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Introduction: Angioedema, a swelling of the subcutaneous or submucosal layers of the skin or gastrointestinal tract, is a potential complication to thrombolytic therapy in the treatment of acute ischemic strokes. In these cases, angioedema develops due to increased levels of bradykinin as a result of the activation of the fibrinolytic pathway and contact activation system. Angioedema can involve the tongue, larynx, and vocal cords, leading to occlusion of the airway and death due to asphyxiation. It is vital for the emergency physician to know that this complication can occur to ensure appropriate monitoring for development of angioedema.Case Report: We report the case of a 65-year-old Black man who presented with signs of an acute ischemic stroke and was treated with tenecteplase. The patient’s stroke symptoms mostly resolved within 90 minutes; however, he developed swelling of his right upper lip consistent with angioedema. The patient was treated with steroids and antihistamines. He was closely monitored and did not require airway intervention. The angioedema was almost fully resolved by the following day.Conclusion: Angioedema is a known complication of thrombolytic therapy for acute ischemic stroke. Risk factors for alteplase-associated angioedema include use of angiotensin-converting enzyme inhibitors, female gender, diabetes, and infarcts of the insula and frontal cortex. As hospital systems switch from alteplase to tenecteplase for the treatment of acute ischemic strokes for reasons of cost and ease of administration, it is important to recognize that angioedema is also a potential complication of tenecteplase.

Bovine respiratory disease (BRD) is the leading cause of mortality and antimicrobial drug (AMD) use in weaned dairy heifers. Limited information is available regarding antimicrobial resistance (AMR) in respiratory bacteria in this population. This study determined AMR gene presence in 326 respiratory isolates (Pasteurella multocida, Mannheimia haemolytica, and Histophilus somni) from weaned dairy heifers using whole genome sequencing. Concordance between AMR genotype and phenotype was determined. Twenty-six AMR genes for 8 broad classes of AMD were identified. The most prevalent, medically important AMD classes used in calf rearing, to which these genes predict AMR among study isolates were tetracycline (95%), aminoglycoside (94%), sulfonamide (94%), beta-lactam (77%), phenicol (50%), and macrolide (44%). The co-occurrence of AMR genes within an isolate was common; the largest cluster of gene co-occurrence encodes AMR to phenicol, macrolide, elfamycin, β-lactam (cephalosporin, penam cephamycin), aminoglycoside, tetracycline, and sulfonamide class AMD. Concordance between genotype and phenotype varied (Matthews Correlation Coefficient ranged from -0.57 to 1) by bacterial species, gene, and AMD tested, and was particularly poor for fluoroquinolones (no AMR genes detected) and ceftiofur (no phenotypic AMR classified while AMR genes present). These findings suggest a high genetic potential for AMR in weaned dairy heifers; preventing BRD and decreasing AMD reliance may be important in this population.

Cardiac catheterization remains the gold standard for the diagnosis and management of pediatric pulmonary hypertension (PH). There is lack of consensus regarding optimal anesthetic and airway regimen. This retrospective study describes the anesthetic/airway experience of our single center cohort of pediatric PH patients undergoing catheterization, in which obtaining hemodynamic data during spontaneous breathing is preferential. A total of 448 catheterizations were performed in 232 patients. Of the 379 cases that began with a natural airway, 274 (72%) completed the procedure without an invasive airway, 90 (24%) received a planned invasive airway, and 15 (4%) required an unplanned invasive airway. Median age was 3.4 years (interquartile range [IQR] 0.7-9.7); the majority were either Nice Classification Group 1 (48%) or Group 3 (42%). Vasoactive medications and cardiopulmonary resuscitation were required in 14 (3.7%) and eight (2.1%) cases, respectively; there was one death. Characteristics associated with use of an invasive airway included age

Background: Angiotensin-converting enzyme inhibitors (ACEI) are the most common cause of drug-induced angioedema in the United States. Our primary objective was to provide descriptive evidence regarding emergency department (ED) disposition of ACEI-induced angioedema patients. Our secondary objective was to evaluate unique patterns in those with ACEI-induced angioedema at a tertiary referral center, including demographics, details of those requiring intubation, length of inpatient stay, and allergy documentation. Methods: This was a retrospective study evaluating all cases of ACEI-induced angioedema at a large, regional academic medical center. We performed a medical record review to identify patients with ACEI-induced angioedema who presented to the ED from January 1, 2016, to December 31, 2022. A structured data abstraction process was utilized to select patients of interest, followed by descriptive statistics, chi-square tests and odds ratios for categorical data, and Kruskal Wallis tests for continuous data. Results: A total of 637 unique patient encounters met potential inclusion. After a substantial, standardized review, 94 patients met inclusion. During the study period, there were 94 patients presenting to the ED who were diagnosed as having angioedema secondary to an ACEI (90 patients) or angiotensin receptor blocker (ARB) (4 patients). Overall, 53 patients (56.38%) improved during their ED stay, and of those, 32 patients (60.38%) were discharged home. None of the 12 patients that worsened were sent home from the ED. Those who were discharged from the ED with a median stay of 4 h had no increased risk of return to the ED versus those who were admitted. The only treatment found to have statistical association with disposition was intramuscular epinephrine. Only 13 of 43 ED discharged patients (23.64%) had their ACEI/ARB documented in their allergy listings compared to 42 of 51 patients (76.36%) of admitted patients, odds ratio of failure to document was 0.0929 (95% CI, 0.0352 to 0.24512). Only one patient out of the total 94 returned to the ED due to recurrent angioedema symptoms during our study period and was subsequently discharged. Conclusion: Our results indicated that at a large, tertiary care referral center, patients with ACEI-angioedema who did not exhibit severe symptoms were safely discharged home with low risk of early return visit to the ED. Severe symptoms were found to be any throat symptoms, voice change, drooling, worsening swelling, or complaints of dyspnea. Further, among those admitted, patients in our study had a short inpatient stay and were safely discharged with no documented early return visit to the ED. [ABSTRACT FROM AUTHOR]

Background and Aims: Temporomandibular Joint (TMJ) ankylosis patients pose serious anesthetic challenges due to difficult airway and obstructive sleep apnoea (OSA). However, data are sparse on anesthetic management and perioperative outcomes of such patients. This study aimed to identify the anesthetic and airway management techniques in children and adolescents with TMJ ankylosis and whether the presence of retrognathia and OSA increases the risk of airway-related complications. Materials and Methods: A retrospective anesthetic chart review of TMJ ankylosis patients undergoing maxillo-facial surgery from 2008 to 2018 in a tertiary care teaching hospital in India was performed. Available anesthetic data were tabulated and analyzed. Difficult mask ventilation, use of nasopharyngeal airway (NPA), difficult intubation, desaturation at induction and extubation, maneuvers to open the airway at extubation, and any post-operative anesthetic complications were noted. Results: Three hundred seventy-two children including 85 patients of OSA were available for analysis. All patients with OSA had retrognathia. Fiber-optic bronchoscopy (FOB) guided intubation was performed in 362 (97.3%) patients. Desflurane and fentanyl were common anesthetics used for the maintenance of anesthesia. Difficult mask ventilation, use of nasopharyngeal airway (NPA) and requirement of airway maneuvers were more common in OSA patients than in non-OSA patients. Difficult mask ventilation was observed in 18.0% and difficult intubation in 12.9% of patients. Desaturation at induction was noted in 5.1% of patients but none required emergency surgical airway access. Maneuvres to open the airway at extubation were required in 24.5% of patients and the incidence of desaturation at extubation was 7.2%. However, no serious adverse event was noted and only one patient required reintubation. Conclusion: FOB-guided intubation should be considered the technique of choice in TMJ ankylosis patients. In the presence of retrognathia and OSA chance of difficult mask ventilation, requirement of NPA and difficulty in maintaining the airway after extubation increase significantly. [ABSTRACT FROM AUTHOR]

Summary: Background: Different sedation regimens have been used to facilitate awake tracheal intubation, but the evidence has not been synthesised robustly, particularly with respect to clinically important outcomes. We conducted a systematic review and network meta‐analysis to determine the sedation techniques most likely to be associated with successful tracheal intubation, a shorter time to successful intubation and a lower risk of arterial oxygen desaturation. Methods: We searched for randomised controlled trials of patients undergoing awake tracheal intubation for any indication and reporting: overall tracheal intubation success rate; tracheal intubation time; incidence of arterial oxygen desaturation; and other related outcomes. We performed a frequentist network meta‐analysis for these outcomes if two or more sedation regimens were compared between included trials. We also performed a sensitivity analysis excluding trials with a high risk of bias. Results: In total, 48 studies with 2837 patients comparing 33 different regimens were included. Comparing overall awake tracheal intubation success rates (38 studies, 2139 patients), there was no evidence suggesting that any individual sedation regimen was superior. Comparing times to successful tracheal intubation (1745 patients, 24 studies), any sedation strategy was superior to placebo. When we excluded trials with a high risk of bias, we found no evidence of a difference between any interventions for time to successful tracheal intubation. Thirty‐one studies (1753 patients) suggested that dexmedetomidine and magnesium sulphate were associated with a reduced risk of arterial oxygen desaturation compared with other interventions, but excluding trials with a high risk of bias suggested no relevant differences between interventions. The quality of evidence for each of our outcomes was low. Conclusions: To maximise effective and safe awake tracheal intubation, optimising oxygenation, topical airway anaesthesia and procedural performance may have more impact than any given sedation regimen. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess the utility of ultrasound (US) imaging for diagnosis of abnormal tracheal morphology, such as tracheal cartilaginous sleeves (TCS), in patients with syndromic craniosynostosis (SC). Study Design: Age‐matched cohort study. Setting: Tertiary pediatric hospital. Methods: Two age‐matched cohorts were identified: patients with SC and known TCS based upon airway endoscopy and normal controls without tracheal pathology. Enrolled patients underwent awake US of the neck which were randomized and reviewed by blinded pediatric radiologists and rated on presence or absence of normal tracheal cartilage morphology and visualization or nonvisualization of a tracheostomy tube. Fisher's exact test was used to assess pooled data. Fleiss' Kappa (κ) was calculated to assess inter‐rater reliability. Results: Ten patients were included in each cohort. Control patients were gender and age‐matched to TCS patients with a mean difference of 3.7 months (±3.9 months). Across all raters, cartilage type was correctly identified in 93% (95% confidence interval [CI]: 84%‐98%) and tracheostomy visualization in 97% (95% CI: 89%‐99%). The sensitivity and specificity for detection of abnormal cartilage pathology was 87% and 100%, respectively. Inter‐rater reliability for cartilage assessment was κ = 0.88 (95% CI: 0.67‐1.00, P <.05) and 0.83 (95% CI: 0.58‐1.00, P <.05) for tracheostomy presence. Conclusion: This study demonstrated that tracheal US is a feasible, accurate screening tool for TCS, and can be successfully performed non‐sedated in patients up to 18 years of age, both with and without tracheostomy tubes in place. [ABSTRACT FROM AUTHOR]

Objective: Fetal imaging often identifies signs of upper airway obstruction due to micrognathia that may require airway intervention at delivery. This study investigated the role of quantitative fetal imaging measurements in predicting the need for otolaryngology consultation and intervention within a multidisciplinary Fetal Center. Methods: Data were retrospectively collected from expectant mothers attending a multidisciplinary Fetal Center from January 2017 to October 2023. Cases of fetal micrognathia associated with potential upper airway obstruction were analyzed, focusing on prenatal ultrasound and magnetic resonance imaging (MRI) findings, genetic testing results, and interventions at birth. Results: Among 25 pregnancies identified, diverse prenatal diagnoses were observed. Post hoc quantitative fetal ultrasound/MRI measurements included inferior facial angle, anteroposterior diameter, biparietal distance, and Jaw Index. Otolaryngology teams were present at delivery for a subset of cases, with various interventions performed, including tracheostomy and intubation. Lower gestational age at birth, rather than more severe quantitative measurements, was associated with the need for intervention. Intubation failure due to airway difficulty was also predicted by lower gestational age. Conclusion: While certain quantitative fetal imaging measurements are often used for clinical decision‐making regarding airway management at birth, they did not clearly predict the need for airway intervention in our sample. Gestational age is an important consideration in decision‐making for fetal teams and should be considered in preterm fetuses to plan for airway difficulties. The findings highlight the complexity of fetal micrognathia management and highlight the need for further research to refine predictive models and optimize clinical decision‐making in this challenging clinical scenario. Level of Evidence: 3 Laryngoscope, 135:393–401, 2025 [ABSTRACT FROM AUTHOR]

Introduction: Endotracheal intubation can be difficult or even fail under certain patient and anaesthesiologist conditions. During the COVID-19 pandemic a country-wide lockdown policy was enforced in Thailand which stipulated that anaesthesiologists wear personal protective equipment, powered air purifying respirator, or goggles and surgical/N95 mask during the intubation procedure. Thus, an anaesthesiologist's vision is restricted and grip on the equipment less sure. Under these conditions, the incidence of difficult intubation was expected to increase. Methods: This time-series study was based on the aggregated age- and sex-standardized monthly incidence of difficult intubation among all intubated patients whose data were recorded in the national insurance claims database and among patients recorded in the records of a university hospital from January 2018 to September 2022. Changes in incidence of difficult intubation following the implementation of a lockdown policy from 26 March 2020 during the COVID-19 pandemic were explored using negative binomial regression and interrupted linear regression time-series analysis. Results: Data of 922,274 individuals in the national database and 95,457 individuals in the university database were retrieved. The overall incidence of difficult intubation in both settings dropped by 25% following lockdown, significantly so in the national database (p < 0.001). At the point of interruption, a significant drop in level was evident in the national data (of 1.682 per thousand per month, P = 0.003) and a non-significant drop at the university level (of 1.118 per thousand per month, P = 0.304). Discussion: The decreased incidence of difficult intubation during the lockdown period was contrary to expectation but might be related to the deployment solely of anaesthesiologists and more experienced anaesthetic staff using videolaryngoscopes during lockdown following the recommendation for intubation during respiratory disease pandemics. [ABSTRACT FROM AUTHOR]

Acute adult supraglottitis is a serious and potentially life-threatening condition marked by inflammation of the supraglottic structures, posing a significant risk for rapid airway compromise. This case series highlights the varied presentations and management challenges associated with adult supraglottitis. The four cases involve adult males, most with uncontrolled diabetes mellitus, presenting with symptoms such as difficulty breathing, sore throat, dysphagia, and voice changes. Diagnostic approaches included soft-tissue neck radiographs and video laryngoscopy, with common findings of an edematous epiglottis and "thumbprint" sign. Management strategies ranged from conservative treatment with antibiotics and steroids to emergent airway interventions like tracheostomy. These cases underscore the importance of early diagnosis, close monitoring, and tailored treatment to prevent severe outcomes. The series emphasizes the need for high clinical suspicion and prompt action in cases of adult supraglottitis, especially given its potential for rapid deterioration and significant morbidity. [ABSTRACT FROM AUTHOR]

Objective: There is often unfamiliarity with the care of artificial airway devices (ie, endotracheal tubes, tracheostomies, and laryngectomies). The objective of this study was to design an Airway Quality Improvement Program (AQIP) to improve airway care. Methods: This was a retrospective chart review of a prospectively-initiated AQIP. The AQIP has 3 parts: 1) Mandatory "airway signs" 2) In-service teaching with a corresponding order set and 3) an overhead "Surgical Airway Emergency" page involving automatic pages to Anesthesia, Otolaryngology, and Respiratory Therapy. Pre- and post-intervention survey data was collected. The incidence of airway emergency was the primary patient outcome and was hypothesized to decrease after AQIP intervention. Results: Airway emergencies decreased 8.4% after AQIP (P =.45). Length of stay decreased after AQIP, 47.0 ± 76.5 days compared to 23.5 ± 23.6 (P =.004). Two hundred eight-one nurses and 76 respiratory therapists were educated. Pre-AQIP comfortability scores improved for the routine care of endotracheal tubes, tracheostomies, and laryngectomies, 4.3 ± 0.9, 4.3 ± 0.8, and 3.5 ± 1.2, compared to 4.7 ± 0.6, 4.5 ± 0.7, and 4.4 ± 0.7 post-AQIP (P =.0006, P =.02, P =.0001). The same improvement was noted for emergency airway care. Tracheostomy vs. laryngectomy recognition increased from 66.5 to 97.0% (P =.0001). Quiz questions regarding emergency airway management for laryngectomies improved from 76.2 to 93.8% (P =.0001). Conclusion: The AQIP was associated with decreased length of hospital stay and improved competency in airway care among hospital staff. Further application of AQIP is needed for replication in other institutions and long-term application. [ABSTRACT FROM AUTHOR]

Background: There is significant variability in airway management training among pulmonary and critical care medicine (PCCM) fellows. Objective: To assess the airway management training of PCCM fellows, specifically evaluating the role of the institutional approach to intubations (anesthesia-predominant primary operators vs. PCCM-predominant) to the overall fellows' educational experience. Methods: We performed a survey of PCCM fellows at 14 institutions to assess the perceptions of airway management training. Summary statistics were used to analyze the Likert scale responses. Based on our hypothesis of a relationship of a fellow's experience to the institutional approach to intubations, we stratified responses based on whether the primary operator for airway management for critically ill patients was generally anesthesiology or PCCM providers. Statistical significance was determined using either t testing (after converting Likert-style responses to continuous variables) or analysis of variance for categorical variables (P < 0.05). Results: Respondents included 132 fellows across 14 PCCM programs (47% response rate), spanning all fellowship years (29% in first year [n = 38], 31% in second year [n = 41], 26% in third/fourth year [n = 34]). Seventy percent (n = 80) of fellows were very or somewhat satisfied with their airway management training. In fellows training where anesthesia providers primarily perform airway management (29% [n = 34]), satisfaction with training was significantly lower, as was the self-assessment of one's airway management skills. The location of airway management experience in anesthesia-predominant programs was mainly the operating room (69% [n = 22]), versus mainly in the intensive care unit for PCCM-predominant programs (94% [n = 77]). The number of completed intubations was lower for fellows in anesthesia-predominant programs (P = 0.02). Conclusion: We found significant differences in fellows' experiences in airway management based on the institutional approach to intubations (anesthesia-predominant primary operators vs. PCCM-predominant). Ongoing focus on strategies to optimize competency-based airway management training is needed, particularly at programs where anesthesia involvement limits the amount of clinical exposure. [ABSTRACT FROM AUTHOR]

Background: Infants hospitalized for bronchiolitis are at high risk for developing recurrent wheeze in childhood. The role of airway lipids in the link between these two conditions remains unclear. This study aimed to identify the association between airway lipids in infants hospitalized for bronchiolitis and the development of recurrent wheeze, with a focus on immunoglobulin E (IgE) sensitization. Methods: In a multicenter prospective cohort study of 919 infants (age <1 year) hospitalized for bronchiolitis, we performed lipidomic profiling of nasopharyngeal airway specimens collected at hospitalization. We first identified lipid modules composed of highly correlated lipids by performing weighted correlation network analysis. We then examined the longitudinal association of those lipid modules with the rate of recurrent wheeze by age 3 years after discharge from hospitalization for bronchiolitis. We also examined the associations of lipid modules with IgE non‐sensitized (i.e., neither sensitized at admission nor at age 3 years) and IgE‐sensitized (i.e., sensitized at admission and/or at age 3 years) recurrent wheeze by age 3 years, respectively. Results: Our analysis identified 15 distinct lipid modules in the nasopharyngeal airway lipidome data. Overall, lipid modules composed of triacylglycerols (hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.26–2.51, FDR < 0.01) and sphingolipids (HR 1.74, 95% CI 1.25–2.44, FDR <0.01) had the strongest associations with recurrent wheeze development. Stratification by IgE sensitization revealed differential associations. For example, the module composed of triacylglycerols was significantly associated with IgE non‐sensitized recurrent wheeze, whereas the module composed of sphingolipids was significantly associated with IgE‐sensitized recurrent wheeze (both FDR <0.05). Conclusion: Distinct nasopharyngeal airway lipid modules are associated with recurrent wheeze development following severe bronchiolitis, with different patterns based on IgE sensitization status. [ABSTRACT FROM AUTHOR]

The cuff of endotracheal tube (ETT) is an indispensable device for establishing an artificial airway, yet cuff-induced compression often causes damage to the airway mucosa. The mechanism of this damage involves mucosal compression ischemia and the oxidative stress injury following reperfusion. Currently, there is a lack of effective strategies to protect the mucosa. Hydrogen, as a natural antioxidant, has demonstrated significant potential in the prevention and treatment of oxidative stress injuries. This study aimed to determine the protective effects of hydrogen on compressed airway mucosa. We found that the damage to the airway mucosa caused by ETT cuff compression was associated with oxidative stress-induced pyroptosis of airway epithelial cells. Inhalation of hydrogen effectively reduced the levels of reactive oxygen species, significantly ameliorating changes in epithelial cell pyroptosis, and this protective effect is linked to the inhibition of the NLRP3-GSDMD pathway. Further cellular studies, involving knockdown and overexpression of NLRP3, clarified that hydrogen exerts its protective effects on the airway mucosa by inhibiting epithelial cell pyroptosis. Additionally, we observed that using hydrogen-rich saline to inflate the ETT cuff in patients under general anesthesia significantly reduced postoperative sore throat. This study confirms that hydrogen effectively enhances tolerance of airway mucosa to oxidative stress injuries, offering a potential preventive and therapeutic strategy for protecting the airway mucosa in patients undergoing endotracheal intubation. [Display omitted] • Endotracheal tube cuff compression caused pyroptosis injury of tracheal mucosa. • Hydrogen neutralization of reactive oxygen species alleviated pyroptosis injury. • Hydrogen reduces airway pyroptosis damage through NLRP3-GSDMD pathway. [ABSTRACT FROM AUTHOR]

Previous studies based on animal models have raised concerns about salbutamol use in ozone air pollution with regard to ozone related lung injury. We conducted a double‐blind, randomized, placebo‐controlled crossover study including 18 subjects diagnosed with EIB by a eucapnic voluntary hyperpnea (EVH) test. Participants completed 30 min of standardized moderate to vigorous exercise in four conditions: ozone plus salbutamol; room air plus salbutamol; ozone plus placebo medication; and room air plus placebo medication. Spirometry, fraction of exhaled nitric oxide, and symptoms were measured before, immediately after, 30 min after and 1 h after exercise. Measurements between the four conditions were compared using percent change from pre to post exercise. There was a statistically significant difference between the salbutamol and placebo medication groups for spirometric variables including FEV1 (Estimate = 6.3, 95% CI: 4.23–8.37, p < 0.001). No differences were observed between ozone and room air exposures. There were no significant differences in FeNO response between experimental conditions. We found that salbutamol improved pulmonary function in individuals with EIB when exercising in ozone and did not increase eosinophilic airway inflammation as indicated by FeNO. This evidence suggests that it is safe for people with EIB to continue to use salbutamol as proscribed when ozone levels are elevated. [ABSTRACT FROM AUTHOR]

This study aimed to assess the availability, design, and contents of difficult airway trolleys in hospitals in Victoria, Australia. A survey audit was conducted with a 92.3% reply rate, and the responses from 22 major Victorian hospitals were analysed. The results showed that difficult airway trolleys were available in 100% of operating theatres, emergency departments and intensive care units, and the rate of standardisation was high. Compliance with recommended design features and resources was on average 68.3%. There was no significant difference in the compliance rate of major tertiary centres compared with other hospitals. The carriage of non-essential items was reduced compared with earlier audits. However, there was heterogeneity in the brands of supraglottic airway devices, videolaryngoscopes and cognitive aids used. The study highlights the need for ongoing improvement to the organization and content of difficult airway trolleys, and for further discussion regarding the safety of equipment variation across institutions. [ABSTRACT FROM AUTHOR]

Airway mucus plugs are frequently identified on CT scans of patients with COPD with a smoking history without mucus-related symptoms (ie, cough, phlegm [silent mucus plugs]). In patients with COPD, what are the risk and protective factors associated with silent airway mucus plugs? Are silent mucus plugs associated with functional, structural, and clinical measures of disease? We identified mucus plugs on chest CT scans of participants with COPD from the COPDGene study. The mucus plug score was defined as the number of pulmonary segments with mucus plugs, ranging from 0 to 18, and categorized into three groups (0, 1-2, and ≥ 3). We determined risk and protective factors for silent mucus plugs and the associations of silent mucus plugs with measures of disease severity using multivariable linear and logistic regression models. Of 4,363 participants with COPD, 1,739 had no cough or phlegm. Among the 1,739 participants, 627 (36%) had airway mucus plugs identified on CT scan. Risk factors of silent mucus plugs (compared with symptomatic mucus plugs) were older age (OR, 1.02), female sex (OR, 1.40), and Black race (OR, 1.93) (all P values <.01). Among those without cough or phlegm, silent mucus plugs (vs absence of mucus plugs) were associated with worse 6-min walk distance, worse resting arterial oxygen saturation, worse FEV 1 % predicted, greater emphysema, thicker airway walls, and higher odds of severe exacerbation in the past year in adjusted models. Mucus plugs are common in patients with COPD without mucus-related symptoms. Silent mucus plugs are associated with worse functional, structural, and clinical measures of disease. CT scan-identified mucus plugs can complement the evaluation of patients with COPD. [Display omitted] [ABSTRACT FROM AUTHOR]

Peri-intubation complications are important sequelae of airway management in the emergency department (ED). Our objective was to quantify the increased risk of complications with multiple attempts at emergency airway intubation in the ED. This is a secondary analysis of a prospectively collected multicenter registry (National Emergency Airway Registry) consisting of attempted ED intubations among subjects aged >14 years. The primary exposure variable was the number of intubation attempts. The primary outcome measure was the occurrence of peri-intubation major complications within 15 min of intubation including hypotension, hypoxemia, vomiting, dysrhythmias, cardiac arrest, esophageal intubation, and failed airway with cricothyrotomy. We constructed multivariable logistic regression models to determine the associations between complications and the number of intubation attempts while controlling for measured pre-exposure variables. There were 19,071 intubations in the NEAR database, of which 15,079 met inclusion for this analysis. Of these, 13,459 were successfully intubated on the first attempt, 1,268 on the second attempt, 269 on the third attempt, 61 on the fourth attempt, and 22 on the fifth or more attempt. A complication occurred in 2,137 encounters (14 %). Major complications accompanied 1,968 encounters (13 %) whereas minor complications affected 315 encounters (2 %). The most common major complication was hypoxia. In our multivariable logistic regression model, odds ratios with 95 % confidence intervals for the occurrence of major complications for multiple attempts compared to first-pass success were 4.4 (3.6–5.3), 7.4 (5.0–10.7), 13.9 (5.6–34.3), and 9.3 (2.1–41.7) for attempts 2–5+ (reference attempt 1), respectively. We found an independent association between the number of intubation attempts among ED patients undergoing emergency airway intubation and the risk of complications. [ABSTRACT FROM AUTHOR]

Massive hemoptysis (MH) is a serious condition that carries with it a high rate of morbidity and mortality. This review highlights the pearls and pitfalls of massive hemoptysis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. MH is a rare but deadly condition. It is defined clinically as any bleeding from the tracheobronchial tree that compromises respiratory or circulatory function. The bronchial artery system is the primary source in the majority of cases of MH. The most common cause is tuberculosis worldwide, but bronchiectasis, bronchogenic carcinoma, and mycetoma are more common causes in the U.S. Patients with MH require rapid assessment and management, as decompensation can be rapid. Patients with altered mental status, inability to clear their sections, respiratory distress, or hemodynamic compromise require emergent airway intervention. The imaging modality of choice is computed tomography angiography with pulmonary arterial phase contrast. A reasonable order or sequence of management includes initial stabilization; assessment for the need for airway intervention; reversal of any coagulopathy; advanced imaging; and emergent consultation of pulmonary, cardiothoracic surgery, and interventional radiology. Ongoing resuscitation including blood products may be required in some patients with MH until definitive hemostasis is achieved. An understanding of MH can assist emergency clinicians in diagnosing and managing this dangerous disease. Providing a prompt evaluation, obtaining intravenous access, pursuing advanced imaging, providing reversal of coagulopathy, supporting hemodynamics, and appropriate consultation are key interventions in MH. [ABSTRACT FROM AUTHOR]

Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI. This paper evaluates key evidence-based updates concerning ETI for the emergency clinician. ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube. An understanding of literature updates can improve the ED care of patients requiring emergent intubation. [ABSTRACT FROM AUTHOR]

Airway management is a key intervention during the resuscitation of critically ill trauma patients. Emergency surgical airway (ESA) placement is taught as a backup option when endotracheal intubation (ETI) fails. We sought to (1) describe the incidence of the emergency department (ED) ESA, (2) compare ESA versus ETI-only recipients, and (3) determine which factors were associated with receipt of an ESA. We searched within the Trauma Quality Improvement Program datasets from 2017 to 2022 for all emergency department surgical airway placement and/or endotracheal intubations recipients. We compared ESA versus ETI-only recipients. From 2017 to 2022, there were 6,477,759 within the datasets, of which 238,128 met inclusion for this analysis. Within that, there were 236,292 ETIs, 2264 ESAs, with 428 (<1 %) having documentation of both. Of the ESAs performed, there were 82 documented in children <15 years of age with the youngest being 1 year of age. The ETI-only group had a lower proportion serious injuries to the head/neck (52 % versus 59 %), face (2 % versus 8 %), and skin (3 % versus 6 %). However, the ETI-only group had a higher proportion of serious injuries to the abdomen (15 % versus 9 %) and the extremities (19 % versus 12 %). Survival at 24-h was higher in the ETI-only group (83 % versus 76 %) as well as survival to discharge (70 % versus 67 %). In the subanaysis of children <15 years (n = 82), 34 % occurred in the 1–4 years age group, 35 % in the 5–9 years age group, and 30 % in the 10–14 years age group. In our multivariable logistic regression analysis, serious injuries to the head/neck (odds ratio [OR] 1.37, 95 % CI 1.23–1.54), face (OR 3.41, 2.83–4.11), thorax (OR 1.19, 1.06–1.33), and skin (OR 1.53, 1.15–2.05) were all associated with receipt of cricothyrotomy. Firearm (OR 3.62, 3.18–4.12), stabbing (2.85, 2.09–3.89), and other (OR 2.85, 2.09–3.89) were associated with receipt of ESA when using collision as the reference variable. ESA placement is a rarely performed procedure but frequently used as a primary airway intervention in this dataset. Penetrating mechanisms, and injuries to face were most associated with ESA placement. Our findings reinforce the need to maintain this critical airway skill for trauma management. • Emergency surgical airway (ESA) access is often used as a primary airway intervention. • ESA access is documented in children as young as 1 with similar survival to adults. • Serious injuries to the face, firearms, and stabbings are associated with receipt of ESA. [ABSTRACT FROM AUTHOR]

Objective: To investigate the utility of preprocedural paracetamol on reducing pain scores post office‐based laryngeal procedures. Study Design: Prospective, controlled before‐after comparative study. Setting: Controlled prospective before‐after study. Methods: A retrospective analysis was performed of 100 patients who underwent office‐based laryngeal procedures without preprocedural analgesia at our center to establish a control group. Age, sex, procedure type, and amount of substance used were documented as well as postprocedural pain score. Pain scores were recorded every 5 minutes for 30 minutes following office‐based laryngeal procedures. A prospective arm of this study was then performed in which every patient undergoing office‐based laryngeal procedures at our center between September 2019 and December 2020 was administered 1000 mg of paracetamol prior to their procedure. The postprocedure pain scores of the 2 groups were then compared. Results: A hundred patients were included in the retrospective arm and 75 patients were included in the prospective arm, receiving 1000 mg of paracetamol a median of 45 (interquartile range: 30‐53) minutes prior to their procedure. The 2 groups were matched for age, sex, and type of laryngeal procedure. Both nonanalgesia and analgesia groups demonstrated a similar proportion of patients who experienced any pain (47% and 48%, respectively) postprocedurally. The prospective arm of this study however reported a statistically significant reduction in the magnitude of their pain scores at all points postprocedurally (P =.005). Conclusion: Paracetamol preprocedurally reduces the severity of pain in office‐based laryngeal procedures and would be a useful consideration for patients who are likely to experience significant postprocedural pain. Level of Evidence: Level 3. [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) can have many adverse effects on people's health, including cognitive decline and high blood pressure. Typical surgical treatment methods include the commonly performed uvulopalatopharyngoplasty and the highly successful maxillomandibular advancement (MMA). These surgical methods are more effective than non-surgical methods because they widen the airway where a collapse has occurred through direct treatment. However, few studies has shown that moving the upper and lower jaws in a specific manner is the most efficient way to treat OSA during an MMA surgery. In this study, the airway of an OSA patient was reproduced digitally, and computational fluid dynamics analysis was performed on various models with changed airway shapes, including the original model based on an actual CT image and three resizing models of the retropalatal (RP) and retroglossal (RG) regions of the airway. Consequently, it was possible to provide more quantitative predicted flow data, which could be helpful in performing sophisticated OSA surgery. Among the four airway models of the OSA patient, a reduction in the epiglottis regional pressure difference of up to 40.2% was evident in the model with an expanded RG region, and a reduction in the wall shear stress of up to 25.8% was confirmed. The proposed process could be an important aid for surgeons in determining the optimal surgical method suitable for an individual patient's uniquely-shaped airway. [ABSTRACT FROM AUTHOR]

Background/Objectives: Acute laryngeal injury (ALgI) is an identified complication of prolonged intubation. Its evolution into mature stenosis and factors affecting decannulation are unclear. This retrospective review aims to characterize the incidence and characteristics of ALgI development and decannulation. Methods: Retrospective study of post‐intubated patients with a tracheostomy seen for screening evaluation at a single long‐term acute care hospital (LTACH) from 2019 to 2022. Results: Patients were followed for an average of 115 days after extubation. Forty‐nine of 119 adult patients had ALgI. Those with ALgI were more likely female (61% vs. 35.7%, p = 0.006) with higher body mass index (BMI; 32.9 vs. 28.1, p = 0.03) and lower height (166 vs. 171.1 cm, p = 0.01). Decannulation rates in patients with ALgI were 69.4% compared to 84.3% in patients without ALgI (p = 0.053). Patients with ALgI were scoped more quickly post‐extubation (28.8 vs. 36.6 days, p = 0.04), but time to decannulation did not differ (66.6 vs. 81.2 days, p = 0.74). Lower CCI (4.03 vs 6.93) and lack of tobacco use (41.2% vs 73.3%) were associated with successful decannulation (p = 0.038, p = 0.0008). Patients with ALgI treated conservatively (observation or medical management) were decannulated up to 71 days post‐extubation. Further decannulations only occurred with surgical intervention. Conclusions: Female gender, higher BMI, and shorter height are associated with ALgI among patients undergoing a LTACH screening evaluation. CCI and tobacco have a negative association with decannulation success. Among the ALgI cohort, no patient treated conservatively was decannulated after 71 days. Level of Evidence: 4 Laryngoscope, 134:4642–4648, 2024 [ABSTRACT FROM AUTHOR]

The management of foreign body airway obstruction has evolved over time from back blows and chest thrusts to abdominal thrusts. However, current guidelines worldwide are based on outdated data, with unclear evidence regarding the effectiveness and safety of these rescue manoeuvres. Concerns persist about the potential of these techniques to cause injury, especially in children; therefore, a critical revision to ensure optimal child safety is necessary. The literature on first aid for paediatric choking was identified through the searching of various databases. Studies were evaluated for their relevance, quality, and currency. The analysis examined guideline consistency with current evidenced-based medicine and identified research gaps. The analysis of the available data was supplemented by adult-based evidence due to the scarcity of paediatric-specific research. First aid guidelines and recommendations for paediatric choking are divergent and generally grounded in low-quality evidence derived primarily from case studies. Studies since 2015 have shown highly diverse methodologies and often lack details on the execution of individual techniques, body positioning or the specific characteristics of study groups, which are crucial when comparing the effectiveness and safety of rescue manoeuvres. Updating evidence-based scientific knowledge for future recommendations is crucial. [ABSTRACT FROM AUTHOR]

Abstract Background Angiotensin-converting enzyme inhibitors (ACEI) are the most common cause of drug-induced angioedema in the United States. Our primary objective was to provide descriptive evidence regarding emergency department (ED) disposition of ACEI-induced angioedema patients. Our secondary objective was to evaluate unique patterns in those with ACEI-induced angioedema at a tertiary referral center, including demographics, details of those requiring intubation, length of inpatient stay, and allergy documentation. Methods This was a retrospective study evaluating all cases of ACEI-induced angioedema at a large, regional academic medical center. We performed a medical record review to identify patients with ACEI-induced angioedema who presented to the ED from January 1, 2016, to December 31, 2022. A structured data abstraction process was utilized to select patients of interest, followed by descriptive statistics, chi-square tests and odds ratios for categorical data, and Kruskal Wallis tests for continuous data. Results A total of 637 unique patient encounters met potential inclusion. After a substantial, standardized review, 94 patients met inclusion. During the study period, there were 94 patients presenting to the ED who were diagnosed as having angioedema secondary to an ACEI (90 patients) or angiotensin receptor blocker (ARB) (4 patients). Overall, 53 patients (56.38%) improved during their ED stay, and of those, 32 patients (60.38%) were discharged home. None of the 12 patients that worsened were sent home from the ED. Those who were discharged from the ED with a median stay of 4 h had no increased risk of return to the ED versus those who were admitted. The only treatment found to have statistical association with disposition was intramuscular epinephrine. Only 13 of 43 ED discharged patients (23.64%) had their ACEI/ARB documented in their allergy listings compared to 42 of 51 patients (76.36%) of admitted patients, odds ratio of failure to document was 0.0929 (95% CI, 0.0352 to 0.24512). Only one patient out of the total 94 returned to the ED due to recurrent angioedema symptoms during our study period and was subsequently discharged. Conclusion Our results indicated that at a large, tertiary care referral center, patients with ACEI-angioedema who did not exhibit severe symptoms were safely discharged home with low risk of early return visit to the ED. Severe symptoms were found to be any throat symptoms, voice change, drooling, worsening swelling, or complaints of dyspnea. Further, among those admitted, patients in our study had a short inpatient stay and were safely discharged with no documented early return visit to the ED.

Background: The current coronavirus disease 2019 (COVID-19) pandemic is an ongoing global healthcare challenge that has caused morbidity and mortality at unprecedented levels. Studies have estimated that approximately 10% of all patients who have recovered from COVID-19 are suffering from persistent symptoms of cough, dyspnea, and fatigue over months after the acute infection. Many patients reported persistent airway symptoms post-COVID. Since the post-COVID pulmonary complications are evolving and challenging, a study was carried out to assess post-COVID new-onset asthma in adults. Objectives: To assess the incidence of new-onset asthma following COVID-19 in adults. Methods: A prospective observational study including all adult patients admitted or treated on an out patient department (OPD) basis for COVID-19 was carried out. All patients on follow-up who reported with airway symptoms (cough, wheezing, breathlessness, or chest tightness) with no prior diagnosed obstructive/restrictive airway disease were included in the study and followed up for a duration of 01 years. New-onset asthma was diagnosed based on symptomatology and assessed as per Global Initiative for Asthma guidelines. Results: Among 411 patients with airway symptoms post-COVID-19, 9.4% (n = 97) developed new-onset bronchial asthma on follow-up. Conclusion: Asthma in patients’ post-COVID-19 disease is not uncommon, and detailed evaluation and follow-up are instrumental in instituting timely and correct therapy and in providing symptomatic relief to patients.

Abstract Introduction Endotracheal intubation can be difficult or even fail under certain patient and anaesthesiologist conditions. During the COVID-19 pandemic a country-wide lockdown policy was enforced in Thailand which stipulated that anaesthesiologists wear personal protective equipment, powered air purifying respirator, or goggles and surgical/N95 mask during the intubation procedure. Thus, an anaesthesiologist’s vision is restricted and grip on the equipment less sure. Under these conditions, the incidence of difficult intubation was expected to increase. Methods This time-series study was based on the aggregated age- and sex-standardized monthly incidence of difficult intubation among all intubated patients whose data were recorded in the national insurance claims database and among patients recorded in the records of a university hospital from January 2018 to September 2022. Changes in incidence of difficult intubation following the implementation of a lockdown policy from 26 March 2020 during the COVID-19 pandemic were explored using negative binomial regression and interrupted linear regression time-series analysis. Results Data of 922,274 individuals in the national database and 95,457 individuals in the university database were retrieved. The overall incidence of difficult intubation in both settings dropped by 25% following lockdown, significantly so in the national database (p

Abstract Dysfunction of motile cilia can impair mucociliary clearance in the airway and result in primary ciliary dyskinesia (PCD). We previously showed that mutations in central pair apparatus (CPA) genes perturb ciliary motility and result in PCD in mouse models. However, little is known about how epithelial cell types in the ciliary microenvironment of the upper airway respond to defects in ciliary motility and mucociliary clearance. Here, we have used single-cell RNA sequencing to investigate responses in tracheal epithelial cells from mice with mutations in CPA genes Cfap221/ Pcdp1, Cfap54, and Spef2. Expected cell types were identified, along with an unidentified cell type not expressing markers of typical airway cells. Deuterosomal cells were found to exist in two states that differ largely in expression of genes involved in differentiation into ciliated cells. Functional enrichment analysis of differentially expressed genes (DEGs) revealed important cellular functions and molecular pathways for each cell type that are altered in mutant mice. Overlapping DEGs shed light on general responses to cilia dysfunction, while unique DEGs indicate that some responses may be specific to the individual mutation and ciliary defect.

Background/purpose: The use of computed tomography (CT) for craniofacial measurements is common in medical imaging, but concerns about accuracy and reliability persist, especially with different CT technologies. This study assessed the accuracy of twenty-six common measurements on consecutive CT images from the same patients, using multidetector CT (MDCT) and cone-beam CT (CBCT) with two software programs (Amira and Dolphin). Materials and methods: Ten adult subjects with consecutive CBCT scans within one year were randomly selected. Another ten subjects with consecutive MDCT scans were paired with the CBCT group based on age, gender, race, occlusion, and craniofacial pattern. All digital imaging and communications in medicine (DICOM) files were randomly coded and analyzed using the two software programs. Intra-examiner reliability was assessed using the intraclass correlation coefficient. Successive measurement errors from consecutive scans for both imaging modalities and software programs were compared. Results: For most skeletal linear and angular measurements, Dolphin showed greater successive measurement errors compared to Amira. Eight of the 26 common measurements had errors greater than one unit (millimeter or degree). Despite almost perfect intra-examiner reliability for upper airway analysis, average successive measurement errors were notably high, particularly for intraoral and oropharyngeal airway volumes. The successive Dolphin measurement error for oropharyngeal airway volume on CBCT images was over three times that on MDCT images. Conclusion: Given the substantial successive measurement errors observed during consecutive CT scanning for the upper airway, this study does not support the quantitative use of CT for analyzing changes in airway dimensions for research purposes.

Abstract Objective This study aimed to develop a deep learning model to predict skeletal malocclusions with an acceptable level of accuracy using airway and cephalometric landmark values obtained from analyzing different CBCT images. Background In orthodontics, multitudinous studies have reported the correlation between orthodontic treatment and changes in the anatomy as well as the functioning of the airway. Typically, the values obtained from various measurements of cephalometric landmarks are used to determine skeletal class based on the interpretation an orthodontist experiences, which sometimes may not be accurate. Methods Samples of skeletal anatomical data were retrospectively obtained and recorded in Digital Imaging and Communications in Medicine (DICOM) file format. The DICOM files were used to reconstruct 3D models using 3DSlicer (slicer.org) by thresholding airway regions to build up 3D polygon models of airway regions for each sample. The 3D models were measured for different landmarks that included measurements across the nasopharynx, the oropharynx, and the hypopharynx. Male and female subjects were combined as one data set to develop supervised learning models. These measurements were utilized to build 7 artificial intelligence-based supervised learning models. Results The supervised learning model with the best accuracy was Random Forest, with a value of 0.74. All the other models were lower in terms of their accuracy. The recall scores for Class I, II, and III malocclusions were 0.71, 0.69, and 0.77, respectively, which represented the total number of actual positive cases predicted correctly, making the sensitivity of the model high. Conclusion In this study, it is observed that the Random Forest model was the most accurate model for predicting the skeletal malocclusion based on various airway and cephalometric landmarks.

Abstract Background Improvement is needed in the remedies used to control Th2 polarization. Bioengineering approaches have modified immune cells that have immunosuppressive functions. This study aims to generate modified eosinophils (Meos) in vivo and use Meos to balance Th2 polarization and reduce airway allergy. Methods A cell editor was constructed. The editor contained a peptide carrier, an anti-siglec F antibody, MHC II, ovalbumin, and LgDNA (DNA extracted from a probiotic, Lactobacillus rhamnosus GG). Which was designated as Cedit. Meos are eosinophils modified using Cedits. An airway Th2 polarization mouse model was established used to test the effect of Meos on suppressing airway allergy. Results The Cedits remained physically and chemically stable in solution (pH7.2) for at least 96 h. Cedits specifically bound to eosinophils, which are designated as Meos. Meos produced programmed death ligand-1 (PD-L1); the latter induced antigen specific CD4+ T cell apoptosis. Administration of Cedits through nasal instillations generated Meos in vivo, which significantly reduced the frequency of antigen specific CD4+ T cells in the airways, and mitigated airway Th2 polarization. Conclusions We constructed Cedit, which could edit eosinophils into Meos in vivo. Meos could induce antigen specific CD4+ T cell apoptosis, and reconcile airway Th2 polarization.

AIM: The aim is to study the demographics and management of unusual airway foreign bodies (UAFBs) in children. MATERIALS AND METHODS: A retrospective observational study (2000–2020) of children with UAFBs, who underwent bronchoscopic removal. The demographics, types of foreign bodies, clinical and radiological features, management, and outcomes were collated and analyzed. Common foreign bodies, such as nuts, seeds, and vegetable aspirations, were excluded. Results: Among 531 children who had bronchoscopic retrieval of airway foreign bodies, 74 (59 males/15 females) had unusual foreign bodies. These included pen caps, whistles, plastic objects, pins, coal piece, stones, clay, pencil, gold ornament, and glass bangle. Thirty-one children presented within 1 day of aspiration, 37 within 1 month and 6 till 6 months. Thirty-nine were below 5 years, and the rest were between 5 and 15 years. Cough, respiratory distress, fever, choking, and noisy breathing were common presentations. Others are stridor, whistling, cyanosis, loss, and change of voice. Chest X-ray showed ipsilateral hyperinflation (23), haziness (21), radio-opaque foreign body (17) and was normal in 14. The left main bronchus, followed by the right main bronchus and trachea, were the sites of impaction. Four children required additional procedures (tracheotomy and thoracotomy). There was one mortality in the study cohort. Conclusion: Aspiration of unusual foreign bodies is not uncommon in children. Most aspirations are witnessed and predominant in boys. The left bronchus is the common site of impaction, and X-ray clinches the diagnosis. Presentation is delayed, and bronchoscopic retrieval, though challenging, has favorable outcome.

Abstract Coffin-Lowry Syndrome (CLS) is a rare X-linked genetic disorder characterized by growth delays, facial dysmorphisms, and intellectual disabilities. Currently, there are limited published case reports regarding the anesthetic management of patients with CLS. Managing anesthesia for CLS patients can be complex due to difficult airway management. In this case report, we present a patient with CLS who underwent surgical intervention, highlighting the anesthetic considerations encountered throughout the perioperative period. We aim to summarize the difficulties involved in anesthetic management of rare conditions like CLS to improve clinical outcomes for affected individuals.

Introduction: Maxillary hypoplasia is a common finding secondary to cleft lip and palate. The resultant Class III skeletal pattern worsens during adolescence due to unaffected mandibular growth. Bone-anchored maxillary protraction (BAMP) involves the intraoral use of orthopedic Class III intermaxillary elastics by means of skeletal anchorage to the zygoma and anterior mandible bilaterally. Aim: The aim of this study was to assess the facial esthetic and functional effects of 1-year of BAMP therapy in growing cleft individuals. Subjects and Methods: Eighteen subjects (mean age: 11.9 years) with cleft maxillary hypoplasia were selected for BAMP. Cephalometric facial assessment of 26 parameters (by an orthodontist), perceptual and lateral videofluoroscopic instrumental speech analyses (by a speech-language pathologist), and clinical temporomandibular joint (TMJ) evaluation were performed before (T1) and after 12 months of BAMP therapy (T2). Paired t-test and Pearson’s Chi-squared test were used for the statistical analyses of the quantitative and qualitative variables, respectively. Pearson’s correlation coefficients were used to assess the associations between cephalometric parameters. Results: Twenty cephalometric variables showed significant change from T1 to T2 toward positive dentoskeletal and soft-tissue Class III facial correction. The mean increase in “SNA” was 3.03°, and maxillary length (“Ptm-A”) and sagittal maxillary position (“N-perp to A”) increments were 3.65 mm and 4.02 mm, respectively. The mean improvement in the dental overjet was 3.86 mm. Backward positioning of the mandible was noted with a mean reduction of “SNB” and “N-perp to Pog” by 1.38° and 1.16 mm, respectively, with a mean 3.8° closure of the gonial angle. The airway changes were insignificant. Speech and TMJ observations remained constant from T1 to T2. Conclusions: BAMP therapy in cleft patients exhibited significant orthopedic maxillary protraction with effective sagittal and vertical mandibular growth control. The positive esthetic effects of BAMP did not have any negative influence over the functions of airway, velopharyngeal (speech) mechanism, and the TMJ in the stipulated 12-month period.

Mitochondria are essential organelles within cells, playing various roles in numerous cellular processes, including differentiation, growth, apoptosis, energy conversion, metabolism, and cellular immunity. The phenotypic variation of mitochondria is specific to different tissues and cell types, resulting in significant differences in their function, morphology, and molecular characteristics. Asthma is a chronic, complex, and heterogeneous airway disease influenced by external factors such as environmental pollutants and allergen exposure, as well as internal factors at the tissue, cellular, and genetic levels, including lung and airway structural cells, immune cells, granulocytes, and mast cells. Therefore, a comprehensive understanding of the specific responses of mitochondria to various external environmental stimuli and internal changes are crucial for elucidating the pathogenesis of asthma. Previous research on mitochondrial-targeted therapy for asthma has primarily focused on antioxidants. Consequently, it is necessary to summarize the multifaceted roles of mitochondria in the pathogenesis of asthma to discover additional strategies targeting mitochondria in this context. In this review, our goal is to describe the changes in mitochondrial function in response to various exposure factors across different cell types and other relevant factors in the context of asthma, utilizing a new mitochondrial terminology framework that encompasses cell-dependent mitochondrial characteristics, molecular features, mitochondrial activity, function, and behavior. [ABSTRACT FROM AUTHOR]

Cystic fibrosis is a life-threatening disease that is caused by mutations in CFTR, a gene which encodes an ion channel that supports proper function of several epithelial tissues, most critically the lung. Without CFTR, airway barrier mechanisms are impaired, allowing for chronic, recurrent infections that result in airway remodeling and deterioration of lung structure and function. Small molecule modulators can rescue existing, defective CFTR protein; however, they still leave a subset of people with CF with no current disease modifying treatments, aside from lung transplantation. Gene therapy directed to the lung is a promising strategy to modify CF disease in the organ most associated with morbidity and mortality. It is accomplished through delivery of a CFTR transgene with an airway permissive vector. Despite more than three decades of research in this area, a lung directed gene therapy has yet to be realized. There is hope that with improved delivery vectors, sufficient transduction of airway cells can achieve therapeutic levels of functional CFTR. In order to do this, preclinical programs need to meet a certain level of CFTR protein expression in vitro and in vivo through improved transduction, particularly in relevant airway cell types. Furthermore, clinical programs must be designed with sensitive methods to detect CFTR expression and function as well as methods to measure meaningful endpoints for lung structure, function and disease. Here, we discuss the current understanding of how much and where CFTR needs to be expressed, the most advanced vectors for CFTR delivery and clinical considerations for detecting CFTR protein and function in different patient subsets. [ABSTRACT FROM AUTHOR]

Background: Some orthodontic devices used in children share similar design principles to appliances used to treat obstructive sleep apnoea in adults. As well as treating malocclusion, orthodontic appliances used in children may therefore also have effects on the upper airway. Objective: A review of the literature to assess the effects of orthodontic treatment on the upper airway dimensions in children assessed on CBCT. Materials and Methods: Following registration of the protocol (PROSPERO CRD42023439056), a systematic electronic search of published studies was performed using several databases (PubMed; Scopus, Web of Science and Science Direct) in accordance with the PRISMA guidelines. Inclusion criteria were as follows: age under 18 years, orthodontic treatment with any appliance, a control group who received no treatment or a non‐active alternative treatment and airway measurement using CBCT. RoB‐2 and ROBINS‐I tools were used to assess risk of bias and quality of the evidence. Results: In total, 341 studies were identified following the initial search. Title and abstract screening resulted in 45 studies for further full‐text analysis. On completion of the screening process, a total of 23 studies met the inclusion criteria. Study interventions included functional appliances (10 studies), rapid maxillary expansion (RME) (9 studies), reverse‐pull headgear (1 study) and 4 premolar dental extractions (3 studies). The included studies had moderate to high risk of bias, and the quality of evidence was low. Conclusion: The scientific evidence shows that functional appliances are associated with significant improvements in both upper airway volume and constriction when used in children however, the effects on the nasal cavity are limited. RME was associated with a significant increase in nasal cavity and nasopharyngeal dimensions, but not the upper pharyngeal airway. Neither reverse‐pull headgear nor dental extractions were associated with any change in airway dimensions; however, the evidence is limited. Functional appliances may reduce the severity of obstructive sleep apnoea (OSA) in children. [ABSTRACT FROM AUTHOR]

The use of computed tomography (CT) for craniofacial measurements is common in medical imaging, but concerns about accuracy and reliability persist, especially with different CT technologies. This study assessed the accuracy of twenty-six common measurements on consecutive CT images from the same patients, using multidetector CT (MDCT) and cone-beam CT (CBCT) with two software programs (Amira and Dolphin). Ten adult subjects with consecutive CBCT scans within one year were randomly selected. Another ten subjects with consecutive MDCT scans were paired with the CBCT group based on age, gender, race, occlusion, and craniofacial pattern. All digital imaging and communications in medicine (DICOM) files were randomly coded and analyzed using the two software programs. Intra-examiner reliability was assessed using the intraclass correlation coefficient. Successive measurement errors from consecutive scans for both imaging modalities and software programs were compared. For most skeletal linear and angular measurements, Dolphin showed greater successive measurement errors compared to Amira. Eight of the 26 common measurements had errors greater than one unit (millimeter or degree). Despite almost perfect intra-examiner reliability for upper airway analysis, average successive measurement errors were notably high, particularly for intraoral and oropharyngeal airway volumes. The successive Dolphin measurement error for oropharyngeal airway volume on CBCT images was over three times that on MDCT images. Given the substantial successive measurement errors observed during consecutive CT scanning for the upper airway, this study does not support the quantitative use of CT for analyzing changes in airway dimensions for research purposes. [ABSTRACT FROM AUTHOR]

Because of the disproportionate amount of time that people spend indoors and the complexities of air pollutant exposures found there, indoor air pollution is a growing concern for airway health. Both infiltration of outdoor air pollution into the indoor space and indoor sources (such as smoke from tobacco products, cooking or heating practices and combustion of associated fuels, and household materials) contribute to unique exposure mixtures. Although there is substantial literature on the chemistry of indoor air pollution, research focused on health effects is only beginning to emerge and remains an important area of need to protect public health. We provide a review of emerging literature spanning the past 3 years and relating indoor air exposures to airway health, with a specific focus on the impact of either individual pollutant exposures or common combustion sources on the lower airways. Factors defining susceptibility and/or vulnerability are reviewed with consideration for priority populations and modifiable risk factors that may be targeted to advance health equity. [ABSTRACT FROM AUTHOR]

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Background: Improvement is needed in the remedies used to control Th2 polarization. Bioengineering approaches have modified immune cells that have immunosuppressive functions. This study aims to generate modified eosinophils (Meos) in vivo and use Meos to balance Th2 polarization and reduce airway allergy. Methods: A cell editor was constructed. The editor contained a peptide carrier, an anti-siglec F antibody, MHC II, ovalbumin, and LgDNA (DNA extracted from a probiotic, Lactobacillus rhamnosus GG). Which was designated as Cedit. Meos are eosinophils modified using Cedits. An airway Th2 polarization mouse model was established used to test the effect of Meos on suppressing airway allergy. Results: The Cedits remained physically and chemically stable in solution (pH7.2) for at least 96 h. Cedits specifically bound to eosinophils, which are designated as Meos. Meos produced programmed death ligand-1 (PD-L1); the latter induced antigen specific CD4+ T cell apoptosis. Administration of Cedits through nasal instillations generated Meos in vivo, which significantly reduced the frequency of antigen specific CD4+ T cells in the airways, and mitigated airway Th2 polarization. Conclusions: We constructed Cedit, which could edit eosinophils into Meos in vivo. Meos could induce antigen specific CD4+ T cell apoptosis, and reconcile airway Th2 polarization. [ABSTRACT FROM AUTHOR]

Effective treatment and immunoprophylaxis of viral respiratory infections with neutralizing monoclonal antibodies (mAbs) require maintaining inhibitory concentrations of mAbs at the airway surface. While engineered mAbs with increased affinity to the neonatal Fc receptor (FcRn) are increasingly employed, little is known how increased affinity of Fc to FcRn influences basal-to-apical transepithelial transport (transcytosis) of mAbs across the airway epithelium. To investigate this, we utilized a model of well-differentiated human airway epithelium (WD-HAE) that exhibited robust FcRn expression, and measured the transepithelial transport of a mAb against SARS-CoV-2 Spike protein (CR3022) with either wildtype IgG1-Fc or Fc modified with YTE or LS mutations known to increase affinity for FcRn. Despite the marked differences in the affinity of these CR3022 variants for FcRn, we did not find substantial differences in basal-toapical transport reflective of systemic dosing, or apical-to-basal transport reflective of inhaled dosing, compared to the transport of wildtype IgG1-Fc. These results suggest increasing FcRn affinity may only have limited influence over transcytosis rates of systemically dosed mAbs across the human airway epithelium over short time scales. Over longer time scales, the elevated circulating levels of mAbs with greater FcRn affinity, due to more effective FcRn-mediated recycling, may better resupply mAb into the respiratory tract, leading to more effective extended immunoprophylaxis. [ABSTRACT FROM AUTHOR]