Airway Blocks Vs LA Nebulization- An interventional trial for Awake Fiberoptic Bronchoscope assisted Nasotracheal Intubation in Oral Malignancies.

BACKGROUND: Patients with intra-oral malignancies warrants use of awake Fiberoptic assisted naso-thracheal intubation to secure an airway due to multiple risk factors leading to anticipated difficult airway. Different techniques such as airway blocks, local anesthesia (LA) gargles, spray, nebulization and  mild  sedation are in practice to improve  the success rate of fiberoptic assisted intubation. METHODS: Sixty patients  of  ASA I and II with Mallampatti score 3 and above, posted for Commando operations were enrolled in this study and were divided into 2 groups. Group AB (Airway Block, n=30) were given Superior laryngeal nerve block bilaterally and recurrent laryngeal nerve block  transtracheally  with Inj  2% Lignocaine. Second Group AN (Airway Nebulization, n=30)  patients airway was nebulized with 4% Lignocaine  with ultrasonic nebulizer. After confirmation of satisfactory anesthesia clinically Fiber-optic assisted naso-tracheal intubation was attempted. Hemodynamic monitoring, total time taken for intubation, patients comfort and any complications occurred were noted. Statistical Analysis- All the observed values were tabulated and analyzed using software SPSS version 17.0. RESULTS: Demography and Hemodynamic observations were comparable in the groups.  The time taken for intubation, patient comfort score, intubation conditions were excellent in AB group than in group AN. Airway complications like laryngospasm and cough were noted in AN Group. CONCLUSIONS: Judicial use of combined Airway blocks such as Bilateral Superior and trans-tracheal recurrent laryngeal nerve blocks could facilitate a successful fiber-optic assisted awake naso-tracheal intubation in anticipated difficult intubation with negligible complications.
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Bronchoscope insertion route and patient comfort during flexible bronchoscopy.

SETTING: Diagnostic flexible bronchoscopy performed in hospitalised and ambulatory patients in a tertiary care academic hospital in Monterrey, Mexico. OBJECTIVE: To determine the effect of the route of insertion of the bronchoscope (oral or nasal) on patient comfort, vocal cord visualisation, local anaesthetic and sedation requirements and possible complications. DESIGN: Prospective study carried out in patients aged ⩾ 18 years with an indication for flexible bronchoscopy. The route of insertion was randomly assigned. Symptoms related to the procedure were evaluated using a questionnaire. RESULTS: Sixty-three patients were included: 32 in the oral insertion group and 31 in the nasal insertion group. There was no statistically significant difference in patient discomfort (1.91 ± 2.95 vs. 2.39 ± 3.56 points on a scale of 1 to 10, P = 0.74) or procedural complications (4 vs. 0 events, P = 0.12) between study groups. Oral insertion was associated with less time to vocal cord visualisation (25.5 ± 156 s vs. 56 ± 61 s, P < 0.01), lower requirement for lidocaine (15 ± 7.50 vs. 16 ± 4 ml, P = 0.01) and fewer insertion failures (0 vs. 6 cases, P < 0.01). CONCLUSIONS: With intravenous sedoanalgesia, route of insertion did not affect patient comfort. However, the oral route was associated with faster vocal cord visualisation, less use of lidocaine and no insertion failure.

Efficacy of Foreign Body Removal using a Cryoprobe in Flexible Bronchoscopy / 고신대학교의과대학학술지

OBJECTIVES: Endobronchial foreign body impaction is a medical emergency because of the air way obstruction. Therefore, immediate foreign body removal is crucial in such situations. Recently, there have been several reports about cryoprobe use as a tool for removal of foreign bodies. In this study, we determined the efficacy and complications of foreign body removal using a cryoprobe during flexible bronchoscopy. METHODS: This is a retrospective review of 27 patients who visited Kosin University Gospel Hospital from August 2007 to August 2010 with respiratory symptoms due to a foreign body in the airway. There were 17 males and 10 females, aged from 7 to 78 years. The foreign bodies were more frequently located (55%) in the right bronchus. The cryoprobe was inserted through the forceps channel of the flexible bronchoscope under local anesthesia. The lesion was quickly frozen for 5 seconds at -80degrees C, and the bronchoscope was removed with the probe after crystal formation on the contacted area. RESULTS: The success rate of removal of foreign bodies was 85% (23/27) using the cryoprobe. One case of broncholith did not undergo attempted removal because of the possibility of excessive hemorrhage by the tight bronchus impaction, and three cases (plastic,silicon,and implant) failed due to limited crystal formation. There were no severe hemorrhages, arrhythmias, or casualties during the procedure. CONCLUSIONS: The removal of foreign body using a cryoprobe during flexible bronchoscopy was shown to be safe and effective. The nature of the material should be attempted before removing a foreign body.

Cytological specimens obtained by endobronchial ultrasound-guided transbronchial needle aspiration: sample handling and role of rapid on-site evaluation.

Recently developed, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for mediastinal lymph node staging in lung cancer patients as well as for the diagnosis of mediastinal and hilar lymphadenopathy. It has been shown in systematic reviews and meta-analysis that a high diagnostic yield can be achieved with EBUS-TBNA for staging lung cancer. Though still not a standard of practice, this novel technology has attracted physicians and surgeons as an alternative modality to surgical biopsy for the assessment of the mediastinum. Standard cytology, thin layer preparations in liquid medium or cell blocks of cells obtained by EBUS-TBNA can be applicable not only for pathological diagnosis but also for further investigations such as immunohistochemistry and fluorescence in situ hybridization. In addition, samples obtained by EBUS-TBNA can also be used for molecular analysis. The key to a successful EBUS-TBNA is to understand the anatomy of the mediastinum as well as the basic steps of the procedure. Moreover, handling of the sample obtained by EBUS-TBNA is crucial for diagnosis since no amount of skill or interest of the interpreter can make up for a badly prepared sample. The goals of rapid on-site evaluation during EBUS-TBNA include determination of whether sampling of the target has been achieved and more importantly triage of samples to secondary investigations. This manuscript explains the detailed techniques of EBUS-TBNA to master this innovative procedure.

Broncoscopia terapéutica flexible / No disponible

No disponible

[ENT-recommendations for tracheobronchoscopy]. / HNO-Leitlinie Tracheo-Bronchoskopie.

INTRODUCTION: Tracheobronchoscopy allows endoscopic inspection and management of the tracheobronchial system. MATERIAL: The recommendation was developed in 1997 and updated in 2004 and 2009. RESULTS: The recommendations comment on indications and contra-indications, instruments, anesthesia and complications of endoscopic tracheobronchoscopy. DISCUSSION: Rapid technical advances in endoscopy have led to changes in indications for different procedures, especially as pertains to rigid and flexible endoscopy. The recommendations are designed to provide guidance for ENT and affiliated specialties for choosing and processing instruments and sedation methods.

Intratumoural chemotherapy of lung cancer for diagnosis and treatment of draining lymph node metastasis.

OBJECTIVES: Reviewed here is the potential effectiveness of cytotoxic drugs delivered by intratumoural injection into endobronchial tumours through a bronchoscope for the treatment of non-small cell lung cancer and the diagnosis of occult or obvious cancer cell metastasis to mediastinal lymph nodes. KEY FINDINGS: Intratumoural lymphatic treatment may be achieved by injection of cisplatin or other cytotoxic drugs into the malignant tissue located in the lumen of the airways or in the peribronchial structures using a needle catheter through a flexible bronchoscope. This procedure is termed endobronchial intratumoural chemotherapy and its use before systemic chemotherapy and/or radiotherapy or surgery may provide a prophylactic or therapeutic treatment for eradication of micrometastases or occult metastases that migrate to the regional lymph nodes draining the tumour area. CONCLUSIONS: To better elucidate the mode of action of direct injection of cytotoxic drugs into tumours, we review the physiology of lymphatic drainage and sentinel lymph node function. In this light, the potential efficacy of intratumoural chemotherapy for prophylaxis and locoregional therapy of cancer metastasis via the sentinel and regional lymph nodes is indicated. Randomized multicenter clinical studies are needed to evaluate this new and safe procedure designed to improve the condition of non-small cell lung cancer patients and prolong their survival.

Bronchoscopic Cryotherapy in Patients with Central Airway Obstruction / 결핵및호흡기질환

BACKGROUND: The efficacious use of interventional bronchoscope for patients with central airway obstruction due to malignant or benign lesions has been proven. Among many therapeutic bronchoscopic procedures, endobronchial cryotherapy is an established recanalization method for the obstruction of the respiratory tract. Recently, the use of this procedure has been increasing in Korea. However, limited data are available in the literature regarding its efficacy in Korea. METHODS: Thirty patients, who had been treated with a flexible cryoprobe for cryotherapy were enrolled; clinical characteristics and treatment outcomes were analyzed. The patients had been treated with the technique using nitrous oxide as a cryogen under local anesthesia. Objective outcomes were 3 different degrees of therapeutic success by use of follow-up bronchoscopic findings as follows: successful, partially successful, and unsuccessful response. Subjective outcomes were evaluated as an improvement in symptoms. RESULTS: The mean age of enrolled patients was 59+/-11 years and there was a male (22/30) dominance. Twenty-three patients had malignant tumor and 7 patients had benign lesions with central airway obstruction. Successful recanalization was achieved in 11 (37%) patients, and partially successful response was achieved in 15 (50%) patients. Dyspnea was improved in 84.2% (16/19) of patients. At least one respiratory symptom was resolved in 91.3% (21/23) patients. Seven patients (23.3%) needed additional bronchoscopic electrocautery because of the bleeding as a complication of cryotherapy. CONCLUSION: Endobronchial cryotherapy is an effective and less expensive procedure for the management of central airway obstruction. However, the procedure should be performed under the preparing for an emergency situation, such as massive bleeding.

[Linear endobronchial ultrasound as the initial diagnostic tool in patients with indications of mediastinal disease]. / La ultrasonografía endobronquial lineal como instrumento de diagnóstico inicial en el paciente con ocupación mediastínica.

BACKGROUND AND OBJECTIVE: Linear endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has proven useful for sampling mediastinal masses and nodes and for staging lung cancer. The aim of this study was to assess the usefulness of this diagnostic tool in patients with indications of mediastinal disease that could not be diagnosed by noninvasive methods or white light bronchoscopy. PATIENTS AND METHODS: All patients undergoing linear EBUS-TBNA for the diagnosis of mediastinal masses and/or adenopathy at our endoscopy unit were included in the study. Diagnoses obtained by linear EBUS-TBNA or any surgical technique performed after a nondiagnostic EBUS-TBNA were considered as final. RESULTS: In the study population of 128 patients with a mean (SD) age of 62.0 (11.2) years, a total of 294 TBNAs were performed on 12 masses and 282 nodes. Satisfactory samples were obtained in 11 cases (91.7%) from masses and in 233 cases (82.6%) from nodes. Linear EBUS-TBNA was diagnostic, obviating the need for mediastinoscopy in 115 patients (diagnostic sensitivity, 89.8%). The technique confirmed the diagnosis in 85 of the 94 patients with cancer (90.4%), in 8 of the 10 patients with tuberculosis (80.0%), and in the 5 patients with sarcoidosis. CONCLUSIONS: Linear EBUS-TBNA is a useful diagnostic tool in patients with mediastinal disease for whom a pathologic diagnosis is not achieved by noninvasive methods or white light bronchoscopy.

[The history of evolvement of bronchoscope].

Since 1897, the year when the bronchoscope was invented, the instrument have experienced three stages of evolvement, namely, the period of conventional rigid bronchoscope, the period of flexible fibreoptic bronchoscope as well as the period of the combined use of electronic bronchoscope, broncho fibrescope and video-assisted rigid bronchoscope simultaneously. Bronchoscope plays a significant role in the fields of thoracic surgery and respiratory internal medicine. In China, the technique started rather late, but after years of hard work, it has approached or reached the international advanced level. The blossoming new techniques and their upgrading make bronchoscope play an even more important role in the interventional pulmonology.

Oral insertion of a flexible bronchoscope is associated with less discomfort than nasal insertion for Korean patients.

OBJECTIVE: The route of bronchoscope insertion varies between centres, without a firm rationale based on well-designed studies. We therefore compared nasal and oral insertion of a flexible bronchoscope and evaluated efficacy and patient satisfaction. DESIGN: Prospective randomised study of patients who underwent flexible bronchoscopy from May to September 2003 and who were randomly assigned to nasal and oral insertion approaches. RESULTS: Clinical characteristics, factors related to the procedure and patient satisfaction were analysed. In total, 307 patients were randomly assigned to the nasal (n = 158) or oral insertion groups (n = 149). No difference in baseline characteristics was identified between the groups. Insertion by the oral route was associated with a smaller amount of lidocaine use during the procedure (P = 0.04) and less frequent insertion site bleeding (P = 0.005). Patients assigned to oral insertion reported less discomfort during anaesthesia (P = 0.01) and scope insertion (P < 0.001), as well as less dyspnoea (P = 0.04) and coughing (P = 0.03). CONCLUSION: Oral insertion of a flexible bronchoscope was associated with less discomfort for patients than nasal insertion, although the route of insertion had no significant effect on outcome.

Novel bronchofiberscopic catheter spray device allows effective anesthetic spray and sputum suctioning.

STUDY OBJECTIVES: To evaluate how serum lidocaine concentrations (SLC) rise when lidocaine is administered by a Bronchofiberscopic Catheter Spray Device (BCSD), and to demonstrate the effect on the aspiration speed of a substitute for sputum when a catheter spray remains in the channel of the bronchofiberscope (BF). METHODS: This is a prospective randomized clinical study. After lidocaine ultrasonic nebulizer, the BF was inserted orally. During the procedure patients received 4% lidocaine by two methods. In Group 1, 11 patients received lidocaine by bronchofiberscopic (BF) injection. In Group 2, 15 patients received lidocaine by spraying from the diameter 1.06 mm catheter through the BF channel. SLC were measured at 40 min from onset of nebulization. Separately, we examined how effectively sputum was aspirated through the BF channel with a catheter. RESULTS: Total lidocaine dose (TLD) is the total dose used for nebulization and for the BF injection or spray. The TLD for Groups 1 and 2 were 698.2+/-162.1 mg (mean+/-SD) and 498.7+/-103.8 mg, respectively (P = 0.03). The SLC for Groups 1 and 2 were 1.28+/-0.72 and 1.48+/-0.70 mg/l, respectively (P = 0.49). CONCLUSIONS: Using BCSD allows easier in administration of lidocaine and is not associated with a significant increase in SLC in comparison with BF injection. Although sputum aspiration using the BF inserted with our catheter was somewhat slow, we did not feel inconvenient so much. Compared to the conventional method, using BCSD may be preferable for patients and bronchoscopists.

Femorofemoral Cardiopulmonary Bypass in the Management of Severe Airway Obstruction by Thyroid Cancer: A Case Report / 대한마취과학회지

Severe upper airway obstruction due to thyroid cancer is often related severe hypoxia and hypercarbia during anesthesia induction. Attempts to insert an endotracheal tube or a bronchoscope may cause complete immediate airway obstruction. We anesthetized two patients. One had a large mediastinal thyroid mass which compressed trachea and caused near complete obstruction, and the other patient had a large papillary thyroid cancer, which had invaded larynx and compressed the upper trachea. Patients were sedated with fentanyl 150microgram i.v. and a target controlled infusion (TCI, 1.8microgram/ml) of propofol. A femorofemoral cardiopulmonary bypass was performed under local anesthesia. After bypass, the propofol TCI concentration was increased to 3.5microgram/ml, and fentanyl 500microgram and vecuronium 6 mg were injected. Ventilation was performed using a laryngeal mask in one patient, and a laryngeal tube in the other. After removing the tumor mass, the airway was secured, and the cardiopulmonary bypass discontinued. All patients recovered uneventfully and were discharged. We discuss the management of severe upper airway obstruction and the usefulness of cardiopulmonary bypass.

Use of an Epidural Catheter Placed Through a Fiberoptic Bronchoscope for Topical Anesthesia of the Larynx and Trachea in a Case of Difficult Intubation: A case report / 대한마취과학회지

Fiberoptic bronchoscope guided tracheal intubation is more popular in patient with expected difficult intubation by conventional laryngoscopy. We report a case of smooth fiberoptic bronchoscope guided tracheal intubation under local anesthesia. A 10% lidocaine spray 2-3 puffs of pharyngolaryngeal topical anesthesia and 2% lidocaine injection through a 19 gauge epidural catheter (ARROW(R)) placed over the fiberoptic bronchoscope suction channel for laryngeal and tracheal anesthesia were sufficient to prevent pain, coughing and nausea.

Use of an Epidural Catheter Placed Through a Fiberoptic Bronchoscope for Topical Anesthesia of the Larynx and Trachea in a Case of Difficult Intubation: A case report / 대한마취과학회지

Fiberoptic bronchoscope guided tracheal intubation is more popular in patient with expected difficult intubation by conventional laryngoscopy. We report a case of smooth fiberoptic bronchoscope guided tracheal intubation under local anesthesia. A 10% lidocaine spray 2-3 puffs of pharyngolaryngeal topical anesthesia and 2% lidocaine injection through a 19 gauge epidural catheter (ARROW(R)) placed over the fiberoptic bronchoscope suction channel for laryngeal and tracheal anesthesia were sufficient to prevent pain, coughing and nausea.

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.