Non-fully reversible airway obstruction in fatal asthma is often seen in association with profound structural changes of the bronchial wall, termed airway remodeling. Evidence suggests that heavy precipitation events can trigger epidemics of severe asthma. We present a case of fatal asthma in a young woman with no prior near-fatal exacerbations and postulate that the patient\'s extensive airway remodeling and puerperal state (susceptibility factors), in combination with a massive allergen challenge during a hurricane landfall (triggering factor), played a central role in her death. The autopsy revealed diffuse obstruction of proximal and distal bronchi by mucous plugs together with transmural chronic inflammation, tissue eosinophilia, extensive goblet cell hyperplasia with MUC-5 expression and airway smooth muscle (ASM) thickening. The observed distribution of airway remodeling was heterogeneous with sparing of the lingula, which exhibited hyperinflation and expansion of perivascular spaces indicative of dissecting air. The massive stagnation of mucus and significant inter-airway structural heterogeneity created an anatomical substrate for unequal airflow distribution facilitating the development of barotrauma. Although not considered conventional risk factors for fatal asthma, we believe that in this case, the patient\'s puerperal state in conjunction with an extreme environmental event dispersing aeroallergens were major contributors to the development of a fatal asthma attack. Our autopsy findings suggest that effective strategies to evacuate stagnated mucus and induce relaxation of thickened ASM are crucial in the management of life-threatening asthma exacerbations.

Mounier-Kuhn syndrome is a rare clinical disorder characterized by tracheobronchial dilation and recurrent lower respiratory tract infections. While the etiology of the disease remains unknown, histopathological analysis of Mounier-Kuhn airways demonstrates that the disease is, in part, characterized by cellular changes in airway smooth muscle.

OBJECTIVE: To describe a technique for tracheostomy in heterotopic ossification that has not yet been described in the literature.
METHODS: We report a case of difficult tracheostomy while using conventional techniques in a 68-year-old patient who underwent mitral valve replacement requiring warfarin therapy three months prior. Imaging revealed heterotopic ossification overlying the trachea. A literature review was performed to identify similar cases or techniques.
RESULTS: Extensive surgical planning was pursued after the initial attempted tracheostomy failed, and the airway was eventually accessed using a lighted intubation stylet for guidance and a drill. Heterotopic ossification has been described after orthopedic and abdominal surgeries. We identified one case report in the literature of tracheostomy performed in the setting of heterotopic ossification by an unspecified mechanism. There are few reported cases of tracheobronchial calcification in cardiac patients receiving warfarin therapy; however, these patients had characteristic imaging findings that were not consistent with those of our patient.
CONCLUSIONS: We illustrate a safe and effective technique for tracheostomy in heterotopic ossification that has not been reported. Coordination with the anesthesia service was paramount for a successful operation.

BACKGROUND: Chronic airway inflammation and remodelling are fundamental features of asthma. The molecular phenotypes in asthma are Th2 high and Th2 low. Serum periostin is a biomarker which aid in understanding Th2 high eosinophilic asthma.
OBJECTIVE: The present study aimed to identify whether or not serum periostin is a systemic biomarker for eosinophilic airway inflammation in asthmatics.
METHODS: The study was designed as a prospective, case control study. Patients who presented with consistent symptoms of asthma and confirmed by spirometry with reversibility were the cases. The controls were healthy subjects who had no history of lung disease with normal lung function. The sputum and blood samples were collected from both the groups. Sputum eosinophils, Absolute Eosinophil Counts (AEC) and serum periostin levels were compared between the groups.
RESULTS: The study comprised of 101 participants in which 30 were controls and 71 were cases. In the study group, mean post FEV1 was 64.45. There was a positive correlation of sputum eosinophils with severity of obstruction. The ROC curve analysis showed the cut-off value of 24.556 for serum periostin with the p-value of <0.001. As the severity of obstruction increased, the serum periostin levels were also found to be increased. Serum periostin had a sensitivity and specificity of 97.18% and 86.67% with a diagnostic accuracy of 94.06%.
CONCLUSIONS: Serum periostin appears to be a more sensitive tool for detection of airflow limitation in asthmatic patients with a Th2 high eosinophilic phenotype when compared to AEC and sputum eosinophils.

BACKGROUND: Relapsing polychondritis is a multi-system autoimmune disease characterised by the inflammation and destruction of cartilaginous structures. The most common sites are the pinna, nose, laryngotracheobronchial tree and peripheral joints. Airway involvement occurs in up to half of patients affected, at any disease stage. It is the most severe and life-threatening aspect of the disease, and proves to be a therapeutic challenge.
OBJECTIVE: This article reports our experience of performing laryngotracheal reconstruction in a patient with relapsing polychondritis. A review of the literature is presented, with a focused discussion of airway treatment options.
METHODS: Laryngotracheal reconstruction for relapsing polychondritis was performed using hyoid bone pedicled on sternohyoid muscle.
CONCLUSIONS: Airway management in relapsing polychondritis can improve quality of life and palliate patients effectively.