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The prone position is extensively used to improve oxygenation in patients with severe acute respiratory distress syndrome caused by SARS-CoV-2 pneumonia. Occasionally, these patients exhibit cardiac and respiratory functions so severely compromised they cannot tolerate lying in the supine position, not even for the time required to insert a central venous catheter. The authors describe three cases of successful ultrasound-guided internal jugular vein cannulation in prone position. The alternative approach here described enables greater safety and well-being for the patient, reduces the number of episodes of decompensation, and risk of tracheal extubation and loss of in-situ vascular lines.

Chronic diffuse lung diseases involve a spectrum of nonneoplastic inflammatory conditions that affect the lung parenchyma. This chapter reviews the spectrum of disease including idiopathic interstitial pneumonias, pulmonary manifestations of systemic collagen vascular disease, diffuse eosinophilc lung disease, drug-associated lung disease, diffuse granulomatous lung disease, and a variety of miscellaneous diseases that defy classification. Individual entities are reviewed, followed by a section highlighting a practical approach to the four most common patterns of injury encountered in practice.

Most patients with cystic fibrosis (CF) develop multisystemic clinical manifestations, the minority having mild or atypical symptoms. We describe an adolescent with chronic cough and purulent rhinorrhoea since the first year of life, with diagnoses of asthma, allergic rhinitis and chronic rhinosinusitis. Under therapy with long-acting bronchodilators, antihistamines, inhaled corticosteroids, antileukotrienes and several courses of empirical oral antibiotic therapy, there was no clinical improvement. There was no reference to gastrointestinal symptoms. Due to clinical worsening, extended investigations were initiated, which revealed Pseudomonas aeruginosa in sputum culture, sweat test with a positive result and heterozygosity for F508del and R334W mutations in genetic study which allowed to confirm the diagnosis of CF. In this case, heterozygosity with a class IV mutation can explain the atypical clinical presentation. It is very important to consider this diagnosis when chronic symptoms persist, despite optimised therapy for other respiratory pathologies and in case of isolation of atypical bacterial agents.

The management of airway and chest wall tumours is a highly specialized area in thoracic surgery which affects a small number of the wider patient population. Familiarization with thoracic anaesthesia, rigid bronchoscopy, LASER technology, airway stenting not only provides stabilization of the airway and relieves obstruction to breathing but provides lifesaving treatment.

Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

Eosinophilic gastrointestinal diseases are delayed-type chronic allergic disorders that show gastrointestinal eosinophil dense infiltration, with an exaggerated Th2-type immune reaction considered to be an important mechanism. These diseases can be roughly divided into two types: eosinophilic esophagitis, mainly found in young and middle-aged men, and eosinophilic gastroenteritis, which is found in both genders equally. A diagnosis of eosinophilic esophagitis is suspected when characteristic endoscopic findings, including longitudinal furrows and rings, are noted. However, characteristic endoscopic abnormalities are rarely found in cases with eosinophilic gastroenteritis, so multiple biopsy sampling from the apparently normal gastrointestinal mucosal surface is important for making an accurate diagnosis. The administration of systemic glucocorticoid is the standard treatment for eosinophilic gastroenteritis, while acid inhibitors and topical glucocorticoid swallowing therapy are effective for eosinophilic esophagitis. Anti-cytokine therapies for eosinophilic gastrointestinal diseases are currently under development.

Rupture of a racemose hemangioma causing dilatation and tortuosity of the bronchial artery can result in massive bleeding and respiratory failure. Bronchial artery embolization (BAE) can treat this life-threatening condition, as we show in two cases. The first case was of an 89-year-old female complaining of sudden-onset chest and back pain. Bronchial artery angiography demonstrated a racemose hemangioma with a 2 cm aneurysm. The second case was of a 50-year-old male with hemoptysis and dyspnea, eventually requiring intubation. Bronchial arteriography showed a racemose hemangioma and a bronchial artery-pulmonary arterial fistula. BAE was successfully performed in both cases, with no recurrent hemorrhage. Therapeutic interventions in bronchial artery racemose hemangiomas include lobectomy or segmentectomy, bronchial arterial ligation, and BAE. BAE should be considered as first-line therapy for bleeding racemose hemangiomas of the bronchial artery because of its low risk of adverse effects on respiratory status, minimal invasiveness, and faster patient recovery.

Introduction Desmoplastic malignant pleural mesothelioma (DMPM) is a sarcoma type mesothelioma, comprising about 5% of malignant pleural mesotheliomas. Although effusion cytology is commonly used as the primary diagnostic approach for mesothelioma, this may not be useful for DMPM due to its desmoplastic nature and bland cellular atypia. We hereby report a case of DMPM diagnosed through autopsy along with its cytological features that have not been described previously. Case presentation A male in his 60s with a history of occupational asbestos exposure was referred to our hospital with right chest pain. Chest computed tomography scan showed right pleural effusion. Thirteen months later, the patient died of respiratory failure. In autopsy, the scrape-imprint smear and the pleural effusions cytology were performed. The scrape-imprint smear samples exhibited spindle cells with mild nuclear atypia and grooves with fibrous stroma. In the pleural effusion cytology, spindle cells having mild nuclear atypia and grooves with loose epithelial connections were observed. Histological examination of the right pleura showed spindle cells proliferating with dense collagen fibers, as seen in cytological samples, thus rendering the diagnosis of DMPM. Diagnosis was confirmed by fluorescence in situ hybridization. Conclusion Cytological procedures, such as pleural effusion cytology and scrape-imprinting method, may be useful as an ancillary tool in the diagnosis of rare tumors such as DMPM.

Background: Asthma is a chronic inflammatory condition of the airways with a complex pathophysiology. Stratification of asthma subtypes into phenotypes and endotypes should move the field forward, making treatment more effective and personalized. Eosinophils are the key inflammatory cells involved in severe eosinophilic asthma. Given the health threat posed by eosinophilic asthma, there is a need for reliable biomarkers to identify affected patients and treat them properly with novel biologics. microRNAs (miRNAs) are a promising diagnostic tool. Objective: The aim of this study was to identify serum miRNAs that can phenotype asthma patients. Methods: Serum miRNAs of patients with eosinophilic asthma (N=40) and patients with noneosinophilic asthma (N=36) were evaluated using next-generation sequencing, specifically miRNAs-seq, and selected miRNAs were validated using RT-qPCR. Pathway enrichment analysis of deregulated miRNAs was performed. Results: Next-generation sequencing revealed 15 miRNAs that were expressed differentially between eosinophilic and noneosinophilic asthma patients, although no differences were observed in the miRNome between atopic and nonatopic asthma patients. Of the 15 miRNAs expressed differentially between eosinophilic and noneosinophilic asthma patients, hsa-miR-26a-1-3p and hsa-miR-376a-3p were validated by RT-qPCR. Expression levels of these 2 miRNAs were higher in eosinophilic than in noneosinophilic asthma patients. Furthermore, expression values of hsa-miR-26a-1-3p correlated inversely with peripheral blood eosinophil count, and hsa-miR-376a-3p expression values correlated with FeNO values and the number of exacerbations. Additionally, in silico pathway enrichment analysis revealed that these 2 miRNAs regulate signaling pathways associated with the pathogenesis of asthma. Conclusion: hsa-miR-26a-1-3p and hsa-miR-376a-3p could be used to differentiate between eosinophilic and noneosinophilic asthma.

Complete tracheal obliteration after tracheostomy remains a considerable challenge for otolaryngologists and pulmonologists. Here, we report for the first time a novel method of interventional bronchoscopy to successfully recanalize complete tracheal obliteration. Three patients with suprastomal tracheal obliteration and tracheostomy dependence were referred to our center for further management. Using interventional bronchoscopy, a TBNA needle was retrogradely inserted from the stoma to locate the original passage through the occlusion, and then its stylet was left as a guide wire for the sequential dilations. Once the tracheal lumen was restored, endoprosthesis would be implanted to maintain the airway patency. All cases achieved successful recanalization with effortless breathing after the treatment and restored phonation. Bronchoscopic retrograde recanalization using a TBNA needle is a promising and effective treatment for complete tracheal obliteration.

Summary Background & aims ESPEN guidelines advocate that energy needs of critically ill patients with COVID 19 should be assessed using indirect calorimetry, if safely available. This study described energy needs of intubated patients with COVID-19 and explores whether neuromuscular blockade administration (NMBAs) is associated with altered energy expenditure. Methods Resting energy expenditure (REE) and respiratory exchange rate (RER) evaluated among critically ill intubated COVID-19 patients until 28th day of intensive care unit stay (ICU–S) by indirect calorimetry. Paralysed patients were defined as those with drug induced paralysis using cicatracurium, for at least 3 days during their ICU-S. Results 34 adult COVID 19 patients (59.8% male, 35.2% obese) requiring mechanical ventilation were assessed prospectively. REE measurements suggest a gradual increase of energy needs post 3rd day of ICU-S in both patients without obesity (non ob) ((from 17.8 kcal/kgr up to 29.3 kcal/kgr actual body weight (AcBW) during 28th day of ICU-S, p = 0.011)) and patients with obesity (ob) ((from 18.1 kcal/kgr up to 30.1 kcal/kgr adjusted body weight (AjBW) during 28th day of ICU-S, p = 0.021)). NMBAs use was accompanied by a significant drop in REE, especially during first 7 days of hospitalization, both in non ob (22.9 vs 17.9 kcal/kgr AcBW, p = 0.014) and ob patients (22.5 vs 19.5 kcal/kgr ABW, p = 0.027). Conclusion We identified the energy needs of COVID-19 intubated patients and highlighted a significant increase beyond the 1st week in the ICU. Administration of NMBAs should be considered, as it may impact resting energy expenditure.

Summary Background & aims Sarcopenia, a loss of muscle mass, quality and function, which is particularly evident in respiratory muscles, has been associated with many clinical adverse outcomes. In this study, we aimed at evaluating the role of reduced muscle mass and quality in predicting ventilation weaning, complications, length of intensive care unit (ICU) and of hospital stay and mortality in patients admitted to ICU for SARS-CoV-2-related pneumonia. Methods This was an observational study based on a review of medical records of all adult patients admitted to the ICU of a tertiary hospital in Milan and intubated for SARS-CoV-2-related pneumonia during the first wave of the COVID-19 pandemic. Muscle mass and quality measurement were retrieved from routine thoracic CT scans, when sections passing through the first, second or third lumbar vertebra were available. Results A total of 81 patients were enrolled. Muscle mass was associated with successful extubation (OR 1.02, 95% C.I. 1.00–1.03, p = 0.017), shorter ICU stay (OR 0.97, 95% C.I. 0.95–0.99, p = 0.03) and decreased hospital mortality (HR 0.98, 95% C.I. 0.96–0.99, p = 0.02). Muscle density was associated with successful extubation (OR 1.07, 95% C.I. 1.01–1.14; p = 0.02) and had an inverse association with the number of complications in ICU (Β −0.07, 95% C.I. −0.13 - −0.002, p = 0.03), length of hospitalization (Β −1.36, 95% C.I. −2.21 - −0.51, p = 0.002) and in-hospital mortality (HR 0.88, 95% C.I. 0.78–0.99, p = 0.046). Conclusions Leveraging routine CT imaging to measure muscle mass and quality might constitute a simple, inexpensive and powerful tool to predict survival and disease course in patients with COVID-19. Preserving muscle mass during hospitalisation might have an adjuvant role in facilitating remission from COVID-19.

Background Enhanced nonpharmaceutical interventions (NPIs) to prevent the Coronavirus Disease 2019 (COVID-19) have shown various levels of impact on common respiratory pathogens. We aimed to analyze the epidemiological changes seen in certain common respiratory viruses found in Taiwanese children (e.g., influenza virus, enterovirus, parainfluenza virus, adenovirus and respiratory syncytial virus (RSV)) after the implementation of public health measures, as well as interpret the possible meaning of these changes. Methods This retrospective observational study examined the viral isolation from children younger than 18 years at a medical center in central Taiwan during the period January 2015 – December 2020, a time frame of six years. Viral isolations prior to the COVID-19 pandemic (January 2015 – December 2019), along with those during the post-COVID-19 period (January – December 2020) were analyzed and compared. Results A total of 6,899 throat swab samples were collected during the pre-pandemic period of 2015 to 2019, with 2,681 of them having a positive result (38.86%). There were a total of 713 samples collected in 2020, with 142 of them showing positive results (19.92%). The overall positive rate of viral isolates significantly decreased in 2020 (p < 0.001). Declines in the isolation of the influenza virus, parainfluenza virus, adenovirus and enterovirus were observed. The RSV surprisingly became the leading isolate, with up to 47 (6.59%) instances in 2020, and showing an unusual peak in the winter of 2020. The rise began in September of 2020 and reached its plateau in November of that year. Conclusions Most respiratory viruses decreased under NPIs regarding SARS-CoV-2. However, the RSV outbreak in the winter of 2020 had shown the limitation of current NPIs. Possible explanations have been discussed in details and public preventive measures should be reinforced for RSV, particularly amongst people having young children both at home and in care centers.

Aim:This study aims to compare the gating signals of patients with lung cancer recorded during the planning computed tomography scan with the ones recorded during treatment fractions. The results provide insights into how representative the respiratory signals from the planning scan are for radiation dose partitioning.Materials and methods:The amplitude and frequency of the respiratory signals of 29 patients with lung carcinoma were analysed and compared with the amplitude and frequency of those recorded during their planning scans. Moreover, a cross-correlation analysis was performed between the difference between the planning scan and fractions and features from the planning scan.Results:Two patients showed significantly different amplitude and frequency during treatment fractions compared to those from the planning scan. These patients showed low variances in frequency and amplitude during the different fractions. The difference between planning scan and fractions is correlated with the variances within the planning scan.Findings:Respiratory signals can differ between the planning scan and the fractions. In this case, a new planning scan may be beneficial. The respiratory signals from the planning scan may be predictive of whether the planning scan will be representative and usable as a control measure during radiotherapy fractions.

Objective Transglutaminase (TGM)2 and peroxisome proliferator-activated receptor (PPAR)γ are thought to participate in the pathogenesis of nasal polyp formation in cystic fibrosis (CF). We herein investigated expressions of cystic fibrosis transmembrane conductance regulator (CFTR), TGM2, PPARγ and isopeptide bonds, a reaction product of TGM, in non-CF nasal polyps. Methods Nasal polyps and inferior turbinates were collected from chronic rhinosinusitis patients without CF during transnasal endoscopic sinonasal surgery. Expressions of CFTR, TGM2, isopeptide bonds and PPARγ were examined by fluorescence immunohistochemistry and quantitative RT-PCR. Expression of CFTR was also analyzed by Western blot. Results Immunohistochemical fluorescence of the nasal polyp was significantly lower for CFTR and PPARγ, and significantly higher for TGM2 and isopeptide bonds than that of the turbinate mucosa. Lower expression of CFTR in the nasal polyp than in the turbinate mucosa was also observed in Western blot. Expression of PPARG mRNA was significantly lower in the nasal polyp than in the turbinate mucosa, whereas expressions of CFTR mRNA or TGM2 mRNA did not differ between the two tissues. Immunohistochemical fluorescence for CFTR showed significant negative correlation with that for TGM2 and isopeptide bonds, and significant positive correlation with that for PPARγ. The fluorescence for TGM2 was positively correlated with that for isopeptide bonds and negatively correlated with that for PPARγ. The fluorescence for isopeptide bonds tended to be negatively correlated with that for PPARγ. Conclusions These results suggest a possible role of the CFTR-TGM2-PPARγ cascade in the pathogenesis of nasal polyp formation in non-CF patients as in CF patients.

INTRODUCCIÓN: La Ecografía Pulmonar es una técnica accesible, de bajo costo y que ha demostrado su utilidad en la estratificación pronostica en pacientes con COVID-19. Además, según estudios previos, nos puede orientar hacia la potencial etiología, especialmente en situaciones epidémicas como la actual. PACIENTES Y MÉTODOS: Se reclutaron prospectivamente 40 pacientes, 30 con neumonía por SARS-CoV-2 y 10 por neumonía adquirida en la comunidad (NAC). A los pacientes incluidos, se les realizó tanto una radiografía como ecografía de tórax. RESULTADOS: No hubo diferencias en los 2 grupos en cuanto a las características clínicas y analíticas. Los principales hallazgos ecográficos fueron en el grupo de SARS-CoV-2 la presencia de líneas B confluyentes y consolidaciones subpleurales y la hepatinización en el grupo de NAC. El derrame pleural fue más frecuente en el grupo de NAC. En ningún caso la ecografía pulmonar fue normal. El análisis de las curvas ROC mostró un área bajo la curva para la Ecografía Pulmonar del 89,2% (IC 95%: 75,0- 100%, p

To differentiate arytenoid subluxation and vocal fold paralysis by CT cine mode scanning combined with three-dimensional (3D) reconstruction image.Seventy-six patients with suspected vocal fold dyskinesia were collected. All patients were examined being asked to inhale deeply and then make "Yi" sound continuously during CT scanning with cine mode. The optimal maximum opening and minimum closing phases of glottis were selected and 3D reconstruction images were performed. The length of vocal fold, the width of glottis, and the subglottal convergence angle, anteversion angle, elevation angle, valgus angle, and varus angle of cricoarytenoid joints were measured. Vocal fold deformation was divided into three types: type I, type II, and type III. Kappa test was used to compare the consistency between CT diagnosis and clinical diagnosis. Single-factor analysis of variance was used to analyze the statistical differences among arytenoid subluxation, vocal fold paralysis, and normal vocal fold.There was high consistency between CT diagnosis and clinical diagnosis (k = 0.731, P0.05), as well as significant differences in the opening width of glottis between type I and type III, the valgus and varus angles of cricoarytenoid joints between type I and type II or type III, and the subglottal convergence angles among the three types of vocal fold deformation.CT scanning with cine mode combined with 3D reconstruction can display the changes of larynx structures in vocal fold dyskinesia, and can be used for the differential diagnosis of arytenoid cartilage subluxation and vocal fold paralysis.

Background Interstitial lung disease (ILD) patients often develop lung cancer. However, previous studies on the incidences of lung cancer in ILD patients focused on specific aetiologies, such as idiopathic pulmonary fibrosis (IPF). The lung cancer incidences in these patients have not been investigated, and thus, we aimed to evaluate them here. Methods ILD patients at our hospital were retrospectively reviewed. The cumulative incidences of lung cancer in patients with various ILDs were estimated with Kaplan-Meier curves and compared between ILD groups using log-rank tests. The association between several variables at initial diagnosis and lung cancer development was assessed with Cox proportional hazards regression analysis to identify predictors. Results In all, 606 ILD patients, including 161 with IPF, 133 with non-IPF idiopathic interstitial pneumonias, 160 with chronic hypersensitivity pneumonitis, 87 with connective tissue disease-related ILDs, 19 with pulmonary sarcoidosis, and 46 with other ILDs, were included. Twenty-eight patients developed lung cancer. The cumulative incidences of lung cancer at 1, 3, and 5 years were: 1.9, 5.7, and 12.3% with IPF, respectively; 0.8, 0.8, and 4.0% in non-IPF idiopathic interstitial pneumonias; 2.0, 4.6, and 11.0% in chronic hypersensitivity pneumonitis; and 1.1, 1.1, and 2.9% in connective tissue disease-related ILDs. IPF patients had a higher incidence of lung cancer than non-IPF idiopathic interstitial pneumonia patients (p = 0.036). A radiological usual interstitial pneumonia pattern, forced vital capacity value, and pack-years were associated with lung cancer development (hazard ratios 2.959, 1.031, 1.011; 95% confidence intervals 1.257–6.963, 1.006–1.057, 1.002–1.020, p = 0.013, 0.017, 0.020, respectively). Conclusions The lung cancer incidence is higher in IPF patients than in non-IPF idiopathic interstitial pneumonia patients and is equally high in patients with chronic hypersensitivity pneumonitis and IPF.

A 70-year-old woman who had been taking oral steroids with tapering after an acute exacerbation of idiopathic pulmonary fibrosis (IPF) was diagnosed with stage IIIB squamous cell lung cancer by transbronchial lung biopsy from left hilum 6 months before admission. At the time, she had anorexia due to

A 45-year-old man, with poorly controlled diabetes (HbA1c-10.1), presented with fever and gluteal pain for 3 days. On examination, there was a swelling over left gluteal region with induration and an overlying discharging sinus. Ultrasonography of the swelling showed subcutaneous oedema with

We report a case of a 74-year-old male patient who was referred to the respiratory clinic with an incidental finding of a left sided pleural effusion. He was initially being treated by the general practitioner for chest infection with productive cough that had limited resolution after course of oral antibiotics. At the pleural clinic, 1.5 L of serosanguineous fluid was drained and sent for diagnostics. However, the diagnosis only reached as far as idiopathic exudative effusion with lymphocytes and plasma cells. He was then referred for video-assisted thoracoscopic surgery pleural biopsy and pleurodesis. It revealed black pleura with abundant IgG4 positive cells. He is followed up in respiratory clinic where further discussion and treatment has commenced.

An 85-year-old woman who lived in Kanuma, Tochigi prefecture, Japan, presented to the emergency department of a hospital with dyspnoea, which developed 3 hours before the visit. At the time of presentation, she was in respiratory distress, with a blood pressure of 171/88 mm Hg, heart rate of 105

Nilotinib is used as standard treatment in managing chronic myeloid leukaemia (CML). A 23-year-old man with CML and on nilotinib was admitted to the intensive care unit due to respiratory failure. Three years prior, he developed pleural effusion from dasatinib therapy thus, his CML regimen was changed to nilotinib. Although the pleural effusion had once improved, the chest imaging revealed left-dominant bilateral pleural effusion. Endotracheal intubation and left thoracic drainage were performed. Nilotinib treatment was discontinued, and approximately 60 hours later, nilotinib concentrations of 927 and 2092 ng/mL were determined in his blood and pleural effusion, respectively. Severe pleural effusion may be induced in patients administering nilotinib, and nilotinib concentrations in blood and pleural effusion can be elevated in patients with nilotinib-related pleural effusion. Cross-occurrence of pleural effusions needs to be monitored precisely, especially in patients who are switched to other tyrosine kinase inhibitors after dasatinib treatment.

Objectives Respiratory syncytial virus (RSV) causes substantial morbidity and mortality in older adults. We assessed severe clinical outcomes among hospitalized adults that were associated with RSV infections. Methods We performed a nested retrospective study in 3 New York City hospitals during 2 respiratory viral seasons, October 2017–April 2018 and October 2018–April 2019, to determine the proportion of patients with laboratory-confirmed RSV infection who experienced severe outcomes defined as intensive care unit (ICU) admission, mechanical ventilation, and/or death. We assessed factors associated with these severe outcomes and explored the effect of RSV-associated hospitalizations on changes in the living situations of surviving patients. Results Of the 403 patients studied (median age, 69 years), 119 (29.5%) were aged ≥80. Severe outcomes occurred in 19.1% of patients, including ICU admissions (16.4%), mechanical ventilation (12.4%), and/or death (6.7%). Patients admitted from residential living facilities had a 4.43 times higher likelihood of severe RSV infection compared with patients who were living in the community with or without assistance from family or home health aides. At discharge, 56 (15.1%) patients required a higher level of care than at admission. Conclusions RSV infection was associated with severe outcomes in adults. Living in a residential facility at admission was a risk factor for severe outcomes and could be a proxy for frailty rather than an independent risk factor. Our data support the development of prevention strategies for RSV infection in older populations, especially older adults living in residential living facilities.

A woman in her 50s presented for surveillance bronchoscopy 3 months after bilateral lung transplantation for alpha-1 antitrypsin deficiency. She was asymptomatic and her physical examination was unremarkable. While performing a prebronchoscopy pleural ultrasound examination to assess for lung

Ichthyosis prematurity syndrome (IPS) is a rare disorder of autosomal recessive inheritance. The cardinal features include prematurity, vernix like hyperkeratosis, eosinophilia and neonatal asphyxiation. This case report discusses the presentation and management of IPS. We aim to characterise the common features, the spectrum of disease within a single family and discuss a potential role for low-dose dexamethasone in the management of ventilator-dependent patients with IPS.

Extracorporeal membrane oxygenation (ECMO) is helpful in providing ventilatory support when other conventional methods of ventilation fail. We report a case of successful management of advanced tracheal malignancy with impeding airway obstruction where veno-venous ECMO (VV-ECMO) was instituted prior to performing critical endotracheal procedure. After securing the VV-ECMO through right jugular vein and left femoral vein under local anaesthesia, the tracheal stent placement was conducted under flexible bronchoscope and fluoroscope control. Oxygenation and carbon dioxide levels were maintained by the ECMO. VV-ECMO is a useful adjunct in the management of subglottic difficult airway obstruction due to complex tracheal pathology where conventional ventilation may not be possible or adequate.

BackgroundGuidelines for sinus of Valsalva (SOV)-thoracic aortic aneurysms in Marfan syndrome recommend size-based criteria for elective surgical repair. Biomechanics may provide a better prediction of dissection risk than diameter. Our aim was to determine magnitudes of wall stress in the aortic root of Marfan patients using finite element analyses.MethodsForty-six Marfan patients underwent patient-specific 3-dimensional SOV-thoracic aortic aneurysm geometry reconstruction using imaging data. Finite element analyses were performed to determine wall stress distributions at SOV, sinotubular junction (STJ), and ascending aorta (AscAo) at systole.ResultsPeak circumferential stresses were 432.8 ± 111 kPa, 408.1 ± 88.3 kPa, and 321.9 ± 83.8 kPa at the SOV, STJ, and AscAo, respectively, with significant differences between SOV and AscAo (P < 3.08E-07), and STJ and AscAo (P < 2.26E-06). Peak longitudinal wall stresses were 352 ± 73.9 kPa, 277.5 ± 89.5 kPa, and 200.6 ± 81 kPa at SOV, STJ, and AscAo, respectively, with significant differences between SOV and STJ (P < 6.01E-06), SOV and AscAo (P < 9.79E-13), and STJ and AscAo (P < 3.34E-07). Diameter was not correlated to wall stresses. Comparison of wall stresses in aneurysm

Background In clinical practice it has been observed that several patients of cured pulmonary tuberculosis (PTB) suffer with lung dysfunction and these problems are less documented routinely. Prevalence of these abnormalities remains unknown. Aim of this study is to estimate the lung function abnormality and exercise capacity including diffusion capacity of lung for carbon monoxide (DLCO) in cured PTB cases. Methods A hospital based observational descriptive study was carried out among 100 patients with PTB, who had been declared cured. These patients were evaluated by spirometry and DLCO to assess their lung function and were classified as normal or abnormal. Modified medical research council (mMRC) dyspnea scale for symptom assessment and 6-minute walk test (6MWT) to determine the exercise capacity was also done. Borg's scale was used for dyspnea assessment in 6MWT. Results 83 (83%) patients having abnormal spirometry, 17 (17%) had obstructive pattern, 32 (32%) had restrictive pattern and 34 (34%) had mixed pattern. 22 (22%) patients had mild decrease in DLCO, 43 (43%) patients had moderate decrease in DLCO, while only 4 (4%) had severe decrease in DLCO. More than half of the patients having normal spirometry had reduced in DLCO. Conclusion The prevalence of abnormal lung functions is high even after complete anti-tubercular treatment. DLCO could be a better tool for evaluation of lung function in these patients. There is need to strengthen the National Programme to detect and treat TB patient earlier, also there is need to formulate guidelines for pulmonary rehabilitation of cured PTB patient.

Objective: Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease that affects 63 in every 100,000 Americans. Its etiology remains unknown, although inflammatory pathways appear...

Aims The aim of the study was to determine the performance of Xpert MTB/RIF assay in diagnosing tuberculosis on thoracoscopic pleural biopsies in exudative pleural effusion. Methods Patients who underwent thoracoscopic pleural biopsy in the defined period were included in the study. Histopathology was done for all and Xpert MTB RIF assay and AFB culture of pleural biopsy specimen and pleural fluid were done as per the clinician's discretion. Results Total of 110 patients underwent pleural biopsy and tissue Xpert MTB/RIF and MTB culture were done in 29 patients. XpertMTB/RIF assay and MTB culture had a sensitivity of 59% and 35% respectively and specificity of specificity of 100. Conclusion The study described the ability of XPERT MTB/RIF in getting additional diagnostic information from thoracoscopic Pleural biopsy. Pleural biopsy Xpert MTB/RIF had sensitivity of 59% and specificity of 100% in diagnosing TPE. In addition to the diagnosis, Xpert MTB/RIF can also give valuable information about rifampicin resistance too. XPERT MTB/RIF assay also helped in getting diagnosis when histopathology alone was not able to confirm or rule out the diagnosis of TPE. Pleural fluid ADA of 38 IU/L had a sensitivity of 71% and a specificity of 86% for diagnosis of TPE in present study.

Nostril stenosis is typically caused by retraction and contraction after trauma or infection, although loss of nasal tissue is not common during rhinoplasty. This clinical report describes the fabrication of a nasal stent to replace the lost columella and a columella prosthesis for a patient who had had reconstructive surgery for nasal valve collapse and a missing columella. The stent established a comfortable means of nasal air exchange that was also esthetically acceptable. The stent also provided the necessary support for the nasal tissue before further nasal reconstructive surgeries.

Acute Lung Injury (ALI) and its severe form Acute Respiratory Distress Syndrome (ARDS) are the major cause of ICU death worldwide. ALI/ARDS is characterized by severe hypoxemia and inflammation that leads to poor lung compliance. Despite many advances in understanding and management, ALI/ARDS is still causing significant morbidity and mortality. Long non-coding RNA (lncRNA) is a fast-growing topic in lung inflammation and injury. lncRNA is a class of non-coding RNA having a length of more than 200 nucleotides. It has been a center of research for understanding the pathophysiology of various diseases in the past few years. Multiple studies have shown that lncRNAs are abundant in acute lung injury/injuries in mouse models and cell lines. By targeting these long non-coding RNAs, many investigators have demonstrated the alleviation of ALI in various mouse models. Therefore, lncRNAs show great promise as a therapeutic target in ALI. This review provides the current state of knowledge about the relationship between lncRNAs in various biological processes in acute lung injury and its use as a potential therapeutic target.

Various types of laryngoscopes have been invented to ameliorate the laryngoscopic view of the glottis, in normal and difficult airway, which helps anaesthesiologists to secure the airway during anaesthesia. In this prospective study, we aimed to compare the efficacy of the Airtraq video laryngoscope (AVL) and the Macintosh curved-blade laryngoscope (MBL), by using a common clinical assessment tool in patients with modified Mallampati class III and IV.A total of 60 patients [group A (AVL) and group M (MBL)] with modified Mallampati class III and IV listed for general anaesthesia were included. Each patient was intubated with either of the laryngoscope based on the group allotted. Time taken for tracheal intubation, grade of visualisation of glottis and need for manoeuvres to optimise the glottic view were compared.The degree of the glottic view during successful intubation attempt was easily appreciated in group A (p 0.0001). Difference in the requirement of manoeuvres for optimising the laryngeal view/assisting in intubation as assessed by manoeuvre score was easily appreciated in group A (p 0.010). Rise in heart rate and mean arterial pressure 1 and 2 min after intubation was more in group M than in group A (p 0.0001). No event of any airway trauma, as evidenced by visible trauma to lips or oral mucosa or blood on laryngoscope, was observed with either of the laryngoscope.The novel AVL provides better intubation conditions with greater ease of intubation, better glottic view and lesser haemodynamic alterations during laryngoscopy than MBL.

Background/Purpose Decompressive laparotomy and open abdomen for abdominal compartment syndrome have been historically avoided during Extracorporeal Membrane Oxygenation (ECMO) due to seemingly elevated risks of bleeding and infection. Our goal was to evaluate a cohort of pediatric respiratory ECMO patients who underwent decompressive laparotomy with open abdomen at a single institution and to compare these patients to ECMO patients without open abdomen. Methods We reviewed all pediatric respiratory ECMO (30 days-18 years) patients treated with decompressive laparotomy with open abdomen at Riley Hospital for Children (1/2000-12/2019) and compared these patients to concurrent respiratory ECMO patients with closed abdomen. We excluded patients with surgical cardiac disease. We assessed demographics, ECMO data, and outcomes and defined significance as p=0.05. Results 6 of 81 ECMO patients were treated with decompressive laparotomy and open abdomen. Open and closed abdomen groups had similar age (p=0.223) and weight (0.286) at cannulation, but the open abdomen group had a higher reliance on vasoactive medications (Vasoactive Inotropic Score, p=0.040). Open abdomen group survival was similar to closed abdomen patients (66.7%, vs 62.7%, p=1). Open abdomen patients had lower incidence of ECMO complications (33.3% vs 83.6%, p=0.014), but the groups had similar bleeding complications (p=0.412) and PRBC transfusion volume (p=0.941). Conclusion/Impact Pediatric ECMO patients with open abdomen after decompressive laparotomy had similar survival, blood products administered, and complications as those with a closed abdomen. An open abdomen is not a contra-indication to ECMO support in pediatric respiratory patients and should be considered in select patients.

Rare earth elements (lanthanide and yttrium, abbreviated as REY) provide important support for national security, energy production, environmental protection and economic growth. In recent years, many studies have shown that the content of REY in some coal or coal by-products is close to or even higher than that in traditional REY ore, which makes coal a potential source of REY. This study took the No. 17 coal of Panzhou mining area in Liupanshui coal field as the research object, and the content and occurrence modes of REY in raw coal and 7 density fraction samples were studied. The results show that the content of REY in the raw coal reaches 220.67 μg/g, which is significantly higher than the average REY in the World coal and Chinese coal as reported in the literature. Gravity separation has a certain pre-enrichment effect on REY and the fraction sample ＞1.8 g/cm3 has the highest REY of 426.27 μg/g (equal to rare earth oxide 0.1%). Study on correlation between REY and ash yields reveals that the organic affinity of the light rare earth is higher than the medium rare earth and the heavy rare earth. As shown by XRD and XRF, the major minerals in coal are kaolinite, quartz and calcite, and the content of REY in coal is significantly related to Al and Si and kaolinite, which implies that REY occur mainly in kaolinite. LA-ICP-MS was adopted to determine chemical composition of micro-zone in kaolinite in coal and the results show that there is no obvious correlation between REY and the content of Al and Si. This indicates that the REY occurred probably in the form of adsorption. The research results provide a scientific reference for the potential extraction of the associated REY in the coal.

Background: Various cutaneous manifestations have been observed in patients with COVID-19 infection. However, the side effects on skin of the medications used for COVID-19, such as famotidine, have not been studied. Objective: This case series aims to present challenges in defining cutaneous manifestations of famotidine in the context of COVID-19. Case Presentation: We identified patients from Imam Khomeini hospital complex who were admitted to the ward with confirmed infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) taking famotidine and having cutaneous rash. Clinical data were obtained through observation and intervention. Discussion: We identified patients from Imam Khomeini hospital complex who were admitted to the ward due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), were taking famotidine and having cutaneous rash. Clinical data were obtained through observation and intervention. Conclusion: These cases prompted us to inform clinicians about cutaneous complications of famotidine in COVID-19 patients.

Objective Ex vivo lung perfusion has emerged as a novel technique to safely preserve lungs before transplantation. Recent studies have demonstrated an accumulation of inflammatory molecules in the perfusate during ex vivo lung perfusion. These proinflammatory molecules, including damage-associated molecular patterns and inflammatory cytokines, may contribute to acute and chronic allograft dysfunction. At present, ex vivo lung perfusion is performed clinically at normothermic temperature (37°C). The effect of lowering temperature to the subnormothermic range during ex vivo lung perfusion has not been reported. In this study, we hypothesized that lower ex vivo lung perfusion temperature will lead to a reduction in allograft inflammation and result in improved post-transplant graft function. Methods Lewis rat heart-lung blocs underwent 4 hours of ex vivo lung perfusion in 3 temperature groups: 37°C (MP37), 30°C (MP30), and 25°C (MP25). In the control group, lung grafts were preserved by static cold storage before transplantation. After ex vivo lung perfusion or static cold storage, the left lung was transplanted for 2 hours before the animal was killed. Sera and tissue were collected and analyzed. Results There were no differences in partial pressure of arterial oxygenation to fraction of inspired oxygen ratios during 4 hours of ex vivo lung perfusion between temperature groups. Tumor necrosis factor α significantly increased in the MP37 group during ex vivo lung perfusion, whereas this was not seen at lower temperatures. Extracellular DNA and high-mobility group box 1 perfusate concentrations increased significantly during ex vivo lung perfusion in all groups, but the rate of increase was diminished at lower temperature. Two hours post-transplant, there were no significant differences in partial pressure of arterial oxygenation to fraction of inspired oxygen ratios of the lung graft or serum damage-associated molecular pattern levels among groups. On histologic grading after transplantation, greater injury was observed in the MP30 and MP37 groups, but not MP25, when compared with static cold storage. Conclusions Subnormothermic ex vivo lung perfusion at 25°C reduces the production of inflammatory mediators during ex vivo lung perfusion and is associated with reduced histologic graft injury after transplantation.

Background Early-life severe respiratory syncytial virus (RSV) infection has been associated with subsequent risk of asthma and recurrent wheeze. However, changes in the association over time and the interaction effect of the age at first RSV infection are less well understood. We aimed to assess the time-varying association between RSV and subsequent asthma and wheeze admission and explore how the association was affected by the age at RSV infection. Methods We retrospectively followed up a cohort of 23 365 children for a median of 6.9 years using Scottish health databases. Children who were born between 2001 and 2013 and had RSV-associated respiratory tract infection (RTI) admissions under 2 years were in the exposed group; those with unintentional accident admissions under 2 years comprised the control group. The Cox proportional-hazards model was used to report adjusted hazard ratios (HRs) of RSV admissions on subsequent asthma and wheeze admissions. We did subgroup analyses by follow-up years. We also explored how this association was affected by the age at first RSV admission. Results The association was strongest in the first 2 years of follow-up and decreased over time. The association persisted for 6 years in children whose first RSV-RTI admission occurred at 6–23 months of age, with an adjusted HR of 3.9 (95% confidence interval [CI], 3.1–4.9) for the first 2 years, 2.3 (95% CI, 1.6–3.2) for 2 to Conclusions We found a more persistent association for subsequent asthma and wheeze in children whose first severe RSV infection occurred at 6–23 months compared to those whose first severe RSV infection occurred at 0–6 months. This provides new evidence for further assessment of the association and RSV intervention programs.

A 74-year-old man was transferred to our hospital following loss of consciousness and a 1-month history of anorexia. He underwent lung lobectomy 3 years before the current presentation because of lung carcinoma (T2N1M0). He was initially treated with antibiotics for aspiration pneumonia and his

The vallecular cyst is formed due to an obstruction in the collecting duct of a submucosal gland, thereby causing the accumulation of mucus within it. It is also known as a ductal cyst, mucus-retention cyst. DeSanto et al [1][1] identified that these vallecular cysts are due to distended ducts and

A 37-year-old man presented to the ENT outpatient clinic with progressive dysphagia and breathlessness on exertion for a year. The patient was tachypnoeic, with mild inspiratory stridor and orthopnoea. The neck had a generalised swelling, but no mass was clinically palpable. Indirect laryngoscopy

Vallecular rupture is a rare but potentially life-threatening condition that could have deleterious outcome due to upper airway and jugular venous compression. Postintubation airway rupture (PiAR) is a rare condition being tracheal rupture associated with emergent endotracheal intubation (EEI) the

A 43-year-old previously healthy man with hypertension presented to his primary care provider with fevers and dyspnea, after a history of cough and sinus congestion lasting several weeks. A chest radiograph demonstrated prominent interstitial markings with scattered alveolar opacities. Based on the

A previously healthy 26-year-old man presented with 1-month history of right-sided neck swelling. According to him, the swelling progressively increased in size over 1 week and concurrently became red and painful. There was no dysphagia or odynophagia. He denied recent fever, upper respiratory

The nasal mucosa functions as a frontline biological defense against various foreign substances and pathogens. Maintaining homeostasis of the nasal epithelium is necessary to promote good health. Nasal epithelia are constantly replaced under normal conditions. However, hereditary diseases, including primary ciliary dyskinesia and cystic fibrosis, can result in intractable dysfunction of the nasal mucosa. Since there is no treatment for this underlying condition, extrinsic manipulation is necessary to recover and maintain nasal epithelia in cases of hereditary diseases. In this study, we explored the use of airway epithelial cells (AECs), including multiciliated airway cells, derived from human induced pluripotent stem cells (iPSCs) on porcine atelocollagen vitrigel membranes, as a candidate of a therapeutic method for irreversible nasal epithelial disorders. To confirm the regenerative capacity of iPSC-derived AECs, we transplanted them into nasal cavities of nude rats. Although the transplanted cells were found within cysts isolated from the recipient nasal respiratory epithelia, they survived in some rats. Furthermore, the surviving cells were composed of multiple cell types similar to the human airway epithelia. The results could contribute to the development of novel transplantation-related technologies for the treatment of severe irreversible nasal epithelial disorders. Impact Statement Nasal respiratory epithelia are important for the functions of nasal cavity, including humidifying the air and filtering various toxic substances. However, hereditary diseases, including primary ciliary dyskinesia and cystic fibrosis, can result in intractable dysfunction of the nasal mucosa. Our novel method to transplant airway epithelial cells derived from human induced pluripotent stem cells will be a candidate method to replace malfunctioned nasal respiratory epithelia in such a situation. To secure our method's safety, we used porcine atelocollagen vitrigel membranes, which prevent the immune response and bovine spongiform encephalopathy, as a scaffold.

Background Cystic fibrosis (CF) is a genetic disease caused by mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR), which results in impaired airway mucociliary clearance, inflammation, infection, and respiratory insufficiency. The development of new therapeutics for CF are limited by the lack of reliable preclinical models that recapitulate the structural, immunological, and bioelectrical features of human CF lungs. Methods We leveraged organ-on-a-chip technology to develop a microfluidic device lined by primary human CF bronchial epithelial cells grown under an air-liquid interface and interfaced with pulmonary microvascular endothelial cells (CF Airway Chip) exposed to fluid flow. The responses of CF and healthy Airway Chips were analyzed in the presence or absence of polymorphonuclear leukocytes (PMNs) and the bacterial pathogen, Pseudomonas aeruginosa. Results The CF Airway Chip faithfully recapitulated many features of the human CF airways, including enhanced mucus accumulation, increased cilia density, and a higher ciliary beating frequency compared to chips lined by healthy bronchial epithelial cells. The CF chips also secreted higher levels of IL-8, which was accompanied by enhanced PMN adhesion to the endothelium and transmigration into the airway compartment. In addition, CF Airway Chips provided a more favorable environment for Pseudomonas aeruginosa growth, which resulted in enhanced secretion of inflammatory cytokines and recruitment of PMNs to the airway. Conclusions The human CF Airway Chip may provide a valuable preclinical tool for pathophysiology studies as well as for drug testing and personalized medicine.

In the clinical assessment of chronic rhinosinusitis with nasal polyps (CRSwNP), evaluation of symptoms, nasoendoscopy findings and sinus computed tomography (CT) scan staging is employed in the management plan. Although prior studies have been done to assess the correlation of the three modalities in CRSwNP, such evaluation in patients with eosinophilic and non-eosinophilic types of CRSwNP requires further investigation. The aim of this study was to correlate the sinus CT scan staging to symptom and endoscopic scores in both types of CRSwNP.Patients with CRSwNP were classified into 2 types, eosinophilic and non-eosinophilic. Both types were assessed by Sino-Nasal Outcome Test 22 (SNOT-22) symptom score, nasal endoscopy Lund Kennedy grading (LK) score and sinus CT Lund Mackay (LM) staging score. All three modalities were correlated.Forty-four patients were recruited for this study. There was significant correlation between sinus CT and symptom scores in the eosinophilic (r=.51, p=.031) and the non-eosinophilic (r=.76, p.001) types. There was no significant correlation between symptom and nasoendoscopic scores in the eosinophilic (r=.12, p=.641) and the non-eosinophilic (r=.22, p=.276) types. There was also no significant correlation between sinus CT and nasoendoscopic scores in the eosinophilic (r=.20, p=.418) and the non-eosinophilic (r=.14, p=.508) types.Sinus CT staging correlates well with the symptom score for both the eosinophilic and the non-eosinophilic types of CRSwNP. The good correlation suggests both modalities are a reliable guide for their evaluation and management planning.

BACKGROUND Postoperative bronchial anastomotic complications are not uncommon in lung transplant recipients. We investigated 2 surgical techniques (continuous and interrupted sutures) during bronchial anastomosis, comparing survival and postoperative bronchial complications. METHODS We retrospectively analyzed 421 patients who were transplanted in our center (February 2012 to March 2018). Patients were divided according to bronchial anastomotic technique (continuous or interrupted). Demographics and clinical parameters were compared for significance (P < .05). Comparison of postoperative morbidity included bronchial complications, venovenous extracorporeal membrane oxygenation support, and intervention requirements. Survival was assessed using Kaplan-Meier curve and log-rank tests (P < .05). RESULTS Of the 421 patients, 290 underwent bronchial anastomoses with continuous suture; 44 of these patients had postoperative bronchial complications (15.2%). Contrarily, 131 patients underwent the interrupted suture technique; 9 patients in this group had postoperative bronchial complications (6.9%). Demographics and clinical parameters included age, sex, ethnicity, etiology, lung allocation score, body mass index, donor age, lung transplant type, cardiopulmonary bypass usage, surgical approaches, and median length of stay. Postoperative complications (continuous vs interrupted) were bronchial complications (P = .017), venovenous extracorporeal membrane oxygenation support (P = .41), venoarterial extracorporeal membrane oxygenation support (P = .38), and complications requiring dilatation with stent placement (P = .09). Kaplan-Meier curve showed better survival in the interrupted group (P = .0002). CONCLUSIONS Our study demonstrated the comparable postoperative results between the continuous and interrupted technique.