A novel pleural-bladder pump for the management of recurrent malignant pleural effusions: a feasibility animal study.

BACKGROUND: Recurrent malignant pleural effusions (MPE) are common and associated with significant morbidity in cancer patients. A new pump connecting the pleural cavity and the bladder may have application for the management of recurrent MPE. In a pre-clinical study, we investigated the utility of this pump in healthy pigs. METHODS: A novel pump system (Pleurapump® system) was inserted into four pigs under general anaesthesia. A tunnelled-pleural catheter was connected to a subcutaneously implanted pump while the urinary bladder was connected by percutaneous technique. Animals were ventilated mechanically and pump functioning was tested using a range of ventilation parameters and spontaneous breathing. Fluid was added to the pleural space to mimic pleural effusion and to assess the effectiveness of the pump at removing fluid to the bladder. RESULTS: The 'pleurapump' system successfully transported fluid from the pleural cavity to the bladder. Pressure variations caused by respiration and variations in the amount of fluid in the pleural cavity had no impact on the pumping. Pumping stopped when the pleural cavity was drained. CONCLUSION: This pump can be implanted into pigs and successfully removed fluid from the pleural cavity to the bladder and may represent a new treatment for management of recurrent MPE. Evaluation in humans is planned.

[Bronchoscopic management of malignant central airway obstructions]. / Traitement endoscopique des obstructions malignes des voies aériennes centrales.

Up to 30% of lung cancer patients suffer from central airway obstruction, resulting in major deterioration in prognosis and quality of life. Interventional bronchoscopy combines a number of invasive techniques used during rigid bronchoscopy. It is designed to rapidly improve symptoms, primarily dyspnea. Applied according to very precise indications, this technique requires careful patient selection and needs to be incorporated into the multimodal oncological management in combination with systemic treatments, radiation therapy and surgery.

Temporary endobronchial embolization with silicone spigots for moderate hemoptysis: a retrospective study.

BACKGROUND: The management of airway bleeding is generally performed in an emergency to prevent hypoxemia and lung flooding. When the bleeding arises from peripheral lesions that are not visible endoscopically, bronchoscopic options have limited curative intents. Endobronchial embolization using silicone spigots (EESS) is a novel approach. OBJECTIVES: We analyzed the efficacy and safety of EESS in a retrospective study. METHODS: We retrospectively reviewed charts of patients referred to our center for moderate hemoptysis (MH) who underwent EESS. Successful management is defined as immediate bleeding cessation. RESULTS: From December 2008 to January 2012, 9 patients were treated with EESS in our endoscopy unit. The MH originated from the left upper lobe in 4 cases, the right upper lobe in 3 cases and the right middle lobe and left lower lobe in 1 case each. Thirteen spigots were inserted. The success rate was 78%. Of the 9 patients, 7 were referred to interventional radiology for bronchial artery embolization, with a success rate of 86%, and 2 were referred for thoracic surgery. One patient had EESS as definitive treatment; the silicone spigots were bronchoscopically removed after a median of 4 days in 6 of the remaining 8 patients. Only 2 patients had hemoptysis recurrence after a median follow-up of 107 days (ranging from 13 to 1,017 days). None of the patients died from hemoptysis. CONCLUSION: EESS is an original, temporary technique that requires only a flexible bronchoscope and biopsy forceps for placement and removal. EESS ensures airway protection while waiting for definitive management.

[Airway stenting: State of the art]. / Prothèses des voies aériennes : état de l'art.

In the overwhelming majority of cases, Airway stents offer relief of malignant or benign central airway obstruction. In some non-tumoral situations, they can be curative, providing a bridge to local or systemic treatments in the context of malignant obstruction. The efficacy and tolerance of these medical devices have dramatically improved over the past three decades with the development of silicone airway stents and, more recently, of third-generation, covered, self-expandable metallic stents with an increasingly widened panel of shapes. We review herein the main categories of airway stents with their specific indications, pitfalls, and advantages, not only in neoplastic situations, but also in the treatment of benign stenoses of the respiratory tract. The recent advances and perspectives in the field are also taken into consideration, particularly the development of biodegradable, drug-eluting, and patient-specific customized AS.

Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management.

Hemoptysis is frequently encountered in clinical practice, and may be the presenting symptom of a number of diseases. Although massive hemoptysis accounts for only 5-15% of episodes, it should always be considered as a life-threatening condition that warrants effective assessment and management. In this article, we review the literature with regard to the definition, etiology, epidemiology, pathophysiology, diagnosis and treatment of massive hemoptysis, with special emphasis on the role of bronchoscopy as a diagnostic and therapeutic tool. We briefly present the circumstances under which the use of rigid bronchoscopy should be preferred for controlling massive bleeding. Moreover, we address the crucial importance of multidisciplinary collaboration by illustrating the roles of endovascular therapy and surgery in the optimal management of massive hemoptysis.

[Trans-vocal cord prostheses - preliminary experience treating benign laryngotracheal stenosis in adults]. / Sténoses laryngotrachéales bénignes de l'adulte : place des prothèses transcordales. Expérience préliminaire.

INTRODUCTION: Benign laryngotracheal stenosis is a rare pathology with multiple etiologies, the management of which is complex. This is because of the configuration and proximity of the larynx and the difficulty with surgical approaches, which are potentially mutilating, especially for the management of a benign disease. When surgery is challenging, iterative dilatations of the stricture or the fashioning of a definitive tracheotomy are therapeutic alternatives. Advances in rigid bronchoscopy and the evolution of prosthetic silicone material allow a new approach in the management of benign laryngotracheal stenosis, by placing flexible silicone prostheses which cover all the stenosis from the arytenoids to the trachea. This preliminary work aims to evaluate the feasibility, effectiveness, tolerance and complications of the implementation of this type of prosthesis. PATIENTS AND METHODS: This is a retrospective single-centre study which analyzed the records of patients with symptomatic benign laryngotracheal stenosis who underwent placement of a transcordial prosthesis over a period of three years. The prosthesis used, inserted under general anesthesia during a rigid tube interventional bronchoscopy, was either a straight silicone prosthesis or a Montgomery T-tube for those with a pre-existing tracheotomy. RESULTS: Six patients were included. Five are still alive, one patient died from a cause unrelated to the placement of the prosthesis. Four have no tracheostomy and two now have no transcordal prosthesis. The data collected on tolerance found, for three patients, two cases of minor aspiration and one case of transient cough. All patients had whispered voice dysphonia. We did not observe prosthesis migration or obstruction. CONCLUSION: These preliminary results are encouraging. Transcordal prostheses in benign laryngotracheal stenosis have a complementary or alternative role compared to surgery with a palliative or even curative objective.

[Management of a tracheal adenoid cystic medico-surgical carcinoma]. / Prise en charge médico-chirurgicale d'un carcinome adénoïde kystique trachéal : l'union fait la force.

Adenoid cystic carcinoma or cylindroma is a rare tumor of the trachea which arises from mucous secreting cells. Its evolution and growth are slow but it is often fatal in the absence of radical treatment. The latter relies on a surgical sleeve resection of the pathological area, with a tracheo-tracheal anastomosis. Therapeutic bronchoscopy plays a crucial role in the clinical improvement of patients before surgery which will be performed under better conditions. For inoperable patients, radiotherapy has proved its efficacy, unlike conventional chemotherapy. The finding of biomarkers expressed by tumor cells could lead to target therapies. This case report illustrates the efficient combination of therapeutic bronchoscopy and surgery for the treatment of adenoid cystic carcinoma affecting central airways.

A multicenter retrospective study investigating the role of interventional bronchoscopic techniques in the management of endobronchial lipomas.

BACKGROUND: Pulmonary lipomas are rare benign tumors that are usually found endobronchially. Undiagnosed, they can lead to the serious late sequelae associated with endobronchial obstruction. In the majority of cases, they are located in the first three subdivisions of the tracheobronchial tree, and therefore, they are amenable to endoscopic techniques for diagnostic and therapeutic purposes. OBJECTIVES: It was our aim to retrospectively study the bronchoscopic management and follow-up of a large series of endobronchial lipomas, as well as defining the demographic and endoscopic characteristics of patients. METHODS: A retrospective multicenter study was performed to identify all cases of lipomas that were treated endoscopically in 4 institutions in the period from 1981 to 2002. Demographic, radiological, endoscopic and histological data were collected. RESULTS: Thirty-eight patients were included in the study; 81.6% of cases were males and the average age was 63.5 +/- 15.2 years. The majority of the patients were symptomatic (63.2%). Lipomas were located proximally in 18 cases (47.4%) and distally in 20 subjects (52.6%). Specimens obtained by rigid bronchoscopy were diagnostic in all cases. Thirty-six out of 38 patients underwent therapeutic rigid bronchoscopy. Laser and mechanical debulking was performed in 29 cases (76.3%), cryotherapy and mechanical debulking in 7 subjects (18.4%), and mechanical debulking alone in 2 cases (5.3%). No cases of recurrence occurred during the follow-up period. CONCLUSIONS: This study demonstrates that endoscopic techniques are effective for the diagnosis and treatment of endobronchial lipomas when there is no evidence of severe distal bronchiectasis. This should be the treatment of choice after a full clinicoradiological evaluation.

[A rare cause of stridor in a 59 year old woman in intensive care]. / Stridor d'étiologie rare en post-réanimation chez une patiente de 59 ans.

INTRODUCTION: Stridor in the post extubation period occurs frequently and is most commonly caused by laryngeal oedema. During this period, the trachea can also be obstructed by pseudomembranes. CASE REPORT: We report the case of a 59 year old woman who required re-intubation, 15 days after extubation because of the acute onset of severe respiratory distress secondary to pseudomembranes in her trachea. CONCLUSION: It is essential that physicians who care for patients during the post extubation period are aware of this severe and life threatening cause of stridor. Definitive treatment with the rigid bronchoscope allows for rapid recanalisation of the airway.

[Blue rubber bleb naevus syndrome involving the pleura]. / Syndrome de Bean (« blue rubber bleb naevus syndrome ¼) avec localisation pleurale.

Bean's syndrome ('blue rubber bleb nevus syndrome') is a rare disease characterized by venous malformations involving various organs. Most often these lesions are localized to the skin and the digestive system. Gastro-intestinal bleeding is the most frequent presentation. Though other organs can be affected, chest localizations are infrequent and pleural localization is exceptional. We report the case of an asbestos-exposed patient with Bean's syndrome with characteristic skin lesions, smoker, hospitalized for the investigation of a hemorrhagic pleural effusion. A medical thoracoscopy revealed pleural lesions similar to the cutaneous lesions and compatible with a pleural localization of the disease. This is the first documented case of this disease involving the pleura. A review of the literature was carried out on account of this clinical case.

[Bronchoscopy in the diagnosis of lung cancer: an evaluation of current practice]. / L'endoscopie bronchique pour le diagnostic de cancer: évaluation des pratiques.

INTRODUCTION: Bronchoscopy is frequently practised by respiratory physicians, particularly when there is a suspicion of lung cancer. However, few guidelines are available and practice varies widely. BACKGROUND: Studies of current practice are few and unstandardised. Few data are available regarding equipment or procedure (information, prior investigations, environment, standardised reporting etc.). The evaluation of new techniques such as endobronchial ultrasound, autofluorescence bronchoscopy, transbronchial needle aspiration (TBNA) has been covered in recent publications. These evaluations are often undertaken without rigourous methodology (retrospective studies) but underline the feasibility of these techniques. Some, especially TBNA are nevertheless underused in practice. In the published studies evaluating practice the results of these investigations are often similar to those obtained in clinical trials even if a learning period is necessary. Complications are rare. Few studies of cost effectiveness are available but they support the use of these new techniques. VIEWPOINT: A national study under the aegis of the SLPF (French Respiratory Society) is necessary to obtain comprehensive and reliable data on the practice of bronchoscopy in the investigation of lung cancer. CONCLUSIONS: Studies evaluating current practices are few and unstandardised, and probably give only a partial survey of the success achieved and the difficulties encountered by respiratory physicians in their clinical routine.

Malignant transformation of a tracheal chondroma: The second reported case and review of the literature.

Tracheal tumors are rare, representing only 0.2% of the respiratory tract malignancies. Chondrosarcoma arising in the trachea was first described in 1959 by Jackson et al. and since then only 20 cases have been described. We report the second documented case of malignant transformation from an endotracheal chondroma, in a 75-year-old woman, and review the literature.

[Pleuro-pneumonia revealing septic thrombophlebitis of the jugular vein: Think about the Lemierre's syndrome]. / Pleuro-pneumopathie révélant une thrombophlébite septique de la veine jugulaire : pensez au syndrome de Lemierre.

INTRODUCTION: Infection by Fusobacterium necrophorum, a Gram negative anaerobic bacteria, can lead to the development of Lemierre's syndrome, an uncommon but potentially fatal infection of the internal jugular vein. Since the introduction of antibiotics, the morbidity and mortality associated with this syndrome have been dramatically reduced. This syndrome is characterized by a pharyngeal infection, which leads to the development of septic thrombophlebitis of the internal jugular vein with septic emboli, which usually spread into the lung. Sometimes the syndrome can be revealed by other unusual clinical symptoms. CASE REPORT: We present the case of a young patient with an atypical pleural infection associated with pharyngeal infection and thrombosis from the internal jugular vein. CONCLUSIONS: The diagnosis of Lemierre's syndrome is mainly clinical, based on a range of suggesting symptoms. Confirmation and monitoring of the condition can be done by ultra-sound and/or contrast enhanced computed tomography. Treatment is based on long-term, high-dose antibiotic therapy and eventually surgical drainage of the infected collection with surgical excision of the internal jugular vein where there is extensive thrombosis. The important message is that in the context of a young patient without comorbidity, who presents with a significant infectious pleurisy, it is important to consider this clinical complication.

[Endobronchial ultrasound in the diagnosis of malignant pleural mesothelioma]. / Échoendoscopie bronchique pour le diagnostic de mésothéliome pleural malin.

The diagnosis of malignant pleural mesothelioma relies mostly on the pathological examination of pleural samples, validated by a panel of experts and generally obtained during medical or surgical thoracoscopy performed for the management of an exudative pleural effusion. In the absence of pleural effusion (dry-type mesothelioma), the diagnostic approach depends on the features of the lesions (pleural thickness, nodules and/or masses) and their pleural location. Ultrasound and CT-guided needle aspiration represent recognized alternative diagnostic techniques in these situations. We present the case of a patient, presenting a dry-type mesothelioma, whose diagnosis was obtained by endobronchial ultrasound (EBUS)-guided needle aspiration of a pleural mediastinal mass and confirmed by a CT-guided needle aspiration of another pleural mass in close contact with the chest wall. The samples have been compared and show quantitative and qualitative similarities. EBUS represents a minimally invasive alternative diagnostic technique for dry-type mesothelioma, showing thickness of the mediastinal pleura in contact with a central airway or when thoracoscopy, which remains the "gold standard" diagnostic approach, is not feasible.

Role of allergens in the natural history of childhood asthma.

This review article deals with the role of allergens in the natural history of asthma. Several studies clearly demonstrate a strong relationship between allergen exposure, especially mite-allergen exposure, and risk of sensitization. Those studies have led to the proposed threshold equal to 2 micrograms/g dust. However, more recent evidence shows that there is no threshold for sensitization, especially in children born to atopic parents. As far as occurrence of asthma is concerned, geographical comparisons of asthma prevalence across Europe, Australia or in other populations with contrasted exposure to mite allergens do show such a relationship. The latter is not exemplified in studies performed within the same geographical area, probably because the exposure categories are not contrasted enough. Finally, asthma severity in mite sensitive asthmatics is partly modulated by allergen exposure but repeated exposure to low amounts of allergen can trigger disease activity. In conclusion, allergen exposure is involved at each step of the natural history of asthma. Even low doses can play a significant role. Thus avoidance methods, in order to be efficient in primary and secondary prevention, should lead to a drastic decrease in allergenic exposure.