"To BAL or not to BAL, that is the question": Variations in smoke inhalation injury guidelines from burn units and centres in England, Scotland and Wales.

AIM: To evaluate variations in diagnostic criteria and management recommendations for smoke inhalation injury (SII) amongst the burn networks of England, Scotland, and Wales. METHODS: A descriptive cross-sectional study examining SII guidelines provided by adult burn units and centres in England, Scotland and Wales. RESULTS: All 16 adult burn units and centres responded. Fourteen (87.5 %) had guidelines. Due to sharing of guidelines, ten unique guidelines were assessed. Diagnostic criteria showed variability with no universal criterion shared amongst guidelines. Bronchoscopy was recommended by 90 % of guidelines, but the timing varied. The use of bronchoscopic scoring systems was recommended by four guidelines. Bronchoalveolar lavage (BAL) was recommended by four, with considerable variation in frequency and choice of lavage fluid. All guidelines advised at least one nebulised agent: heparin (n = 8); N-acetyl cysteine (NAC) (n = 8); or salbutamol (n = 8). All guidelines included advice on carbon monoxide poisoning; however, carboxyhaemoglobin (COHb) cut-off levels for treatment varied (5 % [n-4], 10 % [n = 3], 15 % [n = 1]). All recommended high-flow oxygen. Seven (70 %) guidelines offered guidance on cyanide poisoning. Reduced/altered consciousness was the only consistent diagnostic criterion. Five (50 %) guidelines provided intubation guidance, emphasising the role of a 'senior clinician' as the intubator. Ventilatory guidance appeared in eight guidelines, focusing on lung protective ventilation (n = 8); oxygenation goals (n = 3); and permissive hypercapnia (n = 3). Within lung-protective ventilation, advice on tidal volume (6, or 6-8 ml/kg) and plateau pressures (>30 cmH2O) were presented most commonly (n = 7). CONCLUSION: This study has outlined the substantial variations in guidance for the management of SII. The results underscore the need for a national guideline outlining a standardised approach to the diagnosis and management of SII, within the limitations of the current evidence.

Infantile Subglottic Hemangioma: A Case ReportInfantile Subglottic Hemangioma: A Case Report.

ABSTRACT: Subglottic hemangiomas are rare benign vascular tumors of infancy which involve the airway. It is a subtype of infantile hemangiomas and is a potentially life-threatening condition with a mortality rate of 50% if left untreated. Hence, early intervention in this condition is essential. Here we present a case of a 4-month-old infant, a male infant with a history of cough and noisy breathing requiring multiple hospital visits before eventually being diagnosed with subglottic hemangioma. Due to its similar presentation with other more common respiratory illnesses, the diagnosis can be missed. Oral propranolol is the first-line therapy, which was used successfully in our case.

Pulmonary endoscopy - central to an interventional pulmonology program.

INTRODUCTION: Pulmonary endoscopy occupies a central role in Interventional Pulmonology and is frequently the mainstay of diagnosis of respiratory disease, in particular lung malignancy. Older techniques such as rigid bronchoscopy maintain an important role in central airway obstruction. Renewed interest in the peripheral pulmonary nodule is driving major advances in technologies to increase the diagnostic accuracy and advance new potential endoscopic therapeutic options. AREAS COVERED: This paper describes the role of pulmonary endoscopy, in particular ultrasound in the diagnosis and staging of lung malignancy. We will explore the recent expansion of ultrasound to include endoscopic ultrasound - bronchoscopy (EUS-B) and combined ultrasound (CUS) techniques. We will discuss in detail the advances in the workup of the peripheral pulmonary nodule.We performed a non-systematic, narrative review of the literature to summarize the evidence regarding the indications, diagnostic yield, and safety of current bronchoscopic sampling techniques. EXPERT OPINION: EBUS/EUS-B has revolutionized the diagnosis and staging of thoracic malignancy resulting in more accurate assessment of the mediastinum compared to mediastinoscopy alone, thus reducing the rate of futile thoracotomies. Although major advances in the assessment of the peripheral pulmonary nodule have been made, the role of endoscopy in this area requires further clarification and investigation.

Severe cardiac complication as coronary artery spasm during bronchoscopy: a case report.

Background: Bronchoscopy is widely used in clinical diagnosis and treatment of respiratory diseases. Although it is generally safe, cardiac complications such as acute myocardial ischemia and arrhythmia can also occur in patients especially with comorbidities and in elderly ones. Acute malignant coronary vasospasm as a severe cardiac complication can occur during bronchoscopy. It is essential to observe the occurrence of complications and provide early curing. Case Description: We presented a case of a 52-year-old man who experienced chest pain, dyspnea and even shock during bronchoscopy. Electrocardiogram (ECG) showed an acute muti-leads ST-segment elevation and declined to baseline soon after emergent medication treatment including antithrombotic, expansion of coronary artery and fluid replenishment myocardial infarction. Coronary artery spasm was considered according to the clinical symptom and ECG characteristics. Subsequent coronary angiogram which showed normal coronary artery also supported the diagnosis of coronary artery spasm. The symptom of the patient was discovered timely and was treated successfully with good prognosis. Conclusions: Bronchoscopy is the main and important method of diagnosis and treatment for respiratory diseases. Coronary artery spasm as a serious cardiac complication should be paid more attention during bronchoscopy. Timely and appropriate treatment may lead to better clinical results. Multidisciplinary cooperation plays a key role in the whole therapy. The potential triggers of coronary artery spasm during bronchoscopy mainly include low oxygen, hypersensitivity reactions and chronic inflammatory.

A 47-Year-old Asian female with tracheobronchial space-occupying lesions caused by chronic lymphocytic leukemia.

CASE PRESENTATION: A 47-year-old Asian woman was admitted with worsening chest tightness and dyspnea for 10 days. Computed tomography (CT) showed changes in the trachea and segmental bronchi. Pulmonary function results suggestive of severe obstructive ventilatory dysfunction. Bronchoscopic findings showed the presence of multiple nodular lesions in the patient's trachea and left and right main bronchi. Bronchoscopic biopsy, lymph node biopsy and bone marrow aspiration flow cytometry test results led to a definitive diagnosis of chronic lymphocytic leukemia (CLL), staged as Binet stage B and Rai stage 2.

Pneumothorax following rigid bronchoscopy for foreign body removal in a child: A case report.

INTRODUCTION: Rigid bronchoscopy is an effective tool for the management of pediatric airway foreign bodies. However, it is not exempt from complications that can be fatal, such as pneumothorax. CASE PRESENTATION: A 20-month-old child was admitted to our department after inhaling a foreign body (peanut). Immediately after removal of this foreign body, the child presented with a pre-arrest state with right auscultatory silence. Pneumothorax was suspected and aspirated, and cardiopulmonary resuscitation was performed. After 3 days in the intensive care unit (ICU), the child was discharged. CLINICAL DISCUSSION: Inhalation of foreign bodies is frequent during the first 3 years of life. Its management relies on rigid bronchoscopy. However, this procedure is not devoid of risks, which can be fatal. CONCLUSION: Our case illustrates a rare complication of rigid bronchoscopy in pediatric population and highlights the importance of prompt diagnosis and management.

The Bronchoalveolar Lavage Dilution Conundrum: An Updated View on a Long-Standing Problem.

Bronchoalveolar lavage (BAL) is used by researchers to study molecular interactions within healthy and diseased human lungs. However, the utility of BAL fluid measurements may be limited by difficulties accounting for dilution of the epithelial lining fluid (ELF) sampled and inconsistent collection techniques. The use of endogenous markers to estimate ELF dilution has been proposed as a potential method to normalize acellular molecule measurements in BAL fluid, but these markers are also imperfect and prone to inaccuracy. The focus of this report is to review factors that affect the interpretation of acellular molecule measurements in lung ELF and present original data comparing the performance of several BAL dilution markers during health and in a human endobronchial endotoxin challenge model of acute inflammation. Our findings suggest that incomplete ELF and lavage fluid mixing, flux of markers across the alveolar barrier, and lung inflammation are all possible factors that can affect marker performance. Accounting for these factors, we show that commonly used markers including urea, total protein, albumin, and immunoglobulin M are likely unreliable BAL dilution markers. In contrast, surfactant protein D, appears to be less affected by these factors and may be a more accurate and biologically plausible marker to improve the reproducibility of acellular BAL component measurements across individuals, during health and inflammatory states.

A prospective observation study of the dynamic monitoring of transcutaneous arterial blood oxygen saturation and carbon dioxide during bronchoscopy.

BACKGROUND AND AIMS: Because bronchoscopy is an invasive procedure, sedatives and analgesics are commonly administered, which may suppress the patient's spontaneous breathing and can lead to hypoventilation and hypoxemia. Few reports exist on the dynamic monitoring of oxygenation and ventilation during bronchoscopy. This study aimed to prospectively monitor and evaluate oxygenation and ventilation during bronchoscopy using transcutaneous arterial blood oxygen saturation and carbon dioxide. METHODS: We included patients who required pathological diagnosis using fluoroscopic bronchoscopy at our hospital between March 2021 and April 2022. Midazolam was intravenously administered to all patients as a sedative during bronchoscopy, and fentanyl was administered in addition to midazolam when necessary. A transcutaneous blood gas monitor was used to measure dynamic changes, including arterial blood partial pressure of carbon dioxide (tcPCO2), transcutaneous arterial blood oxygen saturation (SpO2), pulse rate, and perfusion index during bronchoscopy. Quantitative data of tcPCO2 and SpO2 were presented as mean ± standard deviation (SD) (min-max), while the quantitative data of midazolam plus fentanyl and midazolam alone were compared. Similarly, data on sex, smoking history, and body mass index were compared. Subgroup comparisons of the difference (Δ value) between baseline tcPCO2 at the beginning of bronchoscopy and the maximum value of tcPCO2 during the examination were performed. RESULTS: Of the 117 included cases, consecutive measurements were performed in 113 cases, with a success rate of 96.6%. Transbronchial lung biopsy was performed in 100 cases, whereas transbronchial lung cryobiopsy was performed in 17 cases. Midazolam and fentanyl were used as anesthetics during bronchoscopy in 46 cases, whereas midazolam alone was used in 67 cases. The median Δ value in the midazolam plus fentanyl and midazolam alone groups was 8.10 and 4.00 mmHg, respectively, indicating a significant difference of p < 0.005. The mean ± standard deviation of tcPCO2 in the midazolam plus fentanyl and midazolam alone groups was 44.8 ± 7.83 and 40.6 ± 4.10 mmHg, respectively. The SpO2 in the midazolam plus fentanyl and midazolam alone groups was 94.4 ± 3.37 and 96.2 ± 2.61%, respectively, with a larger SD and greater variability in the midazolam plus fentanyl group. CONCLUSION: A transcutaneous blood gas monitor is non-invasive and can easily measure the dynamic transition of CO2. Furthermore, tcPCO2 can be used to evaluate the ventilatory status during bronchoscopy easily. A transcutaneous blood gas monitor may be useful to observe regarding respiratory depression during bronchoscopy, particularly when analgesics are used.

Thermal Ablation of Pulmonary Nodules by Electromagnetic Navigation Bronchoscopy Combined With Real-Time CT-Based 3D Fusion Navigation:Report of One Case.

A nodule in the right middle lobe of the lung was treated by a combination of cone-beam CT,three-dimensional registration for fusion imaging,and electromagnetic navigation bronchoscopy-guided thermal ablation.The procedure lasted for 90 min,with no significant bleeding observed under the bronchoscope.The total radiation dose during the operation was 384 mGy.The patient recovered well postoperatively,with only a small amount of blood in the sputum and no pneumothorax or other complications.A follow-up chest CT on the first day post operation showed that the ablation area completely covered the lesion,and the patient was discharged successfully.

Combining high-flow nasal cannula oxygen therapy with repeated toilet bronchoscopies for respiratory failure due to excessive infected airway secretions: a case report and series from a non-intensive hospital ward.

Fiberoptic bronchoscopy (FBO) has diagnostic or therapeutic purposes but can cause respiratory deterioration, particularly in patients with pre-existing acute respiratory failure (ARF). Non-invasive ventilation (NIV) and high-flow nasal cannula oxygen therapy (HFNC) are used as respiratory support for ARF as well as to prevent significant oxygen deterioration during FBO. The combined use of NIV and early therapeutic FBO to clear retained abundant infected secretions from the airways may be an alternative to intubation and invasive mechanical ventilation (IMV), but no data exist on the combined use of FBO and HFNC. A 78-year-old male patient with ARF secondary to chronic obstructive pulmonary disease (COPD) exacerbation and pneumonia was admitted to our non-intensive geriatric ward. After an initial improvement, his respiratory conditions worsened. While continuing HFNC, he underwent a series of eight FBOs over 9 days, each performed in response to significant decreases in peripheral oxygen saturation (SpO2). The goal was to remove copious and occlusive infected secretions from the airways, with each procedure resulting in good SpO2 recovery. After etiological targeted antibiotic therapy based on bronchial aspirate, the patient improved and was discharged. Next, six consecutive similar ARF patients were treated using the same strategy of combining HFNC with repeated toilet FBO performed within the ward to clear secretions. All patients showed improvement and were discharged. The combination of HFNC and repeated toilet FBO could be a safe and effective intervention in non-intensive wards to prevent intubation and IMV in frail and elderly patients with ARF secondary to copious and occlusive infected secretions in the airways.

Diagnostic value of rEBUS-TBLB combined distance measurement method based on ultrasound images in bronchoscopy for peripheral lung lesions.

Traditional imaging methods have limitations in the diagnosis of peripheral lung lesions. The aim of this study is to evaluate the diagnostic value of the distance measurement method based on ultrasound image-based inverted electrostrain (rEBUS) combined with thoracoscopic lung biopsy (TBLB) for peripheral lung lesions. A group of patients with peripheral lung lesions were recruited for the study, and rEBUS examination was performed simultaneously during TBLB. Using rEBUS ultrasound images combined with electrostrain information, evaluate the morphological characteristics of peripheral lung lesions and the elastic properties of internal tissues. By comparing with pathological examination results, both rEBUS-D-TBLB and rEBUS-GS-TBLB have a higher positive diagnostic rate for PPL under bronchoscopy. However, rEBUS-D-TBLB is more effective in diagnosing benign PPL with ≥ 3cm PPL than rEBUS-GS-TBLB. The rEBUS-TBLB combined ranging method has shown high accuracy and sensitivity in diagnosing peripheral lung lesions. Ultrasound images provide clear morphological features of the tumor, while the electrical strain information of rEBUS provides elastic information of the internal tissue of the tumor, further improving the accuracy of diagnosis.

Role of Spirometry, Radiology, and Flexible Bronchoscopy in Assessing Chronic Cough in Children.

Chronic cough in children is a common and multifaceted symptom, often requiring a comprehensive approach for accurate diagnosis and effective management. This review explores the use of spirometry, radiology (chest X-rays and computed tomography (CT) scans), and flexible bronchoscopy in the assessment of chronic cough in children through current guidelines and studies. The strengths, clinical indications, and limitations of each modality are examined. Spirometry, radiology, and in some cases flexible bronchoscopy are integral to the assessment of chronic cough in children; however, a tailored approach, leveraging the strengths of each modality and guided by clinical indications, enhances diagnostic accuracy and therapeutic outcomes of pediatric chronic cough.

Bronchoscopic Diagnosis of Severe Respiratory Infections.

The diagnosis of severe respiratory infections in intensive care remains an area of uncertainty and involves a complex balancing of risks and benefits. Due to the frequent colonisation of the lower respiratory tract in mechanically ventilated patients, there is an ever-present possibility of microbiological samples being contaminated by bystander organisms. This, coupled with the frequency of alveolar infiltrates arising from sterile insults, risks over-treatment and antimicrobial-associated harm. The use of bronchoscopic sampling to obtain protected lower respiratory samples has long been advocated to overcome this problem. The use of bronchoscopy further enables accurate cytological assessment of the alveolar space and direct inspection of the proximal airways for signs of fungal infection or alternative pathologies. With a growing range of molecular techniques, including those based on nucleic acid amplification and even alveolar visualisation and direct bacterial detection, the potential for bronchoscopy is increasing concomitantly. Despite this, there remain concerns regarding the safety of the technique and its benefits versus less invasive sampling techniques. These discussions are reflected in the lack of consensus among international guidelines on the topic. This review will consider the benefits and challenges of diagnostic bronchoscopy in the context of severe respiratory infection.

Successful Bevacizumab Therapy in a 25-Year-Old Patient with Recurrent Respiratory Papillomatosis.

Background: Recurrent respiratory papillomatosis (RRP) is a chronic condition caused primarily by human papilloma virus (HPV) types 6 and 11, leading to recurrent growths in the respiratory tract. These types of papilloma can cause significant morbidity due to airway obstruction, often requiring frequent surgical interventions. Traditional treatments, including surgical removal and adjunctive therapies like antivirals and immune modulators, often fail to prevent recurrence, impacting the patient's quality of life. Case description: This report presents a 25-year-old female with a long-standing history of RRP, diagnosed at age 2. Despite numerous interventions, including CO2 laser ablations, interferon therapy, HPV vaccination, and a laryngotomy with tracheal reconstruction, the patient continued to experience severe airway obstruction requiring frequent surgeries. In 2023, intravenous therapy with bevacizumab, vascular endothelial growth factor inhibitor was introduced, leading to a significant reduction in the frequency of surgical interventions from 8 to 4 per year. This reduction improved the patient's respiratory function and quality of life, highlighting bevacizumab's therapeutic potential. Conclusion: The case underscores the debilitating nature of RRP and the challenges of its management. Bevacizumab, by targeting vascular endothelial growth factor (VEGF), has shown promise in reducing papilloma growth and the need for frequent surgeries. This case supports the inclusion of bevacizumab as an adjunctive therapy in RRP treatment, warranting further research to confirm its long-term efficacy and safety. LEARNING POINTS: Recurrent respiratory papillomatosis is a rare and complex disease that severely impacts patients' quality of life.This case report demonstrates that bevacizumab can significantly reduce surgical interventions in recurrent respiratory papillomatosis (RRP), offering a promising treatment that improves management of this chronic condition.Bevacizumab, already used in treating various diseases by targeting VEGF, shows promise in managing RRP as well, highlighting its potential across multiple conditions and expanding its therapeutic versatility.

Evolution of transbronchial needle aspiration needles: Over the last half century.

Transbronchial needle aspiration (TBNA) is a commonly used sampling approach in the diagnosis of hilar and mediastinal lymphadenopathy as well as peripheral lesions. As a very important tool, the continued innovation of TBNA needles is a vital driving force for the development of the technique. Although TBNA plays an important role in interventional pulmonology, there are no clear standards guiding operators to choose an appropriate needle for their operation. In recent decades, with the advent of endobronchial ultrasound-guided TBNA (EBUS-TBNA), the real-time visualization of TBNA has been enabled. These modern TBNA needles, such as ViziShot2, FLEX 19G, Acquire FNB, and EchoTip ProCore, have made significant progress in specimen collection, convenience, and safety, though still remain grounded in the basic premise and initial upgrades to the original conventional TBNA (cTBNA) needles. This review introduced the developmental history of WANG cTBNA needles, and summarized the lessons of success and failure and the enlightenments for currently used EBUS- and other emerging TBNA needles, aiming to provide a significant reference for pulmonologists who lived through the cTBNA era and for junior physicians who start working in the EBUS-TBNA era. Despite its long history, TBNA is still playing significant roles in the diagnosis of pulmonary diseases. A deeper understanding from the historical perspectives would facilitate continued innovations in the field of TBNA and beyond.

Using simulated bronchoscopy to improve training on intensive care units in a north London NHS trust.

Flexible bronchoscopy is a vital tool that is used for both diagnostic and therapeutic indications on the intensive care unit. During the COVID pandemic, training opportunities to perform such a skill were decreased and novel methods of teaching, including using bronchoscopy simulators, were explored out of necessity. The aim of this quality improvement project was to investigate how training on an intensive care unit prepared trainees for carrying out bronchoscopy, and whether a simulated bronchoscopy session with a high-fidelity simulator could be a useful adjunct to gain experience. Our pilot, although limited in patient numbers, suggested that current teaching methods might not be adequate for building trainee confidence and that a session with a bronchoscopy simulator could serve as a remedy to this with a significant increase in self-reported confidence. Moving forwards in a post-pandemic era, this serves as a lesson learnt from COVID and would benefit from further development in this area.

Combining intraprocedural CT guided navigation with ventilatory strategy for atelectasis: A modified electromagnetic navigation bronchoscopy.

CT-body divergence limits the accuracy of electromagnetic navigation bronchoscopy(ENB) in peripheral lung lesions diagnosis. Finding one effective and safe method to eliminating CT-body divergence may improve ENB accuracy. Thus, we developed a modified ENB which combining intraprocedural CT guided Navigation with Ventilatory strategy for Atelectasis to eliminate CT-body divergence. We called it inCTNVA-ENB. We present the case of an 80-year-old female with peripheral pulmonary nodule (without bronchial direct connection). She underwent inCTNVA-ENB, and the navigation probe accurately reached 6mm next to the target lesion without complications. The operation time was 42 minutes, and rapid on-site evaluation showed adenocarcinoma cells. CT data revealed the CT-body divergence caused by atelectasis was reduced.

Intraoperative marking of pulmonary nodules in a hybrid operating room: electromagnetic navigation bronchoscopy versus percutaneous marking.

Background: Intraoperative identification of subsolid or small pulmonary nodules during minimally invasive procedures is challenging. Recent localization techniques show varying success and complications. Hybrid operating rooms (HORs), equipped with radiological tools, facilitate intraoperative imaging. This study compares the accuracy and safety of marking pulmonary nodules using electromagnetic navigation bronchoscopy (ENB) combined with Cone Beam Computed Tomography (CBCT) vs. CBCT-guided percutaneous marking (PM). Methods: This retrospective cohort study included patients with pulmonary nodules scheduled for minimally invasive resection in a HOR. Marking techniques included ENB assisted by CBCT and PM guided by CBCT. The study compared the success rate, procedure time, intraoperative complications and radiation dose of both techniques. Results: A total of 104 patients with 114 nodules were included (October 2021-July 2024). Thirty nodules were marked using ENB, and 84 with PM. One case used both techniques due to ENB failure. No differences among groups were found in nodule characteristics. Success rates were similar (93.3% in ENB group vs. 91.7% in PM group, p = 1). Marking took significantly longer time in the ENB group (median 40 min) compared to PM group (25 min, p = 0.007). Five (6%) patients in the PM group experienced intraoperative complications compared to none in the ENB (p = 0.323). Radiation dose was significantly higher in the ENB group (p = 0.002). Conclusions: ENB assisted by CBCT is a safe and effective technique, with success rates comparable to CBCT-guided PM, though it may result in longer procedural times and higher radiation doses.