A 12-year experience in endobronchial intervention using rigid bronchoscopy - account of a tertiary referral centre.

We describe our experience of rigid bronchoscopy and endobronchial intervention at a single tertiary centre over a 12-year period. All rigid bronchoscopy procedures between July 2008 and July 2020 (inclusive) were reviewed. All procedures were performed in cardiothoracic theatres by a designated team under general anaesthesia. 2135 rigid bronchoscopies were performed on 1301 patients aged between 18 and 93 years. Complications occurred in 24 (1.12%) procedures. There was one fatality (0.05%). Haemorrhage >100mls occurred in seven (0.33%) all of which were successfully managed endobronchially. Ten procedures (0.5%) were complicated by pneumothorax and an intercostal drain was required for eight. Five patients required intensive care admission post operatively, all of whom were subsequently discharged from hospital. One patient had stent migration. To the best of our knowledge, this is amongst the largest single centre collection of data available for endobronchial intervention using rigid bronchoscopy. We show that rigid bronchoscopy is a safe and effective procedure when performed in a high-volume specialist centre with designated lists involving a specialist multidisciplinary team.

Acute tracheal tear - A potential cause of spontaneous pneumomediastinum in patients with COVID-19.

Spontaneous pneumomediastinum following prolonged periods of severe coughing should raise the suspicion of tracheal rupture in COVID-19 patients.

Cardiac arrest following protamine administration: a case series.

AIMS: Protamine sulfate is commonly used to reverse the action of heparin after catheter ablation procedures. Serious protamine-related adverse effect is rare, but its recognition and appropriate management by electrophysiologists and intensivists is important. Direct ventricular fibrillation (VF) soon after a slow infusion of protamine has not been clearly described. METHODS AND RESULTS: We examined the records of all patients who suffered apparent adverse events after protamine administration in our electrophysiology lab from 2013 to 2018. We describe a series of three patients, all of whom suffered a precipitous fall in arterial pressure followed by VF within minutes after administration of protamine following ablation for atrial fibrillation. The same supplier of protamine was used in all three cases, but they were from different batches. Serum tryptase levels were measured in all cases, immediately post-cardiac arrest and at 2- and 6-h post-event. Immunoglobulin levels were not measured. Two patients recovered after aggressive supportive therapy; the third died despite similar support. CONCLUSION: We have encountered three cases of profound hypotension followed by VF soon after administration of protamine. Although protamine is safe in a large majority of patients, these adverse events have led our centre to exercise greater selectivity and caution in its use.

Multidetector CT and postprocessing in planning and assisting in minimally invasive bronchoscopic airway interventions.

A widening spectrum of increasingly advanced bronchoscopic techniques is available for the diagnosis and treatment of various bronchopulmonary diseases. The evolution of computed tomography (CT)-multidetector CT in particular-has paralleled these advances. The resulting development of two-dimensional and three-dimensional (3D) postprocessing techniques has complemented axial CT interpretation in providing more anatomically familiar information to the pulmonologist. Two-dimensional techniques such as multiplanar recontructions and 3D techniques such as virtual bronchoscopy can provide accurate guidance for increasing yield in transbronchial needle aspiration and transbronchial biopsy of mediastinal and hilar lymph nodes. Sampling of lesions located deeper within the lung periphery via bronchoscopic pathways determined at virtual bronchoscopy are also increasingly feasible. CT fluoroscopy for real-time image-guided sampling is now widely available; electromagnetic navigation guidance is being used in select centers but is currently more costly. Minimally invasive bronchoscopic techniques for restoring airway patency in obstruction caused by both benign and malignant conditions include mechanical strategies such as airway stent insertion and ablative techniques such as electrocauterization and cryotherapy. Multidetector CT postprocessing techniques provide valuable information for planning and surveillance of these treatment methods. In particular, they optimize the evaluation of dynamic obstructive conditions such as tracheobronchomalacia, especially with the greater craniocaudal coverage now provided by wide-area detectors. Multidetector CT also provides planning information for bronchoscopic treatment of bronchopleural fistulas and bronchoscopic lung volume reduction for carefully selected patients with refractory emphysema.

An approach to improve early detection of sternal wound infection.

We developed a reproducible and reliable method of using a rubber stamp prospectively to document appearances of the sternal wound. 395 consecutive patients undergoing median sternotomy for cardiac procedures were studied over a period of four months. Data were collected by the Senior House Officer during the ward round for all patients at Day 3 and Day 7 post-operatively. Data were entered for 303 patients using the rubber stamp. 78 patients had no stamp entered in their case notes. 21 patients were recorded as having abnormal wounds, 11 of whom confirmed positive microbiological growth. On the other hand, 282 patients were recorded to have normal wounds, 10 of which had positive bacterial growth. Our initial results have been encouraging with almost 80% compliance and 96% specificity. A simple recording system consisting of proven signs of infection known to medical practitioners was our tool.

Does Sildenafil produce a sustained benefit in patients with pulmonary hypertension associated with parenchymal lung and cardiac disease?

BACKGROUND: Sildenafil may be of benefit for selected patients with pulmonary hypertension associated with parenchymal lung and cardiac diseases. However the medium term benefits of this treatment for such patients is unclear. PATIENTS AND METHODS: 16 consecutive patients with secondary pulmonary hypertension who had been on maximal appropriate therapy received Sildenafil 50 mg tds following assessment which included right heart catheter, 2D echocardiography and six minute walk test. Right heart catheterisation, 2D echocardiography and six minute walk test were performed after eight weeks treatment, at 12 months and at six monthly intervals thereafter. Baseline medications were continued. RESULTS: 16 patients with pulmonary hypertension associated with inoperable chronic pulmonary thromboembolism (6 patients), valvular heart disease (4), chronic obstructive pulmonary disease (3), idiopathic pulmonary fibrosis (2), and obstructive sleep apnoea (1) were studied. The age range was 42 to 81 (median 68) years and the period of follow up was 12 to 51 (median 22) months. Six minute walk increased significantly, p=0.002, from baseline to long term follow up. The improvement in 14 patients ranged from 14 m to 300 m with a percentage increase of 5% to 567% increase. In one patient there was no change and in one patient the six minute walk test fell as a consequence of progression of known arthritis. The mean pulmonary artery pressure was significantly reduced at long term follow up (p=0008). The pulmonary vascular resistance (PVR) fell in eleven patients, this reduction ranged from 0.2 woods units to 8.7 woods units (mean reduction 3.3 woods units). The percentage reduction in PVR ranged from 7% to 71% with a mean reduction of 43%. In five patients the pulmonary vascular resistance increased. 2D echocardiography showed a sustained improvement in right ventricular function in 11 patients. There were no deaths during follow up. CONCLUSION: Sildenafil may have a role for selected patients with pulmonary hypertension associated with cardiac and pulmonary diseases. The medication seems well tolerated and for some patients is effective within 8 weeks and results in a sustained long term improvement in haemodynamics and exercise capacity.

Emergency cricothyroidotomy following tracheobronchial stenting.

A man aged 51 years was referred for tracheobronchial stenting after a poorly differentiated oesophageal carcinoma had progressed to cause stridor. Bronchoscopy revealed a left vocal cord palsy and tumour infiltration into the trachea. A tracheobronchial stent was placed, and after distal migration was endoscopically resited. Returning from theatre, the patient developed severe upper airway obstruction that progressed to cause CO2 narcosis and loss of consciousness. A rapid sequence induction was initiated, and a Glidescope revealed bilateral vocal cord palsy with severe oedema causing an inability to pass a tube or stylet. Tracheostomy was attempted above the suprasternal notch but was obstructed by the stent. Oxygen saturations dropped steadily, reaching as low as 38%. Emergency cricothyroidotomy was performed, compliant with DAS guidelines, that proved successful. The stent was removed, which was blocked with blood and secretions, and tracheostomy was placed 2 days later. The patient made a full neurological recovery.

A potential role for sildenafil in the management of pulmonary hypertension in patients with parenchymal lung disease.

BACKGROUND: Sildenafil offers potential to treat patients with pulmonary hypertension by selectively inhibiting phosphodiesterase type five pathways in the lung. It is recommended for selected patients with pulmonary arterial hypertension, but its role in the management of pulmonary hypertension associated with parenchymal lung disease is unclear. PATIENTS AND METHODS: Seven patients (68-86 years) with end stage chronic obstructive pulmonary disease (COPD, 4) and idiopathic pulmonary fibrosis (IPF, 3) were referred to our unit. All patients had a long-term history of chronic lung disease and were on maximal appropriate therapy prescribed by their referring pulmonologist. Thromboembolic disease was excluded by pulmonary angiography and all patients had had high resolution thoracic CT scan. At assessment right heart catheterisation, 2D echocardiography and 6-min walk test were performed prior to commencement of sildenafil 50mg tds. Their medication was otherwise unchanged. After 8 weeks treatment, right heart catheterisation, 2D echocardiography and 6-min walk test were repeated. RESULTS: The pulmonary vascular resistance was reduced in six patients (from 13, 3, 3, 6.5, 3.5 and 10.5 wood units to 9.7, 2.5, 2.8, 4.4, 2.5 and 5.4 wood units, respectively). Six-minute walk test increased in six patients (from 110 m, 210 m, 80 m, 30 m, 210 m and 80 m to 130 m, 312 m, 120 m, 82 m, 244 m and 100 m, respectively). One patient with COPD did not demonstrate a favourable response although their cardiac output increased on sildenafil therapy. 2D echocardiography showed a reduction in estimated PA pressure in six patients with an improvement in right ventricular systolic function in two COPD patients. CONCLUSION: Our results suggest that sildenafil may have a role for selected patients with COPD and IPF who have pulmonary hypertension.

Immunohistologic evidence of myocardial disease in apparently healthy relatives of patients with dilated cardiomyopathy.

OBJECTIVES: This study investigated whether apparently healthy relatives of patients with idiopathic dilated cardiomyopathy (DCM) who have left ventricular enlargement (LVE) have biopsy evidence of underlying myocardial disease. BACKGROUND: Left ventricular enlargement with normal systolic function is common among asymptomatic relatives of patients with DCM. Although there is circumstantial evidence to suggest that LVE may be a marker of early DCM, its pathophysiologic significance remains uncertain. METHODS: Over six years, 767 asymptomatic relatives of 183 consecutive patients with DCM were evaluated: 37 (5%) had DCM and 104 (14%) had LVE (left ventricular end-diastolic dimension >112% predicted) with normal systolic function. Right ventricular biopsy was performed in 32 relatives with LVE, 14 patients with symptomatic DCM and 6 control subjects with normal ventricular function undergoing elective coronary artery bypass graft surgery. Histologic and immunohistochemical analyses, including quantitative double immunofluorescence, were performed for leukocyte markers (CD3 and CD68), intercellular adhesion molecule-1 (ICAM-1) and human leukocyte antigen class II antigens (DR and DQ). RESULTS: Histologic findings consistent with DCM were present in 50% of the patients with DCM, 25% of the relatives with LVE and 0% of the control subjects. The median CD3 count was 2.4/mm(2) in patients with DCM, 4/mm(2) in relatives with LVE and 0 in control subjects (p = 0.04). Using a threshold of >7 cells/mm(2), 21% of patients with DCM and 25% of relatives with LVE were CD3-positive (p = 0.01). Quantitative analysis demonstrated DR expression on 55.8+/-22.8%, 63.5+/-18.8% and 30.9+/-15.7% of the endothelial surface in patients with DCM, relatives and control subjects, respectively (p = 0.003). Corresponding values for ICAM expression were 35.6+/-15.1%, 36.7+/-14.5% and 17.3+/-7.9% (p = 0.013). When combining inflammatory and histologic changes, 28 (86%) of LVE, 14 (100%) of DCM and no control biopsies were abnormal (p < 0.001). CONCLUSIONS: Most asymptomatic relatives of patients with DCM with LVE have histopathologic and immunopathologic findings similar to those of patients with established disease. Clinical identification and follow-up of such individuals are warranted to prevent presentation with advanced DCM and to enable assessment of interventions aimed at attenuating disease progression.

Early haemodynamic benefit of sildenafil in patients with coexisting chronic thromboembolic pulmonary hypertension and left ventricular dysfunction.

Sildenafil, a phosphodiesterase type-5 inhibitor, offers potential to treat pulmonary hypertension associated with a variety of conditions. We assessed the early impact of sildenafil on a cohort of patients referred to our unit who had severe pulmonary hypertension secondary to chronic thromboembolic disease which was not amenable to pulmonary thromboendarterectomy and who also had coexisting left ventricular dysfunction. Six patients were studied. Diagnosis of pulmonary embolic disease was made by ventilation perfusion scanning and/or CT pulmonary angiography. All patients were anticoagulated with oral coumarin derivatives and none were considered suitable for pulmonary thromboendarterectomy. Pulmonary hypertension was diagnosed by right heart catheterisation and each patient had Medical Research Council (MRC) dyspnoea score and New York Heart Association (NYHA) class noted and 2D echocardiography prior to commencement of sildenafil 50 mg three times a day. After 6 weeks of sildenafil therapy, right heart catheterisation and 2D echocardiography were repeated, and MRC dyspnoea score, NYHA class and exercise capacity were recorded. All patients demonstrated an improvement in mean pulmonary artery pressure, mean pulmonary capillary wedge pressure, MRC dyspnoea score, NYHA class and gas transfer. No adverse effects of sildenafil were noted. Our data suggests that sildenafil is an effective and well-tolerated therapy for patients with severe pulmonary hypertension associated with pulmonary thromboembolic disease and impaired left ventricular function, producing beneficial effects as early as 6 weeks.

An approach to tracheostomy in a patient with an expandable metallic tracheal stent.

With increasing use of expandable metallic stents to manage patients with a variety of endobronchial pathologies, some will have a subsequent need for tracheostomy insertion. We describe a successful technique to insert a tracheostomy using rigid and fibre-optic bronchoscopy in a patient who had an 8 cm expandable metallic tracheal stent deployed previously on account of tracheomalacia.

Pulmonary Hypertension.

Pulmonary hypertension is said to occur when the mean pulmonary arterial pressure exceeds 25 mmHg at rest or 30 mmHg during exercise. There are many causes but the term Pulmonary arterial hypertension (PAH) is used to describe a rare group of illnesses that share histopathological similarities in the small muscularised pulmonary arterioles leading to vascular remodelling (plexogenic pulmonary arteriopathy) and progressive elevation in the pulmonary vascular resistance. Left untreated, patients die as a consequence of right heart failure and the mortality approaches that of commonly encountered malignancies. There is no effective cure. Most treatment for PAH patients has focused on the endothelial cell vascular dysfunction known to occur in these disorders and indeed agents such as endothelin receptor antagonists, phosphodiesterase pathway V inhibitors and prostacyclin analogues have been shown to improve morbidity and delay rate of deterioration. More recently evidence has emerged that they may have a positive impact on survival. These agents have also been applied to treat patients with chronic thromboembolic pulmonary hypertension (CTEPH) and selected patients with CTEPH may also benefit from pulmonary thromboendarterectomy. For a small number of patients with PAH lung transplantation may be considered.

A Practical Clinical Approach to the Diagnosis and Treatment of Patients with Pulmonary Hypertension.

Pulmonary hypertension is defined by a mean pulmonary artery pressure of >25 mmHg at rest or 30 mmHg during exercise. There are many causes and currently diseases causing the condition are classified into five groups. The greatest elevation in pulmonary arterial pressure is found among those disorders in group 1 (known as pulmonary arterial hypertension [PAH]) and research and targeted therapy has focused on this group in particular, although patients in group 4 (chronic thromboembolic PH [CTEPH]) also receive advanced pulmonary vasodilator therapy. The symptoms of PH are often vague and the diagnosis is frequently missed or delayed. Efforts are therefore being made to improve awareness of PH among clinicians to enable prompt referral to a PH unit to confirm the diagnosis and instigate appropriate therapy. Multi-disciplinary team (MDT) discussion is necessary if patients with PH require surgical intervention or become pregnant. For patients in the other PH groups, treatment is usually concentrated on the primary disorder. A small number of patients with PAH will respond to calcium-channel-blocking agents. Specific targeted therapy is often given in combination depending on the patients functional performance status. Available agents include phosphodiesterase type V inhibitors, endothelin receptor antagonists, prostglandin analogues and nitric oxide. Many novel agents are under review. For carefully selected patients surgical options, include lung transplantation, pulmonary thromboendarterectomy and atrial septostomy.

Pyogenic psoas abscess: a rare complication after orthotopic heart transplantation.

We describe a 57-year-old man who developed a primary psoas abscess after treatment for acute allograft rejection, 5 years after orthotopic heart transplantation. The infective organism was methicillin-resistant Staphylococcus aureus (MRSA), and the patient underwent successful treatment with computed tomography-guided percutaneous drainage combined with teicoplanin and fusidic acid.

Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology.

BACKGROUND: Experience with Ultraflex expandable metallic stents (Micro-invasive, Boston Scientific, Watertown, MA) in the management of endobronchial pathologies leading to airway compromise is reported. METHODS: Between January 1999 and August 2000, twenty-eight expandable metallic stents were inserted into 25 patients (7 men and 18 women; median age, 65 years) who presented with respiratory distress. Each patient had comorbid medical conditions or end-stage malignancy that precluded formal surgical repair. Seventeen patients had intrinsic airway obstruction, 5 had extrinsic compression, 2 had a tracheal tear, and 1 had a tracheoesophageal fistula. Stents were inserted through a bronchoscope under direct vision. Eighteen patients received tracheal stents alone (1 of these patients received two tracheal stents), and 5 patients received bronchial stents only. Two patients received a tracheal and a bronchial stent. Twenty-one stents were covered and seven were uncovered. RESULTS: All patients had successful stents with restoration of airway patency and closure of tracheal defects. One patient developed a respiratory infection early after the operation. Follow-up bronchoscopy confirmed satisfactory stent position in each patient. Late complications included sputum retention, halitosis, and granulation tissue formation. CONCLUSIONS: Ultraflex expandable metallic stents should be considered in the management of airway compromise in selected patients for whom formal surgical repair is inappropriate or contraindicated.

Removal of long-term tracheal stents with excellent tracheal healing.

Covered metallic endobronchial stents are increasingly used in the management of diverse large airway pathology and once deployed they are considered permanent. Long-term complications of stent fracture and airway granulation tissue formation may necessitate stent removal. We describe successful endoscopic removal of the Ultraflex expandable tracheal metallic stents (Microvasive; Boston Scientific, Natick, MA) in 5 patients at 105, 84, 50, 38, and 21 months after deployment, with excellent tracheal healing and clearance of granulation tissue noted at 6 weeks after removal in each patient.

A retrospective review to evaluate the safety of right heart catheterization via the internal jugular vein in the assessment of pulmonary hypertension.

BACKGROUND: Right heart catheterization (RHC) is important in the evaluation of pulmonary hypertension, but is not without risk. HYPOTHESIS: We wished to assess the safety, efficacy, and tolerability of RHC performed via the internal jugular vein (IJV) at our tertiary cardiothoracic center. METHODS: A retrospective review of the medical records for all patients undergoing RHC via the IJV between January 1, 2007 and July 31, 2009 was performed. We do not routinely use ultrasound guidance or stop anticoagulation. Operators with a median experience of 450 procedures performed the RHCs. RESULTS: Right heart catheterization was performed on 349 patients with a median age of 66 years (range, 17-89), median mean pulmonary artery pressure of 30 mm Hg (range, 8-69), and a median internationalized normal ratio of 2.5. Of 349 patients, we were unable to obtain intravenous access in only 1 patient; 342 (98%) patients tolerated RHC with local anesthetic alone; and 6 patients required additional sedation with benzodiazepines. The median time for the procedure was 15 minutes. Complications occurred in 6 patients (1.7%) and included carotid puncture (n = 3), sinus bradycardia below 45 beats/min, which responded promptly to atropine and intravenous fluid (n = 2), and complete heart block without hemodynamic compromise (n = 1). There were no pneumothoraxes, pulmonary hemorrhage, or deaths related to the procedure. CONCLUSION: Right heart catheterization via the IJV is quick, safe, and well tolerated. It is not associated with an increased risk of pneumothorax or other complications when performed by experienced operators.

Successful endobronchial seal of surgical bronchopleural fistulas using BioGlue.

Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.

Do expandable metallic airway stents have a role in the management of patients with benign tracheobronchial disease?

BACKGROUND: With increasing availability many centers are deploying expandable metallic stents to manage patients with diverse endobronchial disorders. Although these devices have an important role in malignant disease their usefulness in benign large airway disorders is less defined. METHODS: Between 1997 and 2005, 31 patients aged 34 to 83 years with benign large airway compromise secondary to tracheomalacia (n = 7), posttracheostomy stricture (n = 8), posttracheostomy rupture (n = 2), postpneumonectomy bronchopleural fistula (n = 2), stricture after lung transplantation (n = 3), lobectomy, tuberculosis, traumatic injury to right main bronchus (n = 1 patient each), and external compression of the airway secondary to achalasia, multinodular goiter, aortic aneurysm, right brachiocephalic artery aneurysm, right interrupted aortic arch, and dissecting aneurysm (n = 1 patient each) who were medically unfit for formal surgical intervention were treated by Ultraflex stent deployment. The range of follow-up was 1 week to 96 months. Stents were deployed under anesthesia using rigid bronchoscopy. RESULTS: Complications included granulation tissue formation (n = 11) treated with Nd: YAG laser ablation, stent migration (n = 1; stent removed, another deployed), metal fatigue (n = 1), stent removal (n = 1), mucus plugging (n = 2), and halitosis (n = 6) difficult to treat despite antibiotics. Thirteen patients died of unrelated causes between 1 week and 15 months after stent deployment. CONCLUSIONS: Endobronchial metallic stents should be considered only for selected patients with large airway compromise secondary to benign airway diseases for whom other medical comorbidities contraindicate formal airway surgery. Once deployed, they are difficult to remove, are associated with significant complications, and require prospective bronchoscopic surveillance and often further therapeutic intervention.