Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and comparison with Abram's needle biopsy.

STUDY OBJECTIVES: Recently, pulmonologists have performed thoracoscopy under local anesthesia using rigid thoracoscopes or flexible bronchoscopes. The latter allow greater access within the pleural cavity but are difficult to manipulate. The Olympus LTF semiflexible fiberoptic thoracoscope combines features of both instruments, having a solid body and a flexible terminal section. In the first study with this instrument, we evaluated ease of use and compared diagnostic yield with closed needle biopsy. PATIENTS: Twenty-four patients with pleural effusion were investigated. SETTING: Scottish University Hospital. DESIGN: Thoracoscopy was performed in the bronchoscopy suite after premedication with atropine and papaveretum. Following a standard Abram's needle biopsy, the LTF thoracoscope was inserted through a flexible introducer (Olympus Optical Co Ltd; Tokyo, Japan). The pleura was inspected and biopsy specimens were taken of suspicious areas. RESULTS: The final diagnosis was malignant pleural effusion in 16 of 24 patients. Ten of 16 were positive by Abram's biopsy, giving a sensitivity of 62%. Thirteen of 16 were positive by fiberoptic thoracoscopy, giving an improved sensitivity of 81%. The LTF thoracoscope was easy to use for pulmonologists experienced in rigid thoracoscopy and flexible bronchoscopy. Excellent views of the pleura were obtained from a single entry point. The procedure was well tolerated and no complications were encountered. CONCLUSION: The LTF thoracoscope allows excellent pleural access but a larger biopsy channel (currently 2 mm) might increase the accuracy of diagnosis.

Sedation for fibreoptic bronchoscopy: comparison of alfentanil with papaveretum and diazepam.

Sedation for fibreoptic bronchoscopy should produce optimal conditions for the operator, patient comfort and rapid recovery allowing early discharge home. We have compared a regimen producing 'light' sedation with a more traditional regimen producing 'deep' sedation. Seventy-six patients undergoing fibreoptic bronchoscopy under topical anaesthesia were randomized to receive either light sedation with the short acting opiate, alfentanil (median dose 1.1 mg, range 0.5-2.6 mg) or deep sedation with a combination of papaveretum (median dose 10 mg, range 5-15 mg) and diazepam (median dose 8 mg, range 0-20 mg). Both techniques gave equally good operating conditions, although patients given alfentanil coughed less than those given papaveretum and diazepam (U = 2.814 P less than 0.01). Patients recorded their degree of apprehension on a visual analogue scale prior to sedation and the actual degree of comfort experienced after recovery. There was no significant difference between apprehension or comfort between the groups. This was despite a higher degree of amnesia for an irrelevant object shown during the bronchoscopy in the deeply sedated group (chi 2 = 21.084 P less than 0.001). Patients given alfentanil performed significantly better in a modified Romberg test (chi 2 = 4.357 P less than 0.05) and a visualisation test (t = 3.035 P less than 0.01) two hours after the bronchoscopy. Alfentanil produced good operating conditions, patient comfort, less cough and a more rapid recovery, compared to the deep sedation regimen, and is an ideal sedative for fibreoptic bronchoscopy.

A double-blind controlled study comparing temazepam with papaveretum as premedication for fibreoptic bronchoscopy.

One hundred patients undergoing routine fibreoptic bronchoscopy were randomly allocated to receive premedication with either intramuscular papaveretum or oral temazepam in a double-blind manner. They all received atropine before and oxygen during the procedure. Patients found the drugs equally acceptable in terms of discomfort, anxiety and the possibility of repeat bronchoscopy, but more had recall of the procedure with papaveretum. There was no difference in secretions, coughing, relaxation and consciousness, as assessed by the bronchoscopist, but patients who had received papaveretum were more cooperative. Arterial blood gases were performed before and 45 minutes after bronchoscopy. Those given papaveretum had a significant fall in mean arterial oxygen tension of 0.96 kPa, while there was no significant change in the temazepam group. There was also a small mean rise in arterial carbon dioxide tension in both groups, with the mean rise in the papaveretum group (0.625 kPa) being significantly higher than the temazepam group (0.2 kPa). Premedication with temazepam is a useful alternative to papaveretum and has the advantage of oral administration and causing less respiratory depression.

Oral and nasotracheal light wand guided intubation after failed fibreoptic bronchoscopy.

Fibreoptic bronchoscopic guided tracheal intubation is often the first choice for clinicians familiar with the technique, when faced with a patient in whom tracheal intubation presents known or possible difficulties. Regardless of the technique chosen, anticipated and unanticipated problems may arise. We report three patients with known difficult airways that illustrate the utility of light wand guided oral and nasotracheal intubation when tracheal intubation with fibreoptic bronchoscopy proved impossible.