Primary tracheal non-Hodgkin's lymphoma. A case report and review of the literature

BACKGROUND: Primary tracheobronchial non-Hodgkin's lymphoma (NHL) is an uncommon occurrence. The authors report a patient who presented with primary tracheal NHL, the sixth such patient described in the literature. METHODS: Using a MEDLINE search, 41 additional patients presenting with symptomatic primary or secondary tracheobronchial NHL were identified. The characteristics, management, and outcome of these patients are described. RESULTS: Patients with NHL of the upper respiratory tract present with dyspnea, wheezing, and cough, and frequently are misdiagnosed as having asthma. The majority of patients have additional sites of intrathoracic disease with tracheobronchial involvement occurring in the setting of advanced or relapsed NHL. Low grade histology is seen most commonly in patients with primary tracheal NHL. Several patients demonstrate the typical histologic features of mucosa-associated lymphoid tissue. Surgery, chemotherapy, and radiation therapy have been used alone or in combination for treatment. The outcome of these patients does not appear different from that observed in patients with lymphomas of similar histology and stage that do not involve the tracheobronchial tree. CONCLUSIONS: Thoracic surgeons, pulmonologists, and oncologists should recognize that NHL can rarely be confined to the trachea or bronchi. NHL should be considered in the differential diagnosis of airway obstruction, because it represents a highly treatable malignancy.     

The clamshell approach for the surgical treatment of complex cardiopulmonary pathology in infants and children

BACKGROUND: The surgical approach to children with complex cardiovascular and pulmonary anomalies is still controversial. Staged operations through multiple incisions are often performed in this setting. OBJECTIVE: The different applications and clinical advantages of a bilateral thoracosternotomy approach to complex cardiothoracic disease requiring surgical repair were reviewed retrospectively. METHODS: Between January 1993 and June 1995, 33 patients, aged between 2 months and 17 years (mean 7.8 +/- 5.3) underwent surgical treatment of complex cardiovascular or pulmonary disease using a clamshell approach. Twenty-one patients (64%) had undergone 1-5 previous surgical procedures (mean 2.5 +/- 1.0/patient). The technique involved supine position placement, submammary incision, access to the pleural space bilaterally through the fourth intercostal space and transverse division of the sternal body. RESULTS: Four groups of patients were operated on via this approach: (1) patients undergoing lobar, lung or heart-lung transplantation (40%); (2) patients undergoing repair of tetralogy of Fallot/pulmonary atresia (36%); (3) patients with previously corrected miscellaneous procedures (12%), including completion of Fontan, one-stage repair of left main bronchial stenosis and atrial septal defect, one-stage repair of partial anomalous pulmonary venous connection and aortic coarctation, and repair of congenital pulmonary venous stenosis. There were two early (< 30 days) deaths, giving a perioperative mortality of 6% for the entire series. Complications included postoperative hemorrhage in 4 patients (12%), prolonged ventilation time due to mechanical failure in 4 (12%). There were no wound infections. Analysis of complications by group showed the lung transplant group to be more affected (18% of patients experienced complications). Except for 2 infants undergoing complete unifocalization and presently awaiting completion of repair of tetralogy of Fallot/pulmonary atresia, in the remaining 31 (94%) a definitive surgical treatment could be performed in one-stage. CONCLUSIONS: The bilateral thoracosternotomy allows optimal exposure of all intrathoracic anatomic structures making one-stage surgical repair possible in a variety of complex cardiovascular and pulmonary anomalies. Early mortality and technique-related morbidity do not differ from those reported with the conventional approaches to the different disease conditions. A wider application of the clamshell approach for the management of complex intrathoracic pathology in infants and children is advocated.     

Tracheoplasty with an intercostal pedicle flap for tracheal neurilemmoma--a case report

PURPOSE: Negative pressure pulmonary oedema (NPPE) is a well-recognized but rare complication secondary to upper airway obstruction such as laryngeal spasm during emergence from general anaesthesia. Cauterization of the second and third thoracic sympathetic ganglia is a treatment for hyperhidrosis of the hands. We report a case of NPPE induced by direct suctioning of the endotracheal tube adapter during thoracic sympathetic ganglionectomy without recognized upper airway obstruction. CLINICAL FEATURES: A 19-yr-old otherwise healthy, non-smoking man was scheduled for elective bilateral chest endoscopic ablation of the second and third thoracic sympathetic ganglion for hyperhidrosis of the hands under general anaesthesia. To view and cauterize the ganglion with the endoscope, the surgeon requested cessation of positive pressure ventilation. As the surgeon could not satisfactorily visualize the target ganglia, he requested brief application of wall suction via the ETT tube adapter. A pressure of -100 mmHg was generated which lasted for three to four seconds. The goal was to reduce further the lung volume by increasing the pneumothorax produced by the endoscope. The patient developed negative pressure pulmonary oedema without upper airway obstruction. CONCLUSION: This case demonstrated that intrathoracic negative pressure generated by direct ETT adapter suctioning may produce pulmonary oedema similar to that induced by laryngeal spasm during the emergence of general anaesthesia.     

Evaluation of patients with sleep apnea after tracheotomy

OBJECTIVE: To determine the effect of tracheotomy on polysomnographic and arterial blood gas data in patients with obstructive sleep apnea (OSA). DESIGN: A retrospective study of all patients who underwent tracheotomy and were studied polysomnographically at the Johns Hopkins Sleep Disorders Center, Baltimore, Md, since 1981. SETTING: A regional sleep disorders center. PATIENTS: Twenty-eight patients (8 women and 20 men), aged 22 through 77 years. Patients were categorized into 2 groups on the basis of whether they had already undergone tracheotomy before polysomnography. Group 1 patients all had a polysomnographic diagnosis of OSA before tracheotomy. They were further subdivided on the basis of whether cardiopulmonary decompensation had been absent (group 1a, n=10) or present (group 1b, n=13). Group 2 patients (n=5) had undergone tracheotomy to treat upper airway obstruction that developed after non-apnea-related upper aerodigestive tract surgeries. INTERVENTION: Tracheotomy. MAIN OUTCOME MEASURES: Nocturnal non-rapid eye movement, apnea-hypopnea index, percentage oxyhemoglobin saturation, and arterial blood gas data. RESULTS: Patients with OSA underwent tracheotomy as definitive treatment for the apnea (n=15), to prevent postoperative upper airway compromise after uvulopalatopharyngoplasty (n=7), and to treat upper airway compromise after non-apnea-related upper aerodigestive tract surgeries (n=6). Tracheotomy alleviated apnea in all 10 patients with uncomplicated sleep apnea (group 1a). For patients with OSA complicated by cardiopulmonary decompensation (group 1b), tracheotomy improved but did not eliminate sleep apnea in 7 of the 13 patients, despite overall improvement in arterial blood gas values. For patients whose sleep apnea had not been diagnosed polysomnographically before tracheotomy (group 2), tracheotomy was still required to treat OSA that had previously not been recognized. CONCLUSIONS: Tracheotomy effectively treated patients with uncomplicated OSA, but was much less effective in treating patients with OSA and cardiopulmonary decompensation. In patients who underwent tracheotomy in conjunction with other upper aerodigestive tract surgeries, concomitant obstructive sleep apnea often required continued use of a tracheotomy to maintain upper airway patency.     

Self-expanding nitinol stents for treatment of bilateral main bronchial stenosis caused by esophageal cancer]

A 68-year-old man was admitted because of dyspnea. Nine months earlier, he had undergone radiotherapy for esophageal carcinoma. Chest CT scan obtained on admission showed a tumor shadow behind the tracheal carina. Bronchoscopy revealed that the lower trachea and bilateral main bronchi were compressed from the back and narrowed by the esophageal cancer. To maintain the airway, under fluoroscopic and guide-wire control, a self-expanding nitinol stent (SENS, Accuflex, Microvasive) was implanted in the lower trachea and left main bronchus. At the same time, other SENS was similarly implanted in the lower trachea and right main bronchus. During the implantation, the left nitinol stent was connected to the side of the right nitinol stent to form a T-shape. There was little sputum at the joint portion of the stents and the ventilation of both lungs remained adequate. Severe dyspnea markedly improved after placement of two nitinol stents. Knitted SENS is made of a nickel titanium alloy. SENS was formulated for use in the management of biliary obstruction. However, it is highly flexible and easy to implant. So, it is suitable for the treatment of airway obstruction. Although the implantation of SENS in extensive tracheobronchial stenosis has not previously been reported, it should be useful for prevention of airway obstruction.     

Pulmonary sling: morphological findings. Pre- and postoperative course

Pulmonary sling (PS) is a congenital condition in which the left pulmonary artery (LPA) arises from the right pulmonary artery (RPA), forming a sling around the trachea causing tracheal compression. The incidence is not so rare as initially thought. Symptoms of severe airway obstruction often begin in the newborn or young infant. Echo-colour-Doppler may reveal the PS but emphysema can mask the typical findings. Deviation of fluid-filled lungs may be detected prenatally. Chest radiographs show unusual air distribution, deviation of heart and mediastinum and altered tracheobronchial angles. Bronchography and bronchoscopy demonstrate the high incidence of associated tracheal anomalies such as cartilagenous rings and long tracheal stenosis. Anterior oesophageal indentation is not always seen in the oesophogram. Magnetic resonance imaging (MRI) and computed tomography (CT) reveal the PS, but cautious interpretation is necessary because of different levels of the anomalous LPA. PS and associated cardiovascular malformations can be clearly detected by angiography. Associated extrathoracic anomalies are common. Early diagnosis and therapy of PS is mandatory and consists of reimplantation of the LPA into the pulmonary trunk and division of the ligamentum arteriosum. The postoperative course may be cumbersome necessitating bronchological interventions. Tracheal resection may be necessary but restenosis is frequent. A one-stage repair has been proposed in such cases and was successfully done in a few reported cases. Relief of respiratory obstruction is often complete when there are no associated tracheobronchial anomalies. Late postoperative course is favourable but respiratory obstructive attacks may occur with decreasing incidence over time and tracheal growth.     

Wortmannin-sensitive activation of p70S6-kinase and MAP-kinase by the G protein-coupled receptor, G/CCKB

OBJECTIVE: To determine whether emergency rigid bronchoscopic intervention, including Nd-YAG laser resection or stenting, immediately affected the need for continued mechanical ventilation or intensive care level of support in critically ill patients with acute respiratory failure from malignant or benign central airways obstruction. DESIGN: Retrospective review of medical records of all patients with acute respiratory failure and malignant or benign tracheobronchial obstruction necessitating intubation, mechanical ventilation, or hospitalization in the ICU prior to referral for therapeutic bronchoscopy. SETTING: University of California San Diego, a tertiary care institution specialized in airway management. PATIENTS: Medical records of 32 patients with malignant or benign central airways obstruction requiring admission to the ICU prior to rigid bronchoscopic intervention between January 1994 and April 1996. INTERVENTIONS: Emergent rigid bronchoscopy with dilatation, Nd-YAG laser resection, or silicone stent insertion performed in the operating room under general anesthesia. RESULTS: Thirty-two patients with central airways obstruction requiring emergent hospitalization in the ICU were referred for therapeutic rigid bronchoscopy. Airway strictures were caused by benign disease in 18 patients, and by primary bronchogenic lung cancer in 14. Of the 19 patients who were mechanically ventilated, bronchoscopic intervention allowed immediate discontinuation of mechanical ventilation in 10 (52.6%). Twenty-five patients had indwelling artificial airways (12 endotracheal tubes, 13 tracheotomy tubes). Two, however, were considered tracheotomy-dependent because of neuromuscular disease. Of the remaining 23 patients, immediate extubation or decannulation was possible in seven (30.4%). Of seven patients with no indwelling airway, five (71.4%) were immediately transferred to a lower level of care after intervention. Of the 32 total patients, 20 (62.5%) were immediately transferred to a lower level of care immediately after intervention. CONCLUSIONS: Emergency laser resection or stent insertion can favorably affect health-care utilization in patients with acute respiratory distress from central airways obstruction. Treatment may be lifesaving and allows successful withdrawal from mechanical ventilation, hospitalization in a lower level of care environment, relief of symptoms, and extended survival in critically ill patients. In patients with regionally advanced cancer, the palliative nature of this procedure postpones death by respiratory distress and may prompt consideration for institution of conservative comfort measures to reduce patient suffering.     

Left pulmonary artery sling: diagnosis and delineation of associated tracheobronchial anomalies with MR

BACKGROUND: The left pulmonary artery sling anomaly (SLPA) has generated controversy about its diagnosis, imaging and management particularly with regard to associated tracheobronchial anomalies. Objective. To evaluate the role of MR imaging in defining airway and vascular relationships in SLPA. MATERIALS AND METHODS: Retrospective review of the imaging and clinical records of three children with SLPA who underwent MRI including three dimensional image reconstruction. MR was compared and correlated with other imaging methods: plain chest radiographs (3); bronchoscopy (3); barium esophagram (1); echocardiography (2); cineangiography (2). RESULTS: MRI was vastly superior to other methods for clearly depicting airway and vascular anatomy and interrelationships. Good quality imaging and safe sedation was easily achieved in young infants. MR also provided accurate noninvasive evaluation of the reconstructed pulmonary artery and airway postoperatively. CONCLUSION: MR is capable of differentiating the two subtypes of SLPA. Specific delineation of vascular and airway anatomy and spatial relationships is essential for surgical management: reimplantation of LPA in type I and both LPA reimplantation and airway reconstruction in type II because of associated long segment airway stenosis.     

Intramuscular capillary-venous angioma extending into the infratemporal fossa. Apropos of a case]

Tracheobronchial ruptures are rare but potentially lifethreatening events. We report on the case of a 34-year-old suicidal unrestrained car driver, who developed subcutaneous and mediastinal emphysema and right-sided haematothorax following blunt thoracic trauma. Fibreoptical inspection of the tracheobronchial system revealed a rupture (approximately 2 cm in length) of the pars membranacea of the trachea ending shortly above the carina. CT-scan confirmed the diagnosis of mediastinal emphysema, tracheal rupture and, in addition, left-sided pulmonary contusion. A repair of the tracheal tear was performed by right-sided thoracotomy using a double-lumen tube. The left-sided double-lumen tube was used postoperatively to achieve respirator ventilation with low pressure on the tracheal lumen and on the suture of the tracheal tear. On the other hand, sufficient airway pressure with PEEP for the left lung showing contusion could be provided, using the endobronchial tube. The postperative course was without complications. The patient was on respiratory support for three days due to his-pulmonary contusion. Following final endoscopic control of the trachea he was discharged from the ICU one week after the trauma. The clinical and radiological signs of tracheobronchial ruptures are discussed (respiratory distress, haemoptysis, cyanosis, localised pain, hoarseness, coughing, dysphagia, stridor, subcutaneous emphysema and pneumothorax, tension pneumothorax, mediastinal emphysema). Fibreoptic bronchoscopy is the present gold standard for confirming the diagnosis. The surgical and anaesthesiological approach to the management of tracheobronchial ruptures is described reviewing the current literature.     

Stent implantation as a palliative therapeutic measure in stenosing tumors of central airways

PURPOSE: Stent implantation was used to treat patient with malignant tracheobronchial obstructions to determine the effectiveness in producing symptomatic palliation. METHODS: 18 patients (15 men and three women; median age 57 years) with malignant tracheobronchial stenosis were treated by application of metal stents (15 Palmaz-, 10 Gianturco-, 4 Wallstents). The indication for stent implantation was given in 13 patients by clinically significant dyspnea, besides in 5 patients by therapy resistant postobstructive pneumonia. RESULTS: In 17 patients correct positioning of the stents was achieved and the symptoms completely disappeared until tumor related death. Median survival was 137 days (min. 10 days to max. 322 days). In one patient symptoms recurred three months after stent implantation. CONCLUSION: The application of metal stents in patient with malignant tracheobronchial obstruction appears to be a useful palliation procedure. The treatment was well tolerated and very effective.     

Comparison of tissue reactions in the tracheal mucosa surrounding a bioabsorbable and silicone airway stents

BACKGROUND: Treatment of tracheobronchial stenosis is problematic. Conservative methods include stenting the stenotic area, but an ideal stent has not yet been developed. Bioabsorbable airway stents offer benefits; the extraction of the device is unnecessary, and the airway preserves its normal function after stent resorption. The aim of this study was to examine the suitability of self-reinforced poly-L-lactide as a material for an airway stent. METHODS: A spiral airway stent made of 0.7-mm wire of self-reinforced poly-L-lactide was implanted operatively in 9 rabbits intratracheally; silicone stents served as controls. RESULTS: Silicone stents had a tendency to become stenosed with encrustation material and to develop a hyperplastic polyp at both ends. Self-reinforced poly-L-lactide stents were well tolerated and caused no foreign body reaction, and they had a tendency to penetrate into the tracheal wall. They had disappeared at the end of the follow-up of 10 months. CONCLUSIONS: This experimental study showed that bioabsorbable self-reinforced poly-L-lactide is a promising material for an airway stent for treatment of airway stenosis.     

Phantom study of optimization of spiral-CT and 3D reconstruction of the tracheobronchial system

PURPOSE: To optimise three-dimensional spiral CT of the tracheobronchial tree using adequate acquisition and reconstruction parameters for spiral CT of the chest. MATERIAL AND METHODS: Qualitative and quantitative assessment of different 3 D reconstructions of two test objects of the tracheobronchial tree depending on section thickness, reconstruction interval, pitch, and reconstruction algorithm used in spiral CT (Siemens, Somatom plus S) of the chest. The frequency of volume and stairstep artifacts was evaluated. The 3 D reconstructions were generated using a seeded VOI-technique (Allegro, ISG). RESULTS: Reduction of artifacts was achieved by decreasing section thickness. Increasing overlap of source images, lowering the pitch factor, and application of the reconstruction algorithm "slim". Section thickness was the single most important factor which was mainly responsible for the occurrence of volume artifacts. Stairstep artifacts were primarily influenced by the reconstruction interval. CONCLUSION: Spiral CT with a section thickness > 4 mm is not adequate for 3 D reconstructions of the tracheobronchial tree. Overlapping source images with a pitch of 1 and the reconstruction algorithm "slim" can be recommended to reduce artifacts.     

False-positive cytological diagnosis of lung carcinoma in patients with pulmonary infarcts

Cytological examination of specimens obtained from the tracheobronchial tree has become an integral part of the evaluation of pulmonary lesions. Cytological criteria for the diagnosis of carcinoma exist and are well defined. Certain benign processes, however, may possess features strongly suggestive of carcinoma of the lung. We report 3 patients in whom a positive cytological diagnosis of carcinoma of the lung was made by an experienced cytopathologist. At operation each patient was found to have pulmonary infarct and no evidence of carcinoma. Review of this experience has disclosed cytological and clinical features that should alert the clinician to the possibility that the cytological diagnosis of lung cancer may be misleading in certain nonmalignant diseases.     

Congenital diaphragmatic hernia and intrathoracic intestinal volvulus

The main symptom of the congenital diaphragmatic hernia (CDH) is the respiratory distress due to the pulmonary hypoplasia and the persistence of foetal pulmonary circulation. Sometimes the CDH appears outside of the neonatal period with respiratory symptoms, abdominal pain and seldom with intestinal obstruction. A case of CDH presenting with intrathoracic volvulus is reported. This case shows that tendency of delayed repair until the newborn has been recovered, require more attention because the good condition of the patient can be changed not only by the pulmonary hypoplasia and the persistence of the foetal pulmonary circulation but also by the symptoms of the intrathoracic gut complications.     

Extending the concept of the autograft for complete repair of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: a report of ten cases of a modified procedure

BACKGROUND: In most cases of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction, a Lecompte procedure (réparation à l'étage ventriculaire) is possible without interposition of a conduit between the right ventricle and pulmonary artery. However, the anterior location of the pulmonary arteries after the Lecompte maneuver may be a potential cause for right ventricular outflow obstruction, which continues to be reported in 5% to 25% of cases. We have used a tubular segment of aortic autograft to connect the pulmonary artery, left in the orthotopic posterior position (without the Lecompte maneuver), to the right ventricle in 10 consecutive patients with transposition, ventricular septal defect, and left ventricular outflow tract obstruction. METHODS: Ten consecutive patients aged 2 months to 11 years (mean 32 months) have undergone a modified Lecompte operation. Eight had severe pulmonary stenosis, two had pulmonary atresia, and four had a restrictive ventricular septal defect at the time of the operation. Two had multiple ventricular septal defects. Seven had undergone one (n = 5) or two (n = 2) previous modified Blalock-Taussig shunts. All patients underwent a total correction with left ventricular-aortic intraventricular connection (four needed a ventricular septal defect enlargement), connection between the right ventricle and pulmonary arteries with a tubular segment of autograft aorta, without the Lecompte maneuver (anterior location of the bifurcation of the pulmonary arteries) on the right (n = 6) or the left (n = 4) of the aorta. No valvular device was used for the right ventricular outflow repair. RESULTS: No early or late deaths occurred. One patient with multiple ventricular septal defects needed an early (2 weeks) reoperation for a residual muscular ventricular septal defect. All patients are currently in New York Heart. Association class I, without medications, in sinus rhythm, at a mean follow-up of 30 months. Late results up to 3.6 years show no calcification on the chest roentgenogram, and at the most recent echocardiogram, right ventricular pressures were low (25 to 40 mm Hg, mean 33 mm Hg) and no significant gradient (over 10 mm Hg) was found between the right ventricle and pulmonary arteries. Left and right ventricular function was satisfactory. CONCLUSION: This modification of the Lecompte operation using a segment of autograft allows an excellent early and late result, with no danger of compression of anteriorly placed pulmonary arteries, no significant right ventricular outflow obstruction, and normal appearance of the tubular autograft. In view of laboratory and clinical evidence, normal growth of the autograft can be anticipated. It allows an elective correction of transposition, ventricular septal defect, and left ventricular outflow tract obstruction without a previous Blalock-Taussig shunt (three patients) and correction at a young age (three patients younger than 1 year).     

Virtual bronchoscopy: the correlation between endoscopic simulation and bronchoscopic findings

PURPOSE: We carried out a preliminary clinical validation of 3D spiral CT virtual endoscopic reconstructions of the tracheobronchial tree, by comparing virtual bronchoscopic images with actual endoscopic findings. MATERIALS AND METHODS: Twenty-two patients with tracheobronchial disease suspected at preliminary clinical, cytopathological and plain chest film findings were submitted to spiral CT of the chest and bronchoscopy. CT was repeated after endobronchial therapy in 2 cases. Virtual endoscopic shaded-surface-display views of the tracheobronchial tree were reconstructed from reformatted CT data with an Advantage Navigator software. Virtual bronchoscopic images were preliminarily evaluated with a semi-quantitative quality score (excellent/good/fair/poor). The depiction of consecutive airway branches was then considered. Virtual bronchoscopies were finally submitted to double-blind comparison with actual endoscopies. RESULTS: Virtual image quality was considered excellent in 8 cases, good in 14 and fair in 2. Virtual exploration was stopped at the lobar bronchi in one case only; the origin of segmental bronchi was depicted in 23 cases and that of some subsegmental branches in 2 cases. Agreement between actual and virtual bronchoscopic findings was good in all cases but 3 where it was nevertheless considered satisfactory. The yield of clinically useful information differed in 8/24 cases: virtual reconstructions provided more information than bronchoscopy in 5 cases and vice versa in 3. Virtual reconstructions are limited in that the procedure is long and difficult and needing a strictly standardized threshold value not to alter virtual findings. Moreover, the reconstructed surface lacks transparency, there is the partial volume effect and the branches < or = 4 pixels phi and/or meandering ones are difficult to explore. CONCLUSIONS: Our preliminary data are encouraging. Segmental bronchi were depicted in nearly all cases, except for the branches involved by disease. Obstructing lesions could be bypassed in some cases, making an indication for endoscopic laser therapy. Future didactic perspectives and applications to minimally invasive or virtual reality-assisted therapy seem promising, even though actual clinical applications require further studies.     

High-pressure destruction kinetics of Listeria monocytogenes on pork

OBJECTIVE: To define the incidence of complications of endotracheal intubation and the factors associated with these complications. STUDY DESIGN: During a 22-month period, 227 intubated infants weighing <1,501 g were followed prospectively in a neonatal intensive care unit. Detailed records of events associated with airway management were kept after every intubation, in addition to clinical data. RESULTS: Eleven infants (4.8%) developed respiratory stridor after extubation which was treated with either systemic corticosteroids, racemic epinephrine and/or reintubation for respiratory failure. Four infants were submitted for bronchoscopy, mild subglottic stenosis with tracheal edema was found in 1 patient, granulation tissue and airway edema were noted in 3 infants. Traumatic intubation, prolonged ventilation, multiple intubations and bacterial colonization of the endotracheal tube were the factors associated with postextubation stridor. CONCLUSIONS: Subglottic stenosis is an infrequent complication of endotracheal intubation with current airway management of very-low-birth-weight infants. Less severe complications are still common, but they are usually amenable to clinical treatment. Bronchoscopy should be performed selectively only in infants with clinical evidence of airway obstruction after extubation.     

Inhalation injury

Inhalation injury remains a primary determinant of patient survival, with 60% to 70% of burn center fatalities attributed to the pulmonary complications of inhalation injury. Substantial airway damage and pulmonary complications can result from the inhalation of toxic fumes and gases found in smoke. Partial to complete airway obstruction, pulmonary edema, pneumonia, and progressive pulmonary failure may occur. Early diagnosis of inhalation injury and vigorous pulmonary care and support are vitally important to patient survival. Bronchoscopy and xenon 133 ventilation-perfusion scans are two of the newer diagnostic tools used to identify burn patients with inhalation injury. Treatment measures for patients with inhalation injury and recommendations for nursing practice are discussed.     

Preoperative diagnosis of the thoracic aortic aneurysm by three-dimensional CT angiography

Serial eight patients with thoracic aortic aneurysms were evaluated by a newly developed three-dimensional CT angiography (3D-CT) from December 1992 to January 1993. The patients include 3 aortic dissections, 3 aortic arch aneurysms, one descending aortic aneurysm and one thoracoabdominal aortic aneurysm. The surgical treatment was performed after the evaluation of 3D-CT, and the operative findings were compared to the three-dimensional images reconstructed by 3D-CT in all patients. Three-dimensional displays were achieved using the unique method of data collection of the helical (spiral) scanner with continuous tube rotation and continuous table feed. A intravenous contrast material was used to image the thoracic aorta and major aortic branches with the single-breath-hold technique. Two and three-dimensional images reconstructed by 3D-CT were displayed within 10-20 minutes after the scanning. These three-dimensional images of the aortic lesions could be displayed in any angle we chose. Three-dimensional structures of the thoracic aorta and major aortic branches were clearly visualized and easily recognized by 3D-CT. These images were similar to the intraoperative findings and were quite useful to determine the operative procedure. The successful repair of thoracic aortic aneurysm was achieved in all cases. 3D-CT is a new and attractive modality to assess the vascular system. Although our experience is limited, 3D-CT may be a useful and powerful diagnostic method for the surgical treatment of thoracic aortic aneurysm.