Implementation and Results of a Dedicated Telemedicine Program (TeleTrachea) for Patients with Tracheal Diseases

Background: Central airway diseases requiring frequent outpatient visits to a specialized medical center due to tracheal devices. Many of these patients have mobility and cognition restrictions or require specialized transport due to the need for supplemental oxygen. This study describes the implementation and results of a telemedicine program dedicated to patients with central airway diseases based in a Brazilian public health system. Methods: A retrospective study of telemedicine consultation for patients with central airway diseases referred to a public academic hospital between August 1, 2020 and August 1, 2022. The consultations occurred in a telemedicine department using the hospital's proprietary platform. Data retrieved consisted of demographics, disease characteristics, and the treatment modalities of the patients. The analysis included the savings in kilometers not traveled, the carbon footprint based on reducing CO2 emissions, and the cost savings in transportation. Results: A total of 1,153 telemedicine visits conducted in 516 patients (median age of 31.5 years). Two hundred ninety patients (56.2%) had a tracheal device (129 silicone T-Tube, 128 tracheostomy, and 33 endoprosthesis) and 159 patients (30.8%) had difficulties in transportation to the specialized medical center. Patients were served from 147 Brazilian cities from 22 states. The savings in kilometers traveled was 1,224,108.54 km, corresponding to a 250.14 ton reduction in CO2 emissions. The costs savings in transportation for the municipalities was BRL$ 1,272,283.78. Conclusions: Telemedicine consultations for patients with central airway diseases are feasible and safe. Cost savings and the possibility of disseminating specialized care make telemedicine a fundamental tool in current medical practice.

Tracheomediastinal fistula induced by concurrent chemoradiotherapy in small cell lung cancer: A case report and literature review

Tracheomediastinal fistula is a rare but life-threatening complication of cancer. We report a case of tracheomediastinal fistula induced by concurrent chemoradiotherapy in limited stage small cell lung cancer. Despite the treatment response, the metastatic paratracheal lymph node increased gradually during concurrent chemoradiotherapy, resulting in the occurrence of tracheomediastinal fistula and mediastinitis. Without any surgical intervention, the patient achieved successful recovery from mediastinitis through antibiotic treatment, although the tracheomediastinal fistula remained open. In this report, we also review previous studies of tracheomediastinal and bronchomediastinal fistulas and summarize the clinical features.

Osteochondroplastic tracheobronchopathy: Four case reports

Introduction

Osteochondroplastic tracheobronchopathy is a rare benign chronic disease of unknown etiology. Bronchoscopy remains the gold standard for diagnosing osteochondroplastic tracheobronchopathy. Its typical findings are described as a cobblestone, rock garden, mountainscape, or stalactite cave appearance. The present work aims to show the main clinical features of this rare pathology.

Clinical cases

The clinical data of four middle-aged patients, three men and one woman, were analyzed. The main clinical symptoms were chronic cough, dyspnea, and dysphonia. The patient's preliminary diagnosis was made by computed axial tomography of the chest, confirmed by bronchoscopy and histopathological examination. Treatment included medication for symptoms and, in one case, cryosurgery and argon plasma coagulation.

Discussion

Diagnosing osteochondroplastic tracheobronchopathy was not easy, given its uncommon nature and non-specific symptoms often found in other pathologies. No case series articles on this pathology have been published in Peru. Therefore, we used the original articles published in other countries to reference our findings.

Conclusion

Osteochondroplastic tracheopathy is a benign disease that typically affects adults. Men are more likely to be affected. Its clinical manifestations are non-specific and frequently of pharyngeal origin, and the cause is not yet defined. Chest computed axial tomography combined with bronchoscopy are the main diagnostic procedures. There is no standard treatment with consistent therapeutic effects.

Positional relationships between a tracheal diverticulum and the tracheal tube under general anesthesia: a single-center observational and simulation study

BACKGROUND

Incomplete sealing of tracheal diverticula by a tracheal tube cuff during positive-pressure ventilation causes barotrauma but the concrete possibility of incomplete sealing has not been indicated. We aimed to assess the possibility of incomplete sealing in a simulated situation of tracheal intubation for patients with tracheal diverticula with tube fixation where the tracheal tube's vocal cord guide overlaps with the patient's vocal cord.

METHODS

We retrospectively assessed the characteristics of tracheal diverticula based on thoracic computed tomography data in our institution from January 2018 to July 2020. Then, we assessed the structural parameters of three single-lumen tracheal tubes (Parker Flex-Tip [Parker Medical, Bridgewater, CT, USA], Portex Soft Seal [ICU Medical, San Clemente, CA, USA], and Shiley TaperGuard [Medtronic, Dublin, Ireland]; 6.0-8.0 mm inner diameter size) and simulated the positional relationships between tracheal diverticula and the tracheal tube during tracheal intubation where the vocal cord guide overlaps with the patient's vocal cord. We assessed each tube product's possibility of incompletely sealing tracheal diverticula and the possibility of unintended bronchial intubation.

RESULTS

In 5,854 patients, the prevalence of tracheal diverticula was 5.7%. The mean (SD) length from the vocal cord to the distal end of the tracheal diverticula was 52.2 (12.8) mm. Tracheal tubes with length from the distal end of the tracheal cuff to the vocal cord guide of ≥ 70 mm had a low risk of incompletely sealing tracheal diverticula (< 5%) and length from the distal end of the tube to the vocal cord guide of ≤ 95 mm had a low risk of unintended bronchial intubation (< 5%). No products in this study satisfied both outcomes.

CONCLUSIONS

Tube fixation, where the vocal cord guide overlaps with the patient's vocal cord, is associated with risk of incompletely sealing of tracheal diverticula depending on the tube's manufacturer and tube's inner diameter size, although it was not a high risk. The use of small inner diameter sized tube relative to patient's body size is high risk of incomplete sealing of tracheal diverticula.

TRIAL REGISTRATION

This trial was prospectively registered at University Hospital Medical Information Network (UMIN).

CLINICAL TRIAL NUMBER AND REGISTRY URL

UMIN000043317 (URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048055 ).

Tracheal injury characterized by subcutaneous emphysema and dyspnea after improper placement of a Sengstaken-Blakemore tube: A case report

RATIONALE

Tracheal injury characterized by subcutaneous emphysema and dyspnea can occur following the use of a Sengstaken-Blakemore tube. Should tracheal injury occur, it may be possible to manage resultant airway obstruction with a tracheal stent.

PATIENT CONCERNS

We describe the case of a 51-year-old patient who developed a tracheal injury when a Sengstaken-Blakemore tube was inadvertently inserted into the patient's trachea.

DIAGNOSES

Liver cirrhosis, gastric-fundus variceal bleeding, tracheal injury.

INTERVENTIONS

Polyglycol and tissue glue were injected intravenously, and endoscopic variceal ligation was performed. A Sengstaken-Blakemore tube was used to stop the bleeding. A covered tracheal stent was placed via fiberoptic bronchoscopy to relieve the tracheal injury due to improper placement of a Sengstaken-Blakemore tube.

OUTCOMES

After placement of the tracheal stent, the patient was able to breathe spontaneously and subsequently recovered.

LESSONS

Some precautions must be taken to avoid placing a Sengstaken-Blakemore tube in the trachea. If a tracheal injury occurs following misplacement of a Sengstaken-Blakemore tube, it may be possible to manage resultant airway obstruction by placing a tracheal stent.

[Tracheal Injury Successfully Treated without Surgery;Report of a Case]

A 73-year-old man was injured after crashing his automobile into a concrete wall, and was admitted to our hospital with breathing difficulties. Chest computed tomography showed extensive mediastinal emphysema, right traumatic pneumothorax, and a suspected tracheal injury at the membranous region. Because of the associated tracheomalacia, the site of the tracheal injury was difficult to find by bronchoscopy. In addition, as the patient's respiratory condition was stable, surgical treatment was not chosen. Due to the continuous air leakage from the right lung, the patient underwent surgery after mediastinal and subcutaneous emphysema improved. The postoperative course was uneventful.

Lobular capillary hemangioma of the tracheobronchial tree: A case report and literature review

RATIONALE

Lobular capillary hemangioma (LCH) of the tracheobronchial tree is a rare benign tumor, whose characteristics and treatments remain relatively unknown.

PATIENT CONCERNS

A 39-year-old man with hemoptysis caused by neoplasm in the bronchus intermedius was admitted to our hospital.

DIAGNOSES

The patient was diagnosed with LCH.

INTERVENTIONS

The lesions were removed with biopsy forceps, and cryotherapy was performed.

OUTCOMES

After follow up for more than 2 years, no recurrence was found.

LESSONS

Airway LCH can be treated by excisional biopsy, cryotherapy, APC, laser, radiotherapy, and surgery. Cryotherapy is worthy of recommendation.

Nonsurgical Management of Pediatric Tracheal Perforation

Tracheal perforation is a rare complication of intubation. In the pediatric population, the rates of morbidity and mortality are high if diagnosis and management are delayed. Recommendations for treatment in these patients are based on the several reports of this injury in the adult and neonate populations. Surgical repair is generally favored over conservative care in the majority of cases. We describe the case of a 10-year-old girl who presented with subcutaneous emphysema after intubation in the emergency department. The patient had a 3-cm injury to the distal trachea. Nonsurgical management resulted in a normal-appearing trachea and a healed perforation site as confirmed by repeat tracheobronchoscopy 4 months after the initial injury. In clinically stable pediatric patients, nonsurgical management of tracheal perforations should be considered.

Use of the Palmaz Stent in the Treatment of Severe Tracheomalacia

To present our experience with the use of the Palmaz stent in treating cases of severe, life-threatening tracheomalacia, and to report our experience with the use of tracheal stents in patients who have concomitant tracheotomies, we performed a retrospective study in a tertiary-care children's hospital. Nine patients with multiple congenital anomalies including severe tracheomalacia required placement of a Palmaz stent to prolong life. The congenital anomalies included congenital heart disease, congenital lung disease, meningomyelocele, laryngotracheoesophageal cleft, and tracheoesophageal fistula. Three of the patients had concomitant tracheotomies. Each patient had placement of one or more Palmaz stents in the trachea and/or bronchus. Four patients died, and 5 patients are still alive. Three of the 4 patients who died had concomitant tracheotomies and died of complications associated with significant tracheal hemorrhage. The fourth died of pulmonary complications following repeated episodes of pneumonia. None of the 5 patients who are still alive had a concomitant tracheotomy. The Palmaz stent is a useful tool for treating life-threatening tracheomalacia as a final resort in this difficult patient population; however, the use of these stents may lead to subsequent hemorrhage and death, especially in patients with tracheotomies, so their use must be carefully considered.

Complications of Metallic Stents in the Pediatric Airway

OBJECTIVE: Our aim was to present our experience with complications caused by placement of metallic stents in the pediatric airway.

DESIGN AND SETTING: We conducted a retrospective study of the medical records of patients with complications resulting from metallic stent placement, managed by the senior authors between 1993 and 2002.

RESULTS: Nine children had complications associated with the placement of metallic airway stents. Of these, 8 children required stent removal. Granulation tissue and tracheal stenosis were seen in all 7 children with long standing stent placement. There was 1 stent death in this series.

CONCLUSIONS: Metallic airway stents can cause significant complications in the pediatric airway. These complications may supersede the airway compromise that necessitated their initial placement. As such, metallic stent placement should be approached with caution. The likelihood and severity of complications increase with time, as do the difficulties encountered upon removal. The proportion of patients in whom metallic stents may be placed “permanently” without complications is not known. Therefore we recommend that metallic airway stents be considered a temporizing measure of limited duration.

Histological Benefits of Sealants in Tracheal Lesions in Wistar Rats

INTRODUCTION

The purpose of our study was to compare the effect, on the inflammatory response and fibrosis formation, of four commercially available sealant products applied on an injured trachea in a Wistar rat population.

MATERIALS AND METHODS

We compared four different sealants: cyanoacrylate, fibrin/thrombin, albumin/glutaraldehyde, and polyethylene glycol-based hydrogel (PEG). Rats were organized into six groups of similar size. Four of them were experimental, one was a baseline control group (BCG), and the sixth one was a reference control group (RCG). The RCG and experimental groups underwent the same surgical intervention with tracheal puncture, but no sealant was applied in the RCG. The BCG underwent the same cervical and peritracheal dissection without tracheal puncture. Rats were euthanized after eight weeks.

RESULTS

The operation was performed on 54 rats, of which 12 died, leaving a final sample of 42 rats. Macroscopic analysis revealed no superficial tracheal or vascular fistulas, nor signs of local abscess. Although the groups treated with cyanoacrylate, fibrin/thrombin, and albumin/glutaraldehyde showed some degree of fibrosis, the treated area of the PEG group showed neither inflammatory nor scar signs. Microscopic assessment of the BCG and RCG showed no remarkable findings. With the exception of the PEG group, which had a light fibrosis and poor inflammatory response as did the BCG and RCG groups, the other groups showed varying degrees of fibrosis and cicatrization.

CONCLUSION

Our study showed that the group treated with PEG had a mild inflammatory and fibrotic response, which is useful in tracheal or tracheobronchial surgical procedures. However, groups treated with cyanoacrylate, fibrin/thrombin, and albumin/glutaraldehyde showed fibrosis and cicatrization.

[Two Cases of Emergency Extracorporeal Membrane Oxygenation Support in Children Suffering from Tracheo-innominate Artery Fistula]

Tracheoinnominate artery fistula (TIF) is a relatively rare life-threating complication of long-term tracheostomy. Two patients with TIF were successfully resuscitated by extracorporeal membrane oxygenation (ECMO) support along with advanced cardiovascular life support. The first patient was a 16-year-old boy undergoing long-term tracheostomy because of cerebral palsy, and the other patient was a previously healthy 11-year-old girl who had undergone primary tracheal tumor resection. In both cases, the onset of TIF was sudden, and the patients were immediately transferred to the operating room for emergency thoracotomy under ongoing cardiopulmonary resuscitation. Innominate artery division was performed under ECMO support. Adequate fluid replacement and hemorrhage control are primary treatment options for resuscitating a patient with TIF. However, hemorrhagic shock in patients with TIF is different from that in other patients, because bleeding into the trachea causes severe respiratory failure and poor oxygenation, which may worsen the resuscitation rate. Thus, ECMO can be used as an option for maintaining oxygenation during cardiopulmonary resuscitation in TIF. Anesthesiologists should pay attention to the increased risk of bleeding due to anticoagulation during ECMO initiation. In conclusion, the results of these cases demonstrate the effectiveness of extracorporeal cardiopulmonary resuscitation in TIF patients.

Regeneration of tracheal epithelium using mouse induced pluripotent stem cells

Conclusion The findings demonstrated the potential use of induced pluripotent stem cells for regeneration of tracheal epithelium. Objective Autologous tissue implantation techniques using skin or cartilage are often applied in cases of tracheal defects with laryngeal inflammatory lesions and malignant tumor invasion. However, these techniques are invasive with an unstable clinical outcome. The purpose of this study was to investigate regeneration in a tracheal defect site of nude rats after implantation of ciliated epithelium that was differentiated from induced pluripotent stem cells. Method Embryoid bodies were formed from mouse induced pluripotent stem cells. They were cultured with growth factors for 5 days, and then cultured at the air-liquid interface. The degree of differentiation achieved prior to implantation was determined by histological findings and the results of real-time polymerase chain reaction. Embryoid bodies including ciliated epithelium were embedded into collagen gel that served as an artificial scaffold, and then implanted into nude rats, creating an 'air-liquid interface model'. Histological evaluation was performed 7 days after implantation. Results The ciliated epithelial structure survived on the lumen side of regenerated tissue. It was demonstrated histologically that the structure was composed of ciliated epithelial cells.

Large tracheobronchial fistula due to esophageal stent migration: Let it be!

We report tracheal-bronchial migration of a covered esophageal self-expanding metal stent used to relieve dysphagia in a patient with advanced esophageal cancer. The stent eroded the trachea and completely occluded the main left bronchus. Surgery was contraindicated due to her poor clinical condition, and insertion of another stent in the trachea, esophagus, or both was contraindicated due to extension of the fistula. Esophageal exclusion with a combination of cervical esophagostomy and an enteral feeding tube was the only feasible treatment to minimize spoilage by aspirated saliva and provide enteral nutrition.

Tracheobronchopathia osteochondroplastica: two cases and a review of the literature

INTRODUCTION

Tracheobronchopathia osteochondroplastica (TO) is a rare disorder involving the lumen of the trachea-bronchial tree and characterized by multiple sub-mucosal osseous and cartilaginous nodules in the trachea and bronchus, sparing the posterior wall. We here report two cases of patients with tracheobronchopathia osteochondroplastica and review the relevant literature briefly.

CASE PRESENTATION

Case 1 was a 64-year-old woman with a history of Chronic Obstructive Pulmonary Disease (COPD) who presented with frequent non-productive cough for 2 years. Chest computed tomography (CT) showed signs consistent with COPD and evident irregular narrowing of the tracheal and both main bronchial lumen caused by calcific foci. Fibre optic bronchoscope (FOB) was performed and showed dozens of sub-mucosal nodules protruding into the lumen of lower half of the trachea and both main bronchi. Histopathological exam demonstrated sub-mucosal ossification and cartilage in the sample. Her follow-up has been uneventful for 3 years. Case 2 was a 37-year-old man presented with hoarseness, exertional dyspnea, and intermittent dry cough for about 3 years. Chest CT scans showed irregular nodules around the entire circumference of the trachea extending from sub-glottic region to lower trachea. FOB showed glottic stenosis and diffused sub-mucosal calcified nodules protruding from the antero-lateral portion of the trachea in the subglottic region. Over the following 12 months, his disease is stable.

CONCLUSIONS

TO is a rare, benign disease with slow progression, clinicians should be aware of TO and should consider it in patients with chronic cough, recurrent respiratory infection and evolving exertional dyspnea.

Gastrotracheal fistula: Treatment with a covered elf-expanding Y-shaped metallic stent

A 67-year-old man had a sev-ere cough and pulmonary infection for 1 wk before seeking evaluation at our hospital. He had undergone esophagectomy with gastric pull-up and radiotherapy for esophageal cancer 3 years previously. After admission to our hospital, gastroscopy and bronchoscopy revealed a fistulous communication between the posterior tracheal wall near the carina and the upper residual stomach. We measured the diameter of the trachea and bronchus and determined the site and size of the fistula using multislice computed tomography and gastroscopy. A covered self-expanding Y-shaped metallic stent was implanted into the trachea and bronchus. Subsequently, the fistula was closed completely. The patient tolerated the stent well and had good palliation of his symptoms.

Tracheal bioengineering: the next steps. Proceeds of an International Society of Cell Therapy Pulmonary Cellular Therapy Signature Series Workshop, Paris, France, April 22, 2014

There has been significant and exciting recent progress in the development of bioengineering approaches for generating tracheal tissue that can be used for congenital and acquired tracheal diseases. This includes a growing clinical experience in both pediatric and adult patients with life-threatening tracheal diseases. However, not all of these attempts have been successful, and there is ongoing discussion and debate about the optimal approaches to be used. These include considerations of optimal materials, particularly use of synthetic versus biologic scaffolds, appropriate cellularization of the scaffolds, optimal surgical approaches and optimal measure of both clinical and biologic outcomes. To address these issues, the International Society of Cell Therapy convened a first-ever meeting of the leading clinicians and tracheal biologists, along with experts in regulatory and ethical affairs, to discuss and debate the issues. A series of recommendations are presented for how to best move the field ahead.

Airway stenting for tracheal obstruction due to lymph node metastasis of hepatocellular carcinoma

We describe the case of an 80-year-old man with hepatocellular carcinoma (HCC) who developed tracheal obstruction due to peritracheal lymph node metastasis. A metastatic tumor that protruded into the airway was ablated using a neodymium yttrium-aluminium-garnet laser and then a self-expandable metallic stent (SEMS) was deployed in the trachea. Stenting resolved symptoms of severe dyspnea upon mild exertion and in the supine position. Three months later, the patient is alive and has resumed normal activities as an outpatient, despite having metastatic HCC. Peritracheal lymph node metastasis arising from HCC is very rare and a polypoid tumor growing from a metastatic lymph node into the trachea is also extremely unusual. Tracheal obstruction in this patient was successfully treated by airway stenting.

Successful treatment with noninvasive positive-pressure ventilation based on the prediction of disease onset using CT and respiratory function tests in an elderly patient with relapsing polychondritis

An 83-year-old man who had been receiving treatment for bronchial asthma since 62 years of age experienced difficulty breathing on exertion and was admitted to the hospital. On admission, computed tomography revealed tracheal wall thickening, while test results for antinuclear antibodies and anti-type II collagen antibodies were positive. Since a saddle nose deformity, malacia of the auricles and sensorineural deafness were also observed, relapsing polychondritis was diagnosed. Measuring the peak expiratory flow rate was useful in the early airway assessment. During the follow-up period, the patient's dyspnea worsened and noninvasive positive-pressure ventilation was introduced. As a result, the subjective symptoms improved.

[Two cases of airway stent placement to treat tracheal and bronchial fistula using general anesthesia under spontaneous respiration]

Anesthesia for the tracheobronchial stent placement involves the risk of airway narrowing and obstruction. Controlled ventilation with relatively high airway pressure is usually used to maintain oxygenation and ventilation during anesthesia. However, controlled ventilation does not always provide tidal volume and oxygenation due to gas leakage from tracheobronchial fistula. We report 2 cases of general anesthesia under spontaneous respiration for the airway stent placement to treat tracheal and bronchial fistula. Case 1; A 55-year-old man with tracheoesophageal fistula due to the esophageal cancer was scheduled for the stent placement. Anesthesia was given with dexmedetomidine and sevoflurane preserving spontaneous respiration. The surgery was performed without complications of hypoventilation and hypoxemia throughout the procedure. Case 2; A 71-year-old woman developed empyema with large bronchopleural fistula as the result of the complication of radiation for the breast cancer. The stent placement was scheduled for closure of the fistula. Anesthesia was induced with remifentanil and sevoflurane with spontaneous respiration. When inserting the rigid bronchoscope, cough reflex occurred and propofol was added to deepen the anesthesia. The stent placement was performed with general anesthesia under spontaneous respiration without any complications.

An unpredicted case of tracheal necrosis following thyroidectomy

Tracheal rupture is a rare condition, and its most common cause is head and neck injury. Nontraumatic disruption of the anterolateral fibrocartilaginous trachea is an exceptional complication following thyroidectomy with few cases reported in literature. We report a case of upper tracheal necrosis arising 15 days after uneventful total thyroidectomy and resulted in pneumomediastinum and subcutaneous emphysema. The patient felt a sudden pop in his neck following an episode of vigorous coughing and experienced rapid swelling in his neck. The presence of pneumomediastinum was diagnosed on chest Computed Tomography scan and bronchoscopy visualized a small perforation on the right side of the anterolateral tracheal wall. The first interesting aspect is that several factors (female gender, thyrotoxic goiter, wound infection or excessive use of diathermy) reported as possible cause of anterior tracheal necrosis in the previous reports are unlike for the present case. The second unusual point is the spontaneous healing of the tracheal tear. Considering the no-critical ill condition of the patient and the size of the tear we decide for a conservative treatment rather than surgical repair. Finally, our report underlights that the presence of subcutaneous emphysema following thyroidectomy should alert the possible existence of tracheal rupture. The favourable outcome of our patient shows that small tracheal perforation due to tracheal necrosis may be successfully treated with conservative treatment.

Spontaneous tracheal rupture caused by vomiting

OBJECTIVES

To present a pediatric case of spontaneous tracheal rupture caused solely by vomiting and to discuss its diagnosis and management.

STUDY DESIGN

Case presentation and literature review.

RESULTS

A 14-year-old girl with a new diagnosis of type 1 diabetes mellitus presented with respiratory distress. History was significant only for 4 days of violent vomiting, and she was diagnosed with diabetic ketoacidosis. Examination revealed tachypnea and considerable subcutaneous air overlying the upper chest and neck; chest x-ray showed pneumomediastinum. A swallow study showed no evidence of an esophageal tear. Computed tomography of the chest showed a posterior tracheal tear 4.5 cm distal to the cricoid cartilage. The patient's ketoacidosis was controlled, and supplemental oxygen was administered temporarily to promote absorption of the extravasated air. Serial chest x-rays showed complete resolution within 5 days and intubation was not required.

CONCLUSIONS

To our knowledge, this is the first reported pediatric case of tracheal rupture secondary to vomiting. Previous reports of spontaneous tracheal rupture have been related to paroxysmal coughing. In similar cases of subcutaneous emphysema and pneumomediastinum after retching, an esophageal rupture should be ruled out. Conservative management was successful in this case.

[One case report of tracheo-innominate artery fistula responsible of massive haemoptysis in a tracheotomized patient: which strategy to adopt?]

The tracheo-innominate artery fistula is a rare but life-threatening complication of the tracheotomy. Its care management requires a rapid airway control to allow haemostasis by compression and ventilation. The haemostasis must be immediate and two techniques exist: surgery opencast (sternotomy) or interventional radiology. The choice between the two depends largely on the technical platform available. Our case report describes a tracheo-innomninate artery fistula surgically managed with success. The patient carried an anatomic variant, the two carotids come from innominate artery.

[The diagnostic value of flexible bronchoscopy in tracheobronchopathia osteochondroplastica]

OBJECTIVE

To enhance the knowledge of tracheobronchopathia osteochondroplastica (TO), and to describe the value of flexible bronchoscopic diagnosis and treatment for the disease.

METHODS

The clinical data, bronchoscopic findings, histological results and the methods and effect of bronchoscopic treatment in 10 patients with TO admitted to Xiangya Hospital between June 2006 and July 2007 were retrospectively analyzed.

RESULTS

There were 8 males and 2 females (mean age 46 +/- 16, range 33-76 years). The bronchoscopic appearance of TO was multiple whitish, hard nodules projecting into the tracheal lumen (mostly from the anterior and less from the lateral walls). The lesions were found most frequently in the trachea and major bronchi, and lobar and segmental bronchi were involved less frequently. Nodules were restricted to the anterolateral walls in 7 cases. The distribution of the lesions was diffuse in 5, confluent in 2 and scattered in 3 cases. Six patients received bronchoscopic management, including radiofrequency treatment for 2 patients and argon ion laser treatment for the other 4. The lesions in the airways were reduced and clinical symptoms improved to some extent after treatment. No severe complications occurred during and after the procedures.

CONCLUSIONS

The diagnosis of TO can be easily underdiagnosed or misdiagnosed. Flexible bronchoscopy with histological examination is the main method for the diagnosis of TO. Radiofrequency and argon ion laser treatment are safe and effective.

Management of tracheobronchial ulceration induced by high-dose brachytherapy

The most severe complication of high-dose endobronchial brachytherapy is fatal hemoptysis. Intractable tracheobronchial ulceration due to high-dose endobronchial brachytherapy often develops into tracheobronchial necrosis and fatal hemoptysis. Our experience demonstrated that when bleeding from tracheobronchial ulcer, after high-dose endobronchial brachytherapy occurs, blocking the blood supply to the tracheobronchial ulcer alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis. This is the first report that describes an effective management for preventing fatal hemoptysis.

Obstructive lesions and traumatic injuries of the canine and feline tracheas

Tracheal obstruction and tracheal injury can be life-threatening conditions in dogs and cats. Early identification of associated clinical signs and the use of appropriate diagnostic and therapeutic techniques are important to patient survival. Common causes of tracheal obstruction reported in the veterinary literature include tracheal foreign bodies and tracheal tumors. Tracheal injury has been associated with endotracheal intubation and external trauma. Radiography and tracheoscopy are effective diagnostic modalities, and tracheal repair or resection and anastomosis are the most common treatments.

Tracheal diverticulum: a report of 4 cases

Tracheal diverticulum is a rare entity. When it does occur, it is usually discovered incidentally in an asymptomatic patient as an outpouching from the tracheal wall, usually on the right side. It can be either congenital or acquired. A tracheal diverticulum may act as a reservoir for secretions that may spill over into the tracheobronchial tree, predisposing affected patients to cough, dyspnea, stridor, and chronic chest infection. The author describes 4 cases of tracheal diverticulum--3 congenital and 1 acquired--that were discovered on chest x-ray. The congenital form was found incidentally in 3 asymptomatic middle-aged women, and the acquired case (a tracheobronchial diverticulum) was discovered during a workup for chronic cough and fever in a young man. All 4 patients were thoroughly evaluated with conventional chest and neck radiographs, barium-swallow imaging, linear tomography, computed tomography, and magnetic resonance imaging. Resection of these tracheal diverticula was not considered for any patient. The author also reviews the literature on tracheal diverticulum.

Hemoptysis in a patient with tracheopathia osteochondroplasia

Tracheopathia osteochondroplasia is a rare slowly progressive benign disease of unknown etiology characterized by submucosal nodules protruding in the airway. Most patients are asymptomatic but with progression of disease, symptoms of cough, hemoptysis, dyspnea, wheezing, hoarseness, and rarely airway compromise have been reported. Management is symptomatic with control of cough, prophylaxis with antibiotics, and rarely surgery.

[Primary thyrotracheal anastomosis for subglottic stenosis with tracheostomy]

A case of 42-year-old man with postintubation subglottic stenosis underwent primary thyrotracheal anastomosis. Since trachea had been incised longitudinally for previous tracheostomy, tracheal resection came to be longer. Therefore, we had to anastomose the incised trachea with thyroid cartilage even after the suprahyoid release. After the operation, he suffered from the tracheal collapse at the incised portion of the trachea One week after intubation, tracheal patency was achieved. We recommend horizontal incision for tracheostomy in patient with subglottic stenosis, when the following surgical approach is considered.

Noninvasive correction of a fractured endoluminal nitinol tracheal stent in a dog

An 11-year-old, castrated male Pomeranian was presented for intractable cough and dyspnea secondary to severe tracheal collapse. An endoluminal nitinol tracheal stent was placed with good results. Five months following placement of the prosthesis, clinical signs acutely recurred and failure of the implant was noted. A second stent was superimposed over the fractured stent and resulted in resolution of all clinical signs. The dog died several months later from progression of the tracheal collapse to the carina and mainstem bronchi.

Primary tracheobronchial amyloidosis--two case reports

Primary tracheobronchial amyloidosis is a form of respiratory amyloidosis, characterised by insoluble amyloid fibril proteins deposits along the airways wall. It is an uncommon disease, requiring a tissue sample to establish the definite diagnosis based on specific pathological features. The authors report two cases of tracheobronchial amyloidosis, describing their symptoms and the diagnostic and therapeutic procedures that were performed.

Tracheal Ceramic Rings for Tracheomalacia: A Review After 17 Years

BACKGROUND

Despite different support techniques, the surgical management of tracheomalacia is still a challenging problem. Satisfactory results after internal stenting are above 80%, whereas, when performing external stenting using biocompatible ceramic rings, results are reported at over 90%.

OBJECTIVE

The purpose of this study was to examine the efficiency of surgical treatment in patients with segmentary tracheomalacia using external ceramic ring grafts.

METHODS

In this retrospective study, we collected data from 12 patients who underwent surgery during the last 17 years for symptomatic segmentary tracheomalacia by use of biocompatible aluminum-oxide ceramic rings. All except one patient had undergone previous tracheostomy, six had a history of long-term intubation, two had previous trauma, and two patients had previous cancer treatment including radiotherapy. One of the patients still had an existing tracheostoma, which was closed when a ceramic ring was implanted. Tracheal wall collapse with pseudoglottis formation or flattened anterior-posterior tracheal diameter was documented with fiberoscopy at rest, and both pre- and postoperative airway resistance measurements were performed in all 12 patients using a spirometer. After malacic segments were found to be expandable using rigid tracheoscopy while the patient was under general anesthesia, preparation of the trachea was performed using a midline vertical incision in the neck. Subsequently, the malacic trachea was expanded by placing and suturing proper-sized ceramic ring(s) around it.

RESULTS

In all patients, surgical expansion of the malacic segment using ceramic rings was successfully carried out without major complications while inspiratory stridor was resolved. Airway resistance decreased significantly from an average of 0.62 to 0.385 kPascal.

CONCLUSION

Although the results of applying internal tracheal stents are encouraging, complications such as stent migration, granulation tissue and fistula formation, and mucociliary transport arrest are possible. Biocompatible ceramic rings do not cause foreign body reactions, remain stabile, and, with a proper suturing technique, provide a suitable long-term solution.

Tracheal Compression in a Patient with Marfan’s Syndrome-Associated Tracheomegaly Treated by an XXL Stent: The Largest Diameter Airway Stent Ever Placed in a Previously Undescribed Airway Condition

A 43-year-old man was referred to our institution with severe extrinsic compression of the trachea at the level of the main carina secondary to an aortic aneurysm, causing respiratory distress and requiring mechanical ventilation. The patient had a past history of Marfan's syndrome and tracheomegaly (the estimated tracheal diameter bronchoscopically was 28 mm). Palliation of the compression was successfully achieved by a custom-made, self-expandable, fully covered metallic stent with a diameter of 28 mm and a length of 60 mm. The patient was weaned off ventilation. The stent stayed in place for 2 years without major complications. This case represents the first stent ever inserted in a very rare condition combining tracheomegaly and extrinsic compression in Marfan's syndrome. It is also the first report of successful placement of the largest tracheal stent which was manufactured exclusively for the airway.

[Acupuncture in ear, nose and throat medicine: part 1: Diseases and functional disturbances in the area of the trachea, larynx, pharynx and mouth]

The two parts of this article describe acupuncture-therapy in several important ear, nose and throat disorders. The first part deals with diseases and functional disorders of the trachea, larynx, pharynx and mouth. The possibilities and limitations of treatment by ear and body acupuncture are discussed. Connections between traditional Chinese medicine and orthodox medicine are pointed out for some diseases.

Noninvasive treatment of bronchomalacia, successful ventilation of a severely ill infant

Noninvasive treatment of bronchomalacia. Successful ventilation of a severely ill infant.

AIM

To describe an effective treatment of a boy with bronchomalacia by noninvasive mechanical ventilation support.

METHODS

We describe a case of a severely ill patient with bronchomalacia from the time he was born and until the age of five. Bi-level positive airway pressure given through a specially adapted full face mask was used to treat his respiratory condition.

RESULT

Our patient responded well to the noninvasive treatment of bronchomalacia.

CONCLUSION

We found that noninvasive mechanical ventilation support is a low risk and highly effective treatment of infants and children with respiratory distress caused by bronchomalacia.

Tuberculosis of the trachea

Tracheal tuberculosis is an uncommon localized form of tuberculosis with fewer than 150 reported cases in the literature. We report a case of tracheal stenosis caused by tuberculosis in which the diagnosis was suggested by the patient's past medical history. This patient was successfully treated with tracheal resection, adjuvant steroids and anti-tuberculous therapy. This report will review the various types of tuberculosis of the trachea and their clinical features in addition to discussing the different available treatment modalities.

Tracheal diverticulum: a review of the literature

Tracheal diverticulum is a rarely encountered entity. It may be congenital or acquired, the difference residing mainly in the histologic features of the wall. Most cases are asymptomatic, but when symptoms are present they are usually nonspecific. Congenital diverticulum is not normally detected in infancy unless it is suggested by recurrent episodes of tracheobronchial infection or in associated with other malformations. Imaging techniques are useful for diagnosis because the point of communication with the trachea is difficult to detect with bronchoscopy. In the absence of symptoms, management should be conservative. We review the entity and report two new cases, one a casual finding in a 49-year-old man and the other in a 63-year-old woman who presented with occasional bloody sputum.

Tracheobronchomalacia and excessive dynamic airway collapse

Tracheobronchomalacia and excessive dynamic airway collapse are two separate forms of dynamic central airway obstruction that may or may not coexist. These entities are increasingly recognized as asthma and COPD imitators. The understanding of these disease processes, however, has been compromised over the years because of uncertainties regarding their definitions, pathogenesis and aetiology. To date, there is no standardized classification, diagnosis or management algorithm. In this article we comprehensively review the aetiology, morphopathology, physiology, diagnosis and treatment of these entities.

[Tracheobronchopathia osteochondrodysplasias. About one case revealed by haemoptysis]

Tracheobronchopathia osteochondrodysplasias is a benign and rare chronic disease, whose etiology remains obscure. It is characterized by the presence of subepithelial osteocartilaginous focal lesions without any relation to tracheal rings, essentially localized in the lower two thirds of the trachea and the major bronchi. We report a new case of tracheobronchopathia osteochondrodysplasias in a 47-year-old man, localized at the lower half of the trachea, revealed by haemoptysis. The lesion was suspected by bronchoscopy and the diagnosis was made histologically, showing heterotopic bone formation. The evolution of this affection was marked by a good clinical tolerance with only a symptomatic treatment.

A case report of severe tracheal obstruction requiring extracorporeal membrane oxygenation

The authors describe the case of a near-fatal airway obstruction requiring extracorporeal membrane oxygenation. The patient presented with severe respiratory distress owing to a bean impacted in the distal trachea. The foreign body could not be removed by bronchoscopy because of instability of the patient. The patient was placed on extracorporeal membrane oxygenation for temporary pulmonary support, and the foreign body was removed using a rigid bronchoscope. The patient had a full recovery and suffered no neurologic sequelae.