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A boy with subglottic narrowing secondary to laryngotracheitis presented with noisy breathing. Acoustic measurements of tracheal sounds at standardized air flows correlated well with the clinical course and with spirometric assessments. This indicates the potential value of respiratory sound characterization in patients with upper airway obstruction.
Retractions of the lower ribcage (chest wall distortion [CWD]) during inspiration are frequently observed with moderate to severe respiratory disease in the infant. Laryngotracheobronchitis (LTB) results in a reversible partial airway obstruction with severe CWD. We wished to measure the motion of the chest wall during distortion to determine the changes in minute ventilation (VE) and to evaluate this clinical sign as a means of assessing disease severity. The respiratory inductance plethysmograph was used to determine the distortion of the lower chest wall, and distortion was correlated with VE, measured at the mouth, in six infants with severe LTB and ventilatory failure. As the conditions of these infants improved, the CWD decreased with decreasing transcutaneous carbon dioxide tension (tcPCO2), VE increased from 0.27 +/- 0.12 L.min-1 x kg-1 at a tcPCO2 of 64 mm Hg to 0.64 +/- 0.06 L.min-1 x kg-1 when the tcPCO2 had fallen to 28 mm Hg. Over the same change in tcPCO2, the tidal volume (VT) increased from 4.8 +/- 0.5 ml.kg-1 to 15.7 +/- 1.4 ml.kg-1. In the most severe disease state, the excursion of the chest wall (as an inductance) was -14 +/- 3 mV in severe obstruction, but increased to 75 mV +/- 4 mV with resolution of the illness. The timing and vector of movement of the abdomen and chest wall were expressed as a Lissajous figure, which is measured as a phase angle. The severity of the disease process, as determined by tcPCO2 was directly related to the phase relationship, and thus reflected both VE and VT. The severity of the CWD may be assessed rapidly by the use of Lissajous figures.
Necrotizing tracheobronchitis and acute airway obstruction from invasive mycosis developed in a patient who had undergone bone marrow transplantation. The infectious process obstructed the airway and disintegrated the walls of the right mainstem bronchus and pulmonary artery. The airway was cleared using rigid bronchoscopy to extract the detritus. The patient died of hemorrhage after rupture of the pulmonary artery through the right mainstem bronchus.
Two men with severe ulcerative colitis developed ulcerative tracheobronchitis 4 and 8 years after total colectomy. Intense plasma cell infiltration of tracheal mucosa and submucosa and destruction of mucous glands occurred, with partial relief of symptoms with corticosteroids. We compare them with the only other case reported, also years after colectomy.
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Paraneoplastic pemphigus (PNP) is an autoimmune disease associated with leukemia and non-Hodgkin's lymphoma. A patient with stage IVB poorly differentiated lymphocytic lymphoma developed characteristic upper and lower airway involvement with profound mucocutaneous erosion and tracheobronchial epithelial desquamation. Immunofluorescence testing confirmed autoantibody deposition along the basement membrane of bronchial epithelium. Disruption of the cellular adhesion mechanisms, including desmosomes, hemidesmosomes, and possibly the integrin subunits, is presumed to have led to disruption and desquamation of the tracheobronchial epithelial barrier, severe obstruction of the airways and hypoxia, and possibly bacterial superinfection. As far as can be determined, the feature of airflow obstruction occurring in association with PNP has not been described. Physicians should be aware that these complications of PNP may rapidly lead to hypoxic respiratory failure and death.
STUDY OBJECTIVES: To evaluate the histocompatibility of four different materials used to cover expandable metallic stents. DESIGN: Prospective, randomized, unblinded study. SETTING: Animal research laboratory of Kurume University. PATIENTS OR PARTICIPANTS: Twenty 12- to 18-kg mongrel dogs. INTERVENTIONS: Handmade Gianturco-type stents with six bends, 20 mm in length, and 15 to 20 mm in diameter were covered using four different materials: polypropylene mesh, silicone-coated mesh, polyester mesh, and ePTFE. Covered stents were inserted into the trachea after i.v. anesthesia. Five animals were used in each group. MEASUREMENTS AND RESULTS: Postinsertion status was observed using clinical and bronchoscopy measures 7, 14, 28, and 56 days after intervention. Eight weeks after stent insertion, the tracheal specimens were studied pathologically. A scoring system was used to evaluate the histocompatibility of covered stents in each study group. The mean of clinical scores in the polypropylene group was 1.84+/-0.36, which was significantly higher than those in the groups of silicone, polyester, and ePTFE. The means of histopathologic scores in the polypropylene group and the silicone group were 1.60+/-0.55, which were significantly higher than those in groups of polyester and ePTFE. CONCLUSIONS: Polypropylene mesh cover was more suitable than silicone-coated mesh, polyester mesh, and ePTFE because of its excellent histocompatibility.
STUDY OBJECTIVES: To study the flow-volume loop for evidence of variable extrathoracic airflow obstruction in Persian Gulf War veterans. DESIGN: Retrospective case-control, single-center study. SETTING: The pulmonary division of an academic health-care center. SUBJECTS: A convenience sample of the Persian Gulf Registry. MEASUREMENTS AND INTERVENTIONS: (1) Midvital capacity ratio (ratio of maximum forced midexpiratory to maximum forced midinspiratory flow). This ratio is the criterion standard for the diagnosis of variable extrathoracic airflow obstruction. (2) Evaluation of the anatomy and function of the extrathoracic airway by fiberoptic bronchoscopy. (3) Further investigation into the airway abnormality by histologic evaluation of tracheal biopsy samples in Gulf War veterans only. RESULTS: Midvital capacity was > 1.0 in 32 of 37 Gulf War veterans compared with only 11 of 38 control subjects. The mean (+/-SD) value was 1.37+/-0.4 among Gulf War veterans and 0.88+/-0.3 among control subjects (p=0.0000005). FVC and its ratio to FEV1 were normal in all these subjects. Bronchoscopy showed inflamed larynx and trachea in all (n=17) Gulf War veterans. Histologic study showed chronic inflammation of the trachea in everyone (n=12) who had an adequate biopsy sample. CONCLUSION: Physicians should be made aware of the presence of chronic inflammation of the upper airways and inspiratory airflow limitation in a number of Gulf War veterans.
STUDY OBJECTIVES: Unopposed activity of the serine protease, human leukocyte elastase (HLE), is detectable in the airways of patients with purulent tracheobronchitis. The aim of this study was to assess the compartmentalization of HLE activity in the liquid sol phase and the solid gel phase of airway secretions. DESIGN: Seventy samples of tracheobrochial aspirates were obtained from patients who had hypersecretion and were receiving mechanical ventilation. METHODS: Samples were separated into sol and gel ("mucous pellet") phases, and HLE activity was measured using chromogenic substrate degradation. HLE was eluted from the mucous pellet using hypertonic saline solution, 1 mol/L, or bovine pancreatic deoxyribonuclease (DNase), 16 micromol/L. RESULTS: HLE activity partitioned between the sol and gel phases of the secretions, with most of the activity present in the gel phase (32:1 ratio of gel to sol HLE activity). The activity of HLE was 95% inhibited when bound to the gel phase, but activity appeared to be largely restored after elution from the gel phase. The gel phase was capable of binding additional exogenous HLE, and its binding capacity for exogenous HLE was not saturated by concentrations that exceeded the highest clinically relevant HLE levels (1.1 mg/mL). Hypertonic saline solution and DNase I efficiently liberated endogenous and exogenous gel phase-bound HLE activity, suggesting that electrostatic bonds and DNA, respectively, play important roles in binding HLE to the gel phase. CONCLUSIONS: The solid phase of airway secretions is a more important modulator of elastase-antielastase balance than has been previously recognized.
OBJECTIVE: In vitro data suggest that the S-enantiomer of albuterol can induce mucociliary dysfunction. This clinical study assesses the clinical significance of standard doses of the S-enantiomer on airway secretions in long-term intubated patients by comparing a racemic formulation of albuterol, an R-enantiomer formulation, and normal saline solution. DESIGN: A placebo-controlled crossover study. PATIENTS: Fourteen stable intubated patients with a median duration of intubation of 21 months and a median age of 72 years. SETTING: Long-term ventilator unit in skilled nursing facility. INTERVENTIONS: Following a 2-week washout period during which regularly scheduled beta2-agonists were discontinued, tracheal aspirates were collected for 4 h/d for a 5-day period to establish baseline values, and the patients were then randomized in crossover manner to each of three nebulized treatments: normal saline solution, racemic albuterol, and R-albuterol. Each treatment was administered three times daily for 5 days, followed by a 2-day washout. MEASUREMENTS: Tracheal aspirates were analyzed for volume, sodium, chloride, bicarbonate, interleukin (IL)-8, IL-1beta, soluble intercellular adhesion molecule, and tumor necrosis factor-alpha. RESULTS: There were no consistent significant differences among the three treatment periods either in terms of volume of secretions or in the concentrations of the electrolytes or the inflammatory indexes. However, all three treatments, including saline solution, were associated with increased secretion volume after the first dose, but this effect was not apparent on subsequent doses. CONCLUSION: There were no significant differences between racemic albuterol and R-albuterol observed in this study for any of the parameters studied, suggesting that the S-enantiomer does not adversely affect airway secretions at recommended doses. In addition, the routine administration of nebulized beta(2)-sympathomimetic agonists to stable patients undergoing prolonged intubation, for the sole purpose of changing the volume and composition of secretions of airway secretions, is not supported by the results of this study.
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The noninvasive diagnosis of impaired mechanical integrity or compliance of the trachea is most accurately made by fluoroscopic observation recorded on video tape or cineradiography, with or without benefit of artificial contrast media (contrast tracheography). In particular, localized buckling, collapse or dilatation indicative of focal tracheomalacia may thus be diagnosed in vivo and correlated with diseases of the central airways. Congenital tracheomalacia is a rare, bu, well described entity. Cases of acquired tracheomalacia occur with increasing frequency, but are often not clearly recognized. We contrast the dynamic behavior of the normal trachea with the abnormal dynamics characteristic of focal tracheomalacia. Such lesions may result from trauma, surgical procedures, chronic irritation, inflammation, mechanical changes, or malignancy.
At the time of bronchoscopic observation, 28 of 31 patients proved to have aspirated gastric contents by the presence of gastric contents in the trachea or by direct observation of gastric aspiration followed by respiratory distress and erythema of subsegmental bronchi. Since gastric aspiration is a difficult diagnosis to make and few objective data are available to make the diagnosis, the present study would indicate that early fiberoptic bronchoscopic observation of the tracheobronchial tree is a useful procedure to establish a definitive diagnosis and to allow proper planning for clinical management.
Serial tracheal cultures for aerobic and anaerobic bacteria were obtained from 27 pediatric patients during one year of follow-up. The patients had required tracheostomy and prolonged intubation for periods ranging from 3 to 12 months (average, 7 1/2 months). Cultures of tracheal aspirates yielded 1,508 isolates of pathogenic aerobic (969 isolates) and anaerobic (539 isolates) bacteria. The most frequent aerobic isolates were Streptococcus pneumoniae and Staphylococcus aureus. The predominant anaerobes were anaerobic gram-positive cocci, Fusobacterium nucleatum, and Bacteroides fragilis. Replacement of one pathogen by another occurred frequently. Tracheobronchitis occurred in 24 patients, all of whom had episodes of pneumonia. The data suggest that anaerobic bacteria are a part of the bacterial flora in colonization, tracheobronchitis, and pneumonia in patients with tracheostomy and prolonged intubation.
This study compares the use of synthetic absorbable suture (SAS, Vicryl) with that of synthetic nonabsorbable suture (SNS, Ticron) for construction of cervical tracheal anastomoses in the dog. Fourteen mongrel dogs underwent resection of one to four tracheal rings. Paired tracheal anastomoses were constructed, using 10 SAS or 10 SNS. After two months each anastomosis was removed and analyzed. All animals survived with intact anastomoses. There were no visible reactions to the SAS. Twenty-six of 70 SNS developed gross suture granulations. Significant stenosis developed in one of seven SAS and in four of seven SNS anastomoses. Histologic examination revealed no residual inflammatory reaction in the SAS specimens, while the SNS demonstrated a spectrum of inflammatory response that directly correlated in intensity with the gross appearance. These findings support the continued evaluation for the use of SAS in clinical tracheobronchoplastic procedures.
Colonization of the lower respiratory tract by enteric Gram-negative bacilli (EGNB) has been a frequent finding in patients with long-term tracheostomies; however, the association of hospitalization and certain features of serious illness with this phenomenon has not been clearly established. Because such factors can render the oropharynx more susceptible to EGNB colonization, we sought to discover whether they can also have this effect on the tracheobronchial tree and its microflora. Thus, we collected serial paired culture samples from these two mucosal sites in 15 subjects with long-term tracheostomies and examined patterns and rates of colonization and related these findings to clinical parameters. In 49 sets of cultures, we found that EGNB (especially Pseudomonas species) were present in significantly fewer upper-airway cultures (36.7 percent) than lower-airway cultures (75.5 percent) (p = 0.009). At the tracheobronchial site, seven subjects had persistent EGNB colonization, all with Pseudomonas species, while only one subject had this finding at the oropharyngeal site (p = 0.015). Patients with persistent tracheobronchial colonization were more ill than those without this finding. They were treated with higher doses of prednisone (p = 0.06), received antibiotics more often, and developed purulent tracheobronchitis more often (100 percent vs 25 percent) than patients without persistent colonization. In addition, in the month following the culture survey, four subjects developed pneumonia, and three of these had previous persistent tracheobronchial colonization.(ABSTRACT TRUNCATED AT 250 WORDS)
A 50 percent or greater savings in oxygen usage and aesthetic benefits leading to increased compliance are reasons for increasing use of the transtracheal catheter for administration of home supplemental oxygen. Minor complications of the procedure are common and include catheter dislodgement, bronchospasm, subcutaneous emphysema, bleeding at the catheter site, as well as hemoptysis and wound infections. Rare complications include retroflexion of the catheter into the upper trachea from coughing, and fracture of the catheter with loss in the trachea. New, improved catheters and detailed descriptions for operator use may reduce the frequency of these complications. This report describes a potentially serious complication of a transtracheal catheter system which resulted despite appropriate use and care of the catheter.