Search Results (51)

Background: Tracheal stenosis in children is a rare but potentially life-threatening condition. We report a case of multilevel tracheal stenosis in a child who sustained blunt chest trauma in a car accident. Case Presentation: The patient is an 11-year-old previously healthy boy who presented to the pediatric emergency room unconscious after being rolled over while seated unstrained inside a vehicle. A chest CT scan showed bilateral pulmonary contusions. He required intubation and mechanical ventilation initially but was noted to have biphasic stridor after extubation. He presented to the pediatric pulmonary clinic 2 weeks after discharge from the hospital with persistent stridor and shortness of breath on exertion. Spirometry revealed flattening of the inspiratory and expiratory limbs of the flow-volume loop, suggestive of fixed large airway obstruction. Direct laryngoscopy and bronchoscopy were performed and revealed multilevel tracheal stenosis. He was successfully treated with repeated bronchoscopic balloon dilatation with sustained improvement in symptoms and spirometry findings 8 months post final procedure. Conclusion: Tracheal stenosis should be suspected in children who sustain blunt chest trauma. Early recognition and treatment with bronchoscopic balloon dilatation can prevent long-term complications. Full article

Background/Objectives: Relapsing polychondritis (RP) is a rare autoimmune disorder marked by recurrent inflammation of cartilaginous tissues, including the airways. Airway involvement, such as subglottic stenosis and airway malacia, significantly impacts prognosis. Although spirometry is the standard for evaluating respiratory function, it may be unfeasible in patients with severe airway narrowing or tracheostomy. This study evaluated the potential of a smartphone-based application, DepthRecorder, which uses the iPhone’s TrueDepth camera to analyze thoracic motion in real time. Methods: Twelve patients with RP were enrolled. All underwent simultaneous respiratory assessment using spirometry and the DepthRecorder application. Thoracic motion data were corrected for height using previously validated regression formulas. Correlation between DepthRecorder and spirometry values was analyzed using Spearman’s rank correlation for forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), and the FEV₁/FVC ratio. Results: Mean age was 53.8 ± 13.3 years, with equal numbers of males and females. Before correction, DepthRecorder showed moderate correlations for FEV₁ (ρ = 0.48, p = 0.003) and FEV₁/FVC (%) (ρ = 0.57, p < 0.001). After correction, stronger correlations were observed for FVC (ρ = 0.76, p < 0.001), FEV₁ (ρ = 0.72, p < 0.001), and FEV₁/FVC (%) (ρ = 0.60, p < 0.001). Conclusions: The DepthRecorder application demonstrated strong correlations with spirometry following height-based correction. This method may offer a practical, non-invasive tool for respiratory assessment in RP patients who cannot undergo conventional lung function testing. Further studies are needed to validate these findings and establish clinical reference standards. Full article

Purpose: The pulmonary function test holds significant clinical value in assessing the severity, prognosis, and treatment efficacy of respiratory diseases. However, the test is limited by patient compliance, thereby limiting its practical application. Moreover, it only reflects the current state of the patient and cannot directly indicate future health trends or prognosis. Computational fluid dynamics (CFD), combined with airway models built from medical image data, can assist in analyzing a patient’s ventilation function, thus addressing the aforementioned issues. However, current airway models have shortcomings in accurately representing the structural features of a patient’s airway. Additionally, these models exhibit geometric defects such as low smoothness, topological errors, and noise, which further reduce their usability. This study generates airway skeletons based on CT data and, in combination with convolutional surface technology, proposes an individualized airway modeling method to solve these deficiencies. This study also provides a method for predicting a patient’s lung function based on the constructed airway model and using CFD simulation technology. This study also explores the application of this method in preoperative prediction of the required extent of airway expansion for patients with large airway stenosis. Methods: Based on airway skeleton data extracted from patient CT images, a personalized airway model is constructed using convolutional surface technology. The airway model is simulated according to the patient’s clinical statistical values of pulmonary function to obtain airway simulation data. Finally, a regression equation is constructed between the patient’s measured pulmonary function values and the airway simulation data to predict the patient’s pulmonary function values based on the airway simulation data. Results: To preliminarily demonstrate the above method, this study used the prediction of FEV1 in patients with large airway stenosis as an example for a proof-of-concept study. A linear regression model was constructed between the outlet flow rate from the simulation of the stenosed airway and the patient’s measured FEV1 values. The linear regression model achieved a prediction result of RMSE = 0.0246 and R² = 0.9822 for the test set. Additionally, preoperative predictions were made for the degree of airway dilation needed for patients with large airway stenosis. According to the linear regression model, the proportion of airway radius expansion required at the stenotic position to achieve normal FEV1 was calculated as 72.86%. Conclusions: This study provides a method for predicting patient pulmonary function based on CFD simulation technology and convolutional surface technology. This approach addresses, to some extent, the limitations in pulmonary function testing and accuracy caused by patient compliance. Meanwhile, this study provides a method for preoperative evaluation of airway dilation therapy. Full article

Stenosis geometries are constrictions of a biological tube that can be found in many forms in the human body. Capturing the flow field in such geometries is important. For this purpose, simulations were performed using the generalised k-$\omega$ (GEKO) turbulence model to study flow through stenosis geometries with throat constrictions of 75, 50 and 25% area reduction. Laminar flow conditions of Re = 2000 and 1000 were applied and the results were compared with experimental data. The effect of four GEKO parameters ($C_{SEP}$, $C_{NW}$, $C_{JET}$ and $C_{MIX}$) on flow in the post-stenotic region was investigated by simulating a wide range of parameter values. Results showed that the $C_{MIX}$ parameter, combined with a modified GEKO blending function, had the greatest effect on axial velocity, velocity fluctuations and the location of the jet breakdown region. A $C_{MIX}$ value of 0.4 closely matched the experimental results for a 75% area reduction stenosis at $Re=2000$ and showed significant improvements over existing Reynolds-averaged Navier–Stokes models. The GEKO model was also able to closely match the axial velocity results predicted by previously published large-eddy simulation models under the same flow conditions. Furthermore, the GEKO model was applied to a realistic oral-to-tracheal airway model for a Reynolds number of 2000 and produced results consistent with the idealised stenotic tube. Full article

Diffuse alveolar hemorrhage (DAH), a catastrophic complication of connective tissue disorders (CTDs), manifests as rapid-onset hypoxemia, alveolar infiltrates, and progressive bleeding into the airways. While immune-mediated alveolar–endothelial injury primarily drives its pathophysiology, diagnosis is based on bronchoscopy and chest imaging. The clinical urgency lies in securing the compromised airway and stabilizing respiratory failure, a challenge increased by CTD-specific anatomical alterations such as cervical spine instability, cricoarytenoid arthritis, and subglottic stenosis. High-dose corticosteroids and immunosuppression are essential, while severe cases require extracorporeal membrane oxygenation or plasmapheresis. This comprehensive review introduces two novel approaches to address fundamental gaps in the management of CTD-induced DAH: a structured algorithm for a CTD-specific airway risk stratification tool, integrating anatomical screening and the application of lung ultrasounds (LUSs) for post-intubation CTD-induced DAH ventilation management. The need for a multidisciplinary team approach is also discussed. Despite aggressive care, mortality remains high (25–50%), underscoring the necessity for improved early recognition and intervention strategies for these high-risk patients. Full article

Background: The accurate measurement of the distances within the airways during bronchoscopy is necessary for diagnostic purposes; however, a reliable and simple device does not exist. Methods: The LJ system, consisting of a probe, a box with a display, an encoder, and a microcontroller, has been developed, and its prototype has been tested in vitro and validated in clinical practice in suitable procedures of interventional bronchoscopy. Results: In vitro, the device measurements showed a good correlation with the control performed with a digital caliper. Subsequently, ten patients were included in a pilot study evaluating this novel prototype of a measurement device. The device was used on four patients with tracheal stenosis indicated for Y-stent placement, four patients indicated for open surgery, and two cases of tracheoesophageal fistula. The measurements have been validated using computed tomography imaging or by direct inspection and measurement during open surgical procedures. Conclusions: The first experience and pilot study evaluating this novel instrument for distance measurements during interventional bronchology procedures showed that the LJ device can provide precise readings of the distance from the vocal cords, the lengths of tracheal stenoses, or the size of tumorous and other lesions. Its use might be widened to other endoscopic indications. Full article

Background: Central airway obstruction (CAO) remains a major challenge in thoracic oncology, particularly in patients with advanced lung cancer. Despite advances in systemic therapies, interventional bronchoscopy, especially rigid bronchoscopy (RB), plays a critical role in managing CAO. Methods: Between June 2005 and December 2023, 416 patients with central airway obstructions were treated. The cohort included 213 males (51%) and 203 females (49%), with a mean age of 64.8 years. A retrospective review of patient data was conducted, and descriptive statistics were used to summarize demographics and procedural outcomes. Survival rates and complication data were analyzed using Kaplan–Meier survival curves. Multivariate analysis was performed to identify significant predictors of survival and complications, considering factors such as tumor stage, prior treatments, and comorbidities. The study also analyzed the impact of adjuvant therapies and stenting on patient outcomes. Results: Of the 416 patients, 86 (20.7%) had benign lesions, including 61 cases of post-tracheostomy stenosis or prolonged intubation, while the remaining 330 (79.3%) had malignant CAO. Patients receiving adjuvant therapies showed a significant survival advantage, with a median survival of 24 months compared to 15 months for those not receiving adjuvant therapies (p = 0.015). Stenting was performed in 141 cases, but no significant survival difference was found between patients with and without stents (p = 0.52). Complications were rare, with airway rupture observed in 1.9% and perioperative mortality in 0.25%. Symptom relief was achieved in the majority of patients, with significant improvements in quality of life, particularly in those with malignant obstructions. Conclusions: RB remains a cornerstone in the management of CAO, providing effective and durable symptom relief. It is particularly beneficial for advanced malignancies, offering a palliative approach that improves both survival and quality of life. Our study supports the guidelines endorsing RB for CAO management and highlights its role in providing significant symptom relief and stabilization in patients with severe airway obstruction. Full article

Background: Tracheobronchial stenosis is a significant complication in granulomatosis with polyangiitis (GPA), a systemic vasculitis that primarily affects the upper respiratory tract, kidneys, and lungs. The involvement of the tracheobronchial tree in GPA leads to airway narrowing, which can result in severe respiratory symptoms and increased morbidity, often requiring prompt diagnosis and management to prevent life-threatening airway obstruction. Method: We present the case of a 28-year-old male with mild exertional dyspnea, stridor, and retropharyngeal sputum. Clinical investigations revealed subglottic and bronchial concentric stenosis with granulomatous inflammation. A diagnosis of granulomatosis with polyangiitis (GPA) with isolated tracheobronchial stenosis (TBS) was confirmed. Results: Given the severity of airway obstruction, multidisciplinary management was initiated, combining rigid bronchoscopy with systemic immunosuppressive therapy. Post-intervention follow-up demonstrated significant airway improvement and maintained remission after two years. Conclusions: This case highlights TBS as a potentially debilitating GPA manifestation requiring a combination of systemic and endoscopic therapies. Further studies are needed to optimize therapeutic approaches and improve outcomes in GPA-associated TBS. Full article

Background: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare disorder characterized by a narrowed pyriform aperture and nasal obstruction. Children with CNPAS often exhibit a bony ridge on the underside of the secondary palate, a solitary central incisor, and a triangular-shaped palate. Due to its rarity, limited research exists, and there is no established treatment algorithm, which complicates management, particularly in craniofacial treatments and long-term follow-up. Aims: This study aimed to develop a comprehensive treatment algorithm based on long-term follow-up, focusing on maxillofacial deformities, dental considerations, and upper airway assessment. Methods: We conducted a retrospective study of four CNPAS patients treated at our institute. We performed a literature review, and a comparison was executed with our data in order to introduce our novel, age-specific clinical treatment framework. Results: A literature review was conducted, and different clinical parameters were examined. Previously published data were compared to our patients-related findings to develop our clinical treatment algorithm based on patients’ age. Patients were monitored for respiratory distress during the first two years of life. Children with cyclic cyanosis underwent surgical widening of the pyriform aperture through bony excess removal and nasal tubing to ensure airway patency. For those with ongoing desaturation events, neonatal palatal expansion was performed. At ages 10–12, additional evaluations using polysomnography and orthodontic assessments were conducted. Based on these findings, patients received surgically assisted rapid palatal expansion (SARPE) and further surgical widening of the pyriform aperture if obstructive sleep apnea (OSA) was present. Subsequent treatments included orthodontic care and restoration of the missing central incisor. Conclusions: We propose an age-based clinical treatment algorithm for CNPAS tailored to address individual patient needs throughout their growth. Full article

Background/Objectives: This report details a rare instance of an infant with achondroplasia developing acute tetraparesis after a cervical whiplash injury, highlighting key multidisciplinary management considerations and specific anesthetic strategies to mitigate potential risks. Case presentation: A 1-year-old boy with achondroplasia presented with acute tetraparesis after a whiplash injury. Initial craniocervical computed tomography demonstrated a reduced volume of the posterior fossa, foramen magnum stenosis, and ventriculomegaly, without any fractures or dislocations. Moreover, magnetic resonance imaging (MRI) revealed pathological signal changes in the medulla oblongata, cervical spinal cord in segments C1 and C2, and the posterior atlantoaxial ligament. After initial conservative therapy and head immobilization using a soft cervical collar, partial remission of the tetraparesis was achieved. Two weeks post-injury, microsurgical posterior fossa decompression extending to the foramen magnum and C1 laminectomy was performed under general anesthesia with intraoperative neuromonitoring. Following an unsuccessful intubation attempt using a fiberoptic bronchoscope, successful airway management was achieved using a combined technique incorporating video laryngoscopy. Venous access was secured under ultrasound guidance. The patient exhibited complete remission of neurological symptoms by the third postoperative month during follow-up. Conclusions: This case report underscores the crucial need for a multidisciplinary approach in managing children with achondroplasia, especially with foramen magnum stenosis and complex cervical spine injuries. Anesthetic management required meticulously planned airway strategies using advanced techniques like video laryngoscopy and fiberoptic bronchoscopy to reduce airway risks. It also highlights the importance of conservative therapy paired with timely neurosurgical intervention, resulting in the patient’s full recovery. Full article

This study investigates the impact of subglottic stenosis (SGS) on voice production using a subject-specific laryngeal and airway model. Direct numerical simulations of fluid–structure–acoustic interaction were employed to analyze glottal flow dynamics, vocal fold vibration, and acoustics under realistic conditions. The model accurately captured key physiological parameters, including the glottal flow rate, vocal fold vibration patterns, and the first four formant frequencies. Simulations of varying SGS severity revealed that up to 75% stenosis, vocal function remains largely unaffected. However, at 90% severity, significant changes in glottal flow and acoustics were observed, with vocal fold vibration remaining stable. At 96%, severe reductions in glottal flow and acoustics, along with marked changes in vocal fold dynamics, were detected. Flow resistance, the ratio of glottal to stenosis area, and pressure drop across the vocal folds were identified as critical factors influencing these changes. The use of anatomically realistic airway and vocal fold geometries revealed that while anatomical variations minimally affect voice production at lower stenosis grades, they become critical at severe stenosis levels (>90%), particularly in capturing distinct anterior–posterior opening patterns and focused jet effects that alter glottal dynamics. These findings suggest that while simplified models suffice for analyzing mild to moderate stenosis, patient-specific geometric details are essential for accurate prediction of vocal fold dynamics in severe cases. Full article

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed. Full article

Tracheal stenosis (i.e., the abnormal narrowing of the trachea) can occur due to a variety of inflammatory and infectious processes as well as due to therapeutic procedures undertaken by the patient. The most common cause of tracheal obstruction in patients has been prolonged intubation. Depending on the extent of the stenosis and its exact location, the surgical insertion of a tracheal stent is the only option for addressing this issue. The Montgomery T-tube implant is a valuable tracheal stent made from medical-grade silicone that provides a functional airway while supporting the tracheal mucosa. However, its performance is subject to gradual deterioration due to biofilm colonization of the stent’s inner wall, which may explain the discomfort claimed by many patients and clinical failures. Recently, cold atmospheric plasmas (CAPs) have emerged as an alternative technology to many conventional medical procedures, such as wound healing, skin treatment, decontamination of medical devices, etc. Here, we report on plasma-induced surface modification of the inner wall of a T-tube implant, considering future biomedical applications. To generate the plasma, we employed a cold atmospheric pressure plasma jet in gas helium, which was directly inserted into the T-tube implant. To assess the treatment uniformity, the degree of surface modification and its extension along the stent’s inner wall was analyzed using different process parameters. Full article

Background: This paper presents the outcomes of employing the inferiorly based rotated sternocleidomastoid muscle flap in complex tracheal reconstruction/repair scenarios, focusing on the key objectives of ensuring stable airway, functional digestive tract and patient survival. Methods: A retrospective analysis was performed for patients treated at two medical centers (A.O. San Camillo Forlanini, Rome, and A.O.U. Careggi, Florence) from 2011 to 2023, in which the sternocleidomastoid muscle (SCM) flap, detached from the mastoid and basicranium, was rotated on the lower pivot directly onto the repair site and pedicled to the sternal origin to ensure the continuity of the airway. Average postoperative hospital stay, follow-up period and patient survival were analyzed. Follow-up assessments encompassed bronchoscopies and CT scans conducted at intervals of 15 and 28 days, and subsequently at 3 and 9 months. Results: A total of five patients were enrolled in this study. These cases included one patient with anterior tracheal wall lesions with abundant tissue loss, one patient with an anterior wall necrosis due to descending cervical mediastinitis and three patients with extra-long tracheoesophageal fistulas (TEFs) (greater than 4.5 cm or >30% of the total tracheal length). In the case of the direct repair of a TEF with a proximal tracheal stenosis, the sternocleidomastoid muscle was used to reconstruct the tissue deficit caused by extensive loss of substance in the left lateral side of the tracheal wall. In case of repair through exclusion of the TEF, the sternocleidomastoid muscle was interposed between the visceral sutures after exclusion of the TEF by an endomechanical device, in one case even substituting the membranous part of the tracheal wall. Our technique allows rotation on the sternal head of the sternocleidomastoid muscle with the lowest rotation radius, pedicled to the sternal origin, detached from the mastoid process and superior nuchal line, thus providing optimal vascularization from the superior thyroid artery/external carotid artery and accessory vasculature from the suprascapular artery. Patients exhibited uneventful postoperative recovery concerning airway and digestive patency. The mean postoperative hospitalization duration was 41 days. The follow-up assessments were negative for postoperative complications. Conclusions: The use of sternocleidomastoid muscle flap was proposed to ensure repair and protection of the suture margin or to constitute a portion, as a scaffold, of the wall by leveraging the muscle’s vascularization and thickness. This technique may be considered a leading component in managing complex situations in tracheal surgery. Full article

Background: Whether Hyrax maxillary expander is an effective treatment for maxillary transverse deficiency as well as expansion of the upper airway is still controversial. The study’s purpose was to evaluate 3D changes in upper airway dimensions of adolescent patients measured primarily by cone-beam computed tomography (CBCT) after rapid maxillary expansion (RME) with the Hyrax maxillary expander. Methods: Studies up to 1 April 2024 were searched in the following databases: PubMed/MEDICINE, Web of Science, Cochrane Library, and Embase. Inclusion criteria were clinical trials and cohort studies that assessed the effect of RME in adolescent patients with upper airway stenosis using CBCT-based three-dimensional analysis. The risk of bias in the study outcomes was assessed using the Cochrane Collaboration’s risk of bias tool, the GRADE method, and a tool for evaluating non-randomized controlled study (non-RCT) literature from a previous systematic review, depending on the types of articles. The study was reported in accordance with PRISMA guidelines. Results: The study conducted a random effects meta-analysis of mean differences and 95% confidence intervals for changes in upper airway volumes, including the nasal cavity (NC), in the outcomes of 16 included studies, followed by subgroup analyses. Conclusion: A significant increase in nasopharynx volume was observed after rapid maxillary expansion (RME) by Hyrax maxillary expander (MD = 0.69, 95% CI (0.09~1.28), p = 0.02). Full article