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Mondal A, Visner GA, Kaza AK, Dupont PE. A novel ex vivo tracheobronchomalacia model for airway stent testing and in vivo model refinement. J Thorac Cardiovasc Surg 2023; 166:679-687.e1. [PMID: 37156367 PMCID: PMC10524727 DOI: 10.1016/j.jtcvs.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/14/2023] [Accepted: 04/10/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We sought to develop an ex vivo trachea model capable of producing mild, moderate, and severe tracheobronchomalacia for optimizing airway stent design. We also aimed to determine the amount of cartilage resection required for achieving different tracheobronchomalacia grades that can be used in animal models. METHODS We developed an ex vivo trachea test system that enabled video-based measurement of internal cross-sectional area as intratracheal pressure was cyclically varied for peak negative pressures of 20 to 80 cm H2O. Fresh ovine tracheas were induced with tracheobronchomalacia by single mid-anterior incision (n = 4), mid-anterior circumferential cartilage resection of 25% (n = 4), and 50% per cartilage ring (n = 4) along an approximately 3-cm length. Intact tracheas (n = 4) were used as control. All experimental tracheas were mounted and experimentally evaluated. In addition, helical stents of 2 different pitches (6 mm and 12 mm) and wire diameters (0.52 mm and 0.6 mm) were tested in tracheas with 25% (n = 3) and 50% (n = 3) circumferentially resected cartilage rings. The percentage collapse in tracheal cross-sectional area was calculated from the recorded video contours for each experiment. RESULTS Ex vivo tracheas compromised by single incision and 25% and 50% circumferential cartilage resection produce tracheal collapse corresponding to clinical grades of mild, moderate, and severe tracheobronchomalacia, respectively. A single anterior cartilage incision produces saber-sheath type tracheobronchomalacia, whereas 25% and 50% circumferential cartilage resection produce circumferential tracheobronchomalacia. Stent testing enabled the selection of stent design parameters such that airway collapse associated with moderate and severe tracheobronchomalacia could be reduced to conform to, but not exceed, that of intact tracheas (12-mm pitch, 0.6-mm wire diameter). CONCLUSIONS The ex vivo trachea model is a robust platform that enables systematic study and treatment of different grades and morphologies of airway collapse and tracheobronchomalacia. It is a novel tool for optimization of stent design before advancing to in vivo animal models.
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Affiliation(s)
- Abhijit Mondal
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
| | - Gary A Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pierre E Dupont
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
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Martinez Rivera C, Serra Mitjà P, Andreo García F, Crespo-Lessmann A, Solis Solis AJ, Torrego A, Garcia-Olive I, Ramos-Barbón D, Zapata Comas T, Plaza V, Abad J, Rosell A. Factors Associated With Large Airway Collapse in Severe Asthma. Arch Bronconeumol 2023; 59:605-607. [PMID: 37296031 DOI: 10.1016/j.arbres.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Carlos Martinez Rivera
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain.
| | - Pere Serra Mitjà
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain
| | - Felipe Andreo García
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain
| | - Astrid Crespo-Lessmann
- Barcelona Respiratory Network (BRN), Spain; Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Universidad Autónoma de Barcelona, Spain
| | - Alan Jhunior Solis Solis
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain
| | - Alfons Torrego
- Barcelona Respiratory Network (BRN), Spain; Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Universidad Autónoma de Barcelona, Spain
| | - Ignasi Garcia-Olive
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain
| | - David Ramos-Barbón
- Barcelona Respiratory Network (BRN), Spain; Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Universidad Autónoma de Barcelona, Spain
| | - Toni Zapata Comas
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain
| | - Vicente Plaza
- Barcelona Respiratory Network (BRN), Spain; Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Universidad Autónoma de Barcelona, Spain
| | - Jorge Abad
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain
| | - Antoni Rosell
- Servicio de Neumología, Hospital Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Badalona, Barcelona, Spain; Universitat Autònoma de Barcelona, Spain; Barcelona Respiratory Network (BRN), Spain
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3
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Paediatric tracheobronchomalacia: Incidence, patient characteristics, and predictors of surgical intervention. J Pediatr Surg 2022; 57:543-549. [PMID: 35718546 DOI: 10.1016/j.jpedsurg.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/08/2022] [Accepted: 05/06/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Tracheobronchomalacia (TBM), a condition where an abnormality of the tracheal walls causes collapse during the respiratory cycle, is a common cause of airway obstruction in childhood. TBM can present with a large spectrum of disease severity and underlying pathologies that may be managed medically and surgically, and it is not always clear which patients would most benefit from surgical intervention. We aim to describe the incidence, patient characteristics, and predictors of surgical intervention in a large cohort of paediatric patients. METHODS We performed a retrospective review of all children diagnosed with TBM to a paediatric Otolaryngology unit in the west of Scotland between 2010 and 2020. Odds ratios for clinical predictors of surgery were calculated using logistic regression with uni- and multivariate analysis. RESULTS 249 patients were identified of which 219 proceeded to data collection. Primary malacia was noted in 161 (73.5%) and secondary in 58 (26.5%). Causes of secondary malacia included compression by the innominate artery (11%) and vascular rings (7.8%). Surgical interventions were performed in 28 patients (12.8%) including division of vascular ring, aortopexy, and surgical tracheostomy. Multivariate analysis showed secondary TBM, acute life-threatening events, and difficulty weaning from mechanical ventilation were independent risk factors for surgical intervention. CONCLUSIONS TBM can present with a myriad of airway symptoms and is frequently associated with other airway and mediastinal pathologies necessitating multiple interventions. Children aged <1 year present with a more severe form of the disease and the presence of particular independent risk factors may indicate a need for surgical intervention.
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4
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Zhou P, Yu W, Zhang C, Chen K, Tang W, Li X, Liu Z, Xia Q. Tiao-bu-fei-shen formula promotes downregulation of the caveolin 1-p38 mapk signaling pathway in COPD - Associated tracheobronchomalacia cell model. JOURNAL OF ETHNOPHARMACOLOGY 2022; 293:115256. [PMID: 35367574 DOI: 10.1016/j.jep.2022.115256] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/17/2022] [Accepted: 03/28/2022] [Indexed: 06/14/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The Tiao-bu-fei-shen (TBFS) formula, extensively used in Traditional Chinese Medicine (TCM), can enhance therapeutic efficacy and reduce the frequency of acute exacerbations of lung-kidney Qi deficiency in patients with chronic obstructive pulmonary disease (COPD). According to both TCM theory and long-term observation of practice, TBFS has become an effective treatment for COPD-associated tracheobronchomalacia (TBM). AIM OF THE STUDY To investigate the mechanism of the TBFS formula in treating COPD-associated TBM based on caveolin 1-p38 MAPK signaling and apoptosis. MATERIALS AND METHODS A rat COPD model was prepared by exposure to smoking combined with tracheal lipopolysaccharide injection. The trachea or bronchus chondrocytes from COPD rats were isolated, cultured, and treated with 10 ng/mL IL-1β for 24 h to develop a model of COPD-associated TBM. Normal rats were administered TBFS to prepare drug-containing serum, and CCK8 assays were used to screen the optimal drug-containing serum concentration and SB203580 dose. TBFS drug-containing serum and SB203580 were processed separately for the control, model, drug-containing serum, blocker, and drug-containing serum combined with blocker groups. Flow cytometry and CCK8 assays were used to detect apoptosis and proliferative activity. Toluidine blue staining and immunohistochemistry were used to analyze the chondrocyte proteoglycan and type II collagen content. Western blotting was used to detect the expression of caveolin 1, p-p38 MAPK, TNF-α, IL-1β, MMP-13, Bax, and Bcl-2 proteins. Quantitative PCR was used to detect the expression of caveolin 1, p38 MAPK, IL-1β, MMP-13, Bax, Bcl-2, and miR-140-5p. RESULTS The isolation and identification of bronchial chondrocytes from COPD rats revealed that 10 ng/mL IL-1β can produce a stable COPD-associated TBM model. Screened via the CCK8 method, fourth-generation bronchial chondrocytes were determined as the optimal cells, and 5 μM SB203580 and 5% low-dose drug-containing serum were the optimal intervention doses. The experimental chondrocytes of each group were treated separately for 48 h. Toluidine blue staining and immunohistochemical analysis revealed that TBFS drug-containing serum, SB203580, and TBFS drug-containing serum combined with SB203580 can effectively increase the proteoglycan and type II collagen content after chondrocyte degradation. Flow cytometry of cells treated with SB203580 and TBFS drug-containing serum combined with SB203580 revealed significantly reduced cell apoptosis and enhanced cell proliferation activity. Western blot and qPCR analyses revealed that the TBFS drug-containing serum, SB203580, and TBFS drug-containing serum combined with SB203580 effectively inhibit the expression of caveolin 1, p-p38 MAPK, MMP-13, IL-1β, TNF-α, and Bax proteins while promoting Bcl -2 protein expression. Treatment with TBFS drug-containing serum and SB203580 effectively inhibited the expression of MMP-13, p38 MAPK, caveolin 1, and Bax genes, and promoted the expression of Bcl-2 and miR-140-5p genes. CONCLUSIONS A concentration of 10 ng/mL of IL-1β can generate a stable COPD-associated TBM cell model. TBFS can improve the proteoglycan and type II collagen content, increase cell activity, and reduce the amount of chondrocyte apoptosis. The role of TBFS may be related to mechanisms of inhibiting the expression of the key signaling molecules caveolin 1 and p-p38 MAPK in the caveolin 1-p38 MAPK signaling pathway, thereby reducing the expression of the downstream effector products MMP-13, IL-1β, and TNF-α, while inhibiting the expression of the apoptotic gene Bax and improving the expression of Bcl-2 and miR-140-5p genes.
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Affiliation(s)
- Pengcheng Zhou
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
| | - Wei Yu
- Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
| | - Chuantao Zhang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
| | - Keling Chen
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
| | - Wenjun Tang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
| | - Xuelian Li
- Department of Emergency, Sichuan Second Hospital of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
| | - Zijun Liu
- Department of Intensive Care Unit, Sichuan Second Hospital of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
| | - Qianming Xia
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan province, PR China.
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5
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Grillo LJF, Housley GM, Gangadharan S, Majid A, Hull JH. Physiotherapy for large airway collapse: an ABC approach. ERJ Open Res 2022; 8:00510-2021. [PMID: 35211621 PMCID: PMC8864626 DOI: 10.1183/23120541.00510-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/17/2021] [Indexed: 11/05/2022] Open
Abstract
Large airway collapse (LAC) describes the phenomenon of excessive, abnormal, inward movement of the large airways (i.e. trachea and/or main bronchi and/or bronchus intermedius) occurring during the expiratory phase of the respiratory cycle. It is an increasingly well-recognised problem and a prevalent comorbidity in other chronic respiratory conditions (e.g. COPD and asthma). LAC is associated with pervasive respiratory features such as a barking cough, exertional dyspnoea and an increased propensity to lower respiratory tract infection. These symptoms are unpleasant, and patients are often limited in their daily life and their function. The pathophysiology of this condition impairs airway clearance and can cause breathlessness and exercise intolerance, due to a loss of airway patency during expiratory flow. Dysfunctional adaptations to breathing and coughing may further amplify symptoms. This article provides, for the first time, clinically focused physiotherapeutic intervention advice based on our understanding of the pathophysiology of LAC, to support conservative management. It uses the available evidence from LAC, transferable evidence from other conditions and knowledge based on clinical experience. It proposes a practical "ABC model" to ensure physiotherapy assessment and treatments are centred around optimising three key clinical areas: Airways, including airway clearance and cough; Breathing, including breathlessness and breathing pattern; and Capacity for exercise, including an assessment of functional exercise ability.
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Affiliation(s)
- Lizzie J F Grillo
- Royal Brompton and Harefield Hospitals, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | | | - Sidhu Gangadharan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Adnan Majid
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - James H Hull
- Royal Brompton and Harefield Hospitals, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Institute of Sport, Exercise and Health, UCL, London, UK
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6
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Zhou P, Fu B, Zhang C, Chen K, Xia Q, Tang W, Yu W, Huang W. Bronchoscopy-Guided Intervention Therapy With Extracorporeal Membrane Oxygenation Support for Relapsing Polychondritis With Severe Tracheobronchomalacia: A Case Report and Literature Review. Front Med (Lausanne) 2021; 8:695505. [PMID: 34888317 PMCID: PMC8649689 DOI: 10.3389/fmed.2021.695505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 11/04/2021] [Indexed: 12/24/2022] Open
Abstract
Relapsing polychondritis is an immune disorder of unknown etiology involving multiple systems that is characterized by persistent inflammation and destruction of cartilage, including the ears, nose, costal, joint, and airways. Airway involvement caused by relapsing polychondritis is common, and tracheobronchomalacia is the most serious complication, which is life-threatening. Currently, the exact mechanism of relapsing polychondritis with tracheobronchomalacia is unknown. Although glucocorticoids and immunosuppressive agents are administered, failures often occur. Currently, bronchoscopy-guided intervention therapy used in tracheobronchomalacia caused by chronic obstructive pulmonary disease or other etiology has gradually increased, but bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation assist used in tracheobronchomalacia caused by relapsing polychondritis has not been reported. Here, we report a case of relapsing polychondritis with severe tracheobronchomalacia. Although drug therapy was provided and airway stent implantation was performed, the tracheal stenosis was further aggravated. Because conventional anesthesia and mechanical ventilation cannot meet the needs of bronchoscopy-guided intervention therapy or guarantee sufficient safety. The intervention treatment was performed with the support of extracorporeal membrane oxygenation, which was successfully completed without obvious complications. The symptoms were significantly improved, and the patient was discharged uneventfully.
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Affiliation(s)
- Pengcheng Zhou
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bing Fu
- Department of Cardiothoracic Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Chuantao Zhang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Keling Chen
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qianming Xia
- Department of Respiratory Medicine, The Aviation Industry Corporation of China (AVIC) 363 Hospital, Chengdu, China
| | - Wenjun Tang
- Department of Respiratory Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wei Yu
- Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wenhui Huang
- Department of Cardiothoracic Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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7
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Crowhurst TD, Tcherveniakov P, Lorraine B, Polasek JF, Nguyen PT, Yeo A. Obstructive sleep apnoea is associated with dynamic intra-thoracic central airway collapse: results of a 10-year multi-centre retrospective analysis. SLEEP SCIENCE AND PRACTICE 2020. [DOI: 10.1186/s41606-020-00045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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8
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Ahmed MM, Galal IHE, Sakr HM, Gomaa AA, Osman AM, El-Assal MH. Role of ultrasound in airway assessment in the respiratory ICUs. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_59_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Wallis C, Alexopoulou E, Antón-Pacheco JL, Bhatt JM, Bush A, Chang AB, Charatsi AM, Coleman C, Depiazzi J, Douros K, Eber E, Everard M, Kantar A, Masters IB, Midulla F, Nenna R, Roebuck D, Snijders D, Priftis K. ERS statement on tracheomalacia and bronchomalacia in children. Eur Respir J 2019; 54:13993003.00382-2019. [PMID: 31320455 DOI: 10.1183/13993003.00382-2019] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/16/2019] [Indexed: 01/20/2023]
Abstract
Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study.
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Affiliation(s)
- Colin Wallis
- Respiratory Medicine Unit, Great Ormond Street Hospital for Children, London, UK
| | - Efthymia Alexopoulou
- 2nd Radiology Dept, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Juan L Antón-Pacheco
- Pediatric Airway Unit and Pediatric Surgery Division, Universidad Complutense de Madrid, Madrid, Spain
| | - Jayesh M Bhatt
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Andrew Bush
- Imperial College London and Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anne B Chang
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | | | | | - Julie Depiazzi
- Physiotherapy Dept, Perth Children's Hospital, Perth, Australia
| | - Konstantinos Douros
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Dept of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Mark Everard
- Division of Paediatrics, University of Western Australia, Perth Children's Hospital, Perth, Australia
| | - Ahmed Kantar
- Pediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
| | - Ian B Masters
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Fabio Midulla
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy
| | - Raffaella Nenna
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy.,Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Derek Roebuck
- Interventional Radiology Dept, Great Ormond Street Hospital, London, UK
| | - Deborah Snijders
- Dipartimento Salute della Donna e del Bambino, Università degli Studi di Padova, Padova, Italy
| | - Kostas Priftis
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
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10
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Sul B, Altes T, Ruppert K, Qing K, Hariprasad DS, Morris M, Reifman J, Wallqvist A. In vivo dynamics of the tracheal airway and its influences on respiratory airflows. J Biomech Eng 2019; 141:2733770. [PMID: 31074759 DOI: 10.1115/1.4043723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Indexed: 11/08/2022]
Abstract
Respiration is a dynamic process accompanied by morphological changes in the airways. Although deformation of large airways is expected to exacerbate pulmonary disease symptoms by obstructing airflow during increased minute ventilation, its quantitative effects on airflow characteristics remain unclear. Here, we used an exemplar case derived from in vivo dynamic imaging and examined the effects of tracheal deformation on airflow characteristics under different conditions. First, we measured tracheal deformation profiles of a healthy lung using magnetic resonance imaging during forced exhalation, which we simulated to characterize subject-specific airflow patterns. Subsequently, for both inhalation and exhalation, we compared the airflows when the maximal deformation in tracheal cross-sectional area was 0% (rigid), 33% (mild), 50% (moderate), or 75% (severe). We quantified differences in airflow patterns between deformable and rigid airways by computing the correlation coefficients (R) and the root-mean-square of differences (Drms) between their velocity contours. For both inhalation and exhalation, airflow patterns were similar in all branches between the rigid and mild conditions (R > 0.9; Drms < 32%). However, airflow characteristics in the moderate and severe conditions differed markedly from those in the rigid and mild conditions in all lung branches, particularly for inhalation (moderate: R > 0.1, Drms < 76%; severe: R > 0.2, Drms < 96%). Our exemplar case supports the use of a rigid airway assumption to compute flows for mild deformation. For moderate or severe deformation, however, dynamic contraction should be considered, especially during inhalation, to accurately predict airflow and elucidate the underlying pulmonary pathology.
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Affiliation(s)
- Bora Sul
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland; Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Talissa Altes
- Department of Radiology, University of Missouri, Columbia, Missouri
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kun Qing
- Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Daniel S Hariprasad
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland; Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Michael Morris
- Graduate Medical Education, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas
| | - Jaques Reifman
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Anders Wallqvist
- Department of Defense Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Materiel Command, Fort Detrick, Maryland
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11
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Diagnostic flexible versus rigid bronchoscopy for the assessment of tracheomalacia in children. The Journal of Laryngology & Otology 2018; 132:1083-1087. [PMID: 30565533 DOI: 10.1017/s0022215118002050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This project compares the degree of tracheal collapse determined by rigid and flexible bronchoscopy in paediatric patients with tracheomalacia. METHODS A total of nine patients with tracheomalacia underwent both rigid and flexible video bronchoscopy. All patients were breathing spontaneously. Cross-sectional images of the airway were processed using the ImageJ program and analysed via colour histogram mode technique in order to delineate the luminal area. Paired t-tests (conducted using Stata software version 13.0) quantified differences between rigid and flexible bronchoscopes regarding the ratios of luminal pixels at maximum airway collapse to expansion. Correlation between both techniques in terms of airway collapse to expansion ratios was determined by calculating the Pearson correlation coefficient (R). RESULTS The difference in ratios of maximum collapse to expansion between rigid and flexible bronchoscopy was not statistically significant (p = 0.4656) and was positively correlated (R = 0.523). CONCLUSION The ratios suggest that rigid and flexible bronchoscopy are equally efficacious in assessing tracheomalacia severity, and may be used interchangeably in a clinical setting.
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12
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Fielding DI, Travers J, Nguyen P, Brown MG, Hartel G, Morrison S. Expiratory reactance abnormalities in patients with expiratory dynamic airway collapse: a new application of impulse oscillometry. ERJ Open Res 2018; 4:00080-2018. [PMID: 30443553 PMCID: PMC6230814 DOI: 10.1183/23120541.00080-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 09/02/2018] [Indexed: 11/09/2022] Open
Abstract
Expiratory dynamic airways collapse (EDAC) is a condition that affects the central airways; it is not well characterised physiologically, with relatively few studies. We sought to characterise impulse oscillometry (IOS) features of EDAC in patients with normal spirometry. Expiratory data were hypothesised to be the most revealing. In addition, we compared IOS findings in chronic obstructive pulmonary disease (COPD) patients with and without EDAC. EDAC was identified at bronchoscopy as 75–100% expiratory closure at the carina or bilateral main bronchi. Four patient groups were compared: controls with no EDAC and normal lung function; lone EDAC with normal lung function; COPD-only patients; and COPD patients with EDAC. 38 patients were studied. Mean IOS data z-scores for EDAC compared to controls showed significantly higher reactance (X) values including X at 5 Hz, resonance frequency and area under the reactance curve (AX). EDAC showed significantly greater expiratory/inspiratory differences in all IOS data compared to controls. Stepwise logistic regression showed that resonant frequency best discriminated between EDAC and normal control, whereas classification and regression tree analysis found AX ≥3.523 to be highly predictive for EDAC in cases with normal lung function (14 out of 15 cases, and none out of eight controls). These data show a new utility of IOS: detecting EDAC in patients with normal lung function. Central airway expiratory dynamic airway collapse can be “silent” on breathing tests, but impulse oscillometry can reveal ithttp://ow.ly/9oIb30lIOka
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Affiliation(s)
- David I Fielding
- Dept of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Justin Travers
- Dept of Thoracic Medicine, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Phan Nguyen
- The Dept of Thoracic Medicine, The Royal Adelaide Hospital, Adelaide, Australia
| | - Michael G Brown
- Dept of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | | | - Stephen Morrison
- Dept of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
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Aneeshkumar S, Thaha MM, Varun S. Excessive dynamic airway collapse presenting as intractable cough: A case report. Lung India 2018; 35:525-526. [PMID: 30381566 PMCID: PMC6219124 DOI: 10.4103/lungindia.lungindia_89_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Surendran Aneeshkumar
- Department of Respiratory Medicine, KIMS Kollam Multispeciality Hospital, Kollam, Kerala, India
| | - Milan Malik Thaha
- Department of Respiratory Medicine, KIMS Kollam Multispeciality Hospital, Kollam, Kerala, India
| | - S Varun
- Department of Internal Medicine, KIMS Kollam Multispeciality Hospital, Kollam, Kerala, India
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14
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Milman S, Ng T. Robotic tracheobronchoplasty is feasible, but which patients truly benefit? J Thorac Cardiovasc Surg 2018; 157:801-802. [PMID: 30244859 DOI: 10.1016/j.jtcvs.2018.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 08/09/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Steven Milman
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Thomas Ng
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI.
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15
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Abstract
The term tracheobronchomalacia refers to excessively compliant and collapsible central airways leading to symptoms. Although seen as a coexisting condition with various other pulmonary condition, it may cause symptoms by itself. The condition is often misdiagnosed as asthma, bronchitis or just chronic cough due to a lack of specific pathognomonic history and clinical findings. The investigation revolves around different modes of imaging, lung function testing and usually confirmed by flexible bronchoscopy. The treatment widely varies based on the cause, with most cases treated conservatively with non-invasive ventilation. Some may require surgery or stent placement. In this article, we aim to discuss the pathophysiology behind this condition and recognize the common symptoms and causes of tracheobronchomalacia. The article will highlight the diagnostic steps as well as therapeutic interventions based on the specific cause.
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Affiliation(s)
- Abhishek Biswas
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States.
| | - Michael A Jantz
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - P S Sriram
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - Hiren J Mehta
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
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16
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Lee J, Kim HS, Jung YH, Choi CW, Jun YH. Neurally adjusted ventilatory assist for infants under prolonged ventilation. Pediatr Int 2017; 59:540-544. [PMID: 28063223 DOI: 10.1111/ped.13233] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/11/2016] [Accepted: 01/05/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe bronchopulmonary dysplasia often leads to prolonged mechanical ventilation lasting several months. Cyanotic episodes frequently occur in these patients, necessitating long-term sedation and/or intermittent muscle paralysis. Neurally adjusted ventilatory assist (NAVA) might provide precisely the amount of support that these patients need without sedation. METHODS We reviewed the medical records of preterm infants who underwent tracheostomy and required mechanical ventilation for >6 months during a period of 6 years. We compared two groups of patients: those supported with NAVA for ≥2 months versus those supported by pneumatically triggered assist methods. We also evaluated any change after NAVA use in the NAVA group. RESULTS Among 14 prematurely born patients who received prolonged ventilation, nine were supported with NAVA and five were supported using other ventilator modes. Duration of continuous sedation was significantly shorter and the bolus use of sedatives was also significantly lower in the NAVA group than in the pneumatically triggered assist group. In addition, the NAVA group received a lower dose of dexamethasone than the pneumatically triggered assist group. Compared with before NAVA, the frequency of cyanotic episodes and of the bolus sedatives was significantly decreased after implementation of NAVA. CONCLUSIONS For infants on prolonged mechanical ventilation, NAVA could reduce cyanotic episodes and the need for sedatives and dexamethasone. NAVA may be superior to pneumatically triggered modes in terms of the minimization of patient-ventilator dyssynchrony while delivering appropriate respiratory support in premature infants with tracheostomy.
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Affiliation(s)
- Juyoung Lee
- Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Hoon Jun
- Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
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17
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McLaurin S, Whitener GB, Steinburg T, Finley A, Heinke T, Nelson E, Guldan III G, Klapper J, Slinger P, Abernathy JH. A Unique Strategy for Lung Isolation During Tracheobronchoplasty. J Cardiothorac Vasc Anesth 2017; 31:731-737. [DOI: 10.1053/j.jvca.2016.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Indexed: 12/30/2022]
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19
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Miyawaki S, Choi S, Hoffman EA, Lin CL. A 4DCT imaging-based breathing lung model with relative hysteresis. JOURNAL OF COMPUTATIONAL PHYSICS 2016; 326:76-90. [PMID: 28260811 PMCID: PMC5333919 DOI: 10.1016/j.jcp.2016.08.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
To reproduce realistic airway motion and airflow, the authors developed a deforming lung computational fluid dynamics (CFD) model based on four-dimensional (4D, space and time) dynamic computed tomography (CT) images. A total of 13 time points within controlled tidal volume respiration were used to account for realistic and irregular lung motion in human volunteers. Because of the irregular motion of 4DCT-based airways, we identified an optimal interpolation method for airway surface deformation during respiration, and implemented a computational solid mechanics-based moving mesh algorithm to produce smooth deforming airway mesh. In addition, we developed physiologically realistic airflow boundary conditions for both models based on multiple images and a single image. Furthermore, we examined simplified models based on one or two dynamic or static images. By comparing these simplified models with the model based on 13 dynamic images, we investigated the effects of relative hysteresis of lung structure with respect to lung volume, lung deformation, and imaging methods, i.e., dynamic vs. static scans, on CFD-predicted pressure drop. The effect of imaging method on pressure drop was 24 percentage points due to the differences in airflow distribution and airway geometry.
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Affiliation(s)
- Shinjiro Miyawaki
- IIHR-Hydroscience & Engineering, The University of Iowa, Iowa City, Iowa 52242
| | - Sanghun Choi
- IIHR-Hydroscience & Engineering, The University of Iowa, Iowa City, Iowa 52242
| | - Eric A. Hoffman
- Biomedical Engineering, The University of Iowa, Iowa City, Iowa 52242
- Medicine, The University of Iowa, Iowa City, Iowa 52242
- Radiology, The University of Iowa, Iowa City, Iowa 52242
| | - Ching-Long Lin
- IIHR-Hydroscience & Engineering, The University of Iowa, Iowa City, Iowa 52242
- Department of Mechanical and Industrial Engineering, The University of Iowa, Iowa City, Iowa 52242
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Majid A, Alape D, Kheir F, Folch E, Ochoa S, Folch A, Gangadharan SP. Short-Term Use of Uncovered Self-Expanding Metallic Airway Stents for Severe Expiratory Central Airway Collapse. Respiration 2016; 92:389-396. [DOI: 10.1159/000450961] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022] Open
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21
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Murgu SD, Egressy K, Laxmanan B, Doblare G, Ortiz-Comino R, Hogarth DK. Central Airway Obstruction. Chest 2016; 150:426-41. [DOI: 10.1016/j.chest.2016.02.001] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Eberlein M. Excessive dynamic airway collapse and lung transplantation. J Heart Lung Transplant 2016; 35:1044-5. [PMID: 27311375 DOI: 10.1016/j.healun.2016.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/22/2016] [Accepted: 05/04/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Michael Eberlein
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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23
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Schmitt P, Dalar L, Jouneau S, Toublanc B, Camuset J, Chatte G, Cellerin L, Dutau H, Sanchez S, Sauvage M, Vergnon JM, Dury S, Deslée G, Lebargy F. Respiratory Conditions Associated with Tracheobronchomegaly (Mounier-Kuhn Syndrome): A Study of Seventeen Cases. Respiration 2016; 91:281-7. [PMID: 27022925 DOI: 10.1159/000445029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 02/29/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Mounier-Kuhn syndrome (MKS) is a rare disorder characterized by enlargement of the trachea and main bronchi and associated with recurrent respiratory tract infections. OBJECTIVE This multicenter, retrospective study was carried out to describe respiratory conditions associated with tracheobronchomegaly. METHODS Nine institutions involved in the 'Groupe d'Endoscopie de Langue Française' (GELF) participated in this study. A standard form was used to record patient characteristics, treatments and follow-up from medical charts. RESULTS Seventeen patients, 53% male, aged 58 ± 18 years at diagnosis were included. Recurrent infections revealed MKS in 88% of cases. Main comorbid conditions were diffuse bronchiectasis in 88% of patients and tracheobronchomalacia in 67% of cases. The exacerbation rate was 1.5 exacerbations/patient/year. The main non-respiratory morbid condition was gastroesophageal reflux disease in 29% of cases. Interventional bronchoscopy was performed in seven patients (41%), consisting of laser (n = 2) and tracheal stenting (n = 5). Complications related to stents were observed in 80% of cases with a mean stent duration of 8 months. Four deaths, including three due to respiratory causes, occurred during follow-up. CONCLUSIONS This is the largest series of MKS reported in the literature, showing that bronchiectasis and tracheobronchomalacia are the main associated morbid conditions that constitute a challenge for treatment.
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Affiliation(s)
- Pierre Schmitt
- Department of Respiratory Medicine, University Hospital Maison Blanche, Reims, France
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24
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Bhatt SP, Terry NL, Nath H, Zach JA, Tschirren J, Bolding MS, Stinson DS, Wilson CG, Curran-Everett D, Lynch DA, Putcha N, Soler X, Wise RA, Washko GR, Hoffman EA, Foreman MG, Dransfield MT. Association Between Expiratory Central Airway Collapse and Respiratory Outcomes Among Smokers. JAMA 2016; 315:498-505. [PMID: 26836732 PMCID: PMC5173387 DOI: 10.1001/jama.2015.19431] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Central airway collapse greater than 50% of luminal area during exhalation (expiratory central airway collapse [ECAC]) is associated with cigarette smoking and chronic obstructive pulmonary disease (COPD). However, its prevalence and clinical significance are unknown. OBJECTIVE To determine whether ECAC is associated with respiratory morbidity in smokers independent of underlying lung disease. DESIGN, SETTING, AND PARTICIPANTS Analysis of paired inspiratory-expiratory computed tomography images from a large multicenter study (COPDGene) of current and former smokers from 21 clinical centers across the United States. Participants were enrolled from January 2008 to June 2011 and followed up longitudinally until October 2014. Images were initially screened using a quantitative method to detect at least a 30% reduction in minor axis tracheal diameter from inspiration to end-expiration. From this sample of screen-positive scans, cross-sectional area of the trachea was measured manually at 3 predetermined levels (aortic arch, carina, and bronchus intermedius) to confirm ECAC (>50% reduction in cross-sectional area). EXPOSURES Expiratory central airway collapse. MAIN OUTCOMES AND MEASURES The primary outcome was baseline respiratory quality of life (St George's Respiratory Questionnaire [SGRQ] scale 0 to 100; 100 represents worst health status; minimum clinically important difference [MCID], 4 units). Secondary outcomes were baseline measures of dyspnea (modified Medical Research Council [mMRC] scale 0 to 4; 4 represents worse dyspnea; MCID, 0.7 units), baseline 6-minute walk distance (MCID, 30 m), and exacerbation frequency (events per 100 person-years) on longitudinal follow-up. RESULTS The study included 8820 participants with and without COPD (mean age, 59.7 [SD, 6.9] years; 4667 [56.7%] men; 4559 [51.7%] active smokers). The prevalence of ECAC was 5% (443 cases). Patients with ECAC compared with those without ECAC had worse SGRQ scores (30.9 vs 26.5 units; P < .001; absolute difference, 4.4 [95% CI, 2.2-6.6]) and mMRC scale scores (median, 2 [interquartile range [IQR], 0-3]) vs 1 [IQR, 0-3]; P < .001]), but no significant difference in 6-minute walk distance (399 vs 417 m; absolute difference, 18 m [95% CI, 6-30]; P = .30), after adjustment for age, sex, race, body mass index, forced expiratory volume in the first second, pack-years of smoking, and emphysema. On follow-up (median, 4.3 [IQR, 3.2-4.9] years), participants with ECAC had increased frequency of total exacerbations (58 vs 35 events per 100 person-years; incidence rate ratio [IRR], 1.49 [95% CI, 1.29-1.72]; P < .001) and severe exacerbations requiring hospitalization (17 vs 10 events per 100 person-years; IRR, 1.83 [95% CI, 1.51-2.21]; P < .001). CONCLUSIONS AND RELEVANCE In a cross-sectional analysis of current and former smokers, the presence of ECAC was associated with worse respiratory quality of life. Further studies are needed to assess long-term associations with clinical outcomes.
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Affiliation(s)
- Surya P. Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294
- UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL 35294
- UAB Lung Imaging Core, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Nina L.J. Terry
- UAB Lung Imaging Core, University of Alabama at Birmingham, Birmingham, AL 35294
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Hrudaya Nath
- UAB Lung Imaging Core, University of Alabama at Birmingham, Birmingham, AL 35294
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Jordan A. Zach
- Quantitiative Imaging Laboratory, National Jewish Health, Denver, CO 80206
| | | | - Mark S. Bolding
- UAB Lung Imaging Core, University of Alabama at Birmingham, Birmingham, AL 35294
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL 35294
| | | | - Carla G. Wilson
- Department of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO 80206
| | - Douglas Curran-Everett
- Department of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO 80206
| | - David A. Lynch
- Quantitiative Imaging Laboratory, National Jewish Health, Denver, CO 80206
- Department of Radiology, National Jewish Health, Denver, CO 80206
| | - Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224
| | - Xavi Soler
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA 92093
| | - Robert A. Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224
| | - George R. Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Eric A. Hoffman
- Department of Radiology and Biomedical Engineering, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Marilyn G. Foreman
- Division of Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA, 30303
| | - Mark T. Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294
- UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL 35294
- UAB Lung Imaging Core, University of Alabama at Birmingham, Birmingham, AL 35294
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25
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Lyaker MR, Davila VR, Papadimos TJ. Excessive Dynamic Airway Collapse: An Unexpected Contributor to Respiratory Failure in a Surgical Patient. Case Rep Anesthesiol 2015; 2015:596857. [PMID: 26167306 PMCID: PMC4475727 DOI: 10.1155/2015/596857] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/27/2015] [Indexed: 11/20/2022] Open
Abstract
Central airway collapse plays a significant, underrecognized role in respiratory failure after extubation of critically ill patients. Historically, airway collapse has been attributed to tracheomalacia (TM), softening of the cartilage in the trachea and other large airways. More recently, excessive dynamic airway collapse (EDAC) has been described as a distinct process unrelated to a loss of cartilaginous airway support. EDAC is caused by the posterior wall of the trachea bulging forward and causing airway obstruction during exhalation. This process is exaggerated when intrathoracic pressure is increased and results in a clinical picture of coughing, difficulty clearing secretions, dyspnea, and stridor. The increased use of computerized tomography and fiberoptic bronchoscopy has identified varying degrees of EDAC and TM in both symptomatic and asymptomatic individuals. This has led to renewed consideration of airway collapse and the different processes that contribute to it. Here we describe a 43-year-old morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. We will discuss the processes of EDAC and TM, describe how this condition contributed to this patient's respiratory failure, and review diagnosis and management options.
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Affiliation(s)
- Michael R. Lyaker
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
| | - Victor R. Davila
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
| | - Thomas J. Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH 43210, USA
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Camiciottoli G, Diciotti S, Bigazzi F, Lombardo S, Bartolucci M, Paoletti M, Mascalchi M, Pistolesi M. Is intrathoracic tracheal collapsibility correlated to clinical phenotypes and sex in patients with COPD? Int J Chron Obstruct Pulmon Dis 2015; 10:843-52. [PMID: 25960647 PMCID: PMC4423505 DOI: 10.2147/copd.s80558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A substantial proportion of patients with chronic obstructive pulmonary disease (COPD) develops various degree of intrathoracic tracheal collapsibility. We studied whether the magnitude of intrathoracic tracheal collapsibility could be different across clinical phenotypes and sex in COPD. Intrathoracic tracheal collapsibility measured at paired inspiratory-expiratory low dose computed tomography (CT) and its correlation with clinical, functional, and CT-densitometric data were investigated in 69 patients with COPD according to their predominant conductive airway or emphysema phenotypes and according to sex. Intrathoracic tracheal collapsibility was higher in patients with predominant conductive airway disease (n=28) and in females (n=27). Women with a predominant conductive airway phenotype (n=10) showed a significantly greater degree of collapsibility than women with predominant emphysema (28.9%±4% versus 11.6%±2%; P<0.001). Intrathoracic tracheal collapsibility was directly correlated with inspiratory-expiratory volume variation at CT and with forced expiratory volume (1 second), and inversely correlated with reduced CT lung density and functional residual capacity. Intrathoracic tracheal collapsibility was not correlated with cough and wheezing; however, intrathoracic tracheal collapsibility and clinical phenotypes of COPD are closely correlated. In patients with a predominant emphysematous phenotype, a reduced collapsibility may reflect the mechanical properties of the stiff hyperinflated emphysematous lung. The high collapsibility in patients with predominant airway disease, mild airway obstruction, and in women with this phenotype may reflect chronic airway inflammation. The lack of relationship with such symptoms as wheezing, cough, and dyspnea could indicate that intrathoracic tracheal collapsibility itself should be considered neither an abnormal feature of COPD nor a relevant clinical finding.
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Affiliation(s)
- Gianna Camiciottoli
- Section of Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Stefano Diciotti
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi," University of Bologna, Cesena, Italy
| | - Francesca Bigazzi
- Section of Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Simone Lombardo
- Radiodiagnostic Section, Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - Maurizio Bartolucci
- Department of Diagnostic Imaging, Careggi University Hospital, Florence, Italy
| | - Matteo Paoletti
- Section of Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Mario Mascalchi
- Radiodiagnostic Section, Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - Massimo Pistolesi
- Section of Respiratory Medicine, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
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Represas-Represas C, Leiro-Fernández V, Mallo-Alonso R, Botana-Rial MI, Tilve-Gómez A, Fernández-Villar A. Excessive dynamic airway collapse in a small cohort of chronic obstructive pulmonary disease patients. Ann Thorac Med 2015; 10:118-22. [PMID: 25829963 PMCID: PMC4375740 DOI: 10.4103/1817-1737.150733] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/15/2014] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The prevalence of EDAC (Excessive Dynamic Airway Collapse) has not been studied specifically in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE The aim of this study was to investigate the prevalence of EDAC in COPD and to determine whether there are clinical factors or functional variables that could influence the degree of expiratory collapse of central airways. METHODS Prospective observational study of a group of patients with COPD. The degree of tracheobronchial collapse was evaluated by low-dose dynamic airway computed tomography (CT). We recorded clinical and pulmonary function tests data, quality of life and BODE index. RESULTS This study included 53 patients with COPD, 46 (87%) males, mean age 65 (SD, 9) years. CONCLUSIONS The prevalence of EDAC observed in a sample of patients with different levels of COPD severity is low. The degree of dynamic central airway collapse was not related to the patient's epidemiological or clinical features, and did not affect lung function, symptoms, capacity for effort, or quality of life.
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Affiliation(s)
- C Represas-Represas
- Department of Pneumology, Research Group of Respiratory and Infectious Diseases, University Hospital Complex of Vigo, Xerencia de Xestion Integrada de Vigo, Spain
| | - V Leiro-Fernández
- Department of Pneumology, Research Group of Respiratory and Infectious Diseases, University Hospital Complex of Vigo, Xerencia de Xestion Integrada de Vigo, Spain
| | - R Mallo-Alonso
- Department of Radiology, University Hospital Complex of Vigo, Xerencia de Xestion Integrada de Vigo, Spain
| | - MI Botana-Rial
- Department of Pneumology, Research Group of Respiratory and Infectious Diseases, University Hospital Complex of Vigo, Xerencia de Xestion Integrada de Vigo, Spain
| | - A Tilve-Gómez
- Department of Radiology, University Hospital Complex of Vigo, Xerencia de Xestion Integrada de Vigo, Spain
| | - A Fernández-Villar
- Department of Pneumology, Research Group of Respiratory and Infectious Diseases, University Hospital Complex of Vigo, Xerencia de Xestion Integrada de Vigo, Spain
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Fischer AJ, Singh SB, Adam RJ, Stoltz DA, Baranano CF, Kao S, Weinberger MM, McCray PB, Starner TD. Tracheomalacia is associated with lower FEV1 and Pseudomonas acquisition in children with CF. Pediatr Pulmonol 2014; 49:960-70. [PMID: 24166775 PMCID: PMC4711356 DOI: 10.1002/ppul.22922] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 09/17/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Tracheomalacia (TM) occurs in approximately 1 in 2,100 children. Because the trachea develops abnormally in animal models of cystic fibrosis (CF), we hypothesized this may also occur in children with CF, increasing their risk of TM. PURPOSE To examine the prevalence and clinical consequences of TM in children with CF. METHODS We studied children with CF born between 1995 and 2012. TM was defined as dynamic collapse of the trachea, and the severity was recorded as described in the chart. The effect of TM on patient outcomes, including FEV1 , CT changes, and acquisition of CF pathogens, was assessed using a longitudinal patient dataset. RESULTS Eighty-nine percent of children with CF had at least one bronchoscopy (n = 97/109). Fifteen percent of these children had TM described in any bronchoscopy report (n = 15/97). Of the patients with TM, eight had meconium ileus (P = 0.003) and all were pancreatic insufficient. Pseudomonas aeruginosa infection occurred 1.3 years earlier among children with TM (P = 0.01). Starting FEV1 values by age 8 were diminished by over 18% of predicted for patients with TM. Life-threatening episodes of airway obstruction occurred in 3 of 15 patients with CF and TM, including one leading to death. Gender, prematurity, and hepatic disease were not associated with TM. No difference was observed in the frequency of bronchiectasis. CONCLUSIONS TM is significantly more common in infants and children with CF than in the general population and is associated with airway obstruction and earlier Pseudomonas acquisition.
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Watanabe J, Sato K, Fujikura Y, Horiuchi T, Kato S, Hikota R, Maekawa T, Yamamura T, Kobayashi A, Kobayashi S, Kawana A, Kimura F. Tracheobronchomalacia after allogeneic BMT; pulmonary function test findings similar to those of bronchiolitis obliterans. Bone Marrow Transplant 2014; 49:1450-1. [DOI: 10.1038/bmt.2014.175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Long-term success after bilateral lung transplantation for Mounier-Kuhn syndrome: a physiological description. Ann Am Thorac Soc 2014; 10:534-7. [PMID: 24161060 DOI: 10.1513/annalsats.201306-196le] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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O'Donnell CR, Bankier AA, O'Donnell DH, Loring SH, Boiselle PM. Static end-expiratory and dynamic forced expiratory tracheal collapse in COPD. Clin Radiol 2013; 69:357-62. [PMID: 24361144 DOI: 10.1016/j.crad.2013.11.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 09/23/2013] [Accepted: 11/05/2013] [Indexed: 11/15/2022]
Abstract
AIM To determine the range of tracheal collapse at end-expiration among chronic obstructive pulmonary disease (COPD) patients and to compare the extent of tracheal collapse between static end-expiratory and dynamic forced-expiratory multidetector-row computed tomography (MDCT). MATERIALS AND METHODS After institutional review board approval and obtaining informed consent, 67 patients meeting the National Heart, Lung, and Blood Institute (NHLBI)/World Health Organization (WHO) Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for COPD were sequentially imaged using a 64-detector-row CT machine at end-inspiration, during forced expiration, and at end-expiration. Standardized respiratory coaching and spirometric monitoring were employed. Mean percentage tracheal collapse at end-expiration and forced expiration were compared using correlation analysis, and the power of end-expiratory cross-sectional area to predict excessive forced-expiratory tracheal collapse was computed following construction of receiver operating characteristic (ROC) curves. RESULTS Mean percentage expiratory collapse among COPD patients was 17 ± 18% at end-expiration compared to 62 ± 16% during forced expiration. Over the observed range of end-expiratory tracheal collapse (approximately 10-50%), the positive predictive value of end-expiratory collapse to predict excessive (≥80%) forced expiratory tracheal collapse was <0.3. CONCLUSION COPD patients demonstrate a wide range of end-expiratory tracheal collapse. The magnitude of static end-expiratory tracheal collapse does not predict excessive dynamic expiratory tracheal collapse.
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Affiliation(s)
- C R O'Donnell
- Department of Pulmonary, Critical Care and Sleep Medicine, Harvard Medical School, Boston, MA, USA.
| | - A A Bankier
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - D H O'Donnell
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - S H Loring
- Department of Anesthesia, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
| | - P M Boiselle
- Department of Radiology, Harvard Medical School, Boston, MA, USA
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Yin Y, Choi J, Hoffman EA, Tawhai MH, Lin CL. A multiscale MDCT image-based breathing lung model with time-varying regional ventilation. JOURNAL OF COMPUTATIONAL PHYSICS 2013; 244:168-192. [PMID: 23794749 PMCID: PMC3685439 DOI: 10.1016/j.jcp.2012.12.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
A novel algorithm is presented that links local structural variables (regional ventilation and deforming central airways) to global function (total lung volume) in the lung over three imaged lung volumes, to derive a breathing lung model for computational fluid dynamics simulation. The algorithm constitutes the core of an integrative, image-based computational framework for subject-specific simulation of the breathing lung. For the first time, the algorithm is applied to three multi-detector row computed tomography (MDCT) volumetric lung images of the same individual. A key technique in linking global and local variables over multiple images is an in-house mass-preserving image registration method. Throughout breathing cycles, cubic interpolation is employed to ensure C1 continuity in constructing time-varying regional ventilation at the whole lung level, flow rate fractions exiting the terminal airways, and airway deformation. The imaged exit airway flow rate fractions are derived from regional ventilation with the aid of a three-dimensional (3D) and one-dimensional (1D) coupled airway tree that connects the airways to the alveolar tissue. An in-house parallel large-eddy simulation (LES) technique is adopted to capture turbulent-transitional-laminar flows in both normal and deep breathing conditions. The results obtained by the proposed algorithm when using three lung volume images are compared with those using only one or two volume images. The three-volume-based lung model produces physiologically-consistent time-varying pressure and ventilation distribution. The one-volume-based lung model under-predicts pressure drop and yields un-physiological lobar ventilation. The two-volume-based model can account for airway deformation and non-uniform regional ventilation to some extent, but does not capture the non-linear features of the lung.
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Affiliation(s)
- Youbing Yin
- Department of Mechanical and Industrial Engineering, The University of Iowa, Iowa City, IA 52242, US
- IIHR-Hydroscience and Engineering, The University of Iowa, Iowa City, IA 52242, US
- Department of Radiology, The University of Iowa, Iowa City, IA 52242, US
| | - Jiwoong Choi
- Department of Mechanical and Industrial Engineering, The University of Iowa, Iowa City, IA 52242, US
- IIHR-Hydroscience and Engineering, The University of Iowa, Iowa City, IA 52242, US
| | - Eric A. Hoffman
- Department of Radiology, The University of Iowa, Iowa City, IA 52242, US
- Department of Biomedical Engineering, The University of Iowa, Iowa City, IA 52242, US
- Department of Internal Medicine, The University of Iowa, Iowa City, IA 52242, US
| | - Merryn H. Tawhai
- Auckland Bioengineering Institute, The University of Auckland, Auckland, NZ
| | - Ching-Long Lin
- Department of Mechanical and Industrial Engineering, The University of Iowa, Iowa City, IA 52242, US
- IIHR-Hydroscience and Engineering, The University of Iowa, Iowa City, IA 52242, US
- Corresponding author. Telephone: +1-319-335-5673. Fax: +1-319-335-5669. (C.-L. Lin)
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Dal Negro RW, Tognella S, Guerriero M, Micheletto C. Prevalence of tracheobronchomalacia and excessive dynamic airway collapse in bronchial asthma of different severity. Multidiscip Respir Med 2013; 8:32. [PMID: 23673082 PMCID: PMC3670810 DOI: 10.1186/2049-6958-8-32] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/18/2013] [Indexed: 11/23/2022] Open
Abstract
Background Tracheobronchomalacia (TBM) is a pathologic condition in which softening of tracheal and bronchial cartilage causes the dynamic narrowing of transverse or sagittal diameters of tracheobronchial lumen; an excessive dynamic airway collapse (EDAC) may also be associated, with a substantial invagination of the posterior membrane of trachebronchial tree. The aim of this study was to assess the prevalence of both TBM and EDAC in a population of asthmatics with different degrees of disease severity compared to a reference group of subjects without any bronchial obstruction. Methods A cohort of 202 asthmatics was investigated by means of a dynamic flexible videobronchoscopy: 74 mild persistent (MPA - age 18–68 ys; 35 males; mean FEV1 = 88.6% pred. ± 8.3 sd); 63 moderate (MA - age 21–71 ys; 30 males; mean FEV1 = 71.3% pred. ± 9.1 sd), 65 severe asthmatics (SA - age 33–70 ys; 25 males; mean FEV1 = 48.5% pred. ± 7.6 sd), and 62 non obstructed subjects (NO - age 18–71 ys; 38 males; mean FEV1 98.6% pred. ± 2.7 sd). TBM and EDAC were classified according to FEMOS classification. Results TBM and EDAC were observed in only 1/62 subjects (both 1.61%) of NO group, while their prevalence was 2.70% and 6.75% in MPA group; 7.93% and 19.04% in MA group; 18.46% and 69.23% in SA group, respectively. The crude prevalence of thyroid disorders in the population was 12.9%. In particular, the prevalence of thyroid disorders was significantly higher in females than in men, but 54-fold higher in females than in men in the presence of EDAC. Conclusions 1) The prevalence of both TBM and EDAC is directly related to age, gender (females), and asthma severity; 2) EDAC is much more frequent than TBM in all asthma patients; 3) both tracheal abnormalities proved to be more represented in asthmatics with thyroid disorders, and particularly in female asthmatics with EDAC.
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Affiliation(s)
- Roberto W Dal Negro
- Respiratory Unit, Orlandi General Hospital, Via Ospedale 2, Bussolengo, VR 37012, Italy.
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Refractory asthma treatment is complicated by tracheobronchomalacia: case reports and review of the literature. Case Rep Med 2013; 2013:735058. [PMID: 23762075 PMCID: PMC3666332 DOI: 10.1155/2013/735058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 04/22/2013] [Indexed: 12/26/2022] Open
Abstract
Tracheobronchomalacia (TBM) is defined as the condition where the airway lumen narrows more than 50 percent. The acquired TBM usually occurs in adults; however, the prevalence of TBM in asthma is unknown. We report two cases of severe asthma in elderly patients that could not be controlled with higher medication use. Case 1 was a 70-year-old woman with sever persistent asthma for 10 years, presented with uncontrolled symptoms for 4 months. A CT of the chest showed collapse of the trachea at the posterior wall. Case 2 involved a 72-year-old woman with partly controlled asthma presenting with uncontrolled symptoms for 3 months. A CT of the chest showed normal distal tracheal anteroposterior diameter. However, bronchoscopy showed bronchomalacia at the right and left bronchus of the lower lungs. Patients who have severe asthma, despite adequate treatment with medication, should be further investigated to exclude other diseases that have clinical features similar to asthma such as tracheobronchomalacia, particularly in the elderly.
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Wilkey BJ, Alfille P, Weitzel NS, Puskas F. Anesthesia for Tracheobronchial Surgery. Semin Cardiothorac Vasc Anesth 2012; 16:209-19. [DOI: 10.1177/1089253212464715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The airway is a crucial dynamic structure that spans different anatomical zones, including the intrathoracic, extrathoracic, tracheal, bronchial, and alveolar zones. Because of its vital role as the sole oxygen-conducting pathway to the alveoli, and hence to the human body, surgery involving any portion requires careful and specific planning by both the surgeon and the anesthesiologist. The review covers essential management points for proximal and distal tracheal procedures, including a discussion of tracheal stenting and tracheoplasty.
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Affiliation(s)
| | - Paul Alfille
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Abstract
Tracheobronchomalacia (TBM) refers to a weakening of the anterior tracheal rings leading to splaying and collapse of the central airways. In this report, we review the treatment of TBM, including preoperative workup, intraoperative anesthesia management, and surgical technique for posterior splinting tracheobronchoplasty. Imperative in the preoperative preparation is a stent trial in which an airway stent is placed to temporarily relieve the TBM and reassess for improvement in symptoms. Definitive therapy is then carried out with posterior splinting tracheoplasty or tracheobronchoplasty. Surgical results are generally excellent with the majority of patients having significant improvements in breathing.
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Affiliation(s)
- Sagar S. Damle
- University of Colorado School of Medicine, Aurora, CO, USA
| | - John D. Mitchell
- University of Colorado School of Medicine, Aurora, CO, USA
- National Jewish Health, Denver, CO, USA
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Papoff P, Cerasaro C, Caresta E, Barbàra CS, Midulla F, Moretti C. Current strategies for treating infants with severe bronchopulmonary dysplasia. J Matern Fetal Neonatal Med 2012; 25 Suppl 3:15-20. [DOI: 10.3109/14767058.2012.712352] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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[Tracheobronchomalacia in adults: breakthroughs and controversies]. Rev Mal Respir 2012; 29:1198-208. [PMID: 23228678 DOI: 10.1016/j.rmr.2012.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 06/05/2012] [Indexed: 11/23/2022]
Abstract
Tracheobronchomalacia (TBM) in adults is a disease defined by a reduction of more than 50% of the airway lumen during expiration. It encompasses many etiologies that differ in their morphologic aspects, pathophysiological mechanisms and histopathologies. TBM is encountered with increasing frequency, as it is more easily diagnosed with new imaging techniques and diagnostic bronchoscopy, as well as because of its frequent association with Chronic Obstructive Pulmonary Disease (COPD), which represents the most frequent etiology for acquired TBM in adults. A distinction between TBM in association with failure of the cartilaginous part of the airways and TBM affecting only the posterior membranous part is emerging since their physiopathology and treatment differ. The therapeutic management of TBM should be as conservative as possible. Priority should be given to identification and treatment of associated respiratory diseases, such as asthma or COPD. Surgery addressing extrinsic compression (thyroid goiter or tumor, for example) may be necessary. Noninvasive ventilation can be considered in patients with increasing symptoms. Endoscopic options, such as the placement of stents, should only be used as palliative or temporary solutions, because of the high complication rates. Symptomatic improvement after stenting might be helpful in selecting patients in whom a surgical management with tracheobronchoplasty can be useful.
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Tracheobronchomalacia in children: review of diagnosis and definition. Pediatr Radiol 2012; 42:906-15; quiz 1027-8. [PMID: 22426568 DOI: 10.1007/s00247-012-2367-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/18/2012] [Accepted: 01/23/2012] [Indexed: 10/28/2022]
Abstract
Tracheobronchomalacia is characterised by excessive airway collapsibility due to weakness of airway walls and supporting cartilage. The standard definition requires reduction in cross-sectional area of at least 50% on expiration. However, there is a paucity of information regarding the normal range of central airway collapse among children of varying ages, ethnicities and genders, with and without coexisting pulmonary disease. Consequently, the threshold for pathological collapse is considered somewhat arbitrary. Available methods for assessing the airway dynamically--bronchoscopy, radiography, cine fluoroscopy, bronchography, CT and MR--have issues with reliability, the need for intubation, radiation dose and contrast administration. In addition, there are varying means of eliciting the diagnosis. Forced expiratory manoeuvres have been employed but can exaggerate normal physiological changes. Furthermore, radiographic evidence of tracheal compression does not necessarily translate into physiological or functional significance. Given that the criteria used to make the diagnosis of tracheobronchomalacia are poorly validated, further studies with larger patient samples are required to define the threshold for pathological airway collapse.
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Moore P, Smith H, Greer RM, McElrea M, Masters IB. Pulmonary function and long-term follow-up of children with tracheobronchomalacia. Pediatr Pulmonol 2012; 47:700-5. [PMID: 22170871 DOI: 10.1002/ppul.21612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 10/16/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Primary tracheobronchomalacia (TBM) is a disease of the large airways. Long-term follow-up studies of TBM patients have not been reported. This study was undertaken to further elicit the natural history of this condition and the presence of concomitant reactive airways disease through clinical profiling and pulmonary function testing. METHODS Twenty-one children diagnosed with TBM by bronchoscopy between 1998 and 2001 in Queensland were recruited in 2008. Parents completed a questionnaire detailing their child's respiratory symptoms over the previous 12 months. Children then undertook pulmonary function and flow-volume loop classification. Mannitol bronchial provocation testing or post-bronchodilator spirometry was performed to assess for the confounding presence of reactive airways disease. RESULTS Data from 19 children (12 males) were able to be analyzed. The median age was 9.4 (range 7.6-14.3) years. 15 parents indicated their child's symptoms were unresolved. The mean FEV(1) was 81% predicted with 7 <80% predicted. This was significantly lower than the percent predicted population mean (P = 0.0005). Mean FEV(1) /FVC, FEF(25-75) , and PEF were also significantly reduced (P = < 0.0001). Four participants had a classical TBM flow-volume loop on analysis. One of 15 (6.7%) participants recorded a positive test for reactive airways disease. CONCLUSIONS Clinical symptom profiles and pulmonary function indicate persistent functional mechanical abnormalities of the large and small airways in TBM patients, and the absence of reactive airways disease.
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Affiliation(s)
- Peter Moore
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
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Abstract
Computed tomography (CT) is the modality of choice for imaging the airways. Volumetric data sets with isotropic spatial resolution based on multidetector thin-section CT with overlapping reconstruction should be used. Chronic obstructive pulmonary disease and asthma are the 2 most common disease entities that are defined by airflow obstruction. The morphologic correlates of airway changes are dilation of the lumen, thickening of the wall, visibility of small airways due to mucus or edema, air trapping, hypoxic vasoconstriction, and collapsibility. To assess air trapping, additional expiratory low-dose scans are recommended. In clinical routine, these findings are visually assessed and should be routinely reported. However, the interobserver variability is high, and there is a clear need for objective software-based measurements. The development of such tools is challenging, and they are just becoming available on a broader scale. Novel techniques based on dual-energy CT aim to measure iodine distribution maps to assess pulmonary perfusion as well as the distribution of inhaled xenon gas to assess the distribution and time course of pulmonary ventilation. However, these techniques are still being investigated in clinical studies. This review will provide an overview of CT for the diagnosis of chronic obstructive pulmonary disease and asthma, its role in phenotyping these diseases, and the measurement of disease severity and functional compromise.
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Dixon L, Diaz-Cano S, Schulte KM. Psittacosis infection and tracheobronchomalacia in a patient undergoing thyroidectomy. BMJ Case Rep 2011; 2011:bcr0720114516. [PMID: 22675091 PMCID: PMC3207757 DOI: 10.1136/bcr.07.2011.4516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 34-year-old woman with papillary thyroid carcinoma underwent total thyroidectomy with central and lateral lymphadenectomy. Immediate airway compromise required re-intubation immediately after surgery. Marked tracheal and bronchial collapse of greater than 50% of the lumen indicated tracheobronchomalacia. Subsequent attempts at extubation failed over the next week. The patient soon developed evidence of a lower respiratory tract infection. Empirical treatment with penicillins was unsuccessful. A clinical suspicion of chlamydia infection prompted initiation of macrolide treatment followed by resolution of both the patient's respiratory infection and tracheobronchomalacia. Serology returned positive for Chlamydophila psittaci infection. It later transpired that the patient had symptoms of an upper respiratory tract infection just prior to surgery. This case demonstrates an interesting and unreported cause of tracheobronchomalacia as well as providing a good lesson on the importance of preoperative screening for infection.
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Affiliation(s)
- Luke Dixon
- Department of General Surgery, King’s College Hospital, King’s Health Partners, London, UK
| | - Salvador Diaz-Cano
- Histopathology Department, King’s College Hospital, King’s Health Partners, London, UK
| | - Klaus-Martin Schulte
- Endocrine Surgery Department, King’s College Hospital, King’s Health Partners, London, UK
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Ernst A, Odell DD, Michaud G, Majid A, Herth FFJ, Gangadharan SP. Central airway stabilization for tracheobronchomalacia improves quality of life in patients with COPD. Chest 2011; 140:1162-1168. [PMID: 21868463 DOI: 10.1378/chest.10-3051] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Tracheobronchomalacia (TBM) is characterized by excessive collapsibility of the central airways, typically during expiration. TBM may be present in as many as 50% of patients evaluated for COPD. The impact of central airway stabilization on symptom pattern and quality of life is poorly understood in this patient population. METHODS Patients with documented COPD were identified from a cohort of 238 patients assessed for TBM at our complex airway referral center. Pulmonary function testing, exercise tolerance, and health-related quality-of-life (HRQOL) measures were assessed at baseline and 2 to 4 weeks following tracheal stent placement/operative tracheobronchoplasty (TBP). Severity of COPD was classified according to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) staging system. RESULTS One hundred three patients (48 women) with COPD and moderately severe to severe TBM were identified. Statistically and clinically significant improvements were seen in HRQOL measures, including the transitional dyspnea index (stent, P = .001; TBP, P = .008), the St. George Respiratory Questionnaire (stent, P = .002; TBP, P < .0001), and the Karnofsky performance score (stent, P = .163; TBP, P < .0001). The improvement appeared greatest following TBP and was seen in all GOLD stages. Clinical improvement was also seen in measured FEV(1) and exercise capacity as assessed by 6-min walk test. CONCLUSIONS Central airway stabilization may provide symptomatic benefit for patients with severe COPD and concomitant severe airway malacia. Operative airway stabilization appears to impart the greatest advantage. Long-term follow-up study is needed to fully ascertain the ultimate efficacy of both stenting and surgical airway stabilization in this patient group.
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Affiliation(s)
- Armin Ernst
- Department of Pulmonary, Critical Care, and Sleep Medicine, St. Elizabeth's Medical Center, Boston, MA.
| | - David D Odell
- Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gaetane Michaud
- Division of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adnan Majid
- Division of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Sidhu P Gangadharan
- Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Gangadharan SP. Tracheobronchomalacia in adults. Semin Thorac Cardiovasc Surg 2011; 22:165-73. [PMID: 21092895 DOI: 10.1053/j.semtcvs.2010.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2010] [Indexed: 11/11/2022]
Abstract
Severe, diffuse tracheobronchomalacia (TBM) is an underrecognized cause of dyspnea, recurrent respiratory infections, cough, secretion retention, and even respiratory insufficiency. Patients often have comorbidities, such as asthma or chronic obstructive pulmonary disease, and inappropriate treatment for these conditions may precede eventual recognition of TBM by months or years. Most of these patients have an acquired form of TBM in which the etiology in unknown. Diagnosis of TBM is made by airway computed tomography scan and flexible bronchoscopy with forced expiration. The prevailing definition of TBM as a 50% reduction in cross-sectional area is nonspecific, with a high proportion of healthy volunteers meeting this threshold. The clinically significant threshold is complete or near-complete collapse of the airway. Airway stenting may treat TBM, although complications resulting from indwelling prostheses often limit the durability of stents. Surgical stabilization of the airway by posterior splinting (tracheobronchoplasty) effectively and permanently corrects malacic airways. Proper surgical selection is facilitated by a short-term stent trial.
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Affiliation(s)
- Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Gangadharan SP, Bakhos CT, Majid A, Kent MS, Michaud G, Ernst A, Ashiku SK, DeCamp MM. Technical aspects and outcomes of tracheobronchoplasty for severe tracheobronchomalacia. Ann Thorac Surg 2011; 91:1574-80; discussion 1580-1. [PMID: 21377650 DOI: 10.1016/j.athoracsur.2011.01.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 12/31/2010] [Accepted: 01/04/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Tracheobronchomalacia is an underrecognized cause of dyspnea, recurrent respiratory infections, and cough. Surgical stabilization with posterior membranous tracheobronchoplasty has been shown to be effective in selected patients with severe disease. This study examines the technical details and complications of this operation. METHODS A prospectively maintained database of tracheobronchomalacia patients was queried retrospectively to review all consecutive tracheobronchoplasties performed from October 2002 to June 2009. Posterior splinting was performed with polypropylene mesh. Patient demographics, surgical outcomes, and operative data were reviewed. RESULTS Sixty-three patients underwent surgical correction of tracheal and bilateral bronchial malacia. Twenty-three patients had chronic obstructive pulmonary disease, 18 had asthma, 5 had Mounier-Kuhn syndrome, and 4 had interstitial lung disease. Seven patients had a previous tracheotomy. Operative time was 373 ± 93 minutes. Median length of stay was 8 days (range, 4 to 92 days), of which 3 days (range, 0 to 91 days) were in intensive care. Seventy-five percent of patients were discharged home (28% with visiting nurse follow-up), and 25% went to a rehabilitation facility. Two patients (3.2%) died postoperatively-1 of worsening usual interstitial pneumonia, and the other of massive pulmonary embolism. Complications included a new respiratory infection in 14 patients, pulmonary embolism in 2, and atrial fibrillation in 6. Six patients required reintubation, and 9 received a postoperative tracheotomy; 47 patients required postoperative aspiration bronchoscopy. CONCLUSIONS In experienced hands, tracheobronchoplasty can be performed with a very low mortality rate and an acceptable perioperative complications rate in patients with significant pulmonary comorbidity. Intervention for postoperative respiratory morbidity is often necessary.
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Affiliation(s)
- Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Department of Surgery, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Andregnette MV, de la Barrera EHG, Flandes-Aldeyturriaga J, Sastre J. Resolution of bronchomalacia presenting as severe asthma by endoscopic intervention. Ann Allergy Asthma Immunol 2011; 106:443-4. [PMID: 21530880 DOI: 10.1016/j.anai.2011.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 01/17/2011] [Accepted: 01/21/2011] [Indexed: 11/19/2022]
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Tsukada H, O'Donnell CR, Garland R, Herth F, DeCamp M, Ernst A. A Novel Animal Model for Hyperdynamic Airway Collapse. Chest 2010; 138:1322-6. [DOI: 10.1378/chest.10-0165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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