Flexible bronchoscopic intubation through a supraglottic airway device: An evaluation of consultant anaesthetist performance.

BACKGROUND: Few clinical studies investigate technical skill performance in experienced clinicians. METHODS: We undertook a prospective observational study evaluating procedural skill competence in consultant anaesthetists who performed flexible bronchoscopic intubation (FBI) under continuous ventilation through a second-generation supraglottic airway device (SAD). Airway management was recorded on video and performance evaluated independently by three external assessors. We included 100 adult patients undergoing airway management by 25 anaesthetist specialists, each performing four intubations. We used an Objective Structured Assessment of Technical Skills-inspired global rating scale as primary outcome. Further, we assessed the overall pass rate (proportion of cases where the average of assessors' evaluation for every domain scored ≥3); the progression in the global rating scale score; time to intubation; self-reported procedural confidence; and pass rate from the first to the fourth airway procedure. RESULTS: Overall median global rating scale score was 29.7 (interquartile range 26.0-32.7 [range 16.7-37.7]. At least one global rating scale domain was deemed 'not competent' (one or more domains in the evaluation was scored <3) in 30% of cases of airway management, thus the pass rate was 70% (95% CI 60%-78%). After adjusting for multiple testing, we found a statistically significant difference between the first and fourth case of airway management regarding time to intubation (p = .006), but no difference in global rating scale score (p = .018); self-reported confidence before the procedure (p = .014); or pass rate (p = .109). CONCLUSION: Consultant anaesthetists had a median global rating scale score of 29.7 when using a SAD as conduit for FBI. However, despite reporting high procedural confidence, at least one global rating scale domain was deemed 'not competent' in 30% of cases, which indicates a clear potential for improvement of skill competence among professionals.

Balloon Dilatation for Bronchoscope Delivery in a Swine Model: A Novel Technique for Ultra-Peripheral Lung Field Access and Accurate Biopsy.

INTRODUCTION: In transbronchial biopsy of peripheral pulmonary lesions, the bronchoscope can reach only a limited depth due to the progressive narrowing of bronchi, which may reduce the diagnostic rate. This study examined the balloon dilatation for bronchoscope delivery (BDBD) technique, employing a novel balloon device to enhance bronchoscopy into the peripheral lung areas. METHODS: Anaesthetised swine served as our primary model. Using computed tomography (CT) scans, we positioned virtual targets characterised by a positive bronchus sign and a diameter of 20 mm beneath the pleura. The bronchoscope was navigated along the pathways determined from the CT images. We performed balloon dilatation when bronchial narrowing obstructed progress to assess whether balloon dilatation would enable the bronchoscope to enter further into the periphery. RESULTS: We established 21 virtual targets on the CT scans. An average of 12.1 branches were identified along the pathways on the CT scans; however, bronchoscopy without BDBD only allowed access to an average of 6.7 branches. Based on 72 balloon dilatations with 3.0-mm or 4.0-mm ultra-thin bronchoscopes, there was an average increased access of 3.43 and 5.14 branches per route, respectively, with no significant BDBD complications. The bronchoscope was able to reach the planned location along all pathways, and the mean final bronchoscopic endpoints were at an average distance of 14.7 mm from the pleura. Post-procedure CT confirmed biopsy accuracy. CONCLUSION: The BDBD technique can enhance access of a flexible bronchoscope into the peripheral lung fields, which could potentially allow more accurate transbronchial interventions for peripheral targets.

Value of ultrathin bronchoscope in improving the endobronchial ultrasound localization rate and diagnosing peripheral pulmonary nodules by cryobiopsy.

BACKGROUND: A 3.0-mm ultrathin bronchoscope (UTB) with a 1.7-mm working channel provides better accessibility to peripheral bronchi. A 4.0-mm thin bronchoscope with a larger 2.0-mm working channel facilitates the use of a guide sheath (GS), ensuring repeated sampling from the same location. The 1.1-mm ultrathin cryoprobe has a smaller diameter, overcoming the limitation of the size of biopsy instruments used with UTB. In this study, we compared the endobronchial ultrasound localization rate and diagnostic yield of peripheral lung lesions by cryobiopsy using UTB and thin bronchoscopy combined with GS. METHODS: We retrospectively evaluated 133 patients with peripheral pulmonary lesions with a diameter less than 30 mm who underwent bronchoscopy with either thin bronchoscope or UTB from May 2019 to May 2023. A 3.0-mm UTB combined with rEBUS was used in the UTB group, whereas a 4.0-mm thin bronchoscope combined with rEBUS and GS was used for the thin bronchoscope group. A 1.1-mm ultrathin cryoprobe was used for cryobiopsy in the two groups. RESULTS: Among the 133 patients, peripheral pulmonary nodules in 85 subjects were visualized using r-EBUS. The ultrasound localization rate was significantly higher in the UTB group than in the thin bronchoscope group (96.0% vs. 44.6%, respectively; P < 0.001). The diagnostic yield of cryobiopsy specimens from the UTB group was significantly higher compared to the thin bronchoscope group (54.0% vs. 30.1%, respectively; p = 0.006). Univariate analysis demonstrated that the cryobiopsy diagnostic yields of the UTB group were significantly higher for lesions ≤ 20 mm, benign lesions, upper lobe lesions, lesions located lateral one-third from the hilum, and lesions without bronchus sign. CONCLUSIONS: Ultrathin bronchoscopy combined with cryobiopsy has a superior ultrasound localization rate and diagnostic yield compared to a combination of cryobiopsy and thin bronchoscopy.

Factors associated with damages and repair costs of reusable flexible bronchoscopes in pediatrics in China.

BACKGROUND: Frequent repairs of pediatric flexible bronchoscopes can lead to a huge financial burden for the hospital. This study aimed to investigate the common causes of the failures in pediatric flexible bronchoscopes and propose the measures to prevent the failures. METHODS: This was a retrospective study. We collected repair information of the pediatric flexible bronchoscopes reprocessed in the Department of Sterile Processing at a hospital between September 1, 2018 and September 1, 2022 in order to investigate the causes and possible factors associated with the failures in pediatric flexible bronchoscopes. RESULTS: The Department of Sterile Processing staff reprocessed the pediatric flexible bronchoscopes 4280 times. A total of 29 failures were identified. The failure rate was 0.678%. The average repair cost was USD7246.60. The common failures in the pediatric flexible bronchoscopes included dim video image, black dots, improper video image display or no image during angulation adjustment, and pressure marks in the insertion tube. The failure rates in flexible electronic bronchoscopes and small-diameter flexible bronchoscopes were 65.5% and 93.1%, respectively. The failure rate in the pediatric flexible bronchoscopes reprocessed by the staff members with less work experience was 75.9%. CONCLUSION: The failure rate in the pediatric flexible bronchoscopes was not high but the repair costs were extremely high. The types and size of the flexible bronchoscopes and work experience of the staff members responsible for bronchoscope reprocessing were the possible factors associated with the failure rate in the pediatric flexible bronchoscopes. It is advisable to further optimize the central workflow and management mode for reprocessing the pediatric flexible bronchoscopes, thereby extending their useful life and reducing costs.

Chlamydia psittaci Pneumonia in a patient with motor neuron disease: a case report.

BACKGROUND: Motor neuron disease (MND) is a fatal neurodegenerative disorder that leads to progressive loss of motor neurons. Chlamydia psittaci (C. psittaci) is a rare etiology of community-acquired pneumonia characterized primarily by respiratory distress. We reported a case of C. psittaci pneumonia complicated with motor neuron disease (MND). CASE PRESENTATION: A 74-year-old male was referred to the Shaoxing Second Hospital at January, 2022 complaining of fever and fatigue for 2 days. The patient was diagnosed of MND with flail arm syndrome 1 year ago. The metagenomic next-generation sequencing (mNGS) of sputum obtained through bedside fiberoptic bronchoscopy showed C. psittaci infection. Then doxycycline was administrated and bedside fiberoptic bronchoscopy was performed to assist with sputum excretion. Computed Tomography (CT) and fiberoptic bronchoscopy revealed a significant decrease in sputum production. On day 24 after admission, the patient was discharged with slight dyspnea, limited exercise tolerance. One month later after discharge, the patient reported normal respiratory function, and chest CT showed significant absorption of sputum. CONCLUSIONS: The mNGS combined with bedside fiberoptic bronchoscopy could timely detect C. psittaci infection. Bedside fiberoptic bronchoscopy along with antibiotic therapy may be effective for C. psittaci treatment.

Ultrathin bronchoscopic cryobiopsy of peripheral pulmonary lesions.

BACKGROUND AND OBJECTIVE: Ultrathin bronchoscopy aids in the diagnosis of peripheral pulmonary lesions. However, both the working channel and the specimens are small. A 1.1-mm ultrathin cryoprobe that can enter the working channel of the ultrathin bronchoscope is now available, which may overcome the limitations of small specimen size. The aim of this study was to evaluate the feasibility, efficacy and safety of ultrathin bronchoscopic cryobiopsy using an ultrathin cryoprobe for diagnosing peripheral pulmonary lesions. METHODS: Patients with peripheral pulmonary lesions ≤30 mm in diameter were prospectively enrolled in the study. All patients underwent forceps biopsy followed by cryobiopsy using a 3.0-mm ultrathin bronchoscope under radial probe endobronchial ultrasound guidance, virtual bronchoscopic navigation and fluoroscopic guidance. The primary endpoint was the feasibility of cryobiopsy. RESULTS: In total, 50 patients with peripheral pulmonary lesions were enrolled in the study; the median longest diameter on computed tomography was 17.9 mm. Cryobiopsy was performed successfully in 49 patients (98%). Forceps biopsy, cryobiopsy and the combination of these two methods provided a specific diagnosis in 54% (27/50), 62% (31/50) and 74% (37/50) of patients, respectively. The median size of specimens obtained via cryobiopsy was significantly larger than the median size obtained via forceps biopsy (7.0 vs. 1.3 mm2 , respectively, p < 0.001). Mild bleeding during cryobiopsy occurred in 47 patients (94%). No moderate/severe bleeding or pneumothorax occurred. CONCLUSION: Ultrathin bronchoscopic cryobiopsy is feasible, effective and sufficiently safe for the diagnosis of peripheral pulmonary lesions.

Value of adding ultrathin bronchoscopy to thin bronchoscopy for peripheral pulmonary lesions: A multicentre prospective study.

BACKGROUND AND OBJECTIVE: The diagnostic yield of thin bronchoscopy with radial probe endobronchial ultrasound (rEBUS) of peripheral pulmonary lesions into which the rEBUS probe cannot be inserted is unsatisfactory. In such cases, adding ultrathin bronchoscopy may be an option. We evaluated the efficacy of sequential ultrathin bronchoscopy for peripheral pulmonary lesions into which the rEBUS probe could not be inserted during thin bronchoscopy. METHODS: In this multicentre prospective study, patients with peripheral pulmonary lesions ≤30 mm in diameter underwent rEBUS-guided transbronchial biopsy using a 4.0 mm diameter thin bronchoscope. In patients with lesions into which a rEBUS probe could not be inserted using that bronchoscope, bronchoscopy using a 3.0 mm diameter ultrathin bronchoscope was performed. RESULTS: A total of 342 patients were enrolled and 340 were analysed. Among them, 87 patients with lesions of a median longest diameter of 17.5 mm underwent thin bronchoscopy followed by ultrathin bronchoscopy. Of the 87 patients, the rEBUS probe was successfully inserted into the lesions via the ultrathin bronchoscope in 50 patients (57.5%). Of the 87 patients, the diagnostic yields of thin bronchoscopy and ultrathin bronchoscopy were 12.6% (11 of 87) and 41.4% (36 of 87), respectively (p < 0.001). CONCLUSION: Ultrathin bronchoscopy affords a higher diagnostic yield for lesions into which a rEBUS probe cannot be inserted via a thin bronchoscope.

Xpert MTB/RIF in the Diagnosis of Mediastinal Tuberculous Lymphadenitis by Endoscopic Ultrasound-Guided Needle Aspiration Techniques: A Systematic Review and Meta-Analysis.

BACKGROUND: Lymphadenopathy is one of the most prevalent clinical manifestations of extrapulmonary tuberculosis. Endosonography is the recommended technique in the diagnostic work-up of mediastinal lymphadenopathies. Xpert MTB/RIF assay is a self-contained cartridge-based fully automated DNA testing platform which can accurately detect both tuberculosis and mycobacterial resistance to rifampicin. A few studies assessed its accuracy for mediastinal lymph node aspirates collected using endosonography. A systematic review of observational studies was performed to provide a pooled estimate of sensitivity and specificity of Xpert MTB/RIF in the diagnosis of mediastinal tuberculous lymphadenitis using endoscopic ultrasound-guided needle aspiration techniques. METHODS: A search of the scientific evidence was carried out using PubMed, Embase, and Scopus. Articles describing observational studies on Xpert MTB/RIF in the diagnosis of mediastinal tuberculous lymphadenitis using endoscopic ultrasound-guided needle aspiration techniques were selected. RESULTS: Eight studies met the inclusion criteria. The overall pooled sensitivity was 61% (95% CI = 55-68%; I2 = 66.3%; p = 0.004), overall pooled specificity was 89% (95% CI = 85-91%; I2 = 90.1%; p < 0.0001). Area under the sROC curve was 0.68. Only one study reported data on rifampin resistance detection and showed a sensitivity of 83.3% and a specificity of 16%. CONCLUSIONS: Xpert MTB/RIF shows a good accuracy in the diagnosis of mediastinal mycobacterial lymphadenitis by endosonographic needle aspiration techniques. It should be always recommended for suspected mediastinal tuberculosis.

Efficacy of a hybrid technique of simultaneous videolaryngoscopy with flexible bronchoscopy in children with difficult direct laryngoscopy in the Pediatric Difficult Intubation Registry.

Children with difficult tracheal intubation are at increased risk of severe complications, including hypoxaemia and cardiac arrest. Increasing experience with the simultaneous use of videolaryngoscopy and flexible bronchoscopy (hybrid) in adults led us to hypothesise that this hybrid technique could be used safely and effectively in children under general anaesthesia. We reviewed observational data from the international Pediatric Difficult Intubation Registry from 2017 to 2021 to assess the safety and efficacy of hybrid tracheal intubation approaches in paediatric patients. In total, 140 patients who underwent 180 attempts at tracheal intubation with the hybrid technique were propensity score-matched 4:1 with 560 patients who underwent 800 attempts with a flexible bronchoscope. In the hybrid group, first attempt success was 70% (98/140) compared with 63% (352/560) in the flexible bronchoscope group (odds ratio (95%CI) 1.4 (0.9-2.1), p = 0.1). Eventual success rates in the matched groups were 90% (126/140) for hybrid vs. 89% (499/560) for flexible bronchoscope (1.1 (0.6-2.1), p = 0.8). Complication rates were similar in both groups (15% (28 complications in 182 attempts) hybrid; 13% (102 complications in 800 attempts) flexible bronchoscope, p = 0.3). The hybrid technique was more likely than flexible bronchoscopy to be used as a rescue technique following the failure of another technique (39% (55/140) vs. 25% (138/560), 2.1 (1.4-3.2) p < 0.001). While technically challenging, the hybrid technique has success rates similar to other advanced airway techniques, few complications and may be considered an alternative technique when developing an airway plan for paediatric patients whose tracheas are difficult to intubate under general anaesthesia.

Single-use flexible bronchoscopes vs traditional reusable flexible bronchoscopes: a prospective controlled study.

BACKGROUND: Single-use flexible bronchoscopes(SFB) eliminate the risk of bronchoscopy-related infection compared with traditional reusable flexible bronchoscopes(RFB). At present, there is no comparative study between SFB and RFB in the aspects of biopsy and interventional therapy. This study aims to explore whether SFB can perform complex bronchoscopic procedures such as transbronchial biopsies just like RFB. METHODS: We conducted a prospective controlled study. A total of 45 patients who required bronchoscopic biopsy in our hospital from June 2022 to December 2022 were enrolled. The patients were divided into the SFB group and the RFB group, and routine bronchoscopy, bronchoalveolar lavage, and biopsy were performed respectively. Data on the time of routine bronchoscopy, the recovery rate of bronchoalveolar lavage fluid(BALF), biopsy time, and bleeding volume were collected. Then we used the two-sample t-test and the χ2 test to assess the performance differences between SFB and RFB. We also designed a questionnaire to compare the performance between SFB and RFB by different bronchoscope operators. RESULTS: The routine examination time of SFB and RFB was 3.40 ± 0.50 min and 3.55 ± 0.42 min, respectively. There was no significant difference between the two groups (P = 0.308). The recovery rate of BALF was (46.56 ± 8.22) % in the SFB group and (47.00 ± 8.07) in the RFB group, without a significant difference between the two groups(P = 0.863). The biopsy time was similar(4.67 ± 0.51 min VS 4.57 ± 0.45 min) in both groups, with no significant difference(P = 0.512). The positive biopsy rate was 100% in both groups, with no significant difference. Overall, the bronchoscope operators were generally satisfied with SFB. CONCLUSION: SFBs are non-inferior to RFBs in routine bronchoscopy, bronchoalveolar lavage, and biopsy. It is suggested that SFBs have a wider clinical application.

A missed diagnosis of sputum crust with fiberoptic bronchoscope causing extubation failure: a case report.

BACKGROUND: Fiberoptic bronchoscopy (FOB) and bronchoscopic biopsy are the established methods for diagnosing and treating sputum crust. However, sputum crust in concealed locations can sometimes be missed or undiagnosed, even with bronchoscopy. CASE PRESENTATION: We present the case of a 44-year-old female patient who experienced initial extubation failure and postoperative pulmonary complications (PPCs) due to the missed diagnosis of sputum crust by FOB and low-resolution bedside chest X-ray. The FOB examination showed no apparent abnormalities prior to the first extubation, and the patient underwent tracheal extubation 2 h after aortic valve replacement (AVR). However, she was reintubated 13 h after the first extubation due to a persistent irritating cough and severe hypoxemia, and a bedside chest radiograph revealed pneumonia and atelectasis. Upon performing a repeat FOB examination prior to the second extubation, we serendipitously discovered the presence of sputum crust at the end of the endotracheal tube. Subsequently, we found that the sputum crust was mainly located on the tracheal wall between the subglottis and the end of the endotracheal tube during the "Tracheobronchial Sputum Crust Removal" procedure, and most of the crust was obscured by the retained endotracheal tube. The patient was discharged on the 20th day following therapeutic FOB. CONCLUSION: FOB examination may miss specific areas in endotracheal intubation (ETI) patients, particularly the tracheal wall between the subglottis and distal end of the tracheal catheter, where sputum crust can be concealed. When diagnostic examinations with FOB are inconclusive, high-resolution chest CT can be helpful in identifying hidden sputum crust.

Safety and utility of Endoscopic Ultrasound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA) in suspected lung cancer patients with poor respiratory or general conditions: a prospective three-center observational study.

BACKGROUND: Although transbronchial diagnostic procedures are sometimes difficult to perform because of the patient's respiratory or general conditions, endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA), a known transesophageal diagnostic procedure, might be useful for such cases. We conducted this prospective three-center observational study to evaluate the safety and efficacy of EUS-B-FNA in suspected lung cancer patients with poor respiratory or general conditions. METHODS: Patients with suspected lung cancer with respiratory failure, Eastern Cooperative Oncology Group performance status of 2 or higher, or severe respiratory symptoms, were enrolled. The primary endpoints were the diagnostic yield of lung cancer and its safety, and the secondary endpoints were the success rate of molecular and programmed death ligand 1 (PD-L1) analyses, and the 6-month survival rate in patients with lung cancer. RESULTS: We enrolled 30 patients, of which 29 were included in the analysis. Among them, 26 were eventually diagnosed with lung cancer. The diagnostic yield for lung cancer was 100% (26/26). There were no adverse events associated with EUS-B-FNA requiring procedure discontinuation. The success rates of molecular analysis for EGFR, ALK, ROS-1, and BRAF were 100% (14/14), 100% (11/11), 100% (9/9), and 75% (6/8), respectively. The success rate of the PD-L1 analysis was 100% (15/15). The 6-month survival rate in patients with lung cancer was 53.8% (95% confidence interval [CI]: 33.4-76.4), and the median overall survival (OS) was 196 days (95% CI: 142-446). CONCLUSIONS: EUS-B-FNA is a safe and effective diagnostic method, even in patients with suspected lung cancer with poor respiratory or general conditions. TRIAL REGISTRATION: This clinical trial was registered at https://www.umin.ac.jp/ctr/index.htm (UMIN000041235, approved on 28/07/2020).

A randomized controlled trial comparing three supraglottic airway devices used as a conduit to facilitate tracheal intubation with flexible bronchoscopy.

PURPOSE: Once difficult ventilation and intubation are declared, guidelines suggest the use of a supraglottic airway (SGA) as a rescue device to ventilate and, if oxygenation is restored, subsequently as an intubation conduit. Nevertheless, few trials have formally studied recent SGA devices in patients. Our objective was to compare the efficacy of three second-generation SGA devices as conduits for bronchoscopy-guided endotracheal intubation. METHODS: In this prospective, single-blinded three-arm randomized controlled trial, patients with an American Society of Anesthesiologists Physical Status of I-III undergoing general anesthesia were randomized to bronchoscopy-guided endotracheal intubation using AuraGain™, Air-Q® Blocker, or i-gel® devices. We excluded patients with contraindications to an SGA or drugs and who were pregnant or had a neck, spine, or respiratory anomaly. The primary outcome was intubation time, measured from SGA circuit disconnection to CO2 measurement. Secondary outcomes included ease, time, and success of SGA insertion; success of intubation on first attempt; overall intubation success; number of attempts to intubate; ease of intubation; and ease of SGA removals. RESULTS: One hundred and fifty patients were enrolled from March 2017 to January 2018. Median intubation times were similar across the three groups (Air-Q Blocker, 44 sec; AuraGain, 45 sec; i-gel, 36 sec; P = 0.08). The i-gel was faster to insert (i-gel: 10 sec; Air-Q Blocker, 16 sec; AuraGain, 16 sec; P < 0.001) and easier to insert (Air-Q Blocker vs i-gel, P = 0.001; AuraGain vs i-gel, P = 0.002). Success of SGA insertion, success of intubation, and number of attempts were similar. The Air-Q Blocker was easier to remove than the i-gel (P < 0.001). CONCLUSION: All three second-generation SGA devices performed similarly regarding intubation. Despite minor benefits of the i-gel, clinicians should select their SGA based on clinical experience. STUDY REGISTRATION: ClinicalTrials.gov (NCT02975466); registered on 29 November 2016.

RéSUMé: OBJECTIF: Une fois qu'une ventilation et une intubation difficiles sont déclarées, les lignes directrices préconisent le recours à un dispositif supraglottique comme modalité de sauvetage pour ventiler le patient et, si l'oxygénation est rétablie, être ensuite utilisé comme conduit d'intubation. Toutefois, peu d'études ont formellement analysé l'utilisation des dispositifs supraglottiques récents chez de véritbales patients. Notre objectif était de comparer l'efficacité de trois dispositifs supraglottiques de deuxième génération utilisés comme conduits pour l'intubation endotrachéale guidée par bronchoscopie. MéTHODE: Dans cette étude prospective randomisée contrôlée à trois bras et à simple insu, les patients de statut physique I-III selon l'American Society of Anesthesiologists bénéficiant d'une anesthésie générale ont été randomisés à recevoir une intubation endotrachéale guidée par bronchoscopie via les dispositifs AuraGain™, Air-Q® Blocker ou i-gel®. Nous avons exclu les patients présentant des contre-indications à l'utilisation d'un dispositif supraglottique ou aux médicaments, ainsi que les patientes enceintes et les patients présentant une anomalie au niveau du cou, de la colonne vertébrale ou des voies aériennes. Le critère d'évaluation principal était le temps d'intubation mesuré entre le moment de déconnexion du dispositif supraglottique du circuit et le moment de mesure du CO2. Les critères d'évaluation secondaires comprenaient la facilité, le délai et la réussite de l'insertion du dispositif supraglottique; la réussite de l'intubation à la première tentative; la réussite globale de l'intubation; le nombre de tentatives d'intubation; la facilité d'intubation; et la facilité de retrait du dispositif supraglottique. RéSULTATS: Cent cinquante patients ont été recrutés de mars 2017 à janvier 2018. Les délais d'intubation médians étaient similaires dans les trois groupes (Air-Q Blocker : 44 sec; AuraGain : 45 sec; i-gel : 36 sec; P = 0,08). L'i-gel était plus rapide à insérer (i-gel : 10 sec; Air-Q Blocker : 16 sec; AuraGain : 16 sec; P < 0,001) et plus facile à insérer (Air-Q Blocker vs i-gel : P = 0,001; AuraGain vs i-gel : P = 0,002). La réussite de l'insertion du dispositif supraglottique, la réussite de l'intubation et le nombre de tentatives étaient similaires. L'Air-Q Blocker était plus facile à retirer que l'i-gel (P < 0,001). CONCLUSION: Les trois dispositifs supraglottiques de deuxième génération ont tous affiché une performance similaire en matière d'intubation. Malgré des avantages mineurs de l'i-gel, les cliniciens devraient choisir leur dispositif supraglottique en fonction de leur expérience clinique. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02975466); enregistrée le 29 novembre 2016.

Flexible Bronchoscopy Combined With Videolaryngoscope For Tracheal Intubation In A Child With Hunter Syndrome: A Case Report.

Hunter syndrome (mucopolysaccharidosis type II) has the highest reported prevalence of difficult tracheal intubation among the seven known types of mucopolysaccharidoses. Despite improved difficult airway guidelines and equipment, conventional approaches may fail in some cases. A 10-year-old child with Hunter syndrome, was scheduled for multiple dental extractions. On the first visit, failed intubation was declared as per Difficult Airway Society guidelines in the surgical day-care suite of our institute and the procedure was postponed. The case was then planned to be handled in the main operating room with additional preparation and input from the paediatric otolaryngologist for possible tracheostomy, paediatric intensive care for postoperative need for ventilation, and difficult airway resource faculty for an unconventional approach-videolaryngoscope combined with fibreoptic bronchoscope-which resulted in safe administration of anaesthesia. This case illustrates the importance of meticulous planning in the management of previously failed airway.

AIRWAY MANAGEMENT WITH RIGID BRONCHOSCOPE IN ADULT PATIENT DURING CERVICAL SPINE SURGERY: A CASE REPORT.

SCIWOCTET is a cervical spine injury (CSI) with objective signs of myelopathy, due to trauma, without evidence of ligament injury or bone fractures on x-ray and computed tomography (CT) images. It is rare, found in about 3% of patients with CSI. Perioperative manipulation of these patients may cause secondary spinal cord injury. The challenge for the anesthesiologist is to manage an airway with as little movement of the patient's head and neck as possible. A patient is presented after a fall from a motorbike. At hospital admission, he had neurological deficit in the innervation area of the cervical spinal cord. Multi-slice CT of the head and cervical spine was without signs of acute bone trauma. Magnetic resonance imaging was performed and the diagnosis met the criteria defining SCIWOCTET. Elective cervical spine surgery under general anesthesia was performed, the patient was intubated with a rigid bronchoscope using manual in-line immobilization. The selection of instruments and procedures is emphasized. Other procedures, techniques and instruments that can be used for airway management and their influence on the movement of the patient's head and neck are listed. It is concluded that rigid bronchoscopy with the application of manual in-line immobilization is suitable for emergency and elective intubation of patients with cervical spine pathology.

Changes in Pulmonary Function Test Results and Respiratory Symptoms before and after Airway Stent Removal.

BACKGROUND: Airway stenting is a useful form of palliation for patients with airway stenosis/fistulas; the stent can be removed after addressing the cause of the airway disorder. Patients with airway stents often complain of coughing and difficulty with expectoration, so the use of such stents can negatively affect pulmonary function and worsen symptoms. OBJECTIVES: The aim of this study was to compare pulmonary function and respiratory symptoms before and after stent removal. METHODS: Patients who would later undergo simple airway stent removal were prospectively recruited in two institutions. All stents were removed using both rigid and flexible bronchoscopes with patients under general anesthesia. Pulmonary function tests were performed before stent removal and at 1 and 4 weeks after stent removal. All patients self-reported their respiratory symptoms using a 100-mm visual analog scale (VAS). RESULTS: Of the 31 patients enrolled, 28 (23 with malignant stenoses, 3 with benign stenoses, and 2 with fistulas [21 silicone and 7 metallic stents]) were included in analyses. Pulmonary function measurements before stent removal and at 1 and 4 weeks after stent removal were as follows: vital capacity, 3.00, 3.04, and 3.08 L (p = 0.387); forced expiratory volume in 1 s, 1.96, 1.96, and 2.12 L (p = 0.034); and peak expiratory flow, 3.60, 4.28, and 5.06 L/s, respectively (p < 0.001). Symptoms (cough, sputum production, difficulty with expectoration, and dyspnea) evaluated using the VAS improved significantly after stent removal. No complications were encountered during removal. CONCLUSION: Removal of unnecessary airway stents improves pulmonary function and respiratory symptoms. Any stent that is no longer functioning should be removed.

Accuracy and Predictors of Success of EUS-B-FNA in the Diagnosis of Pulmonary Malignant Lesions: A Prospective Multicenter Italian Study.

BACKGROUND: The role of endoscopic ultrasound with bronchoscope fine-needle aspiration (EUS-B-FNA) in the diagnosis of suspected malignant pulmonary lesions adjacent to the esophagus has been poorly investigated. The aim of the present study was to assess the accuracy of EUS-B-FNA for the diagnosis and molecular profiling of paraesophageal pulmonary lesions, as well as its predictors of success. MATERIALS AND METHODS: Patients who underwent EUS-B-FNA for the diagnosis of paraesophageal lesions were consecutively enrolled in four Italian centers. Demographic, clinical, procedural, pathological, and molecular characteristics of the malignant samples were collected. The primary outcome was the diagnostic accuracy for pulmonary malignancies. Secondary outcomes were diagnostic yield and predictors of success for diagnosis and molecular profiling. RESULTS: 107 adult patients (60 [56.1%] males; median (interquartile range) age: 69 [60-70] years) were enrolled. The diagnostic accuracy of EUS-B-FNA was 95.3% in the overall cohort and 95.2% in the 99 patients with a final diagnosis of malignancy. Neither clinical nor procedural variables significantly affected the diagnostic accuracy, whereas rapid on-site evaluation (ROSE), performed by pathologists or trained pulmonologists, was a strong predictor for a complete molecular profiling (OR [95% CI]: 12.9 [1.2-137.4]; p value: 0.03). CONCLUSION: EUS-B-FNA is a safe and accurate method for the diagnosis of paraesophageal pulmonary lesions. The presence of ROSE is relevant for a complete molecular profiling in this selected cohort of patients with advanced lung cancer.

EUS-B-FNA Enhances the Diagnostic Yield of EBUS Bronchoscope for Intrathoracic Lesions.

INTRODUCTION: Endobronchial ultrasound (EBUS) bronchoscopes have been used mainly through the airway for EBUS-guided transbronchial needle aspiration (EBUS-TBNA); however, they can also be used through the esophagus. The esophageal approach, endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA), has gradually become popular, as it can evaluate lesions that cannot be accessed through the airway. PURPOSE: This study aimed to evaluate the value of adding EUS-B-FNA to EBUS-TBNA performed by pulmonologists for intrathoracic lesions in the clinical setting. METHODS: Between March 2009 and March 2020, all patients who underwent EUS-B-FNA and EBUS-TBNA for diagnostic purposes were included and retrospectively analyzed at a single institution. RESULTS: A total of 1794 procedures using an EBUS bronchoscope including, EBUS-TBNA, EUS-B-FNA, and the combination of EBUS-TBNA and EUS-B-FNA for evaluating intrathoracic lesions, were performed. We finally analyzed 276 patients who underwent EUS-B-FNA for diagnostic purposes. EUS-B-FNA provided diagnostic materials from only EBUS-TBNA-inaccessible lesions in 26 patients and in 18 patients whose conditions were inappropriate for bronchoscopy (e.g., respiratory failure, airway stenosis, etc.). EUS-B-FNA provided diagnostic results in four patients with non-diagnostic EBUS-TBNA results. EUS-B-FNA was preferable to EBUS-TBNA in 4.4% (48 of 1091) of patients; therefore, adding EUS-B-FNA to EBUS-TBNA increased the diagnostic yield from 72.6% (1043 of 1437) to 75.9% (1091 of 1437). CONCLUSION: Pulmonologists are able to enhance diagnostic yields by acquiring the EUS-B-FNA technique.

Evaluation of a new developed disposable and portable bronchoscopy system.

BACKGROUND: Bronchoscopy is critical in the treatment of patients with coronavirus disease (COVID-19), and its use is associated with the challenges of stringent sterilization and virus transmission risk. We developed a disposable and portable bronchoscope (YunSendo-R) and compared its safety and function with those of current reusable and single-use bronchoscopes using an animal model. METHODS: We compared the YunSendo-R system with a commercially available reusable bronchoscope (Olympus, BF-H290) and single-use bronchoscope (Ambu, Ambu® aScope3™). Eight physicians used the three types of bronchoscopes to operate on Guangxi Bama mini pigs. Each operator performed bronchoscopy and completed a 10-point Likert scale questionnaire for evaluating visual ability and manoeuvrability. Operation time and scores were collected. RESULTS: Operation time had no significant differences among the three bronchoscopes. In visual ability, the YunSendo-R bronchoscope showed superior performance to the Ambu bronchoscope in image clarity, colour contrast, and illumination (P < 0.05) and no significant difference in performance compared with the Olympus bronchoscope (P > 0.05). The YunSendo-R bronchoscope had similar manoeuvrability to the Olympus bronchoscope and better scope tip flexibility than the Ambu bronchoscope (P > 0.05). No relevant complications were reported. CONCLUSION: We have developed a new bronchoscopy system with the advantages of disposability and portability, which was effective and safe in an animal model. It has better visual ability than the Ambu bronchoscope and similar visual ability and manoeuvrability to the Olympus bronchoscope. The YunSendo-R bronchoscope is a promising device for clinical practice, especially in reusable-endoscope-transmitted infectious diseases such as COVID-19.

Thin bronchoscopic cryobiopsy using a nasobronchial tube.

BACKGROUND: Transbronchial lung cryobiopsy is useful when diagnosing lung lesions. However, prevention of associated bleeding complications is essential. This study aimed to evaluate the safety and efficacy of our novel bronchoscopic cryobiopsy technique, which uses a long nasobronchial tube to prevent blood flooding the central airway. METHODS: Patients with localized or diffuse lung lesions were prospectively enrolled and underwent cryobiopsy using a 1.9 mm diameter cryoprobe and a 4.0 mm diameter thin bronchoscope under conscious sedation. For cryobiopsy, a long silicone tube (inner diameter, 5.0 mm) was advanced through the nose to the target bronchus, then wedged to drain blood under thin-tube bronchoscopic control. The primary endpoint was the frequency of bleeding complications. RESULTS: Of the 80 patients initially enrolled, 73 that underwent at least one cryobiopsy were ultimately included. Mild bleeding during cryobiopsy occurred in 58 patients (79.5%), but there was no moderate or severe bleeding. Other complications occurred in four patients (two pneumothorax, one pneumomediastinum, and one pneumonia). Tube dislocation was noted in eight patients (11%). Cryobiopsy specimens were significantly larger than forceps biopsy specimens (9.0 mm2 vs. 2.7 mm2, P < .001) and allowed specific diagnoses in 50 patients (68.5%). CONCLUSIONS: Thin bronchoscopic cryobiopsy using a nasobronchial tube in consciously sedated patients is safe and effective. Trial registration Date of registration: 24/06/2019. UMIN-Clinical Trials Registry; Identifier: UMIN000037156 https://www.umin.ac.jp/ctr/index.htm.