Airway Injury Research Articles

Cardiac arrest after hanging: a scoping review.

Hanging is a common cause of suicide and asphyxial cardiac arrest. There are few data to inform the treatment of cardiac arrest after hanging. We designed a scoping review to describe evidence relating to interventions and outcomes in patients with and without cardiac arrest after hanging. Medline, Embase and Cochrane were searched from inception to 05/12/2024. Titles and abstracts were screened, and duplicates were removed. Articles were eligible for inclusion if they studied non-judicial hanging in adults or children, included cardiac arrest patients and provided functional or survival outcomes. The search retrieved 855 articles. One hundred and nineteen references underwent full-text review. Forty-five studies were included in the review. Studies were mainly from high-income countries and were all observational. There was variation in the terminology for hanging and in the outcomes reported. Survival with favourable functional outcome was rare in patients with cardiac arrest after hanging but was very common in patients without cardiac arrest. Cervical spine, airway and vascular injuries were rare. No studies identified interventions that were associated with improved survival following return of spontaneous circulation. There are few data to inform treatment of patients with cardiac arrest after hanging. The available data suggest that cardiac arrest is a critical determinant of poor outcome following hanging. Further research should uniformly report outcomes of patients with cardiac arrest after hanging based on the Utstein template.

Tenascin-X deficiency causing classical-like Ehlers Danlos syndrome type 1 in humans is a significant risk factor for GI and tracheal ruptures.

Classical-like Ehlers Danlos Syndrome type 1 (clEDS1) is a very rare form of Ehlers Danlos Syndrome (EDS) caused by tenascin-X (TNX) deficiency, with only 56 individuals reported. TNX is an extracellular matrix protein needed for collagen stability. Previous publications propose that individuals with clEDS1 might be at risk for gastrointestinal (GI) tract perforations and/or tracheal ruptures. 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 centres. 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, seven 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.

FATORES PREDITORES NA SÍNDROME DO DESCONFORTO RESPIRATÓRIO AGUDO EM PACIENTES COM A DOENÇA PULMONAR OBSTRUTIVA CRÔNICA: UMA REVISÃO INTEGRATIVA DE LITERATURA

Acute Respiratory Distress Syndrome (ARDS) is characterized by severe respiratory failure and represents a critical complication, often associated with the need for mechanical ventilation (MV). Chronic Obstructive Pulmonary Disease (COPD) is defined as a progressive condition that causes airway obstruction and injury to the lung parenchyma, often associated with smoking, and is one of the main causes of morbidity and mortality worldwide. Thus, patients with COPD are particularly susceptible to ARDS due to chronic impairment of the components of the respiratory system. This study addresses the relationship between COPD and ARDS, and aimed to identify the main predictors of ARDS in this population. Thus, this integrative literature review followed a methodological design that involved searching the PubMed, BVS and Scopus databases, with the selection of articles published in the last ten years. The research identified five relevant studies, which indicated factors such as COPD exacerbations, use of MV, advanced age, sepsis and environmental factors as predictors of ARDS in patients with COPD. Although the studies showed an association between these conditions, the scarcity of specific research on predictors of ARDS in patients with COPD was an important limitation, but among the studies of the qualitative analysis, 8,431 patients and 26 reviews were evaluated that comprised the 2024 meta-analysis evaluated, which strengthens the evidence on the subject.

Left main bronchial rupture: bronchoscopy and chest CT.

Left main bronchial rupture: bronchoscopy and chest CT.

Acute exposure to nitrogen mustard induces rapid nuclear component regulation and delayed stress to exogenous stimuli.

Nitrogen mustard (NM) is a vesicant agent with potent toxic effects on various tissues. Numerous theories have been proposed to explain its toxic mechanisms, yet research on the interconnections among these theories is lacking. This study focuses on analyzing the characteristics of genes involved in NM-induced bronchial injury within the Comparative Toxicogenomics Database (CTD). Subsequently, based on the CTD, we compared and analyzed the acute exposure and delayed changes following exposure in 16HBE cells. The injury processes caused by NM to bronchial and skin tissues are similar, primarily involving metabolism and regulation of nuclear constituents and inflammatory responses within the cellular matrix. During the acute exposure phase, NM rapidly induces nuclear stress, with the JUN family at the core of regulating metabolic and nucleic acid activities, and various nuclear binding proteins exhibit abnormalities. Delayed reactions following acute exposure are primarily centered in the cytoplasmic region, with diverse reaction types, including oxidative stress and responses to exogenous stimuli. Abnormalities in the activity of multiple cellular matrix enzymes are observed, with a relatively even involvement of various stress responses. Communication between the nucleus and cytoplasm is extreme active during the injury, and the content of the communication changes over time. These results suggest a temporal sequence in which NM causes chromatin damage and mediates cytoplasmic stress responses. In prevention and first aid, rapid DNA repair should be the primary focus, while subsequent treatment after acute exposure should focus more on delayed inflammatory and oxidative stress responses.

Combating COVID-19 and its co-infection by Aspergillus tamarii SP73-EGY using in vitro and in silico Studies

The COVID-19 pandemic has caused significant mortality and morbidity for millions of people. Severe Acute Respiratory Syndrome-2 (SARS-CoV-2) virus is capable of causing severe and fatal diseases. We evaluated the antiviral properties of Aspergillus tamarii SP73-EGY isolate extract against low pathogenic coronavirus (229E), Adeno-7- and Herpes-2 viruses. The extract showed a high selectivity index (SI = 43.4) and a significant inhibition of 229E (IC50 = 8.205 μg/ml). It was stronger than the drug control, remdesivir (IC50 = 38.2 μg/ml, SI = 7.29). However, the extract showed minimal efficacy against Adeno-7- and Herpes-2-Viruses (IC50 = 22.52, 47.79 μg/ml, and SI = 6.75, 5.08, respectively). It exhibited profound efficacy against the highly pathogenic SARS-CoV-2 (IC50 = 8.306 μg/ml, SI = 42.2). Kojic acid, the primary component of the extract, showed substantial antiviral activity against SARS-CoV-2 (IC50 = 23.4 μg/ml, SI = 5.6), Remdesivir (IC50 = 4.55 μg/ml, SI = 61.45). Therefore, the extract demonstrated the most notable antiviral characteristics against coronavirus infection. Co-infecting microorganisms may contribute to immune system deterioration and airway injury caused by SARS-CoV-2. The extract showed significant efficacy against E. coli and P. aeruginosa, with an inhibition range of 3.5–10 mm at a concentration of 200 mg/ml. A molecular docking study showed that hexadecanoic, Kojic, octanoic acids, and 4(4-Methylbenzylidene)cyclohexane-1,3-dione have stronger binding affinity to the SARS-CoV-2 Mpro than Remdesivir. Molecular dynamics simulations were employed to examine the structural stability and flexibility of these complexes. This confirmed the high binding affinities of Kojic acid and 4(4-Methylbenzylidene)cyclohexane-1,3-dione, thereby proving their potential as novel anti-SARS-CoV-2.

Cold stimulated bronchial epithelial cells derived exosomes HMGB1 aggravates bronchial epithelial cells injury.

The aim of this study was to reveal the mechanism of cold stimulation (CS)-bronchial epithelial cells (BECs) derived exosomes (CS-BECs-exo) aggravated sepsis induced acute lung injury (SALI). CS-BECs-exo were separated by differential centrifugation and were characterized. Proteomics, immunoprecipitation, and RAGE knockout (RAGE) mice were used to investigate the mechanism of CS-BECs-exo aggravated SALI. The results of transmission electron microscope (TEM) showed that CS-BECs-exo showed a double-layer membrane structure like a saucer. Nanoparticle tracking analysis (NTA) particle size analysis showed that the average particle size of CS-BECs-exo was 123.6 nm. The results of proteomics showed that the expression level HMGB1 was significantly increased in CS-BECs-exo compared with BECs-exo. CS-BECs-exo significantly increased oxidative stress and inflammatory reaction of SALI. In addition, CS-BECs-exo significantly increased RAGE and decreased the levels of Nrf-2 and OH-1. RAGE knockout (RAGE KO) and silence of RAGE (RAGE siRNA) significantly canceled the effects of CS-BECs-exo on SALI. HMGB1 knockout (HMGB1) and silence of HMGB1 also significantly (HMGB1 siRNA) canceled the effects of CS-BECs-exo on SALI. In conclusion, CS-BECs-exo aggravated ALI in sepsis via HMGB1/RAGE/Nrf-2/OH-1 signal pathway.

Traumatic bronchial injury management

Traumatic bronchial injury management

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

BACKGROUND: In the structure of childhood traumatism, thoracic trauma occurs in less than 10% of cases, but it is the second most likely cause of death in children. A bronchial rupture that disrupts adequate ventilation of the lungs can be the culprit of the fatal outcome. The purpose of our publication is to demonstrate a rare clinical observation of successful endoscopic treatment of an intermediate bronchus rupture in a 4-year-old child with polytrauma. CLINICAL CASE DESCRIPTION: A 4-year-old boy was injured in a traffic accident as a pedestrian. During the first three days, he was treated for multiple injuries (Injury Severity Score 41) in a local hospital where, because of 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 done. Because of patient’s relative stabilization by the 3rd post-trauma day, he was transferred to our clinic (level 1 trauma center). We could stabilize his hemodynamics; however, air blowing through the drains was maintained, complete straightening of the parenchyma of the right lung was not reached, and blood gas composition remained subcompensated. On day 5 of the post-traumatic period, laryngotracheobronchoscopy was performed, and the rupture of intermediate bronchus measuring 3×9 mm was diagnosed. Its occlusion with a positive effect was done. After 7 days, laryngotracheobronchoscopy was repeated, and blockers were removed. After that, complete straightening of the right lung was reached; no recurrence of bronchopulmonary fistula. Long mechanical ventilation and long hospital stay were results of severe traumatic brain injury. At the follow-up visit in a year, no pathology in respiratory organs was detected at clinical laboratory, radiological and endoscopic examination. CONCLUSION: Bronchial rupture may be a cause of inadequate ventilation and aggravation of the post-traumatic period in a polytrauma patient. The present observation demonstrates that intraluminal endoscopy allows to timely detect the rupture of the large bronchus and to perform a minimally invasive surgical treatment. Such a tactics ensured further positive dynamics in child's condition and favorable outcomes after polytrauma, as a whole.

Hemoptysis caused by bronchial artery-pulmonary artery fistula complicated with Dieulafoy disease: A case report.

Bronchial artery-pulmonary artery fistula (BPF) is a rare vascular malformation of the bronchial arteries, associated with congenital heart disease, pulmonary hypertension, or pulmonary infections. It typically presents in adulthood and has a low incidence. Another rare vascular anomaly, bronchial Dieulafoy disease (BDD), is characterized by an abnormally developed artery within the submucosa of the bronchial tree. This condition is thought to arise from a combination of congenital dysplasia and chronic airway inflammation or injury. Both BPF and BDD are uncommon causes of hemoptysis, and their simultaneous occurrence is exceptionally rare. This report discusses a case of BPF complicated by BDD in a patient who presented with recurrent hemoptysis. The diagnosis was established through bronchial artery angiography, bronchoscopy, and surgical pathology. By examining the clinical features, imaging findings, and diagnostic criteria of these conditions, this case report aims to enhance clinicians' understanding of cryptogenic hemoptysis and provide valuable insights for clinical practice.

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.

Oxidative Injury to Lung Mitochondrial DNA is a Key Contributor for the Development of Chemical Lung Injury.

The mechanisms and extent to which inhalation of oxidant gases damage the mitochondrial genome contributing to the development of acute and chronic lung injury have not been investigated. C57BL/6 mice exposed to chlorine (Cl 2 ) gas and returned to room air, developed progressive loss of lung DNA glycosylase OGG1, significant oxidative injury to mtDNA, decreased intact lung mitochondrial (mt) DNA, generation of inflammatory pathway by DAMPs causing airway and alveolar injury with significant mortality. Global proteomics identified over 1400 lung proteins with alteration of key mitochondrial proteins at 24 h post Cl 2 exposure. Intranasal instillation of a recombinant protein containing mitochondrial targeted OGG1 (mitoOGG1) post exposure, decreased oxidative injury to mtDNA, lung mitochondrial proteome, severity of the acute and chronic lung injury and increased survival. These data show that injury to the mt-genome is a key contributor to the development of acute and chronic lung injury.

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.

The Role of Gastroesophageal Reflux in Airway Inflammation.

Gastroesophageal reflux disease occurs when the barrier at the esophagogastric junction is weakened, allowing for transient relaxations of the lower esophageal sphincter or disruption of the esophagogastric junction. This leads to the refluxate traveling up the esophagus, and potentially into the pharynx, where it can be aspirated into the airway. The refluxate can cause a range of symptoms, including sore throat, coughing, wheezing, and shortness of breath, which may occur with or without visible airway inflammation. Both experimental and clinical studies have shown that aspirated refluxate can directly damage the airway lining and trigger immune responses that contribute to airway injury and inflammation. While traditional diagnostic tests for gastroesophageal reflux disease can identify abnormal reflux patterns, there is a need for more specific methods to predict airway inflammation or therapeutic outcomes related to reflux aspiration.

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.