Foreign Body in the Tracheobronchial Tree as a Cause of Hemoptysis in an Adult Without Risk Factors for Aspiration: A Case Report.

Although aspiration of a foreign body into the trachea and bronchi can occur in all age groups, it is more common in infants and young children. Foreign bodies in the tracheobronchial tree are uncommon in adults and mainly present in patients with dysphagia and an altered level of consciousness. The identification of foreign bodies in the tracheobronchial tree is frequently overlooked or delayed, leading patients to present later with chronic symptoms and potential complications. These complications may include persistent coughing, wheezing, obstructive pneumonitis, bronchiectasis, and abscess formation secondary to recurrent pulmonary infections. This article aims to present the case of a 27-year-old patient without risk factors for aspiration who has experienced recurrent self-limiting hemoptysis episodes for five years. Bronchoscopy revealed a foreign body at the entrance to the middle lobe bronchus. The presence of a foreign body in the tracheobronchial tree should be considered in any patient with recurrent hemoptysis. Bronchoscopy leads to accurate diagnosis, treatment, and prevention of complications.

A cytodiagnosis of adenoid cystic carcinoma of the tracheobronchial tree through a systematic clinical case comparison and analysis.

BACKGROUND: Primary adenoid cystic carcinoma (AdCC) of the tracheobronchial tree is very rare with a high risk for recurrence and metastasis. The diagnosis of AdCC by histologic and immunohistochemical means has been well studied clinically. However, the identification of AdCC by cytologic features remains elusive due to the atypical features the cancer presents. This study aimed to describe the cytologic features of AdCC by using bronchial brushing, which could aid in distinguishing AdCC from other pulmonary carcinomas. METHODS: The cytopathological features of bronchial brushing smears collected from seven cases were histologically diagnosed as AdCC. The defined cytologic features, which could potentially be diagnostic, were systemically analyzed. RESULTS: Four out of the seven cytologic cases were inconcordance with the histologic diagnosis and cytologically classified as positive for malignant cells, small cell carcinoma, or atypical cells. Three cases showed a characteristic adenoid structure and magenta stroma forming globule, which was distinguished from the four cases. Cytologically, the above mentioned three cases were uniform with relatively small bland nuclei and little cytoplasm. In this study, only one case showed atypical polygonal medium-sized cells with conspicuous nucleoli. CONCLUSIONS: Unlike fine-needle aspiration cytology, magenta stroma globules might offer an alternate clue for cytodiagnosis of AdCC clinically. Bronchial brushings cytology was more present in bland uniform cells with high nuclear to cytoplasmic ratios and background mucoid substance. More cases should be collected and confirmed using histopathology with careful film reading to reduce the rate of misdiagnosis.

Granular cell tumor of the lung and tracheobronchial tree: Two case-presentation with a review of the literature.

Pulmonary granular cells tumors (CGT) are rare tumors, that derive from Schwann cells. In the tracheobronchial and pulmonary tree, they remain a diagnostic challenge. There are no well-established criteria to differentiate between benign, atypical, and malignant GCT. Moreover, its real frequency in the respiratory tract is still unknown. Here, we represent 2 cases of bronchial and lung GCTs. We aim to highlight the frequency of all clinicopathological characteristics of this rare tumor in the tracheobronchial and pulmonary tree location based on our cases and the available literature in a large systematic review.

Evaluation of angles of the tracheobronchial tree with the 3-dimensional reconstruction method: a morphometric and radiologic study / Evaluación de los ángulos del árbol traqueobronquial con el método de reconstrucción tridimensional: un estudio morfométrico y radiológico

SUMMARY: The objective of the current research is to assess the branching angles of the tracheobronchial tree and the correlation between these angles and the lung volume using the 3-dimensional reconstruction method. Thorax CT (computed tomography) images of 150 individuals, who were over 18 years of age and did not have any pathology on CT, were obtained retrospectively. A 3-dimensional reconstruction of the trachea, bronchi, and lungs was carried out. External and internal angles between the trachea and main bronchi, between the main bronchi and lobar bronchi, and between the lobar bronchi were measured. The volume measurement of the right and left lungs was performed. The individuals included in the study were grouped by sex and age (20-40 years, 41-61 years, and 62-87 years). The left subcarinal angle (LSA), total subcarinal angle (TSA), and left interbronchial angle (LIA) were found to be greater in the 62-87 age group. Both the external angle (LULB-LMBE) and the internal angle (LULB- LMBI) between the left upper lobar bronchus and the left main bronchus were observed to be greater in males. In males, a statistically significant negative moderate correlation was identified between the right lung volume and the right subcarinal angle (RSA). In females, a statistically significant positive moderate correlation was revealed between the external (RULB-IBE) and internal angles (RULB-IBI) between the right upper lobar bronchus and the intermediate bronchus, and the right lung volume. In the literature review we performed, we did not find any studies investigating the correlation between the branching angles of the tracheobronchial tree and the lung volume using the 3-dimensional reconstruction method. Therefore, we are of the opinion that our study will contribute to the literature.

El objetivo de la investigación fue evaluar los ángulos de ramificación del árbol traqueobronquial y la correlación entre estos ángulos y el volumen pulmonar utilizando el método de reconstrucción tridimensional. Se obtuvieron retrospectivamente imágenes de tomografía computarizada de tórax de 150 individuos mayores de 18 años sin patología. Se realizó una reconstrucción tridimensional de la tráquea, los bronquios y los pulmones. Se midieron los ángulos externo e interno entre la tráquea y los bronquios principales, entre los bronquios principales y los bronquios lobares, y entre los bronquios lobares. Se realizó la medición del volumen de los pulmones derecho e izquierdo. Los individuos incluidos en el estudio fueron agrupados por sexo y edad (20-40 años, 41-61 años y 62-87 años). Se encontró que el ángulo subcarinal izquierdo, el ángulo subcarinal total y el ángulo interbronquial izquierdo eran mayores en el grupo de edad de 62 a 87 años. Tanto el ángulo externo (LULB-LMBE) como el ángulo interno (LULB-LMBI) entre el bronquio lobular superior izquierdo y el bronquio principal izquierdo era mayor en los hombres. En los hombres, se identificó una correlación moderada negativa estadísticamente significativa entre el volumen pulmonar derecho y el ángulo subcarinal derecho. En mujeres, se reveló una correlación positiva moderada estadísticamente significativa entre los ángulos externos (RULB-IBE) e internos (RULB-IBI) entre el bronquio lobar superior derecho y el bronquio intermedio, y el volumen pulmonar derecho. En la revisión bibliográfica que realizamos, no encontramos ningún estudio que analizara la correlación entre los ángulos de ramificación del árbol traqueobronquial y el volumen pulmonar utilizando el método de reconstrucción tridimensional. Por lo tanto, consideramos que nuestro estudio contribuirá a la literatura especializada del tema.

Targeted delivery of inhalable drug particles in the tracheobronchial tree model of a pediatric patient with bronchopneumonia: A numerical study.

Pneumonia is a common cause of hospitalization and death in children worldwide. Inhalation therapy is one of the methods treating pneumonia However, there are limited studies that distinguish between the physiology of children and adults, especially with respect to targeted drug delivery. A tracheobronchial (TB) tree model of an 11-year-old child with bronchopneumonia is selected as a testbed for in silico trials of targeted drug delivery. The airflow and particle transport are solved by the computational fluid dynamics method at an airflow rate of 15 LPM. The results indicate that the distribution of deposited particles shows aggregation on the particle release map. Point-source aerosol release (PSAR) method can significantly reduce the deposition efficiency (DE) of particles in the TB tree model. Specifically, the PSAR method can reduce the DE of large particles (i.e., 7.5 µm and 10 µm) by 7.57% and 9.61%, respectively. This enables rapid design of patient-specific treatment for different population age groups and different airway diseases.

The anatomical landmarks for positioning of double lumen endotracheal tube using flexible bronchoscopy: A prospective observational study.

Background: To examine the tracheobronchial anatomy and its common variations after double-lumen tube (DLT) placement, and to determine the anatomical landmarks that can be easily identified by practitioners for DLT positioning. Method: In total, 200 patients with American Society of Anesthesiologists I-II, who were aged 20-75 years and scheduled for video-assisted thoracic surgery (VATS), were prospectively enrolled. The types of DLT position in each patient was recorded [Type I, the DLT bronchial end was in the left main bronchus (LMB), and the primary carina could be observed; Type Ⅱ, the DLT bronchial end was in the right bronchus intermedius (RBI); and Type III, an unidentified trachea or bronchus wall was observed from the DLT tracheal lumen] and the main tracheobronchial tree images were collected using Flexible bronchoscopy (FB). Result: Five patients were excluded due to excessive bronchus secretions impacting image collection. Type Ⅰ, II, and III positions of DLT were detected in 134 (68.7%) patients, 28 (14.4%) patients, and 33 (16.9%) patients, respectively. Examples of the tracheobronchial tree, common features, and variations in each lung lobe were demonstrated using FB. Furthermore, image analysis showed that each superior segment orifice of the right lower lobe (RLL) and the left lower lobe (LLL) was less variable and recognizable, determining it an important anatomical landmark for DLT positioning. Conclusion: The tracheobronchial tree and its common variations after DLT placement were described. The superior segment orifice of the RLL and LLL can be considered as an important landmark for DLT positioning.

Targeted delivery of inhalable drug particles in a patient-specific tracheobronchial tree with moderate COVID-19: A numerical study.

The coronavirus disease 2019 (COVID-19) pandemic has led to severe social and economic disruption worldwide. Although currently no consent has been reached on a specific therapy that can treat COVID-19 effectively, several inhalation therapy strategies have been proposed to inhibit SARS-CoV-2 infection. These strategies include inhalations of antiviral drugs, anti-inflammatory drugs, and vaccines. To investigate how to enhance the therapeutic effect by increasing the delivery efficiency (DE) of the inhaled aerosolized drug particles, a patient-specific tracheobronchial (TB) tree from the trachea up to generation 6 (G6) with moderate COVID-19 symptoms was selected as a testbed for the in silico trials of targeted drug delivery to the lung regions with pneumonia alba, i.e., the severely affected lung segments (SALS). The 3D TB tree geometry was reconstructed from spiral computed tomography (CT) scanned images. The airflow field and particle trajectories were solved using a computational fluid dynamics (CFD) based Euler-Lagrange model at an inhalation flow rate of 15 L/min. Particle release maps, which record the deposition locations of the released particles, were obtained at the inlet according to the particle trajectories. Simulation results show that particles with different diameters have similar release maps for targeted delivery to SALS. Point-source aerosol release (PSAR) method can significantly enhance the DE into the SALS. A C++ program has been developed to optimize the location of the PSAR tube. The optimized simulations indicate that the PSAR approach can at least increase the DE of the SALS by a factor of 3.2× higher than conventional random-release drug-aerosol inhalation. The presence of the PSAR tube only leads to a 7.12% change in DE of the SALS. This enables the fast design of a patient-specific treatment for reginal lung diseases.

CT Features of Lymphatic Plastic Bronchitis in Adults: Correlation with Multimodality Lymphatic Imaging.

Purpose: To distinguish CT patterns of lymphatic and nonlymphatic causes of plastic bronchitis (PB) through comparison with lymphatic imaging. Materials and Methods: In this retrospective study, chest CT images acquired prior to lymphatic workup were assessed in 44 patients with PB from January 2014 to August 2020. The location and extent of ground-glass opacity (GGO) was compared with symptoms and lymphatic imaging. Statistical analysis was performed using descriptive statistics, logistic regression, Pearson correlation coefficient, and unweighted κ coefficient for interobserver agreement. Sensitivity and specificity of GGO for lymphatic PB were calculated. Results: Lymphatic imaging was performed in 44 patients (median age, 52 years ± 21 [IQR]; 23 women): 35 with lymphatic PB and nine with nonlymphatic PB. GGO was more frequently observed in patients with lymphatic PB than in those with nonlymphatic PB (91% [32 of 35] vs 33% [three of nine]; P < .001). Univariate logistic regression confirmed this result by showing that GGO was a significant predictor of lymphatic PB (odds ratio, 21 (95% CI: 3.8, 159.7). The model areas under the receiver operating characteristic curve (AUCs) of GGO unadjusted and adjusted for demographics were 0.79 and 0.86, respectively. The location of GGO correlated with lymphatic imaging and bronchoscopic findings. Overall sensitivity and specificity of GGO for lymphatic PB were 91% (32 of 35; 95% CI: 76, 98) and 67% (six of nine; 95% CI: 30, 93), respectively. Conclusion: Patients with lymphatic PB predominantly had multifocal GGO with or without a "crazy paving" pattern; identification of GGO should prompt lymphatic workup in this frequently misdiagnosed condition.Keywords: Lymphography, Lymphatic, CT, Tracheobronchial Tree, Thorax© RSNA, 2022See also commentary by Kligerman and White in this issue.

Thoracoscopic treatment of iatrogenic injuries of the tracheobronchial tree: a retrospective analysis of 5 cases and review of the literature.

INTRODUCTION: Iatrogenic injuries to the trachea and main bronchi present one of the most dramatic complications traditionally treated by thoracotomy and transcervical-transtracheal approaches but almost never by video-assisted thoracic surgery. AIM: To evaluate our experience in a video-assisted thoracic surgery repair of iatrogenic tracheal lacerations. MATERIAL AND METHODS: The group under analysis consisted of 5 consecutive patients (1 male, mean age: 52 years, range: 32-56 years) who were treated for postintubation and intraoperative damage to the tracheobronchial tree using video-assisted thoracic surgery within the period 2015-2018. Thoracic computed tomography and fibreoptic tracheobronchoscopy were used to confirm iatrogenic tracheal ruptures before surgery. The membranous rupture of the trachea was closed with interrupted absorbable sutures, which were additionally sutured through the oesophageal wall or the wall of the gastric conduit to strengthen the suture line. Postoperative treatment included broad-spectrum antibiotic therapy and control tracheobronchoscopy. RESULTS: The average duration of thoracoscopic tracheal rupture repair with suture line reinforcement was 103 min (range: 60-180 min). All patients were treated thoracoscopically without resorting to open surgery and were discharged without any postoperative complications within 16 days (range: 8-22 days). CONCLUSIONS: The minimally invasive thoracoscopic approach may be the method of choice for the treatment of intraoperative and post-intubation injuries of the tracheobronchial tree.

On the possibility of photodynamic inactivation of tracheobronchial tree pathogenic microbiota using methylene blue (in vitro study).

BACKGROUND: The treatment of patients after mechanical ventilation of lungs suffering from a multi-species infection of the tracheobronchial tree can be complicated.. The situation is aggravated in patients with post-intubation tracheal stenosis, where infection plays a leading pathogenetic role in damage to the tracheal wall. As a result of such a pathological process, cicatricial stenosis of the trachea of purulent-inflammatory infectious genesis or infected tracheal stenosis (ITS) may occur. METHODS: In this work, we studied the possibility of photodynamic inactivation of pathogenic microbiota typical for patients with ITS using methylene blue (MB) as a photosensitizer. RESULTS: 13 clinical isolates of 8 species of bacteria from 9 patients were susceptible to photodynamic inactivation with MB. 30 µM of MB at a light irradiation dose of 25 J/cm2 and incubation with MB for 15 min allows to completely inactivate bacteria found in the tracheobronchial secretions of patients with ITS. CONCLUSIONS: MB retains its optico-physical properties in the range of 3-30 µM and provides effective inactivation of isolated Gram-positive and Gram-negative bacteria, including multi- and pan-resistant to antibiotics.

A Rare Case of Intrapulmonary Sequestration With Multiple Feeding Arteries and an Anomalous Pulmonary Vein Draining Into the Azygos Vein.

Pulmonary sequestration is an isolated mass of lung tissue that has no identifiable bronchial communication and that receives its blood supply from one or more anomalous systemic arteries. The feeding vessel is the aorta or its major vessels and venous drainage usually is to the pulmonary veins to the left atrium. We present a rare case of intralobar sequestration in a 65-year-old man with multiple feeding arteries from the aorta and partial anomalous venous return draining into the azygos vein. He remained asymptomatic and this anomaly was detected incidentally when computed tomography (CT) scan of the chest with contrast was done to rule out pulmonary embolism.

Computational fluid dynamics of the airways after left-upper pulmonary lobectomy: A case study.

Pulmonary lobectomy is the gold standard intervention for lung cancer removal and consists of the complete resection of the affected lung lobe, which, coupled with the re-adaptation of the remaining thoracic structures, decreases the postoperative pulmonary function of the patient. Current clinical practice, based on spirometry and cardiopulmonary exercise tests, does not consider local changes, providing an average at-the-mouth estimation of residual functionality. Computational Fluid Dynamics (CFD) has proved a valuable solution to obtain quantitative and local information about airways airflow dynamics. A CFD investigation was performed on the airway tree of a left-upper pulmonary lobectomy patient, to quantify the effects of the postoperative alterations. The patient-specific bronchial models were reconstructed from pre- and postoperative CT scans. A parametric laryngeal model was merged to the geometries to account for physiological-like inlet conditions. Numerical simulations were performed in Fluent. The postoperative configuration revealed fluid dynamic variations in terms of global velocity (+23%), wall pressure (+48%), and wall shear stress (+39%). Local flow disturbances emerged at the resection site: a high-velocity peak of 4.92 m/s was found at the left-lower lobe entrance, with a local increase of pressure at the suture zone (18 Pa). The magnitude of pressure and secondary flows increased in the trachea and flow dynamics variations were observed also in the contralateral lung, causing altered lobar ventilation. The results confirmed that CFD is a patient-specific approach for a quantitative evaluation of fluid dynamics parameters and local ventilation providing additional information with respect to current clinical approaches.

Transport and deposition of ultrafine particles in the upper tracheobronchial tree: a comparative study between approximate and realistic respiratory tract models.

This paper presents a computational fluid dynamics (CFD) study of air-particle flows in the upper tracheobronchial tree. Two respiratory tract models, including a parametrically controlled approximate airway model developed by Kitaoka (KG model) and a CT-based patient specific airway (realistic model) were used. Assuming laminar, quasi-steady, three-dimensional air flow and spherical non-interacting ultrafine particles in sequentially bifurcating rigid bronchial airways, airflow patterns and particle transport/deposition in these two airway models were evaluated and compared. Overall deposition efficiency data was compared with the widely adopted ICRP data published by The International Commission on Radiological Protection. Good deposition efficiency agreements were observed between the present respiratory tract models and the ICRP data, which validated the numerical prediction accuracy of the present computational fluid-particle dynamics (CFPD) model. For the two respiratory models, the comparison showed both difference and similarity between the approximate KG model and the realistic model. Specifically, the realistic model showed more complicated airflow patterns due to the increased surface irregularity. The deposition efficiency data revealed a deposition preference in the first-generation airways compared to the rest regions. For ultrafine particles smaller than 10 nm, Brownian diffusion remains the dominant particle deposition mechanism. However, for ultrafine particles with size ranging from 10 nm to 100 nm, the deposition efficiency decreased dramatically with the 100 nm particles approaching to zero deposition in the present bronchial tree scope. The generation-by-generation deposition data presented in this paper is indispensable to the formulation of new lung inhalation exposure models.

Case report: A tracheobronchial schwannoma in a child.

Neurogenic tumors of the tracheobronchial tree are extremely rare, and these include neurofibroma and schwannoma. The rare schwannoma most frequently is reported in adults. We will report an endobronchial schwannoma in an 11-year-old boy.

Structural and functional alterations of the tracheobronchial tree after left upper pulmonary lobectomy for lung cancer.

BACKGROUND: Pulmonary lobectomy has been a well-established curative treatment method for localized lung cancer. After left upper pulmonary lobectomy, the upward displacement of remaining lower lobe causes the distortion or kink of bronchus, which is associated with intractable cough and breathless. However, the quantitative study on structural and functional alterations of the tracheobronchial tree after lobectomy has not been reported. We sought to investigate these alterations using CT imaging analysis and computational fluid dynamics (CFD) method. METHODS: Both preoperative and postoperative CT images of 18 patients who underwent left upper pulmonary lobectomy are collected. After the tracheobronchial tree models are extracted, the angles between trachea and bronchi, the surface area and volume of the tree, and the cross-sectional area of left lower lobar bronchus are investigated. CFD method is further used to describe the airflow characteristics by the wall pressure, airflow velocity, lobar flow rate, etc. RESULTS: It is found that the angle between the trachea and the right main bronchus increases after operation, but the angle with the left main bronchus decreases. No significant alteration is observed for the surface area or volume of the tree between pre-operation and post-operation. After left upper pulmonary lobectomy, the cross-sectional area of left lower lobar bronchus is reduced for most of the patients (15/18) by 15-75%, especially for 4 patients by more than 50%. The wall pressure, airflow velocity and pressure drop significantly increase after the operation. The flow rate to the right lung increases significantly by 2-30% (but there is no significant difference between each lobe), and the flow rate to the left lung drops accordingly. Many vortices are found in various places with severe distortions. CONCLUSIONS: The favorable and unfavorable adaptive alterations of tracheobronchial tree will occur after left upper pulmonary lobectomy, and these alterations can be clarified through CT imaging and CFD analysis. The severe distortions at left lower lobar bronchus might exacerbate postoperative shortness of breath.

Combined Use of a Fiberscope and Fuji Uniblocker for Removal of Retained Bronchial Tissue Glue After Repair of a Disrupted Left Main Bronchus.

We describe the novel combined use of a fiberoptic bronchoscope and a Fuji Uniblocker placed outside the endotracheal tube (ETT) for removal of a retained BioGlue polymerized tissue fragment (2.8 × 0.8 cm) from the right main bronchus (RMB). The patient was a trauma victim who presented with a diffuse axonal injury, cervical spine and maxillofacial injuries, and a flail chest, and the procedure we describe took place following the surgical repair of a disrupted left main bronchus. Endoscopic retrieval using different sizes of grasping forceps and a Dormia basket failed to remove the foreign body (FB). Under combined GlideScope videolaryngoscopic and bronchoscopic guidance, a 9.0 F Uniblocker was introduced outside the ETT, placed into the RMB beyond the FB, initially inflated, and then gradually increased in volume during withdrawal from the RMB into the trachea so as to trap the FB between the tip of the ETT and the blocker balloon. The ETT, bronchoscope, blocker catheter, and the FB were then removed from the glottis as a single unit. The FB was then removed using Magill forceps with the aid of a GlideScope. We conclude that the combined use of a GlideScope, bronchoscope, and an Uniblocker placed outside the ETT can be an effective method for removal of a retained FB.

Airflow in Tracheobronchial Tree of Subjects with Tracheal Bronchus Simulated Using CT Image Based Models and CFD Method.

Tracheal Bronchus (TB) is a rare congenital anomaly characterized by the presence of an abnormal bronchus originating from the trachea or main bronchi and directed toward the upper lobe. The airflow pattern in tracheobronchial trees of TB subjects is critical, but has not been systemically studied. This study proposes to simulate the airflow using CT image based models and the computational fluid dynamics (CFD) method. Six TB subjects and three health controls (HC) are included. After the geometric model of tracheobronchial tree is extracted from CT images, the spatial distribution of velocity, wall pressure, wall shear stress (WSS) is obtained through CFD simulation, and the lobar distribution of air, flow pattern and global pressure drop are investigated. Compared with HC subjects, the main bronchus angle of TB subjects and the variation of volume are large, while the cross-sectional growth rate is small. High airflow velocity, wall pressure, and WSS are observed locally at the tracheal bronchus, but the global patterns of these measures are still similar to those of HC. The ratio of airflow into the tracheal bronchus accounts for 6.6-15.6% of the inhaled airflow, decreasing the ratio to the right upper lobe from 15.7-21.4% (HC) to 4.9-13.6%. The air into tracheal bronchus originates from the right dorsal near-wall region of the trachea. Tracheal bronchus does not change the global pressure drop which is dependent on multiple variables. Though the tracheobronchial trees of TB subjects present individualized features, several commonalities on the structural and airflow characteristics can be revealed. The observed local alternations might provide new insight into the reason of recurrent local infections, cough and acute respiratory distress related to TB.