Noninvasive positive pressure ventilation in the assessment of extrinsic tracheal stenosis.

In patients with extrinsic tracheal stenosis caused by a mediastinal mass, an airway stent is a palliative measure to relieve airway obstruction. However, the self-expanding force of the stent may be insufficient to force a rigid stenosis. Our goal was to report a simple strategy to indirectly estimate the rigidity of the stenosis and predict airway patency after inserting the stent. Before the procedure, the inspiratory and expiratory flows and their ratio were evaluated under spontaneous breathing and after positive pressure ventilation generated by a facial mask. In patients with stenosis successfully treated with a stent (n = 11), we found significant changes in expiratory (2.3 ± 0.7 vs 2.8 ± 0.7; p = 0.03) and inspiratory (1.5 ± 0.6 vs 2.5 ± 0.9; p = 0.001) flows and a reduction of their ratio (1.4 ± 0.3 vs 1.1 ± 0.2; p = 0.01) whereas no significant changes were observed in patients (n = 2) whose stent failed to force the stenosis. In these cases, a tracheostomy was performed to assure ventilation. Our simple strategy may help physicians predict airway patency after stenting or plan alternative treatments in patients with rigid stenosis difficult to force by stenting.

Laparoscopic adrenal surgery: ten-year experience in a single institution.

BACKGROUND: Minimal invasive adrenalectomy has become the procedure of choice to treat adrenal tumors with a benign appearance, ≤ 6 cm in diameter and weighing < 100 g. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA), performed for ten years in a single endocrine surgery unit. METHODS: We retrospectively reviewed 88 consecutive patients undergone LA for lesions of adrenal glands from 2003 to 2013. The first 30 operations were considered part of the learning curve. Doxazosin was preoperatively administered in case of pheochromocytoma (PCC), while spironolactone and potassium were employed to treat Conn's disease. Perioperative cardiovascular status modifications and surgical and medium- and long-term results were analyzed. RESULTS: Forty nine (55.68%) functioning tumors, and one (1.13%) bilateral adrenal disease were identified. In 2 patients (2.27%) a supposed adrenal metastasis was postoperatively confirmed, while in no patients a diagnosis of incidental primitive malignancy was performed. There was no mortality or major post operative complication. The mean operative time was higher during the learning curve. Conversion and morbidity rates were respectively 1.13% and 5.7%. Intraoperative hypertensive crises (≥180/90 mmHg) were observed in 23.5% (4/17) of PCC patients and were treated pharmacologically with no aftermath. There was no influence of age, size and operative time on the occurrence of PCC intraoperative hypertensive episodes. Surgery determined a normalization of the endocrine profile. One single PCC persistence was observed, while in a Conn's patient, just undergone right LA, a left sparing adrenalectomy was performed for a contralateral metachronous aldosteronoma. CONCLUSIONS: LA, a safe, effective and well tolerated procedure for the treatment of adrenal neoplasms ≤ 6 cm, is feasible for larger lesions, with a similar low morbidity rate. Operative time has improved along with the increase of the experience and of the technological development. Preoperative adrenergic blockade did not prevent PCC intraoperative hypertensive crises, but facilitated the control of the hemodynamic stability.

Assessment of ventilation during the performance of elective endoscopic-guided percutaneous tracheostomy: clinical evaluation of a new method.

STUDY OBJECTIVES: To evaluate the feasibility of uninterrupted translaryngeal open ventilation delivered through a pediatric, uncuffed endotracheal tube during percutaneous endoscopic tracheostomy (PET). DESIGN AND SETTING: Prospective, observational clinical study in a six-bed ICU of a university hospital. PATIENTS: Forty consecutive adult patients requiring an elective tracheostomy. INTERVENTIONS: We employed the basic Ciaglia technique with multiple dilators (n = 10), a single dilator (n = 15), and the Fantoni method (n = 15). During PET, pressure-controlled ventilation was maintained through an uncuffed, 4-mm inner-diameter pediatric tube. The fraction of inspired oxygen was 1.0. Ventilator settings were as follows: pressure-controlled ventilation, 40 cm H(2)O; respiratory rate, 25/min; inspiratory time, 1.2 s of inspiratory time (inspiratory/expiratory ratio, 1:1); and positive end-expiratory pressure, 0 cm H(2)O. MEASUREMENTS AND RESULTS: Measurements of arterial blood gas (ABG) tensions were obtained before the start of each tracheostomy and every 3 min during the procedure. An average of 8.28 +/- 2.28 ABG measurements were obtained from each patient (+/- SD). All patients were successfully assisted during performance of the tracheostomy, and no patient required ventilation through a cuffed endotracheal tube. The maximum increase in PaCO(2) was 8.49 +/- 5.50 mm Hg, and the maximum decrease in pH related to hypercarbia was 0.04 +/- 0.04. The PaO(2) increased in all patients (maximum change, 69.75 +/- 57.00 mm Hg; p < 0.01), and no patient had desaturation during the procedure. CONCLUSIONS: The technique that we propose for airway management during PET was safe and effective. A mild increase in PaCO(2) was not associated with significant metabolic and hemodynamic consequences, and an adequate PaO(2) was maintained throughout the study.