmed, which significantly improved survival rates, vascular and mucosal regeneration, reduced occurrences of intraluminal infections, tracheal stenosis, and cartilage damage complications. This research presents an initial proposition outlining a strategy employing biomaterials to mitigate tracheal mucosal injury, offering novel perspectives on the treatment of mucosal injuries and other tracheal diseases.

74 Reducing unplanned extubations in a level 3 neonatal intensive care unit - the nuts and bolts of UE bundle implementation

Abstract Background Unplanned extubations (UEs) are preventable adverse events that may lead to short term consequences (e.g. cardiopulmonary collapse) and long term sequelae (e.g. acquired airway injury, brain injury) for patients admitted to the Neonatal Intensive Care Unit (NICU). UE prevention care bundles have been demonstrated to reduce UE rates in NICUs; however, implementation of bundle elements is unit dependent. Objectives To describe the work of a UE Prevention Team in a Level 3 NICU with rising UE rates despite implementation of UE prevention bundle per Children’s Hospital Solutions for Patient Safety (SPS). Design/Methods A neonatologist / respiratory therapist pair was assembled in March 2022 to tackle rising UE rates in a 69 bed NICU. Contributing unit stressors included implementation of a new electronic health record, COVID-19 policies, and nursing shortages. Baseline UE rates were &amp;gt;3x the centerline for SPS network NICUs and likely underreported. Steps undertaken include: 1) daily audit to ensure reporting of all UEs, 2) structured post-event team debriefs, 3) unit education campaign to raise awareness of UE prevention and bundle elements, 4) prominent posting of last UE date and reporting on daily team huddle, 5) rapid UE case reviews and apparent cause analysis with reporting of findings unit-wide, 6) optimize endotracheal tube (ETT) securement methods, 6) enforce T2-T3 ETT tip position, 7) standardize x-ray frequencies and reporting, 8) trial of daily rounds ETT safety checklist. Results From rapid case reviews, apparent causes were determined to be incorrect ETT securement device sizing, taping method prone to loss of tape integrity in high humidity, high ETT positions, and inadequate ETT monitoring during high risk activities other than repositioning (invasive/painful procedures, diaper changes). Post-event structured debriefs and unit-wide vigilance increased reporting of UE events to 100%. UE rates fell from a peak of &amp;gt;4 UEs/month, &amp;gt;2.4/100 ventilation days to 1 UE/month, 0.465/100 ventilation days, a 80% reduction.(Figure 1) Most impactful interventions were standard x-ray reporting template in the electronic health record, reinforcing T2-T3 ETT tip positioning, correcting ETT holder sizing, and change in ETT method (Figure 2). Daily rounds checklist was not effective. UE reductions were achieved without changing patient ratios as nurse staffing shortages continued. Conclusion A nimble systems approach is needed to ensure success in implementation of UE prevention care bundles. Simple changes can be made to decrease UEs, guided by rapid case reviews.

Retrospective Observational Analysis of Computed Tomography Scans of Trauma Patients in Overseas Operations (SCANOPEX Study).

High-intensity conflicts are on Europe's doorstep. The French expertise in the medical management of frontline casualties in overseas operations is well established. However, in the management of severe trauma, we lack data on the injuries identified by body scanners in the field. Understanding the associations between injury mechanisms and radiological lesions would enable us to anticipate medical and surgical management. To study this possible link, we collected and interpreted scanogaphic data and analyzed them according to lesion mechanisms, following the algorithm MARCH used to implement the concept of Damage Control Resuscitation, which includes life-saving measures to ensure that the wounded reach medical-surgical facilities alive. This retrospective monocentric study collected data from body scanners performed in overseas operations between June 2011 and September 2023. Inclusion criteria were to be French military personnel and to have undergone a whole-body scanner in a theater of overseas operations. Exclusion criteria were to have died before the scan, to be foreign, non-military and a minor. Of 164 available files, 96 were eligible, 1 patient declared aged 70 years was excluded, and 95 files were retained. In our population, 18% of injured patients had a spinal fracture. Compared with road traffic accident casualties, improvised explosive device casualties were the most severely injured patients arriving alive at computed tomography, with a relative risk of Injury Severity Score > 8 of 2.29 [1.09-4.80] (P = .019). Improvised explosive device casualties had a relative risk of airway injuries of 2.57 [1.03-6.39] (P = .030), injuries leading to functional impairment of 3.21 [1.17-8.82] (P =.013), injuries leading to infection of 2.14 [1.21-3.76] (P = .0045), and injuries leading to shock of 3.21 [0.96-10.70] (P = .039). Deep metal splinters were only found in the improvised explosive device group. Preparing the medical corps to deal with war casualties is fundamental. Our study shows that it is essential to consider the mechanism of injury to understand the casualty better and predict potential injuries. In addition, the study of postmortem scans could greatly help analyze potentially avoidable deaths.

Optimizing patient safety: Unveiling the significance of cuff pressure in anaesthesia

BackgroundInadequate pressure in the endotracheal tube (ETT) cuff can lead to compromised ventilation or airway injury. Accurate assessment of ETT cuff pressure is essential and should be performed using a manometer, with an optimal target range of 20–30 cmH2O. AimIn this study, we aimed to audit ETT cuff pressures in the operating theatre of our institution, utilizing a manometer from VBM Medizintechnik GmbH™. MethodsFollowing approval from the ethics committee, we conducted an audit from January 2023 to November 2023. A convenience sample was utilized, including adult patients who were intubated in our operating rooms (ORs) during either the morning or afternoon shifts at the time of the audit. ResultsA total of 49 patients were evaluated. Our findings revealed that 78 % of the patients had cuff pressures outside the recommended target range, with recorded pressures ranging from 18 cmH2O to 120 cmH2O, and a mean pressure of 63 cmH2O. Nitrous oxide was not used in any of the cases. Cuff inflation was performed using different syringe volumes: a 5 mL syringe was used in one case, a 10 mL syringe in 20 cases, and a 20 mL syringe in 28 cases, with a mean inflation volume of 9 mL. Statistical analysis indicated no significant difference in ETT cuff pressure related to the type of syringe used or the size of the endotracheal tube. Additionally, no correlation was found between the volume of air used for cuff inflation and the resulting ETT cuff pressure. ConclusionOur audit revealed that only 22 % of the patients had cuff pressures within the recommended limits, highlighting a significant need for increased awareness and education. As maintaining appropriate cuff pressure is a standard of care, systematic implementation of reliable cuff pressure monitoring is strongly recommended.

Endoscopic Removal of Uncovered Metallic Airway Stents.

Self-expandable uncovered metallic stents (SEUMS) have been used in benign tracheobronchial stenosis. Stent complications may require risky removal due to SEUMS integration in the tracheobronchial wall. Our study aims to report techniques, including a novel one, and outcomes of SEUMS removal by rigid bronchoscopy. We studied a case series of 7 patients from a tertiary medical center, who underwent SEUMS removal from 2017 to 2022. SEUMS removals were performed through rigid bronchoscopy. We used a new technique with bronchoscopic hook scissors to gradually dissect the stent from the airway wall. Nine SEUMS were removed from 7 patients. The mean duration of stenting was 7 years (5 to 12y). Indications for stent removal included mostly recurrent pulmonary infections, obstructive granulation tissue, and stents' fractures. We used the usually described technique in the literature known as the "piecemeal fashion" without dissection in 4 SEUMS removals and a new dissection technique in 5 procedures. We reported one major intraoperative complication using the former technique in the form of tracheal tear with mediastinal breach, while we did not experience any major complications with the later one. One patient died 8 days after surgery from respiratory failure. Dissection and "piecemeal fashion techniques" can be used to remove SEUMS by rigid bronchoscopy even after long-term stenting. SEUMS removal is a very risky procedure and must be performed by a trained operator. Patients should be aware of possible severe complications.

Mucus-inspired lubricative antibacterial coating to reduce airway complications in an intubation cynomolgus monkey model

Endotracheal intubation-related complications are common in clinical, and there are currently no effective strategies to address these matters. Inspired by the biological characteristics of human airway mucus (HAM), an artificial airway mucus (ARM) coating is straightforwardly constructed by combining carboxymethyl chitosan with methyl cellulose. The ARM coating exhibited excellent lubricity (coefficient of friction (CoF) = 0.05) and hydrophilicity (water contact angle (WCA) = 21.3°), and was capable of coating both the internal and external surfaces of the endotracheal tube (ETT). In vitro experiments demonstrated that the ARM coating not only showed good broad-spectrum antibacterial activity, but also significantly reduced nonspecific protein adhesion. Through an in vivo intubation cynomolgus monkey model, ARM-coated ETT potently mitigated airway injury and inflammation, and was highly potential to prevent bacterial infection and catheter blockage. This work offers a promising avenue for the development of airway-friendly invasive devices.

Single-cell transcriptomics reveals e-cigarette vapor-induced airway epithelial remodeling and injury

BackgroundIn recent years, e-cigarettes have been used as alternatives among adult smokers. However, the impact of e-cigarette use on human bronchial epithelial (HBE) cells remains controversial.MethodsWe collected primary HBE cells of healthy nonsmokers and chronic obstructive pulmonary disease (COPD) smokers, and analyzed the impact of e- cigarette vapor extract (ECE) or cigarette smoke extract (CSE) on HBE cell differentiation and injury by single-cell RNA sequencing, immunostaining, HE staining, qPCR and ELISA. We obtained serum and sputum from healthy non- smokers, smokers and e-cigarette users, and analyzed cell injury markers and mucin proteins.ResultsECE treatment led to a distinct differentiation program of ciliated cells and unique patterns of their cell–cell communications compared with CSE. ECE treatment caused increased Notch signaling strength in a ciliated cell subpopulation, and HBE cell remodeling and injury including hypoplasia of ciliated cells and club cells, and shorter cilia. ECE-induced hypoplasia of ciliated cells and shorter cilia were ameliorated by the Notch signaling inhibition.ConclusionsThis study reveals distinct characteristics in e-cigarette vapor-induced airway epithelial remodeling, pointing to Notch signaling pathway as a potential targeted intervention for e-cigarette vapor-caused ciliated cell differentiation defects and cilia injury. In addition, a decrease in SCGB1A1 proteins is associated with e- cigarette users, indicating a potential lung injury marker for e-cigarette users.

Extracorporeal Membrane Oxygenation in Complex Tracheobronchial Surgery: A Series Case Reports and Systematic Review

Airway management in complex tracheobronchial surgery (TBS) remains a challenge in thoracic surgery. The use of extracorporeal membrane pulmonary oxygenation (ECMO) in thoracic surgery is rather rare, except for lung transplantation. To report the safety and efficacy of ECMO in complex TBS, a total of 5 patients with tracheobronchial and bronchial reconstructive surgery supported by ECMO in the Department of Thoracic Surgery of Tangdu Hospital, Air Force Medical University from May 2019 to June 2024 were collected. Among them, 4 cases of tracheal tumor (including long-segment trachea resection and reconstruction, or carinal resection and reconstruction) and 1 case of acute airway obstruction caused by tracheal rupture were included, all of which were performed in veno-venous ECMO (V-V ECMO) mode. Systemic heparinization was used in 2 patients, and anticoagulation was not performed in 3 patients, which were maintained only by ECMO heparin-coated lines. 4 patients recovered well after surgery, and 1 patient died 1 month after surgery due to immune-related pneumonia. For complex TBS, or in emergency situations (tracheal stenosis with risk of asphyxiation), ECMO can provide adequate support and safeguard. .

Airway Injuries During Orotracheal Intubation: Risk Factors, Prevention, and Management

Airway Injuries During Orotracheal Intubation: Risk Factors, Prevention, and Management

Who Can Be Discharged Early? Factors Affecting the Length of Hospital Stay Post-thyroidectomy

Abstract Introduction: Thyroidectomy is the most common head-and-neck surgical procedure, generally considered a safe procedure in experienced hands. However, complications following thyroid surgery may occur. Despite its prevalence, there is a lack of studies in Makkah region, Saudi Arabia, on factors affecting the length of hospital stay (LHS) postthyroidectomy. Study Aim: This study aims to determine the factors that increase the LHS postthyroidectomy in a tertiary care center. Subjects and Methods: This retrospective study included 792 patients aged 18 and above who underwent thyroidectomy at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from 2012 to 2022. Data from medical records were analyzed using Chi-squared, Mann–Whitney, and Spearman’s tests. Results: The mean age of studied patients was 43.03 years, the majority of which were female (84.5%). The mean LHS was 3 days. Factors associated with prolonged LHS were: older age (mean 45 years), hypertensive female patients, chronic corticosteroids use, lower preoperative platelet, hematocrit, and calcium levels, as well as reduced postoperative parathyroid hormone and calcium levels, patients who underwent total thyroidectomy, and patients who had papillary carcinoma (P &lt; 0.05). In addition, postoperative complications such as hypoparathyroidism, tracheal injury, hematoma, and infections had longer LHS (P ≤ 0.05). Conclusion: While early discharge after thyroid surgery may be safe in certain cases, our findings suggest several factors influencing hospital stay duration. Patients presenting with these factors should be carefully evaluated to ensure optimal patient care.

A Comparison of Conventional Rotating Method and Non-Rotating Method for Double-Lumen Tube Insertion Using a Customized Rigid J-Shaped Stylet for One-Lung Ventilation: A Randomized Controlled Trial.

Background: The conventional double-lumen tube (DLT) insertion method requires a rotatory maneuver that was developed using direct laryngoscopy and may not be optimal for video laryngoscopy. This study compared a new non-rotatory maneuver with the conventional method for DLT insertion using video laryngoscopy. Methods: Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly assigned to either the rotating (R) or non-rotating (NR) method groups. All patients were intubated using a customized rigid J-shaped stylet, a video laryngoscope, and a left-sided silicone DLT. The conventional rotatory maneuver was performed in the R group. In the NR group, the stylet was inserted with its tip oriented anteriorly (12 o'clock direction) while maintaining the bronchial lumen towards the left (9 o'clock direction). After reaching the glottic opening, the tube was inserted using a non-rotatory maneuver, maintaining the initial orientation. The primary endpoint was the intubation time. Secondary endpoints included first-trial success rate, sore throat, hoarseness, and airway injury. Results: Ninety patients (forty-five in each group) were included. The intubation time was significantly shorter in the NR group compared to the R group (22.0 [17.0, 30.0] s vs. 28.0 [22.0, 34.0] s, respectively), with a median difference of 6 s (95% confidence interval [CI], 3-11 s; p = 0.017). The NR group had a higher first-attempt success rate and a lower incidence of sore throats. Conclusions: The non-rotatory technique with video laryngoscopy significantly reduced intubation time and improved first-attempt success rate, offering a viable and potentially superior alternative to the conventional rotatory technique.

55 Smooth sailing despite no sail: Ventilation through a tracheal tear

55 Smooth sailing despite no sail: Ventilation through a tracheal tear

86 Post-intubation tracheal rupture in a patient with covid-19: case report

86 Post-intubation tracheal rupture in a patient with covid-19: case report