Development of a Bioinspired, Self-Adhering, and Drug-Eluting Laryngotracheal Patch.

OBJECTIVES/HYPOTHESIS: Novel laryngotracheal wound coverage devices are limited by complex anatomy, smooth surfaces, and dynamic pressure changes and airflow during breathing. We hypothesize that a bioinspired mucoadhesive patch mimicking how geckos climb smooth surfaces will permit sutureless wound coverage and also allow drug delivery. STUDY DESIGN: ex-vivo. METHODS: Polycaprolactone (PCL) fibers were electrospun onto a substrate and polyethylene glycol (PEG) - acrylate flocks in varying densities were deposited to create a composite patch. Sample topography was assessed with laser profilometry, material stiffness with biaxial mechanical testing, and mucoadhesive testing determined cohesive material failure on porcine tracheal tissue. Degradation rate was measured over 21 days in vitro along with dexamethasone drug release profiles. Material handleability was evaluated via suture retention and in cadaveric larynges. RESULTS: Increased flocking density was inversely related to cohesive failure in mucoadhesive testing, with a flocking density of PCL-PEG-2XFLK increasing failure strength to 6880 ± 1810 Pa compared to 3028 ± 791 in PCL-PEG-4XFLK density and 1182 ± 262 in PCL-PEG-6XFLK density. The PCL-PEG-2XFLK specimens had a higher failure strength than PCL alone (1404 ± 545 Pa) or PCL-PEG (2732 ± 840). Flocking progressively reduced composite stiffness from 1347 ± 15 to 763 ± 21 N/m. Degradation increased from 12% at 7 days to 16% after 10 days and 20% after 21 days. Cumulative dexamethasone release at 0.4 mg/cm2 concentration was maintained over 21 days. Optimized PCL-PEG-2XFLK density flocked patches were easy to maneuver endoscopically in laryngeal evaluation. CONCLUSIONS: This novel, sutureless, patch is a mucoadhesive platform suitable to laryngeal and tracheal anatomy with drug delivery capability. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1958-1966, 2021.

The impact of surgery on quality of life, esophageal motility, and tracheal anatomy and airflow in patients with benign nodular goiter.

Surgery - is it any good for goiter? In patients with goiter the benefits of thyroid surgery have previously rarely been investigated, as only few alternatives existed. However, the increasing evidence of the advantages with non-surgical substitutes with lower costs and preferable risk profiles prompted us to investi-gate the evidence base for thyroid surgery thoroughly. This thesis consists of three published studies investigating the impact of thyroidectomy on: 1) changes in disease-specific quality of life, 2) swallowing symptoms and esophageal motility, and 3) tracheal anatomy and airflow, in a cohort of patients with benign nodular goiter.

Modified-release recombinant human TSH (MRrhTSH) augments the effect of (131)I therapy in benign multinodular goiter: results from a multicenter international, randomized, placebo-controlled study.

BACKGROUND: Recombinant human TSH (rhTSH) can be used to enhance (131)I therapy for shrinkage of multinodular goiter (MG). OBJECTIVE, DESIGN, AND SETTING: The objective of the study was to compare the efficacy and safety of 0.01 and 0.03 mg modified-release (MR) rhTSH as an adjuvant to (131)I therapy, vs. (131)I alone, in a randomized, placebo-controlled, international, multicenter study. PATIENTS AND INTERVENTION: Ninety-five patients (57.2 ± 9.6 yr old, 85% females, 83% Caucasians) with MG (median size 96.0, range 31.9-242.2 ml) were randomized to receive placebo (group A, n = 32), MRrhTSH 0.01 mg (group B, n = 30), or MRrhTSH 0.03 mg (group C, n = 33) 24 h before a calculated activity of (131)I. MAIN OUTCOME MEASURES: The primary end point was a change in thyroid volume (by computerized tomography scan, at 6 months). Secondary end points were the smallest cross-sectional area of the trachea; thyroid function tests; Thyroid Quality of Life Questionnaire; electrocardiogram; and hyperthyroid symptom scale. RESULTS: Thyroid volume decreased significantly in all groups. The reduction was comparable in groups A and B (23.1 ± 8.8 and 23.3 ± 16.5%, respectively; P = 0.95). In group C, the reduction (32.9 ± 20.7%) was more pronounced than in groups A (P = 0.03) and B. The smallest cross-sectional area of the trachea increased in all groups: 3.8 ± 2.9% in A, 4.8 ± 3.3% in B, and 10.2 ± 33.2% in C, with no significant difference among the groups. Goiter-related symptoms were effectively reduced and there were no major safety concerns. CONCLUSION: In this dose-selection study, 0.03 mg MRrhTSH was the most efficacious dose as an adjuvant to (131)I therapy of MG. It was well tolerated and significantly augmented the effect of (131)I therapy in the short term. Larger studies with long-term follow-up are warranted.

Airway catastrophes.

PURPOSE OF REVIEW: The article reviews the epidemiology of airway injuries, airway anatomy, techniques for airway management, helpful pharmacologic adjuncts and finally alternatives to airway manipulation. RECENT FINDINGS: Principles of airway management including the maintenance of spontaneous ventilation and careful and adequate preparation for an alternative plan will always be important. Advances in pharmacologic agents provide a safer, more controlled environment through which the patient's compromised airway can be controlled. Recent publications add to the evidence that alternative methods of oxygenation and ventilation such as cardiopulmonary bypass can be used successfully to treat patients with catastrophic airway injuries. SUMMARY: Trauma to the airway, either blunt or penetrating or iatrogenic, can result in significant patient morbidity and mortality. Although, relatively rare, if we practice long enough, each of us will encounter such a patient. The anesthesiologist must be familiar with airway anatomy and the location of injury for successful treatment. Along with airway injuries, associated injuries are common and often complicate definitive airway treatment. Modern anesthetic medications such as dexmedetomidine and proven techniques such as awake fiberoptic intubation can be used to safely treat these difficult patients. Alternative therapies such as cricothyroidotomy and cardiopulmonary bypass should be available if first-line therapies fail to secure an injured airway.

An automatic video instillator for intratracheal instillation in the rat.

Intratracheal instillation (ITI) of a test compound is an alternative method to inhalation methods that require complex aerosol generation, exposure chambers and airflow monitoring instruments for exposing the lungs of animals to a test compound. For ITI in the rat, a laryngoscope is generally used for endotracheal intubation, and the procedure is difficult to perform. Therefore, we designed and constructed an automatic video instillator (AVI) for the accurate delivery of a dose of a test compound into the trachea of rats. The device has a videocamera probe for image guidance, and a liquid-crystal display for image display. These two items are used to visualize the larynx and trachea for intratracheal insertion of the tubing, and for placing the tip of the instillation tubing beyond the vocal cords for ITI of the test compound. After a 2 h training session on the use of the AVI in an anaesthetized rat, we assessed the utility of the device by ITI of 0.25% (w/v) solution of Evans Blue dye into the lungs of 30 isoflurane-anaesthetized rats. Necropsy examinations were performed on 20 rats immediately after the completion of the procedure, and on 10 rats three days after the procedure. Based on the results of these examinations, we concluded that the device could be used for rapid, reproducible and successful ITI of a test compound into the lungs of a rat by one operator.

Measurement of the linear and nonlinear mechanical properties of the oscine syrinx: implications for function.

We have measured the vibrational modes of the sound producing membrane in the syrinx of zebra finches and canaries. Excised syringes were driven with a frequency-swept acoustic pressure wave through the trachea, and the resulting vibrations measured using a laser interferometer. The frequency-dependent membrane compliance was measured at 10-20 different positions, giving a detailed picture of the linear vibrational modes of the two membrane components, the medial labium and the medial tympaniform membrane. Nonlinear properties of the membrane were determined by measuring the linear response at several superimposed static pressures. The membrane compliance is dominated by the lowest vibrational mode, a narrow mechanical resonance, at roughly 700 Hz in the zebra finch, that extends over the entire membrane. Several higher-frequency modes were also observed. The frequency of the lowest vibrational mode is determined largely by the mass of the heavier medial labium, rather than the thinner medial tympaniform membrane, suggesting that the medial labium is critical in determining the oscillatory frequency of the syrinx. The difference in mass of the medial labium and medial tympaniform membrane may serve to produce a wave-like motion of the membranes during flow-driven oscillations, thus increasing the efficiency of sound production. Implications for mechanisms of frequency tuning are discussed.

Lung growth response after tracheal occlusion in fetal rabbits is gestational age-dependent.

In utero tracheal occlusion (TO) is a potent stimulus of fetal lung growth, and is currently being applied in clinical trials to treat severe forms of pulmonary hypoplasia. The aim of this study was to examine the effect of timing of TO on pulmonary growth and maturation rates. Fetal rabbits (term = 31 d) were subjected to in utero tracheal clipping at 24 (late pseudoglandular stage) or 27 d of gestation (late canalicular/early terminal sac stage). Sham-operated littermates served as controls (C). Animals were killed at time intervals ranging from 1 to 6 d (early group) or 1 to 3 d (late group) after occlusion. Lung growth was measured by computerized stereologic volumetry and 5'-bromo-2'-deoxyuridine (BrdU) pulse labeling. Pneumocyte II population kinetics were analyzed using a combination of anti-surfactant protein-A and BrdU immunohistochemistry and computer-assisted morphometry. Statistical analysis was performed using unpaired Student's t test. Early TO was followed by an initial 3-d stagnation of growth and subsequently a dramatic acceleration of growth (BrdU-labeling index [LI] 10.1 +/- 0. 6% in TO versus 2.7 +/- 0.5% in C at 29 d, P < 0.001). In contrast, late TO induced an immediate and sustained moderate increase of lung growth (BrdU-LI 2.8 +/- 0.9% in TO versus 1.1 +/- 0.2% in C at 30 d, P < 0.05), associated with relatively more pronounced air-space distension. Whereas late TO caused no significant alterations in type II cell density or proliferation, early TO was followed by a marked increase in type II cell proliferation, paradoxically associated with dramatic reduction of type II cell density after 29 d. The effects of intrauterine TO on fetal lung growth and type II cell kinetics critically depend on the gestational age, and thus on the maturity of the lungs at the time of surgery. These findings have important clinical implications with respect to the timing of fetal interventions aimed at promoting lung growth. The fetal rabbit provides an invaluable model to study the mechanics and age dependency of TO-induced lung growth.

Responses of isolated Japanese monkey tracheal muscle to allergic mediators.

The responsiveness of isolated Japanese monkey (Macaca fuscata) tracheal muscle to antigen, carbachol, histamine, leukotriene C4 (LTC4), U-46619 and substance P (SP) was compared to that of isolated human trachea. Weak but persistent contraction was observed after the addition of antigen to isolated Japanese monkey tracheal muscle passively sensitized with monkey serum containing IgE antibody against Japanese cedar (Cryptomeria japonica) antigen. Unlike monkey tracheal muscle, a fair amount of contraction was caused by the antigen in human tracheal muscle passively sensitized with human atopic serum. When chopped, passively sensitized monkey or human lung tissue was challenged with antigen, a significant level of histamine was released from these tissues. In Japanese monkey tracheal muscle, histamine and SP produced no contraction of tracheal muscle, whereas carbachol, LTC4 and U-46619 caused contraction in a dose-dependent fashion. Contrary to the Japanese monkey, histamine and carbachol caused distinct contraction in tracheal muscle obtained from the cotton-headed tamarin (Saguinus oedipus). In human tracheal muscle, all test substances (carbachol, histamine, LTC4, U-46619 and SP) induced clear contraction. In lung parenchyma obtained from Japanese monkey, histamine induced a weak contraction, and this histamine-induced contraction was also inhibited by pyrilamine (H1 receptor antagonist). These results indicate that antigen-induced contraction of isolated Japanese monkey tracheal muscle, passively sensitized with monkey atopic serum, is not a useful model for human allergic bronchoconstriction in vitro because of the unresponsiveness of tracheal muscle to histamine and SP.