Blunt traumatic tracheobronchial injury is rare, but can be potentially life-threatening. It accounts for only 0.5%-2% of all trauma cases. Patients may present with non-specific signs and symptoms, requiring a high index of suspicion with accurate diagnosis and prompt treatment. A 26-year-old female was brought into the emergency department after sustained a blunt trauma to the chest from a high impact motor vehicle accident. She presented with signs of respiratory distress and extensive subcutaneous emphysema from the chest up to the neck. Her airway was secured and chest drain was inserted for right sided pneumothorax. CT of the neck and thorax revealed a collapsed right middle lung lobe with a massive pneumothorax, raising the suspicion of a right middle lobe bronchus injury. Diagnosis was confirmed by bronchoscopy. In view of the difficulty in maintaining her ventilation and persistent pneumothorax with a massive air leak, immediate right thoracotomy via posterolateral approach was performed. The right middle lobar bronchus tear was repaired. There were no intra- or post-operative complications. She made an uneventful recovery. She was asymptomatic at her first month follow-up. A repeated chest X-ray showed expanded lungs. Details of the case including clinical presentation, imaging and management were discussed with an emphasis on the early uses of bronchoscopy in case of suspected blunt traumatic tracheobronchial injury. A review of the current literature of tracheobronchial injury management was presented.
Foreign body aspiration in the adult airway is very rare. A neglected foreign body can occur when the patient is mentally challenged or is in an unconscious condition such as following trauma. The diagnosis can be delayed because there is no typical history of choking or breathing difficulty.
Peripheral transbronchial needle aspiration (pTBNA) allows the access of pulmonary nodules without bronchus sign but is limited to cytological examination. A 39-year-old man with left parotid carcinoma presented with an incidental lung nodule. Target localisation was performed with manual airway mapping, virtual bronchoscopic navigation, and pTBNA. Direct target validation using radial endobronchial ultrasound (rEBUS) was performed through the puncture defect. Targeted pinpoint biopsy with a 1.1 mm cryoprobe through the pTBNA puncture defect confirmed metastatic adenoid cystic carcinoma. Guided pTBNA with rEBUS validation followed by cryobiopsy of lung nodules without bronchus sign is potentially feasible for histological and molecular analyses.
Bronchial artery embolization (BAE) is the mainstay treatment for massive haemoptysis. Herein we briefly discuss the tips and tricks of super-selective embolization of bronchial artery using N-butyl-2 cyanoacrylate (NBCA). Based on our experience, this technique produces a better resolution and exhibit high non- recurrence rate in the treatment of massive haemoptysis.
Congenital lobar emphysema has been described under various designations. Although the etiology is not clear, some form of bronchial obstruction has been documented in about 50% of the patients. A rare case of congenital lobar emphysema with a membranous septum in the left main bronchus is described. Although prompt lobectomy has been the treatment of choice in most cases, this case demonstrates the importance of early bronchoscopy to exclude treatable intra luminal abnormalities.
A J-shaped suction catheter was tailored to facilitate aspiration of the right upper lobe bronchus during rigid bronchoscopy in pediatric patients. This suction catheter was used successfully in three patients.
A fractured tracheostomy tube is a rare complication; cases have been reported in the past, usually associated with prolonged usage in patients with chronic airway obstruction. We present here a fracture occurring in a new tube, and also describe a method for retrieving the tube from the tracheobronchial tree.
From 1973 to 1982,40 children with respiratory distress was bronchoscoped for suspected foreign body in the trachea-bronchial tree. In 31 children, foreign bodies were found and were successfully removed. The condition appeared to be confined to the early toddler group. Six children had pulmonary complications post-operatively. There was no death. A plea is made for early diagnosis and referral to lessen the likelihood of residual pulmonary damage.
Study site: University Hospital, Kuala Lumpur, Malaysia (current name: University Malaya Medical Centre)
405 cases of bronchial brushing cytology were evaluated for its effectiveness in detecting pulmonary carcinoma. Cytohistologic findings were correlated whenever endoscopic biopsies were performed. Sputum cytological investigations were also included in this paper to examine the total diagnostic sensitivity of all the three methods combined.
Foreign bodies in the laryngotracheobronchial tree are not uncommon. Their clinical presentations, the radiological and endoscopic findings in sixteen cases that presented to the Department of Otorhinolaryngology, Universiti Kebangsaan Malaysia were reviewed. The technique of removal is also discussed.
Study site: Hospital Kuala Lumpur, Malaysia (UKM unit)
A retrospective review of all bronchoscopy cases for investigation of lung cancer between January 1997 and December 1999 was done. The cases were included if endobronchial mass was visible (Group A) or when there was an abnormal mucosa and/or bronchial narrowing in the absence of a mass (Group B). All patients in Group A (n = 177) underwent endobronchial biopsy (EB) bronchial brushings (BB) and bronchial washings (BW). All cases in Group B underwent transbronchial biopsy (TBB), BB and BW. Only a small increase in the positive results for cancer was seen when cytology specimens (BB and BW) were added to EB (85.3% vs 88.1%, McNemar's P = 0.06) in Group A but there was a significant increase in Group B (37.3% vs 54.2%. McNemar's, P = 0.001). Therefore although cytology specimens did not significantly add to overall yield of positive results when endobronchial lesions were visible, when mass lesions were not visible, cytology specimens increased the yield by 16.9%.
Study site: Chest clinic, Hospital Sultanah Aminah (HSA), Johor Bahru, Johor, Malaysia
Cladosporium spores are ubiquitous in indoor and outdoor environment and may potentially trigger allergic responses upon inhalation. To date, there is limited investigation on the fate of Cladosporium spores after being inhaled into the respiratory tract. This study was conducted to investigate the interaction of Cladosporium sphaerospermum with Human Bronchial Epithelial Cells (BEAS-2B) and Human Pulmonary Alveolar Epithelial Cells (HPAEpiC). C. sphaerospermum conidia were harvested and co-cultured with BEAS-2B or HPAEpiC cells for 72 hours. At each time point (30 minutes, 2, 4, 24, 48 and 72 hours), adherence and invasion of the cells by C. sphaerospermum conidia (and hyphae) were investigated by immunofluorescence staining. This study demonstrated the adherence and internalization of C. sphaerospermum conidia within these epithelial cells. In addition, the conidia were able to germinate and invade the epithelial cells. The ability of the fungal conidia to adhere, internalize, germinate and invade both the bronchial and alveolar epithelial cells of the respiratory tract in vitro might contribute to the understanding of the pathogenesis of Cladosporium in respiratory infection and allergy in vivo.
Understanding the fundamental processes involved in repairing the airway wall following injury is fundamental to understanding the way in which these processes are perturbed during disease pathology. Indeed complex diseases such as asthma and chronic obstructive pulmonary disease (COPD) have at their core evidence of airway wall remodeling processes that play a crucial functional role in these diseases. The authors sought to understand the dynamic cellular events that occur during bronchial airway epithelial repair in sheep. The injury was induced by endobronchial brush biopsy (BBr), a process that causes epithelial débridement and induces a consequential repair process. In addition, the current experimental protocol allowed for the time-dependent changes in airway wall morphology to be studied both within and between animals. The initial débridement was followed by evidence of dedifferentiation in the intact epithelium at the wound margins, followed by proliferation of cells both within the epithelium and in the deeper wall structures, notably in association with the submucosal glands and smooth muscle bundles. Seven days after injury, although the airway wall was thickened at the site of damage, the epithelial layer was intact, with evidence of redifferentiation. These studies, in demonstrating broad agreement with previous studies in small animals, indicate the wider relevance of this system as a comparative model and should provide a solid basis upon which to further characterize the critical cellular and molecular interactions that underlie both effective restitution and pathological repair.
A trial was conducted to observe the immediate and chronic effects in goats of dexamethasone administration on the bronchus-associated lymphoid tissue (BALT) response to intranasal administration of formalin-killed Pasteurella haemolytica A2. Twenty-four goats were divided into four groups. Those in group 1 were injected intramuscularly with 1 mg/kg dexamethasone on three consecutive days, followed by intranasal exposure to formalin-killed P. haemolytica A2 one day after the last dexamethasone treatment. The goats in group 2 were similarly injected with dexamethasone followed by intranasal exposure to formalin-killed P. haemolytica A2 21 days after the last dexamethasone treatment. The animals in group 3 were exposed intranasally to formalin-killed P. haemolytica A2 without prior dexamethasone treatment. The animals in group 4 were untreated controls. The intranasal exposures to formalin-killed P. haemolytica A2 were repeated 2 weeks later. Intranasal exposure to formalin-killed P. haemolytica 1 day after dexamethasone treatment further reduced the number and size of BALT compared to the untreated control. Significantly (p < 0.01) more reduction of BALT occurred in goats exposed to formalin-killed P. haemolytica A2 21 days after dexamethasone treatment. On the other hand, intranasal exposure of goats without prior dexamethasone treatment stimulated the BALT compared to the untreated controls.
The Malaysian strain of Nipah virus (NiV) first emerged in 1998/99 and caused a major disease outbreak in pigs and humans. While humans developed fatal encephalitis due to a prominent infection of brain microvessels, NiV-infected pigs mostly suffered from an acute respiratory disease and efficiently spread the infection via airway secretions. To elucidate the molecular basis of the highly productive NiV replication in porcine airways in vitro, physiologically relevant cell models that have maintained functional characteristics of airway epithelia in vivo are needed. Here, we describe in detail the method of isolating bronchial epithelial cells (PBEpC) from pig lungs that can be used for NiV infection studies. After the dissection of primary bronchia and removal of the mucus and protease digestion, bronchi segments are cut open and epithelial cells are scraped off and seeded on collagen-coated cell culture flasks. With this method, it is possible to isolate about 2 × 106 primary cells from the primary bronchi of one pig lung which can be cryopreserved or further subcultured. PBEpC form polarized monolayers on Transwell membrane inserts as controlled by immunostainings of epithelial marker proteins. NiV infection causes rapid formation of syncytia, allowing productive NiV infections in living PBEpC cultures to be monitored by phase-contrast microscopy.
Tracheobronchial injuries are uncommon and a high level of suspicion is needed for immediate diagnosis and prompt treatment. In this case series, two rare cases of tracheobronchial injuries is described showing variable clinical presentations with different levels of injury. Our first case was seen in a 20 years old male whom had a direct impact on the neck and presented with upper tracheal injury. On arrival, this patient was in respiratory distress and had bilateral pneumothorax. Bilateral chest tube was inserted with subsequent neck exploration. During the neck exploration, anastomosis of the injured trachea was performed. The second case was represented by a 35 years old man with right main bronchial injury. Upon initial presentation, this patient appeared well and was comfortable under room air. However he gradually deteriorated one week after the trauma requiring surgical intervention. Eventually a thoracotomy with primary anastomosis of the bronchial tear was performed. Details of both cases including clinical presentation, imaging and procedures done will be discussed in this article.
An experiment was designed to study the in vivo effect of Pasteurella haemolytica A2 infection on the phagocytosis activity of caprine broncho-alveolar macrophages and the extent of pneumonic lesions. Twelve healthy local Kacang goats, about 7 months of age, were divided into two groups of six. Goats in group 1 were inoculated intratracheally with 4 ml inoculum containing 2.8 x 10(9) colony-forming units (CFU)/ml of Staphylococcus aureus. Goats in group 2 were inoculated intratracheally with 4 ml of inoculum containing 9.5 x 10(8) CFU/ml of Pasteurella haemolytica A2 isolated earlier from pneumonic lungs of goat. At intervals of 3 and 7 days post-challenge five goats from each group were killed and the lungs were washed with sterile phosphate-buffered saline. Smears were prepared from the lung washing fluid and the number of macrophages with phagocytic activity was determined. At day 3 post-infection, goats of both groups showed a similar pattern of pneumonic lesion. The lung washing fluid of goats in group 2 was found to contain numerous neutrophils and macrophages. Goats in group 2 showed significantly (P < 0.05) higher extent of lung lesions than group 1. Similarly, the average extent of lung lesions was significantly (P < 0.05) more severe in group 2 at day 7 post-infection. The lung washing fluid contained mostly macrophages. The phagocytic activity following S. aureus infection was more efficient and significantly (P < 0.01) higher compared with infection by P. haemolytica A2. There were weak correlations between the extent of pneumonic lesion and the phagocytic activity. Thus, goats with poor phagocytic activity were likely to develop more extensive lung lesions.
Twenty goats of about 7 months of age were divided into five groups. The goats in groups 1 and 2 were exposed once, using an intranasal spray to 2 ml of an inoculum containing 10(6) colony-forming units/ml of living or dead Pasteurella haemolytica A2, respectively. The goats in groups 3 and 4 were similarly exposed twice at a 2-week interval. Group 5 was the untreated control. The number and size of the bronchus-associated lymphoid tissue (BALT) in goats exposed twice to either living or dead organisms were significantly (p < 0.05) increased compared with those exposed once and with the unexposed control. In vitro colonization by living P. haemolytica A2 onto the lung tissue in which the BALT had been stimulated by two exposures of either living or dead organisms was significantly (p < 0.05) reduced. The study indicates that stimulation of the respiratory mucosal immunity may prevent P. haemolytica A2 infection.
Accidental endobronchial intubation is a frequent complication in critically ill patients requiring tracheal intubation (TI). If such complication occurs, it is more often the right main bronchus that is intubated due to anatomical reasons. Left main bronchus (LMB) intubation is rare. Here, we report a case with auscultatory, bronchoscopic, and radiographic evidence of accidental LMB intubation in a pregnant woman with dengue shock syndrome. We highlight this case to increase awareness about this possible-but-rare complication of TI.