Evidence of lung surfactant abnormality in respiratory failure. Study of bronchoalveolar lavage phospholipids, surface activity, phospholipase activity, and plasma myoinositol.

Autopsy findings suggest that lung surfactant is damaged in the adult respiratory distress syndrome. In the present study 225 bronchoalveolar lavage specimens (78 from 36 patients, 1-78 yr old with respiratory failure, 135 from another 128 patients with other respiratory disease, and 12 from healthy controls) were assayed for the lung profile [lecithin/sphingomyelin (L/S) ratio, saturated lecithin, phosphatidylinositol, and phosphatidylglycerol]. Bronchoalveolar lavage fluid was further analyzed for phospholipids and for phosphatidic acid phosphohydrolase, phospholipase A2, and phosphatidylinositol phosphodiesterase activities. A lipid-protein complex was isolated and analyzed for surface activity, and plasma was measured for myoinositol. There were only small differences seen in the recovery of total phospholipid between respiratory failure patients and normal controls. However, in respiratory failure, phospholipids in bronchoalveolar lavage were qualitatively different from those recovered either from normal controls or from patients with other lung disease: the LO/S ratio, phosphatidylglycerol, and disaturated lecithin were low, whereas sphingomyelin and phosphatidylserine were prominent. These abnormalities were present early in respiratory failure and tended to normalize during recovery. Low L/S ratio (less than 2), and low phosphatidylglycerol (1% or less of glycerophospholipids) in bronchoalveolar lavage was always associated with respiratory failure. Abnormal lavage phospholipids were not due to plasma contamination. The phospholipase studies revealed little evidence of increased catabolism of phospholipids. In respiratory failure, the lipid-protein complexes from lung lavage were not surface active, whereas that from healthy controls had surface properties similar to lung surfactant. Phospholipids from patients with respiratory failure were similar to those from respiratory distress syndrome in the newborn. However, the latter condition is characterized by fast recovery of surfactant deficiency and by high plasma myoinositol that suppresses the synthesis of surfactant phosphatidylglycerol and increases phosphatidylinositol (Pediatr. Res. 1981. 15: 720). On the other hand, in adult respiratory distress syndrome, the abnormality in surfactant phospholipids may last for weeks and in most cases is associated with low phosphatidylinositol, low phosphatidylglycerol, and low plasma myoinositol.

Inter-hospital transport of neonatal patients on extracorporeal membrane oxygenation: mobile-ECMO.

OBJECTIVE: To describe the equipment, personnel requirements, training, management techniques, and logistic problems encountered in the design and implementation of a mobile extracorporeal membrane oxygenation (ECMO) program. DESIGN: This is a report of a technique for the transport of patients on ECMO and a description of our retrospective case series. SETTINGS: The study was conducted at a regional referral children's hospital and ECMO unit. PATIENTS: Thirteen neonatal medical patients with acute respiratory failure were transported with mobile-ECMO. RESULTS: Over a 24-month period, we transported 13 neonatal patients with mobile-ECMO. The reason for transport with mobile-ECMO was inability to convert from high-frequency ventilation (4 of 13), patient already on ECMO (1 of 13), and patient deemed too unstable for conventional transport (8 of 13). Eleven of the 13 patients were transported from other ECMO centers. Of the 13, 9 survived. No major complications during transport were reported for any of the patients. Follow-up data were available on all nine survivors of neonatal mobile-ECMO. Eight of these had normal magnetic resonance imaging scans of the brain; the ninth had a small hemorrhage in the left cerebellum. CONCLUSION: Our limited series shows that patients can be safely transported with mobile-ECMO. This program does not replace the early appropriate transfer for ECMO-eligible patients to an ECMO center.

Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction.

OBJECTIVE: To determine whether emergency rigid bronchoscopic intervention, including Nd-YAG laser resection or stenting, immediately affected the need for continued mechanical ventilation or intensive care level of support in critically ill patients with acute respiratory failure from malignant or benign central airways obstruction. DESIGN: Retrospective review of medical records of all patients with acute respiratory failure and malignant or benign tracheobronchial obstruction necessitating intubation, mechanical ventilation, or hospitalization in the ICU prior to referral for therapeutic bronchoscopy. SETTING: University of California San Diego, a tertiary care institution specialized in airway management. PATIENTS: Medical records of 32 patients with malignant or benign central airways obstruction requiring admission to the ICU prior to rigid bronchoscopic intervention between January 1994 and April 1996. INTERVENTIONS: Emergent rigid bronchoscopy with dilatation, Nd-YAG laser resection, or silicone stent insertion performed in the operating room under general anesthesia. RESULTS: Thirty-two patients with central airways obstruction requiring emergent hospitalization in the ICU were referred for therapeutic rigid bronchoscopy. Airway strictures were caused by benign disease in 18 patients, and by primary bronchogenic lung cancer in 14. Of the 19 patients who were mechanically ventilated, bronchoscopic intervention allowed immediate discontinuation of mechanical ventilation in 10 (52.6%). Twenty-five patients had indwelling artificial airways (12 endotracheal tubes, 13 tracheotomy tubes). Two, however, were considered tracheotomy-dependent because of neuromuscular disease. Of the remaining 23 patients, immediate extubation or decannulation was possible in seven (30.4%). Of seven patients with no indwelling airway, five (71.4%) were immediately transferred to a lower level of care after intervention. Of the 32 total patients, 20 (62.5%) were immediately transferred to a lower level of care immediately after intervention. CONCLUSIONS: Emergency laser resection or stent insertion can favorably affect health-care utilization in patients with acute respiratory distress from central airways obstruction. Treatment may be lifesaving and allows successful withdrawal from mechanical ventilation, hospitalization in a lower level of care environment, relief of symptoms, and extended survival in critically ill patients. In patients with regionally advanced cancer, the palliative nature of this procedure postpones death by respiratory distress and may prompt consideration for institution of conservative comfort measures to reduce patient suffering.

Obstructing endobronchial bands complicating radiation therapy for lung carcinoma.

A 57-year-old man with small cell lung carcinoma developed benign, obstructing endobronchial bands five months after external beam radiation therapy. We believe that this represents an unusual delayed complication of radiation therapy for airway tumors. An excellent clinical response was obtained after laser ablation of the lesion.

Angioscopic visualization of pulmonary emboli.

A flexible, fiberoptic device, fitted with an inflatable distal balloon, has been used to directly visualize the great veins, right cardiac chambers, pulmonary arteries, and experimental emboli in vivo in the dog. Insertion and manipulation of the device have been well-tolerated. The angioscope has significant potential for investigative and clinical application.

Management of arterial hypoxemia induced by fiberoptic bronchoscopy.

Twenty patients undergoing fiberoptic bronchoscopy (FOB) (bronchofiberscopy) were studied with serial arterial blood gas analyses. Ten patients were managed using a 40 percent Venturi mask with a 2-cm opening cut out for the FOB; there were ten other patients, with this opening modified by a thin rubber diaphragm with a slit for insertion of the FOB. Both masks decreased the extent of hypoxemia after bronchoscopy, but the mask with the diaphragm provided significantly higher PaO2 values. A significantly higher mean FIO2 was found at the carina in the group using the diaphragm-modified mask. This study suggests that declines in PaO2 after bronchoscopy can be avoided in most patients undergoing diagnostic FOB by using a diaphragm-modified 40 percent Venturi mask during and after the procedure. However, patients with a PaO2 below 60 mm Hg before bronchoscopy may require other measure to avoid potentially hazardous degrees of hypoxemia after bronchoscopy.

High dose rate intraluminal irradiation in recurrent endobronchial carcinoma.

Palliative therapy for previously irradiated patients with symptomatic recurrent endobronchial malignancy is a difficult problem. We have had the opportunity to treat 20 such patients with high dose rate (50-100 rad/min) endobronchial brachytherapy. Eligible patients had received previous high dose thoracic irradiation (TDF greater than or equal to 90), a performance status of greater than or equal to 50, and symptoms caused by a bronchoscopically defined and implantable lesion. The radiation is produced by a small cobalt-60 source (0.7 Ci) remotely afterloaded by cable control. The source is fed into a 4 mm diameter catheter which is placed with bronchoscopic guidance; it may oscillate if necessary to cover the lesion. A dose of 1,000 rad at 1 cm from the source is delivered. We have performed 22 procedures in 20 patients, four following YAG laser debulking. Most had cough, some with hemoptysis. Eight had dyspnea secondary to obstruction and three had obstructive pneumonitis. In 12, symptoms recurred with a mean time to recurrence of 4.3 months (range 1-9 months). Eighteen patients were followed-up and reexamined via bronchoscope 1-2.5 months following the procedure; two were lost to follow-up. All had at least 50 percent clearance of tumor, and six had complete clearance; most regressions were documented on film or videotape. In six, the palliation was durable. The procedure has been well tolerated with no toxicity. We conclude that palliative endobronchial high dose rate brachytherapy is a useful palliative modality in patients with recurrent endobronchial symptomatic carcinoma.

Alveolar proteinosis. Lobar lavage by fiberoptic bronchoscopic technique.

Lavage limited to an isolated lobe was performed on multiple occasions using a cuffed fiberoptic bronchoscope in a patient with alveolar proteinosis. Sequential ventilation-perfusion scintiphotoscans were used to preselect and follow the functional behavior of the lavaged lobe. Lavage led to functional improvement. The technique of fiber-optic bronchoscopic lobar lavage is simple and may find application in patients in whom lavage of an entire lung may be hazardous.

The treatment of endobronchial stenosis using balloon catheter dilatation.

Acquired bronchial stenosis has been associated with sleeve resection, tuberculosis, sarcoidosis, and prolonged intubation. Various modalities of therapy for the relief of such stenoses include surgery, cryotherapy, and laser photoresection. Several recent reports have described the use of angioplasty balloon catheters for dilatation of stenotic areas. In two patients with endobronchial stenosis, we found that balloon dilatation, using either angioplasty or valvuloplasty catheters, in combination with laser photoresection can be safely and effectively performed with alleviation of pulmonary symptoms.

Lack of utility of bronchial brush biopsy in patients infected with the human immunodeficiency virus.

While bronchoalveolar lavage has been shown to be more sensitive than brush biopsy (BB) for the diagnosis of Pneumocystis carinii pneumonia in AIDS patients, some have reported that BB occasionally is positive in spite of a negative BAL. Many bronchoscopists, therefore, continue to perform routine BB when doing bronchoscopy on AIDS patients. We performed a retrospective study of all fiberoptic bronchoscopies done on human immunodeficiency virus-infected patients over a one-year period at our institution to determine if the use of BB added to the diagnostic yield of bronchoscopy over that of BAL alone. Of 84 bronchoscopies in which BB was performed in addition to BAL, BB yielded no diagnoses that were not obtained by BAL. Brush biopsy added approximately $400 to the cost of bronchoscopy. We conclude that BB should not be routinely done when performing bronchoscopy on HIV-infected patients.

Laser resection of granulation tissue secondary to transtracheal oxygen catheter.

Oxygen therapy through a transtracheal catheter has been used increasingly for the long-term delivery of continuous oxygen. Compared to nasal cannula it results in significant reduction in oxygen flow requirements. This form of therapy has gained patient acceptance because of several advantages including improved convenience, aesthetics, compliance, and mobility. Reported complications generally have been minor, including subcutaneous emphysema, cough, "mucous ball" formation and mild hemoptysis. In this report, we describe a case of granulation tissue formation at the transtracheal catheter puncture site which was treated with Nd:YAG laser bronchoscopy to reestablish patency of the upper airway. No recurrence was noted after two years of follow-up.

Endobronchial metastases due to colorectal carcinoma.

Metastatic disease from colorectal carcinoma to the tracheobronchial tree has previously been reported in only 15 cases. Various modalities of treatment have been attempted but have met with limited success. We describe an additional nine cases, as documented by fiberoptic bronchoscopy, treated by Nd-Yag laser therapy debulking. Improvement in bronchial patency was evidenced visually in each case, and relief of symptoms occurred in eight cases. Survival periods of up to 21 months occurred. This type of metastatic disease may be more common than previously reported and combination therapy to include Nd-Yag laser debulking offers a safe and effective alternative in the palliative management of pulmonary symptoms and increased survival in select patients.

Ventilation-perfusion alterations induced by fiberoptic bronchoscopy.

Pulmonary perfusion (Q) and ventilation (V) scintiphotography was performed in 16 patients undergoing diagnostic fiberoptic bronchoscopic examinations. Regional V/Q did not change in the majority of the patients who developed hypoxemia after bronchoscopic studies. An improvement in V/Q was detectable in the patients with a rise in arterial oxygen pressure (PaO2) after bronchoscopic examination, and this rise was associated in most with the removal of mucous plugs or extensive secretions. The data indicate that the behavior of PaO2 after bronchoscopic study is dependent upon both the extent of lavage and the yield of the procedure in terms of secretions and plugs. The results also indicate that the removal of secretions or plugs can be associated with rapid return of regional V and Q.

Transthoracic needle aspiration biopsy following negative fiberoptic bronchoscopy in solitary pulmonary nodules.

To evaluate the utility of transthoracic needle aspiration biopsy (TTNAB) following negative fiberoptic bronchoscopy (FOB) in a patient with a solitary pulmonary nodule (SPN), we reviewed the records from 262 patients who had undergone TTNAB over an eight-year period. Fifty-eight patients had a SPN and met the criteria for inclusion in this series. Twenty-five of these (43 percent) were diagnosed by TTNAB; 24 had malignant lesions; one had M tuberculosis. Of the remaining 33 patients, 18 went on to definitive diagnostic procedures (surgery, repeat FOB or TTNAB). Nine of these patients had a malignancy. Fifteen patients were followed long-term; one was diagnosed with carcinoma two years after the initial work-up. Carcinoma was not found in any patient under 40 years of age. A benign lesion was diagnosed by TTNAB in only two patients. We conclude that TTNAB is a valuable procedure in the evaluation of patients with a SPN and negative FOB. While a negative FOB and TTNAB do not assure that the lesion is benign, a complex of variables influences the decision regarding thoracotomy vs careful follow-up.

Novel flexible bronchoscope and single-use disposable-sheath endoscope system. A preliminary technology evaluation.

OBJECTIVE: To measure image clarity, ease of use, and handling performance of a flexible fiberoptic bronchoscope (B-F 100; Vision Sciences; Natick, MA) and sterile single-use disposable-sheath endoscope system (BS-F21 EndoSheath; Vision Sciences). DESIGN: Prospective, multicenter diagnostic technology evaluation of a medical device newly approved by the US Food and Drug Administration. SETTING: Three tertiary care referral centers with busy bronchoscopy practices. PATIENTS: Twenty-four patients undergoing bronchoscopy with a flexible fiberoptic bronchoscope and disposable sheath endoscope system. METHODS: Flexible bronchoscopy was performed through a transnasal or transoral route after topical upper airway anesthesia using standard techniques. After each procedure, the bronchoscopist rated the performance of the medical device under study using a linear scale of 1 (poor) to 5 (excellent and equal to that of a conventional flexible fiberoptic bronchoscope). RESULTS: Mean performance ratings were > 4.0 (range, 4.17 to 4.63) for image clarity, illumination, lack of fogging, distal tip angulation, and ease of transnasal passage. All other ratings were > 3.0 (range, 3.54 to 3.87), the lowest of which was handling comfort. CONCLUSION: The flexible fiberoptic bronchoscope with sterile single-use disposable-sheath endoscope system has the potential to reduce scope downtime by eliminating the need for high-level disinfection between procedures. Illumination, image clarity, and ease of insertion are very good, justifying future prospective studies comparing this device to conventional flexible fiberoptic bronchoscopes.

Percutaneous nephroscopy using fiberoptic bronchoscope: removal of renal calculus.

A method for percutaneous removal of renal calculus within the collecting system is presented. Thus utilized, a flexible fiberoptic bronchoscope with fluoroscopic guidance provides a safe and quick alternative treatment to reoperative surgery for retained renal calculi.

Early onset of childhood pulmonary lymphangiomyomatosis.

The authors present the first case of lymphangiomyomatosis in a pediatric patient. Radiographic findings, biopsy, computerized tomography, and electron microscopy were useful in detailing the presentation of early onset of pulmonary lymphangiomyomatosis. The unusual presentation of this child includes a description of her disease prior to any pulmonary symptomatology and 4 years of follow-up.

Bronchoscopic and serologic diagnosis of Aspergillus fumigatus pulmonary infection in a bottlenose dolphin (Tursiops truncatus).

A 4-yr-old male bottlenose dolphin (Tursiops truncatus) developed an Aspergillus fumigatus pneumonia. Fungal elements were identified by cytology and microbiology from endoscopic bronchoalveolar lavage and brushings of a raised yellow endobronchial lesion. The results of qualitative immunodiffusion serology, a technique that identifies specific circulating antibodies to Aspergillus fumigatus, were suggestive of an active infection. The dolphin was treated with itraconazole for over 2 yr, which resulted in remission of clinical signs. Pneumonia caused by Aspergillus sp. accounts for the large majority of pulmonary mycoses in marine mammals. Bronchoscopy facilitated an early definitive diagnosis, accurate treatment, and remission.