[Contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation]. / Kontaminatsiya operatsionnoi rany v zavisimosti ot varianta IVL pri rezektsii trakhei.

OBJECTIVE: To analyze contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation. MATERIAL AND METHODS: There were 976 patients. Circular tracheal resection was made in 396 of these patients. RESULTS: Overall postoperative morbidity was 15.7%, mortality - 0.8%. Bacteriological examination of surgical wound was performed before tracheotomy and after formation of anastomosis depending on the method of mechanical ventilation. Surgical field was sterile before tracheotomy in all cases, contamination was confirmed after tracheotomy in all patients. Minimal contamination was observed in case of apneic oxygenation (100 times less than volumetric mechanical ventilation or high frequency mechanical ventilation). In all cases, several species of pathogenic microorganisms were identified. The number of species was also minimal in case of hypnotic mechanical ventilation. CONCLUSION: Contamination does not directly affect the development of local purulent-inflammatory process. However, this factor should not be ignored and compliance with all preventive measures is required.

The Incidence of Laryngotracheal Stenosis in Neonates With a History of Ventilator-Associated Pneumonia.

OBJECTIVES/HYPOTHESIS: Neonatal patients requiring prolonged intubation are susceptible to both infection and laryngotracheal stenosis (LTS). This study investigated the effect of ventilator-associated pneumonia (VAP) on the development of LTS in neonates. STUDY DESIGN: Retrospective case-control study. METHODS: The incidence of LTS in neonates with VAP was compared with the incidence of LTS in matched intubated controls without VAP. Patients were treated at a tertiary-care medical center from 2004 to 2014. Eligible patient records were assessed for the development of LTS. Demographics, medical comorbidities, infection characteristics, and treatment variables were compared using unpaired t test or χ2 test. Statistical significance was set a priori at P < .05. RESULTS: When comparing the VAP patients with matched non-VAP controls, we found no significant differences in the incidence of LTS (VAP vs. non-VAP, 8.3% vs. 6.7%; P = .73). In subgroup analysis of the VAP cohort, LTS and non-LTS patients demonstrated similar VAP organisms on broncho-alveolar lavage (Klebsiella pneumoniae, Pseudomonas aeroginosa, Escherichia coli, methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, and Enterobacter). Additionally, within the VAP cohort, LTS and non-LTS patients showed similar gestational age (LTS vs. non-LTS, 31.3 days vs. 28.1 days; P = .22), birth weight (LTS vs. non-LTS, 1.6 kg vs. 1.2 kg; P = .33), and similar intubation duration (LTS vs. non-LTS, 37.8 days vs. 27.5 days; P = .52). CONCLUSIONS: In this neonatal cohort, VAP was not associated with an increased incidence of LTS. Given severity of the burden of LTS on the healthcare system, multi-institutional longitudinal investigation into contributing risk factors for neonatal LTS is warranted. LEVEL OF EVIDENCE: NA Laryngoscope, 130:2252-2255, 2020.

Laryngotracheal Microbiota in Adult Laryngotracheal Stenosis.

Laryngotracheal stenosis is an obstructive respiratory disease that leads to voicing difficulties and dyspnea with potential life-threatening consequences. The majority of incidences are due to iatrogenic etiology from endotracheal tube intubation; however, airway scarring also has idiopathic causes. While recent evidence suggests a microbial contribution to mucosal inflammation, the microbiota associated with different types of stenosis has not been characterized. High-throughput sequencing of the V4 region of the16S rRNA gene was performed to characterize the microbial communities of 61 swab samples from 17 iatrogenic and 10 adult idiopathic stenosis patients. Nonscar swabs from stenosis patients were internal controls, and eight swabs from four patients without stenosis represented external controls. Significant differences in diversity were observed between scar and nonscar samples and among sample sites, with decreased diversity detected in scar samples and the glottis region. Permutational analysis of variance (PERMANOVA) results revealed significant differences in community composition for scar versus nonscar samples, etiology type, sample site, groups (iatrogenic, idiopathic, and internal and external controls), and individual patients. Pairwise Spearman's correlation revealed a strong inverse correlation between Prevotella and Streptococcus among all samples. Finally, bacteria in the family Moraxellaceae were found to be distinctly associated with idiopathic stenosis samples in comparison with external controls. Our findings suggest that specific microbiota and community shifts are present with laryngotracheal stenosis in adults, with members of the family Moraxellaceae, including the known pathogens Moraxella and Acinetobacter, identified in idiopathic scar. Further work is warranted to elucidate the contributing role of bacteria on the pathogenesis of laryngotracheal stenosis.IMPORTANCE The laryngotracheal region resides at the intersection between the heavily studied nasal cavity and lungs; however, examination of the microbiome in chronic inflammatory conditions of the subglottis and trachea remains scarce. To date, studies have focused on the microbiota of the vocal folds, or the glottis, for laryngeal carcinoma, as well as healthy larynges, benign vocal fold lesions, and larynges exposed to smoking and refluxate. In this study, we seek to examine the structure and composition of the microbial community in adult laryngotracheal stenosis of various etiologies. Due to the heterogeneity among the underlying pathogenesis mechanisms and clinical outcomes seen in laryngotracheal stenosis disease, we hypothesized that different microbial profiles will be detected among various stenosis etiology types. Understanding differences in the microbiota for subglottic stenosis subtypes may shed light upon etiology-specific biomarker identification and offer novel insights into management approaches for this debilitating disease.

Molecular analysis of idiopathic subglottic stenosis for Mycobacterium species.

OBJECTIVES/HYPOTHESIS: Idiopathic subglottic stenosis (iSGS) is an unexplained obstruction involving the lower laryngeal and upper tracheal airway. Persistent mucosal inflammation is a hallmark of the disease. Epithelial microbiota dysbiosis is found in other chronic inflammatory mucosal diseases; however, the relationship between tracheal microbiota composition and iSGS is unknown. Given the critical role for host defense at mucosal barriers, we analyzed tissue specimens from iSGS patients for the presence of microbial pathogens. METHODS: Utilizing 30 human iSGS, 20 intubation-related tracheal stenosis (iLTS), and 20 healthy control specimens, we applied molecular, immunohistochemical, electron microscopic, immunologic, and Sanger-sequencing techniques. RESULTS: With unbiased culture-independent nucleic acid, protein, and immunologic approaches, we demonstrate that Mycobacterium species are uniquely associated with iSGS. Phylogenetic analysis of the mycobacterial virulence factor rpoB suggests that, rather than Mycobacterium tuberculosis, a variant member of the Mycobacterium tuberculosis complex or a closely related novel mycobacterium is present in iSGS specimens. CONCLUSION: These studies identify a novel pathogenic role for established large airway bacteria and provide new targets for future therapeutic intervention. LEVEL OF EVIDENCE: NA Laryngoscope, 127:179-185, 2017.

Bronchoscopic balloon dilatation for tuberculosis-associated tracheal stenosis: a two case report and a literature review.

BACKGROUND: Bronchoscopic balloon dilatation (BBD) is a common strategy in the treatment of bronchostenosis. However, the longer dilating time in each inflation cycle (approximately 3-5 min) without mechanical ventilation is not possible for the treatment of tracheal stenosis. CASE PRESENTATION: In this study, we reported our experience of BBD with shorter dilating time (10 s or 1 min) and intermittent ventilation for the repair of tuberculous-associated tracheal stenosis in two cases of our hospital. After the surgeries, the physical examinations and pulmonary function were tested. In case 1, the cough and dyspnea syndromes subsided, wheeze and strid or in lungs were remarkably reduced, tracheal lumen was considerably expanded and pulmonary function was improved following the treatment. For the case 2, her chest tightness, shortness of breath symptoms were alleviated after the treatment. The middle and lower trachea stenosis was dilated and patent, but the right main bronchus stenosis was slightly improved. No restenosis occurred in the two patients in 1 year outpatient follow-up. CONCLUSIONS: These findings suggest that our modification in BBD is safe and effective for treating this patient with tracheal stenosis caused by tuberculosis, but the longer-term effect of the surgery in a large number of patients with longer follow-up remains to be seen.

Bacterial biofilms and increased bacterial counts are associated with airway stenosis.

OBJECTIVES: Most airway stenoses are acquired secondary to the use of prolonged endotracheal intubation. Antibiotics have been shown to decrease local inflammation and granulation tissue formation in the trachea. However, antibiotic therapy is not 100% effective in preventing or treating granulation tissue formation. Development of bacterial biofilms may explain this finding. This study evaluates the difference between tracheal stenotic segments and normal trachea in terms of (1) presence of bacterial biofilms, (2) quantitative bacterial counts, and (3) inflammatory markers. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care academic medical center. SUBJECTS: A total of 12 patients were included in the study. Tissue from stenotic segments from 6 patients with airway stenosis undergoing open airway procedures were compared with tracheal tissue from 6 patients without airway stenosis undergoing tracheostomy. METHODS: Scanning electron microscopy for biofilm detection, quantitative polymerase chain reaction for quantitative analysis of bacterial count, and immunohistochemistry were performed for inflammatory markers transforming growth factor ß1 (TGF-ß1) and SMAD3. RESULTS: Compared with the patients without airway stenosis, patients in the airway stenosis group showed presence of bacterial biofilms, a significantly higher expression of 16S rRNA gene copies per microgram of tissue (187.5 vs 7.33, P = .01), and higher expression of TGF-ß1 (91% vs 8%, P < .001) and SMAD3 (83.5% vs 17.8%, P < .001). CONCLUSION: Bacterial biofilms, increased bacterial counts, and higher expression of TGF-ß1 and SMAD3 are associated with airway stenosis.

Biofilm accumulation on endotracheal tubes following prolonged intubation.

OBJECTIVE: To demonstrate that patients who have been intubated for prolonged periods of time will have an increased likelihood of developing bacterial biofilm on their endotracheal tubes. METHODS: We collected endotracheal tubes from patients at the time of extubation, and analysed representative sections with scanning electron microscopy for morphologic evidence of biofilms. RESULTS: From September 2007 to September 2008, 32 endotracheal tubes were analysed with electron microscopy. Patients who had been intubated for 6 days or longer had a significantly higher percentage of endotracheal tubes that exhibited bacterial biofilms, compared with patients intubated for less than 6 days (88.9 versus 57.1 per cent, p = 0.0439). CONCLUSIONS: Longer duration of intubation is associated with a higher incidence of bacterial biofilm. Further research is needed to link the presence of bacterial biofilms to acquired laryngotracheal damage.

Bacterial tracheobronchitis. A rare cause of adult airway stenosis.

Bacterial tracheobronchitis is a rare cause of airway stenosis in adults. This report describes a 73-year-old woman with a recent history of polysialadenitis, who presented with severe airway obstruction due to infection and stenosis of tracheal and bronchial tissue. Tissue culture of the bronchial mucosa showed growth of methicillin resistant Staphylococcus epidermidis (MRSE). Sputum culture showed growth of MRSE, Pseudomonas aeruginosa, Enterobacter cloacae and Enterococcus faecalis; the same organisms were cultured from the salivary glands. Tracheostomy and antibiotic therapy were effective in controlling the disease.

Pseudomembranous aspergillus tracheobronchitis superimposed on post-tuberculosis tracheal stenosis.

Pseudomembranous aspergillus tracheobronchitis superimposed on post-tuberculosis tracheal stenosis has not been previously reported. In the patient described in this case report, the airway obstruction was worsened by aspergillus infection which responded to antifungal therapy and debridement of pseudomembranous tissues by rigid bronchoscopic procedures. A silicone stent was successfully placed in the trachea to restore airway patency when there was no more evidence of tracheobronchial aspergillosis. This case raises the questions of whether, how and when to restore airway patency in patients with tracheal stenosis and concurrent aspergillus tracheobronchitis.

[Causes of benign central airway stenoses and the efficacy of interventional treatments through flexible bronchoscopy].

OBJECTIVE: To analyze the causes of benign central airway stenoses and to evaluate the efficacy of interventional treatments through flexible bronchoscopy. METHODS: Three hundred and eighty-six outpatients and inpatients with benign central airway stenoses in our hospital from January 1999 to December 2006 were retrospectively analyzed. Interventional treatments through flexible bronchoscopy were used to treat the benign central airway stenoses. The endoscopic interventional treatments included laser, electrocautery, argon plasma coagulation, cryotherapy, balloon dilation and stent insertion. Airway diameters, FEV1 and dyspnea index of patients were evaluated before and immediately after the last treatment procedure. RESULTS: The main causes of benign central airway stenoses were as follows: tuberculosis in 64.25% (248/386), secondary to prolonged orotracheal intubation or tracheotomy in 15.03% (58/386), injury in 3.63% (14/ 386) and inhalation burns in 3.11% (12/386), others were 54 cases. All the 386 patients received endoscopic interventional treatments. 89.89% (347/386) of the patients experienced improvement in dyspnea and cough. The average airway diameter increased from (2.49 +/- 1.57) mm to (6.41 +/- 1.70) mm (t = 47.427, P < 0.01). Dyspnea index decreased from 2.40 +/- 0.79 to 0.64 +/- 0.50 (t = 44.226, P < 0.01). The average value of FEV1 evaluated in 115 inpatients increased from (2.11 +/- 0.60) L to (3.46 +/- 0.75) L (t = 20.128, P < 0.01). Most patients needed multiple interventional treatments except 26 patients who received a single endoscopic treatment. Stable control of the diseases was achieved in 65.54% (253/ 386) patients 3 months after the last operation. CONCLUSION: Tuberculosis is the most common cause of benign central airway stenoses in this series. Utilization of interventional methods through flexible bronchoscopy is effective in treating benign central airway stenoses.

Tuberculous tracheobronchial stricture causing post-pneumonectomy-like syndrome corrected by insertion of a bespoke Dumon stent.

Post-pneumonectomy syndrome is a well-recognised but uncommon late complication of pneumonectomy. Usually occurring after right-sided surgery, the mediastinal contents are rotated and displaced into the right hemithorax, producing airways or oesophageal compression. We report a case in which the radiological features and symptoms of post-pneumonectomy syndrome appeared to be precipitated by the development of a complex tuberculous tracheobronchial stenosis that resolved after the insertion of a bespoke Dumon stent.

Matrix metalloproteinase-1 polymorphism in Taiwanese patients with endobronchial tuberculosis.

Endobronchial tuberculosis (TB) often leads to some degree of tracheobronchial stenosis. Because matrix metalloproteinases (MMPs) play an essential role in tissue remodeling in the airways, we investigated the role of MMP-1 polymorphism in patients with endobronchial TB. One hundred and one cases of pulmonary TB in Taiwanese patients were genotyped for the 1G/2G polymorphism of MMP-1 promoter (-1607 bp). Bronchoscopic examination was performed to determine the presence of endobronchial involvement. Levels of MMP-1 in peripheral blood monocytes and in bronchial biopsies were also determined. 1G genotypes of MMP-1 polymorphism, containing at least one 1G allele, were associated with the presence of endobronchial TB. Using multivariate analysis, 1G genotypes and female gender were independent predictors of the development of endobronchial TB. Endobronchial TB patients with 1G genotypes had a 9.86-fold greater risk of developing tracheobronchial stenosis. IL-1beta increased levels of MMP-1 in peripheral blood monocytes of TB patients with 1G genotypes. MMP-1 activity was also present in the endobronchial TB granuloma from patients with 1G/1G genotype. 1G genotypes of MMP-1 polymorphism were associated with a greater risk of developing tracheobronchial stenosis through up-regulation of MMP-1 activity.

[Balloon dilation using fiberoptic bronchoscope in the management of bronchial stenosis due to tuberculosis].

OBJECTIVE: To investigate the safety and efficacy of balloon dilation using fiberoptic bronchoscope in the management of bronchial stenosis due to tuberculosis. METHODS: The clinical data and long term follow-up results of 25 patients with bronchial stenosis due to tuberculosis who had received balloon dilation using a fiberoptic bronchoscope were retrospectively analyzed. Before the procedure and immediately after the last operation, airway diameters were estimated in all patients. RESULTS: Two to seven operations were required to achieve satisfactory dilatation. After balloon dilatation, the average airway diameter increased from (2.8 +/- 1.1) mm to (6.7 +/- 2.3) mm (t = 5.471, P < 0.05). No complications occurred during inflation among all patients. After 2 to 36 months follow-up, no re-stenosis appeared. Sixteen patients were followed for more than 1 year, and the average airway diameter was (5.5 +/- 2.0) mm 1 year after the last balloon dilation. There was a significant difference compared with the average airway diameter before dilation (t = 2.834, P < 0.05). However, there was no significant difference as compared with the average airway diameter after the last balloon dilation. Of 11 patients with atelectasis, the atelectasis completely resolved after balloon dilation in 2 cases. CONCLUSION: Balloon dilation using fiberoptic bronchoscope is an effective, safe, and simple method for treatment of bronchial stenosis due to tuberculosis.

[Microbiological monitoring in prophylaxis and treatment of pyoinflammatory complications during early postoperative period in patients with cicatricial tracheostenosis].

The species composition and antibiotic susceptibility of microflora isolated from patients with cicatricial tracheostenosis (CTS) and infectious processes were investigated. Schemes for the treatment of CTS with an account of the pathogen species and multidrug resistant staphylococcal infection are described. Comparative efficacy of the combined schemes (antibiotic + bacteriophage) for the therapy of pyoinflammatory processes in the patients with CTS and the efficacy of the treatment of the patients with CTS according to the traditional antibacterial schemes were studied.

[Active tracheo-bronchial caseous tuberculosis. Ten patients]. / La tuberculose active caséeuse trachéo-bronchique. A propos de 10 cas.

BACKGROUND: We report 10 cases of active endobronchial tuberculosis in female patients. PATIENTS AND METHODS: Diagnosis of endobronchial tuberculosis was established by demonstrating the presence of Koch bacilli in the bronchial washings or at pathology examination of a bronchial mucosa biopsy. Follow-up was available for 5 of the 10 cases. RESULTS: These women were aged 19 to 756 years. Clinical signs included persistent cough (n=10), wheezing (n=10), dyspnea (n=5), dysphonia (n=4) and fever (n=8). Chest x-ray was normal in 4 cases but showed condensation in 4 others with infiltration of the superior lobe in 2 cases. Bronchoscopy findings were characteristic with a thick layer of white caseum on the mucosa. Koch bacilli were found in all bronchial wash specimens. Pathology examination confirmed the diagnosis of tuberculosis in 5 of the 10 cases.

Resultados del uso de tubo de Montgomery / Results using the Montgomeryïs T-tube

Los autores presentan tres casos clínicos de uso de tubo T de Montgomery en pacientes con lesiones extensas de tráquea que estaban fuera del manejo quirúrgico. Dos de ellos eran pacientes adultos con estenosis parciales; un caso corresponde a un niño con estenosis total, en que se efectuó reconstrucción laringotraqueal con hueso hioides. Todos lograron ser extubados y evolucionaron favorablemente, desarrollando las mismas actividades diarias que desempeñaban previo a la aparición de su patología, con pruebas de función respiratoria aceptables