A dedicated tracheobronchial stent.

A dedicated tracheobronchial stent to be used in the treatment of external compression of the main airway is described. This stent is made of molded silicone. Its outside surface bears regularly placed studs to prevent displacement. First results are encouraging. So far, 118 prostheses have been placed in 66 patients. Tolerance was excellent and complications were rare. Migration occurred 12 times: in seven cases an early prototype that was poorly designed had been used. Obstruction was noted in two cases without major problems. Mean follow-up at the time of this writing is three months, with the longest follow-up 19 months.

Development of a disposable spray canister for talc pleurodesis. A preliminary report.

Talc pleurodesis has been used for more than 50 years in both the United States and in Europe, and it has proven to be safe and effective in patients with malignant pleural effusions as well as recurrent pneumothorax. In this preliminary report, we describe a disposable, single-use spray canister that allows intrapleural administration of sterile, asbestos-free Luzenac talc, thus facilitating thoracoscopic talc insufflation for pleurodesis, particularly in patients with recurrent malignant effusions. The talc is delivered ready to use, administered via a hollow plastic delivery catheter that can be inserted through the pleural trocars used during thoracoscopy. Use of this spray canister allows practitioners to avoid complex handling and sterilization procedures required for bulk talc powder.

A reappraisal of blind bronchial sampling in the microbiologic diagnosis of nosocomial bronchopneumonia. A comparative study in ventilated patients.

STUDY OBJECTIVE: To assess the usefulness of fiberscopy for microbiologic diagnosis of nosocomial bronchopneumonia (NBP) in ventilated patients. DESIGN: Data were collected prospectively. We compared the results of semiquantitative cultures obtained by protected specimen brush (PSB), bronchoalveolar lavage (BAL) and blind bronchial sampling (BBS). Positive thresholds were 10(3) CFU ml-1 for PSB and BAL and 10(4) CFU ml-1 for BBS. We also evaluated the diagnostic performance of direct examination of samples obtained by BAL and BBS. PATIENTS: We carried out this study in 64 ventilated patients admitted to a medico-surgical ICU. RESULTS: During the study, 85 sets of samplings were obtained. The concordance between the results of specimen cultures obtained with the three techniques was 87 percent. The concordance between BBS and PSB or between BBS and BAL was 91.8 percent. In two of seven patients with discordant results between BBS and PSB, the microorganisms isolated from blood cultures were found on BBS, but not on PSB samples. As for direct examination, the thresholds for the diagnosis of NBP using BBS were as follows: > or = 10 polymorphonuclear neutrophils (PMN)/high-power field (HPF), > or = 1 bacteria/oil immersion field (OIF), presence of intracellular bacterial inclusions. Using BAL, the thresholds were as follows: > or = 1 PMN/HPF, presence of bacteria/OIF, presence of intracellular bacterial inclusions. The specificity of the presence of bacterial inclusions was excellent regardless of the sampling technique, but the sensitivity of this criteria was mediocre (30.8 percent with BBS and 19.2 percent with BAL). Except for the number of PMN on BBS, all the other diagnostic criteria (PMN count on BAL, bacterial count, count of cells exhibiting inclusions) provide a similar prediction of NBP (correctly classified: 61.2 to 81.2 percent). No combination of criteria enabled significantly better classification regardless of the sampling technique. CONCLUSIONS: In view of these findings and the high cost and morbidity of fiberscopy, it is arguably better to use a simple, repeatable, and risk-free technique for obtaining culture specimens from mechanically ventilated patients. Obviously, protected brushing techniques remain the most effective for nonintubated patients.

Treatment of tracheobronchial lesions by laser photoresection.

One hundred eleven patients underwent 205 laser photo-irradiation treatments using a Neodynium YAG laser with a flexible bronchoscope or an open tube for various tracheobronchial conditions, such as obstructing bronchogenic carcinomas, bronchial adenomas, and postintubation tracheal stenosis. The procedure was performed with either local or general anesthesia. Results were especially rewarding with endobronchial tumors. Tracheal stenoses were best treated by a combination of laser surgery and tracheal dilatation. No complication was encountered. Specific indications suggested for laser surgery are resection of inoperable tracheobronchial tumors, correction of tracheal stenosis, removal of surgical sutures, retrieval of tissue-embedded foreign bodies, and cauterization of hemorrhaging endobronchial tissues.

Teaching models for Nd:YAG laser bronchoscopy.

A number of groups have demonstrated the efficacy of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser bronchoscopy for treatment of patients with selected tracheobronchial disorders. This therapy involves a new technology, the laser, and new adaptations of conventional rigid and flexible bronchoscopy that are unfamiliar to many bronchoscopists. We describe two teaching models for laser bronchoscopy that have been employed successfully in our laser courses. Using these models, bronchoscopists can become familiar with laser bronchoscopic equipment and appreciate the interaction of laser and soft tissue in a controlled setting in the laboratory before applying this therapy to patients.

Benign tumors of the tracheobronchial tree. Endoscopic characteristics and role of laser resection.

We conducted a review of all the bronchoscopies performed at our institutions for benign tumors from 1980 to 1991 to determine the endoscopic characteristics of these lesions. We reviewed the charts, the endoscopic characteristics from our video records, and finally the pathologic findings of these cases. We tried to identify the effectiveness of laser resections in each group. Of a total of 3,937 patients, 185 (4.7%) were benign tumors. On these patients, 317 procedures were carried out. There were 3 myoblastomas, 53 papillomas, 1 adenoma, 8 chondromas, 4 fibromas, 45 hamartomas, 15 hamartochondromas, 6 lipomas, 19 angiomas, 5 leiomyomas, 4 schwannomas, 1 neurofibroma, and 21 amyloidomas. Results of laser resection were "very good" in 115 (62%) and "good" in 70 (38%). Complications were minimal: two mediastinal emphysemas, one pneumothorax, and one anesthesia-related cardiac arrest leading to the single death in this series. In general, benign tumors of the proximal endobronchial tree responded well to laser resection when their endoscopic appearance is recognized and prognosis known. Even when recurrent, repeated procedures can be performed easily with good results. This series is probably the largest in the world's literature about endoscopic recognition and the role of laser resection in patients presenting with benign endobronchial tumors.

Safety of interventional rigid bronchoscopy using intravenous anesthesia and spontaneous assisted ventilation. A prospective study.

STUDY OBJECTIVE: To investigate the safety of total intravenous anesthesia and spontaneous assisted ventilation during interventional rigid bronchoscopy (IRB). DESIGN: Prospective, noncomparative study. SETTING: A university hospital thoracic endoscopy and laser center. PATIENTS: Eighty-three patients underwent a total of 124 procedures (including Nd:Yag laser therapy, stent insertions, transbronchial biopsies/bronchoalveolar lavages (TBB/BALs) in transplant patients and others). Results of preanesthesia consultation, endoscopic and anesthesia intervention, perioperative complications, and time spent in recovery room were recorded prospectively. RESULTS: Respiratory complications occurred in 22 procedures (18 percent) and included severe intraoperative or postoperative oxyhemoglobin desaturations (19 cases), bronchospasms/laryngospasms (two cases), and one recurrent pneumothorax. These complications were mostly related to the endobronchial surgical procedure. Respiratory complications occurred more frequently in patients with American Society of Anesthesiologists (ASA) 3 and 4 status (p < 0.005) and in patients with a karnofsky Performance Scale (KPS) below 70 (p < 0.05). No cardiac complications were noted, although 13 patients had significant underlying heart disease. Propofol was used in 121 procedures. Etomidate was used 15 times for induction and three times for both induction and maintenance in patients with ASA status 4 or low blood pressure before induction. CONCLUSION: Total intravenous anesthesia and spontaneous assisted ventilation is a well-suited technique for IRB. Severe hypoxemia, however, may occur in approximately 15 percent of patients. This complication is usually related to the procedure itself and is easy to reverse. Propofol is well tolerated in the majority of patients but it must be used with care in patients with poor functional or cardiovascular status.

Endoscopic management of bronchial stenosis after double lung transplantation.

Double lung transplantation with bilateral bronchial sutures is an increasingly popular therapeutic alternative for endstage, bilateral, septic pulmonary disease; however, surgical outcome has been hampered by mechanical complications at the level of the airway anastomoses. In our institution, therefore, the protocol for surveillance includes frequent flexible fiberoptic and rigid bronchoscopy under general anesthesia in all patients. Since 1988, there were 24 double lung transplantations (mean age, 19 yr) performed at the University of Marseille Hospitals using bilateral sutures without omental wrapping. Nineteen patients had cystic fibrosis; of the ten individuals (53 percent) with cystic fibrosis who ultimately developed bronchial stenosis, six required therapeutic endoscopic intervention including dilatation or Nd:YAG laser resection. Five patients required endobronchial silicone stents. Statistically significant risk factors for postsurgical airway narrowing included young age (mean, 14.3 yr vs 24.0 yr in patients without stenosis) and prolonged mechanical ventilation prior to transplant (all five patients ventilated before surgery developed stenosis). Results of interventional bronchoscopy were good, and an excellent level of physical activity was maintained in most patients. A team familiar with all aspects of therapeutic bronchoscopy is essential to ensure proper management of airway complications in patients after lung transplantation.

Principles for safety in application of neodymium-YAG laser in bronchology.

The YAG laser is being used more often in cases of nonresectable bronchogenic cancer and in some cases is called on in lieu of surgery for tracheal stenosis. Patient safety hinges first on the endoscopist's technical skill and second on his understanding of the dangers involved in laser therapy. This report is based on experience gleaned from a 1,503 case series of endoscopic YAG laser treatments on 839 patients. These treatments were carried out by seven endoscopists in four teams using exactly the same equipment and techniques. In spite of the use of this high-risk technique in a high-risk patient population comprising a majority of major airways malignancy, the mortality rate was only 0.4 percent (six deaths: all in the postoperative period). We attribute this success to careful screening prior to resection, whenever possible, and above all to our methodology which not only emphasizes prevention but also enables rapid response.

Double-lung transplantation for cystic fibrosis. The Cystic Fibrosis Transplant Study Group.

One hundred twenty cystic fibrosis patients were accepted for transplantation. Twenty-five patients underwent double-lung transplantation. Twenty-five patients died awaiting transplantation (20.6%). There were 13 female and 12 male patients. Their mean age was 28 years (range, 7 to 34 years), and mean percentage ideal body weight was 76% (range, 58.5% to 91.9%). Most patients were hypoxic and hypercarbic. Two patients underwent tracheal anastomosis, 15 had en bloc bronchial anastomoses, and 8 had sequential single-lung transplants. Operative mortality was 16%; all deaths were related to bleeding from extensive adhesions. Actuarial survival at 1 year was 64%. Rejection and infection were frequent during the first month and decreased thereafter. Airway complications occurred in 5 patients but were amenable to laser therapy and stenting. We conclude that double-lung transplantation is an acceptable modality for the treatment of cystic fibrosis patients with end-stage lung disease. It may be a better alternative to heart-lung transplantation considering the paucity of thoracic organ donors.

Airway stents. Present and future.

Tracheobronchial stent insertion is a relatively new technique used to palliate or cure central airways obstruction. When performed by experienced thoracic endoscopists, this procedure is both safe and effective, even if complications of indwelling stents may require repeat endoscopic intervention. Although proven clinically beneficial to many patients, airway prostheses have not yet been the subject of large comparative case studies or randomized controlled investigations. Reports are often experiential and anecdotal. Further research is needed to determine the effects of stenting on survival in patients with malignant airway disease and its degree of success in patients with benign airway strictures. Only then will airway stents truly deserve their place alongside other therapies for tracheobronchial obstruction.

Bilateral bronchial anastomosis in double lung and heart-lung transplantations.

During heart-lung or double lung transplantation, the airway anastomosis is usually made at the tracheal level. Healing of this anastomosis is one source of postoperative complications especially after double lung transplantation (DLT). In this series of 10 patients with cystic fibrosis undergoing DLT, the tracheas of donor and recipient were anastomosed with omental wrapping in 2 cases while the two main stem bronchi were joined without omental wrapping in 8. Endoscopy disclosed no sign of ischaemia in the patients with bilateral bronchial anastomoses. Three patients died on day 20, 21 and 35, respectively, after DLT. Two of these patients (one with a tracheal and the other with bronchial anastomoses) showed no complication at the level of the suture line. The third patient (with bronchial suture) suffered dehiscence of both anastomoses which was attributed to a misdosage of corticosteroids. Of the 6 patients alive after bronchial anastomosis, 3 recovered uneventfully and 3 who had required prolonged postoperative mechanical ventilation developed bronchomalacia. Bronchomalacia was treated by laser resection and stenting. Dehiscence did not occur in any of these six cases. This technique was based on the findings of 12 fresh cadaver dissections showing that collaterals between the bronchial arteries and the pulmonary arteries and veins extend up to the origin of the main stem bronchus. Bronchial suture without omental wrap may be used for double lung and heart-lung transplantation instead of tracheal suture.

Endoscopic treatment of tracheobronchial malignancy. Experience with Nd-YAG and CO2 lasers in 506 operations.

Laser technology and the endoscope have been combined for the palliation of obstructive tracheobronchial malignant lesions. The neodymium-yttrium-aluminum-garnet (Nd-YAG) laser was used to treat 249 patients (447 operations), and the CO2 laser was used on 34 patients (59 operations). Hemorrhage, the major complication in both groups of patients, was more easily controlled with the Nd-YAG laser. One patient in the CO2 laser group died, and one patient in the group being treated with Nd-YAG laser bronchoscopy died. The Nd-YAG laser can be applied more efficiently through a fiber system, with better optic control and secure hemostasis. The commonest indications for treatment were dyspnea, obstructive pneumonia, and hemoptysis. Extrinsic compression was the most frequent reason for failure. The Nd-YAG laser, most often applied through open rigid bronchoscopes under general anesthesia, has become our treatment of choice for the palliation of tracheobronchial malignancy.

Total cervical tracheal stenosis: treatment by laser, dilation, and stenting.

Twelve patients with total cervical tracheal stenosis were treated by endoscopic laser excision (neodymium:yttrium aluminum garnet or carbon dioxide laser), bronchoscopic dilation, and prolonged stenting with a silicone T-tube. All patients had previous traumatic or prolonged endotracheal intubation requiring a tracheotomy and presented with aphonia as the major complaint. Multiple laser and dilation treatments were necessary in ten patients. Average duration of T-tube placement was 6 months. Excellent results (decannulation and good voice) were achieved in eight patients with a follow-up of 9 months to 6 years. Persistent granulation tissue and some degree of fibrosis were the most common complications (eight of 12 patients). Two patients died of medical complications. A high success rate with this endoscopic technique justifies this approach as our initial therapy, with open surgical techniques reserved for failure.

[Treatment of tracheobronchial lesions with Laser Yag]. / Trattamento delle lesioni tracheobronchiali con Laser Yag.

Various tracheobronchial obstruction indications have been treated with laser yag neodyme with flexible fibre introduced into a bronchofibroscope. Experience covers 44 patients who underwent 75 photocoagulation sessions under local or general anaesthesia. Inoperable tracheo-bronchial tumours are the most frequent and spectacular indications. Malignant tumour, cylindromas, carcinomas and benign tumours are the best indications. Tracheal stenoses were treated in association with instrumental dilatation. The other indications proposed are resections of granulomas, resection of suture threads, extraction of peripheral foreign bodies and control of major haemorrhages. No complications were observed. The immediate effectiveness of this new technique is considerable. Long-term development depends on the aetiology of tracheobronchial stenosis.

[Bronchial mucoepidermoid carcinoma: apropos of 3 cases]. / Carcinome muco-épidermoïde bronchique: à propos de 3 observations.

We report three cases of bronchial mucoepidermoid carcinoma (BMEC) of low-grade malignancy with a relafase-free follow up. BMEC are rare tumors. The microscopic findings distinguish low-grade tumors which occur in children and young adults and high-grade tumors concerning older patients; this grading is based on the study of the epidermoid component. If possible, conservative therapy is appropriate in low-grade tumors. The prognosis of high-grade tumors is poor.

[Double lung transplantation. Report of the 1st French case and comments on the 5 subsequent cases]. / Les transplantations bi-pulmonaires. Rapport de la première observation française et commentaires des cinq suivantes.

Using a modified version of the technique described by the Toronto group, the Marseille group has performed 6 double lung transplantation procedures. In 6 cases the underlying disease was cystic fibrosis. Four patients are currently alive. The technique was modified in two ways. First anastomosis was made on the two main stem bronchi in order to rule out the risk of ischemic complications. Second a special postoperative care technique in which the patient is regularly turned from one side to the other was applied to avoid lymph stasis during the first postoperative weeks.

[Non-malignant esophagotracheal fistulas in adults. Experience with 35 cases]. / Les fistules oeso-trachéales non malignes de l'adulte. Expérience de trente-cinq cas.

Esophagotracheal fistula always constitutes a serious, life-threatening complication. Fistulae occurring during medical intensive care with mechanical ventilation are currently the most frequent. Their diagnosis was strongly suspected by clinical examination of the patient, but was always confirmed by endoscopy which revealed their exact site in relation to the vocal cords or carina, essential information for the choice of incision when it is decided to perform surgery. Twenty-five patients were treated medically. Treatment was always combined with gastrointestinal resting, control of gastro-oesophageal reflux and broad-spectrum systemic antibiotics. There were 19 deaths and 6 fistulae closed spontaneously. Three of these 6 patients developed a secondary tracheal stenosis, 2 of which were treated surgically by resection-anastomosis. Ten fistulae were closed surgically with a good long-term result. The indication for surgery was essentially based on the patients general and infectious status and on his or her respiratory autonomy. Technically, we always combined direct suture of the two organs with interposition of muscular or pleural tissue.

[Surgical treatment of benign laryngotracheal stenosis. Apropos of 12 cases]. / Traitement chirurgical des sténoses laryngo-trachéales bénignes. A propos de douze observations.

The authors report a series of twelve benign laryngotracheal strictures. In almost every case, these lesions were secondary to tracheal intubation and consisted of extensive, circumferential and almost complete stenosis. All were treated surgically. The authors obtained enlargement of the airway be means of an interposed cartilaginous graft and an intraluminal prosthesis which was left in place. In nine cases, this procedure was combined with posterior cricotomy. One eight month old infant died during the postoperative period. Ten patients had an uneventful postoperative course with a satisfactory anatomical and functional result.

[A specific tracheobronchial endoprosthesis]. / Une endoprothèse trachéobronchique spécifique.

The author describes a dedicated tracheobronchial stent in treatment for the external compression of the main airway. The stent is made of moulded silicone and its outside surface has regular studs which are placed so as to prevent displacement. The first results are very encouraging. 146 prostheses have been positioned in 80 patients. Tolerance has been excellent and complications were rare. Unfortunately migration occurred 14 times: in 7 cases this was with one of the early prototypes which was poorly designed, and obstruction was noted in 4 cases without major problems. At the time of writing there has been a mean follow-up of 3 months, and the longest follow-up has been 21 months.