Massive pneumomediastinum following orotracheal intubation in an emergency setting

We admitted in our intensive care unit, a 34-year old, Female patient from the emergency room, with a hypothesis of COVID-19 disease, who was intubated before transportation due to hypoxemic respiratory insufficiency. In physical examination the patient showed a massive subcutaneous emphysema. A computed tomography confirmed the hypothesis of pneumomediastinum/pneumothorax (Figure 1A). Refractory hypoxemia issued despite optimized mechanical ventilation, so we opted to submit the patient to Extracorporeal Membrane Oxygenation (ECMO). A diagnostic bronchoscopy showed an important laceration of the trachea (Figure 1B, black arrow, and Figure 1C), near the carina. Despite rare, tracheal lesion after intubation may have a dramatic outcome.

Tracheal lesion during shoulder surgery: a case report and systemic review of the literature

Pneumomediastinum (PNM) and pneumothorax (PNX) are documented complications of arthroscopic shoulder surgery (ATS). Plexus anesthetic block and tracheal lesions during endotracheal intubation are hypothesized to be the underlying risk factors; however, the actual evidence supporting this hypothesis is scarce.A case of bilateral laterocervical emphysema, subcutaneous edema, and signs of PNM after ATS performed under general anesthesia and supra-scapular nerve block is presented. An up-to-date systematic review of PNM/PNX during orthopedic surgery was performed, involving six databases: PubMed (1996–present), Embase (1974–present), Scopus (2004–present), SpringerLink (1950–present), Ovid Emcare (1995–present), and Google Scholar (2004–present).Twenty-five case studies met the eligibility criteria. In 24 cases, the patient underwent general anesthesia and orotracheal intubation; in 9 of these, a plexus anesthetic block was also performed. One case involved ATS under plexus anesthetic block only. In 10 cases, the diagnostic finding was PNM. In 5 cases, the diagnostic finding was associated with PNX. PNX was detected in 17 cases. In 2 cases, SE was found in the absence of any evidence of either PNM or PNX. A tracheal lesion was identified in 3 cases.Endotracheal intubation and loco-regional anesthesia are not the only predisposing risk factors at play in the pathogenesis of PNM/PNX. Rather, multi-factorial pathogenesis seems more probable, necessitating that specific attention is paid during ATS to the change in patient position on the operating bed, to any slipping of the endotracheal tube, to patient monitoring whilst under the drapes, and to the cuff pressure. PROSPERO registration number: CRD42021260370.

Anatomopathological, ultrastructural, immunohistochemical and molecular characterization of infectious laryngotracheitis outbreaks in poultry farms in Egypt (2018–2020)

Infectious laryngotracheitis (ILT) is a severe respiratory disease, which causes high morbidity and mortality in affected birds. In our study, ILT were reported in 42 farms from nine governates over two years (2018–2020) that showed clinical signs of ILT including dyspnea, blood expectoration of, excessive lacrimation, rattling, conjunctivitis. The disease affected different chicken breeds and age groups despite vaccination with licensed and commonly used vaccines. Samples of larynx, trachea, lungs and air sacs were examined and collected for histopathological, ultrastructural, immunohistochemical examination and molecular detection. Gross examination of laryngeal and tracheal lumen revealed different types of exudate varied from catarrhal to fibrinonecotric, also pneumonia and airsacculitis were detected. Histopathological examination showed different alternation in larynx, trachea, lung and air sac as characteristic syncytial cells containing intranuclear inclusion body hanged in fibrinoheterphilic exudate that precent in laryngeal, tracheal, bronchial and parabronchial lumen and air sacs. Tracheal lesion scoring system was used to categorize the severity of lesion in different governates. Tracheal lesion score showed that 6.02%, 26.5%, 43.3% of the birds exhibited mild, moderate, and severe changes, respectively, while 24.18% of the birds exhibited very severe changes. Furthermore, severe cases were related to the Qalyubia , Fayoum then Sharkia Governorate. Moreover, immunohistochemistry was used to detect viral particles in syncytial cells, inflammatory cells beside epithelium of trachea and lung. Transmission electron microscopy enabled the detection of virus particles and demonstrated that heterophils could be infected. PCR targeting a region in the thymidine kinase gene and glycoprotein gJ gene confirmed the presence of infectious laryngotracheitis ILT virus-specific DNA. In conclusion, anatomopathological, immunohistochemical, molecular and ultrastructural findings showed increased of ILTV severity in Egypt. Larynx, trachea, lungs and air sac should be collected and examined that aid in diagnosis. Importance of good biosecurity level to be considered.

Tracheobronchopathia osteochondroplastica: a rare tracheal lesion in a free-ranging grizzly bear

A mature male grizzly bear ( Ursus arctos) that died of blunt-force trauma had numerous hard 1–3-mm nodules protruding from tracheal rings into the lumen of the distal trachea. Histologically, these were round aggregates of mature cartilage within the submucosa. Such lesions are consistent with tracheobronchopathia osteochondroplastica, a rare tracheal disease in humans and animals.

Chicken interferon gamma fold expression level and tracheal lesion score differences between commercial broiler chickens vaccinated with live and vectored ILT vaccines

Infectious laryngotracheitis (ILT) is a respiratory tract disease affecting chickens around the world. The disease generates severe production losses due to increased mortality, decreased egg production, delayed body weight gain, and a predisposition to other respiratory pathogens causing enormous economic losses to the intensive poultry industry. Two licensed vaccines, comprising live or vectored ILT, are available to control the disease. The present trial was conducted to determine changes in chicken interferon gamma fold expression levels in chicken spleens and to evaluate tracheal lesion scores before and after vaccination with live and vectored infectious laryngotracheitis vaccines. Broilers were kept under commercial conditions until 35 days of age. Spleen and trachea samples were taken at 14, 28, and 35 days of age. Tracheas were stained with H&E, histopathology was performed, and the INF-γ fold expression level in spleen samples was analyzed. In the spleens of birds vaccinated with the live ILT vaccine, the increase in INF-γ expression levels was statistically significantly (p < 0.01) lower at 28 days of age, or 7 days post vaccination, (trial 1) and higher at 35 days of age, or 14 days post vaccination, (both trials). At 7 days post vaccination with the live ILT vaccine, the mean tracheal lesion score was significantly higher (p < 0.01) than it was in the control group (both trials). At 14 days post vaccination with the live ILT vaccine, the mean tracheal lesion score was significantly higher (p < 0.05) than it was in the control group 3 (trial 1). No significant differences were found between the control group 3 and group 2, which was vaccinated with the vectored HVT/LT vaccine (both trials). The results of the histology of trachea lesions indicate that vaccination with live ILT may have induced early local immunity. The INF-γ analysis results might indicate that the birds in group 2 (HVT/LT) did not develop local immunity until 35 days of age From the practical point of view, the vectored ILT vaccine is more beneficial because of its ease of administration in the hatchery, lower labor cost, and the absence of clinical signs post vaccination. Its potential drawback, however, is poor local immunity and the slow onset of optimal immunity in commercial broiler chickens

Importance of flexible bronchoscopy in decannulation of tracheostomy patients

OBJECTIVE: To evaluate the importance of flexible bronchoscopy in tracheostomy patients in the process of decannulation to assess the incidence and types of laryngotracheal injury and compare the presence of such lesions with clinical criteria used for decannulation. METHODS: We studied 51 tracheostomized patients aged between 19 and 87 years, with tracheal stent for a mean of 46 ± 28 days and with clinical criteria for decannulation. They were submitted to tracheostomy tube occlusion tolerance testfor 24 hours, and then to flexible bronchoscopy. We described and classified the diagnosed laryngotracheal changes. We compared the clinical criteria for decannulation indication with the bronchoscopy-diagnosed laryngotracheal injuries that contraindicated decannulation. We identified the factors that could interfere in decannulation and evaluated the importance of bronchoscopy as part of the process. RESULTS: Forty (80.4%) patients had laryngotracheal alterations. Of the 40 patients considered clinically fit to decannulation, eight (20%) (p = 0.0007) presented with laryngotracheal injuries at bronchoscopy that contraindicated the procedure. The most frequent laryngeal alteration was vocal cords lesion, in 15 (29%) individuals, and granuloma, the most prevalent tracheal lesion, in 14 (27.5%) patients. CONCLUSION: flexible bronchoscopy showed a large number of laryngotracheal injuries, the most frequent being the vocal cords injury in the larynx and the granuloma in the trachea, which contributed to increase the decannulation procedure safety.