A Technique of Tracheostomy

The Björk technique of performing tracheostomy is outlined. This consists of suturing an inverted U-shaped flap of trachea to the skin edge. Some of its advantages, particularly in infants, are outlined.     

An alternative method of endotracheal intubation of common marmosets (Callithrix jacchus)

Endotracheal intubation was carried out in 11 common marmosets (Callithrix jacchus). A commercially available tilting stand and a Miller laryngoscope blade were used to visualize the larynx. Anaesthesia was induced with alphaxalone (10.6 ± 1.6 mg/kg intramuscularly, followed by 3.2 ± 1.2 mg/kg intravenously). The diameter of the proximal trachea easily fitted an endotracheal tube made from readily available material (a 12 G 'over the needle' catheter). Once the tip of the endotracheal tube was at the level of the vocal folds, the tube had to be gently rotated through a 180° angle in order to pass through the larynx into the trachea. Assessment of the dimensions of the larynx and trachea, and comparison with external anatomical features of the animals (n = 10) showed that the length of the trachea could be predicted by multiplying the craniosacral length of the marmoset by a factor of 0.42.     

Progress in larynx-sparing surgery for glottic cancer through tracheal transplantation.

The current surgical treatment for unilateral, advanced glottic cancer is a total laryngectomy. Usually, the noninvolved hemilarynx needs resection because the resulting laryngeal defect cannot be reconstructed after adequate tumor resection. Experimental findings suggest that segments of autologous trachea may restore extended laryngeal defects. The authors used tracheal transplantation to save laryngeal function after the removal of advanced glottic cancer. In this case series review, 10 patients were treated during a 1.5-year period, with an average follow-up of 8 months. Evaluated factors included survival of the tracheal transplant and functional outcome with regard to the onset and quality of the airway, speech, and deglutition. The authors showed that segments of cervical trachea may restore extended laryngeal defects after initial revascularization by a radial forearm fascial flap. The fascial flap served as a vascular carrier for the transplanted trachea. Follow-up showed the stability of the reconstruction. Compared with a total laryngectomy, a striking improvement in patient comfort and function was noticed. Transplantation of the trachea is a technique that may save laryngeal function after the treatment of advanced-stage glottic cancer. These findings may improve laryngeal preservation strategies in treating laryngeal cancer.     

Ontogeny of endocrine cells in the respiratory system of Syrian golden hamsters

The ontogeny of protein gene product 9.5 (PGP 9.5), serotonin (5-HT), calcitonin gene-related peptide (CGRP), and calcitonin (CT) immunoreactivity was evaluated in small-granule endocrine cells of hamster laryngotracheal epithelium from fetal day 11 to adulthood. Two centrifugal (proximal-to-distal) patterns of differentiation occur. The first pattern begins during fetal life. Endocrine cells, single and clustered in groups (presumptive-or protoneuroepithelial bodies, pNEBs), initially colocalize immunostaining for PGP 9.5, 5-HT, and CGRP in the larynx and proximal 2/3 of the trachea on day 12 and spread to the caudal trachea on day 13.5-HT disappears fleetingly during the 24 h preceding birth; other-wise immunoreactivity for all three substances persists into adulthood. The clusters of endocrine cells survive beyond birth but are so diluted by expansion of the nonendocrine epithelium as to become inconspicuous. Since innervation was not actually observed, these clusters may persist as pNEBs, without developing connections to afferent or efferent nerve fibers. The second pattern concerns single small-granule cells stainable for CGRP but not for 5-HT. These cells first appear in the larynx and cartilaginous part of the cranial trachea on postnatal day 3, and in the middle and caudal trachea, on day 5. The cells increase in number on day 7. In adults, they predominate among endocrine cells of the cartilaginous region. A subset of these cells begins to co-express CT proximally on postnatal day 10, reaching the caudal end of the trachea by 3 weeks. A few elements of the older 5-HT-positive population may also become immunoreactive for CT in juvenile hamsters.     

Long-term retention of 133Ba in the rat trachea following local administration as barium sulfate particles

Long-term retention of 133Ba in the trachea from intratracheally administered BaSO4 particles was determined by both serial sacrifice and external scanning methods up to 6 months after injection. The amount of 133Ba retained 1 week after injection in the caudal region of the trachea, where the tip of the cannula had been at injection, was 0.41% of the initial dose. Thereafter the 133Ba was cleared exponentially with a mean half-time of 88 days, as determined from the autopsy samples. The cranial region of the trachea, including the site of the tracheostomy, contained 133Ba at 10 times the level in the caudal region 1 week after injection and was cleared with a half-time of 66 days. These clearance rates were confirmed by repeated external scanning over the trachea. The 133Ba was drained to the lymph nodes not only in the thoracic cavity but also in the cervical region, suggesting the possibility of lymphatic drainage from the trachea to the cervical lymph nodes.     

Residual strains in porcine and canine trachea

Residual strains exist in canine and porcine tracheas. They are revealed by cutting the trachea first perpendicular to its axis into rings, then radially into sectors. Each sector is characterized by an opening angle which is defined as the angle subtended between two radii joining the middle point of the inner wall to the tips of the inner wall. The trachea being non-axisymmetric, the opening angle depends on the position of the radial cut. The trachea being also nonuniform in the axial direction, the opening angle varies along the length of the trachea. In the dog, the opening angle of the trachea cut at the anterior position (cartilaginous) is about 100 degrees at the larynx; it increases fairly linearly to 180 degrees midway down the trachea; then increases slowly to about 200 degrees at the lower end where the trachea bifurcates into the main bronchi. Dog trachea cut in the posterior (muscular) position have an opening angle of about 50 degrees at the larynx, which increases to about 70 degrees three-quarters of the way down the trachea, then drops to 60 degrees at the lower end. In the pig, the opening angle of the trachea is much smaller, the values at anterior and posterior cuts are similar (without significant difference), and their mean value decreases from about 15 degrees at the laryngeal end to about 5 degrees at the lower end. These species and regional differences are discussed in relation to tracheal geometry and structure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ventilation of a rat with a large-animal respirator

Rats were effectively ventilated with 100% O2 mixed with room air utilizing a modified tracheostomy tube and a Bird Mark 7 respirator to maintain arterial blood gases within normal limits. A 3-cm segment of rubber pilot tubing was attached to a 15-mm respiratory connector and a 3-cm piece of polyethylene catheter tubing was fitted snugly into the other end. The catheter was inserted and secured into the trachea of 250- to 500-g Sprague-Dawley rats with the adaptor hose of the respirator fitted onto the 15-mm connector following tracheostomy. Manometer and inspiratory flow rate controls of the respirator were set to their minimum operating position. Appropriate rate control adjustments were made when necessary as determined by arterial blood gas measurements. By use of the above ventilation system, adequate arterial blood gases of anesthesized rats can be maintained for greater than 3 h.     

Ontogeny of endocrine cells in the respiratory system of Syrian golden hamsters

The ontogeny of protein gene product 9.5 (PGP 9.5), serotonin (5–HT), calcitonin gene-related peptide (CGRP), and calcitonin (CT) immunoreactivity was evaluated in small-granule endocrine cells of hamster laryngotracheal epithelium from fetal day 11 to adulthood. Two centrifugal (proximal-to-distal) patterns of differentiation occur. The first pattern begins during fetal life. Endocrine cells, single and clustered in groups (presumptive- or protoneuroepithelial bodies, pNEBs), initially co-localize immunostaining for PGP 9.5, 5–HT, and CGRP in the larynx and proximal 2/3 of the trachea on day 12 and spread to the caudal trachea on day 13. 5–HT disappears fleetingly during the 24 h preceding birth; otherwise immunoreactivity for all three substances persists into adulthood. The clusters of endocrine cells survive beyond birth but are so diluted by expansion of the nonendocrine epithelium as to become inconspicuous. Since innervation was not actually observed, these clusters may persist as pNEBs, without developing connections to afferent or efferent nerve fibers. The second pattern concerns single small-granule cells stainable for CGRP but not for 5–HT. These cells first appear in the larynx and cartilaginous part of the cranial trachea on postnatal day 3, and in the middle and caudal trachea, on day 5. The cells increase in number on day 7. In adults, they predominate among endocrine cells of the cartilaginous region. A subset of these cells begins to co-express CT proximally on postnatal day 10, reaching the caudal end of the trachea by 3 weeks. A few elements of the older 5–HT-positive population may also become immunoreactive for CT in juvenile hamsters.     

气管插管患者行经皮扩张气管切开术的安全性研究

目的研究气管插管患者行经皮扩张气管切开术的安全性。方法将121例经口气管插管患者随机分成对照组59例,观察组62例。两组患者均行经皮扩张气管切开术,对照组按常规方法于局麻前将气管插管拔出至门齿18～20cm处,观察组在经皮扩张完气管前壁后将气管插管全部拔出。结果两组患者手术操作时间、出血量比较差异均无统计学意义（P〉0.05）;气管插管意外脱出发生率比较,对照组高于观察组,差异有统计学意义（P〈0.05）。结论在扩张气管前壁后拔出气管插管更有利于患者安全。     

Modeling the bifurcating flow in a CT-scanned human lung airway

The inspiratory flow characteristics in a CT-scanned human lung model were numerically investigated using low Reynolds number (LRN) kappa-omega turbulent model. The five-generation airway is extracted from the trachea to segmental bronchi of a 60-year-old Chinese male patient. Computations were carried out in the Reynolds number range of 900-2100, corresponding to mouth-air breathing rates of 190-440ml/s. Flow patterns on the Re=2100 and flow rate distribution were presented. In this model, the flow pattern is very complex. To count the effect of laryngeal jet on trachea inlet, the trachea was extended and modified to simulate the larynx, consequently the inlet velocity profile is biased towards the rear wall. In the inferior lobar bronchi, there are two stems in which the axial velocity is stronger but secondary velocity is weaker. Secondary flow in the lateral bronchi is stronger than the medial ones. With increasing Re, the air flow increases in the middle, inferior lobes and left main bronchus, i.e., flow biases to left and downward.     

Particle deposition in a CT-scanned human lung airway

The particle deposition in a computerized tomography (CT)-scanned human lung was numerically investigated. The five-generation airway is extracted from the trachea to segmental bronchi of a 60-year-old Chinese male patient. Computations were carried out in the flow rate range of 210–630 ml/s (Reynolds number range of 1000–3000) and particle size of 2–10 μm (Stokes number range of 0.0007–0.049). To count the effect of laryngeal jet on trachea inlet, the trachea was extended and modified to simulate the larynx, consequently the inlet velocity profile is biased towards the rear wall. The laryngeal jet-induced turbulence was simulated using low Reynolds number (LRN) κ–ω turbulent model. Particle deposition patterns, deposition efficiency and deposition factor were studied in detail. The turbulent flow has significant effect on the particle deposition, and the present deposition factor is compared well with the available data.     

胃促胰酶和肥大细胞在豚鼠过敏性休克死亡的应用

目的:建立豚鼠过敏性休克模型,研究胃促胰酶和肥大细胞在过敏性休克诊断上的应用。方法:20只清洁级豚鼠随机分为10只实验组和10只对照组,应用混合人血清构建的过敏模型,ELISA方法测定豚鼠血清Ig E含量,免疫组化染色观察胃促胰酶在喉头、气管、肺、胃、肠的表达,肥大细胞特殊染色计数肥大细胞。结果:实验组豚鼠有70%发生过敏性休克死亡,实验组豚鼠血清中Ig E的含量显著高于对照组豚鼠(P0.05),实验组豚鼠于喉头、气管、肺胃促胰酶的表达高于对照组(P0.05),实验组豚鼠于喉头、气管、肺、胃的肥大细胞总数高于对照组豚鼠(P0.05),肺组织观察到肥大细胞脱颗粒。结论:胃促胰酶和肥大细胞可以为过敏性休克死亡的法医学鉴定提供参考。     

Invasive <Emphasis Type="Italic">Aspergillus</Emphasis> Laryngotracheobronchitis in an Adult with Primary CNS Lymphoma

Invasive aspergillosis can be difficult to diagnose, and early recognition and initiation of therapy is imperative for improving patient outcomes. A case of invasive Aspergillus laryngotracheobronchitis is presented here with a review of the relevant literature. A 58-year-old male undergoing treatment for CNS lymphoma presented with neutropenic sepsis and acute respiratory distress requiring intubation. Following extubation, he reported persistent hoarseness for 1-month duration and he was found to have pseudomembranous plaques and ulcers of the larynx, trachea, and right mainstem bronchus consistent with Aspergillus laryngotracheobronchitis. Invasive Aspergillus laryngotracheobronchitis should be considered in immunocompromised patients presenting with persistent hoarseness.     

A retrospective analysis of 48 infected sternal wound closures: delayed closure decreases wound complications

Forty-eight patients who suffered sternal wound infections following coronary artery bypass grafting were retrospectively reviewed over a 5-year period. All patients in this study had clinical signs of major infection including redness, pain, and purulence at the time of mediastinal drainage and debridement. One patient died 11 days postoperatively because of heart failure, leaving 47 patients available for long-term follow-up. All muscle flaps (pectoralis and rectus abdominis) survived completely. All wound complications were related to chest wall skin flap dehiscence or continued infection. Seventeen of 22 patients (77 percent) undergoing flap closure 4 days or less after sternal debridement and irrigation suffered wound complications. Five of these 22 patients (23 percent) had major wound complications, meaning that the wound required more than 2 months of care before healing was complete. No major wound complications and only three minor complications (12 percent) occurred in 25 patients undergoing sternal flap closure 5 days or more after mediastinal debridement and irrigation. The frequency and severity of wound complications were significantly decreased in the group of patients undergoing sternal flap closure 5 or more days after sternal drainage and debridement (p < 0.00005). In the majority of cases [29 of 47 (62 percent)], secure sternal wound closure was obtained with a single, split, medially based, right pectoralis major muscle flap.     

Reflex changes in tracheal smooth muscle tone during high-frequency oscillation

We examined the effect of high-frequency oscillatory ventilation (HFOV) on tracheal smooth muscle tension and upper airway resistance in anesthetized dogs. The animals were ventilated via a low tracheostomy by HFOV or conventional intermittent positive pressure ventilation (IPPV) with and without added positive end-expiratory pressure (PEEP). The transverse muscle tension of the trachea above the tracheostomy was measured and found to be lower during HFOV when compared with IPPV or IPPV with PEEP. When both vagi were cooled to 8 degrees C to interrupt afferent traffic from the lungs, there was no longer any difference between the modes of ventilation. In a second series of experiments, the airflow resistance of the upper airway above the tracheostomy was measured (Ruaw). During HFOV, Ruaw was significantly lower than during either IPPV or IPPV with PEEP. We conclude that HFOV induces a relaxation of tracheal smooth muscle and a reduction of upper airway resistance through a vagally mediated mechanism.     

Resistance and reactance of the excised human larynx, trachea, and main bronchi

We investigated the impedance of excised preparations of the human larynx before and after resection of the vocal cords and of the trachea whether or not in connection with the main bronchi for steady (75-700 ml.s-1) and oscillatory flows (4-64 Hz). To simulate the influence of respiratory flow on oscillatory resistance (Rosc), oscillatory and steady flow were superimposed. This resulted in a marked increase of Rosc, dependent on the value of steady flow, a change of the frequency dependence of Rosc, and a decrease of the reactance. The latter effects were particularly pronounced in the preparations of the larynx, especially with a narrow glottis opening. The influence of steady flow on oscillatory resistances is probably the expression of interactions of steady and oscillatory flow regimes in the larynx. Similar but less pronounced interactions are also met in the trachea. These effects lead to a systematic overestimation of upper airway resistance when measured during spontaneous breathing by means of a forced oscillation technique.     

Bronchial distribution of gas mixing in a model of the upper and central airways

Longitudinal mixing of He, O2, and sulfur hexafluoride boluses with air flowing through a three-generation tracheobronchial airway model was evaluated as the increase in volume variance of gas concentration distributions monitored at upstream and downstream sampling ports. Mixing was partitioned between tracheal and branched regions of the model at steady inspiratory and expiratory airflows from 0.044 to 0.884 l/s, both in the absence and in the presence of a removable larynx cast. During inspiration in the absence of the larynx, mixing increased as airflow increased, reaching a peak value at 0.2 l/s, and decreasing as airflow increased further. This mixing peak was higher in the branched region than in the tracheal region and was inversely related to the diffusion coefficient of the indicator gas-air mixture. During inspiration in the presence of the larynx, a mixing peak was observed in the tracheal region, but mixing peaks in the branched region were eliminated by turbulence propagated downstream from the larynx. During expiration, laryngeal turbulence was propagated far enough downstream (i.e., proximal to the trachea) that mixing peaks could be observed in both tracheal and branched regions whether or not the larynx cast was present.     

Unusual metastasis of papillary thyroid carcinoma to larynx and hypopharynx a case report

Background  

Although direct infiltration of papillary carcinoma of thyroid to larynx, trachea and esophagus is well recognized, lymphatic and vascular metastases to larynx and hypopharynx have rarely been reported.     

Respiratory Nursing Interventions Following Tracheostomy in Acute Traumatic Cervical Spinal Cord Injury

Tracheostomy is frequently performed in severe cervical spinal cord injury (SCI) patients with the pulmonary dysfunction. A series of respiratory nursing interventions are required to plan tracheostomy removal. Tracheostomy was performed in 29 patients after acute traumatic cervical SCI. A series of respiratory nursing interventions were introduced in these patients after closed tracheostomy and decannulation, including closed tracheostomy tube training, manually assisted cough. Chacheostomy was successfully removed in 21 patients after the respiratory nursing interventions. In contrast, eight patients died from associated injuries. The average time from tracheostomy to decannulation was 40 days (14–104 days), the average time from closed tracheostomy to decannulation was 18.80 ± 13.50 days. Second tracheostomy was performed in one patient after 29 days’ removal due to pulmonary infection. One patient presented with delayed incision healing for 29 days. Closed tracheostomy tube training and manually assisted cough are key factors for tracheostomy removal, although intensive nursing are also needed. The time from tracheostomy to decannulation and from closed tracheostomy to decannulation is increased in case of "late" (>24 h) tracheostomy and longer mechanical ventilation.     

Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure

In surgical treatment of head and neck cancer, when local tumor recurrence or failure of the previous reconstruction method occurs, reoperation for reconstruction of complicated soft-tissue defects can become a challenge for the plastic surgeon. This article describes the authors' experience with the extended vertical trapezius myocutaneous flap for head and neck complicated soft-tissue defects in nine patients ranging in age from 17 to 72 years. The causes of the defects were squamous cell carcinoma of the external ear (n = 2), lip (n = 2), larynx (n = 1), and oral cavity floor (n = 1); congenital hemifacial atrophy-temporomandibular joint ankylosis (n = 1); synovial sarcoma at the mandibular ramus (n = 1); and malignant fibrous histiocytoma at the posterior cranial fossa (n = 1). Eight of the nine patients had previously been operated on using other flap procedures, including free flaps and/or distant pedicled flaps (pectoralis major and deltopectoral flaps). One patient had been operated on using a graft procedure. After failure of the previous flap procedures in four patients and tumor recurrence in five patients, the extended vertical trapezius myocutaneous pedicled flap was used as a salvage procedure. The mean flap size was 7 x 34 cm. The flap was based solely on the transverse cervical artery. Superior muscle fibers of the trapezius were preserved and the caudal end of the flap was extended from 10 to 13 cm beyond the caudal end of the trapezius muscle. Three weeks postoperatively, the pedicle was separated. No flap failure occurred. The donor sites were closed primarily. There were no disabilities with regard to shoulder motion. Tumor recurrence was observed in two patients. In conclusion, for complicated soft-tissue defects of the head and neck, the extended vertical trapezius flap can be preferred as a salvage procedure because it is a simple, reliable, large flap that is located far enough from the damaged area.