Life-Threatening Tracheal Diverticulum Rupture Following Laparoscopic Cholecystectomy: A Rare Case Report.

BACKGROUND We present an exceptional case of asystole and tracheal diverticulum rupture as a result of cardiopulmonary resuscitation (CPR) immediately following laparoscopic cholecystectomy performed at Riga 1st Hospital. Tracheal rupture after tracheal intubation is a severe but very rare complication that can be fatal. We present an incidental finding of the tracheal diverticulum and its rupture during CPR. CASE REPORT A 71-year-old woman (American Society of Anesthesiologists class II, body mass index 28.58) underwent a planned laparoscopic cholecystectomy. Preoperative chest X-ray showed no abnormalities. Endotracheal intubation was performed, with the first attempt with a 7-mm inner diameter cuffed endotracheal tube without an introducer. Five minutes after rapid desufflation of the pneumoperitoneum, severe bradycardia and hypotension occurred, followed by asystole. CPR was performed for a total of 2 min, until spontaneous circulation returned. Twenty hours after surgery, subcutaneous emphysema appeared on the chest. Computed tomography scan of the chest revealed subcutaneous neck emphysema, bilateral pneumothorax, extensive pneumomediastinitis, and a pocket-like, air-filled tissue defect measuring 10×32 mm in the distal third of the trachea, with suspected rupture. Two hours after the diagnosis was established, the emergent surgery was performed. The patient was completely recovered after 15 days. CONCLUSIONS Our case illustrates that tracheal diverticula is sometimes diagnosed by accident and too late, which then can lead to life-threatening situations. Tracheal rupture can be made not only by mechanical piercing by an endotracheal tube but also during interventions, such as CPR. Rapid desufflation of the pneumoperitoneum can lead to asystole, induced by the Bezold-Jarisch reflex.

Building and validating an artificial intelligence model to identify tracheobronchopathia osteochondroplastica by using bronchoscopic images.

BACKGROUND: Given the rarity of tracheobronchopathia osteochondroplastica (TO), many young doctors in primary hospitals are unable to identify TO based on bronchoscopy findings. OBJECTIVES: To build an artificial intelligence (AI) model for differentiating TO from other multinodular airway diseases by using bronchoscopic images. DESIGN: We designed the study by comparing the imaging data of patients undergoing bronchoscopy from January 2010 to October 2022 by using EfficientNet. Bronchoscopic images of 21 patients with TO at Anhui Chest Hospital from October 2019 to October 2022 were collected for external validation. METHODS: Bronchoscopic images of patients with multinodular airway lesions (including TO, amyloidosis, tumors, and inflammation) and without airway lesions in the First Affiliated Hospital of Guangzhou Medical University were collected. The images were randomized (4:1) into training and validation groups based on different diseases and utilized for deep learning by convolutional neural networks (CNNs). RESULTS: We enrolled 201 patients with multinodular airway disease (38, 15, 75, and 73 patients with TO, amyloidosis, tumors, and inflammation, respectively) and 213 without any airway lesions. To find multinodular lesion images for deep learning, we utilized 2183 bronchoscopic images of multinodular lesions (including TO, amyloidosis, tumor, and inflammation) and compared them with images without any airway lesions (1733). The accuracy of multinodular lesion identification was 98.9%. Further, the accuracy of TO detection based on the bronchoscopic images of multinodular lesions was 89.2%. Regarding external validation (using images from 21 patients with TO), all patients could be diagnosed with TO; the accuracy was 89.8%. CONCLUSION: We built an AI model that could differentiate TO from other multinodular airway diseases (mainly amyloidosis, tumors, and inflammation) by using bronchoscopic images. The model could help young physicians identify this rare airway disease.

[Tracheobronchial involvement in relapsing polychondritis and differential diagnoses]. / Atteinte trachéo-bronchique de la polychondrite atrophiante et diagnostics différentiels.

Relapsing polychondritis is a systemic auto-immune disease that mainly affects cartilage structures, progressing through inflammatory flare-ups between phases of remission and ultimately leading to deformation of the cartilages involved. In addition to characteristic damage of auricular or nasal cartilage, tracheobronchial and cardiac involvement are particularly severe, and can seriously alter the prognosis. Tracheobronchial lesions are assessed by means of a multimodal approach, including dynamic thoracic imaging, measurement of pulmonary function (with recent emphasis on pulse oscillometry), and mapping of tracheal lesions through flexible bronchoscopy. Diagnosis can be difficult in the absence of specific diagnostic tools, especially as there may exist a large number of differential diagnoses, particularly as regards inflammatory diseases. The prognosis has improved, due largely to upgraded interventional bronchoscopy techniques and the development of immunosuppressant drugs and targeted therapies, offering patients a number of treatment options.

Osteochondroplastic tracheobronchopathy: Four case reports. / Traqueobroncopatía osteocondroplástica: reporte de cuatro casos clínicos.

Introduction: Osteochondroplastic tracheobronchopathy is a rare benign chronic disease of unknown etiology. Bronchoscopy remains the gold standard for diagnosing osteochondroplastic tracheobronchopathy. Its typical findings are described as a cobblestone, rock garden, mountainscape, or stalactite cave appearance. The present work aims to show the main clinical features of this rare pathology. Clinical cases: The clinical data of four middle-aged patients, three men and one woman, were analyzed. The main clinical symptoms were chronic cough, dyspnea, and dysphonia. The patient's preliminary diagnosis was made by computed axial tomography of the chest, confirmed by bronchoscopy and histopathological examination. Treatment included medication for symptoms and, in one case, cryosurgery and argon plasma coagulation. Discussion: Diagnosing osteochondroplastic tracheobronchopathy was not easy, given its uncommon nature and non-specific symptoms often found in other pathologies. No case series articles on this pathology have been published in Peru. Therefore, we used the original articles published in other countries to reference our findings. Conclusion: Osteochondroplastic tracheopathy is a benign disease that typically affects adults. Men are more likely to be affected. Its clinical manifestations are non-specific and frequently of pharyngeal origin, and the cause is not yet defined. Chest computed axial tomography combined with bronchoscopy are the main diagnostic procedures. There is no standard treatment with consistent therapeutic effects.

Introducción: La traqueobroncopatía osteocondroplástica es una rara enfermedad crónica benigna de etiología desconocida. La broncoscopía sigue siendo el estándar de oro para el reconocimiento de traqueopatía osteocondroplástica. Sus hallazgos típicos se describen como un empedrado, un jardín de rocas, una apariencia de paisaje montañoso o de una cueva con estalactitas. El objetivo del presente trabajo es mostrar las principales características clínicas de una patología poco conocida. Casos clínicos: Se analizaron los datos clínicos de cuatro pacientes de mediana edad, tres fueron hombres y una mujer. Los principales síntomas clínicos fueron tos crónica, disnea, disfonía. Los pacientes tuvieron un diagnóstico preliminar mediante tomografía axial computarizada de tórax, confirmado por examen video broncoscópico e histopatológico. El tratamiento incluyó medicamentos para los síntomas y en un solo caso criocirugía y coagulación con argón plasma. Discusión: El diagnóstico de traqueobroncopatía osteocondroplástica no fue sencillo por ser una entidad rara, cuyos síntomas son inespecíficos y muy frecuentes en otras patologías. En Perú no se han publicado artículos de serie de casos sobre esta patología. Por lo tanto, tomamos como referencia artículos originales publicados en otros países para compararlos con nuestros hallazgos. Conclusión: La traqueopatía osteocondroplástica es una enfermedad benigna que predispone a los adultos, los hombres tienen más probabilidades de verse afectados. Sus manifestaciones clínicas son inespecíficas; frecuentemente de origen faríngeo y la causa no está aún definida. La tomografía axial computarizada de tórax combinada con video broncoscopía son los principales procedimientos para el diagnóstico. No existe un estándar de tratamiento con efectos terapéuticos consistentes.

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

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

A Systematic Review of Mortality Associations in Patients who Develop Tracheoinnominate Artery Fistula Following Tracheostomy.

OBJECTIVE: Tracheoinnominate artery fistulas (TIFs) are a rare but deadly complication of tracheostomy. Tracheoinnominate artery fistula cases in the literature were summarized in order to understand mortality associations. METHODS: MEDLINE was searched for studies reporting individual characteristics of patients with TIFs after tracheostomy, excluding cases without tracheostomy or with additional procedures at the tracheostomy site. This study followed PRISMA guidelines. RESULTS: 121 TIF patients from 18 case series and 46 case reports were included. The median age was 40 years, and 52.9% were male. The overall mortality rate was 64.5%. There were differences in mortality between cases that presented initially with vs without sentinel bleeding (odds ratio [OR] .34; CI [confidence interval] .16-.73; P = .006). The mortality rate also differed in whether or not the tracheostomy cuff was over-inflated for temporary hemostasis during resuscitation (OR 3.57 (CI 1.57-8.09); P = .002). Treatment compared to no treatment had lower mortality rates (OR .11 (CI 0.04-.32); P < .001); no differences were found if treatment was endovascular vs open surgical. CONCLUSIONS: Mortality is a major concern after detection of a TIF and resuscitation paired with endovascular or open surgical intervention is imperative. Rapidly investigating sentinel bleeds and intervening upon hemorrhage with temporary cuff over inflation may lead to improved outcomes.

Pediatric Tracheotomy Stomal Maturation and Tracheocutaneous Fistulas.

OBJECTIVE: The purpose of this study is to determine whether tracheostomy stomal maturation affects the risk of tracheocutaneous fistula (TCF) in children. METHODS: A retrospective chart review was conducted for all children who both underwent a tracheostomy and were decannulated between 2012 and 2021 at a tertiary children's hospital. Charts were analyzed for demographics, surgical technique, and development of a TCF. TCF was defined as a persistent fistula following 3 months after decannulation. RESULTS: 179 children met inclusion criteria. The median (interquartile range) age at tracheostomy was 1.5 (82.4) months, average (standard deviation [SD]) duration of tracheotomy was 20.0 (20.6) months, and length of follow-up after decannulation (range; SD) was 39.3 (4.4-110.0; 26.7) months. 107 patients (60.0%) underwent stomal maturation and 98 patients developed a TCF (54.7%). Younger age at tracheostomy placement was significantly associated with increased risk of TCF, mean (SD) age 28.4 (51.4) version 80.1 (77.5) months (p < 0.001). Increased duration of tracheostomy was significantly associated with increased risk of TCF, 27.5 (18.4) version 11.0 (18.2) months (p < 0.001). Stomal maturation was not significantly associated with the risk of TCF, including on multivariable analysis adjusting for age at tracheostomy and duration of tracheostomy (p = 0.089). CONCLUSION: Tracheostomy stomal maturation did not affect the risk of TCF in children, even after adjusting for age and duration of tracheostomy. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2941-2944, 2024.

Tracheobronchopathia Osteochondroplastica - to Biopsy or not to Biopsy? A Relook at The Rare Disease.

BACKGROUND: Tracheobronchopathia osteochondroplastica (TPO) is a rare idiopathic disease involving the tracheobronchial tree. It is mostly an incidental finding with non-specific clinical manifestations. It has typical bronchoscopic, radiological features and biopsy is usually considered non-essential. The study aimed to determine whether biopsy makes a difference in the management of patients. METHODS: All patients diagnosed with TPO in our institution over 15 years (2005 to 2020) were included in this study. Their medical records, chest computed tomography (CT), and bronchoscopy reports were retrospectively reviewed, and data were analysed. All the CT images were reviewed by a senior chest radiologist. RESULTS: From the 20,000 bronchoscopies and 260,000 CT thorax images obtained, 28 cases were diagnosed as TPO based on either bronchoscopy or radiology or both. Among the 19 cases diagnosed through bronchoscopy, 16 underwent a biopsy. In addition to TPO features, biopsy showed additional diagnoses in 6 cases. In 9 cases, TPO was not initially diagnosed by CT but by bronchoscopy. In 8 patients, TPO was diagnosed incidentally on CT performed for other reasons. On follow-up with the treatment of underlying/co-existing concomitant aetiologies, clinical improvement was noted in all patients. None of them progressed to respiratory failure or airway obstruction until the last follow-up. CONCLUSION: Among patients who underwent bronchoscopic biopsy of TPO lesions, 38% had biopsy results showing an alternative aetiology, which led to changes in the treatment plan for all these patients. Hence, a bronchoscopic biopsy of TPO lesions should be performed to rule out other aetiologies.

Tracheal injury following robotic thyroidectomy: A literature review of epidemiology, etiology, diagnosis, and treatment and 3 case reports.

Robotic thyroidectomy is one of the most advanced surgical procedures used to manage benign and malignant thyroid nodules. However, complication risks such as tracheal injury still exists. Tracheal injury in robotic thyroidectomy is difficult to detect and is one of the life-threatening complications. This study reviews the current literature on the tracheal injury following robotic thyroidectomy and also discusses our findings on 2060 cases of robotic thyroidectomy via Da Vinci Surgical System performed in our department and finally presents 3 cases treated in our center. PubMed and Web of Science database were searched using Medical Subject Headings (Mesh) related to "tracheal injury" and "robotic thyroidectomy". The search was conducted without publication date limits. We reviewed the literature and summarized common causes, diagnosis and therapeutic options of tracheal injury in robotic thyroidectomy, which has been described in comparison studies or retrospective studies. Tracheal injury is often diagnosed when patients suffer from dyspnea and usually leads to severe postoperative consequences. Tracheal injury can be suspected in all patients having subcutaneous emphysema, pneumomediastinum, pneumothorax or dyspnea after robotic thyroidectomy. Tracheoscopy is necessary to determine the location and size of tracheal injury. In patients whose condition is stable and the injury is contained, conservative treatment is feasible. Certainly, primary closure or tracheotomy is necessary for patients with serious respiratory difficulty or pneumothorax.

Flap of the sternocephalicus muscle in the repair of a partial defect in the trachea of a rabbit (Oryctolagus cuniculus)

Purpose: The current study aimed at evaluating the repair of a partial defect of the trachea with a muscle flap, an advanced technique that employs combined suture patterns. Methods: Sixteen healthy male New Zealand white rabbits were used as an experimental model. A partial defect in the trachea within the ventral region of the fourth to eighth tracheal ring was created. Subsequently, repair was initiated with a flap of the sternocephalicus muscle. The animals were divided into four groups for postoperative evaluation using clinical, tracheoscopic, and histopathological analyses. Each group was separated according to the time of euthanasia, programmed at interval of seven (G7), 15 (G15), 30 (G30), and 60 days (G60). Results: One animal from the G60 group died, whereas the other animals had good surgical recovery without serious changes in the breathing pattern. The major clinical signs observed were stridor and coughing. Tracheoscopy revealed secretions in the tracheal lumen, exuberant granulation, and stenosis. Histopathological analysis showed growth of the ciliary respiratory epithelium at the flap site 30 days after implantation. Conclusions: Partial repair showed satisfactory results owing to the anatomical location of the muscle, adequate vascular support, and structural and physiological maintenance without serious changes in the respiratory system.

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

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

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

BACKGROUND: Incomplete sealing of tracheal diverticula by a tracheal tube cuff during positive-pressure ventilation causes barotrauma but the concrete possibility of incomplete sealing has not been indicated. We aimed to assess the possibility of incomplete sealing in a simulated situation of tracheal intubation for patients with tracheal diverticula with tube fixation where the tracheal tube's vocal cord guide overlaps with the patient's vocal cord. METHODS: We retrospectively assessed the characteristics of tracheal diverticula based on thoracic computed tomography data in our institution from January 2018 to July 2020. Then, we assessed the structural parameters of three single-lumen tracheal tubes (Parker Flex-Tip [Parker Medical, Bridgewater, CT, USA], Portex Soft Seal [ICU Medical, San Clemente, CA, USA], and Shiley TaperGuard [Medtronic, Dublin, Ireland]; 6.0-8.0 mm inner diameter size) and simulated the positional relationships between tracheal diverticula and the tracheal tube during tracheal intubation where the vocal cord guide overlaps with the patient's vocal cord. We assessed each tube product's possibility of incompletely sealing tracheal diverticula and the possibility of unintended bronchial intubation. RESULTS: In 5,854 patients, the prevalence of tracheal diverticula was 5.7%. The mean (SD) length from the vocal cord to the distal end of the tracheal diverticula was 52.2 (12.8) mm. Tracheal tubes with length from the distal end of the tracheal cuff to the vocal cord guide of ≥ 70 mm had a low risk of incompletely sealing tracheal diverticula (< 5%) and length from the distal end of the tube to the vocal cord guide of ≤ 95 mm had a low risk of unintended bronchial intubation (< 5%). No products in this study satisfied both outcomes. CONCLUSIONS: Tube fixation, where the vocal cord guide overlaps with the patient's vocal cord, is associated with risk of incompletely sealing of tracheal diverticula depending on the tube's manufacturer and tube's inner diameter size, although it was not a high risk. The use of small inner diameter sized tube relative to patient's body size is high risk of incomplete sealing of tracheal diverticula. TRIAL REGISTRATION: This trial was prospectively registered at University Hospital Medical Information Network (UMIN). CLINICAL TRIAL NUMBER AND REGISTRY URL: UMIN000043317 (URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048055 ).

Rare and unexpected ventilation difficulties due to tracheal diverticulum: A case report.

RATIONALE: Tracheal diverticulum is a rare airway-related particular occurrence, and the forcible tube insertion may cause tracheal ruptures during tracheotomy. Therefore, fiberoptic bronchoscopy (FOB) should be used routinely on all patients undergoing tracheal intubation or tracheotomy. PATIENT CONCERNS: A 60-year-old male with laryngeal neoplasms was scheduled for partial laryngectomy using a suspension laryngoscope in July 2020. All operations were performed under general anesthesia through orotracheal intubation. Orotracheal intubation was a noninvasive procedure that could effectively control breathing. At the end of the surgery, the percutaneous tracheostomy was performed to maintain airway patency, facilitate spontaneous respiration, and remove the secretions. DIAGNOSES: At this moment, the tracheal diverticulum, located at the right posterolateral region of the trachea, became an unexpected airway-related particular occurrence, which led to tracheal tube placement difficulty, mechanical ventilation difficulty, and high airway pressure. INTERVENTIONS: Subsequently, the tracheal tube was repositioned, with placement again confirmed by the FOB. LESSONS SUBSECTIONS: Tracheal diverticulum is an infrequent cause of tube inserting difficulty for the tracheotomy, and FOB is the first option for patients with catheter placement difficulty and mechanical ventilation difficulty.