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Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.
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Objective: Although the neurological and olfactory symptoms of coronavirus disease 2019 have been identified, the neurotropic properties of the causative virus, severe acute respiratory syndrome-associated coronavirus 2 (SARS-CoV-2), remain unknown. We sought to identify the susceptible cell types and potential routes of SARS-CoV-2 entry into the central nervous system, olfactory system, and respiratory system. Method(s): We collected single-cell RNA data from normal brain and nasal epithelium specimens, along with bronchial, tracheal, and lung specimens in public datasets. The susceptible cell types that express SARS-CoV-2 entry genes were identified using single-cell RNA sequencing and the expression of the key genes at protein levels was verified by immunohistochemistry. We compared the coexpression patterns of the entry receptor angiotensin-converting enzyme 2 (ACE2) and the spike protein priming enzyme transmembrane serine protease (TMPRSS)/cathepsin L among the specimens. Result(s): The SARS-CoV-2 entry receptor ACE2 and the spike protein priming enzyme TMPRSS/cathepsin L were coexpressed by pericytes in brain tissue;this coexpression was confirmed by immunohistochemistry. In the nasal epithelium, ciliated cells and sustentacular cells exhibited strong coexpression of ACE2 and TMPRSS. Neurons and glia in the brain and nasal epithelium did not exhibit coexpression of ACE2 and TMPRSS. However, coexpression was present in ciliated cells, vascular smooth muscle cells, and fibroblasts in tracheal tissue;ciliated cells and goblet cells in bronchial tissue;and alveolar epithelium type 1 cells, AT2 cells, and ciliated cells in lung tissue. Conclusion(s): Neurological symptoms in patients with coronavirus disease 2019 could be associated with SARS-CoV-2 invasion across the blood-brain barrier via pericytes. Additionally, SARS-CoV-2-induced olfactory disorders could be the result of localized cell damage in the nasal epithelium.Copyright © Wolters Kluwer Health, Inc. All rights reserved.
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The purpose of this study is to evaluate changes in the trachea and bronchi using 3-dimensional reconstruction images obtained from the initial and follow-up computed tomography (CT) scans of COVID-19 patients. A hundred COVID-19 patients over the age of 18 were included in our study. CT images were transferred to Mimics software, and a 3-dimensional reconstruction of the trachea and bronchi was performed. The initial and follow-up CT images of COVID-19 patients were graded as none (grade 0), mild (grade 1), moderate (grade 2), and severe (grade 3) according to the total lung severity score. The patients were divided into progression and regression groups according to the grade increase/decrease between the initial and follow-up CTs. Moreover, the patients were divided into groups as 0-2 weeks, 2-4 weeks, 4-12 weeks, and over 12 weeks according to the duration between the initial and follow-up CTs. The mean cross-sectional area, circumference, and diameter measurements of the right upper lobar bronchus, intermediate bronchus, middle lobar bronchus, and left lower lobar bronchus decreased in the follow-up CTs of the progression group. This decrease was not found to be statistically significant. In the follow-up CTs of the regression group, the left upper lobar bronchus and left lower lobar bronchus measurements increased but not statistically significant. Upon comparing the onset of the disease and the follow-up period, statistically significant changes did not occur in the trachea, main bronchus, and lobar bronchus of COVID-19 patients.Copyright © 2023, Universidad de la Frontera. All rights reserved.
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Introduction: VCA transplantation is progressing despite challenges including the COVID-19 pandemic. Method(s): The OPTN cohort includes 108 VCA candidates listed and 66 recipients transplanted between 7/3/2014 - 4/30/2022. Result(s): Seven VCA candidates were listed in 2021: 3 abdominal wall (AW) and 4 uterus. One AW and 2 uterus candidates were listed in the first 4 months of 2022. AW registrations became the predominant registration type on the VCA waiting list in 2022, surpassing uterus registrations. As of 4/30/2022, the waiting list included 17 candidates: 6 AW, 5 uterus, 4 upper limb (UL;1 bilateral, 3 unilateral), 1 face, and 1 face/scalp. Since 7/3/2014, 66 recipients received 67 VCA transplants, including 14 UL (9 bilateral, 5 unilateral), 9 face, 1 bilateral UL and face, 1 scalp, 1 trachea, 2 AW, 36 uterus (14 deceased donor, 22 living donor), and 2 penis recipients. In 2021, 1 bilateral UL, 1 trachea, and 2 living donor uterus transplants were performed. In the first 4 months of 2022, 3 uterus transplants (2 deceased donor, 1 living donor) were performed. Discussion and Conclusion(s): The composition of the VCA waiting list is changing. VCA transplantation continues to advance despite the COVID-19 pandemic.
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Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).
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Introduction: Patients with COVID pneumonia who require intubation and prolonged mechanical ventilation are at risk for complications such as recurrent infection, tracheomalacia, tracheal stenosis, and the development of tracheoesophageal fistula (TEF). TEF is a devastating complication where the trachea and esophagus develop an abnormal connection in the lower airway that dramatically increases the mortality of critically ill patients by recurrent aspiration and pneumonias. Though commonly associated with neoplasms another risk is pressure induced ischemia of the common wall between the trachea and esophagus. This can occur due to overinflation of the endotracheal (ET) cuff, especially with concomitant use of a nasogastric tube (NGT). Definitive management requires surgical repair. Case Description/Methods: A 69-year-old male patient presented with acute hypoxemic respiratory failure secondary to COVID pneumonia requiring intubation and insertion of an NGT. On day 29 the patient underwent percutaneous enterogastrostomy (PEG) placement and tracheostomy;it was noted intraoperatively that the tracheal mucosa was inflamed and friable. On day 36 bronchoscopy was performed through the tracheostomy tube due to concerns for mucus plugging. Friable mucosa with granulation tissue was seen at the distal end of the tube, so an extra-long tracheostomy tube was exchanged to bypass the granulation tissue. Later that night the ventilator measured a 50% discrepancy between the delivered and exhaled tidal volumes, triggering an alarm. Exam noted distension of the PEG-bag with a fluid meniscus in the tubing moving in sync with each respiration. TEF was considered and bronchoscopic evaluation confirmed a 1-centimeter TEF. The patient underwent successful TEF repair and is slowly recovering (Figure). Discussion(s): Critically ill patients who require prolonged support are at high risk of complications and device related injury. With each device-day there is an increased risk of complications, such as infection, dislodgement, and pressure-related injuries. This case highlights the importance of serial physical examinations as well as understanding possible device related complications. An unexpected finding, such as a persistent air leak, air in a PEG bag, or a fluctuating meniscus should raise suspicion for the development of a serious complication and would warrant prompt confirmatory testing. Our literature review revealed no reports of a PEG tube abnormalities as a presenting finding for TEF.
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[Objective] To prepare broad-spectrum monoclonal antibody against N protein of avian infectious bronchitis virus (IBV), so as to lay a foundation for identifying conservative domain epitope of N protein and establish a universal IBV detection method. [Method] N protein of GX-YL5, a representative strain of IBV dominant serotype in Guangxi, was expressed in prokaryote. BALB/c mice were immunized with the purified protein. After the serum titer of the immunized mice reached 104 or more, the splenocytes were fused with SP2/0 myeloma cells. After screening by indirect ELISA, monoclonal antibody was prepared by ascites-induced method. Western blotting, IFA and indirect ELISA were used to identify the titer, subtype, reaction specificity and cross-reaction spectrum. And the prepared monoclonal antibody was used for immunohistochemical detection. And the prepared monoclonal antibody was used to detect the IBV in the trachea and kidney tissues of SPF chickens artificially infected with 4 representative IBV variants (GX-N130048, GX-N160421, GX-QZ171023 and GX-QZ170728). [Result] The prepared monoclonal antibody N2D5 had a titer greater than 217 and its subtype was IgG2b. The Western blotting and IFA results showed that the monoclonal antibody N2D5 only reacted with IBV, and were negative with Newcastle disease virus (NDV), infectious laryngotracheitis virus (ILTV), avian metapneumovirus (aMPV), infectious bursal disease virus (IBDV), avian leukosis virus (ALV) and Marek's disease virus (MDV). Monoclonal antibody N2D5 reacted with many genotypes in China and all 7 serotypes of IBV currently prevalent in Guangxi, including commonly used standard strains, vaccine strains and field strains. Immunohistochemistry showed that the virus signals could be detected in the trachea and kidney tissues of SPF chickens at different time after artificial infection of 3 representative IBV strains from chicken and 1 isolated strain from duck, which further proved its broad spectrum. [Conclusion] The monoclonal antibody N2D5 of IBV prepared based on hybridoma technology belongs to the IgG2b subtype. It has the characteristics of high specificity, wide response spectrum and strong binding ability with IBV. It can be used as a specific diagnostic antibody for clinical diagnosis of IBV and the study of virus distribution.
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In order to perform the isolation of avian infectious bronchitis virus (IBV) and study the pathogenicity of IBV isolate, the RT-PCR was used to detect nucleic acid extracted from a clinical sample of chickens, which were suspected to be infected with infectious bronchitis virus (IBV) and provided by a farmer in Yuncheng, Shanxi province. And the sample was detected as IBV positive by RT-PCR. Then 9-11-day-old SPF chicken embryonated eggs were inoculated with the sample filtered from the grinding fluid, and the obtained allantoic fluid was blindly passed by three generations (F3) and was also tested as IBV positive;The F11 generation passaged in embryonated eggs caused typical "dwarf embryo" lesions to SPF chicken embryonated eggs, and induced the loss of cilia in tracheal rings. The results showed that an IBV strain was isolated and named as YC181031. The S1 gene amplification and sequencing analysis showed that YC181031 strain belonged to IBV GI-22 genotype, which is also nephropathogenic type IBV. Seven-day-old SPF chicks were used to test the pathogenicity of the isolate. The results showed that several clinical symptoms were showed in chicks infected with YC181031, such as breathing with difficulty, depression, excreting watery droppings and death. The mortality of infected chicks was 20%. Typical pathological changes such as enlargement of kidney and urate deposition in the kidney were observed in infected chicks. The immunohistochemical assay and viral load detection were performed for the tissue samples from infected and dead chicks. The tissue lesions and distribution of virus were observed in the kidney, trachea, lung, glandular stomach, spleen and liver samples of infected chicks. RT-PCR detection of pharyngeal anal swabs showed that the virus shedding by infected chicks could be continuously detected within 14 days of the test period;The viral loads of various tissues were detected by RT-qPCR and the results showed that the viral load from high to low was kidney, trachea, lung, stomach, spleen and liver. The viral load of kidney was significantly higher than that of other tissues (P < 0.05).In this study, the pathogenicity characteristics of GI-22 genotype strain were systematically studied for the first time, providing a reference for the prevention and treatment of the disease.
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The potential antiviral effects of indole-3-carbinol (I3C), a phytochemical found in Cruciferous vegetables, were investigated. Fibroblasts and epithelial cells were co-cultured on Alvetex® scaffolds, to obtain ad hoc 3D in vitro platforms able to mimic the trachea and intestinal mucosae, which represent the primary structures involved in the coronavirus pathogenesis. The two barriers generated in vitro were treated with various concentrations of I3C for different incubation periods. A protective effect of I3C on both intestinal and trachea models was demonstrated. A significant reduction in the transcription of the two main genes belonging to the Homologous to E6AP C-terminus (HECT)-E3 ligase family members, namely NEDD4 E3 Ubiquitin Protein Ligase (NEDD4) and WW Domain Containing E3 Ubiquitin Protein Ligase 1 (WWP1), which promote virus matrix protein ubiquitination and inhibit viral egression, were detected. These findings indicate I3C potential effect in preventing coronavirus cell egression processes that inhibit viral production. Although further studies are needed to clarify the molecular mechanisms whereby HECT family members control virus life cycle, this work paves the way to the possible therapeutic use of new natural compounds that may reduce the clinical severity of future pandemics.
Subject(s)
Brassicaceae , Coronavirus , Vegetables/chemistry , Coronavirus/metabolism , Trachea/metabolism , Ubiquitin-Protein Ligases/chemistry , Ubiquitin-Protein Ligases/genetics , Ubiquitin-Protein Ligases/metabolism , Brassicaceae/metabolismABSTRACT
Enhanced experience in performing percutaneous tracheostomies during the COVID-19 pandemic resulted in changes to airway management protocol for patients undergoing major head and neck reconstructive surgery within our department. Most patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy. The aim of this study was to review our experience in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. All consecutive patients undergoing free flap reconstructive surgery for head and neck cancer between June 2020 and November 2021 were included, with 56 patients receiving a percutaneous tracheostomy. Data across a range of variables including age, BMI, comorbidities and complications was compared with 56 surgical tracheostomies performed for the same group of patients before the COVID-19 pandemic and resultant protocol changes. In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group;28.57% and 30.35% respectively. Analysis of the 16 patients who experienced complications in the percutaneous group led to development of selection criteria to identify appropriate patients to receive a percutaneous tracheostomy in future, based on factors such as BMI, bleeding risk and positioning deformities. The COVID-19 pandemic has offered a multitude of learning experiences for healthcare professionals to change our practice. In our unit, this has involved modifying the routine tracheostomy procedure used for airway management intra- and post-operatively in major head and neck reconstruction surgery.Copyright © 2023 The Authors
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Ferula asafoetida is an endemic species in Iran and is rich in oleo-gum resin with high economic value in the world. One important application of F. assafoetida is its traditional use for the management of respiratory ailments. The aim of this review was to collect papers dealing with F. asafoetida oleo-gum resin in respiratory tract's diseases in modern medicine. For preparing the manuscript the scientific databases (Google scholar, PubMed, Springer, Science Direct, Magiran), books, thesis, etc. were searched using the keywords of "Ferula asafoetida", "Ferula scorodesma", "Scorodesma foetida", "Northex asafoetida" plus "respiratory tract", "respiratory disorder" "infection", "cough", "trachea", "traditional medicine" up to Feb 2022 and the collected data were sum-marized, analyzed, and discussed. The results of the investigation confirmed the traditional belief on the efficacy of Ferula asafoetida in the treatment of respiratory viral infection (Coronavirus, influ-enza), cigarette smoking, asthma, cough and cancer, but most studies were limited to in vitro. There was only one registered randomized, blinded, placebo controlled clinical trial for 300 mg F. asafoet-ida aqueous extract capsules (three times a day for 14 days) on 40 patients with COVID-19 without any published results. Although, the studies implied the efficacy of F. asafoetida in the treatment of respiratory treatments, but design large clinical studies for evaluating its efficacy and safety is essential in future investigations.Copyright © 2023 Bentham Science Publishers.
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Case report Background: Hereditary angioedema (HAE) is a rare disease that usually manifests during childhood and is characterized by recurrent swelling episodes in various body tissues. Effective treatment options, including replacement therapy with C1 inhibitor (C1-INH) concentrate, are available for acute attacks and, for patients with high disease burden, for prophylaxis. More convenient than intravenous (IV) injections, and better suitable for patients with difficult venous access, is subcutaneous (SC) administration. However, treatment with SC prophylactic C1-INH is not yet approved in Europe for children < 12 years of age. Case Description: The boy presented to our clinic in 2014 at the age of 3, with a diagnosis of HAE due to C1-INH deficiency. During the last 3 months, he had been given IV C1-INH concentrate on-demand for HAE attacks. During the following year, the boy experienced monthly attacks at different body sites and had to be hospitalized several times for edema of the extremities and face, and abdominal colicky pain. At 5 to 6 years of age, attack frequency increased to once weekly and a first swelling of the trachea with dyspnea occurred. Over time, this led to repeated occurrence of panic attacks and psychological problems, which were exacerbated by social distancing during the coronavirus disease-19 pandemic. To mitigate disease burden, his therapy was switched to weekly prophylaxis with IV C1-INH, and the bradykinin receptor inhibitor icatibant was kept on hand as emergency medicine. Less than half a year later, attack frequency increased again and the regimen was changed to twice weekly. This led to drastic deterioration of venous access, so that a switch to SC prophylaxis became inevitable. The patient, now 10 years old, and his mother were trained in SC injection techniques and since June 2021, they administer twice weekly SC C1-INH (2000 International Units) at home, with no breakthrough attacks and significant improvement of quality of life. Conclusion(s): Because of high disease burden and impairment of quality of life due to high edema frequency, routine prophylaxis was chosen. In patients receiving frequent IV prophylaxis, occurrence of breakthrough attacks and deterioration of venous access warrants a switch to SC treatment. In the present case, this switch was unavoidable, although this treatment option is not approved for children. It allows the boy to self-administer his C1-INH and has improved his quality of life significantly.
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Introduction: During the COVID-19 pandemic, the number of patients who required admission to the intensive care unit (ICU) and prolonged intubation (ETI) or a tracheotomy (TT) due to severe ARDS has increased. Causes of persistent dyspnea after severe COVID-19 pneumonia include diffuse lung disease and pulmonary embolism. However, other causes of persistent dyspnea need to be ruled out in COVID-19 ICU-survivors, including iatrogenic tracheal stenosis (TS). Iatrogenic TS account for 50% of the 15-20 patients evaluated every year in the laryngotracheal multidisciplinary team (MDT) of our center. The management of these patients requires an individualized and multidisciplinary assessment, including Interventional Pulmonologists, Thoracic Surgeons and Otolaryngologists. The objective of this study was to describe the cases of iatrogenic TS after severe pneumonia due to COVID-19. Material(s) and Method(s): A descriptive study of the cases of iatrogenic TS in COVID-19 ICU-survivors evaluated at our center's MDT, from the end of the first wave to present. Result(s): A total of 10 patients were included, 70% were women, with a median age of 60 years [53.5-64.5]. The median ICU stay was 58.5 days [34-91]. All patients were intubated and 9 of them (90%) required TT, in 2 cases due to extubation failure. Symptoms at diagnosis included dyspnea in 3 (30%), stridor in 6 (60%) and 1 (10%) was asymptomatic. TS location was glottic in 2 (20%) and tracheal in 8 (80%). The main cause of TS was ring fracture secondary to TT (40%). Conclusion(s): Iatrogenic TS is a rare cause of dyspnea in COVID-19 ICU-survivors, but it must be considered in these patients given the high number of patients who required prolonged ETI or TT during the COVID-19 pandemic.
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Relevance. The coronavirus rush, which has appeared since December 2019, has an impact on economic, medical, and social development in all countries of the world. There are still no standard diagnostic and therapeutic plans aimed at limiting this infection. Purpose. To determine the therapeutic role of tracheostomy with patients with coronavirus infection. Material. The prospective study of 100 patients with coronavirus infection was carried out on the basis of State Budgetary Healthcare Institution "Interdistrict Multidisciplinary Hospital" in Nartkala city. When patients were admitted to the clinic, they were randomized into 2 groups depending on the therapy: the first group (comparison, n=50) - patients received traditional therapy in intensive care;the second (main, n=50) group - patients underwent tracheostomy in addition to standard therapy. The average age was 56.2+/-4.8 years. The women's average age was 55 years (55.0%), and the men's - 45 years (45.0%). Methods. Determination of the syndrome of endogenous intoxication, taxation of lipid peroxidation intensification. The local microcirculation was investigated by the apparatus LAKK-02. The activity of the coagulation-lytic blood system was found by thrombelastograph TEG 5000. Results. Early COVID-19 infection demonstrates signs of intoxication, oxidative depression, phospholipase activity, microcirculatory and hemostatic disorders. These changes were the cause of the development of life-threatening complications (neurological, pulmonary, cardiac, etc.). They were associated with the type of treatment. Traditional treatment and the use of mask oxygen turned out to be ineffective, since the homeostasis system disorders remained throughout the investigation period. The inclusion of tracheostomy in traditional therapy makes it possible to quickly improve the course of pathology as it purposefully affects the pathogenetic links of the homeostasis system. Conclusion. The use of tracheostomy in the scheme of standard treatment of coronavirus infection allows improving the effectiveness of general therapy of COVID-19 patients, especially with severe forms.Copyright © 2023, Codon Publications. All rights reserved.
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Objectives: Cytomegalovirus (CMV) reactivation is a significant cause of morbidity and mortality in critically ill patients. Existing or newly developed immunosuppression appears to be the main factor for reactivation. COVID-19 patients with acute respiratory distress syndrome can be affected by a variety of conditions that cause immunosuppression. Clarifying CMV reactivation and notably its predictive features became important during the epidemic. Method(s): This is a retrospective, observational, and cohort study. All COVID-19 patients admitted to the ICU between March 11, 2020 and March 11, 2021 were analyzed. All of the information was gathered from the hospital's electronic records. CMV reactivation was defined as CMV DNA >=1000 copies/ml in tracheal samples. The patient population was analyzed in two groups, namely, patients with CMV reactivation and patients without reactivation. Result(s): During the study period, 99 of all COVID-19 ARDS patients fulfilled the inclusion criteria, and CMV reactivation was detected in 55 (55.6%) of them. Age, BMI, APACHE-II score, hypertension, chronic respiratory disease, the usage of interleukin blockers, the duration of steroid usage, procalcitonin (PCT), and CD-8 T-cell levels differed significantly from the patients without CMV reactivation. Furthermore, the reactivation group had longer ICU stays, longer durations of mechanical ventilation, and higher mortality. Conclusion(s): CMV can be reactivated in critically ill COVID-19 ARDS patients, which appears to correlate with worse outcomes. Obesity, the usage of IL-blockers and steroids >12 days, high PCT, and low CD-8 T-cell levels appear to be risk factors. Critically ill COVID-19 patients should be closely monitored with regard to immunosuppression and CMV status.Copyright © 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.
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Introduction: Postintubation tracheal stenosis (PITS) is a rare complication of mechanical ventilation (MV). Risk factors for PITS include prolonged MV, reintubation and poor endotracheal tube cuff management, all of which are common in severe COVID19 patients during pandemic surges. Aims and objectives: to describe the patient characteristics and outcomes of PITS after MV for COVID19. Method(s): we conducted a retrospective review of all patients referred to our tertiary teaching hospital for endoscopic PITS treatment after COVID19 during 2021. Result(s): 60% of the 15 referred patients were female with a mean age of 60.1 years. Median duration of MV was 11.5 (8.5 - 16) days. 13.3% of patients were reintubated and 26.7% required tracheostomy during their ICU stay. 86.7% presented with stridor after a median of 32 (16.5-60) days after extubation with a further delay of 14 (2-42) days until the diagnosis of PITS. 73.3% had simple PITS with a mean diameter of 5.73+/-1.53 mm. 12 patients were successfully treated endoscopically with serial dilatation and electrocautery. Restenosis after treatment was observed in 66.7% of patients after a median of 30 (22.5-35) days. 5 patients required surgery while 2 patients required further endoscopic dilatation after surgery. Interestingly, 13 of the 15 patients were referred from a single tertiary hospital, after treatment in the same ICU. Conclusion(s): We observed an increase in referrals for PITS treatment during the study period with a cluster of patients from a single ICU. The high restenosis rate emphasizes the importance of multidisciplinary management as well as the prevention of PITS with high quality ICU care during the COVID19 pandemic.
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Background: Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature. Case description and systematic review: A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky haemoptysis, and hoarseness of voice 2 weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycaemic control, posaconazole, and inhaled amphotericin B (8 weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in two lung transplant recipients), post-viral illness (post-COVID-19 [n = 3], and influenza [n = 1]), and post-intubation mucormycosis (n = 1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26;19.2%) or bronchoscopic instillation (1/26;3.8%) of amphotericin B and surgery (6/26;23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive haemoptysis. Conclusion: Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible. © 2022 Wiley-VCH GmbH.
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Case Report: Purpose: Milrinone is an inodilator that is used in the treatment of cardiogenic dysfunction and shock. It causes increased cardiac output by stimulating myocardial contractility, enhancing cardiac relaxation, and reducing afterload via phosphodiesterase III inhibition, preventing cyclic adenosine monophosphate (cAMP) degradation. Increased cAMP concentrations are known to inhibit platelet aggregation. Veno-arterial-extracorporeal membrane oxygenation (VA-ECMO) is an extracorporeal treatment option for inotrope-refractory cardiogenic shock and is often used in conjunction with inodilators. Often, patients supported on ECMO require systemic anticoagulation to prevent clotting complications. Therefore, thromboelastography (TEG) with platelet mapping is used to help gauge a patient's clotting status and gives clinicians information about the degree of platelet inhibition present. We present the case of two patients, both supported on VA-ECMO, who developed platelet inhibition with clinically significant bleeding while on milrinone, requiring the cessation of the milrinone infusion. Cases: First, we present an adult female in her fourth decade of life who required VA-ECMO for Covid-19 ARDS and cardiogenic shock. TEG platelet mapping was obtained for clinically significant bleeding from her trachea and gastrointestinal tract. Ten days after starting milrinone, adenosine-5'-diphosphate (ADP) inhibition was elevated at 67.4% and arachidonic acid (AA) inhibition normal at 1.8%. Twenty days after starting milrinone, ADP inhibition was 93.3% and AA inhibition was 76.4%. Milrinone discontinued and repeat TEG platelet mapping (10 days after discontinuation) showed ADP inhibition of 76.8% and AA inhibition of 0%. Her lowest ADP inhibition was 41.9%, approximately 1 month after milrinone discontinuation. Milrinone again attempted and ADP inhibition was 87.9% and AA inhibition 89.2% within 24 hours of initiation. No data available for platelet inhibition prior to starting milrinone. Next, we present a 9 year old female with acute myeloid leukemia who required VA-ECMO for septic shock. Initial TEG platelet mapping, obtained 2 days after milrinone initiation, showed ADP inhibition of 43.6% and AA inhibition of 98.7%. Two days after discontinuation of milrinone, her ADP inhibition was 19.6% but AA inhibition remained elevated at 91.9%. However, after 4 days off milrinone, her ADP inhibition was normal at 15.5% and AA inhibition mildly elevated at 33.6%. No data available for platelet inhibition prior to starting milrinone. Conclusion(s): Milrinone is a known platelet inhibitor due to increased intracellular cAMP concentrations. For patients on ECMO and milrinone, care should be given to the degree of platelet inhibition and potential risk of clinically significant bleeding. Further studies are needed to further investigate the correlation between milrinone, platelet inhibition, and clinically significant bleeding in ECMO patients. Copyright © 2023 Southern Society for Clinical Investigation.
ABSTRACT
Case Report: Most common causes of shortness of breath are asthma, COPD, CHF, pulmonary embolism, diffuse lung parenchymal diseases and obesity hypoventilation syndrome. Rare conditions can be bronchiectasis, constrictive pericarditis, kyphoscoliosis, tracheomalacia, cardiomyopathies and so on. We present a rare case of tracheal stenosis presenting with repeated hospital admissions followed by intubations and resolution after spontaneous expectoration. A 52-year-old female with a history of end stage renal disease on hemodialysis, resistant hypertension, and COVID pneumonia on supplemental oxygen, presented with dyspnea associated with yellowish productive sputum for one day. She was admitted one week prior due to the same complaint associated with encephalopathy due to hypercapnia, required endotracheal intubation, got extubated four days later, was provisionally diagnosed with asthma and volume overload, and discharged home. During the admission of interest, the patient's examwas normal except severe hypertension with BP of 192/101, bilateral crackles and rhonchi. Arterial blood gasses (ABGs) again showed hypercapnia. CT thorax showed evidence of left lower lobe pulmonary infiltrate and ground-glass opacities. Due to repeated admissions for hypercapnic respiratory failure, suspicion for persistent anatomic or pathologic abnormality was high. Reexamination of CT thorax suggested subglottic stenosis and she underwent fiberoptic laryngoscopy which revealed grade 3 subglottic stenosis. On day three, she became hypoxic and unresponsive, ABGs revealed PCO2 of 150, and got intubated again. Soon after intubation, the patient had spontaneous expectoration of a large piece of firm, fleshy, blood-tinged, thick, luminal tissue. On the histologic examination, the material was found to be a plug of fibrin with small to moderate numbers of inflammatory cells embedded in the matrix. Follow-up CT neck and chest revealed resolution of previously visualized tracheal stenosis. She underwent repeat direct laryngoscopy and flexible bronchoscopy which did not show any tracheal stenosis. The patient remained hemodynamically stable and was discharged home. Tracheal stenosis is challenging to diagnose. Examples of tracheal stenosis due to pseudomembrane formation are rare in medical literature, and the expectoration of fibrin material after intubation in a person with this condition is even rarer. A similar case has been described before with an identical situation of coughing up soft tissue and comparable histopathology report. Our case highlights the importance of critical analysis for broad differentials, adding up pieces of the puzzle to explain the missing link. This patient came with recurrent episodes of dyspnea that were misdiagnosed as volume overload, pneumonia, and asthma exacerbations. CT chest findings of possible subglottic stenosis were the missing link in this case which steered further work-up and led to the final diagnosis. Copyright © 2023 Southern Society for Clinical Investigation.
ABSTRACT
Complications of the endotracheal tube (ETT) displacement during head and neck positional changes are related to not only the tip position but also the cuff pressure against the larynx. Here, we evaluated movement of the ETT cuff relative to laryngeal structures as well as tip displacement from the carina.Sixty-two patients scheduled for thyroidectomy were recruited. The distance from the cricoid cartilage to the upper margin of the cuff (CC) and that from the ETT tip to the carina (TC) were measured using ultrasonography and fiberoptic bronchoscopy, respectively, during flexion and extension. The total tracheal length (TTL) was defined as the combination of CC, TC, and the distance from the upper margin of the cuff to the tip.During flexion, the CC and TC were 1.5 ± 0.6 and 2.9 ± 1.0 cm respectively. Seven patients (11.7%) exhibited excessively deep intubation. After adjusting the cuff position under ultrasonography (CC = 0), the tip position was corrected in 96.7%. While the TC increased by 2.1 ± 1.0 cm after the positional change in extension, the CC decreased by 0.6 ± 0.7 cm because the TTL lengthened (1.4 ± 1.1 cm). Four patients (6.7%) exhibited excessive cuff displacement beyond the cricoid cartilage, which could have been corrected under ultrasonography.In conclusion, the ETT cuff displaced toward the larynx in a less degree than the tip did from the carina due to the tracheal lengthening during head and neck extension. Nevertheless, we suggest that ultrasonographic assessment of cuff position may avoid ETT misplacement. Trial registration https://cris.nih.go.kr/ (approval no. KCT0005319); registered on May 14, 2019.